June 2017 by Doctor's Review

IVE ADOS S U L L-INC IN BARB L A -DAY HOLIDAY 7 A WIN AWAY” E “CM

MEDICINE ON THE MOVE

Oki island

secrets Canada

on tracks

JUNE 2017

Paragliding in Nepal

Sandcastle summer Inside a BC kitchen

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

GAD and comorbidity update

WIN

THIS MONTH’S

GADGET PAGE 14

Wondering if ASMANEX® Twisthaler® (mometasone furoate) can help your asthmatic patients? Compared to PULMICORT* Turbuhaler* (budesonide) 400 mcg BID, ASMANEX® Twisthaler® 200 mcg BID demonstrated a: Statistically significant greater improvement in FEV1 in patients ≥12 years of age (p <0.05†)1‡ Change in FEV1 from Baseline to Endpoint

2.6x

Change from baseline (L)

0.25

greater improvement

in FEV1 at endpoint (p <0.05)

0.20

0.15

ASMANEX® Twisthaler® (mometasone furoate) 200 mcg BID (n=176); baseline 2.52 L

0.10

0.05

0.00 0

6 Time (weeks)

PULMICORT* Turbuhaler* (budesonide) 400 mcg BID (n=181); baseline 2.47 L

Adapted from Bousquet et al., 2000.1

ASMANEX® Twisthaler®: The flexibility of three dosage strengths with the convenience of once-daily dosing in many patients.2§

ASMANEX® Twisthaler®, a preventative agent, is indicated for the prophylactic management of steroid-responsive bronchial asthma in patients 4 years of age and older.2 Refer to the page in the bottom-right hand icon for additional safety information and a web link to the product monograph discussing: • Contraindications in patients hypersensitive to this drug, milk proteins (from the excipient lactose), or any component of the container; in the primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required; in untreated systemic fungal, bacterial, viral or parasitic infections, active or quiet tuberculous infection of the respiratory tract, or ocular herpes simplex.2 • Other relevant warnings and precautions regarding abrupt discontinuation, risk of adrenal insufficiency in patients transferred from systemically active corticosteroids, oropharyngeal candidiasis, risk of systemic effects of inhaled corticosteroids, risk of dose-dependent bone loss, enhanced effect of corticosteroids in patients with cirrhosis or hypothyroidism, exceeding the recommended dose, rare systemic eosinophilic conditions, use with acetylsalicylic acid in hypoprothrombinemia, risk of immunosuppression, relief of acute asthma episodes, possible inhalation induced bronchospasm, pregnant/nursing women, hypoadrenalism in infants born to women receiving corticosteroids, monitoring of HPA axis function and haematological status, use of short-acting inhaled bronchodilators, bone and ocular effects, height of children and adolescents.2 • Conditions of clinical use, adverse reactions, drug interactions and dosing/administration instructions.2 The Product Monograph is also available by calling us at 1-800-567-2594. *All trademarks are properties of their respective owner(s). † p<0.05 for the 200 mcg BID ASMANEX® Twisthaler® vs. PULMICORT* Turbuhaler* (budesonide) 400 mcg BID at Week 12 (endpoint). ‡ This was a 12-week, randomized, active-controlled, evaluator blind, international study of 730 patients from 57 centres, which included researchers from multiple Canadian institutions. All patients were ≥12 years of age and previously maintained on daily inhaled corticosteroids for treatment of moderate persistent asthma. Patients were randomized with no inhaled corticosteroid wash-out period to BID treatment with ASMANEX® Twisthaler® (mometasone furoate) 200 mcg or PULMICORT* Turbuhaler* (budesonide) 400 mcg. The mean change from baseline to endpoint in FEV1 was the primary efficacy endpoint. All study medications were taken as one inhalation, twice daily.1 § ASMANEX® Twisthaler® should be taken regularly, even when the patient is asymptomatic. Improvement in asthma control following inhaled administration of ASMANEX® Twisthaler® can occur within 24 hours of beginning treatment, although maximum benefit may not be achieved for 1 to 2 weeks or longer. The lowest dose required to maintain good asthma control should be used. Attempt at dose reduction should be carried out on a regular basis. For patients ≥12 years of age, the recommended dose is 200 mcg or 400 mcg administered by oral inhalation once daily in the evening. In some patients ≥12 years of age, such as those previously on high doses of inhaled corticosteroids, 200 mcg given twice daily may provide more adequate asthma control. For patients ≥12 years of age who require systemic corticosteroids, the recommended starting dose is 400 mcg twice daily (maximum dose). Once reduction of the oral steroid dose is complete, titrate ASMANEX® Twisthaler® to the lowest effective dose. In pediatric patients 4 to 11 years of age, the recommended dose is 100 mcg administered by oral inhalation once daily in the evening.2 BID=twice daily. FEV1=forced expiratory volume in 1 second. ® MSD International Holdings GmbH. Used under license. © 2017 Merck Canada Inc. All rights reserved.

See additional safety information on page xx 47

Always take the train My first job as an editor was with a company that had their offices on the third floor of a cooperative printing company in Sainte-Anne-de-Bellevue, Quebec. I enjoyed the job and the people I worked with, but the biggest perk was that I could ride the train to work every morning. No big deal, right? Millions of people take trains to work. Yes, but are they served a full breakfast on a linen tablecloth with heavy silverware by an attentive waiter? I thought not. I got in on the very tail end of such service. The CNR train I caught was on the Montreal-Toronto run and the dining car was eliminated soon after I’d discovered it. Not long after that, the publishing company was sold to a national outfit and I was transferred to Toronto. For a couple of months during the transition I continued to live in Montreal and returned for weekends. I did it in grand style. Since 1867 (!) midnight trains, one going each way, had connected our two biggest cities. I enjoyed the great luxury of boarding a sleeper each Sunday night in Montreal to arrive in Toronto around 7am the next morning and repeating the trip back to Montreal on Friday nights — well, technically Saturday since the train left Toronto’s Union Station at midnight — to get me home for a full weekend. I was hooked. These days when I travel, I eschew the airlines and take the train whenever possible. That can be a challenge here and in the States. Europe got it right. There, riding the rails is a delight and they keep adding sleek, fast new service all over the continent. Federal and provincial governments have been promising rail upgrades since the Mulroney conservatives eliminated that historic Montreal-Toronto midnight run. Last month, the Wynn government in Ontario announced a new, $21-billion high-speed train link between Toronto and Windsor. It’s expected to be completed — wait for it — in 2031! For a big dose of choo-choo nostalgia take a listen to Harry Nilsson sing “Nobody cares about the railroads anymore” (youtube.com/ watch?v=84DauEmPRAk). One of the places I’d very much like to pass some time between now and 2031 is among Japan’s Oki Islands. See Will Aitken’s fine article beginning on page 30. The only caveat is that you must keep the islands’ charms to yourself — too many discovering them would not be good. Normally, sharing is a good thing and you’re encouraged to share Managing Editor Camille Chin’s photo-spread on small towns all you like. Big cities are fine, but they get entirely too much attention to the detriment of all the other wonderful spots across the country. Summertime and the livin’ is easy. Watch for our combined summer issue coming at the end of July. Until then, let up a little and relax, you deserve it and, as you tell your patients, vacations are good for the health.

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David Elkins, publisher and editor delkins@parkpub.com

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@doctorsreview JUNE 2017 • Doctor’s

Review

FOR THE TREATMENT OF MOD

A new option in hormone therapy for women with a uterus DUAVIVE demonstrated: Significant reduction in the number and severity of average daily moderate to severe hot flushes (from baseline to week 12, n=122) vs. placebo (n=63)1† Mean change for number was -7.63 vs. -4.92 and -0.87 vs. -0.26 for severity, p<0.001 for both Incidence of breast pain and change in breast density shown not to be significantly different from placebo Incidence of breast pain at Weeks 9-12: 9% vs. 6%, respectively1† Mean percentage change in breast density from baseline after 1 year of treatment: -0.49 vs. -0.51, respectively1‡ Low incidence of endometrial hyperplasia1§ In clinical studies up to 2 years’ duration, <1% incidence of endometrial hyperplasia or malignancies observed (0% and 0.30% at year 1, 0.68% at year 2)

Indications and Clinical use: DUAVIVE is indicated in women with a uterus for the treatment of moderate to severe vasomotor symptoms associated with menopause. Should not be taken with a progestin, additional estrogens or selective estrogen receptor modulators (SERMs). Not recommended for women >75 years of age. Not indicated for pediatric use. Contraindications: • Active or past history of confirmed venous thromboembolism (VTE) or active thrombophlebitis • Active or past history of arterial thromboembolic disease • Hypersensitivity to estrogens • Undiagnosed abnormal genital bleeding • Known, suspected, or past history of breast cancer • Known or suspected estrogen-dependent malignant neoplasia • Liver dysfunction or disease as long as liver functions tests have failed to return to normal • Endometrial hyperplasia • Known protein C, protein S, or antithrombin deficiency or other known thrombophilic disorders • Known or suspected pregnancy, women who may become pregnant, and nursing mothers

• Partial or complete loss of vision due to ophthalmic vascular disease Most serious warnings and precautions: Risk of stroke and deep vein thrombosis: estrogen-alone therapy (mean age 63.6 years). Therefore, estrogens with or without progestins: • Should not be prescribed for primary or secondary prevention of cardiovascular diseases • Should be prescribed at the lowest effective dose and for the shortest period possible for the approved indication Other relevant warnings and precautions: • Possible risk of ovarian cancer • Monitor blood pressure with hormone replacement therapy use • Caution in patients with otosclerosis • Caution in women with pre-existing endocrine and metabolic disorders • Caution in patients with rare hereditary galactose intolerance • Abnormal vaginal bleeding • May increase pre-existing uterine leiomyomata • May exacerbate previous diagnosis of endometriosis • May increase the risk of VTE • Risk of gallbladder disease • Caution in patients with history or liver and/or biliary disorders

NEW

THE FIRST AND ONLY TISSUE-SELECTIVE ESTROGEN COMPLEX (TSEC) * 1

ERATE TO SEVERE VASOMOTOR SYMPTOMS

Cummulative amenorrhea rates similar to placebo1‡§ In SMART 1, cumulative amenorrhea at Year 1 was 83% in women treated with DUAVIVE, similar to placebo (85%). In SMART 5, cumulative amenorrhea at Year 1 (Cycle 1 to 13th), was 88% with DUAVIVE, similar to placebo (84%). Improved sleep adequacy and menopause-specific quality of life total score vs. placebo (secondary endpoints)2† Adjusted mean change from baseline in sleep adequacy score 16.53 vs. 1.07, respectively, p<0.001 The parameters of sleep quantity, somnolence, snoring and shortness of breath were not significantly different from placebo2 Mean change from baseline in MENQOL total score at Week 12: -1.6 vs. -1.0, respectively, DUAVIVE demonstrated p <0.001

• Caution in women with hepatic hemangiomas • Angioedema • Caution in women with systemic lupus erythematosus • Cerebrovascular insufficiency • May exacerbate epilepsy • Fluid retention • Not recommended in renal impairment • Not recommended in premenopausal women • Women with higher BMIs (≥30 kg/m2) may exhibit decreased bazedoxifene which may be associated with an increased risk of endometrial hyperplasia For more information: Please consult the product monograph at http://pfizer.ca/pm/en/duavive.pdf for important information relating to adverse reactions, drug interactions and dosing information, which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001.

A purposeful pairing of conjugated estrogens (CE) with a selective estrogen receptor modulator (SERM) bazedoxifene (BZA)1*

* Clinical significance has not been established. † SMART 2: 12-week, double-blind, placebo-controlled trial in 318 women who had 7 moderate to severe hot flushes/day or ≥50/week at baseline who were randomized to DUAVIVE (n=127), CE 0.625 mg/BZA 20 mg (n=128), or placebo (n= 63). Primary endpoint assessed efficacy of vasomotor symptom relief. Secondary endpoints included: number of mild, moderate, and severe hot flushes, sleep parameters [Medical Outcomes Study (MOS) scale], and overall Menopause Specific Quality of Life (MENQOL). Baseline MENQOL total scores: DUAVIVE 4.46, placebo 4.42. The domain of the MOS sleep scale designed to measure sleep adequacy included: getting enough sleep to feel rested upon waking in the morning and getting amount of sleep needed. Responders were defined as >75% reduction from baseline in daily number of hot flushes. ‡ SMART 1: 24-month, double-blind, placebo- and active-controlled dose-ranging trial of 3397 women who were randomized to DUAVIVE (n=433), raloxifene 60 mg or placebo. Women took calcium and vitamin D (Caltrate 600 + D™) daily. Primary endpoint was the incidence of endometrial hyperplasia; secondary endpoint was the treatment of vasomotor symptoms. § SMART-5: 12-month, double-blind, placebo- and active-controlled trial of 1843 women who were randomized to DUAVIVE (n=445), CE 0.625 mg/BZA 20 mg (n=474), BZA 20 mg (n=230), conjugated estrogens 0.45 mg /medroxyprogesterone acetate (MPA) 1.5 mg (n=220) or placebo (n=474). Women also took calcium, 600 mg and vitamin D, 400 IU daily.

References: 1. DUAVIVE Product Monograph. Pfizer Canada Inc., October 20, 2014. 2. Utian WH et al. Bazedoxifene/conjugated estrogens and quality of life in postmenopausal women. Maturitas. 2009;63:329-35. DUAVIVETM Wyeth LLC, Pfizer Canada Inc. Licensee ® Pfizer Inc., used under license © 2017 Pfizer Canada Inc., Kirkland, Quebec H9J 2M5

CA0117DUA001E

contents JUNE 2017

features 26 Oh Canada!

COVER SHUTTERSTOCK.COM

Extraordinary sand sculptures, goats on a grass roof, a big Acadian party plus more from the small towns you should visit this summer by Camille Chin

Oki island secrets This little visited part of Japan will take your heart away but you must promise not to tell your friends about it by Will Aitken

Free as a bird in Nepal A woman confronts her fear of heights by going parahawking, a combination of falconry with, yes, paragliding by Mary Jean Pramik

40 The great Canadian rail adventure A 41-day luxury train trip from Toronto to BC — and there’s no better time to do it as Canada turns 150 by Gary Crallé

Doctor’s Review • JUNE 2017

Indications 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, • pioglitazone (alone or with metformin), • metformin and a sulfonylurea, • basal or prandial insulin (alone or with metformin), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control. Add-on combination in patients with established cardiovascular disease: JARDIANCE® is indicated as an adjunct to diet, exercise and standard care therapy to reduce the incidence of cardiovascular death in patients with type 2 diabetes mellitus and established cardiovascular disease who have inadequate glycemic control. Important Limitation of Use: 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, endstage renal disease and patients on dialysis Most Serious Warnings and Precautions: Diabetic Ketoacidosis: Clinical trial and post-market cases of diabetic ketoacidosis (DKA), a serious, life-threatening condition requiring urgent hospitalization, have been reported in patients on JARDIANCE® and other sodium-glucose co-transporter 2 (SGLT2) inhibitors. Some cases of DKA have been fatal. A number of these cases have been atypical with blood glucose values below 13.9 mmol/L (250 mg/dL) • Patients should be assessed for DKA immediately if non-specific symptoms of DKA occur (difficulty breathing, nausea, vomiting, abdominal pain, confusion, anorexia, excessive thirst, unusual fatigue, or sleepiness), regardless of blood glucose level, and JARDIANCE® should be discontinued immediately • JARDIANCE® should not be used for the treatment of DKA or in patients with a history of DKA • Not indicated, and should not be used, in patients with type 1 diabetes Other Relevant Warnings and Precautions: • 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 • Caution should be observed in patients at high risk for cerebrovascular accidents • In clinical situations known to predispose to ketoacidosis (e.g., major surgical procedures, serious infections and acute serious medical illness), consider temporarily discontinuing JARDIANCE® • Use caution in patients at higher risk of DKA • Use caution when reducing the insulin dose in patients requiring insulin • 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 • 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 be discontinued if eGFR falls below 45 mL/min/1.73m2 • 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. For important safety information on SGLT2 inhibitors and the risk of DKA, please refer to http:// www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2016/58404a-eng.php. References: 1. JARDIANCE Product Monograph. Boehringer Ingelheim, September 12, 2016. 2. Boehringer Ingelheim (Canada) Ltd. Data on File. Medical Letter. September 6, 2016. JARDIANCE® is a registered trademark of Boehringer Ingelheim International GmbH, used under license.

CA/EMP/00086 BI/EMP/00086

NEW INDICATION

In type 2 diabetes patients with inadequate glycemic control and established CV disease…

CV DEATH HAS A NEW OPPONENT. JARDIANCE® is the only T2D agent indicated as an adjunct to diet, exercise and standard care therapy to reduce the incidence of cardiovascular death in patients with T2D and established CV disease who have inadequate glycemic control.1,2*

JARDIANCE® is not recommended for use in patients who are volume depleted. Due to its mechanism of action, JARDIANCE® causes diuresis that may be associated with decreases in blood pressure. Caution should be exercised in patients for whom an empagliflozin induced drop in blood pressure could pose a risk, such as patients with known cardiovascular disease, patients on antihypertensive therapy (particularly loop diuretics), elderly patients, patients with low systolic blood pressure, or in case of intercurrent conditions that may lead to volume depletion (such as gastrointestinal illness). Careful monitoring of volume status is recommended. Temporary interruption of JARDIANCE® should be considered for patients who develop volume depletion until the depletion is corrected. CV=cardiovascular; T2D=type 2 diabetes. *Comparative clinical significance is unknown.

contents JUNE 2017

features

The West Coast kitchen Cured salmon, cauliflower and broccoli pesto pizza, and raspberry mousse: easy summer recipes from a BC chef by Denise Marchessault

regulars

LETTERS

PHOTO FINISH BC in bloom by Dr David R. Brook

contest! Win a seven-day “CME Away” holiday at Sandals Barbados! Turn to page 16 for details.

In your own words

PRACTICAL TRAVELLER An affordable new way to get around NYC, unusual art installations in Austin and Venice, the world’s best beaches and more! by Camille Chin

GADGETS A patio umbrella that does double duty at night and during the day by David Elkins

TOP 25 The best conferences scheduled for October and November

HISTORY OF MEDICINE Lyme disease — past, present and, unfortunately, future by Tilke Elkins

DEPRESSION KEYPOINTS GAD and comorbidity update by Alison Palkhivala

Coming in

July/August

Be the first to cruise the Ganges Sail one of the most storied rivers in the world like a maharaja A doctor does New Zealand Travel with this Halifax OB/GYN on a two-month retirement spree Six US cities well worth a visit Everything wonderful doesn’t happen in NYC, LA, Chicago or San Fran Best-rated US resort is not what you’d expect The Lodge at Glendorn is a Relais & Château known for fly fishing and trap shooting

JUNE 2017 • Doctor’s

Review

LETTERS

In your own words

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

PEI POINTS OF INTEREST As an Islander and an Island doctor I can see you were well-informed while planning your vacation [“PEI by the senses,” I Prescribe a Trip to…, May 2017, page 24]. I have to endorse Basin Head, the Fireworks Feast, and particularly the Village Feast for which I’ve volunteered since its inception (this year is the 10th anniversary Feast). Visitors are so welcome here. We love showing off the Island at its best in the summer. Glad you had a great visit!

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

OFFICE MANAGER

Denise Bernier

CIRCULATION MANAGER

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

MONTREAL HEAD OFFICE

Parkhurst Publishing Ltd. 3 Place Ville Marie, 4th floor Montreal, QC H3B 2E3 Tel: (514) 397-8833 Email: editors@doctorsreview.com www.doctorsreview.com

TORONTO SALES OFFICE

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

None of the contents of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means, without prior permission of the publishers. ISSN 0821-5758 Canadian Publications Mail Sales Product Agreement No. 40063504 Post-paid at St. Laurent, QC. Return undeliverable Canadian addresses to: Circulation Department, Parkhurst Publishing Ltd., 3 Place Ville Marie, 4th floor, Montreal, QC H3B 2E3. Subscription rates: One year (12 issues) – $17.95 Two years (24 issues) – $27.95* One year U.S. residents – $48.00 *Quebec residents add PST. All prescription drug advertisements appearing in this publication have been precleared by the Pharmaceutical Advertising Advisory Board.

EVAN GARLAND

Claudia Masciotra

EDITORIAL BOARD

Dr Laura Hogan Via DoctorsReview.com Cabot Beach, PEI.

THE WRITE STUFF Here are some online comments we received about the Caduceus pens [Gadgets, May 2017, page 14]: Doctors are well renowned for writing badly. With this beautiful pen, every doctor will make the effort to write better! Dr Constance Goulet

I love pens and I collect them. I have different ones depending on how I feel that day. Dr Nikki Powar

This pen is beautiful — and would be especially appropriate for my office manager! Dr Sandi Frank

We want to hear from you! Send your comments and questions to: Doctor’s Review, Parkhurst Publishing Ltd., 3 Place Ville Marie, 4th Floor, Montreal, QC H3B 2E3. Or email us at editors@doctorsreview.com.

Doctor’s Review • JUNE 2017

THE SWEET STUFF The article is interesting, but the skill of the author is amazing [“Does sugar kill?” History of Medicine, April 2017, page 26]. It is so nice to see people who can express information and ideas so well and with such precision. Way to go Tilke! Dr David Cameron Via DoctorsReview.com

BIKE LIGHTS I bike to work from spring to December. I put a reflective band around my wrist so it can be seen when I signal [“Light up your (bike) life,” Gadgets, April 2017, page 14]. I also have a reflective vest. I had two bike accidents and still love biking. Good for health and against pollution! Dr Gilda Bowdridge Via DoctorsReview.com

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

C a mi lle C hi n

Elk in Banff National Park.

Countries that

wildlife

KAVRAM / SHUTTERSTOCK.COM

BGSMITH / SHUTTERSTOCK.COM

protect

Which countries are doing the most to conserve their wildlife? A group of biologists led by Peter A. Lindsey of South Africa pondered that question and decided to find out via a study of 152 countries. Their findings were recently published in Global Ecology and Conservation. Ninety percent of the countries in North and Central America, and 70 percent in Africa, were considered above-average performers; Elephants in Chobe 25 percent of the countries in Asia National Park, Botswana. and 21 percent in Europe were identified as underperformers. The focus of the study was “megafauna,” adult carnivores weighing 15 kilos or more, adult herbivores or omnivores 100 kilos and upwards. These are the animals that attract tourists and are most likely to be protected. Three things were considered: the proportion of land occupied by megafauna in a country; the percentage of the megafauna habitat that’s strictly protected; the percentage of the GDP devoted to funding for domestic and international conservation efforts. Canada and the US scored well. Surprisingly, Australia did poorly. Here are the 10 best and worst of the rankings. For the entire study: bit.ly/2rmxY4B.

COUNTRIES WITH THE HIGHEST SCORES*:

Botswana Namibia Tanzania Bhutan Zimbabwe Norway Central African Republic Canada Zambia Rwanda

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

COUNTRIES WITH THE LOWEST SCORES*:

143. 144. 145. 146. 147. 148. 149. 150. 151. 152.

Iraq Oman Liechtenstein Uruguay Yemen Qatar Libya Syria UAE San Marino

*Megafauna conservation index JUNE 2017 • Doctor’s

Review

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

An affordable cruise in NYC 2017 Route Map EAST RIVER

LEGEND

Astoria

NYC FERRY ROUTES/SERVICES

QUEENS

Roosevelt Island

East River

Rockaway

Long Island City

South Brooklyn (June 2017)

Gantry Plaza State Park

East 34th Street

Astoria (August 2017)

ASTORIA

Midtown East

Hunters Point South

EAST RIVER

Shuttle Service East River Summer Service South Brooklyn Summer Service

Greenpoint

MANHATTAN

OTHER FERRY ROUTES/SERVICES

North Williamsburg

EAST RIVER

Staten Island Ferry South Williamsburg Brooklyn Navy Yard (Future) DUMBO

Wall Street

Pier 11

Brooklyn Bridge Park – Pier 1

SOUTH BROOKLYN

BROOKLYN JAMAICA BAY

Atlantic Avenue

Whitehall

Brooklyn Bridge Park – Pier 6

Governors Island

Red Hook

Atlantic Basin

RR Y

AY AW

ST AT E

Sunset Park

Brooklyn Army Terminal

Bay Ridge

UPPER BAY Saint George

STATEN ISLAND

FARE INFORMATION

One-Way Bike

$ 2.75 $ 1.00

30-Day* 30-Day+Bike*

$ 121.00 $ 141.00

Discounts available for seniors and people with disabilities. Visit ferry.nyc for more info.

Rockaway

There’s a new way to get around NYC and it doesn’t involve roads, cars or traffic. The NYC Ferry debuted the Rockaway and East River routes on May 1, the first of six that will be added throughout the summer and into next year. The routes will connect southern Queens, Brooklyn and Manhattan; rides will cost the same as a subway ride, US$2.75. Bikes are welcome for an additional US$1. The new fleet of boats will have 129 seats inside and 28 seats on the outer deck, and will feature charging stations for your devices. Wi-Fi will come later. A snack stand will sell food and drinks. For suggestions of things to see and do along the routes, go to the official NYC travel website: nycgo.com/articles/dont-miss-these-placesnear-nyc-ferry-stops. To buy tickets, go to www.ferry.nyc

DOWNLOAD THE NYC FERRY APP FOR REAL-TIME ADVISORIES LOWER BAY

Don’t Miss the Boat! Download the NYC Ferry App • Real-Time Route Updates & Alerts • Mobile Ticketing • Trip Planner

Artistic support Two gigantic hands seem to be holding up the very old and very beautiful Ca’ Sagredo Hotel which overlooks the Grand Canal in Venice. The larger-than-life sculpture called Support was created by Italian artist Lorenzo Quinn and was installed in May as part of the Venice Biennale International Art Exhibition, which runs until November 26. The hands represent humanity’s ability to be both creative and destructive as well as our capacity to make positive and negative impacts on history and the environment. Quinn made the hands in his Barcelona studio; they’re modelled after those of one of his three children. He often thinks about the world that will be passed on to them. A March study published in Quaternary International predicted that if global warming isn’t curbed in the next few decades, all of Venice will be underwater by 2100.

Doctor’s Review • JUNE 2017

BUFFY1982 / SHUTTERSTOCK.COM

*30-Day tickets are temporarily only available via the NYC Ferry mobile app.

COURTESY THE ARTIST AND LISSON GALLERY. PHOTOGRAPH BY GAO YUAN

Iron Tree Trunk, 2015.

Ai Weiwei in Austin Art by Ai Weiwei will be all over the US this year. The Beijing-born contemporary artist and political activist will build 10 major fence-themed installations around NYC in October, will be part of a Mural Arts project in Philadelphia in September, will open Trace (2014) in Washington on June 28, and currently has two large works in Austin, Texas. Forever Bicycles (2014), near Austin’s Waller Creek, a popular urban hike and bike trail system, arrived on June 3. It combines 1200 bikes in one edgy, out-ofthis-world sculpture with an archway that visitors can walk through. Bikes ruled the streets of Beijing when Weiwei was growing up and were, for him, a coveted luxury item. Iron Tree Trunk (2015), near Austin’s Sculpture Park, is a heavy, five-metre-tall project that resembles a hollowed-out, decomposing tree trunk. Weiwei was inspired by a Chinese tradition local to the city of Jingdezhen in which parts of dried trees are displayed in homes. They’re admired for their complexity and contemplative qualities. Iron Tree Trunk looks real from a distance, but its oversized bolts and screws are purposely visible up close. thecontemporaryaustin.org/exhibitions/ai-weiwei.

DOCTORS REVIEW - COLOUR - MAY 2017 6.812" x 1.75"

JUNE 2017 • Doctor’s

Review

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

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Playa del Arenal-Bol beach in Calpe, Spain.

Most people would agree that beach days are the best. Some might say they’re particularly good in Spain, which boasts more Blue Flag beaches than any other country in the world. Started in 1987 and bestowed by the European Environmental Foundation, the Blue Flag recognizes beaches for their all-round high quality. The four criteria include water quality, environmental management, environmental education and safety. The flag went international in scope when South Africa joined in 2001. Spain’s been the blueflag leader in the 30 years the award has been granted. This year, 579 of its beaches have been certified — or one in five. The Valencia region has the most flags with 129, Galicia has 113, Catalunya 95. Greece is the second ranked country with the most flags, followed by France, Turkey and Italy. Note: Canadian beaches are ranked, but those of the US are not. Some unexpected spots on the list include Birch Cove Beach in Halifax and Bell Park Beach in Sudbury. blueflag.global.

Doctor’s Review • JUNE 2017

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G AD G E T S A N D GE A R by

D a v i d Elk i n s

Let the sunshine in — sort of Canada’s a funny place. For much of the year we complain about the cold and wet, then at the first sign of warm weather, we slather on sunblock and hide under big solar-protective umbrellas. It wasn’t always like this, of course. We once thought sunshine was good for you and the more the better. When I was growing up, my mother couldn’t wait to get me and my younger sister out of the house on summer days. It’s true that she often had us wait while she greased us up, but it wasn’t with sunscreen, it was with a sun enhancer, gleaming oils intended to make us as dark as possible as quickly as possible. She especially encouraged us running around without our shirts on. The more tanned skin on her kids, the better she liked it and we did our best to please her. It was a sign to the world that she knew how to raise healthy offspring. On beach vacations she did double duty to make sure we came home as brown as berries. Beach umbrellas were simply nowhere to be seen. Families stretched out on towels all down the sand like so many walruses baking their bodies to a deep mahogany. The lessons stuck. During our teen years, I caught the rays anytime I got a chance and my

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sister used a reflector to direct as much curing sunshine on her face as possible. When I was 18 or 19, I read Ken Kesey’s popular novel One Flew Over the Cuckoo’s nest and went on to his book Sometimes a Great Notion which stuck in my craw as “Sun-times a great lotion.” That was then and this is now. We take our sunshine in vitamin D tablets and haul out the deck umbrellas in May and now, ta-da!, there’s one that does double-duty day and night: meet the Outsunny, a 2.75-metre, solar-powered patio and pool umbrella. The remarkable “why-didn’t-I-think-of-that” invention has three LED lights on each of the arms to bathe those beneath it in a romantic glow.

CONGRATULATIONS to Kelsey Stearns, a family physician from Calgary, winner of a pair of lighted turn signal biking gloves. 14

Doctor’s Review • JUNE 2017

Available online at aosom.ca/outdoorliving/outsunny-solar-led-patio-umbrellabrown.html. $109.99 with red, green and blue lights or at Amazon.ca with clear lights, $94.99. Both offer free shipping.

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THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Edmonton, AB November 1-4 20th Professional Conference and Annual Meetings of Diabetes Canada diabetes.ca/clinical-practice-education/ professional-conference-annual-meetings

Montreal, QC November 8-11

Toronto, ON November 1-4 2017 Annual Meeting of the Canadian Society of Internal Medicine csim.ca/annual-meetings/csim-annualmeeting-2017

November 2-4 9th Canadian Conference on Dementia canadianconferenceondementia.com

November 4-5 26th Annual Scientific Conference of the Canadian Academy of Geriatric Psychiatry cagp.ca/Annual-Scientific-Meeting-2017

Around the world Abu Dhabi, UAE October 26-29 19th Annual Conference of the International Society of Addiction Medicine isam2017abudhabi.ae

Atlanta, GA October 23-28 2017 Annual Conference of the American Congress of Rehabilitation Medicine acrm.org/meetings/2017-annual-conference

Barcelona, Spain October 28-November 1

JJFARQ / SHUTTERSTOCK.COM

2017 Family Medicine Forum fmf.cfpc.ca

Carnaby Street, Soho, London.

To register and to search 2500+ conferences, visit doctorsreview.com/meetings Berlin, Germany November 24-26 4th International Symposium: Low Vision and the Brain 4r-vision.com

Boston, MA October 4-7 12th Annual Cardiometabolic Health Congress cardiometabolichealth.org/2017/register-12thannual.html

October 9-13 25th Annual Update: Neurology 2017 neurology.hmscme.com

Chicago, IL October 9-10 2017 International Conference on Viral Hepatitis iapac.org

25th UEG (United European Gastroenterology)

Florence, Italy October 27-29

Week 2017 ueg.eu/week

11th Men’s Health World Congress lp.www2.kenes.com/mhwc_2017_lp

Kansas City, MO October 4-7 46th Annual Meeting of the Child Neurology Society childneurologysociety.org/meetings/future-cnsannual-meetings

London, England October 26-28 Pediatric Allergy and Asthma Meeting (PAAM 2017) eaaci.org/focused-meetings/paam-2017

New Orleans, LA October 31-November 5 Kidney Week 2017 asn-online.org/education/kidneyweek

MEDICAL QUIPS Take a hike Before I criticize a man, I like to walk a mile in his shoes. That way, when I do criticize him, I’m a mile away and I have his shoes.

JUNE 2017 • Doctor’s

Review

NEW

VIACORAM

EN ROUTE TOWARDS BP CONTROL The only combination antihypertensive medication with an ACEi (perindopril arginine) and a dihydropyridine CCB (amlodipine besylate)*

Contraindications 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 < 60 ml/min/1.73 m2) • 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 •

Most serious warnings and precautions sulphate): May lead to life-threatening anaphylactoid reactions. Pregnancy: When used in pregnancy, angiotensin converting enzyme (ACE) Other relevant warnings and precautions inhibitors can cause injury or even death • Caution in driving a vehicle or performing of the developing fetus. When pregnancy other hazardous tasks is detected, VIACORAM® should be • Co-administration of ACE inhibitors, discontinued as soon as possible. including the perindopril component of Hyperkalemia (serum VIACORAM®, with other agents blocking the potassium > 5.5 mEq/L): Can cause serious, RAS, such as ARBs or aliskiren-containing sometimes fatal arrhythmias; serum potassium drugs, is generally not recommended in must be monitored periodically in patients patients other than patients with diabetes receiving VIACORAM®. Concomitant use with mellitus (type 1 or type 2) and/or potassium supplements, potassium-sparing moderate to severe renal impairment diuretics, or potassium-containing salt (GFR < 60 ml/min/1.73 m2) as it is substitutes is not recommended. contraindicated in these patients Collagen vascular disease, • Risk of hypotension; closely monitor immunosuppressant therapy, treatment patients at high risk of symptomatic with allopurinol or procainamide, or a hypotension. Similarly monitor patients combination of these complicating with ischaemic heart or cerebrovascular factors (especially if there is pre-existing disease; an excessive fall in blood pressure impaired renal function): May lead to could result in a myocardial infarction or serious infections, which may not respond to cerebrovascular accident ® intensive antibiotic therapy. If VIACORAM is • Risk of mild to moderate peripheral edema used in such patients, periodic monitoring of • Safety and efficacy of VIACORAM® in white blood cell counts is advised and patients hypertensive crisis have not been established should be instructed to report any sign of • Risk of angina worsening/acute myocardial infection to their physician. infarction after starting therapy or dose increases Angioedema: May be life-threatening and occur at any time during therapy. Where there • Risk of hyperkalemia; monitor serum potassium periodically is involvement of the tongue, glottis or larynx • Risk of neutropenia/agranulocytosis, likely to cause airway obstruction, it may be thrombocytopenia and anemia fatal. Emergency therapy should be • Increases in serum transaminase and/or administered promptly. bilirubin levels, cholestatic jaundice, Syndrome starting with cholestatic cases of hepatocellular injury with or jaundice with progress to fulminant without cholestasis hepatic necrosis: May lead to death. • Not recommended in patients with impaired Use during low-density lipoproteins liver function (LDL) apheresis (with dextran • Angioedema

•

• •

• • •

•

Risk of anaphylactoid reactions during desensitization or membrane exposure (hemodialysis patients) Risk of nitritoid reactions in patients on therapy with injectable gold Patients undergoing major surgery or during anesthesia with agents that produce hypotension Black patients vs. non-black patients Not recommended in patients with a recent kidney transplantation Risk of changes to renal function in susceptible patients; potassium and creatinine should be monitored in these patients Risk of cough Dermatological reactions Not indicated for the initiation of treatment in the elderly (> 65 years) patients; not recommended in pediatrics (children < 18 years of age) Patients with diabetes treated with oral antidiabetic agents or insulin, glycemic control should be closely monitored during the first month of treatment with VIACORAM® 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/indexeng.jsp for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-363-6093.

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). VIACORAM® is not indicated for the initiation of treatment in elderly patients (> 65 years of age). There is 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.

Access 2500+ conferences at doctorsreview.com/meetings

National Air and Space Museum, Washington, DC.

Oslo, Norway November 16-17 2017 Meeting of the European Delirium Association europeandeliriumassociation.com/eda-2017oslo.html

Rome, Italy November 15-17 27th Congress of the European Childhood Obesity Group ecog-obesity.eu

San Antonio, TX October 28-November 1 INDICATED IN INITIAL THERAPY

3.5 mg Perindopril arginine / 2.5 mg Amlodipine

2017 Scientific Congress and Expo of the American Society for Reproductive Medicine scientific.asrmcongress.org

San Diego, CA October 4-8 Infectious Disease Week 2017 idweek.org

October 15-17 *Comparative clinical significance unknown. Reference: VIACORAM® Product Monograph. Servier Canada Inc. February 17, 2016.

Code: drcme

To register and to search 2500+ conferences, visit doctorsreview.com/meetings Vienna, Austria November 30-December 2 25th World Congress on Controversies in Obstetrics, Gynecology and Infertility cogi-congress.org

Washington, DC October 11-15 3rd World Congress on Abdominal and Pelvic Pain pelvicpain.org/meetings/annual-meeting/ conference-pricing.aspx

October 23-28 64th Annual Meeting of the American Academy of Child and Adolescent Psychiatry aacap.org

MEDICAL QUIPS

142nd Annual Meeting of the American Neurological Association 2017.myana.org

Unforgettable password

Tokyo, Japan Oct 26-28

I changed my password to “incorrect”. So whenever I forget what it is the computer will say “Your password is incorrect”.

VIACORAM® is a registered trademark of Servier Canada Inc.

Servier Canada Inc. 235, boulevard Armand-Frappier Laval, QC H7V 4A7 1-888-902-9700

3rd World Congress on Controversies in Breast Cancer cobrca.org

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A new option in the treatment of mild to moderate essential hypertension in initial therapy

THE TOP 25 MEDICAL MEETINGS

JUNE 2017 • Doctor’s

Review

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

T i lk e Elk i n s

Lyme disease: past, present and future Infected ticks are crawling toward your patients at an alarming rate LYME ALERT: You are likely to see far more patients this summer and in the coming months and years suffering from Lyme disease. That’s a big challenge. Diagnosis is difficult and treatment — especially if not begun soon after the patient has been bitten by an infected tick — is controversial. Blame the growing case load on the warming climate which has resulted in more ticks surviving through our winters, and growing populations of birds and rodents that are vectors for the bacteria. Blame the diagnostic difficulty on the symptoms of Lyme’s disease resemblance to a host of others including, but not limited to, fibromyalgia, chronic fatigue syndrome, multiple sclerosis, ALS, Parkinson’s, Alzheimer’s, bipolar disorder and, most commonly, rheumatoid arthritis, and on inadequate diagnostic tests. Blame the narrow treatment options on unproven theories on if and how antibiotics work against Lyme when symptoms persist. Blame all three for increasing patient activism coming soon to a practice near you.

H The classic erythematous Lyme disease rash makes diagnosis easier but only occurs in about half the cases.

unting buddies who coincidentally begin to show symptoms of Parkinson’s disease as the season draws to a close; the star pupil whose reading

comprehension suddenly drops; athletes too exhausted to get out of bed; a brilliant scientist diagnosed with frontal dementia in the prime of his career: these are all victims of a looming global epidemic. Meningopolyneuritis, Garin-Bujadoux syndrome, Bannwarth syndrome, Afzelius’ disease, Montauk Knee, sheep tick fever, or Lyme disease: today, scientists tend to refer to the condition simply as borreliosis, after the bacterial spirochete class of the genus Borrelia that’s transmitted to humans by tick bites. In the US, there are 329,000 new diagnoses reported every year. That’s six times the number of HIV cases, and twice the number of people diagnosed with breast cancer. The Canadian government, on the other hand, reported that only 841 people were diagnosed

with Lyme in 2016, causing many experts to believe that the disease is significantly underreported in this country.

LYME’S LONG HISTORY Lyme’s relatively recent widespread recognition gives the false impression that the disease is a modern scourge. Until 1975, when a cluster of cases in Old Lyme, Connecticut, thought at first to be juvenile rheumatoid arthritis, were linked to a similar condition in Europe by the bull’s eye-shaped rash that preceded joint pain, few were aware of the tick-borne illness. Throughout the ’80s and ’90s, it was generally assumed to be endemic only in the small region in New England JUNE 2017 • Doctor’s

Review

that gave it its current name. But borrelia has been around a lot longer than that. The gut of a 3.9-million-year-old tick preserved in Dominican amber carried large numbers of spirochete-like cells bearing a close resemblance to current borrelia. A 2010 autopsy of Otzi the Iceman, a 5300-year-old mummy, revealed the presence of borrelia burgdorferi’s DNA sequence, suggesting that the fellow probably struggled with the same achy joints and other symptoms that plague sufferers today. In 1764 this achiness was aptly described by Scottish Reverend Dr John Walker as “exquisite pain [in] the interior parts of the limbs.” The Reverend said while visiting the Island of Jura off the West Coast of Scotland he’d been bitten by a “worm of a reddish colour and a compressed shape with a row of feet on each side.” Almost 150 years later, the characteristic bull’s eye skin rash that warns of infection was noted by the Swedish dermatologist Arvid Afzelius, who gave the rash the name that has stuck with it: erythema migrans, or ER. The New World, too, was not without its “reddish worms.” In 1638, New England resident John Jocelyn wrote that the ticks were reported to hang in “infinite numbers” on woodsy undergrowth in summer, lying in wait for the opportunity to “creep into a man’s breeches” and “eat themselves in a short time into the very flesh of a man.” Chances were good that some of them

Microscopic images of borrella-burgdorferi-bacteria.

Doctor’s Review • JUNE 2017

Patients who are dissatisfied with their diagnosis and treatment for Lyme frequently blame their doctors as these British signs indicate.

carried borrelia. But it wasn’t until the Old Lyme cases that ticks became actively associated with borreliosis, itself not classified until 1981.

The smaller the tick, the more difficult to find — tiny nymphs, looking for their second feed, are the most likely to bite.

WHY THE SUDDEN SPIKE? Why the sudden flourishing of the malevolent microbe? North America isn’t its only stomping ground — infection rates are mounting steadily in 80 countries, with particular concentrations in Europe, Mexico, North Africa, and Australia. In England, even London parks host infected ticks. One theory is that the loss of biodiversity has resulted in a glut of animals, including birds and rodents, that are vectors for spirochetes. They transfer the infection to tiny tick larva when the larva have

their first blood feeding. The larva then molt into nymphs and go looking for their second blood meal — that is when they are most likely to bite unsuspecting humans. The nymphs are the size of poppy seeds, nearly impossible to detect even by the scrupulous. The longer they remain attached, the more likely they are to transmit Lyme. Standard wisdom is that infection requires an attachment period of 24 hours or more. That said, some victims report much shorter attachment periods, some as little as six hours. Last summer’s mouse infestation is a signal of a higher-than-average spread of Lyme this year, say ecologists in eastern Canada and the US. But burgeoning rodent populations aren’t the only reason for the apparently sudden increase in Lyme diagnoses in recent years. Criteria and testing accuracy are also at fault suggest critics of the way the epidemic has been handled. It is true that the Public Health Agency of Canada and the Atlanta-based Center

In 2016, a study failed to show reduced symptoms following prolonged antibiotic use for Disease Control in the US have been slow to come to grips with the inaccuracy of current forms of testing. The ELISA test, most commonly used to diagnosis Lyme, has an inaccuracy rate of 35 to 50 percent. And while diagnosis guidelines include the presence of a rash following a tick bite, fewer than 50 percent of Lyme patients remember either the bite or a rash. The Global Lyme Alliance claims that owing to the diverse nature of the symptoms and shortcomings in testing, only 1 in 10 cases are officially reported. Diagnosis is not the only controversy. More significant is the question of prolonged symptoms which persist long after treatment has ended. For many patients — the lucky ones — a course of antibiotics seems to clear up symptoms for good. But for perhaps as many as 40 percent, symptoms persist, especially if antibiotic treatment is delayed. The large range of presenting symptoms can make an accurate diagnosis difficult and delays in the start of a course of antibiotics is common. Lyme has been called “the new great imitator” due to its resemblance to fibromyalgia, chronic fatigue syndrome, multiple sclerosis, ALS, Parkinson’s, Alzheimer’s, bipolar disorder, and a host of other neurological disorders. The consequences of a misdiagnosis can be serious, like those of syphilis, another spirochetes infection which plagued earlier generations. Untreated borreliosis eventually gravitates to the brain and causes neuropsychiatric disease. Due to the difficulty of obtaining a positive test result for Lyme, especially once the disease has progressed for years, scores of patients with Lyme-like symptoms have been sent home without diagnosis or treatment. Some medical opinion suggests these patients are suffering from Post Treatment Lyme Disease (PTLD), caused not by the presence of a borreliosis infection, but by residual damage to tissues and the immune system, and do not consider it a chronic condition. On the other hand, there are physicians who treat

Neon green-clad protesters the world over demand changes in how Lyme is defined, diagnosed and treated.

these continuing symptoms with a combination of long-term antibiotics and nutritional supplements despite regulatory cautions about extended antibiotic treatment, who report positive patient results.

PROTECTIVE BIOFILM? In 2016 a double-blind placebo-controlled Dutch study into the effects of long-term antibiotic treatment for Lyme disease failed to show that there were any signs of reduced symptoms following prolonged antibiotic use. So, who’s right? A possible reason for the marked difference of opinion between practitioners is suggested by another peer-reviewed study published recently in the European Journal of Microbiology. That paper suggests that borrelia spirochetes can “hide” from antibiotic treatment by creating a biofilm around the bacteria, making it up to 1000 times more resistant to antibiotics than other bacteria. Doctors who say they have successfully treated lingering Lyme disease with antibiotics may be finding ways to penetrate this biofilm. One Arizona center for Lyme treatment claims that its treatment “strip[s] the anion polysaccharide matrix

layer of the biofilm while exposing the infection to oxygen-rich saturation and deliver[ing] targeted antibiotics all in one sequence in order to penetrate into the cell wall.” Protesters clad in neon green t-shirts and pinned with green ribbons have demanded changes in how Lyme is defined, diagnosed and treated in cities the world over. And while controversy continues to surround Lyme issues on all fronts, there is one thing everyone seems to agree on: the epidemic is building, and it is building fast. The challenge is to find better diagnostic tools and to accelerate research into what remains a mysterious and confounding disease for the GP/FPs on the front line and for their increasingly frantic patients.

MEDICAL QUIPS Screens down, screens down When I call a family meeting I turn off the house wifi and wait for them all to come running.

JUNE 2017 • Doctor’s

Review

DE PRESSIO N K EY PO I NT S by

A li son Pa lkhi va la

Comorbid mental disorders Major depressive disorder and generalized anxiety disorder

M .

ore often than not, patients who present with a primary complaint of depression are suffering from more than one mental disorder. In Canada, a 2012 epidemiological survey of depressive episodes revealed that 25% of individuals with MDD also suffered from GAD over a 12-month period.1 To acknowledge the common comorbidity between anxiety and depression, the 5th edition of the Diagnostic and Statistical Manuel of Mental Disorders (DSM-5) includes a specifier for MDD “with anxious distress”. To meet the criteria for this specifier, patients must experience 2 or more of the symptoms listed in Table 1.

Burden of disease The presence of anxiety among patients with MDD is associated with poorer outcomes, including a greater degree of work disability and absenteeism,2 poorer response to antidepressant medication,3 more severe symptoms,4 more serious impairment,1 earlier age of onset,5 poorer quality of life,6,7 and increased risk of suicide.8

Identification and treatment The 2016 update of the Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with MDD specifies that patients with suspected MDD should undergo a complete psychiatric assessment with an evaluation for comorbid conditions, including anxiety. According to the CANMAT guidelines, MDD should be treated with psychotherapy, often in combination with pharmacotherapy. This remains true for patients who have comorbid GAD. There is evidence that both acceptance and commitment therapy (ACT) and cognitive behavioural therapy (CBT) are effective for the management of anxiety and depression, with the greatest evidence in favor of CBT.10 For patients who receive CBT for comorbid depression and anxiety the primary focus should be on the depressive symptoms if they are severe, followed by the anxiety symptoms. If depression symptoms are mild to moderate, then the reverse approach should be employed. Reducing residual symptoms of depression to the status of remission is important to minimize the risk of relapse and recurrence.9 CANMAT also recommends that, when selecting antidepressant therapy for patients with MDD and comorbid GAD, preference be given to antidepressants that are also approved for use in GAD. Currently, there are no demonstrated differences in efficacy for this indication among selective serotonin reuptake inhibitors (SSRIs) or serotonin-norephinephrine reuptake inhibitors (SNRIs), so drug selection can be made based on standard criteria.

Doctor’s Review • JUNE 2017

Table 1: DSM-5 criteria for “anxious distress” specifier of MDD ✓✓ ✓✓ ✓✓ ✓✓ ✓✓

Feeling keyed up or tense Feeling excessively restless Having difficulty concentrating because of worry Fearing that something awful may happen Being afraid of losing control of oneself

Note: Severity is determined by number of symptoms; 2 =“mild”, 3 =“moderate”, 4-5 =“severe”

The approach recommended by CANMAT for the treatment of comorbid MDD and GAD is to start at a low dose and titrate slowly, in order to avoid early exacerbation of anxiety symptoms. Benzodiazepines can be used short-term to help patients tolerate the titration period, which can take 12 weeks or more. Typically, the optimal dose will be in the high range. There is limited data with regard to use of add-on treatments for patients with MDD and GAD, but atypical antipsychotics, gabapentin, pregabalin, and other anticonvulsants can all be considered.11 CANMAT suggests the online MoodFX symptom tracking tool, available at www.moodfx.ca, for screening, monitoring, and assessment of patients with MDD and anxiety. In addition, BlueBoard (https://blueboard.anu.edu.au) provides an online supportive community for individuals suffering from depression and anxiety.10 1. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003 Jun 18; 289(23):3095-105. 2. Carter RM1, Wittchen HU, Pfister H, One-year prevalence of subthreshold and threshold DSM-IV generalized anxiety disorder in a nationally representative sample. Depress Anxiety. 2001;13(2):78-88. 3. Patten SB, Williams J, Lavorato DH, et al. Descriptive epidemiology of major depressive disorder in Canada in 2012. Can J Psychiatry. 2015;60:23-30. 4. Hendriks SM, Spijker J, Licht CM, et al. Long-term work disability and absenteeism in anxiety and depressive disorders. J Affect Disord. 2015;178:121-130. 5. Fava M, Rush AJ, Alpert JE, et al. Difference in treatment outcome in outpatients with anxious versus nonanxious depression: a STAR*D report. Am J Psychiatry. 2008 Mar; 165(3):342-51. 6. Hofmeijer-Sevink MK, Batelaan NM, van Megen HJ,et al. Clinical relevance of comorbidity in anxiety disorders: A report from the Netherlands Study of Depression and Anxiety (NESDA). J Affect Disord. 2012 Mar;137(1-3):106-12. 7. Lamers F1, van Oppen P, Comijs HC, et al. Comorbidity patterns of anxiety and depressive disorders in a large cohort study: The Netherlands Study of Depression and Anxiety (NESDA). J Clin Psychiatry. 2011 Mar;72(3):341-8. 8. Johansson R, Carlbring P, Heedman Å, et al. Depression, anxiety and their comorbidity in the Swedish general population: Point prevalence and the effect on health-related quality of life. PeerJ. 2013 Jul 9;1:e98. 9. D’Avanzato C, Martinez J, Attiullah N, et al. Anxiety symptoms among remitted depressed outpatients: Prevalence and association with quality of life and psychosocial functioning. J Affect Disord. 2013 Oct;151(1):401-4. 10. CANMAT Depression Work Group. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder. Can J Psychiatry. 2016 Sep;61(9):506-603. 11. Schaffer A, McIntosh D, Goldstein BI, et al. The CANMAT task force recommendations for the management of patients with mood disorders and comorbid anxiety disorders. Ann Clin Psychiatry. 2012 Feb;24(1):6-22.

Count on

for powerful symptom relief

PRISTIQ is indicated for the symptomatic relief of major depressive disorder.1

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

Demonstrated improvements in functional outcomes: work, family life and social life (secondary endpoints)2*

PRISTIQ 50 mg demonstrated signiﬁcant improvements in functional outcomes from baseline vs. placebo, as measured by the Sheehan Disability Scale (SDS).2† 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 Clinical use: • PRISTIQ is not indicated for use in children under the age of 18 • The short-term efficacy of PRISTIQ has been demonstrated in placebo-controlled trials of up to 8 weeks • The efficacy of PRISTIQ in maintaining an antidepressant response for up to 26 weeks, following response during 20 weeks of acute, open-label treatment, was demonstrated in a placebo-controlled trial Contraindications: • Concomitant use with monoamine oxidase inhibitors (MAOIs) or within the preceding 14 days • Hypersensitivity to venlafaxine hydrochloride Most serious warnings and precautions: Behavioural and emotional changes, including self-harm: SSRIs and other newer antidepressants may be associated with:

•

− Behavioural and emotional changes including an increased risk of suicidal ideation and behaviour − Severe agitation-type adverse events coupled with self-harm or harm to others − Suicidal ideation and behavior; rigorous monitoring • Discontinuation symptoms: should not be discontinued abruptly. Gradual dose reduction is recommended Other relevant warnings and precautions: Concomitant use with venlafaxine not recommended • Allergic reactions such as rash, hives or a related allergic phenomenon • Bone fracture risk with SSRI/SNRI • Increases in blood pressure and heart rate (measurement prior to and regularly during treatment) • Increases cholesterol and triglycerides (consider measurement during treatment) • Hyponatremia or Syndrome of Inappropriate Antidiuretic Hormone (SIADH) with SSRI/SNRI •

Potential for GI obstruction Abnormal bleeding SSRI/SNRI • Interstitial lung disease and eosinophilic pneumonia with venlafaxine • Seizures • Angle-Closure Glaucoma • Mania/hypomania • Bipolar Disorder • Serotonin syndrome or neuroleptic malignant syndrome-like reactions • •

For more information: Please consult the Product Monograph at http://pfizer.ca/ pm/en/Pristiq.pdf for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-463-6001.

* A randomized, double-blind, parallel-group, placebo-controlled, multicentre trial involving 485 patients with MDD and a 17-item Hamilton Rating Scale for Depression (HAM-D17 ) total score ≥20, a HAM-D17 item 1 score ≥2, and a Clinical Global Impression-Severity (CGI-S) scale score ≥4. Patients were randomized to receive fixed-dose PRISTIQ 50 mg/day, PRISTIQ 100 mg/day, or placebo for 8 weeks. Primary endpoint was change from baseline to last observation carried forward (LOCF) in HAM-D17 total score. Secondary endpoints included change from baseline to LOCF in SDS individual domain scores.2

References: 1. PRISTIQ Product Monograph, Pfizer Canada Inc., October 26, 2016. 2. 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 Psychopharmacol 2008;23:243-253. 3. Sheehan DV. Sheehan Disability Scale in: Rush AJ, Pincus HA, First MB, et al. eds. Handbook of psychiatric measures. Washington, DC: American Psychiatric Association; 2000:113-115.

CA0116PRI017E

† The SDS measures the functional impairment that depressive symptoms have on a patient’s work, family life and social life.2 A decrease in SDS score represents improved functional outcomes.3

The Parksville sand sculpting show will run from July 13 to August 20 this year.

Oh Canada! PHIL WHITEHOUSE / FLICKR.COM

Take a break from the big city by exploring the country’s best small towns from BC to New Brunswick by Camille Chin

PARKSVILLE, BC

HERB NEUFELD / FLICKR.COM

The Old Country Market has a grass roof and three pygmy goats to help “mow” it.

Doctor’s Review • JUNE 2017

You can see the snow-capped peaks of Mount Arrowsmith from some of the crescent-shaped, goldensand beaches of Parksville. Talk about a postcard. Located on the sheltered eastern shore of Vancouver Island where swimmers can frolic in gentle Pacific rollers rather than get slammed by pounding surf, Parksville, population 24,000, is 37 kilometres north of Nanaimo. A huge, very serious, sand sculpting competition erupts on its beaches mid-July, but, fret not, there’s more to do in the area than summer by the sea. Cathedral Grove, 25 minutes west, has hiking trails and sculptures of another kind: towering Douglas firs, some more than 800 years old. The Old Country Market, 10 minutes west in Coombs, has groceries and baked goods under its roof — and goats on top of it. Its grass roof is “mowed” by fourlegged groundskeepers that live onsite in a Norwegianstyle log house. hellobc.com/parksville.aspx.

Don’t be surprised if a horse and buggy roll up next to you on your way to St. Jacobs. The community of 2000, 15 minutes north of Waterloo, is near Elmira, a working Mennonite town. But don’t head there to see bonnets and button-up shirts. The St. Jacobs Farmers’ Market is the talk of the town. It sells hearth-baked breads that are naturally leavened, low-sugar jams and chutneys, gourmet meatballs in sauce, and more. There’s solid wood furniture made by Mennonite artisans too. The century-old Village of St. Jacobs, three kilometres north on the Conestogo River, has clothing and craft shops, but also the Block Three Brewery, a small, local microbrewery that gets rave reviews for its beer — and crokinole game boards. The Mennonite Story interpretive centre (admission by donation) is there too, as is the decades old St. Jacobs & Aberfoyle Model Railway (adults $8; kids $5). The hand-built, small-scale

You can buy Ontario maple syrup at the St. Jacobs Farmers’ Market every weekend.

MISS BOSSY / FLICKR.COM

ST. JACOBS, ON

model depicts southern Ontario in the 1950s and features movable CP and CN freight and passenger trains. stjacobs.com.

ALLIE CAULFIELD / FLICKR.COM

The fully narrated Mennonite farm tour is 90 minutes long.

JUNE 2017 • Doctor’s

Review

DEREK R. AUDETTE

ALMONTE, ON

Almonte’s 19th-century main street is lined with boutiques and galleries.

The 19th-century buildings on Almonte’s main street will charm the pants off of you. The sweet little red brick structures house antique and collectible shops, art galleries, craft stores and more. Cradled within the larger town of Mississippi Mills, the community of Almonte, 45 minutes west of Ottawa, is also a hub for artists and artisans. They make furniture and glassware, jewellery and soap. There’s even a blacksmith for custom work. But this community of 5000 also knows food. Robin’s Nest Tea Room is famous for its house-made butterscotch pie; Hummingbird Chocolate Maker has won international awards for its bars made with beans from the Dominican Republic, Guatemala and Vietnam. What’s more, Almonte is a former mill town that straddles Canada’s Mississippi River, which flows into the Ottawa River via a series of elevation drops. In other words, there’s even more to see here: waterfalls. almonte.com.

Hummingbird Chocolate Maker has won international awards for its bars made with beans from Vietnam

SAINT-JEAN-PORT-JOLI, QC The Chaudière-Appalaches region is vast and green and so very pretty. It stretches for 200 kilometres along the shoreline of the St. Lawrence River across from Quebec City, and skirts the state of Maine, the summits of the Appalachians ever present in an already perfect setting. The Route Verte’s 200 kilometres of bike paths crisscross the region from west to east, north to south. It’s one of the oldest regions in North America, and the land is peppered with 300-year-old stone mills and sweet-as-pie churches, many that are historic monuments. The beautiful church in the town of Saint-Jean-Port-Joli, population 1400, was built in 1779. It’s made of fieldstone, and features a high-sloping red roof with two charming bell towers. The town is famous for wood carving; intricate sculptures by Médard Bourgault of the Bourgault brothers are inside. For more wood art, go to Le parc des Trois-Bérets for open-air waterfront sculptures. saintjeanportjoli.com.

Doctor’s Review • JUNE 2017

NEW BRUNSWICK DEPARTMENT OF TOURISM AND PARKS

Caraquet is home to one of the most popular Acadian festivals in North America.

CARAQUET, NB The Acadian Peninsula in northeastern New Brunswick is dotted with tiny towns full of gracious people who are fiercely proud of their Acadian heritage — whether the CBC series, Canada: The Story of Us, acknowledges them or not. Caraquet, population 3100, is unofficially Acadia’s capital so it’s a great place to get acquainted with the culture that brought the French, tricolour, Stella Maris flag (blue, white and red with a yellow star in the upper left) to Canada 400 years ago. Start your visit at the Acadian Historical Village (adults $20, kids 6 to 18 $16 for two days); it has amazing recreations of 40 homes and other buildings from 1770 to 1949. End your visit with the 55th edition of the Acadian Festival, August 3 to 15 this year. Sample plenty of clam pie, chicken fricot and poutine râpée in between. The island of Lamèque, 45 minutes away, has quiet beaches and hosts a Baroque Music Festival every July; the island of Miscou has a pretty, 19th-century lighthouse and boardwalks over natural peat bogs. caraquet.ca.

The Parc des Trois-Bérets in Saint-Jean-Port-Joli is named in honour of the Bourgault brothers, local sculptors.

VILLAGE HISTORIQUE ACADIEN

TOURISME CHAUDIÈRE-APPALACHES

You can join the villagers as they go about their chores at the Village Historique Acadien.

JUNE 2017 • Doctor’s

Review

Oki island

Nishinoshima Island offers splendid walks through sloping pasture along the 300-metre Matengai cliff.

secrets WARNING: Do not read unless you promise not to tell your friends by Will Aitken Oki Islands

p Ja

Tokyo

Osaka

GANMED64 / FLICKR.COM

Hiroshima

FIVE REASONS YOU PROBABLY SHOULDN’T VISIT JAPAN’S OKI ISLANDS: 1. They’re hard to find — this large archipelago of almost 200 volcanic islands is located in the Sea of Japan off the northwestern coast of Honshu, Japan’s main island; 2. They’re hard to get to — streamlined Bullet Train from Tokyo to Osaka at 230 km/hr, an old school express train rocking through striking mountain vistas, followed by a toy-like and extremely local train whose interior is painted over with murals of giant squid and mythical sea creatures, and finally a hydro-foil ferry to reach your first Oki port; 3. They’re not ready for mass tourism — on the four main inhabited islands, there’s a single nine-storey hotel — everywhere else it’s family-run minshuku (guesthouses) or ryokan (traditional Japanese inns); 4. No Starbucks; 5. Spotty Wi-Fi. JUNE 2017 • Doctor’s

Review

So there. You really shouldn’t go. Probably not your kind of place at all. The Okis are so remote, Japanese warlords used to exile uncooperative emperors there. If you tell Japanese people you’re going, they’ll either look confused (“Where’s that?”) or envious (“So lucky!”). If despite all this you persist in going, you have to promise in advance not to tell any of your friends or post gorgeous photos on Facebook or Twitter because it’s important to keep the Okis between you and me, okay? They’re that amazing.

TO START: DINE Someone once told me all great travel articles should begin with a meal, and who am I to argue with that? I’m seated on a flat bean cushion set on the tatami mat of the dining room of a small guesthouse called Tajimaya on the outskirts of Ama Town, on Nakanoshima Island. On the low table my legs are wedged under, fresh white squid, chewy spirals of

Spectacular rock formations along Nishinoshima’s Kuniga coastline are favoured by Technicolor sunsets.

DOGO

Okinoshima

Ama NISHINOSHIMA NAKANOSHIMA CHIBURIJIMA

Food and drink offerings include white squid, seafood soup, seaweed salad and fine local sake.

911SKYWALKER

turban shell innards, cool sashimi slices, a small curving fish, a rich seafood soup — and all of it pulled from the nearby sea this morning. Seaweed salad comes soaked in vinegar — the briny smell of the sea distilled — pearly rice straight from the family paddy and a local sake made with the sweet spring water that bubbles up from the volcanic rock aquifer. This isn’t simply a guesthouse but also a smallhold farm — my spacious room looks out onto verdant rice fields and low hills — a pocketsize fishery and an all-round community centre, thanks to its ebullient innkeeper, Yoshi Uno. Early this morning the whole place rocked with villagers carrying large containers of today’s catch from young fishermen who’d gone out in darkness to bring it in. But now, gorged with their findings, it’s time for a show. Mrs. Uno, accompanied by a three-string shamisen (like a fiddle but not) sings ancient Japanese folksongs in the warbled style Western ears often find discordant but that this evening sounds just right. Topping up my sake yet again, I’m startled when a

masked demon leaps into the room to perform a quaking, lunging dance that in the candlelit room seems spookily menacing until the dancer removes the mask to reveal she’s Mrs. Uno’s mother, who looks to be in her 80s. Next day I rent a bike from the Ama Tourism Association and head along the coast in search of a beach. It’s early October with temperatures in the high 20s, but for the punctilious Japanese summer ends in September. After that no one swims or even hangs out at the beach. Well, no one except two young women — in their office worker togs — wetting their toes in the waves of the narrow beach I’ve come upon. The water’s a rich dark blue, the sun’s hot and high, the surrounding mountains enveloped in a violet haze. When I strip down to my trunks and dive into the warmish water, the young women scream in unison, whether at my daring or my impropriety, it’s not clear. On nearby Nishinoshima Island, a two-hour walk along a virtually deserted blacktop road brings me to a high sloping pasture that ends abruptly in the sheered off Matengai cliff that plunges almost 300 metres to the sea below. Grazing this highland pasture are horses whose coats range from roan to palomino and whose manes and fetlocks shine a glamorous blond. A narrow slippery path takes me down to a series of intricately sculpted rock formations that jut into the sea. These formations, striated in shades of blue-grey and copper, ochre and saffron, are where locals and visitors come for Technicolor sunsets. Nishinoshima and the three other main islands have been inhabited continuously for 30,000 years. In interacting with islanders, whose families have lived here generation upon generation, there’s the sense that change comes slow here. Unlike their mainland cousins, Oki people lack that typical Japanese reserve. Strangers greet me on the street or on hiking paths. Everyone has time to talk, to have that extra cup of tea or sake at the end of a meal. When someone moves to another island — say, to lovely Chiburijima, a 20-minute ferry ride away — the whole island turns out to perform an elaborate farewell. JUNE 2017 • Doctor’s

Review

TERESA / WIKITRAVEL.ORG

The islands are famous for horses whose coats range from roan to palomino set off with glorious blond manes and fetlocks.

HERE SHINTO ABIDES Shinto, Japan’s animistic religion, has a particularly prominent place on the islands, for at the end of the 19th century an anti-Buddhist movement sprang up here. In a bout of nationalistic fervour, Buddhism was condemned as foreign, coming as it does from India, and many temples and monasteries were destroyed. Shinto was seen as the true and original Japanese religion. Attractively, it has no commandments or concept of sin, doesn’t proselytize, involves thousands of different gods or spirits and is worshipped using mirrors, hemp rope, rice, salt and, yes, sake in its rituals. Nishinoshima has two prominent Shinto shrines. The Yurahime Jinja, AKA “squid shrine,” dates to the 10th century and is set back in a grove of trees next to a small bay. Its tori, the ceremonial arch that marks the entryway to a Shinto shrine, actually stands with its legs in the bay’s waters. The shrine’s a simple structure of weathered wood, with an enormous knotted rope over the sanctuary entrance.

Doctor’s Review • JUNE 2017

The goddess enshrined within is Yurihime-noMikoto. In mythical times, she was sailing by Nishinoshima in a tub. She dangled her fingers in the water and a squid bit her. Ever since the squid have come in great numbers to this small bay every autumn to express their regret. Local fishermen scoop them up by the thousands. Some repentant squid are said to throw themselves onto the shore to make the fishermen’s job easier. The oldest shrine on Nishinoshima, Takuhi-Jinja, is found well up Takuhi mountain. The oldest part of the shrine, which dates to the 9th century, is embedded in the rock face, surrounded by ancient cedars and smelling faintly of incense, its intricately carved walls and gables rubbed silver by age and weather. If you’re lucky, the shrine’s priest, the 21st generation of his family to preside here, will invite you in for green tea and a chunk of barley sugar, while he smokes a cigarette and produces his iPhone to show you Ukiyo-e artist Utagawa Hiroshige’s 1853 woodblock print of the shrine. You can also spend timeless moments looking out at the sea and the other Oki islands’ small villages and green mountains, or avail yourself of the shrine’s free Wi-Fi.

SNOTCH / FLICKR.COM

Dogo Island’s the largest and most populous of the Okis at 16,000 inhabitants — this is also where the largish hotel’s located, and rumour has it there’s a shopping centre here too, although I didn’t search it out. The western coast’s particularly rugged and mountainous, with frequent bays that offer sea-kayaking and superb fishing. But it’s inland Dogo that lingers in my mind, with its forests dotted with ancient Japanese cedars ranging from 600 to 2000 years old. Some grow straight up and are thick as houses; others have formed into gigantic candelabra, with as many as 15 interjoined trunks. In keeping with Shinto tradition, many of these leafy giants are shrines where people have worshipped for centuries, even millennia. At one of these I met a group of young guys, all Dogo natives. One of them — Kenji, a cook in a local ramen restaurant — spoke English. Curious about how young people feel about living in such an isolated place, I asked what they do for fun. Kenji’s face lit up. “When the moon is full we come here wearing only our fundoshi (traditional loincloths) and get really drunk. Then we run up and down the mountain and tear down all the vines we can. We bring all the vines to this big tree and wrap them around it.” “Why do you do this?” Kenji shrugs. “I don’t know. It’s what guys like us have always done here. It’s a lot of fun.” Yet one more reason — as if you needed one — to visit the uncannily beautiful Oki Islands.

WILL AITKEN

A geko takes its spot in the sun at Tajimaya guesthouse on the outskirts of Ama Town on Nakanoshima Island.

For tourist information and help with booking accommodations and travel for the main Oki islands, contact Nicola Jones at the Nishinoshima Tourist Association: http://nkk-oki.com/english/about/.

The Takuhi-Jinja shrine on Takuhi mountain, pictured here, is the subject of a famous 1853 Utagawa Hiroshige print.

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.

Free as a bird in Nepal

Paragliding high above the Annapurna Mountains with a vulture as a guide

JENNIFER JULIET / SHUTTERSTOCK.COM

by Mary Jean Pramik

Parahawking in Nepal consists of tandem paragliding while feeding water buffalo meat to a large raptor.

hen I hit 60, my eldest daughter said, “60 is the new 40.” These words spawned in me a wanderlust the likes of which I couldn’t believe and weeks after my birthday I challenged myself to go alone to Antarctica.

After cavorting with flocks of frenzied penguins and climbing out of a dormant volcano, I returned to Ushuaia in Tierra del Fuego — and an email bearing the news that my 91-year-old father was fading fast. I rushed from Argentina to Ohio to hold his hand for the last five days of his life. I never did tell him, a great watcher of birds, about my adventure with the penguins he would have so loved. After witnessing my father’s death, I resolved to live more fully in each moment. My most vivid moments come when I’m somewhere new, moving through uncharted waters or air. Not only did I commit to hitting the road more frequently each year, I pledged to my father’s memory to let go of fears that, at 60, still held me back.

I have a particular fear of heights. Even Ferris wheels stop me cold. My breath freezes whenever the bucket pauses at the top. I have peered warily at the London Eye, never gathering the gumption to purchase a ticket. Similarly, I have always adamantly refused to look down from the Empire State Building and when flying I automatically select an aisle seat. However, having watched my father face death with grace and courage, I vowed to face life without the reticence and trepidation that had tugged at me for a lifetime. It was in this spirit of abandon that I pulled a running jump (with some help from a launch crew) off the over 1430‑metre Sarangkot Mountain in Pokhara, Nepal to parahawk with a bird named Kevin. JUNE 2017 • Doctor’s

Review

A parahawking adventure in Nepal includes a bird’s-eye view of the white-peaked Annapurnas.

Doctor’s Review • JUNE 2017

CORNFIELD / SHUTTERSTOCK.COM

efore I went to Nepal, the concept of parahawking had never entered my consciousness. The British falconer Scott Mason and his crew created this hybrid of falconry and paragliding in 2001, melding adventure with conservation. The Parahawking Project educates about hawk and vulture flight behaviour, and how these birds survive in the wild. Through parahawking tandem rides, the organization raises funds to restore the nearly decimated vulture population in Nepal. Vultures have an enduring image problem. People often envision them circling above a nearly dead animal, ready to dive in once it heaves its last breath. On top of humans’ general distaste for these creatures, a crisis occurred in the late 1990s when Nepalese, Indian and Pakistani farmers, as a compassionate gesture, treated their farm animals with the anti-inflammatory diclofenac to reduce their pain as they aged. These creatures eventually died in the open and, as the many varieties of Asian vultures rid the streets of the carrion, the diclofenac-laced flesh poisoned the birds and their numbers decreased precipitously. Parahawking consists of tandem paragliding while feeding water buffalo meat to a large raptor. I hung suspended in a bag seat while Scott, a seasoned British paraglider and expert falconer, sat behind me and operated the guide lines and controls. On my maiden flight, I paired with Kevin, a trained white-feathered Egyptian vulture whose blacktipped white wings were a stunning sight to behold, spanning almost two metres.

The Shanti Stupa in Pokhara, Nepal’s largest city, is one of two World Peace pagodas in the country.

Kevin is a rescue bird. The Egyptian vulture, which inhabits southern Europe, northern Africa, and western and southern Asia, is one of 10 species nearing extinction. On Phewa Lake, Scott’s base and home to his young family, Kevin demonstrated his species’ expertise at the use of tools by dropping

rocks onto an egg to crack the shell. His thin beak and long neck allows him to claim carrion larger birds cannot. Choosing to fly off a cliff was not my usual modus operandi. I required a slight coaxing. Christina, organizer of my Nepal expedition, encouraged me. “They haven’t lost anyone yet,” she said. But there’s always the first time, I thought. However, my 60-year-old new resolve allowed another rather surprising thought: if I must die someday, soaring through the unseen wind currents above the white Annapurnas will be as lovely place as any.

n the days leading up to my flight I continued trekking the sites around Pokhara, panting my way up to the Shanti Stupa, or Peace Pagoda, the Buddhist shrine on an island in Phewa Lake adjoining Pokhara. The stunning Annapurnas kept me in the present. My only instructions for parahawking were: leap off the cliff and keep running in case the chute doesn’t open. Right. My mind pressed my legs to move through the huge and powerful gusts of wind. However, matter over mind won and I slammed back into my harness seat. A crewmember had to help our tandem launch by essentially tossing me over the cliff. Then we were off, circling the Sarangkot with two dozen other paragliders. In flight, we soared eye-to-eye with the enormous birds, following their movements to catch updrafts and keep our chute apparatus aloft. The eyesight of birds betters that of humans by 10 to 15 times. Their keen eyes identified the swirls of dust defining drafts and currents that were invisible to me on this bright, blue-skied day. Suspended in the air, time stopped. Scott swooped up, whistled for Kevin. The graceful great vulture made his approach to my outstretched, leathergloved hand that held his treat. He gently retrieved the fresh-cut water buffalo chunk that would fuel his long journeys through the air. We repeated this scene many times. I filled my lungs fully during each of the 30 minutes aloft. One abrupt updraft did surprise me. I had to close my eyes and trust my pilot during a quick right jolt and ascent. We climbed hundreds of metres fast, then turned and the entire snow-capped Annapurna range spread out before us, a heavenly vision. The sky resplendent with multi-coloured chutes,

SAINAM51 / SHUTTERSTOCK.COM

PICHUGIN DMITRY / SHUTTERSTOCK.COM

I now seek discomfort travel or travel that offers me opportunities to confront my fears, push my boundaries and expand my worldview

Egyptian vultures have bright yellow bills and are fairly intelligent — they use tools to crack open large eggs.

I found I had no time to even consider my fear. Our half-hour flight ended so gently. Much like Kevin, we glided to a small patch of grass bordering Phewa Lake, smack-dab across the road from the impressive Maya Devi Temple. Enlightenment indeed. I find myself agreeing more and more with my sometime travelling companion, an Australian septuagenarian whose motto is: “Comfort travel doesn’t interest me.” If anything, I now seek discomfort travel or travel that offers me opportunities to confront my fears, push my boundaries, expand my worldview, and build trust and connections with my fellow creatures on this earth. I hear some people speak of bucket lists and thousands of places to see before they leave this earth, as if travel exists as a checklist to complete. I find that each second spent travelling breathes life into the following moment of time and place. I now see the distinct shape of each leaf on the trees lining my street and inhale the scent of cantaloupe in my local market with gratitude. I meditate while watching the birds gliding above my San Francisco home. Travelling deepens one’s senses and sense of self. It lengthens and stretches out the time we have to challenge ourselves to begin anew, each day to rise above this earth. Reprinted with permission. The original article appears on TravelersTales.com and BestTravelWriting.com under the title Parahawking in Nepal. It won the Bronze Award in the Travel and Sports category of the 10th Annual Solas Awards sponsored by Travelers’ Tales. JUNE 2017 • Doctor’s

Review

The Skeena freewheels its way through classic mountain scenery from Prince Rupert, BC to Jasper, Alberta.

The great Canadi Celebrate our big 150 on a train trip from coast to coast text and photos by Gary CrallĂŠ

ROSS, ALEXANDER, BEST & CO., WINNIPEG

The driving of the last spike by Donald Alexander Smith, co-founder of the CPR and president of the Bank of Montreal, took place November 7, 1885 at Craigellachie, BC.

ian rail adventure T

rains have always been magical. They can take you far, far away from life’s daily concerns. Cocooned in a timeless capsule, passengers glide effortlessly through panoramic landscapes, changeable weather and childhood dreams. Luxury trains are in a class of their own, land cruises that offer one of life’s great escapes. There are only a handful of places on earth where this experience can be enjoyed and Canada, celebrating its 150th birthday this year, is among them — reason enough to explore the country that built a railway to build the country. Take one part adventure, add a whiff of nostalgia, mix with anticipation, gently fold in a dollop of romance and another of mystery, blend thoroughly with a colourful history, place amid picturesque scenery. Adjust seasons to taste and let the good times roll.

JUNE 2017 • Doctor’s

Review

Passengers who complete a round trip on The Canadian are gifted with certificates to commemorate the occasion.

THE TRACK THAT BINDS It’s remarkable that eastern and western territories came together somewhat tenuously as one country bound by two skeletal sinews of steel stretching 6000 kilometres from the Atlantic to the Pacific. As the CPR website proudly states, “the Canadian Pacific Railway was formed to physically unite Canada and Canadians from coast to coast.” That was accomplished November 7, 1885 when the last spike was hammered into place at Craigellachie, BC by railroad financier Donald Alexander Smith, co-founder of the CPR and president of the Bank of Montreal. Since the mid 1970s, the great Canadian coast-tocoast train trip has been conducted by VIA Rail, a Crown corporation with a mandate to provide intercity

Dome cars are put on the transcontinental and Skeena trains. They sit above the train and offer better viewing than newer wraparound window coaches.

passenger service. The full journey incorporates three segments: The Ocean train runs from Halifax to Montreal, The Corridor connects to Toronto, and The Canadian/Le Canadien runs west to Vancouver. East to west or west to east, the pleasure’s the same. In 2010, my wife, Lis, and I made a lengthy trip west from Toronto that began with The Canadian to Vancouver and continued with a BC ferry boat north through the Haida Gwai inland passage islands. For the next leg, we boarded The Skeena train from Prince Rupert to Jasper, Alberta, and then headed back east to Toronto on The Canadian once again. VIA’s accordion-style tickets were almost as long as the train. With lengthy stopovers along the way, the 41-day odyssey covered a total distance of 11,779 kilometres. What a trip!

A morning ride with trail guide Jacklyn gave splendid views of the Quilchena Hotel, built during boom times in 1908, and Douglas Lake Ranch, known as Canada’s largest working cattle ranch, located in the interior of BC.

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Trips include wine tastings and performances by solo musicians — never-ending scenery and conversation are always free CPR’s William Cornelius Van Horne, who said, “If we can’t export the scenery, we’ll import the tourists,” initiated the tradition of luxury rail travel in Canada in the late 19th century. He then followed up with a series of grand hotels including the Château Frontenac in Quebec City, Alberta’s Banff Springs and The Empress in Victoria.

THREE WAYS TO DO IT There are three basic comfort levels on a VIA Rail trip. Prestige offers a private cabin with bed, chairs, wash basin, toilet and shower. Sleeper gives you a berth (bed) and access to public showers and toilets. Prestige and Sleeper classes include meals. Economy provides a seat for both day use and sleeping. Trips include mini presentations such as wine tastings, talks about the region and performances by solo musicians. Of course, never-ending scenery and conversation with fellow travellers are always available at no additional charge. Onboard dress code is casual, which can mean anything from hiking boots and jeans to jackets, trousers and skirts. Passengers can opt for a custom-made itinerary, which includes hotels and local guided tours at several

In Kamloops, BC, one performer wears a coyote skin headdress as the Secwepemc First Nations people dance for visitors on the grounds of a former residential school.

A BC Ferry takes travellers north through the inland passage known as the Haida Gwai to Prince Rupert, where they join The Skeena for the next leg of the trip.

destination stops. Or make your own land arrangements, with layovers wherever your fancy takes you. We chose the latter and, glad to say, it worked perfectly, giving us experiences that were unique, unexpected and most of all, fun. In the mood to party big time? VIA’s Commemorative Bundle to celebrate Canada’s 150th birthday is a lux 23-day package that includes train, hotels, tours and extras such as a Canada by Train book, a Tim Horton’s gift card (eh!) and a half bottle of Veuve Clicquot. There are two-day stopovers in Vancouver, Winnipeg, Toronto, Ottawa, Montreal and Quebec City, and a three-dayer in Halifax. Prices start at $12,396 per person (freshtrackscanada.com/ vacation/pancanadian-coast-to-coast). All VIA trains offer Internet service and onboard entertainment on your own electronic device, which includes news, TV shows and movies. Carry-on luggage of up to 11.4 kilograms and an additional bag of up to 15 kilograms are free of charge. Although our trip was done seven years ago, everything mentioned, unless otherwise noted, has stood the test of time and is currently available. Would we do it again? Just two words: “All aboard!” JUNE 2017 • Doctor’s

Review

The West Coast kitchen Recipes from a BC chef inspired by the land she loves recipes by

Denise Marchessault

recipes photos by

Caroline West

Cured salmon.

he recipes in British Columbia from Scratch (Whitecap Books) are completely biased. Born in the Cowichan Valley, the cookbook’s author,

Denise Marchessault, admits that the book is a personal collection of the “rustic” foods she’s enjoyed since childhood. One of BC’s greatest blessings is its water, which includes the Pacific and the salmon-rich Fraser River. Not surprisingly, there are several seafood recipes in the book and we’ve included one here. Naturally, there are also recipes that celebrate fresh, local produce:

Doctor’s Review • JUNE 2017

berries from Westham Island, peaches from the Okanagan Valley, wild mushrooms from ancient forests on Vancouver Island. The recipes are divided by the seasons with stunning photos by friend Caroline West. Marchessault describes them as simple, but “simple,” she says “is not always synonymous with quick.” We’re sure they’re worth the time.

CURED SALMON Cured salmon is a nice change from smoked salmon. If you’ve never cured fish before you’ll be surprised how easy it is. There are many ways to cure salmon, but the principles are pretty much the same: bury the fish in seasoned salt and sugar, add a few pounds of weight (compressing salmon in the cure helps to draw out its moisture) and refrigerate for 24 to 48 hours. In this recipe, salt is mixed with fennel fronds and fennel seeds, which impart a warm and subtle hint of liquorice. You could also use dill or parsley or a combination of your favourite herbs and spices. Just stay away from strong herbs like rosemary because they’ll overpower the fish. Serve cured salmon with crackers or dark rye and let guests help themselves to shallots, fresh dill, capers and lemon. Cured salmon will keep for about a week in the refrigerator, but never seems to last that long.

weighing about 5 pounds (2.2 kg) in total. Refrigerate for 24 hours. Remove the salmon from the curing mixture and rinse thoroughly in cool water. The salmon’s texture will be firm. Pat completely dry with paper towels. Using a sharp knife, slice the salmon thinly at a 45-degree angle, holding a corner of the skin to keep it in place. Discard the skin. Serve with fresh lemon, capers, shallots and freshly ground black pepper. Makes 8 to 10 appetizer-sized servings.

ROASTED CAULIFLOWER AND BROCCOLI PESTO PIZZA This makes a nice change from a typical tomato-based pizza. The dough is easy

to make and comes together quickly. Plus, it tastes even better after a day in the fridge! The crust is slathered with a vibrant garlic-lemon broccoli pesto, and topped with feta and sweet roasted cauliflower. The pesto, which also doubles as a great pasta topping, can be made in advance. If you have a pizza stone, use it; it distributes the heat evenly and makes for a crisp crust. whole wheat pizza dough (recipe follows) 1 small head cauliflower (about ½ lb. / 250 g) 2 tbsp. (30 ml) vegetable oil, divided ¼ tsp. (1 ml) kosher salt broccoli pesto (recipe follows) 1 c. (250 ml) crumbled feta (about 4 oz. / 120 g), divided 2 tbsp. (30 ml) freshly grated Parmesan cheese ½ lemon, sliced

1½ lb. (700 g) fresh salmon fillet, preferably sockeye, skin on fennel fronds from 1 fennel bulb 2½ c. (625 ml) kosher salt 2½ c. (625 ml) sugar 1 tbsp. (15 ml) fennel seeds, crushed 1 fresh lemon, sliced 2 tbsp. (30 ml) capers, rinsed 1 shallot, thinly sliced freshly ground black pepper

Coarsely chop the fennel fronds and set aside the bulb for another use. Thinly sliced raw fennel is delicious in salads. Remove any pin bones from the salmon. Toss the chopped fennel fronds into a bowl with the salt, sugar and crushed fennel seeds. (The salmon releases plenty of liquid as it cures, so select a container at least 2 inches / 5 cm deep.) Scatter half the curing mixture in an even layer in the container, nestle the salmon on top and cover with the balance of the mixture. Cover the salmon and curing mixture with plastic wrap, then place a flat object, like a small plastic cutting board, on top. Weight the board with 2 to 3 cans or other suitable objects Roasted cauliflower and broccoli pesto pizza.

Prepare the pizza dough. Preheat a pizza stone or baking sheet in a 375°F (190°C) oven. Divide the pizza dough in half and place each portion on a sheet of parchment dusted with flour. Stretch and shape the dough with your hands or a rolling pin to fashion two pizzas about 9 inches (23 cm) each in diameter. Cover and set aside while you prepare the toppings. Trim and core the cauliflower; slice the florets to a ¼-inch (6 mm) thickness and break into bite-sized pieces. Transfer to a large bowl, drizzle with 1 tablespoon (15 ml) oil and sprinkle with salt. Toss to combine, then spread onto a parchment-lined baking sheet in a single layer. Bake for about 20 to 30 minutes, tossing occasionally, or just until the cauliflower starts to turn golden around the edges. (The cauliflower will be baked again with the pizza.) Meanwhile, prepare the pesto. Remove the cauliflower and increase the oven temperature to 450°F (230°C).

Spread each pizza with about ¼ cup (60 ml) pesto, leaving a ½-inch (1-cm) border. Distribute the feta over the pesto, then top with the roasted cauliflower. Brush the pizza border with oil. Transfer each pizza, along with the parchment, to the preheated pizza stone or baking sheet in the oven; bake for about 10 to 12 minutes or until the edges are crisp. Sprinkle with freshly grated Parmesan and serve with lemon slices on the side. Makes two 9-inch (23-cm) pizzas.

Whole wheat pizza dough This dough comes together very quickly and makes a nice change from a traditional white flour pizza dough. The dough tastes even better after a day in the fridge, so plan to make it the night before you serve it. If you enjoy pizza, a pizza stone and wooden paddle are good investments;

the stone provides a crisp crust and the paddle makes it easy to get your pizza in and out of the oven without any mishaps. ½ tsp. (2.5 ml) quick-rise (instant) yeast 1 c. (250 ml) lukewarm water 1½ c. (375 ml) white flour ½ c. (125 ml) whole wheat flour 1 tsp. (5 ml) sugar 1½ tsp. (7.5 ml) salt 2 tbsp. (30 ml) vegetable oil 2 tbsp. (30 ml) plain yogurt

Dissolve the yeast in the water in a spouted cup and stir to combine. Mix the dry ingredients together in a large bowl. Add the oil and yogurt to the yeast and water, mix well, then pour over the dry ingredients and stir together with a fork. When the mixture becomes too unwieldy, use your hands to gather the dough into a ball, swiping the sides of the bowl with the dough to gather any stray bits of flour. Turn the dough onto a lightly floured surface and knead for 1 to 2 minutes until the dough becomes soft and pliable. Place the dough into a lightly oiled bowl, and cover and rest in a warm draft-free area, such as the top of the stove, or in an oven with only the light bulb on, for about 1 hour. After the dough has rested, knead for about 1 minute, re-shape and return it to the bowl. Cover and refrigerate at least 4 hours, preferably overnight before using. Makes two 9-inch (23-cm) pizzas.

Broccoli pesto 2 c. (500 ml) broccoli florets (about 1 small crown), broken into 2-inch (5 cm) pieces ½ c. (125 ml) flat-leaf parsley ½ c. (125 ml) fresh basil leaves 1 garlic clove, sliced 2 anchovies, lightly rinsed ½ tsp. (2.5 ml) kosher salt 4 tsp. (20 ml) freshly squeezed lemon juice 6 tbsp. (90 ml) vegetable oil

Blanch the broccoli florets in heavily salted boiling water, about 2 teaspoons (10 ml) salt per 4 cups (1 L) water for about 2 minutes; remove with a slotted Raspberry mousse.

spoon and transfer to a bowl of very cold water and drain. Place the broccoli and remaining pesto ingredients into the bowl of a food processor and pulse to a spreadable consistency, leaving some irregular pieces. Alternatively, chop the ingredients finely with a knife. Taste and season with additional salt and lemon juice, if desired. Pesto keeps in the fridge for up to 1 week. Makes 1 cup (250 ml).

RASPBERRY MOUSSE A few ingredients is all it takes to create this light, delicate raspberry mousse. Topped simply with plump raspberries, this dessert is the perfect ending to a summer’s meal. If you don’t have raspberries on hand, this recipe can be made with strawberries or blackberries instead. Mousse can be prepared up to two days in advance, covered and refrigerated. 3¼ c. (810 ml) fresh or frozen raspberries (thawed if frozen), plus extra for garnish ½ c. (125 ml) granulated or superfine

sugar, plus extra as needed 1 tbsp. (15 ml) unflavoured gelatin (usually 1 packet) 1 c. (250 ml) whipping cream

Process the raspberries in a food processor or blender until smooth, then press the purée through a fine-mesh strainer into a bowl, using the back of a ladle or large spoon to extract as much juice as possible. Discard the seeds. Measure out 1¼ cups (310 ml) strained purée. Add the sugar to the purée, mix well and set aside for the sugar to dissolve, about 5 minutes. Taste the purée; if your berries are tart, you may need to add additional sugar. Bring 1 cup (250 ml) of water to a boil (you’ll only use a small amount). Pour the packet of gelatin into a small bowl or teacup. Cover with 3 tbsp. (45 ml) boiling water and mix continuously with a small spoon until the gelatin is completely dissolved with no lumps, about 1 minute. Scrape the gelatin into the berry purée and mix until well combined. Whip the cream in a large bowl until soft peaks form, being mindful not to over-whip the cream.

INDICATION: ASMANEX® Twisthaler®, a preventative agent, is indicated for the prophylactic management of steroid-responsive bronchial asthma in patients 4 years of age and older.2 CONTRAINDICATIONS:2 • Hypersensitivity to this drug, milk proteins (from the excipient lactose), or any component of the container • Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required • Untreated systemic fungal, bacterial, viral or parasitic infections, active or quiet tuberculous infection of the respiratory tract, or ocular herpes simplex RELEVANT WARNINGS AND PRECAUTIONS:2 • Should not be stopped abruptly • Risk of adrenal insufficiency in patients transferred from systemically active corticosteroids • Oropharyngeal candidiasis • Risk of systemic effects of inhaled corticosteroids • Hypercorticism, adrenal suppression, growth retardation in children/adolescents, reduced bone mineral density, osteoporosis, fracture, cataracts, glaucoma • Risk of dose-dependent bone loss • Enhanced effect of corticosteroids in patients with cirrhosis or hypothyroidism • Do not exceed recommended dose • Rare systemic eosinophilic conditions

Pour the fruit purée into the whipping cream, in three batches, gently folding the purée into the cream after each addition. Mix until the mousse is uniform in colour. Transfer the mixture into a spouted jug (for easy pouring) and distribute into containers immediately, before the mousse sets. Refrigerate until firm, about 2 hours. Garnish with fresh raspberries. Makes eight 3-ounce (90 ml) servings. Recipes and images from British Columbia from Scratch: Recipes for Every Season (Whitecap Books, 2016).

MEDICAL QUIPS It makes sense She wanted a puppy. But I didn’t want a puppy. So we compromised and got a puppy.

• Caution when used with acetylsalicylic acid

in hypoprothrombinemia

• Risk of immunosuppression • Not for rapid relief of bronchospasm • Possible inhalation induced bronchospasm • No adequate studies in pregnant/nursing women • Risk of hypoadrenalism in infants born to women

receiving corticosteroids

• Monitoring of: HPA axis function and haematological status

periodically during long term therapy, use of short-acting inhaled bronchodilators, bone and ocular effects, height of children and adolescents

For more information: Please consult the Product Monograph at http://www.merck.ca/ assets/en/pdf/products/ASMANEX_Twisthaler-PM_E.pdf for important information relating to adverse reactions, drug interactions, and dosing/administration information (particularly dose reduction to the lowest possible dose required to maintain asthma control) which have not been discussed in this advertisement. The Product Monograph is also available by calling us at 1-800-567-2594. References: 1. Bousquet J et al. Comparison of the efficacy and safety of mometasone furoate dry powder inhaler to budesonide Turbuhaler®. Eur Respir J. 2000;16:808-816. 2. ASMANEX® Twisthaler® Product Monograph. Merck Canada Inc., March 18, 2015.

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P H OT O FI NI SH by

Dr Da v i d R . B r ook

BC in bloom advertisers index ALLERGAN INC. Fibristal....................................................OBC BOEHRINGER INGELHEIM (CANADA) LTD Jardiance....................................................4, 5 MERCK CANADA INC. Asmanex................................................... IFC PFIZER CANADA INC. Duavive......................................................2, 3 Pristiq...........................................................25 SEA COURSES INC. Corporate.....................................................11 SERVIER CANADA INC. Viacoram......................................................18 VALEANT CANADA INC. Jublia..............................................................6 WELLESLEY THERAPEUTICS Ultimate Glucosamine.................................15 XLEAR INC. Xlear nasal spray..........................................13

Photographing springtime in Victoria is like shooting ducks in a barrel. I was on my way back from a visit to a nursing home when I spotted fawn lilies growing in perfusion near the road in Beacon Hill Park in mid-April. A gentle rain had just ended and the sun had come out. The Latin name for fawn lilies is Erythronium Oregonum. Ask your Harry Potter-loving kids about these spellbindingly beautiful flowers. Canada’s West Coast, and Southern Vancouver Island in particular, is a paradise for birders, foragers, horticulturalists, and lovers of the Universe. BC’s Father of Confederation, Amor de Cosmos (born William Alexander Smith) was probably inspired to choose his new name based on where he resided — not far from Beacon Hill Park.

MDs, submit a photo! Please send a high-resolution photo along with a 150- to 300-word article to:

editors@doctorsreview.com

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FAIR BALANCE INFORMATION Asmanex......................................................47 Viacoram......................................................19

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RA EXP TI AN O D N E O D F US E DU

FIBRISTAL® FOR THE MEDICAL MANAGEMENT OF UTERINE FIBROIDS Indication: FIBRISTAL is indicated for the intermittent treatment of moderate to severe signs and symptoms of uterine fibroids in adult women of reproductive age. The duration of each treatment course is three months. ®

Contraindications: • Use during pregnancy and in women who are breastfeeding • Women with genital bleeding of unknown etiology or for reasons other than uterine fibroids • Women with uterine, cervical, ovarian or breast cancer Relevant warnings and precautions:

• Concomitant use of hormonal contraceptives not recommended • Use in patients with severe hepatic impairment unless the patient is

closely monitored

• Use in patients with moderate or severe renal impairment • Use in severe asthmatics insufficiently controlled by oral glucocorticoids • Changes in the histology of the endometrium may be observed in patients.

• Concomitant use with moderate or potent CYP3A4 inhibitors, CYP3A4

inducers, and potent enzyme inducers

• Should excessive bleeding persist beyond the first 10 days of treatment,

patient should notify physician

• If altered, persistent or unexpected bleeding pattern occurs during treatment,

investigation of the endometrium including endometrial biopsy should be performed to exclude other underlying conditions

For more information: For additional information relating to adverse reactions, drug interactions, and dosing information, please consult the product monograph at http://fibristal. ca/docs/Fibristal_Product_Monograph_E.pdf. The product monograph is also available by calling us at 1-800-668-6424. REFERENCES: 1. FIBRISTAL Product Monograph, Allergan Pharma Co., November 2016. 2. Data on File, Allergan Inc., November 2016. ®

These changes are denoted as “Progesterone Receptor Modulator Associated Endometrial Changes” (PAEC) and are reversible after treatment cessation. Investigate persistent endometrial thickening beyond 3 months following end of treatment. Studied in up to 4 intermittent treatment courses. FIBRISTAL and its design are registered trademarks of Allergan Sales, LLC, used under license by Allergan Pharma Co. ALLERGAN and its design are trademarks of Allergan Inc. © 2017 Allergan. All rights reserved. ®