June 2016 by Doctor's Review

Is Donald Trump

MEDICINE ON THE MOVE

certifiable? Nothing beats

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

JUNE 2016

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Laid-back at the lake Funky fairway hits Circling Smartphone the Sisters light ups

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GADGET PAGE 14

The beauty

of recovery Depression/anxiety

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A CANADIAN DEVELOPMENT

INTRODUCING REPATHA (EVOLOCUMAB) – FIRST-IN-CLASS PCSK9 INHIBITOR * TM

In patients with atherosclerotic CVD as adjunct therapy to simvastatin, atorvastatin or rosuvastatin, at 12 weeks

REPATHA 140 MG Q2W – PROVIDED POWERFUL LDL-C REDUCTION TM

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Indications and clinical use: Repatha (evolocumab) is indicated as an adjunct to diet and maximally tolerated statin therapy in adult patients with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low-density lipoprotein cholesterol (LDL-C).

• Use with caution in patients with severe hepatic impairment • Needle cap contains dry natural rubber; may cause an allergic reaction in latex-sensitive patients For more information: Please consult the Product Monograph at www.amgen.ca/Repatha_PM.pdf for important information relating to adverse reactions, drug The effect of Repatha on cardiovascular morbidity and mortality has not been determined. interactions and dosing information which have not been discussed in this piece. Contraindication: The Product Monograph is also available • Hypersensitivity to Repatha or to any by calling Amgen Medical Information at ingredient in the formulation or component 1-866-502-6436. of the container Most serious warnings and precautions: LDL-C=low density lipoprotein cholesterol; PCSK9=proprotein • Refer to Contraindications and Warnings convertase subtilisin/kexin type 9; Q2W=every 2 weeks; and Precautions for any concomitant lipid QM=monthly; SC=subcutaneous lowering medications * Comparative clinical significance has not been established. † Significant LDL-C reduction vs. placebo was consistently seen with Other relevant warnings and precautions: Repatha 140 mg Q2W and 420 mg QM in combination with a • No studies have been conducted with statin, as assessed over 12-week and 52-week treatment periods. Repatha in pregnant women and relevant ‡ LAPLACE-2 was a multicentre, double-blind randomized data from clinical use are very limited controlled trial in which patients with atherosclerotic CVD • Statin product monographs recommend (n=296) received Repatha or placebo as add-on therapy discontinuation when a patient becomes to daily doses of atorvastatin 80 mg, rosuvastatin 40 mg or simvastatin 40 mg. Patients were initially randomized to a pregnant, therefore Repatha should also 4-week lipid stabilization period (open-label statin regimen) be discontinued followed by random assignment to Repatha 140 mg Q2W, • Not recommended for use in nursing women or Repatha 420 mg QM or placebo for 12 weeks. in pediatric patients with primary hyperlipidemia § Overall difference, mean % change from baseline to Week 12 • Use of Repatha in patients with severe in LDL-C, mean difference from placebo with Repatha 140 mg renal impairment is not recommended Q2W (95% CI: -84%, -64%, p<0.0001). ™

™

PATIENT SUPPORT PROGRAM

YOUR PARTNER IN CARE, EVERY STEP OF THE WAY ▪ONE-STEP ENROLMENT ▪REIMBURSEMENT NAVIGATION/SUPPORT ▪GETTING STARTED WITH AUTOINJECTOR TRAINING AND NURSE SUPPORT ▪PATIENT TREATMENT REMINDERS, ONGOING SUPPORT

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1,2

References: 1. Repatha (evolocumab) Product Monograph. Amgen Canada Inc., September 10, 2015. 2. Robinson JG, et al. Effect of evolocumab or ezetimibe added to moderate- or high-intensity statin therapy on LDL-C lowering in patients with hypercholesterolemia. The LAPLACE-2 randomized clinical trial. JAMA 2014;311(18):1870-82. © 2016 Amgen Canada Inc. All rights reserved. Repatha and RepathaREADY are trademarks of Amgen Inc., used with permission. ™

™

Goin’ to the cottage

GARY CRALLÉ

Lakes have a special place in the Canadian psyche. Come warmer weather, they act like Lake life at Kawartha Highlands Provincial Park. magnets to draw millions of us out of the city and deposit us beside bodies of water. My first experience of lake life came when I was four. The family that lived upstairs above our flat in Montreal invited us up to their place in the Laurentians on Lac Val-Morin. The house was set back from the water and seemed enormous. A lawn ran down to a rowboat pulled up on a sandy beach. I couldn’t wait to go out in it and that very afternoon my dad took me for a row. The wooden boat sported many coats of dark green paint with a blue-grey interior, as I recall. It was a heavy craft and so were the oars that easily slipped out to the locks. We lost one shortly after we got underway and papa had to take off his pants and jump in to retrieve it, which caused a tremendous amount of excitement for me and my friend Ruth who was along for the ride. After that it was smooth sailing down the shore and up a small inlet that was filled with the most miraculous things I’d ever seen: lily pads, and white and yellow water lilies. It was a great introduction to country life and the fun wasn’t over yet. After supper Ruth’s mother let out a tremendous scream from the kitchen. “A bat! A bat!” she yelled and, sure enough, something black and fast shot into the dining room and began to circle the hanging lamp. The men were quick responders. “Cover your heads!” they shrieked at the ladies. There were rumours that bats liked to nest in beehive hairdos. Then, armed with two large straw brooms, they took to swinging madly around the dining room while Ruth’s mother, her head covered with a paper bag, shouted, “George, for God’s sake, be careful you don’t smash the light, it belonged to my grandmother.” The drama ended soon enough with the bat exiting swiftly through the front door. Afterwards we had a bonfire and marshmallows. I went to bed knowing that the world was a far more exciting place than I had yet dared to imagine. Later we spent vacations for a couple of summers in a rented cabin on another lake and I learned to swim and row myself. In high school, I got a job at a summer camp and did some canoe tripping — another important part of coming of age in Canada — which included swarms of mosquitoes and black flies and long swampy portages. For a taste of lake life, do read Gary Crallé’s cover story, Bright waters, happy days (page 26) about Peterborough and the Kawarthas. A fine summer to you,

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JUNE 2016 • Doctor’s

Review

Introducing

Sam does it on Sunday, and only on Sunday

BYDUREON® A new once-weekly GLP-1 receptor agonist for the treatment of type 2 diabetes

Powerful and sustained A1c reductions from baseline shown vs titrated insulin glargine at 3 years • Demonstrated signiﬁcantly greater mean A1c reduction from baseline vs titrated insulin glargine at week 261* • A1c reductions were sustained at 3 years (-1.01% vs -0.81%, respectively; p=0.03)2

BYDUREON

Titrated insulin glargine

-1.48%

-1.32%

p=0.047

• BYDUREON was associated with fewer hypoglycemic events1*†

* 26-week, 2-arm, open-label, comparator-controlled study, followed by a 130-week open-label, comparator-controlled assessment period, plus a 10-week off-treatment follow-up period. 456 patients with type 2 diabetes were randomized to BYDUREON 2 mg QW SC (n=233) or titrated insulin glargine OD (n=223) and continued their usual diabetes treatment throughout the 26-week treatment period and the open-ended assessment period. After Week 48, addition of oral antidiabetes drugs or change to the dose of metformin or sulfonylurea was permitted as needed. † When BYDUREON is added to sulfonylurea therapy, a decrease in the dose of the sulfonylurea may be considered to reduce the risk of hypoglycemia. ‡ Please see Product Monograph for complete dosing and administration information. BYDUREON® is a registered trademark of Amylin Pharmaceuticals LLC, used under license by AstraZeneca Canada.

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One injection, ONCE A WEEK

1‡

2 mg once a week May be administered at any time of day, with or without meals

01/17

contents JUNE 2016

Indications and clinical use: BYDUREON is indicated for use as monotherapy as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance. BYDUREON is also indicated in patients with type 2 diabetes mellitus to improve glycemic control in combination with metformin, a sulfonylurea, or metformin and a sulfonylurea (dual therapy), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control. Use with caution in the elderly. Should not be used in pediatric patients. Contraindications: Personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) End-stage renal disease or severe renal impairment (creatinine clearance <30 mL/min), including patients on dialysis Most serious warnings and precautions: Thyroid C-cell tumours: Exenatide extended-release causes an increased incidence of thyroid C-cell tumours at clinically relevant exposures in rats compared to controls. It is unknown whether BYDUREON causes thyroid C-cell tumours, including MTC, in humans. Patients should be counselled regarding the potential risk for MTC and informed of symptoms of thyroid tumours. Routine monitoring of serum calcitonin or thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with BYDUREON. Acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis: patients should be observed carefully for signs and symptoms of pancreatitis; if suspected, discontinue and initiate appropriate management; if confirmed, BYDUREON should not be restarted. Other relevant warnings and precautions: Not for use in type 1 diabetes or for the treatment of diabetic ketoacidosis Should not be used in combination with PrBYETTA® (exenatide), other glucagon-like peptide-1 (GLP-1) agonists or dipeptidyl peptidase-4 (DPP-4) inhibitors Not studied with warfarin; frequent INR monitoring recommended in patients taking warfarin Plasma levels decline over 10 weeks after discontinuation; choice of other medicinal products and dose selection should be considered accordingly Must not be administered by intravenous or intramuscular injection Heart rate increase; caution in patients with a history of ischemic heart disease or tachyarrhythmias Prolongation of heart rate-corrected PR interval of the electrocardiogram; caution in patients with underlying structural heart disease, pre-existing conduction system abnormalities, ischemic heart disease, cardiomyopathies and history of atrial fibrillation Increased risk of hypoglycemia in combination with sulfonylureas Not recommended in patients with severe gastrointestinal disease Serious hypersensitivity reactions, including anaphylaxis and angioedema; discontinue if a reaction is suspected, assess for other potential causes and institute alternative treatment for diabetes Potential for antibody development; discontinue if there is worsening glycemic control or failure to achieve targeted glycemic control and alternative antidiabetic therapy should be considered Serious injection site reactions Caution in patients with moderate renal impairment and in renal transplant patients; assess renal function prior to initiation and periodically thereafter, as appropriate Not for use in pregnant or nursing women; women of childbearing potential should use contraception during treatment For more information: Please consult the Product Monograph at www.azinfo.ca/bydureon/pm293 for important information relating to adverse reactions, drug interactions and dosing information that has not been discussed in this piece. The Product Monograph is also available by calling 1-800-668-6000.

features

Bright water, happy days The Kawarthas are famous for their lakes and parks, and now Peterborough, the gateway, is in the midst of a major tart up by Gary Crallé

Circling the Sisters A four-day hike around Oregon’s volcanic trio through old-growth forests and alpine meadows that make the elevation changes well worth the climb by Tilke Elkins

26 COVER: GARY CRALLÉ

Golf with benefits Plus-fours, wooden clubs, motorized GolfBoards and pay-by-the-hole are a few of the innovations designed to put more fun in the game by Anita Draycott

References: 1. BYDUREON Product Monograph. AstraZeneca Canada Inc., October 30, 2015. 2. Diamant M et al. Exenatide once weekly versus insulin glargine for type 2 diabetes (DURATION-3): 3-year results of an open-label randomised trial. Lancet Diabetes Endocrinol 2014;2:464-73.

BYDUREON® is a registered trademark of Amylin Pharmaceuticals LLC, used under license by AstraZeneca Canada. The AstraZeneca logo is a registered trademark of AstraZeneca AB, used under license by AstraZeneca Canada Inc.

01/17

Notes supplémentaires

ÉPREUVE

02F

JUNE 2016 • Doctor’s

Review

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

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

Demonstrated EFFICACY and AE proﬁle in a study of ELDERLY OAB patients • In ELDERLY OAB patients (VES-13 score of ≥3): TOVIAZ signiﬁcantly improved urgency urinary incontinence episodes/24 hrs vs. placebo at week 122† – LS mean change from baseline: -2.20 placebo (n=250) and -2.84 TOVIAZ (n=256, p=0.002)

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; caution in patients with ischemic heart disease, congestive heart failure, cardiac arrhythmias or tachycardia • Interaction with potent CYP3A4 inhibitors (i.e., max of 4 mg) • Patients at risk of gastric retention • Patients at risk of urinary retention • Patients with impaired hepatic function • Angioedema • Patients with myasthenia gravis • Patients with controlled narrow-angle glaucoma • Patients with impaired renal function (i.e., max of 4 mg for severe impairment) • Contraception in women of childbearing potential • Not recommended during breastfeeding For more information: Please consult the product monograph at http://www.pfizer.ca/en/our_products/ products/monograph/317 for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001. * 12-week, double-blind, placebo-controlled, parallel-group trial of 990 patients with OAB (≥8 micturitions/24 hrs and ≥2 to <15 UUI episodes/24 hrs on a 3-day bladder diary). Before being randomized to the treatment study period, patients entered a 2-week, open-label, run-in period to identify subjects who the study defined as responding sub-optimally to tolterodine ER 4 mg/day. Patients were randomized to placebo (n=320) or TOVIAZ 8 mg/day (4 mg for 1 week then 8 mg for 11 weeks, n=322). Baseline means for UUI episodes/24 hrs were 3.93 for TOVIAZ and 3.83 for placebo. † 12-week, randomized, double-blind, flexible-dose, placebo-controlled, parallel-group, multicenter trial in patients aged ≥65 years with OAB symptoms (≥3 months, mean of 2-15 UUI episodes/24 hrs, mean of ≥8 micturitions/24 hrs reported in 3-day bladder diary). Patients were randomized to placebo (n=283) or TOVIAZ 4 mg/day (n=283), with the option to increase to 8 mg at Week 4 only. Baseline means for UUI episodes/24 hrs were 4.1 and 3.9, respectively. References: 1. Kaplan SA et al. Efficacy and safety of fesoterodine 8 mg in subjects with overactive bladder after a suboptimal response to tolterodine ER. Int J Clin Pract 2014;68:1065-73. 2. DuBeau CE et al. Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: a double-blind, placebo controlled trial. J Urol 2014; 191:395404. 3. Pfizer Canada Inc. TOVIAZ Product Monograph. February 12, 2015.

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

Learn about TOVIAZ and order samples at ToviazPro.ca

CA0115TOV005E

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

features

Namibia wild

contents JUNE 2016

Two men tackle the 17-kilometre Waterkloof Trail and encounter hundreds of cackling baboons that aren’t happy to see distant relatives by Gerald Yeung

Season’s eatings Easy summer recipes from the follow-up to The Homemade Pantry for when rhubarb and tomatoes overfloweth by Alana Chernila

regulars

7 9

17 21

• US National Parks: lesser-known spots worth a visit in this centennial year

HISTORY OF MEDICINE Mental illness and the world’s most famous leaders by Rose Foster

July/August

DEPRESSION STRATEGIES When patients suffer from both depression and anxiety by Mairi MacKinnon

PRACTICAL TRAVELLER

Coming in

TOP 25 The biggest medical meetings happening this November

A history of tattoos in Toronto, France gets a “Guggenheim” for grape lovers, a new study on bed bugs and more! by Camille Chin

GADGETS New LED bulbs and a hub to control them with your smartphone by David Elkins

LETTERS Guiding lights

VIEWPOINT ON ADDICTION

Cures are tough, but they can be hugely transformative by Fardous Hosseiny

PHOTO FINISH Southern reflections by Dr Ilmar J. Kents

• Cooking courses coast to coast: summer never tasted so good • Bicycles, a love affair: from boneshaker to Bixi, they just keep getting better • Sicily’s new golden age: you don’t know Italy until you know where it all began • Depression: case studies from the famous to the person down the block PUR15TA007_bootlug_1E_E1.indd 1

JUNE 2016 • Doctor’s

Review

2016-01-25 4:56 PM

Introducing

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

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

CODE

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

EN167

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

EN148

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

EN149

DPP-4 = Dipeptidyl peptidase-4

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

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

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

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

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

LETTERS

Guiding lights EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

FRANCE NOW AND THEN Dordogne is a lovely region [France at its most enchanting, March 2016, page 34] — also interesting for its “pre-history.” Dr Ian Hammond Via DoctorsReview.com

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

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WHEN SPARKS FLY What is the name of the bird on the April cover? Natalie Via DoctorsReview.com

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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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Editor’s note: It’s a southern red-billed hornbill photographed in South Africa’s Kruger National Park.

THE POWERS THAT BE Took a look at the specs on the V1 PRO from J5 Tactical [“Light up your life,” Gadgets, April 2016, page 19] and it may possibly put out 300 lumens, but you would need to be using a Lithium 14500 battery, not an AA. With an AA, you would be unlikely to get anything more than 100 lumens. If a flashlight ships with a battery, then the stated output must be the maximum with the shipped battery. If it doesn’t, which is the case here, then they can state the maximum possible. And the maximum possible is always with a lithium battery, if the light is able to handle the higher voltage. The reason this matters is that most people do not have 14500s handy. Howard Via DoctorsReview.com

Here are more of the online comments we received about both the J5 and Suaoki tactical flashlights: Never know when one might get lost in the woods! Dr Jeff King

CONGRATULATIONS!

The winner of two tactical flashlights is Dr Gabrielle Weiler, a pediatric nephrologist from Ottawa.

Would be awesome to finally have something “tactical.” Sounds Ramboish! Dr Martin Robichaud

Great items for in your car, home and during emergencies. Gloria Fredericks

Never thought that a flashlight could be a self-defense object! Dr Denis Rivest

Would “brighten up” my day! Dr Sayanthan Sabanathan

BY LAND AND SEA By coincidence I was on the same cruise [Spain to Italy by sailing ship, April 2016, page 40]. At Cannes, my wife and I joined about a dozen other travellers on a shopping trip with the ship’s chef. We visited the local market where the chef purchased spices, cheese, ham, sausages, and fruits and vegetables to be used in his kitchen. Weren’t we delighted when a tray of his creations was delivered to our cabin in the evening?! Joe Lubomski Via DoctorsReview.com JUNE 2016 • Doctor’s

Review

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

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

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

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

C a mi lle C hi n

CLAUDE GERMAIN, © MUSÉE DU QUAI BRANLY, PARIS

CLOCKWISE: Early 20th-century tattooing kit from the Solomon Islands. Untitled. Serie maras, 2006. Fang-Od Oggay (Whang Od, b.1920).

Tattoos: Ritual. Identity. Obsession. Art., on now through September 5 at the Royal Ontario Museum in Toronto, comes from the Musée du Quai Branly in Paris, which received record crowds in 2014/15 when it hosted its version of the show, Tattooists, Tattooed. The exhibit is a 5000-year-old visual history of body art, and explores tattoos across continents and over time, tattoo artists and the tattooed as well as the factors that have made tattooing an important cultural practice, art form, and worldwide modern phenomenon. Two hundred objects are on display (prints, posters, ancient tools), including 13 silicone body parts inked by leading contemporary artists including Tin-Tin (France), Horiyoshi III (Japan), Filip Leu (Switzerland), Paul Booth (USA), Chimé (Polynesia), and Yann Black (Montreal). Adults $8; students $6; kids four to 14 $4. rom.on.ca/en/ tattoos-ritual-identity-obsession.

Toronto ink

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

Landmark love TripAdvisor recently released its Travellers’ Choice Award for the Top 25 Landmarks around the World. The travel website applied an algorithm to millions of user reviews over a 12-month period to determine the winners. Machu Picchu tops the list this year (bumping 2015’s leader, Angkor Wat, to third); the Lincoln Memorial Reflecting Pool is North America’s only top 10 entry (the Golden Gate Bridge, number 10 last year, is now number 11). For the full list: tripadvisor.ca/travelerschoice-landmarks.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Machu Picchu, Peru (2) Sheikh Zayed Grand Mosque, Abu Dhabi, UAE (4) Angkor Wat, Siem Reap, Cambodia (1) St. Peter’s Basilica, Vatican City, Italy (6) Taj Mahal, Agra, India (3) Mosque-Cathedral of Cordoba, Spain (NEW) Church of the Savior on Blood, St. Petersburg, Russia (NEW) The Alhambra, Granada, Spain (NEW) Lincoln Memorial Reflecting Pool, Washington, US (NEW) Duomo, Milan, Italy (7)

Bugs that see red According to a new study in the Journal of Medical Entomology, travellers should avoid hotel beds that have red sheets. Bed bugs prefer the colour red over other hues — they drink blood, after all — with black coming in second. Green and yellow are the critters’ least favourite colours. The bugs’ colour preferences were evaluated using cards of eight different colours that were folded into little “tents” and fit into petri dishes. Researchers released the bugs into the dishes and gave them 10 minutes to choose a hiding spot. The bugs called the red tent home 29 percent of the time — and also released a lot of eggs there; they called the black tent home 23 percent of the time; they avoided the green and yellow tents entirely. jme.oxfordjournals.org/ content/early/2016/04/20/jme.tjw033.

Doctor’s Review • JUNE 2016

BARONE FIRENZE / SHUTTERSTOCK.COM

Mosque – Cathedral of Córdoba in Spain’s Andalusia region.

La Cité du Vin opened on June 1 in Bordeaux, France and, depending on your tastes, the museum on wine may leave you drunk, in love, or both. Designed by Paris-based XTU Architects, the 10-storey, $120-million structure is both fluid and futuristic, calling to mind the movement of the Garonne River on which it sits, and the swirl of wine in a flute. Its exterior consists of 900 glass panels and 2500 iridescent aluminum panels, evocative of the city’s neoclassical golden limestone façades. Inside, there are 20 themed areas (3D imagery, olfactory whiffs, multi-sensory moving décors); on the eight floor the panoramic Belvedere wine saloon features a chandelier made of thousands of bottles and a 10-metre-long oak counter. Here, visitors can enjoy samples from the best wine regions in the world while discovering the city of Bordeaux, the river and its vineyards from a birds-eye view. €20 for a self-guided tour with a digital guide available in eight languages. laciteduvin.com.

A new temple for grape lovers

JUNE 2016 • Doctor’s

Review

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

China airs its billions

Big ol’ bragging rights You’ve probably heard the figures: 18 decks; 2747 staterooms; seven distinct neighbourhoods; 20 dining options; an international crew of 2100 for 6780 guests. And here’s one more: Royal Caribbean’s new Harmony of the Seas took 32 months to construct and is indeed the biggest cruise ship in the world. In addition to 23 pools, waterslides and flowriders, it also features a full-sized basketball court, two climbing walls, a zip line, a skating rink and — if you have a quiet moment to read the news and catch up on social media — the fastest Internet at sea available throughout the ship. The official launch of Harmony’s inaugural summer season was a seven-night western Mediterranean sailing on June 7. In November, she will arrive at her homeport of Port Everglades in Fort Lauderdale from where she’ll offer seven-night Eastern and Western Caribbean sailings. royalcaribbean.com/harmonyoftheseas.

Doctor’s Review • JUNE 2016

Chengdu, the capital of the Sichuan province, will become the third Chinese city to have two airports after Beijing and Shanghai. The $11-billion project will have three runways capable of processing 40 million passengers a year. It’s scheduled for completion in 2025. Beijing’s new $14-billion airport designed by the late Iraq-born British architect Zaha Hadid is expected to process 45 million passengers initially and eventually 72 million annually. It’s slated to open in 2019. China’s airports received 915 million passengers in 2015. A shortage of aircraft parking slots has caused delays and even riots.

Chengdu’s famous shopping strip, Chunxi Road.

CANADASTOCK / SHUTTERSTOCK.COM

The Government Quarter and Reichstag (parliament) building in Berlin.

The hostess with the mostess Berlin is probably the easiest place for an MD to do CME. Germany’s capital was the number one location choice for gatherings of international associations in 2015, according to rankings published in May by the International Congress and Convention Association (ICCA) — annual stats that are eagerly anticipated by tourism boards. Vancouver is one of North America’s most sought-after destinations for international meetings. It hosted 78 international meetings in 2015 and placed 29th in the world, ahead of Montreal and Toronto. Legend: number of meetings in 2015, change in rank ➔

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

Berlin 195 ▲ 3 Paris 186 ▼ 1 Barcelona 180 ▲ 2 Vienna 178 ▼ 2 London 171 ▲ 1 Madrid 171 ▼ 2 Singapore 156 (NEW) Istanbul 148 ▲ 1 Lisbon 145 ▲ 3 Copenhagen 138 ▲ 3 Prague 123 ▼ 1 Amsterdam 120 ▼ 4 Brussels 117 ▼ 2 Seoul 117 ▲ 2 Hong Kong 112 ▲ 1 Bangkok 103 ▲ 13 Rome 99 (NEW) Dublin 97 ▲ 6 Beijing 95 ▼ 5 Budapest 95 ▼ 2

JUNE 2016 • Doctor’s

Review

GA D GE T S by

D a v i d Elk i n s

Smartphone light control You knew it was coming and now it has arrived: a practical way to control the lighting in your home using your smartphone. The accent here is on practical. I don’t know if you’ve tried to buy a light bulb lately, but if you have, you know it’s no simple matter. Check out the lighting section in any hardware store and you’ll be confronted by a dumbfounding display of alternates. You may

Win a Philips HUE A19 Starter Kit by entering the Win the Gadget of the Month contest online at doctorsreview.com

Doctor’s Review • JUNE 2016

also find a small group of puzzled customers trying to read the boxes or find a salesperson to help. The easiest choice is the old standby: the incandescent bulb. You can find a pack of four 60-watt bulbs for under $4 and that’s not likely to change anytime soon. After that, things get complicated. Do you, for example, opt for a long-life, 10-watt spiral bulb (60-watt equivalent) that starts at $4 each, but emits a light that has a whitish glow? Or perhaps a brighter 26-watt smart energy spiral at $11.50? Would you consider then an efficient 38-watt halogen at $13? The confusion factor moves up when you attempt to figure out which bulb will last longer: 10,000 hours? Maybe better to go for 25,000 hours, a decision that may depend on how old you are, among other things. Be done with all that. If price isn’t a major consideration, move with the times, go LED. At least you’ll have the satisfaction of knowing you may never have to purchase another bulb in this lifetime. Until recently, the LED choice here was pretty simple. The Cree Connected LED at under $15 offered the best deal by a considerable margin. Enter the Philips HUE A19, which uses 9.5 watts to produce 800 lumens with a projected life of 23 years for three hours of use a day (25,000 hours total). At $14.97, it matches Cree’s specs and price. And here’s the thing — the company also offers the Hue Bridge 2.0, a hub that allows your smartphone to turn the lights on and off wirelessly from upstairs

or almost anywhere else on the planet. There’s even a geo-fencing feature that will activate the bulbs when you come up the walk or driveway. iPhone Siri users can control the lights with voice commands. Installation is easy. Simply screw the Hue A19 bulb into a socket, turn it on, download the Philips Hue app and follow the instructions. Users report no difficulty using either a recent iPhone or Samsung Galaxy. The latest version of the app makes it easy to identify and name rooms, arrange where bulbs are located and adjust the brightness of the whole group. A “Routines” tab lets you set lighting schedules, while “Scenes” allows you to set a variety of mood lighting. The HUE White A19 Starter Kit that includes the Hue Bridge and two bulbs is available at Home Depot and Best Buy. $79.99.

MEDICAL QUIPS What does this say?

A doctor is to give a speech at a healthcare dinner. She jots down notes, but when she gets to the podium she finds she can’t read them. After a few uneasy seconds she asks the audience: “Is there a pharmacist in the house?”

Picture yourself in Edinburgh. Doctorâ&#x20AC;&#x2122;s Review makes planning your personal and professional travel easier.

Go to doctorsreview.com/meetings to search 2500+ top world conferences. Access code: drcme

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Halifax, NS October 23-25 2016 Annual Conference of the Canadian Association of Paediatric Health Centres conference.caphc.org

Montreal, QC October 20-22 XXVII Annual Meeting and Scientific Conference of the International Society of Addiction Medicine and Canadian Society of Addiction Medicine csam-smca.org/events 2016 Canadian Cardiovascular Congress cardiocongress.org

October 26-29 2016 Annual Meeting of the Canadian Society of Internal Medicine csim.ca/annual-meetings

MEDICAL QUIPS Sorry I misspoke Psychiatrist to her receptionist: “Could you please just say we’re very busy instead of ‘It’s a madhouse.’”

Grouse Mountain in North Vancouver, 20 minutes from downtown.

October 22-25

Ottawa, ON October 24-26

Vancouver, BC November 9-12

6th Conference on Recent Advances in the Prevention and Treatment of Childhood and Adolescent Obesity interprofessional.ubc.ca/Obesity2016

Family Medicine Forum fmf.cfpc.ca

October 26-29 19th Annual Professional Conference and Annual Meetings of the Canadian Diabetes Association, and the Canadian Society of Endocrinology and Metabolism diabetes.ca/clinical-practice-education/ professional-conference-annual-meetings

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

Around the world Abu Dhabi, UAE November 17-19 Gastro 2016: EGHS-WGO International Congress gastro2016.com

Amsterdam, Netherlands November 10-13

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24th World Congress on Controversies in Obstetrics, Gynecology and Infertility congressmed.com/cogi

Bangkok, Thailand November 12-15 21st Congress of the Asian Pacific Society of Respirology apsr2016.com The Renzo Piano-designed Science Museum in Amsterdam.

JUNE 2016 • Doctor’s

Review

THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Street performers in New Orleans’ French Quarter district.

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

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Boston, MA October 5-8 11th Cardiometabolic Health Congress cardiometabolichealth.org

Cape Town, South Africa November 18-22 2016 World Psychiatry Association International Congress wpacapetown2016.org.za

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

Hyderabad, India October 26-29 10th World Stroke Congress wsc.kenes.com

Manchester, England November 17-19

To register and to search 2500+ conferences, visit doctorsreview.com/meetings New Orleans, LA November 12-16 2016 Scientific Sessions of the American Heart Association professional.heart.org/professional/index.jsp

November 16-20

eaaci-isaf.org

2016 Annual Scientific Meeting of the Gerontological Society of America geron.org/meetings-events/2016-gsa-annualscientific-meeting

New Delhi, India November 30-December 4

Orlando, FL November 14-18

3rd International Severe Asthma Forum

XXII World Congress of the World Association for Social Psychiatry wasp2016.com

45th AAGL Annual Global Congress on Minimally Invasive Gynecology aagl.org/calendar

Rome, Italy November 29-December 2 XVII International Symposium on Progress in Clinical Pacing pacing2016.com

San Antonio, TX October 21-24 US Psychiatric and Mental Health Congress psychcongress.com/psychcongress

Valencia, Spain October 26-29 42nd Annual Conference of the International Society for Pediatric and Adolescent Diabetes 2016.ispad.org

November 23-25 6th International Congress of the Union of European Neonatal and Perinatal Societies uenps2016.org

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

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Doctor’s Review • JUNE 2016

You Youcan canwin win the thefight fight against against colon colon cancer cancer ColonColon Cancer Cancer is theis number the number two two killerkiller of all of cancers all cancers – and–itand canitaffect can affect anyone. anyone. But with But with earlyearly detection detection the survival the survival rate israte estimated is estimated at 90%. at 90%. And it And all it starts all starts with with a simple a simple self- selfadministered administered test that test that you do youindo in the privacy the privacy of your of your own home. own home. Talk Talk with with your your doctor doctor and get andthe gettest. the test. Not knowing Not knowing is notisthe notanswer. the answer.

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Olympic Olympic medalist medalist FatherFather is a colon is a colon cancercancer survivor survivor

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Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

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

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

• Interstitial lung disease and eosinophilic pneumonia with venlafaxine • Seizures • Narrow angle glaucoma • Mania/hypomania • Serotonin syndrome or neuroleptic malignant syndrome-like reactions For More Information: Please consult the product monograph at http://pfizer.ca/ en/our_products/products/monograph/226 for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001.

CA0115PRI005E

Clinical Use: − Severe agitation-type adverse events coupled with self-harm or harm to others • PRISTIQ is not indicated for use in children under the age of 18 − Suicidal ideation and behavior; rigorous monitoring • The short-term efficacy of PRISTIQ has been demonstrated in placebo-controlled trials of up to 8 weeks • The efficacy of PRISTIQ in maintaining an antidepressant • Discontinuation symptoms: should not be discontinued abruptly. Gradual dose reduction is response for up to 26 weeks, following response during recommended 20 weeks of acute, open-label treatment, was demonstrated in a placebo-controlled trial Other Relevant Warnings and Precautions: Contraindications: • Concomitant use with venlafaxine not recommended • Concomitant use with monoamine oxidase inhibitors • Allergic reactions such as rash, hives or a related (MAOIs) allergic phenomenon or within the preceeding 14 days • Bone fracture risk with SSRI/SNRI • Hypersensitivity to venlafaxine hydrochloride • Increases in blood pressure and heart rate (measurement prior to and regularly during treatment) Most Serious Warnings and Precautions: • Increases cholesterol and triglycerides • Behavioural and emotional changes, (consider measurement during treatment) including self-harm: SSRIs and other newer • Hyponatremia or Syndrome of Inappropriate antidepressants may be associated with: Antidiuretic Hormone (SIADH) with SSRI/SNRI − Behavioural and emotional changes including an • Potential for GI obstruction increased risk of suicidal ideation and behaviour • Abnormal bleeding SSRI/SNRI

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

Mairi MacKinnon

Comorbid depression and anxiety What you need to know Reviewed by Toba Oluboka, MD, FRCPC; Site Chief Addiction and Mental Health Services, South Health Campus, AHS, Calgary; Assistant Clinical Professor of Psychiatry, University of Calgary

Here are some things you need to know Between 30% and 50% of adults with major depressive disorder (MDD) also fulfill diagnostic criteria for one or more anxiety disorders: panic disorder (PD), social phobia (SP), obsessivecompulsive disorder (OCD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD). Roughly half of patients with anxiety disorders also suffer from depression.1 Among depressed youth, 25% to 50% have comorbid anxiety disorders.1 Over 80% of PTSD patients have a comorbid mental disorder (depression, anxiety, or a combination of anxiety, depression and PTSD).1 Comorbidity significantly raises the risk of suicide: one report cites a 70% increase in suicide attempts among patients with comorbid MDD and PD compared to those with MDD alone, and a four-fold higher incidence than in people with PD alone.4 Comorbid anxiety influences both the manner in which symptoms present and the approach to treatment/response of patients with mood disorders.1,3 Consequently, “anxious distress” was added as a subtype of MDD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).6 Treatment of MDD in the presence of anxiety symptoms can follow recent Canadian guidelines for MDD (with first-line serotonin reuptake inhibitors [SSRIs/SNRIs]), but dosage requirements, time to response and duration of treatment may differ.1 When there is a diagnosable anxiety disorder, the clinician is encouraged to use an antidepressant with an indication for that disorder to manage the comorbidity.1

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A .

nxiety and depression are among today’s most common mental health issues.1,2 While the two conditions frequently coexist, the comorbidity is often underrecognized in clinical practice.1,3,4 Symptoms of one disorder may obscure those of the other, and/or some symptoms (e.g. insomnia, appetite loss, motor tension, excessive worry, agitation, fatigue, difficulty concentrating) may overlap.4,5 Comorbid anxiety and depression are associated with higher recurrence, impaired academic, occupational and social functioning, increased use of medical services, greater psychosocial disability and distress, diminished quality of life and increased suicide risk. Effects can continue after treatment of the acute episode, often indicating the need for long-term intervention.1,3,4

People with comorbid anxiety may be more vulnerable to early treatment side effects (e.g. heightened body sensations such as nervousness).1,3 Thus, the recommendation is to “start low, go slow, aim high”: begin with a low dose and increase as tolerated (may take 12 weeks or more). The requisite dose may be higher for comorbid anxiety disorders (OCD, PD, PTSD), and response/remission may take longer in comparison with treatment for MDD alone.1 Research and clinical experience support the role of cognitive behavioural therapy (CBT) in the management of depressive and anxiety disorders. For severe depression, treating the depression first may enhance patient motivation/engagement; this can be followed with treatment of the anxiety symptoms. For mild to moderate depression, the suggested approach is to initiate CBT for the anxiety and, once successful, treat the depression to remission (reduce residual symptoms) in order to lower the risk of relapse and recurrence.1 Comorbidity between depression and PTSD is associated with more severe symptoms of both conditions, worse psychosocial adjustment, greater sleep difficulties and more disability days.1 First-line therapies include long-term CBT, pharmacotherapy (SSRI or SNRI) or combined antidepressants plus CBT. However, response to SSRI treatment does not generally exceed 60% and remission rates with PTSD are poor (only 20% to 30%).1 CONTINUED ON PAGE 55 JUNE 2016 • Doctor’s

Review

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

R os e F os t e r

The mental state of world le The US election spawns some alarming questions

s the Trump campaign gathers steam, so do Trump epithets. He’s been called everything from the Cheeto-Dusted Bloviator and Xenophobic

Sweet Potato to the Orange Hairball of Death and Destruction, and, more darkly, Hair Hitler and The Furor. Comedians like Stephen Colbert and Rosie O’Donnell have a simpler name for him: job security.

WHITE HOUSE PRESS OFFICE, 1961

John F. Kennedy’s judgment was impaired by the medication he took to ease the pain of Addison’s Disease.

The humour derived from Trump’s antics may serve as a protective reflex that absorbs the shock of the fear that he could actually become president. Others, including those inside the Republican party, ask if he suffers from a mental illness and even if evil can exist in otherwise healthy minds.

WHAT DO DOCTORS THINK? Many a psychiatrist, looking back on history, has attempted to blame the existence of evil on mental states by diagnosing the maladies of cruel dictators. Hitler, of course, is a favourite. As early as 1933, respected psychiatrists dedicated their lives’ work to what is known as “the psychopathography of Hitler,” diagnosing the dictator with such disparate conditions as schizophrenia, hysteria, borderline personality disorder, abnormal brain laterization, Asperger syndrome, and PTSD. Dr Nassir Ghaemi, a professor of psychiatry at Harvard Medical School who holds degrees in history, philosophy and public health, has a different view of the role that mental illness can take in determining the behaviours of world leaders. His somewhat radical thesis, put forth in his book A First Rate Madness, proposes that in times of peace, mentally healthy leaders perform well — but in times of crisis, mental illness can actually be an asset for a leader.

Donald Trump’s doctor, Dr Harold N. Bornstein, says his patient’s recent tests results were, “astonishingly excellent” — others question that statement.

leaders Dr Ghaemi sees three mental abnormalities cropping up in a host of revered leaders:, hyperthymia, cyclothymia, and dysthymia; or their more severe forms; mania, bipolar, and severe depression. He charts the presence of mental illness in historical figures by looking at symptoms, genetics, treatment, and the course taken by the illness. Churchill, Abraham Lincoln, Mahatma Ghandi, and Martin Luther King Jr., he says, were depressed, General William T. Sherman, media mogel Ted Turner, John F. Kennedy, and Hitler all experienced varying degrees of mania or bipolar states. Linking genius with madness is an idea that Aristotle speculated about 2500 years ago. At the height of the 19th century Romantic era, Italian psychiatrist Cesare Lombroso went so far as to assert that genius and insanity were inseparable. For Dr Ghaemi, desperate times call for desperate leaders. He draws attention to four key elements of mental illnesses which can, he says, accentuate leadership during crises: realism, resilience, empathy and creativity. Depression, he suggests, brings out all four of these qualities, while creativity and resilience can be found in manic illness.

Winston Churchill referred to his severe bouts of depression as “the Black Dog.” He was also noted for his high energy and huge work output, which continued into his old age. His wartime chief of staff, General Hastings, described in Churchill the classic cyclothymic per-

sonality, saying, “He’s either on the crest of the wave or in a trough … when he isn’t fast asleep, he’s a volcano.” Dr Ghaemi argues that Churchill’s depressive episodes provided him with the realism he needed to determine the level of threat posed by Germany, and the emotional experience needed to overcome despair on a global level. His mania, on the other hand, gave him energy and strength to refuse to submit to tyranny. He wrote 43 books in 72 volumes, talked incessantly, and was always plotting and planning.

UNITED NATIONS INFORMATION OFFICE, NEW YORK 1942

CHURCHILL’S FINE MADNESS

Dr Ghaemi proposes that in times of crisis mental illness is actually an asset

Winston Churchill referred to his severe bouts of depression as “the Black Dog.”

Abraham Lincoln also famously struggled with depression. In 1841, as a 32-year-old state legislator, he was intensively medicated by his physician, Dr Anson Henry. A friend commented on the future president’s mental state at the time, “The doctors say he is within an inch of being a perfect lunatic for life. He was perfectly crazy for some time, not able to attend to his business at all.” He was given mercury tablets, which he called “my blue pills,” and probably subjected to blood-letting. In 1841, he wrote, “I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth.” The acute empathy conjured by Lincoln’s depression made it impossible for him to tolerate the lack of equality for African Americans, while a powerful sense of realism allowed him to see the complexity of the political issues at work in his country. Mahatma Ghandi and Martin Luther King, who also struggled with depression through their lives, prevailed in the face of similar issues, perhaps also because of their high degrees of realism and empathy associated with depression. JUNE 2016 • Doctor’s

Review

John F. Kennedy had a hyperthymic personality that was first worsened and later improved by medication, Dr Ghaemi theorizes. JFK and his family kept his medical details secret, including the fact that he suffered from Addison’s Disease, a condition in which the adrenal glands fail to produce enough hormones. The disease severely compromised his immune system, leading to chronic intestinal disturbances and terrible back pain. He was treated with four kinds of steroids daily, as well as intramuscular procaine, barbiturates and amphetamines at his own request. Halfway through his presidency, in 1962, doctors got a better hold on what had become steroid abuse. After adjustments to his drug use, his career, which had been fraught with challenges, took a turn for the better. A victorious conclusion to the Cuban Missile Crisis was followed by crucial advances in the Civil Rights Movement. He was what his physician Dr Herbst called “a spectacular psychochemical success.” Adolf Hitler had clear manic and depressive episodes throughout his life. During young adulthood, dangerous fits of depression, during which he wandered aimlessly in the fields and forests around Linz, his hometown, alternated with euphoric moods characterized by hyperactivity, grandiosity, over-talkativeness, and decreased need for sleep. He was also plagued by obsessiveness and prone to outbursts of temper. Hitler himself refers to his depression in Mein Kampf, where he writes, “As the Goddess of Misery took me in her arms and so often threatened Adolf Hitler had clear manic and depressive episodes throughout his life.

Doctor’s Review • JUNE 2016

to break me, the Will to Resist grew, and in the end the Will triumphed.” Where medications helped JFK, they had an opposite effect on Hitler. When Kennedy’s mental health floundered as a result of drug abuse, his doctors took the reigns and corrected his treatment. Not so with Hitler, whose doctors were loathe to defy him. By 1937 methamphetamines were exacerbating the symptoms of Hitler’s bipolar disorder. Three kinds of psychoactive drugs — opiates, barbiturates and amphetamines, which were all the more potent for being administered intravenously — tipped the scales on his mental health. On one occasion in December 1942, he shouted nonstop for three hours. Twice, in 1938 and 1942, several generals tried unsuccessfully to persuade prominent psychiatrists to commit Hitler to a mental asylum. Hitler’s descent into illness, and its monstrous results, point to an important factor in whether mental illness will help or hinder in leadership: treatment. With the right treatment, mental illness can deepen a leader’s capacity for wisdom and energy. When treatment goes awry, things can go very, very wrong.

TRUMP IN HISTORY What do today’s doctors have to say about Donald Trump? According to Dr Harold N. Bornstein, Trump’s family physician, Trump recently completed a medical examination that “showed only positive results,” a strange choice of words. The doctor, who addressed his letter “To Whom It May Concern,” should indeed have given cause for concern if all his patient’s medical tests were positive. But the doctor blithely concluded that Trump’s test results were “astonishingly excellent.” Not everyone is so certain. Prominent psychologists seem to agree that Trump is a textbook case of narcissistic personality disorder, as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). “He’s so classic that I’m archiving video clips of him to use in workshops because there’s

Martin Luther King’s bipolar disease may have contributed to his “non-violent” approach to racism.

YOICHI OKAMOTO, 1966

“The doctors say Abraham Lincoln is within an inch of being a perfect lunatic for life”

no better example of his characteristics,” says clinical psychologist George Simon, who conducts seminars on manipulative behavior. Devoid of empathy, suffering from persecutory delusions, governed by feelings of omnipotence and grandiosity, and requiring excessive adulation. Trump certainly fits the bill. As with the other mental illnesses, a little narcissism can be a good thing. According to the DSM-5, “Many highly successful individuals display personality traits that might be considered narcissistic.” Pablo Picasso and Elvis Presley pulled it off admirably. But, warns the manual, when narcissistic traits become inflexible and maladaptive, they veer towards “disorder,” and have a high rate of comorbidity with other mental disorders, depressive and bipolar disorders in particular. The final decision on Mr. Trump is left to history to decide.

MEDICAL QUIPS Neither eat nor drink The only way to keep your health is to eat what you don’t want, drink what you don’t like and do what you’d rather not. — Mark Twain

V I E WP O I N T O N A D DI CT I ON

The beauty of recovery

Beyond the hell of addiction, a fresh world beckons Fardous Hosseiny, MS

IAKOV KALININ /SHUTTERSTOCK.COM

Mr. Hosseiny is a recent U of T Master of Science graduate. His principal field of study was the neuroscience of addiction. He has just completed a stint on the staff of Renascent, an abstinence-based treatment centre in Toronto, an experience that changed his attitude toward addiction.

ddiction is a brain disease. I know this. I know, for example, that the effect of cocaine originates in a region of the midbrain called the ventral tegmental area which extends to dopamine-rich regions like the nucleus accumbens, caudate nucleus and putamen, and specifically works by blocking the removal of dopamine from the synapse, which results in an accumulation of dopamine and causes that initial euphoria. To take another example, I also know that alcohol increases the effects of the neurotransmitter GABA and inhibits the neurotransmitter glutamate, causing a physiological slowdown while at the same time increasing dopamine levels in the brain to give users that feeling of pleasure. My education has taught me significant things about the role of addiction on the brain, and I am thankful for that, but it never taught me about the beauty of recovery. And let me tell you, it truly is a beautiful thing. My education taught me that recovery is a lifelong battle because of the physiological changes to the brain. It also suggested that prolonged abstinence may allow brain activity to get back to a normal level of functioning, although never really completely. It also described what cues and contexts could trigger a relapse after abstinence. But this is more brain stuff.

I would have never known he was in recovery unless he mentioned it to me, because I never knew recovery could look that good

The other side Walking into Renascent on my first day was exciting and nerve-racking, despite the warm welcome I received. A couple of days went by and nothing out of the ordinary happened until one of my coworkers made a comment about a time he remembered anxiously sitting on the corner of Sherbourne and Dundas streets waiting for his dealer to come by. Given that Renascent is an accredited treatment centre, I found this a bit unusual — then he went on to tell me he has been CONTINUED ON PAGE 55 JUNE 2016 • Doctor’s

Review

Kawartha Highlands Provincial Park features a rugged landscape of small lakes, forests and rocky barrens.

Bright water,

happy days Summer vacation in and around Ontario’s Kawarthas text and photos by Gary Crallé

ater made Peterborough. Native People first arrived in the Kawarthas region about 2000 years ago, settled here among the rivers and lakes. Many centuries later, the Iroquois and Mississaugans floated in,

and started building canoes. Then, in 1615, the first European, Samuel de Champlain, set his own canoe down on the Otonabee River after portaging south on a trail that is now Chemong Road. About 300 years later, in 1892, Edison General Electric set up hydro generators on the river and made Peterborough the first city in Canada to boast electric streetlights. “The Electric City” now also headquarters Parks Canada’s Ontario Waterways, appropriately given its location on the Trent–Severn

Waterway, a 386-kilometre-long system of canals, rivers and lakes that connects Lake Ontario’s Bay of Quinte near Trenton to Lake Huron at Port Severn. Built at the end of the 19th century and one of the longest such routes on the planet, it was intended to carry freight, but was superseded by the burgeoning railway shortly after completion. Shipping’s loss was pleasure boaters gain. With passages cut through the granite of the Canadian Shield, the waterway offers spectacular scenery not JUNE 2016 • Doctor’s

Review

the least along the more than 50 lakes in cottage country northwest of the city. Getting there, in this case, really is half the fun. Peterborough’s Lift Lock, number 21 on the waterway, is a dual hydraulic lift lock that hikes boats almost 20 metres and is the highest ever built. The Peterborough Lift Lock Visitors Centre (pc.gc.ca/eng/lhn-nhs/on/trentsevern/visit/visit12. aspx), will be joined by a spectacular new building to house the Canadian Canoe Museum (canoemuseum.ca; adults $10.50, students five to 17 $8.25), which is now down the street. Before jumping into a canoe and paddling away to a nearby provincial park, stick around for a while — this is a town with more to see every day. The whole region is in the midst of a major tart up and Peterborough is plum.

There are 18 known Eastern Wolf packs in Algonquin, possibly the park’s most famous residents

rom creative tourism, like the highly competitive Kawarthas-Northumberland Butter Tart Tour (kawarthasnorthumberland.ca/experiences/butter-tart-tour), to a larger homegrown food culture, city and region are revelling in a coming out party. Peterborough’s culinary delights are becoming a trademark of note as the city reinvents its charms.

Doctor’s Review • JUNE 2016

Lil ol’ Peterborough has one of the nation’s highest concentrations of eateries per capita, with a surprising variety of international foods, artisan chocolates, breads, pastries, brews, fruit wines and an energetic farm-to-table culinary culture including locally sourced meats and dairy. Donald Fraser offers an insider intro to wholesome edibles — with samples! — on Downtown Culinary Tours (ptbolocalfoods.ca; $35 per person, June 22 through September 21). All tours leave from the Farmers’ Market (ptbodowntownmarket.com; Wednesdays from May to October) and include stops at restaurants, bakeries and cafes that are sprinkled like surprises on a birthday cake throughout the city and beyond. At NaKed Chocolate (nakedchocolate.ca), chocolatier Warren Eley imports his ingredients from France to create shoes — quite a feat! — and other shapes. Over at Sam’s Place (downtownptbo.ca/business/sams-place), Sam Sayer considers herself neither a butcher nor a chef, “just a lover of food.” She uses humanely raised livestock to make her extra-tasty deli sandwiches. Chef Lindsey Dupuis, the owner of Brio Gusto brasserie (briogusto.com), says she prefers being in the kitchen where she humbly creates dishes for sophisticated palates. At the Olde Stone Brewing Company (oldestone.ca), brew master Doug Warren limits his inventiveness to five types of ale, the most popular being pumpkin, which many call pie in a glass. For fine dining within an hour’s drive from the city centre, there’s Elmhirst’s Resort (elmhirst.ca), a century-old family property on Rice Lake; Viamede Resort (viamede.com) features a wine tasting menu at Mount Julian, Stoney Lake; Lantern Restaurant & Grill (lanternresto.ca) also on Stoney Lake, run by husband and wife chefs Geoff and Lesley Kirkland, offers three varieties of local mushrooms, and fries served with truffle oil and black pepper (and salt too).

Bannock is a biscuit-type flat bread that’s a specialty of Aboriginal cooks.

There are plenty of canoe camping and backcountry experiences in Kawartha Highlands Park.

Park naturalist Chris Boettger displays a logger’s broadax from decades past at the Algonquin Logging Museum.

The spacious dining hall at Arowhon Pines Resort features hand-hewn logs and plenty of sunlight.

Peterborough’s dual hydraulic lifts raise boats 20 metres in the air and are the highest in the world.

The local craft beer, live music and artwork make the Canoe & Paddle Lakefieldâ&#x20AC;&#x2122;s favourite pub.

Lake Opeongo is the biggest lake in Algonquin Park and home to the Algonquin Outfitters Opeongo Store and water taxi.

Kawartha Highlands Park is ideal for tranquility and dark night skies.

ven the finest of fine dining must come to an end, especially if you came here for what has been attracting visitors since the 19th century: the provincial parks. Established in 1893 because the land wasn’t good enough for farming, Algonquin Provincial Park (algonquinpark.on.ca; $17 a vehicle per day) is the Grand Dame of the system, bigger than Prince Edward Island, and only an hour’s drive north of Peterborough. The park has wildlife galore — 279 species of birds, 45 types of mammals, 15 different reptiles, 17 amphibians and 56 varieties of fish. There are 18 known Eastern Wolf packs in Algonquin, possibly Some evenings at Killarney Lodge in the park’s most famous residents. Organized wolf Algonquin Park include lectures by howls, especially in August, are enormously popular fishing specialist Greg Betteridge. with visitors. Near the East Gate, you’ll find an outdoor Logging Museum at the 55-kilometre mark. The visitor centre, at the 43-kilometre mark, features lots of free displays. Canoeing is the top activity on many bucket lists, followed closely by fishing, and four outfitters and three historic lodges (algonquinpark.on.ca/visit/ park_lodges_outfitters) are there to see that visitors get to do that as well as other activities in rugged luxury that includes gourmet cuisine. The park also has six summer youth camps and the Algonquin Art Centre (algonquinartcentre.com) hosts informal art classes. uch of the park is unreachable except on foot or by canoe. These backwoods were the adopted park with Algonkian rock carvings plus an interpretive home of Canada’s iconic landcentre, located one hour northeast of Peterborough. scape painter Tom Thomson who Kawartha Highlands Provincial Park (ontarioparks. died in the park under mysterious circumstances, com/park/kawarthahighlands) is the new jewel in the (likely drowning) in 1917. He was 40 years old. Ontario Parks system. It’s easy to see why Tom favoured the park as a Located 50 kilometres north of Peterborough, place of beauty to replicate on canvas, especially in this is semi-wilderness for cottagers who live in the autumn when the landscape blazes with colour. The area and the urban crowd who visit. Not as established trees turn early in the park which sits on an elevated as Algonquin, it’s a park born of controversy, pitting bump of Canadian Shield granite in a unique transiestablished rural communities against the surging tion zone between northern and southern Ontario. demands of an urban populace. For GTA residents without a car, Parkbus I explored the park on a three-day canoe trip (parkbus.ca) will bring you to and from Algonquin. paddling and portaging with four expert woodsmen. The concept fittingly grew Aside from an involuntary out of a campfire discussion contribution to the mosquito by the owner operators. Priblood bank, the experience vate lodging within the park proved its worth as a fine is generally available mid-May tonic to counter my excess to mid-October at Arowhon urbanities. Don’t bother calling back Pines Resort (arowhonpines.ca), At journey’s end, we drove Bartlett Lodge (bartlettlodge. 1st man: I woke up this morning to Lakefield to celebrate padcom) and Killarney Lodge and felt so bad that I tried to kill dles and portages well done (killarneylodge.com). myself by taking 1000 aspirins. at the appropriately named Petroglyphs Provincial 2nd man: Oh really, what happened? Canoe and Paddle gastropub Park (ontarioparks.com/park/ 1st man: After the first two, I felt (facebook.com/canoeandpaddle). petroglyphs; from $11.25 a vehicle better. The Group of Seven should per day) is a small, day-use have had it so easy.

At the Olde Stone Brewing Company, the most popular type of ale is pumpkin, which many call pie in a glass

MEDICAL QUIPS

JUNE 2016 • Doctor’s

Review

Setting out on the 80-kilometre loop around the female siblings.

Circling the T

The 80-kilometre Three Sisters Loop in the Cascades near Bend, Oregon is one of the most iconic trails in the state. It climbs through old growth forests, lush alpine meadows, rock-strewn lava fields and obsidian-lined streams. Pristine lakes reflect the Sistersâ&#x20AC;&#x2122; soaring peaks. Thereâ&#x20AC;&#x2122;s an elevation change of 1800 metres, enough to put intermediate hikers through their paces, but the rewards are considerable. The best time of year to go is between June and October. Last June, the author, her partner Kalan and black pug Winnie, spent four days circumnavigating with the famous siblings.

Sisters

Four glorious days hiking Oregon’s famous volcanic trio by Tilke Elkins

JUNE 2016 • Doctor’s

Review

North Sister is an extinct volcano, Middle Sister is inactive, but South Sister last erupted 2000 years ago — and could again

hampoo. That’s what the flowers smelled like. This alpine meadow, bright with scarlet paintbrushes, purple lupines and yellow primroses clustering between black ruins of trees destroyed in a recent forest fire. The scent of these tender blooms combined with morning’s freshness and a sense of well-being was a distillation that could well have inspired the manufacturers of bottled hair froth. One of the secrets of these mountains, I thought. A delicate scent that could only come from the slow suspirations of snow-capped peaks like the ones that gazed quietly down on us. The trail left the counterpane of colour and darkened under dense pines, switch-backing upwards. Afternoon lengthened. A switch flipped, one between mildly hungry and famished. Cheer dissipated, the frayed stain of crankiness intruded. A good time to keep silent and march on, I thought. Don’t pick a fight with the end of the day. Trees thinned and a small sign indicated Golden Lake. Daggers of gold light between tree trunks turned us blue, yellow, blue as we padded along the soft path. An open bowl, a great green ballroom at the base of two conspiratorial white peaks that were pinking in the setting sun. A lake, tiny, perfect, Narnian. Grass short, as if shorn, or painted on, perfectly overlapped the lake’s edge. A stream, similarly spare, wound down the nearest slope. The whole scene a surprise for us, not on the rudimentary map we’d sketched. Exhilaration. No tent necessary, we decide. The grass is flat, there’s one rock there by the edge of the scree, a gesture of a table, something to gravitate to, lean the packs against. The pug, who’s marched bravely on for 32 kilometres, is covetous of anything soft to press her belly into. She climbs to the top of a pack as soon as it’s set down. In her book, synthetic trumps organic any day. Kalan pulls the sleep rolls out while I go looking for tinder for the stove. Dense pine islands of wind-twined and tightened needles are knit so tightly to the ground that my fuel hunt turns up only the small dark mouth of a mammal-made opening. Foxes? Pushing through the resistant green curtain I find a twig-strewn chamber laced with just what I’m looking for: thin dry sticks. The neon yellow lichen is even better, brighter than Nikes, fluorescing from thick bark that is much older than it looks, the tricks of wind-shrinkage. The new stove is light, two cans packed into each other, containers for a compact fire fed by

Doctor’s Review • JUNE 2016

whatever happens to be lying around. Sounds simple, but there’s a technique that has to be mastered to make it catch. Break twigs, no thicker than a pencil, into five centimetre pieces and stand them upright like toothpicks in the silver cylinder. A wad of sap on the lichen with some cone scales sprinkled in — light that first and rest it on the twig tops. Blow gently. After several failures — success! — and a hot meal after all.

trange, that deep yet somehow wakeful sleep under stars. Opening eyes attentively to catch the silver-spangled blackness that glowsoaked cities extinguish. Hip against a hard place, sleep returning faithfully between interludes of gratitude and incredulousness. How is it I am here? A gradual acceptance of the gentle wind, the long loom of the peak tops in the moonless shadows, a settling certainty that mountain lions have also tucked themselves in somewhere to sleep. Like human siblings, the Three Sisters, North, Middle and South, are chronologically disparate. Though arm-in-arm in convivial gladness, appearing as of-a-piece as stegosaurus crenellations, they arose at different times. North Sister, an extinct volcano, is the eldest. Middle Sister is inactive, but South Sister, the youngest, last erupted 2000 years ago and could again, keeping the United States Geological Survey on its toes. We loop the bottom of the southern mountain through patches of snow, sinking every few feet. In June the piles are scant. Upon waking, the pug took a couple of pathetic steps and paused. Her foot pads are curiously swollen. Was it the heat or the roughness of the rocks? We don’t know, but we make a sling and carry her, taking turns. A vast linear valley flanks South Sister, fields so green and flat they’d be right at home behind a high school. Instead, eventually, a long green lake. A flock of rust-bellied blue birds skims the water. And suddenly — people. Couples with babies in backpacks, teenagers, groups of athletic-looking seniors. A steady stream is hiking up for the day from a parking lot at the Green Lakes Trailhead 6.5 kilometres from the top. Some keep going all the way to South Sister’s summit and Teardrop Pool, the state’s highest lake, at the bottom of a crater rimmed with glaciers, but not us. We’re on a mission to circle the Sisters: four days, three nights, 80 kilometres. Walking here is like passing through a pack of postcards titled “Stunning Landscapes Around the

The popular loop is well-travelled and well-marked, fall hikers avoid the mosquitoes.

In June, alpine meadows are bright with purple lupines and yellow primroses.

Winnie, well-accustomed to long hikes, rests her swollen foot pads.

Sparks Lake glistens on the flanks of South Sister.

NEW

VIACORAM

En route towards BP control.

A new option in the treatment of mild to moderate essential hypertension in initial therapy In an 8-week study, VIACORAM® 3.5 mg/2.5 mg • Demonstrated superiority vs. placebo, perindopril arginine 3.5 mg and amlodipine 2.5 mg on reducing SBP (secondary endpoint)/DBP: mean change from baseline to last post-baseline value* was -22.0/-13.6 mmHg for VIACORAM® 3.5 mg/ 2.5 mg vs. -14.2/-9.3 mmHg, -16.3/-9.7 mmHg and -16.0/-10.3 mmHg for placebo, perindopril arginine 3.5 mg and amlodipine 2.5 mg, respectively; p<0.001 for all.1†‡

3.5 mg / 2.5 mg

• Demonstrated non-inferiority vs. perindopril arginine 5 mg and amlodipine 5 mg on reducing SBP (secondary endpoint)/DBP: mean change from baseline to last post-baseline value* was -22.0/-13.6 mmHg for VIACORAM® 3.5 mg/ 2.5 mg vs. -18.2/-10.5 mmHg and -21.8/-12.6 mmHg for perindopril arginine 5 mg (p<0.001) and amlodipine 5 mg (p=0.003/p<0.001), respectively.1†§

mg mg perindopril arginine/ amlodipine

• Demonstrated better controlled rate (secondary endpoint) (SBP<140 mmHg and DBP<90 mmHg) vs. perindopril arginine 5 mg (43.5% versus 33.3%, p=0.018, 95% CI: [1.8; 18.5]) and a trend toward a better controlled rate than amlodipine 5 mg (43.5% versus 37.9%, p=0.202, 95% CI: [-3.0; 14.1])1‡

mg mg perindopril arginine/ amlodipine

VIACORAM® (perindopril arginine/amlodipine) is indicated for the treatment of mild to moderate essential hypertension in patients for whom combination therapy is appropriate. VIACORAM® 3.5 mg/2.5 mg is indicated for initial therapy in patients with mild to moderate essential hypertension. VIACORAM® is not indicated for switching therapy from the individual drugs currently on the market (perindopril as erbumine or arginine salt, amlodipine). Dosages of the perindopril arginine in VIACORAM® are not marketed individually. Patients cannot be titrated with the individual drugs currently on the market prior to the initiation of VIACORAM, since dosages of perindopril arginine in VIACORAM are not equivalent to those marketed individually (perindopril as erbumine or arginine salt).

Available in three dosage strengths perindopril arginine/ amlodipine

7 /5

14 /10

INDICATED IN INITIAL THERAPY

3.5mg Perindopril arginine / 2.5mg Amlodipine

The ONLY antihypertensive medication that combines an ACEi (perindopril arginine) and a dihydropiridine CCB (amlodipine besylate)1¶ Clinical use not discussed elsewhere in the piece VIACORAM® is not indicated for the initiation of treatment in elderly patients (>65 years of age). There are not sufficient clinical experience to justify the use in these patients. VIACORAM® is not indicated in pediatric patients <18 years of age. The efficacy and safety have not been studied in this population. Contraindications VIACORAM® is contraindicated in: • Patients who are hypersensitive to the active ingredients of this drug, to any ingredient in the formulation or component of the container, to any other angiotensin converting enzyme inhibitor (ACE-inhibitor), or to any other dihydropyridine derivatives • Patients with renal impairment (creatinine clearance <60 ml/min) • Patients with a history of hereditary/idiopathic angioedema, or angioedema related to previous treatment with an ACE-inhibitor • Pregnant women or planning to become pregnant • Nursing women • Patients with mitral valve stenosis and left ventricular outflow tract obstruction (e.g., aortic stenosis, hypertrophic cardiomyopathy) • Patients with heart failure. • Concomitant use of angiotensin converting enzyme (ACE) inhibitors, including VIACORAM®, with aliskiren-containing drugs in patients with diabetes mellitus (type 1 or 2) or moderate to severe renal impairment (GFR<60ml/min/1.73m2) • Patients with hereditary problems of galactose intolerance, glucose-galactose malabsorption, or the Lapp lactase deficiency as VIACORAM® contains lactose • Patients with extracorporeal treatments leading to contact of blood with negatively charged surfaces • Patients with bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney

any time during therapy. Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, it may be fatal; emergency therapy should be administered promptly. Syndrome starting with cholestatic jaundice and progresses to fulminant hepatic necrosis: May lead to death. Use with Low-Density Lipoproteins (LDL) apheresis: May lead to life-threatening anaphylactoid reactions.

Other relevant warnings and precautions • Caution in driving a vehicle or performing other hazardous tasks • Co-administration of ACE inhibitors, including the perindopril component of VIACORAM®, with other agents blocking the RAS, such as ARBs or aliskirencontaining drugs, is generally not recommended in patients other than patients with diabetes mellitus (type 1 or type 2) and/or moderate to severe renal impairment (GFR<60ml/min/1.73m2) as it is contraindicated in these patients • Risk of hypotension; closely monitor patients at high risk of symptomatic hypotension. Similarly monitor patients with ischaemic heart or cerebrovascular disease; an excessive fall in blood pressure could result in a myocardial infarction or cerebrovascular accident • Risk of mild to moderate peripheral edema • Safety and efficacy of VIACORAM® in hypertensive crisis have not been established • Risk of angina worsening/acute myocardial infarction after starting therapy or dose increases • Risk of hyperkalemia; monitor serum potassium periodically • Risk of neutropenia/agranulocytosis, thrombocytopenia and anemia • Increases in serum transaminase and/or bilirubin levels, cholestatic jaundice, cases of hepatocellular injury with or without cholestasis • Not recommended in patients with impaired liver function Most serious warnings and precautions • Angioedema • Risk of anaphylactoid reactions during desensitization or Pregnancy: When used in pregnancy, angiotensin membrane exposure (hemodialysis patients) converting enzyme (ACE) inhibitors can cause injury or even death of the developing fetus. When pregnancy • Risk of nitritoid reactions in patients on therapy is detected, VIACORAM® should be discontinued as with injectable gold soon as possible. • Patients undergoing major surgery or during anesthesia with agents that produce hypotension Hyperkalemia (serum potassium >5.5 mEq/L): Can cause serious, sometimes fatal arrhythmias; serum • Black patients vs. non-blacks potassium must be monitored periodically in patients • Not recommended in patients with a recent kidney transplantation receiving VIACORAM®. Concomitant use with potassium supplements, potassium-sparing diuretics, or potassium- • Risk of changes to renal function in susceptible containing salt substitutes is not recommended. patients; potassium and creatinine should be monitored in these patients Collagen vascular disease, immunosuppressant therapy, treatment with allopurinol or procain- • Risk of cough amide, or a combination of these complicating • Dermatological reactions factors (especially if there is pre-existing impaired • Not indicated for the initiation of treatment in the renal function): May lead to serious infections, which may elderly (>65 years) patients; not recommended in not respond to intensive antibiotic therapy. If VIACORAM® pediatrics (children <18 years of age) is used in such patients, periodic monitoring of white blood • Patients with diabetes treated with oral antidiabetic cell counts is advised and patients should be instructed agents or insulin, glycemic control should be closely to report any sign of infection to their physician. monitored during the first month of treatment with VIACORAM® Angioedema: May be life-threatening and occur at • Patients with unilateral or bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney • Sexual function/reproduction For more information Please consult the Product Monograph at http:// webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for uncomplicated essential hypertension important information relating to adverse reactions, (i.e., not at high cardiovascular risk and without target organ damage, supine 95 ≤DBP <110 mmHg and 150 ≤SBP drug interactions, and dosing information which have <180 mmHg, mean baseline SBP/ DBP was 161/101 mmHg) received not been discussed in this piece. treatment with perindopril arginine 3.5/amlodipine 2.5 mg (n=246), The product monograph is also available by calling us perindopril arginine 3.5 mg (n=268), perindopril arginine 5 mg (n=270), amlodipine 2.5 mg (n= 270), amlodipine 5 mg (n=261), or placebo (n= 248). at 1-800-363-6093. References: 1. Servier Canada Inc. VIACORAM® Product Monograph. February 17, 2016. 2. Laurent S et al. Randomized evaluation of a novel, fixed-dose combination of perindopril 3.5 mg/amlodipine 2.5 mg as a first-step treatment in hypertension. J Hypertens. 2015; 33(3):653-661. BP=blood pressure; SBP=systolic BP; DBP=diastolic BP; ACEi=angiotensin converting enzyme inhibitors; CCB=calcium channel blockers * For patients with a last post-baseline value not under treatment but with a post baseline value under treatment, the last post-baseline value under treatment was taken into account. † 8-week multicenter, international, randomized, double-blind, placebocontrolled, parallel group factorial study in patients with mild to moderate

The primary efﬁcacy endpoint was changes in supine DBP from baseline to last post-baseline visit. Baseline supine SBP (mmHg): VIACORAM® (161.8/100.7), placebo (161.0/100.5); perindopril 3.5 mg (161.4/100.7); amlodipine 2.5 mg (161.2/100.6); perindopril 5 mg (160.7/100.1) and amlodipine 5 mg (162.3/100.6). ‡ Superiority tests of perindopril 3.5/amlodipine 2.5 as compared to reference treatment (placebo, perindopril 3.5, amlodipine 2.5); one-sided type I error rate: 0.025. § Non-inferiority tests of perindopril 3.5/amlodipine 2.5 as compared to reference treatment (perindopril 5, amlodipine 5); Non-inferiority limit: 2 mmHg for DBP -3 mmHg for SBP; one-sided type I error rate: 0.025. ¶ Comparative clinical signiﬁcance has not been established. ® VIACORAM is a registered trademark of Servier Canada Inc.

World.” Every corner offers a different variety of gorgeous, a deliciously variable palette of intimate tawny meadows, turquoise, indigo and slate-grey lakes. We strip down, leap in and, for a micro-second, the icy water envelopes us. Compressed forested vistas reach to the far horizon. A rolling valley dotted with massive odd-shaped boulders evokes a heraldic scene out of Game of Thrones and seems incomplete without jauntily flying coloured flags and horses in gaudy face masks.

R .

ain from the coast drops when clouds encounter the west side of the Sisters, leaving the east side, where we started, dry, and the west side, where we finish, lush with plants and pools — and mosquitoes. The legendary swarms keep people away all summer, which is why, we guess, the hiking trails are nearly empty. The guidebooks say, don’t go until late August when the bugs are gone, but this is June and the solitude seems worth all the buzzing even when it amplifies at dusk. Lucky for us they can’t get through our head net. The smoke from our stove helps too. Ten kilometres to go and the bottoms of my feet are nearly as swollen as the pug’s, who we’re still carrying. My boots have a thin sole, no more than a centimetre thick, and I’m finally feeling it. We’ve eaten all our food, including the last boiled egg and sheets of nori. Eerie white ghost flowers we’ve affectionately dubbed “toilet brushes” line the wooded path which is increasingly patterned with shards of black glass, made when lava rose to the surface without meeting with water first. The obsidian sparkles through the duff. It’s dusk when we make it back to the McKenzie Highway. Our car is parked a few miles down the road, but I can’t take another step. Kalan sticks his thumb out while I slump on my backpack and the pug shivers. At last, a pickup truck pulls over, motions us in and we’re flying along blissfully, wind in our hair, back to our own vehicle, back to the bag of potato chips we left on the passenger seat for our returning selves, back to the extra-large pizza we order from the road and devour in the car when we finally make it, at 9:30pm, back to the crowded lit-up streets of downtown Eugene, back to our memories of the days spent with the Sisters, which will grow into longing until we return.

Servier Canada Inc., 235 Armand-Frappier Boulevard Laval, Quebec, H7V 4A7, 1-888-902-9700 JUNE 2016 • Doctor’s

Review

Indications And Clinical Use: Adults: TARGIN® (oxycodone hydrochloride/naloxone hydrochloride) is a controlled release tablet having a dual therapeutic effect. The oxycodone component in TARGIN® is indicated for the management of pain severe enough to require daily, continuous, long-term opioid treatment, and that is opioid-responsive and for which alternative treatment options are inadequate. The naloxone component in TARGIN® is indicated for the relief of opioid-induced constipation (OIC). TARGIN® is not indicated as an as-needed (prn) analgesic. Not recommended for use in patients <18 years of age. Select dose cautiously in elderly patients, usually starting at the low end of the dosing range. Contraindications: • Known or suspected mechanical gastrointestinal obstruction or any known condition that affects bowel transit • Rectal administration • Suspected surgical abdomen • Mild, intermittent or short duration pain that can be managed with other pain medications • Management of acute pain • Management of perioperative pain • Acute asthma or other obstructive airway, and status asthmaticus • Acute respiratory depression, elevated carbon dioxide levels in the blood, and cor pulmonale • Acute alcoholism, delirium tremens, and convulsive disorders • Severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury • MAO inhibitor use • Pregnancy, labour and delivery, breast-feeding • Opioid-dependent patients and for narcotic withdrawal treatment • Moderate to severe hepatic impairment Most Serious Warnings And Precautions: Limitations of use: Should only be used in patients for whom alternative treatment options are ineffective, not tolerated, or would be otherwise inadequate to provide appropriate management of pain. Addiction, abuse, and misuse: Assess patient risk prior to prescribing; monitor all patients regularly; store TARGIN® securely. Life-threatening respiratory depression: May occur with TARGIN® use. Monitor patients for respiratory depression, especially during initiation or following dose increases. Must be swallowed whole. Cutting, breaking, crushing, chewing, or dissolving TARGIN® can lead to rapid release and absorption of a potentially fatal dose of oxycodone. Accidental exposure: Serious medical consequences, including death, may occur, especially in children. Neonatal opioid withdrawal syndrome: Can result from prolonged maternal use during pregnancy. Administration: Must be swallowed whole. Broken, chewed, dissolved, or crushed tablets could lead to rapid release and absorption of a potentially fatal dose of oxycodone. Do not administer rectally. 40/20 mg tablets: For opioid-tolerant patients only. Medication sharing: Patients for whom TARGIN® is prescribed should not give TARGIN® to anyone else. Constipation: Not for patients with constipation not related to opioid use. Patients currently taking oral oxycodone: Switch to TARGIN® based on an equivalent oxycodone dose. Conversion from other opioids/opioid preparations: Initiate at the lowest available strength, provide adequate rescue medication, with dose titration to achieve satisfactory pain relief with acceptable side effects. Maximum dosage: Single doses should not exceed 40/20 mg. Maximum daily dose is 80/40 mg. Other Relevant Warnings And Precautions: • 5/2.5 mg tablets are intended for titration and dose adjustment • Do not consume alcohol • An oxycodone dose reduction or change in opioid may be required in hyperalgesia • Use in peritoneal carcinomatosis • Potential diarrhea • Marked withdrawal symptoms if abused rectally, intravenously or intranasally • Withdrawal symptoms after abrupt discontinuation of therapy • Dependence/tolerance • Not approved for managing addictive disorders • Use cautiously in patients receiving other CNS depressants • Increased respiratory depression in patients with head injuries • Use cautiously in patients with pre-existing cardiovascular conditions • Psychomotor impairment: Advise patients that TARGIN® may impair mental and/or physical ability required for the performance of potentially hazardous tasks especially when starting TARGIN®, when dose has been adjusted, and receiving other CNS-active drugs. Patients should be advised not to drive a car or operate machinery unless they are tolerant to the effects of TARGIN® • Administer with caution and at reduced dosage to debilitated patients, and patients with Addison's disease, cholelithiasis, hypotension, hypothyroidism, mild hepatic impairment, myxoedema, renal impairment, toxic psychosis, prostatic hypertrophy or urethral stricture • Disposal and security: Unused or expired TARGIN® should never be thrown into household trash, where children and pets may find it. Return to pharmacy for proper disposal. Should be kept under lock and out of sight and reach of children and pets. Adverse Events: Adverse events often observed with other drugs with opioid-agonist activity were also seen with TARGIN®. The most frequently observed were nausea, which tends to reduce with time, as well as constipation, diarrhea, fatigue, headache and hyperhidrosis. For More Information: Please consult the Product Monograph at http://www.purdue.ca/files/2014-08-05_Targin-pm-mktg-eng.pdf for important information relating to adverse reactions, patient counselling, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-387-5349. References: 1. TARGIN® Product Monograph, Purdue Pharma, August 2014. 2. Purdue Pharma, letter on file, September 25, 2014. 3. Cloutier C et al. Controlled-release oxycodone and naloxone in the treatment of chronic low back pain: A placebo-controlled, randomized study. Pain Res Manag. 2013;18(2):75-82.

You can rent a kilt and sporran at the Kierland in Scottsdale if you really want to get in the Celtic swing of things.

Golf with benefits Six courses with innovative perks that’ll change the way you play — and pay for — the game by Anita Draycott

he golf industry in North America has been in a slump since the economic meltdown of 2008. Too many golf courses are too long, too tough and too expensive for the average handicapper. But there is light at the end of the fairway. A number of courses are offering golfers extra perks and innovative ways to both speed and spice up the game. JUNE 2016 • Doctor’s

Review

ARIZONA

Segway in a kilt If the 27 fairways at the Westin Kierland Resort & Spa (kierlandresort.com) aren’t challenging enough, try tackling them on a Segway while wearing a kilt. It’s the only resort in Scottsdale where golfers can opt to ride the three desert nines — Acacia, Ironwood and Mesquite — on Segways, bicycles or GolfBoards (motorized “surf the earth” boards) customized to hold your bag. If you really want to get into the Celtic swing of things, try the Scottish Experience and play your round in a rented kilt and sporran, laddie. After the game, retire to the Scotch Library for a tasting and freshly rolled cigar. Friday Night Lights (in spring and fall) offers fun for all ages on the driving range: golf contests, clinics with pros, a nine-hole glow putt course, music and beverage cart service. Admission is US$10 per person, kids under six free when accompanied by a paying adult. In keeping with the Scottish theme, a piper clad in full Highland regalia squeezes the bagpipe every evening at sunset on the Dreamweavers Canyon patio. Now you know why Golf Digest named Kierland “one of the most cheerful courses in America.” The Ultimate Golf for Two package starts at US$219 through August. In addition to unlimited golf for two at 27 holes, climate-controlled golf carts and Segway golf are included.

Kierland resort was the first in the US to offer Segways to manoeuvre around a golf course.

At Keirland in Scottsdale, golfers can ride the three desert nines on Segways or GolfBoards customized to hold their bag

The three courses at Kierland, Acacia, Ironwood and Mesquite, are named after the indigenous plants found on-site.

Doctor’s Review • JUNE 2016

There are views of the Pacific from every hole at the Jack Nicklaus-designed golf course at Quivira in Los Cabos.

The all-inclusive experience at Quivira features Baja cuisine at its multi-storey clubhouse.

MEXICO

Eat and play Los Cabos has become one of Mexico’s finest golf destinations. Nowhere else do craggy mountains and desert palettes meet the cobalt Sea of Cortez to create such a compelling backdrop for verdant fairways. The most spectacular public course is Quivira (quiviragolfclub.com). With a view of the Pacific from every hole, Quivira has more oceanfront exposure than any other course in Los Cabos. From December to March, you’re likely to spot whales leaping in the wild blue yonder. An all-inclusive golf day here starts with complimentary shuttle service to the club from the Pueblo Bonito resorts. Warm up on the range where a full array of beverages is available. Light bites like tuna sliders and fish tacos are also served. After the first four holes, golfers will experience the “greatest drive in golf” as they manoeuvre their carts to the first snack station perched 200 feet above the ocean. You’ll need fortification to tackle the 5th hole. The fairway, slanted below a shouldering dune on the right, 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. The putting surface is defended to

During their round, players can get refreshments at Quivira’s “Oasis” situated near the eighth green.

the left by a huge deep bunker. Long hitters can attempt to drive it, but it’s adios if you miss the rockwalled, cliff-hanging green. The Oasis, which serves as a halfway house for golfers transitioning from the 8th and 11th holes, showcases the culinary talents of the resort’s chefs with inventive takes on classic Baja cuisine. Players may refresh themselves again at the 16th tee, which sits high above the course and marks the layout’s return to home. You have to be a guest of one of the four Pueblo Bonito Oceanfront Resorts and Spas to play Quivira. This summer’s Stay and Play packages start at US$329. JUNE 2016 • Doctor’s

Review

Go fish Re-opening this summer, the previously private Sagebrush (sagebrushlife.com) near Merritt, BC is now a public course managed by Troon. It’s part of a new evolution of minimalist/naturalist courses meaning that Mother Nature has designed the layout with limited dirt moving. In this case, the land is part of a sprawling cattle ranch where Nicola Lake and surrounding mountains cradle the course. Rod Whitman, who also designed Cabot Links in Cape Breton, NS, has created a course that tumbles and rolls with natural rhythm. The bent grass greens are huge and the generous fairways are seeded with fescue to be hard and fast with authentic links-style playability. Bump and run is encouraged and rewarded. With ragged dunes and bunkers that chew into landing areas, your score at Sagebrush will depend on the wind and hole locations on what might be the biggest and most tumultuous greens you’ll ever play. Because of Sagebrush’s remote location (three hours from Vancouver), golfers are encouraged to take their time. The green fee ($175) gets you unlimited golf for the day and there are no tee times. Aside from the 7400-yard course, golfers can try their luck fly-fishing for feisty Kamloops Rainbow Trout when they stop for refreshments at the pond The Sagebrush Club in the Nicola Valley outside of Vancouver will reopen this season with numerous upgrades.

Golfers can fish for rainbow trout when they stop for refreshments between Sagebrush’s 12th and 13th fairways.

Doctor’s Review • JUNE 2016

between the 12th and 13th fairways. The new Tap House offers craft beers, fine wines, and gourmet dogs and burgers. Unlike some golf courses where you have to rush your “halfway house” visit, at Sagebrush you can pause for as long as you want. The “Sagebrush Experience” starts at $800 per person (minimum four) and includes three days of unlimited golf, two nights accommodation in a twobedroom suite and two dinners.

Golfers can manage their schedules by playing 18 holes over seven days HAWAII

Break the rules Ka’anapali (kaanapaligolfcourses.com), once the playground of Hawaiian royalty, was the first planned resort community in Hawaii. For years Ka’anapali beamed gorgeous tropical scenery into the homes of TV viewers with the broadcast of the Senior PGA Tour’s Ka’anapali Classic, making them want to grab their clubs and fly to paradise. Today, there are more reasons to take a swing at Ka’anapali’s two 18-hole courses, the Royal and the Kai. Golf Inc. magazine recently called general manager Ed Kageyama, one of the “Most Innovative People in Golf.” His programs include Golf My Way that allows golfers to play 18 holes over seven days. For example, an avid swinger could play four holes while the family is asleep, return for a few holes after an afternoon at the beach, then play a few holes another day before dinner. Also new to Ka’anapali are motorized GolfBoards to carry your clubs. The one-passenger vehicles combine elements of snowboarding, surfing and skateboarding, and users guide their vehicles by leaning into turns. Named “Best New Product” at the 2014 PGA Merchandise Show, GolfBoards provide traction on steep hills and allow golfers to traverse the course more quickly. After 3:30pm, Ka’anapali has introduced FootGolf played with soccer balls that are kicked into 21-inch cups dug into the rough. It’s US$15 per person plus US$5 for the ball and has proven to be a family hit. Ka’anapali’s Breakfast Fore Two package starts at US$489 and includes one night of accommodation, one round of golf for two, rental clubs and breakfast.

Help your OAB patients fight the urge

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

The Fairmont Banff Springs course winds along the Bow River under the snow-capped peaks of Sulphur Mountain and Mount Rundle.

the antique technology. Tip: bring along some vintage duds for a photo op. The “Heritage Golf Experience” starts at $369 per person or $699 per twosome (minimum of two golfers per tee time booked). Tee times must be booked seven days in advance.

If you don’t have time for nine or 18 holes, you can play as few as one At Banff Springs golfers can play with hickory-shafted clubs like those used in the 1930s.

NOVA SCOTIA

Pay by the hole

ALBERTA

Swing back in time In 1928, Stanley Thompson was hired to design the Fairmont Banff Springs Golf Course (fairmont. com/banff-springs/golf) in Alberta’s Rockies. Banff was the first track on the planet to cost more than one million dollars to construct. Today, it’s one of the top ten courses in the world, with the Devil’s Cauldron signature hole touted as one of the best. In 1989, the course was re-routed, and to celebrate its 75th anniversary, architect Les Furber upgraded the green sites and restored the bunkers to the original design. Banff’s Heritage Golf Experience allows you to play the course as Thompson originally routed it — and with the appropriate equipment in tow. For the ultimate 1930s-style round, your caddie, clad in period plus-fours, will help you chose from a selection of hickory-shafted clubs, including a brassie, spoon, jigger, mashie and niblick. You’ll also get three balls pressed to replicate those gutta percha orbs used in the 1930s and some tips on how to swing your mashie. For your Heritage round, the distance from the tips has been reduced from 7083 to 6301 yards to compensate for

Doctor’s Review • JUNE 2016

At the Links at Brunello (thelinksatbrunello.com), 15 minutes from Halifax in Timberlea, Nova Scotia, I discovered not only a fabulous new course designed by Canadian architect Thomas McBroom, but also some smart marketing ideas. Brunello’s Advantage Card allows golfers to buy a package that suits their budget and schedule. The bronze card costs $650 for 10 mid-week rounds; the platinum $1950 for 30 rounds anytime. All packages cost less than regular green fees, which range from $95 to $125. The Advantage Cards are fully transferable so your friends, family members and business associates can play on your card with your permission. You don’t have to accompany them. Another innovation is the opportunity to play by the hole. If you don’t have time for 18 or even nine, you can play as few as one. Your card will be charged accordingly. If you don’t have a card, you can pay $7 per hole. Mortensen and his team understand the importance of introducing the next generation of golfers to the game so they’ve created a comprehensive Junior Academy program to teach kids starting at age five. They offer rental clubs to juniors at no cost. There are five regular tee blocks from which to choose with the forward tees set at 5271 yards. In addition, there are four “4Fun” tees for beginners ranging from 1118 to 2216 yards. Thomas McBroom’s design, named “3rd Best New Course in North America” by Golf Digest magazine, winds its way through stands of pines and over wetlands and rocky outcroppings. Big greens, wide fairways and only 38 bunkers are all part of the plan to make golf at Brunello fun, fast and playable.

Covered in 8 out of 10 provinces with special authorization*

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

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

Indication and clinical use: MYRBETRIQ® (mirabegron) is indicated for the treatment of overactive bladder (OAB) with symptoms of urgency, urgency incontinence and urinary frequency. • Safety and efﬁcacy in pediatric patients have not been established. •

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

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

1†

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

For more information: Please consult the Product Monograph at http://www.cmsastellas.ca/uploads/pdf/2015-12-17%20 Myrbetriq%20English.pdf for more information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-888-338-1824. Reference: 1. Astellas Pharma Canada, Inc. MYRBETRIQ® Product Monograph, 2015.

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

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

Namibia wild Two men. One hike. Hundreds of cackling baboons. To run or not to run?

JT PLATT / SHUTTERSTOCK.COM

by Gerald Yeung

Doctor’s Review • JUNE 2016

The southern part of Naukluft Mountains belong to Namib-Naukluft National Park; the northern part is occupied by privately held farms.

amibia was founded on two indisputable truths. One: it never rains. Thus I lose my favourite excuse to opt out of a hike. Two: every Asian person is Bruce Lee. These two random facts play pivotally in the attack of the baboons.

STYVE REINECK / SHUTTERSTOCK.COM

Baboons prefer rocky mountain areas and live in hordes of 20 to 100 in a strict hierarchy with one leading male.

MICHEL PICCAYA / SHUTTERSTOCK.COM

The 17-kilometre-long Waterkloof Trail winds through the rocky outcrops, deep river valleys and freshwater springs of Naukluft Mountains.

The Waterkloof Trail, which exists only in a theoretical sense, consists of 17 kilometres of yellow markers. My friend Bearcat and I are told to follow them religiously. “Oh, and take this map, too,” says one of the park rangers. On a crumpled piece of paper he sketches a crooked circle and scribbles small words along the perimetre. This is a Picasso of maps and a leap of faith to follow. Our hike begins on a high note. We talk, we laugh and we trap tadpoles in our baseball caps. With Taylor Swift blasting on my iPod, I am having the time of my life. “You smell that?” I ask, navigating through a thicket of tall grass. “Smells like piss.” “Really strong piss.” “It’s getting worse.” When I can find nothing comical to say about this pungency, a sense of urgency ensues. We inspect our shoes for rhinoceros diarrhea and find none. Then we scan for lurking predators, recalling from a recent game drive that it is a male lion’s territorial nature to urinate on everything. No lions. Good. Then we identify the source: a rotting zebra. I dart away from the carcass before my breakfast returns as projectile vomit. My previous craving for zebra steak has evaporated, but Bearcat has already removed his pocketknife. “What cut would you like for lunch?”

Doctor’s Review • JUNE 2016

We continue and the midpoint marker materializes after a protracted climb. We feast on Goldfish, apples, tangerines and beef jerky while mesmerized by the landscape beneath. This place has a natural sense of order to it. “You think they have Wi-Fi up here?” I ask. “Probably not.” “O.K.”

O .

nly three hours in and a record-breaking finish looms. Encouraged, fed and rested, we begin our descent, fearless and unsuspecting. But much to our irritation, the yellow markers, aplenty thus far, have developed a newfound penchant for hiding. I haven’t had to look for anything so hard since Where’s Waldo? In Hollywood. Also, good vision, I discover, doesn’t come easier with age. Neither does patience. With our confidence sky high and patience wearing thin, we invent our own shortcut. It takes us around a hill through human-sized thorn bushes and then down a waterfall on algae-slick rocks. We blaze through every improbable opening, driven by the intangible concept of “manhood” and the unthinkable concept of turning back. When we stumble into a dreamlike cove borrowed from the movie Avatar, it finally hits us — we are lost. Recognizing the severity of our stupidity, we backtrack desperately up the hill. Forty minutes later, the sacred yellow marker reappears.

Baboons are scavengers and for the most part herbivores, but they’ll make prey of vulnerable animals if required.

ARTUSH / SHUTTERSTOCK.COM

WALKING THE WATERKLOOF TRAIL

“I never once doubted our abilities,” I announce. Bearcat takes a celebratory dip in the river, very much bearlike. I can’t tell if he is trying to cool off or catch salmon. But his victory lap proves premature. The river leads us to a valley tucked between two towering cliffs — the proud home of hundreds of baboons. When their piercing war cries descend upon us, our immediate reaction is denial. “It can’t be because of us,” I plead to the air. “We just got here. Besides, we humans are distant relatives, honoured guests who have travelled from afar to visit.” But with each measured step we take, the cacophony explodes tenfold. There is no turning back now, not without backtracking 13 kilometres and getting lost again. Alternatively, if we can somehow explain our situation to these estranged cousins — perhaps mention an ailing grandfather — will they commiserate and let us through? But how do we do this? With our eyes? “Don’t look them in the eye,” warns Bearcat. He removes his baseball cap to wipe his forehead. If I were the volatile drama queen in our partnership, Bearcat would be the cool-headed ranger in good times and bad. Now though, his expression betrays raw fear. Make no mistake, death is a distinct possibility here, if not from direct attack, then certainly from subsequent infection. (Fun fact: Untreated rabies can lead to coma and death.) I take his expression as a cue to pick up something sharp and put an angry rap song on my iPod. Where

The Waterkloof Trail is a 17-kilometre, circular route in Namib-Naukluft National Park. It generally takes six to seven hours to complete and is suitable for untrained hikers, though there is a steep climb or two. A guide is recommended because the route isn’t always clearly marked and hikers can get lost easily. April to October are the cooler months of the year. The base camp is southwest of Büllsport in the Sossusvlei region. Camping and a permit for the trail cost around $10 per person. For more info: info-namibia.com/activities-and-places-of-interest/ sossusvlei-and-surrounds/waterkloof-trail.

is the face paint when you need it? Being called “Bruce Lee” by everyone in Africa used to annoy me; now it offers a possible escape. Would my Asian heritage demand the same respect from King Baboon? I am mortally scared of combat. Shaken though I am, I can smell a character-defining opportunity. Will this be the grand stage where my untried whitebelt karate moves wow the world? Or, at the other extreme, a zoological experiment to see if I can outrun a baboon? Bearcat and I exchange a knowing nod and take the brave first step. I resist the urge to peek behind my shoulder for fear of coming across as weak. As the baboons’ bellows of rage reach a crescendo, the past reading I’ve done on survival springs to mind.

ungle survival, especially on the subject of predatory encounter, has long been a hot topic. Countless literature and academic research, which likely includes several Ph.D. theses, have offered differing views on what to do and what not to do. Yours truly happens to have a massive appetite for such information. Peter Allison, author of two candid African safari guides, said it all in his book title, Whatever You Do, Don’t Run. According to wildlife experts, animals often mock charge to see if you flinch. The best thing to do in these situations, they all claim, is to simply stand tall. “Food runs,” Allison’s friend Alpheus cunningly puts it, “and there is nothing [in the wild] you can outrun anyway.” JUNE 2016 • Doctor’s

Review

T:2.125” S:1.875”

MOGENS TROLLE / SHUTTERSTOCK.COM

Refer to the page in the bottom icon for additional safety information and a web link to the Product Monograph discussing:

In addition to baboons, hikers may encounter mountain zebras, klipspringers (rock-climbing antelope) and kudus (woodland antelope, pictured here).

Inaction was Allison’s recipe to surviving a standoff against two male lions. When I was reading his encounter from the safety of my couch, it made a world of sense to me. “Just. Stand. There.” I’d repeated to myself, sipping warm Ovaltine. I mean, shit, how hard can that be?

• The most serious warnings and precautions regarding limitations of use; addiction, abuse, and misuse; life-threatening respiratory depression; accidental exposure; neonatal opioid withdrawal syndrome; administration including must be swallowed whole; 40/20 mg tablets for opioid-tolerant patients only; use by patient only; not for patients with constipation not related to opioid use; patients currently taking oral oxycodone; conversion from other opioids/opioid preparations; maximum dosage

T:10”

• Other relevant warnings and precautions regarding use of 5/2.5 mg tablets for titration and dose adjustment; do not consume alcohol; dose reduction or change in opioid may be required in hyperalgesia; peritoneal carcinomatosis; potential diarrhea; marked withdrawal symptoms if abused; withdrawal symptoms after abrupt discontinuation; dependence/ tolerance; not approved for managing addictive disorders; use cautiously in patients receiving other CNS depressants; increased respiratory depression in patients with head injuries; use cautiously in patients with pre-existing cardiovascular conditions; psychomotor impairment; administer with caution and at reduced dosage to debilitated patients, and patients with Addison’s disease, cholelithiasis, hypotension, hypothyroidism, mild hepatic impairment, myxoedema, renal impairment, toxic psychosis, prostatic hypertrophy or urethral stricture; disposal of TARGIN®

S:9.75”

ast-forward two months and here I am in Naukluft National Park, presented with the opportunity of a lifetime to prove just that. For all the discipline with which I committed Allison’s words to memory, it takes one swift glance at a baboon’s fearsome teeth to swing my pendulum of indecision. In A Walk in the Woods, Bill Bryson offered a more cynical approach. “If you are in an open space with no weapons and a grizzly comes for you,” Bryson wrote, “run. You may as well,” he added, “if nothing else, it will give you something to do with the last seven seconds of your life.” To run or not to run, that is the question. Do I bet on expertise derived from years of field experience or side with my vulnerable literary idol? In the end, I choose the latter; the coward in me relates to Bryson’s human shortcomings. Besides, being the elder of the two, Bryson has a longer track record of survival. In times like this, trust the numbers. The baboons jump and wail and flail their arms. Then finally, the army charges our way. I freeze on the spot, moving only my arm to reach for Bearcat. “It has been an honour” is what I would have said had I not been so busy crapping my pants. Then, a miracle. They halt three metres short of our defense line. They hover back and forth behind an invisible fence. I can see aggression draining from their faces. Then slowly and reluctantly, they move on. Perhaps they sensed my readiness to fight them to the bitter end. Or perhaps they knew better than to mess with Bruce Lee. The moment Bearcat and I reach the other end of the valley, we toss our weapons and sprint up the hill to safety. Just like that, a showdown between primates is averted. And just like that, these baboons live to see another day.

• Contraindications in patients with known or suspected mechanical gastrointestinal obstruction or any known condition that affects bowel transit; rectal administration; suspected surgical abdomen; mild, intermittent or short duration pain that can be managed with other pain medications; management of acute pain; management of perioperative pain; acute asthma or other obstructive airway, and status asthmaticus; acute respiratory depression, elevated carbon dioxide levels in the blood, and cor pulmonale; acute alcoholism, delirium tremens, and convulsive disorders; severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury; MAO inhibitor use; pregnancy, labour and delivery, breastfeeding; opioid-dependent patients and for narcotic withdrawal treatment; moderate to severe hepatic impairment

• Conditions of clinical use, adverse reactions, drug interactions, patient counselling information, dosing instructions and storage under lock and key The additional safety information page contains the reference list relating to this advertisement. *Multicentre, randomized, 8-week, double-blind, placebo-controlled, double-dummy, cross-over study in adults (N=83) with chronic low back pain of moderate or greater intensity (a score of ≥2 on a 5-point ordinal scale). At enrolment, patients were taking opioids or had not previously responded to non-opioid therapy (nonsteroidal anti-inflammatory drugs or muscle relaxants). These patients, requiring around-the-clock opioid therapy, were randomized to receive 10/5 mg TARGIN® or placebo q12h. Patients were titrated weekly according to efficacy and tolerability to 20/10, 30/15, and 40/20 mg or placebo q12h. All patients were provided with codeine/acetaminophen PRN as rescue medication. Baseline mean (±SD) VAS pain scores: 61.4±16.3 mm and 61.4±16.3 mm; and final week: 48.6±23.1 mm and 55.9±25.4 mm for TARGIN® and placebo, respectively.1,3 The studies included both subjective (i.e. drug liking VAS) and objective (i.e. pupillometry) measures. Collectively for these studies, the subjective results that were produced were supported by similar results in objective measures. Solutions contained a 2:1 ratio by weight of oxycodone HCl to naloxone HCl.1

‡

Comparative clinical significance has not been established. Naloxone is for the relief of opioid-induced constipation (OIC).

See page xxx 38 for additional safety information.

Reprinted with permission. The article appears on TravelersTales.com and BestTravelWriting.com under the title The Battle of Waterkloof. It won the Gold Award in the Animal Encounter Category of the Tenth Annual Solas Awards sponsored by Travelers’ Tales.

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2016-01-19 5:30 PM

Assessing a chronic pain patient can be complex. TARGIN® offers three features: Provided reduction in pain intensity compared to placebo.1* TARGIN® provided significantly greater reductions in pain intensity compared to placebo (reduction in mean 100-mm VAS scores from baseline after 4 weeks of treatment: TARGIN® -12.8 from 61.4; placebo -5.5 from 61.4; p =0.0296)

Demonstrated safety and tolerability profile.1 The most frequently reported adverse events (>5%; % of patients, N=520) were nausea (12.3%), constipation (6.5%), hyperhidrosis (6.5%), diarrhea (6.2%), headache (6.2%), vomiting (5.4%), and fatigue (5.4%)1

Demonstrated reduced drug liking relative to oxycodone, when administered intranasally or intravenously.1†‡ Demonstrated in a series of clinical studies designed to explore the abuse/misuse potential of TARGIN® in recreational drug users †

The clinical significance of these results has not yet been established.1

The first and only analgesic that combines the efficacy of oxycodone and the benefits of oral naloxone in one tablet.1,2§¶ Adults: TARGIN® (oxycodone hydrochloride/naloxone hydrochloride) is a controlled release tablet having a dual therapeutic effect. The oxycodone component in TARGIN® is indicated for the management of pain severe enough to require daily, continuous, long-term opioid treatment, and that is opioid-responsive and for which alternative treatment options are inadequate. The naloxone component in TARGIN® is indicated for the relief of opioid-induced constipation (OIC).

Tagliatelle with fresh tomatoes and balsamic vinegar.

Season’s eatings Easy recipes for simple summer suppers recipes by

Alana Chernila

photos by

lana Chernila built The Homemade Kitchen around the phrases she has taped on her fridge: start where you are; feed yourself; do your best and then let go;

be helpful; do the work; slow down; eat outside; invite people over; don’t be afraid of food. The cookbook author confesses that her garden grows as many weeds as

Doctor’s Review • JUNE 2016

Jennifer May

vegetables and has admitted, over a glass of wine, that she even hates making dinner sometimes. She hastens to explain, however, that cooking for herself and her family is the one daily task that she

can do entirely her way and that makes her optimistic not only about creating what she wants in the kitchen, but also in her life and beyond. Alana sees cooking as an opportunity to live consciously and in the follow-up to The Homemade Pantry, The Homemade Kitchen (published by Clarkson Potter) contains recipes that are equally modern and rustic, fit for every occasion. The 320-page book includes recipes like roasted red pepper corn chowder, chicken salad with grapes, and cinnamon swirl bread. The dishes we want to make follow.

GREEK SALAD This is one of those salads that makes you love summer. All the key ingredients are at their peak at exactly the same time, and for that little window, you can eat this every single day. Serve with pita or other fresh bread, and it’s a meal in itself.

TAGLIATELLE WITH FRESH TOMATOES AND BALSAMIC VINEGAR In the summer, the whole family-dinner thing tends to fall apart. The days are long, the kitchen is hot, and more often than not, you end up looking in the fridge or the garden at seven o’clock for something, anything, to turn into dinner. But in late August, when there are piles of ripe tomatoes on the counter and there is plenty of basil in the garden, make this dish; it’s inspired The Splendid Table: Recipes from Emilia-Romagna by Lynne Rossetto Kasper. If you can swing it, this is especially good with homemade pasta.

3 tbsp. (45 ml) balsamic vinegar 1½ tsp. (7.5 ml) minced garlic (1 clove) 2 tbsp. (30 ml) minced shallot salt 3 large ripe tomatoes, cored and cut into bite-sized pieces ½ c. (125 ml) tightly packed fresh basil leaves, cut into ribbons freshly ground black pepper 1 lb. (500 g) store-bought tagliatelle ¼ c. (60 ml) extra-virgin olive oil 1½ oz. (45 g) Parmesan cheese, shaved with a vegetable peeler

Combine the vinegar, garlic and shallot in a large serving bowl, and let sit for a few minutes. Bring a large pot of salted water to boil. Fold the tomatoes, basil and black pepper into the vinegar mixture, and let marinate while you cook the pasta.

Greek salad.

2 tsp. (10 ml) red wine vinegar 1 tsp. (5 ml) lemon juice 1 garlic clove, crushed into a paste with the side of a knife 1 tbsp. (15 ml) chopped fresh oregano or 1 tsp. (5 ml) dried ½ tsp. (2.5 ml) salt 1 small red onion, diced 6 tbsp. (90 ml) olive oil 2 large cucumbers (or 4 to 5 small), peeled, quartered and sliced into 1-inch (2.5-cm) chunks 2 or 3 medium tomatoes, cored and cut into wedges 1 small sweet red pepper, cut into large dice ½ c. (125 ml) pitted kalamata olives, coarsely chopped 6 oz. (180 g) feta cheese, cubed or crumbled ½ c. (125 ml) coarsely chopped fresh flat-leaf parsley

Combine the vinegar, lemon juice, garlic, oregano, salt and red onion in a large bowl. Let the mixture sit for 10 minutes. Stir in the olive oil, then add the cucumbers, tomatoes, pepper, olives, feta and parsley to the bowl, gently folding them into the dressing. Let the salad sit for a few minutes, taste, and adjust for salt if necessary. Serves 4. JUNE 2016 • Doctor’s

Review

Add the pasta to the water and cook until just barely done, 6 to 8 minutes for dried or 2 minutes for fresh. Drain the pasta and add to the bowl with the tomato mixture. Pour the olive oil over the top and gently fold in the pasta, taking care not to crush the tomatoes. Top with the shaved cheese and more pepper. Serves 4 with leftovers.

RHUBARB SNACKING CAKE Somewhere between three and four in the afternoon, the day can start to break you. The hopeful optimism of the morning is over and now the clock is ticking and the to-do list feels way too long. This is when tea and cake come to the rescue. It creates a break, a remedy for the frantic searching through the fridge for peanut butter, the immediate post-school “I’m hungry!” and the hungry panic that gets dinner prep started on the wrong foot. This is not-so-sweet teacake, simple and easy to make. It’s great with rhubarb, but works with any seasonal berry or stone fruit. Top with whipped cream or ice cream and it’s great for dessert, too. 8 tbsp. (120 g) unsalted butter, at room temperature, cut into chunks, plus more for the pan (1 stick / 115 g) ¼ c. (60 ml) granulated sugar ¼ c. (60 ml) packed light brown sugar 3 large eggs 2 tsp. (10 ml) vanilla extract 2 c. (500 ml) all-purpose flour 1 tbsp. (15 ml) baking powder ½ tsp. (2.5 ml) salt ¾ c. (180 ml) buttermilk 2½ c. (625 ml) ¼-inch (0.6-cm) sliced rhubarb (2 to 3 stalks) 1 tbsp. (15 ml) turbinado or other coarse sugar

Preheat the oven to 375°F (190°C). Grease a 9-inch (23-cm) square baking pan with butter. Combine the butter, granulated sugar and brown sugar in the bowl of a stand mixer fit with the paddle attachment and beat until fluffy, about 3 minutes.

Doctor’s Review • JUNE 2016

Rhubarb snacking cake.

Scrape down the sides of the bowl, add the eggs and vanilla, and beat again until combined. Whisk together the flour, baking powder and salt in a medium mixing bowl. Add the dry mix and the buttermilk to the stand mixer bowl, and beat just until the ingredients are incorporated, scraping down the sides of the bowl if necessary. The batter will be lumpy, but that’s okay. Fold the rhubarb into the batter and transfer it all to the prepared pan. Sprinkle with the turbinado sugar and bake until the cake starts to pull away from the sides of the pan and is slightly golden on top, about 40 minutes. Cool for 20 minutes before serving from the pan. Makes one 9×9-inch (23x23-cm) cake.

Excerpted from The Homemade Kitchen. © 2015 Alana Chernila. Photographs © 2015 Jennifer May. Published by Clarkson Potter/Publishers, an imprint of the Crown Publishing Group, a division of Penguin Random House. Reproduced by arrangement with the Publisher. All rights reserved.

MEDICAL QUIPS Up in smoke A man walked into a psychiatrist’s office, took out a cigarette, unrolled it, and stuffed the tobacco up his nose. The doctor frowned and said, “I see you need my help!” The guy replied, “Sure do, Doc. You gotta match?”

DEPRESSION KEYPOINTS CONTINUED FROM PAGE 21

Recognize and treat both conditions The existence of either anxiety or depression should alert clinicians to conduct careful screening for symptoms of the other.1,3 Useful rating scales include the Primary Care Evaluation of Mental Disorders (for depression and anxiety)4 and the Generalized Anxiety Disorder-7 (for anxiety symptoms in management of depression).7 Greater awareness of the incidence and impact of comorbid anxiety and depression, as well as the use of evidence-based guidelines, are needed to effectively diagnose and treat both conditions.1 Optimal management may necessitate the use of more than one strategy, such as antidepressants and CBT. Left untreated, severe depression may reduce the effectiveness of CBT for anxiety.1 References 1. Schaffer A, McIntosh D, Goldstein BI et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid anxiety disorders. Ann Clin Psychiatry 2012;24:6-22. 2. Government of Canada. The human face of mental health and mental illness in Canada. Ottawa: Minister of Public Works and Government Services Canada, 2006. www.phac-aspc.gc.ca/ 3. Bouchard S, Verrier P. Anxiety disorders and comorbidities. Anxiety Canada, 2005. www.anxietycanada.ca/ english/pdf/comorbidEn.pdf 4. Hirschfeld RM. The comorbidity of major depression and anxiety disorders: Recognition and management in primary care. Prim Care Companion J Clin Psychiatry 2001;3:244-54. 5. Coplan JD, Gorman JM. Treatment of anxiety disorder in patients with mood disorders. J Clin Psychiatry 1990; 51(suppl):9-13. 6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition. Washington, DC: American Psychiatric Association, 2013. 7. Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-7.

VIEWPOINT ON ADDICTION CONTINUED FROM PAGE 25

sober for 18 years. I would have never known he was in recovery unless he mentioned it to me, because I never knew recovery could look that good. One of the great things about Renascent is that many of the staff are in active recovery. I could line them all up and I promise you, you would not be able to tell. I could possibly have told you who was in active addiction, but I would not be able to tell you who was in active recovery. That’s part of the beauty of recovery. You can’t tell the difference between someone who used to have an addiction problem (active recovery) and someone who has never had a problem with drugs. Second, recovering addicts are some of the hardest working people I have ever met. They’re brilliant and kind, dedicated and helpful, adjectives most people would not associate with someone who has had an addiction problem because of the stigma associated with this disease. Our education system does a remarkable job teaching us about addiction and the brain, but it could do a better job teaching us about the beauty of recovery. If we better educate our students about recovery, it will equip them in the battle against stigma, help build awareness and remove barriers to people finding recovery. Addiction is a disease — point blank. You would not shame a diabetic for having an issue with sugar and we should not have a negative attitude towards people with an addiction problem. Addiction is the disease, abstinence is the cure and recovery is the outcome. And it’s astonishingly beautiful.

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Renascent has been a leader in abstinence-based drug and alcohol treatment in Toronto and the Durham Region since 1970. For more info: (866) 232-1212 or renascent.ca. JUNE 2016 • Doctor’s

Review

PHOTO FINISH by

D r I lma r J. K e n t s

Southern reflections

This area is known as the Lemaire Channel in Antarctica. A pristine world with no pollution, no man-made changes to mar the views. We were blessed with excellent sunny weather that is not the norm in this area of the world. An experience well worth placing on your bucket list of things to do.

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

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Doctor’s Review • JUNE 2016

She’s a busy working mom who tries to manage her type 2 diabetes the best she can.

A type 2 diabetes add-on you and your

may agree on. New once-daily JARDIANCE™ is an oral SGLT2 inhibitor to improve glycemic control. Visit Jardiance.ca to learn more.

Indication and Clinical Use: Monotherapy: JARDIANCE™ (empagliﬂozin) is indicated for use as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance. Add-on combination: JARDIANCE™ is indicated in adult patients with type 2 diabetes mellitus to improve glycemic control, when metformin used alone does not provide adequate glycemic control, in combination with: • metformin, • metformin and a sulfonylurea, • pioglitazone (alone or with metformin), • basal or prandial insulin (alone or with metformin), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control. Important Limitation of Use: In combination therapy, use of JARDIANCE™ with insulin mix (regular or analogue mix) has not been studied. Therefore, JARDIANCE™ should not be used with insulin mix. Contraindications: • Patients with a history of hypersensitivity reaction to the active substance or to any of the excipients • Renally impaired patients with eGFR less than 45 mL/min/1.73m2, severe renal impairment, end-stage renal disease and patients on dialysis Relevant warnings and precautions: • Not indicated for use in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis

• Patients should be assessed for diabetic ketoacidosis (DKA) immediately if non-speciﬁc symptoms of DKA occur (nausea, vomiting, anorexia, abdominal pain, excessive thirst, difﬁculty breathing, confusion, unusual fatigue, or sleepiness), regardless of blood glucose level. Discontinuation or temporary interruption of JARDIANCE™ should be considered. Caution should be taken when reducing a patient’s insulin dose • Not recommended for use in patients who are volume depleted • Use with caution in patients for whom a drop in blood pressure could pose a risk or in case of intercurrent conditions that may lead to volume depletion. Careful monitoring of volume status and electrolytes is recommended. Temporary interruption of JARDIANCE™ should be considered for patients who develop volume depletion until the depletion is corrected • The use of JARDIANCE™ in combination with a secretagogue or insulin was associated with a higher rate of hypoglycemia • Dose-related increases in LDL-C can occur with JARDIANCE™. LDL-C levels should be measured at baseline and monitored • JARDIANCE™ increases the risk of genital mycotic infections, particularly for patients with a history of genital mycotic infections • JARDIANCE™ increases the risk of urinary tract infections • Use with caution in patients with an elevated hematocrit • Not recommended in patients with severe hepatic impairment • Assessment of renal function is recommended prior to JARDIANCE™ initiation and regularly during treatment. Do not initiate JARDIANCE™ in patients with an eGFR <60 mL/ min/1.73m2

* Fictitious patient. May not be representative of all cases. CA/EMP/00019 | BI/EMP/00019 JARDIANCE™ is a trademark of Boehringer Ingelheim International GmbH, used under license.

• Monitoring of renal function is recommended prior to and following initiation of any concomitant drug which might have an impact on renal function • JARDIANCE™ must not be used during pregnancy or breastfeeding • Should not be used in patients <18 years of age • Use with caution in patients ≥65 years of age due to a greater increase in risk of adverse events, and because diminished efﬁcacy is expected in this population as older patients are more likely to have impaired renal function • Patients ≥75 years of age are at a higher risk of volume depletion. Prescribe with caution • Initiation of therapy in patients ≥85 years of age is not recommended • Patients receiving JARDIANCE™ will test positive for glucose in their urine For more information: Please refer to the product monograph at www.JardiancePM.ca for important information relating to adverse events, drug interactions, dosing, and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633.

Introducing