March 2016 by Doctor's Review

MARCH 2016 CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

Enchanting Dordogne Alluring Alsace Shimmering Ireland Astonishing golf Nourishing recipes Cutting the TV cable

MEDICINE ON THE MOVE

SPRINGTIME inEUROPE WIN

THIS MONTH’S

GADGET PAGE 20

First Nations diabetes Depression strategies

IN E L B ILA A AV

D NA

FORXIGA (dapagliflozin) is a reversible inhibitor of sodium-glucose co-transporter 2 (SGLT2) that improves glycemic control by reducing renal glucose reabsorption leading to urinary excretion of excess glucose (glucuresis)1,2 *â&#x20AC;

The first and only fixed-dose combination of an SGLT2 inhibitor with metforminâ&#x20AC;Ą XIGDUO combines two antihyperglycemic agents with complementary mechanisms of action to improve glycemic control in patients with type 2 diabetes: dapagliflozin and metformin hydrochloride2 *

There have been no clinical studies conducted with XIGDUO tablets. XIGDUO tablets demonstrated comparable bioavailability of dapagliflozin and metformin with co-administered tablets of dapagliflozin and metformin in a four-way crossover comparative bioavailability study.

XIGDUO

• Increased mean hemoglobin/hematocrit and frequency of patients with abnormally elevated values of hemoglobin/hematocrit

Indications and clinical use:

• Hypoglycemia

XIGDUO is indicated for use as an adjunct to diet and exercise in adults with type 2 diabetes mellitus who are already being treated with dapagliflozin and metformin as separate tablets and achieving glycemic control. XIGDUO is also indicated for use in combination with insulin as an adjunct to diet and exercise in adults with type 2 diabetes mellitus who are already achieving glycemic control with dapagliflozin, metformin and insulin.

• Increased risk of genital mycotic infections • Temporary suspension for any surgical procedure; discontinue 2 days before procedure and should not be restarted until patient’s oral intake has resumed and renal function is normal

Not for use in pediatrics (<18 years).

• Use of concomitant medications that may affect renal function or result in significant hemodynamic change or may interfere with the disposition of metformin

Geriatrics (≥65 years of age): caution as age increases.

• Periodic measurements of fasting blood glucose and A1c levels

Contraindications:

For more information:

• Unstable and/or insulin-dependent (Type I) diabetes mellitus

Please consult the Product Monograph at www.azinfo.ca/xigduo/pm944 for important information relating to adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling 1-800-668-6000.

• Acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma, history of ketoacidosis with or without coma, history of lactic acidosis, irrespective of precipitating factors • In patients with serum creatinine levels above the upper limit of normal range or when renal function is not known, renal disease or renal dysfunction, or abnormal creatinine clearance (<60 mL/min), which may result from conditions such as cardiovascular collapse (shock), acute myocardial infarction, and septicemia • Excessive alcohol intake, acute or chronic • Severe hepatic dysfunction, since severe hepatic dysfunction has been associated with some cases of lactic acidosis, XIGDUO should not be used in patients with clinical or laboratory evidence of hepatic disease • Cardiovascular collapse and in disease states associated with hypoxemia, which are often associated with hyperlactacidemia • Stress conditions

FORXIGA FORXIGA is indicated in monotherapy 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. FORXIGA is also indicated in adult patients with type 2 diabetes mellitus to improve glycemic control in add-on combination with metformin, a sulfonylurea, metformin and a sulfonylurea, sitagliptin (alone or with metformin), or insulin (alone or with metformin), when metformin alone or the existing therapy listed above, along with diet and exercise, does not provide adequate glycemic control. Consult the complete Product Monograph at www.azinfo.ca/forxiga/pm367 for important information about:

• Severe dehydration • During pregnancy and breastfeeding

• Contraindications in patients with moderate to severe renal impairment, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, end-stage renal disease and patients on dialysis.

• Period around administration of iodinated contrast materials Most serious warnings and precautions: Lactic acidosis: can occur due to metformin accumulation during treatment. Patients should be cautioned against excessive alcohol intake as it can potentiate the effect of metformin on lactic acidosis. Other relevant warnings and precautions: • Not for use in patients with active bladder cancer and use with caution in patients with a prior history of bladder cancer • Not for use in patients concomitantly treated with pioglitazone • Not recommended for use in patients who are volume-depleted; caution in patients for whom a dapagliflozin-induced 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 is recommended and temporary interruption of XIGDUO should be considered for patients who develop volume depletion until the depletion is corrected

• Relevant warnings and precautions: not for use in type 1 diabetes or for the treatment of diabetic ketoacidosis; not for use in patients with active bladder cancer and use with caution in patients with a prior history of bladder cancer; not recommended for use in patients who are volume depleted; caution in patients for whom a FORXIGA-induced 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 is recommended and temporary interruption of FORXIGA should be considered for patients who develop volume depletion until the depletion is corrected; DKA, caution in patients at higher risk of DKA and when reducing a patient’s insulin dose; risk of hypoglycemia when used in combination with insulin or insulin secretagogues; dose-related LDL-C increases; monitor LDL-C levels; increased mean hemoglobin/hematocrit and frequency of patients with abnormally elevated values of hemoglobin/hematocrit; increased risk of genital mycotic infections and urinary tract infections; not recommended in severe hepatic impairment; renal function should be assessed prior to initiation of FORXIGA and regularly thereafter; not for use in pregnant or nursing women; patients taking FORXIGA will test positive for glucose in their urine.

• Hypoxic states have been associated with lactic acidosis and may also cause prerenal azotemia. When such events occur, XIGDUO should be promptly discontinued

• Conditions of clinical use, adverse reactions, drug interactions, and dosing instructions.

• Risk of hypoglycemia when used in combination with insulin

The Product Monograph is also available by calling 1-800-668-6000.

• Dose-related LDL-C increases; monitor LDL-C levels • Laboratory abnormalities or clinical illness should be evaluated promptly in patients previously well controlled on XIGDUO for evidence of ketoacidosis or lactic acidosis; if acidosis occurs, XIGDUO must be stopped immediately and corrective measures initiated

* Clinical significance unknown. † The amount of glucose removed by the kidney through this mechanism is dependent upon the blood glucose concentration and glomerular filtration rate. ‡ Comparative clinical significance unknown.

• Temporary loss of glycemic control when exposed to stress • Decrease in vitamin B12 levels; initial and periodic monitoring of hematologic parameters advised

01/17

References: 1. FORXIGA Product Monograph. AstraZeneca Canada Inc., December 8, 2015. 2. XIGDUO Product Monograph. AstraZeneca Canada Inc., December 9, 2015.

A CANADIAN DEVELOPMENT

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

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

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

O140 NMG ESC O N E EVERY FIXED

DOSE

CLICK

TWO WEEKS

1,2†

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

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

™

PATIENT SUPPORT PROGRAM

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

™

1,2

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

™

There’s magic in the world

THIEURY / SHUTTERSTOCK.COM

The town of Rocamadour sits atop a gorge above the Dordogne River Valley in southwest France. It’s a magical place with a history that goes back almost to the time of Christ. Legend has it that it was founded by Saint Amator whose wife, Veronica, was said to have wiped Jesus’ face on the way to Calvary. Be that as it may, the spectacular setting and the many monasteries and churches built there over the centuries have attracted pilgrims since the Middle Ages. And there’s a Canadian connection. In February 1536, Jacques Cartier, who claimed what is now Canada for France, prayed to the Blessed Virgin, Our Lady of Rocamadour, and promised that he would visit her shrine “if he should obtain the grace to return to France safely.” It’s not recorded whether he made good on his pledge, but had he done so he would have discovered a most magical spot. My wife and I first visited some years ago, and experienced a miracle or two of our own. On our first night we chose to dine at a Michelin-starred restaurant famous for its coq au vin. The place was tiled, floor to ceiling, in glistening white ceramic. Moreover, it was lit with fluorescent lights. It was like dining in a public washroom. We’d only taken a mouthful when my wife said she’d enjoy it more in a less antiseptic atmosphere. The instant the words were out of her mouth, the lights in the entire town went out. The waiters brought candles and we enjoyed a delightful dinner bathed in a romantic glow. The next day, we spread a picnic under a large tree along the river, as charming a setting as you could possibly find. We laid out a baguette and a round of Rocamadour cheese and some fruit, and were about to uncork a bottle of wine when there was an ominous creaking and the tree came crashing down. This was no sapling, the trunk was too large to get my arms around and the ground was piled metres high with fallen branches. It was a small miracle it missed us — and our rental car. Read more about this fascinating area in the article by long-time contributor Jeremy Ferguson beginning on page 34. While enjoying rural France, you may want to visit an entirely different part of the country. Alsace is in the northeast and offers a three-in-one pleasure punch. Switzerland and Germany are just across the border. Read all about it in Alluring Alsace, page 31, by Philippe Erhard, a Manitoba family physician who grew up in the area. There’s a lot more to enjoy in this issue including a delightful piece on southwest Ireland by Robb Beattie, page 40. Golfers won’t want to miss Anita Draycott’s enthusiastic description on a round at Cabot Cliffs in Cape Breton, our newest and best links course, page 46. Warmer weather’s on the way!

Rocamadour, France.

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David Elkins, publisher and editor delkins@parkpub.com

@doctorsreview MARCH 2016 • Doctor’s

Review

heartburn

Because doesn’t give a hoot what time it is

DEXILANT : Demonstrated 24-hour heartburn relief ®

96% of 24-hour periods were heartburn-free

99% of nights were heartburn-free

vs. 29% with placebo in patients maintaining healed erosive esophagitis (EE) with DEXILANT® 30 mg (median; p<0.00001, secondary endpoint)1,2†

vs. 72% with placebo in patients maintaining healed EE with DEXILANT® 30 mg (median; p<0.00001, secondary endpoint)1,2†

Dual Delayed Release® (DDR®) technology in a PPI: Unique to DEXILANT®1

‡§

Two types of enteric-coated granules deliver 2 distinct releases of drug: • The first type of granule is designed to release drug early in the proximal small intestine • The second type of granule is designed to release drug several hours later in the distal small intestine

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

• Patients >71 years of age may already be at high risk for osteoporosis-related fractures and should be managed carefully according to established treatment guidelines • Chronic use may lead to hypomagnesemia. For patients expected to be on prolonged treatment or concurrent treatment with digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), initial and periodic monitoring of magnesium levels may be considered • May interfere with absorption of drugs for which gastric pH is important for bioavailability • Co-administration of HIV protease inhibitors for which gastric pH is important for bioavailability (e.g., atazanavir, nelfinavir) is not recommended • Prolonged use may impair absorption of protein-bound Vitamin B12 and may contribute to development of cyanocobalamin deficiency • Should not be administered to pregnant women unless the expected benefits outweigh the potential risks • Should not be given to nursing mothers unless its use is considered essential. In this case nursing should be avoided

DEXILANT® and Dual Delayed Release® are registered trademarks of Takeda Pharmaceuticals U.S.A., Inc. and used under licence by Takeda Canada Inc. Product Monograph available on request. Printed in Canada © 2016 Takeda Canada Inc.

For more information: For more information on Contraindications, Warnings, Precautions, Adverse Reactions, Interactions, and Dosing, please consult the Product Monograph at www.takedacanada.com/dexilantpm. The Product Monograph is also available by calling us at 1-866-295-4636. † Results of a 6-month, multicenter, double-blind, placebo-controlled, randomized study of patients who dosed DEXILANT® 30 mg (n=140) or placebo (n=147) once daily and had successfully completed an EE study and showed endoscopically-confirmed healed EE.2 ‡ Clinical significance has not been established. § Comparative clinical significance unknown. References: 1. DEXILANT® Product Monograph, Takeda Canada Inc., April 22, 2015. 2. Metz DC, Howden CW, Perez MC et al. Clinical trial: dexlansoprazole MR, a proton pump inhibitor with dual delayed-release technology, effectively controls symptoms and prevents relapse in patients with healed erosive oesophagitis. Aliment Pharmacol Ther 2009;29(7);742-54.

contents MARCH 2016

COVER: CREATIVE SOUL / SHUTTERSTOCK.COM

features

Alluring Alsace Colourful timbered houses and hillside vineyards give Eguisheim a fairytale feel by Dr Philippe Erhard

34 France at its most enchanting

A ramble along the Dordogne River in the southwest countryside known for its castles, monasteries and cuisine by Jeremy Ferguson

Thrills on Cabot Cliffs Cape Breton’s new true links golf course where you can play as they did in Scotland back in the day by Anita Draycott

Under Irish skies County Kerry’s shimmering green, home to the Wild Atlantic Way, the Skellig Rocks and some very artful sheep by Robb Beattie

The whole truth Apricot ginger granola plus more recipes with beans, nuts and seeds for breakfast, lunch and dinner by Nettie Cronish and Cara Rosenbloom

53 MARCH 2016 • Doctor’s

Review

CONSIDER

COVERSYL®

DISPENSED ACEI IN INITIAL THERAPY*

COVERSYL® reduces blood pressure in patients with mild to moderate essential hypertension. COVERSYL® is indicated for the treatment of mild to moderate essential hypertension. It may be used alone or in association with other drugs, particularly thiazide diuretics. The safety and efficacy of COVERSYL® in renovascular hypertension have not been established and therefore, its use in this condition is not recommended. The safety and efficacy of concurrent use of COVERSYL® with antihypertensive agents other than thiazide diuretics have not been established. Use in children is not recommended.

COVERSYL® reduces CV risk in hypertensive and/or post-MI patients with stable CAD. COVERSYL® is indicated for the reduction of cardiovascular (CV) risk in patients with hypertension or post-myocardial infarction (MI) and stable coronary artery disease (CAD). COVERSYL® has been demonstrated to reduce the risk of CV death, non-fatal MI and cardiac arrest in mild or moderately hypertensive patients with stable CAD, or in patients with a previous (> 3 months ago) MI and stable CAD, including patients with previous revascularization when administered as an add-on to conventional treatment, such as platelet inhibitors, beta blockers, lipid-lowering agents, nitrates, calcium channel blockers or diuretics. Use in children is not recommended.

Please consult the product monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for contraindications, warnings, precautions, adverse reactions, interactions, dosing and conditions of clinical use. The product monograph is also available by calling us at 1-800-363-6093. ACEI = Angiotensin converting enzyme inhibitor *Data on file, IMS Brogan, Servier Canada Inc., April 2014 to March 2015.

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

COVERSYL® is a registered trademark of Servier Canada Inc.

contents MARCH 2016

regulars 11

LETTERS Doctors in opera

PRACTICAL TRAVELLER Space Center Houston’s new $14-million shuttle show, Whistler-Blackcomb gets a museum, Lonely Planet’s free app and more by Camille Chin

DEPRESSION KEYPOINTS Strategies in remission and relapse by Mairi MacKinnon

GADGETS Cut the TV cable by David Elkins

TOP 25 The biggest medical meetings happening this summer

HISTORY OF MEDICINE Do residential schools have a role in the First Nations diabetes epidemic? by Rose Foster

Coming in

April

• Travel along China’s ancient Silk Route that’s linked east and west for 2000 years • Eat and drink your way up and down the New England coast • Sail from Barcelona to Rome on a 300-passenger luxury yacht

• Safari on steroids: make a luxurious South African villa your base for adventure MARCH 2016 • Doctor’s

Review

PA R T O F T H E N OVA R T I S C O P D P O R T FO L I O

NOW ON PROVINCIAL FORMULARY (Specia l Authorization)

A once-daily dual LAMA/LABA bronchodilator for COPD1 Indications and clinical use: ULTIBRO® BREEZHALER® (indacaterol maleate and glycopyrronium bromide) is a combination of a long-acting β2-agonist (LABA) and a long-acting muscarinic antagonist (LAMA), indicated for the long-term once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema. Consult the complete Product Monograph at www.novartis.ca/UltibroMonograph for important information about: • Contraindications in asthma, severe hypersensitivity to milk proteins or hypersensitivity to any component of ULTIBRO® BREEZHALER® • The most serious warnings and precautions regarding asthma-related death • Other relevant warnings and precautions regarding acute episodes of bronchospasm; acutely deteriorating COPD; concomitant use with other LABAs and LAMAs; use in patients with narrow-angle glaucoma, urinary retention, cardiovascular disorders, especially coronary insufficiency, acute myocardial infarction, cardiac arrhythmias, and hypertension, known history of QTc prolongation, risk factors for torsade de pointes, or patients who are taking medications known to prolong the QTc interval; convulsive disorders, thyrotoxicosis; patients who are unusually responsive to sympathomimetic amines, severe renal impairment, severe hepatic impairment; risk of hypokalemia, hyperglycemia, immediate hypersensitive reactions including angioedema, urticaria, or skin rash; risk of paradoxical bronchospasm; use during labour, pregnancy/nursing and delivery • Conditions of clinical use, adverse reactions, drug interactions and dosing/administration instructions The Product Monograph is also available by calling the Medical Information Department at 1-800-363-8883.

Reference: 1. ULTIBRO® BREEZHALER® Product Monograph. Novartis Pharmaceuticals Canada Inc., August 18, 2014. ULTIBRO and BREEZHALER are registered trademarks. Product Monograph available on request. PRO/ULT/0009E © Novartis Pharmaceuticals Canada Inc. 2015

LETTERS

EDITOR

David Elkins

Doctors in opera

MANAGING 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

Claudia Masciotra

EDITORIAL BOARD

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

MONTREAL HEAD OFFICE

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

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

HEALING THOUGHTS I was interested in reading about the volunteering opportunities [doctorsreview. com/volunteer], however it would be nice to know if the various programs ensure that there is continuity of care. I have worked in Central America before. In some programs healthcare workers fly in, run clinics and then fly out again. Were there links to any public health care system that exists? Prescribed medicines may become unavailable. Side effects are not monitored. We may feel good helping the needy, but they may not be benefiting in the long term. Dr David Rosen Mississauga, ON

CLASS ACTS Opera, yes, I love it... now. It grows on you. The more you see it, the more you appreciate it. The drama, the intensity, the bipolarity of emotions. Nothing is ever grey. The more you read about it, the more links you make. Opera is theatre, music, emotions, dance or ballet. Nothing is static. I appreciated your article on doctors in the opera in the November issue [Dr Grenvil in Verdi’s La Traviata, page 42]. It seems to me these doctors always come in too late. There is often nothing to be done to save the dying one (La Traviata, Pelléas et Mélisande). Sometimes the doctors are vengeful (Dr Bartolo in Le Nozze di Figaro), sometimes selfish (the scientist in the person of the doctor in Wozzeck who trades the sake of the patient for his reputation, Dr Miracle who asks Antonia weakened by an arrythmia to sing, knowing she might die from it, which she does). Other times the doctors are influential (Dr

CONGRATULATIONS!

The winner of an atomic projection clock by Oregon Scientific is Dr Virginia Clark, a family physician from Golden, BC. Malatesta in Don Pasquale exercises psychological influence to get Norina to agree to a sham marriage with the old Don Pasquale) or simple-minded (Dr Spinelloccio who is unaware that his patient has been substituted for another). Doctors in the opera don’t have a great reputation. They don’t look like one you would hope to have on a house call. Good thing opera is fiction! I would greatly be interested in reading more about opera in your magazine. Dr Nadine Cassiani Via email

In La Traviata, Dr Grenvil (Alan Fairs) treats the dying Violetta (Carmen Giannattasio). Scottish Opera, 2008.

DREW FARRELL

Camille Chin

CONTRIBUTING EDITOR

MARCH 2016 • Doctor’s

Review

For your adult patients with type 2 diabetes

Equipped for glycemic control. Trajenta® is indicated in adult patients with type 2 diabetes mellitus (T2DM) to improve glycemic control. • Monotherapy: In conjunction with diet and exercise in patients for whom metformin is inappropriate due to contraindications or intolerance. • Combination therapy: • With metformin when diet and exercise plus metformin alone do not provide adequate glycemic control. • With a sulfonylurea when diet and exercise plus a sulfonylurea alone do not provide adequate glycemic control. • With metformin and a sulfonylurea when diet and exercise plus metformin and a sulfonylurea do not provide adequate glycemic control. Please refer to the product monograph at www.TrajentaPM.ca for important information relating to contraindications, warnings, precautions, adverse events, drug interactions, dosing and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633. Jentadueto™ (linagliptin/metformin hydrochloride) is indicated as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus when treatment with both linagliptin and metformin is appropriate, in patients inadequately controlled on metformin alone or in patients already being treated and well controlled with the free combination of linagliptin and metformin. Jentadueto™ is also indicated in combination with a sulfonylurea (i.e., triple combination therapy) as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on metformin and a sulfonylurea. Please refer to the product monograph at www.JentaduetoPM.ca for contraindications, warnings, precautions, adverse reactions, drug interactions, dosing and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633.

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

BITRJ00110 CATRJ00110

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

Whistler’s artistic side

PHOTO COURTESY HEFFEL.COM

PHOTO COURTESY TREVOR MILLS

Whistler’s new Audain Art Museum opened on March 12. Built in a grove of Engelmann and Sitka spruce hybrids on Blackcomb Way, it’s designed to integrate seamlessly into its surroundings. “The feeling is that the museum will be quietly inserted into a void within the forest,” architect John Patkau said prior to the opening. “It will be recessive and restrained in its visual presence.” The museum’s main section is on two levels and features the collection of art philanthropist Michael Audain and his wife Yoshiko. Spanning from the 18th century to present day, the permanent show features 200 works including one of the finest First Nations mask collections in the world, many pieces by Emily Carr, and others by post-war modernists such as E.J. Hughes, Gordon Smith and Jack Shadbolt. The temporary exhibition wing is used for rotating shows. Mexican Modernists: Orozco, Rivera, Siqueiros and Tamayo is on now through May 26. Adults $18; kids 16 and under free. Closed Tuesdays. audainartmuseum.com.

LEFT: Emily Carr’s The Crazy Stair (The Crooked Staircase), circa 1928-30. ABOVE: A yellow cedar Tsimshian chest, circa 1800-50.

MARCH 2016 • Doctor’s

Review

RENDERING COURTESY PATKAU ARCHITECTS

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

LMSPENCER / SHUTTERSTOCK.COM

Beginning in February, the Kenya Ministry of Tourism has waived the visa fee for kids of all nationalities under the age of 16. Visa fees start at US$50 a person for those 16 and up. Also, the Kenya Wildlife Service has capped park fees at US$60, down from US$90. According to tourism board figures, the number of visitors to Kenya fell by 25 percent in the first five months of 2015 following increased attacks by Islamist militants in recent years. Global Affairs Canada urges Canadian travellers to exercise “a high degree of caution” and advises against travel near the Somalia, Ethiopia, or South Sudan borders as well as the Eastleigh neighbourhood of Nairobi, but a nationwide advisory isn’t in effect. For details: travel.gc.ca/destinations/kenya.

Kenya with kids with care Hendrix’s home turned museum

Doctor’s Review • MARCH 2016

Jimi Hendrix described his flat on the upper floors of 23 Brook Street in London as “[his] first real home of [his] own.” His girlfriend, Kathy Etchingham, found it in June 1968 while he was in New York. He decorated it with curtains and cushions from the nearby John Lewis department store as well as knickknacks from Portobello Road market before heading back to the US to tour. He returned to the flat in January 1969 where he did a series of interviews and photo shoots, but travelled back to New York in March and never lived at the flat again. Composer George Frideric Handel lived next door at 25 Brook Street between 1723 and 1759, now the Handel House museum. In 2014, the Handel House Trust was awarded a heritage grant to restore the Hendrix flat. It opened as a museum this past February and features some of Hendrix’s personal items including two telephones and a scallop shell ashtray on the night table. Adults £7.50; kids five to 16 £3. handelhendrix.org.

Glacier National Park in Montana’s Rocky Mountains.

Go inside a space shuttle Space Center Houston opened its new $14-million complex on January 23. Independence Plaza features the 80-tonne shuttle replica Independence mounted on top of the original 159-tonne Boeing 747 shuttle carrier aircraft (SCA), and visitors can tour the interiors of both via a six-storey tower. The first stop is the Independence’s flight deck where visitors can see how astronauts piloted the orbiter through missions. One floor down is the mid-deck and its cramped living quarters as well as the payload bay where guests can see an artifact from STS-49, the satellite rescue mission that marked the first time that three people from the same spacecraft walked in space at the same time. The retrofitted Boeing 747 called Nasa 905 features exhibits about designing the shuttle and about how outside-the-box thinkers like John Kiker convinced his bosses that a shuttle mounted on an aircraft would work. Adults US$24.95; kids four to 11 US$19.95. spacecenter.org/independence.

MARCH 2016 • Doctor’s

Review

PR A CTICA L T RAVEL L ER

Looking sharp in Rome

JOLLY / SHUTTERSTOCK.COM

The Pyramid of Cestius is 36 metres tall with an exterior of white Carrara marble, but amazingly few people visit the 2000-year-old structure given Rome’s many ancient sites. Constructed as the burial tomb for a Roman magistrate named Caius Cestius, the pyramid’s burial chamber features frescoed figures in the style of Pompeii. Located near a busy intersection and subway station, the pyramid is one of four known to have been built in ancient Roman days, but the only surviving one today. Japanese clothing magnate Yuzo Yagi recently footed its €2 million restoration — Rome’s heavy pollution blackens and corrodes monuments. To reserve a spot on a tour (€5.50), call (011-39-06) 3996-7700. coopculture.it.

Lonely Planet gets an app Lonely Planet recently launched a free app that features guides to 38 cities around the world. Simply named Guides, the app lets users browse each city by categories — see, eat and shop, for example — and also by lists of curated content based on themes — a list of free activities or a list of attractions that have appeared in films. There are 1000 points of interest for each location, and essential tips and maps are available offline. iPhones and Androids.

Doctor’s Review • MARCH 2016

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

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

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

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

CA0115PRI005E

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

DE PRESSIO N K EY PO I NT S by

Mairi MacKinnon

with

Jeffrey S. Habert, MD, CCFP, FCFP

Optimal depression strategies Aim for remission and full functional recovery

Dr Habert is an Assistant Professor at the University of Toronto Department of Family and Community Medicine

P .

atients who respond well soon after being treated for major depressive disorder (MDD) may wonder if they can stop taking their antidepressants and attending cognitive behavioural therapy sessions — or may even decide to discontinue treatment on their own. In fact, a large percentage will stop their medications in the first 12 weeks.1 The risk of recurrence in MDD is high, especially if patients are still having residual symptoms.2-4 What are some of the challenges in treating to remission? How can you help your patients make a full recovery and stay well?

Burden of depression Depression takes a heavy toll on individuals, families/caregivers and society, with negative consequences in psychosocial, medical, occupational/functional and socioeconomic domains.2-4 Further, people who are diagnosed with MDD stand a good chance of facing recurring episodes over their lifetime. The risk of relapse rises incrementally with the number of episodes an individual experiences: from 50% after one episode, to 70% after two, and as high as 90% after three.2,4-6 Also, subsequent occurrences tend to be more severe.6 An evidence-based approach to diagnosis and treatment can help to reduce the burden of depression and lower the likelihood of relapse.3,4

Who is most at risk? Several clinical risk factors can predispose some individuals more than others to higher rates of recurrence. These include: older age; three or more previous episodes; chronic/severe/ psychotic or difficult-to-treat episodes; significant psychiatric or medical comorbidities; residual symptoms during current episode; and pattern of recurrence when stopping antidepressants.7 Among these factors, residual symptoms — present in many patients who respond initially to treatment — are of primary importance.3,7,8 Individuals with residual depressive symptoms have significantly higher rates of recurrence, and tend to relapse earlier, than those without symptoms.3,8 While 60 to 70% of patients respond to treatment, only 20 to 40% achieve full remission.3

Doctor’s Review • MARCH 2016

Remission vs response According to current Canadian guidelines, symptom reduction, or “response,” is not a sufficient treatment goal because residual symptoms are significant predictors of relapse and worse outcomes. Response equals a reduction of 50% or more in the score on rating scales such as the Hamilton Depression Rating Scale, Brief Patient Health Questionnaire (PHQ-9) or Beck Depression Inventory. Remission is equivalent to a score within “normal” on such scales.4 There is strong evidence to support long-term therapy (6 to 24 months or longer) for patients at high risk of recurrence. The goal of maintenance therapy is to address individual risk factors, deal with residual symptoms, treat any comorbid conditions, restore baseline functioning and quality of life, and prevent symptoms from coming back.4,7,9 This concept is known as full functional recovery. Besides antidepressants, evidence-based psychotherapies for maintenance, notably cognitive-based therapy (CBT) and mindfulness-based CBT, can help improve adherence and overcome other obstacles to continuation of treatment, and prevent relapse.3,8-10

Stumbling blocks One of the major barriers to remission is nonadherence — taking medication improperly or stopping treatment too early.3,5,6 This can result from patients not recognizing residual symptoms

Strategies for success and/or the severity of their symptoms (believing they’re “cured”); frustration with treatment or dissatisfaction with their progress; side effects; inadequate access to healthcare; and stigma associated with undergoing therapy for depression. Supporting patients and educating them about depression and how treatment works (both the challenges and benefits) can help to alleviate their concerns and improve adherence (see sidebar).3,4,11 Undertreatment (“treatment inertia”) can also be an issue, and may entail: • insufficient medication dosing and/or therapy duration • failure to optimize antidepressant dose or add therapy early on; follow-up should occur within 2–3 weeks to make possible drug therapy changes • failure to follow evidence-based practice guidelines • physician lack of time As many as two-thirds of patients do not achieve full remission with the first antidepressant; in these cases, it is important to reassess the diagnosis and treatment plan, and adjust as needed. For partial response to the first-line antidepressant, switching, augmentation and/or combination therapies might be of benefit. Validated rating scales can be helpful to monitor treatment response and tolerability.3,7

Adopt a personalized approach While the incidence of recurrence in MDD is high, measures are available to lower the chances. Consider your patients’ individual risk factors and treatment preferences, and follow an evidencebased management plan. Patient education and engagement are key. Encourage your patients by helping them understand the need to stick with the program for “as long as it takes” to ensure their prospects of full remission. References 1. Nutt DJ, Davidson JR, Gelenberg AJ et al. International consensus statement on major depressive disorder. J Clin Psychiatry 2010;71 Suppl E1:e08 2. Government of Canada. The human face of mental health and mental illness in Canada 2006. Ottawa: Minister of Public Works and Government Services Canada, 2006. 3. Van Rhoads R, Gelenberg AJ. Treating depression to remission: Target recovery, and give patients back their lives. Current Psychiatry 2005;4:14-28. 4. Patten SB, Kennedy SH, Lam RW et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. J Aff Disord 2009;117(Suppl 1):S5–S14. 5. CANMAT CME. Depression. Treating depressive disorder. Relapse and recurrence. www.canmat.org/cme-depression-relapse-and-recurrence.php. Accessed Feb. 15, 2015.

• Treat to remission and full functional recovery. Anything less than a full return to baseline functioning calls for further assessment and intervention.3,7 • Treat residual depressive symptoms robustly to help achieve your goals.3,4,7,8 • Follow evidence-based practice guidelines in recommending pharmacologic and cognitive behavioural therapies.3,7,8 Early treatment, optimization and followup are essential.4 • Educate patients about the need to continue treatment for at least six months after symptom remission and up to 2 years (or longer) if they are at high risk of relapse.4,7,9 • Enhance adherence by explaining that it might require trial and error to find the right antidepressant, and that it can take up to eight weeks to work. Also, make sure patients are aware that they should take medications as prescribed and not go off them without consultation; the risk of recurrence can be highest when antidepressants are stopped, and stopping abruptly can pose dangers to health (discontinuation syndrome).6,7,9,11 • Discuss common antidepressant side effects: most can be managed and will resolve over time.7,11 • Encourage self-management and emphasize the benefits of a healthy lifestyle, including diet, exercise, sleep and stress avoidance.4,7 • Monitor patients frequently to assess response to treatment and watch for side effects.3,4,7,11

6. University of Michigan Depression Center. Depression Toolkit.org. Preventing Recurrence. www.depressiontoolkit.org/aboutyourdiagnosis/preventingrecurrence.asp. Accessed Feb. 15, 2015. 7. Lam RW, Kennedy SH, Grigoriadis S et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy. J Aff Disord 2009;117(Suppl 1):S26–S43. 8. Paykel ES. Partial remission, residual symptoms, and relapse in depression. Dialogues in Clinical Neuroscience 2008;10:431-7. 9. Kennedy SH, Placenza FM. Guidelines for relapse prevention in the treatment of major depressive disorder. Medicographia 2011;33:158-62. 10. Parikh SV, Segal ZV, Grigoriadis S et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Aff Disord 2009;117(Suppl 1):S15–S25. 11. CANMAT CME. Depression. Treating depressive disorder.Tips to get depressed patients well. www.canmat.org/cme-depression-tips-to-get-depressed-patients-well.php. Accessed Feb. 15, 2015. MARCH 2016 • Doctor’s

Review

GADG ETS by

D a vid El kin s

Cut the cable Two reasons why you might want to cancel your cable or satellite service: 1) it’s expensive; 2) it may not provide the local channel that you want most. Here’s a good example: Downton Abbey is in its final season and it’s a “must-see” for millions. PBS is not available on the basic package in our area. Some months ago, we opted to go with an indoor HDTV antenna and now a neighbour and cable subscriber from down the street who doesn’t get the series joins us for it on Sunday nights. A thin sheet of shiny black plastic plugged into the antenna connection does all the heavy lifting. When first installed, I ran the TV though its channel selection scan and it came up with about a dozen HDTV channels including CBC (French and English), CTV, Global and ABC. Reception is reliable and near perfect. When it comes to these nifty devices, location is key. Distance from a broadcast tower, the terrain, and even the wood and metal inside your walls affects it, and so does where you place the antenna in the room. Finding the right spot is a matter of trial and error. I’ve been lucky here. The device sits out of sight on the top of a bookcase and never has to be moved. Placing it high in the room helps. Some report the best reception when placed in a window affixed to the glass with double-sided tape. There are other considerations. Performance varies widely between devices. There are dozens on the market and price doesn’t always tell the story. Have a look at reviews on the Web before you buy and then choose a retailer with an easy return policy — you may have to try two or three before you find the one that works best for you. I’ve chosen the Winegard FL5U00A FlatWave Amplified Razor Thin HDTV Indoor Antenna. Users report excellent reception in a wide variety of locations. For example, a Coquitlam, BC resident picks up 12 channels, and Calgary, Ottawa and Montreal users report excellent multi-channel reception as well. It’s extremely lightweight, black on one side and white on the other, and has a long, 5.5 metre coaxial cable. Sound too fussy to bother with? It really isn’t. I’ve tried similar antennas in four different locations from central Canada to the West Coast and they’ve performed admirably every time. It’s hard to wipe the grin off your face when you run the scan and see it picking up 4, 6, 8 and 12 channels knowing you’ll never have to pay another nickel for TV reception. $89.99. angelelectronics.ca.

Doctor’s Review • MARCH 2016

Enter to Win the Gadget of the Month contest at doctorsreview.com. It would be a pleasure to ship an antenna to the winner.

For the Treatment of IBS-C and CIC in Adults CONSTELLA ® (linaclotide) is indicated for the treatment of: • irritable bowel syndrome with constipation (IBS-C) in adults • chronic idiopathic constipation (CIC) in adults CONSTELLA ® showed significant improvement in abdominal discomfort vs. placebo (secondary endpoints, mean change from baseline at Week 12)

IBS-C

CIC

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

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

Clinical use: Clinical studies of CONSTELLA® did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. CONSTELLA® is contraindicated in children under 6 years of age and is not recommended for use in children between 6 and 18 years of age as the safety and efficacy of CONSTELLA® in pediatric patients have not been established. Contraindications: • Pediatric patients under 6 years of age • Patients with known or suspected mechanical gastrointestinal obstruction Most serious warnings and precautions: Children: Not recommended in children between 6 and 18 years of age

Other relevant warnings and precautions: • Diarrhea most common adverse reaction; may cause serious diarrhea • Use in pregnant women only if the potential benefit justifies the potential risk to the fetus • Caution should be exercised when CONSTELLA® is administered to nursing women For more information: Please consult the Product Monograph at www.actavis.ca/ NR/rdonlyres/94008767-D103-460E-B854-766C324A3CE8/ 0/CONSTELLA_ProductMonograph.pdf for important information relating to adverse reactions, food interactions and dosing information not discussed in this piece. The Product Monograph is also available by calling Actavis Specialty Pharmaceuticals at 1-855-892-8766.

* 11-point ordinal scale; Trial 1, Trial 2. † 5-point ordinal scale; Trials 3 and 4. CONSTELLA® is a registered trademark of Ironwood Pharmaceuticals, Inc. used under license by Allergan, Inc. or its affiliates. ©2015 Allergan. All rights reserved. Reference: 1. CONSTELLA® (linaclotide) Product Monograph, Forest Laboratories Canada Inc., May 12, 2014.

Binge Eating Disorder (BED) BED has recently been defined by the American Psychiatric Association as a distinct entity from other eating disorders such as bulimia Valerie Taylor, MD, PhD nervosa (BN) and anorexia nervosa (AN).1 BED is a serious disorder characterized by recurrent episodes of excessive eating accompanied by a sense of lack of control, guilt, shame and distress. Unlike BN, binge-eating episodes are not associated with compensatory behaviour such as purging, excessive exercise or fasting. As a result, people with BED are often (although not always) overweight or obese.1,2

Individuals with BED must meet all of the following criteria1: At least once per week for 3 months, they experience a loss of control over eating and consume an abnormally large amount of food in a short period of time compared with what others might eat in the same amount of time.1 These episodes feature at least 3 of the following: consuming food faster than normal; consuming food until uncomfortably full; consuming large amounts of food when not hungry; consuming food alone due to embarrassment; and/or feeling disgusted, depressed, or guilty after eating a large amount of food.1 Overall, individuals with BED feel significant distress about their binge eating.1 They do not show regular compensatory behavior associated with bulimia nervosa, nor do they binge eat solely during an episode of bulimia nervosa or anorexia nervosa.1 Diagnosis should be based upon a complete evaluation of the patient.1

BED – The most common eating disorder BED is four times more prevalent than AN or BN, and actually impacts more individuals than the other eating disorders combined. According to a survey, the lifetime prevalence of BED is 2.8% compared with 1.0% for BN or 0.6% for AN.2 BED is slightly more common in women than in men (3.5% vs. 2.0%, respectively).1,2 Prevalence rates of BED are also comparable across ethnicities.2-4

How does BED differ from other eating disorders? Bulimia nervosa BED is similar to BN in that patients exhibit recurrent episodes of binge eating. However, unlike BN, patients with BED do not compensate with purging, excessive exercising or fasting. In addition, those with BED do not generally practice marked or sustained dietary restriction between binging episodes.1 Obesity and other comorbidities Binge-eating disorder occurs in normalweight/overweight and obese individuals. As per DSM-5, it is associated with individuals presenting as overweight or obese. Nevertheless, binge-eating disorder is distinct from obesity. Most obese individuals do not engage in recurrent binge eating.1 Individuals with BED tend to overvalue body weight and shape compared with obese individuals without the condition.1 In addition, rates of psychiatric comorbidity are high among those with BED.1,2 For instance, 32.3% of adults with lifetime BED have been found to have comorbid major depressive disorder.2 This illness is about more than food intake and weight control. It is also often associated with other psychiatric comorbidities that need to be addressed.

Causes of BED While the exact causes of BED are unknown, research suggests that it may have a neurobiological basis in addition to genetic and environmental influences.5-7 Nearly half of individuals diagnosed with BED have a history of mood disorders.2 Impulsive behaviour also seems to be more common in people with BED.2 Per DSM-5, the psychiatric comorbidity is linked to the severity of the binge eating and not the degree of obesity.1

Could it be BED? Simple questions to ask your patients Individuals with BED may be unaware they have this diagnosis, or they may not seek help because of the stigma and bias associated with binge eating behaviour. It is important that physicians are able to recognize this illness and start a dialogue with clients with a few simple questions: • Do you often eat, within a 2-hour period, what most people would regard an unusual amount of food? • Do you sense a lack of control over eating during the episode? • During these periods, did you eat: – Much more rapidly than normal? – Until you felt uncomfortably full? – Large amounts of food when you didn’t feel physically hungry? – Alone because you were embarrassed by how much you were eating? • After eating, did you feel guilt, shame or distress? BED is a serious disorder that can significantly impact both psychological and physical health.1 It is distinct from other eating disorders. However, very few individuals with BED are ever diagnosed.8 This highlights the importance of querying patients about eating problems, even if they do not include them among their presenting complaints.2 Improved diagnosis is important to begin helping the patient.

References: 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. 2. Hudson JI, et al. The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biol Psychiatry 2007;61(3):348-58. 3. Franko DL, et al. Racial/ethnic differences in adults in randomized clinical trials of binge eating disorder. J Consult Clin Psychol 2012;80(2):186-95. 4. Marques L, et al. Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: implications for reducing ethnic disparities in health care access for eating disorders. Int J Eat Dis 2011;44(5):412-20. 5. Balodis IM, et al. Divergent neural substrates of inhibitory control in binge eating disorder relative to other manifestations of obesity. Obesity 2013;21(2):367-77. 6. Davis C, et al. Binge eating disorder and the dopamine D2 receptor: Genotypes and sub-phenotypes. Prog Neuropsychopharmacol Biol Psychiatry 2012;38(2):328-35. 7. Mitchell KS, et al. Binge eating disorder: a symptom-level investigation of genetic and environmental influences on liability. Psychol Med 2010;40(11):1899-1906. 8. Data on file, Shire. September 27, 2014.

Dr. Valerie Taylor is Psychiatrist-in-chief at Women’s College Hospital and Head of Women’s Mental Health and Co-Director of the Equity, Gender and Population Division. She is an Associate Professor in Psychiatry at the University of Toronto, and holds a part-time appointment as Associate Clinical Professor of Psychiatry at McMaster, where she heads the bariatric surgery psychiatry program.

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Quebec City, QC September 14-17 7th Canadian Stroke Congress strokecongress.ca

Toronto, ON September 22-24

66th Annual Conference of the Canadian Psychiatric Association cpa-apc.org

Vancouver, BC August 17-22 August 21-24

149th Annual Meeting of the Canadian Medical Association cma.ca/En/pages/upcoming-annual-meetings.aspx

August 24

2016 Annual Meeting of the Canadian Medical Protective Association cmpa-acpm.ca/annual-meeting

MEDICAL QUIPS

28th International Congress of Pediatrics ipa2016.com

Glass prisms let visitors see the remains of the Saint-Louis forts and châteaux on Dufferin Terrace in Quebec City.

Around the world Amsterdam, Netherlands July 13-16 18th Annual Conference of the International Society for Bipolar Disorders isbd2016.com

September 2-3

Bad timing

2016 European Congress of Internal Medicine efim.org/events/congresses/european-congressinternal-medicine-2016

The worst time to have a heart attack is during a game of charades.

Annapolis, MD August 11-13 2016 Annual Meeting of the Infectious Diseases Society for Obstetrics and Gynecology idsog.org/annual-meeting/annual-meetingoverview/2016-annual-meeting

To register and to search 2500+ conferences, visit doctorsreview.com/meetings Bali, Indonesia August 22-25 33rd World Congress of Internal Medicine wcimbali2016.org

Boston, MA July 30-August 1 21st World Congress on Heart Disease cardiologyonline.com/wchd2016/index.html

Cancun, Mexico August 20-23 9th Latin American Congress on Epilepsy epilepsycancun2016.org

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

Go to doctorsreview.com/meetings for conferences in these cities... and many more! MARCH 2016 • Doctor’s

Review

THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme New Orleans, LA August 3-7 67th Annual Meeting of International Doctors in Alcoholics Anonymous idaa.org/2016

2016 World Congress of the World Federation of Hemophilia wfh.org

Perth, Australia September 4-7

Religious offerings are an integral part of daily life for Hindus who live in Bali, Indonesia.

Copenhagen, Denmark September 3-6

Los Angeles, CA August 7-11

39th Annual Meeting of the European Thyroid Association eta2016.com

2016 Annual Congress of the World Association for Medical Laws wafml.memberlodge.org

Huntington Beach, CA August 4-6

Melbourne, Australia August 21-26

17th Annual International Lung Cancer Congress gotoper.com/conferences/ilc/meetings/17thinternational-lung-cancer-congress

16th Edition of the International Congress of Immunology ici2016.org

Istanbul, Turkey July 6-10

Munich, Germany September 6-9

2016 International Congress of the World Psychiatric Association wpaistanbul2016.org

12th Congress of the European Hip Society ehs-congress.org

2016 Conference of the Fertility Society of Australia fertilitysociety.com.au

Rome, Italy August 27-31 2016 Congress of the European Society of Cardiology escardio.org

Vienna, Austria July 28-31 30th International Congress of the Medical Women’s International Association mwiavienna2016.org

August 31-September 3 16th World Congress on Cancers of the Skin wccs2016.com

Kampala, Uganda August 16-19 5th International African Palliative Care Conference africanpalliativecare.org/conference2016

London, England September 3-7 2016 International Congress of the European Respiratory Society erscongress.org

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

Doctor’s Review • MARCH 2016

The Webb Bridge spans the Yarra River in Melbourne, Australia.

ROBYN MACKENZIE / SHUTTERSTOCK.COM

LUCKY BUSINESS / SHUTTERSTOCK.COM

Orlando, FL July 24-28

HIS T ORY O F MED I C I NE by

Ros e Fos ter

Food for thought Cultural assassination and its effect on the aboriginal diet

A sudden shift away from traditional diets such as the whale skin called maktaaq being enjoyed by these Inuit elders is one of the causes of skyrocketing diabetes rates.

n epidemic is wreaking havoc on Canada’s Aboriginal Peoples. First Nations, Inuit and Metis on reserve have a rate of Type 2 diabetes

that is three to five times higher than that of non-aboriginal Canadians. As many as 40 percent of adults on First Nations reserves have Type 2 diabetes, compared with seven percent of the general population. Aboriginal people are also diagnosed with diabetes when they are 10 to 20 years younger. Nearly a third are morbidly obese and fully one in twenty have had a diabetes-related amputation. These ever-rising statistics are only a few of many that reveal the health crisis currently experienced by Canadian Aboriginal Peoples and one that affects many indigenous people globally. Obesity and its attendant chronic illnesses are on the rise with many people all

over the world, but why is indigenous health deteriorating more quickly than that of other populations? One popular theory suggests that a rapid change in the nutritional environment can be blamed for the high rates of diabetes among aboriginals. The sudden move from a traditional diet of foods low in fats and sugars and high in micronutrients like vitamin A and omega-3 fatty acids to a diet of white flour, sugar and other processed foods brought about by the introduction to European culture was bound to cause a decline in health. The larger question is whether aboriginal populations are genetically predisposed to diabetes?

“THRIFTY” GENES?

ANSGAR WALK

A nature/nurture debate is at play here. Some researchers, such as Dr Stewart Harris, Professor of Family Medicine at the University of Western Ontario, believe genetics are a factor. “Aboriginal people have a genetic make-up that was ideal in their ancestors’ feast-famine environment, which made energy storage a priority,” he asserts. Critics disagree. They contend theories like those of Dr Harris veer dangerously close to promoting a racist discourse and question the science behind them. The idea stems from the “thrifty gene hypothesis,” proposed in 1962 by Dr James Neel, a prominent US geneticist. He asserts that indigenous people share a susceptibility gene as a result of evolving as hunter-gatherers, a so-called “thrifty” gene which acts to conserve energy by

Doctor’s Review • MARCH 2016

First Nations people on the West Coast have long relied on salmon like that being dried here at the Nuxalk Nation in BC’s Bella Coola Valley.

quickly converting it to glucose. A release of insulin causes the body to store the excess glucose for later use, saving it for a time when food is scarce. This ability to survive long food shortages would offer a selective advantage and spread the genes throughout the larger population. When a people becomes less active, the suggestion is the thrifty genes are still active. They promote an excessive amount of insulin and result in obesity and Type 2 diabetes. People of European descent ostensibly lost such a gene long ago after leaving the huntergatherer lifestyle to pursue agriculture. This theory has been widely questioned and is generally considered less significant than the effects of environmental and cultural changes, poor diet and a sedentary lifestyle brought on by contact with the European population. In the realm of genetics, another factor is perhaps more relevant: aboriginal women, who have greater rates of gestational diabetes related to obesity, have an increased likelihood of passing diabetes on to their offspring, who are more likely to pass on the trait in turn. This could be a factor accounting for the sudden increases in diabetes in the youngest aboriginal Canadians. The federal government has thrown a fair bit of money at the aboriginal diabetes epidemic, yet the statistics don’t indicate much success. In 1999, the Canadian Diabetes Strategy (CDS) was funded $115 million over five years. The Aboriginal Diabetes Initiative (ADI) was included as a key component. The direness of the situation inspired the ADI to direct

Are aboriginal populations genetically predisposed to diabetes? $58 million of the total to address aboriginal diabetes with the focus on screening and treatment and several studies to determine the quality of diabetes healthcare in 19 First Nations communities.

CULTURE THEN DIET Meanwhile, in Montreal, an independent, multidisciplinary research and education centre created by Canada’s aboriginal leaders took a different approach. The Centre for Indigenous Peoples’ Nutrition and Environment (CINE) opened its doors on McGill University’s campus in 1993, led by Chief Bill Erasmus and Dr Harriet Kuhnlein. The centre, heavily supported by McGill University, was designed to work with indigenous people globally on topics related to food systems, independent of the government. Anecdotal evidence of the program’s success praises its culturally holistic approach to health. Instead of discussing diet and nutrients, CINE focuses first on supporting the rich culture that surrounds traditional diets. A return to a traditional way of eating brings with it a host of health benefits, not the least of which is the physical activity required to harvest traditional foods. Cultural cohesion is, perhaps, of

even greater significance. CINE has worked extensively with the Nuxalk, who live along the fjords on the central west coast of British Columbia, both to document elders’ knowledge of traditional foods as well as to promote community harvesting of salmon, berries and other foods. CINE has also helped document the change in diet between older and younger generations in Inuit populations.

ROOT CAUSES Dr Mark Aquash, a member of the Walpole Island First Nation reserve located in the mouth of Ontario’s St Claire River, is Dean of the School of Indigenous and Community Relations at Winnipeg’s Red River College, and former Professor of Education at UBC. He has written extensively on indigenous issues and believes that at the root of the health crisis lie the psychological effects of colonization and forced assimilation, an idea that has at last been accepted by Canada’s government. This concept was of central focus to those who wrote the final, 94-page report of the Truth and Reconciliation Committee, released last December 15. The report included a request that the Canadian government, “Acknowledge MARCH 2016 • Doctor’s

Review

Igunaq, being shared here among Inuit families, is made up of walrus and other marine steaks which are buried over the winter and consumed the next year.

CINE focuses on supporting the culture that surrounds traditional diets that the current state of aboriginal health in Canada is a direct result of previous Canadian government policies, including residential schools, and to recognize and implement the health-care rights of Aboriginal Peoples as identified in international law, constitutional law, and under the Treaties.” Prime Minister Trudeau told an overflowing crowd present for the report’s release that Canada fully accepted its “failing” with regard to the centurylong abuse of aboriginal children in residential schools, and received hoots, hollers and a standing ovation from those in the room, many of whom had been residential school students themselves. Trudeau went on to promise that the government would take action on all proposals in the report that come under federal jurisdiction, including the endorsement of the UN Declaration on the Rights of Indigenous Peoples, which the previous government refused to do. Trudeau summarized this hopeful change of relationship in his statement: “Today, we find ourselves on a new path, working together toward a nation-to-nation relationship based on recognition, rights, respect, co-operation and partnership.”

LET’S EAT Assuming that the new government is sincere and the changes are implemented, the real work can begin. According to

Dr Aquash, a process of decolonization through self-determination at an individual level is necessary in order to undo history’s deleterious effects. The process, he says, is fourfold. First comes a rediscovery and recovery stage, which brings an individual into contact with lost culture as well as with the atrocities experienced by that culture through forced assimilation. Second comes a period of anger and grief. Third comes visioning in which the individual discovers new purpose in life and community. A commitment to action which reinforces the vision is the fourth and final stage. One such vision is at play at Salmon n’ Bannock, a Vancouver bistro that offers First Nations food cooked in a modern way. The restaurant is staffed entirely by First Nations people and has won accolades on the hotly competitive Vancouver restaurant scene. Co-owner Inez Cook, Nuxalk Nation, is a buoyant spokesperson for a return to traditional foods. “I’m very proud of First Nations food,” she says. “It’s great. I want to shout out: try it! Eat it!” The menu brims with treats like barbecued salmon mousse on bannock and blueberry chutney on bison carpaccio. And while this may seem a far cry from a meal plan on an isolated reserve where pizza and soda prevail, this broad cultural recognition of “country foods” is one step on the path towards health — both physical and spiritual.

Indications and clinical use: BYDUREON is indicated for use as monotherapy as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance. BYDUREON is also indicated in patients with type 2 diabetes mellitus to improve glycemic control in combination with metformin, a sulfonylurea, or metformin and a sulfonylurea (dual therapy), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control. Use with caution in the elderly. Should not be used in pediatric patients. Contraindications: Personal or family history of medullary thyroid carcinoma (MTC) or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) End-stage renal disease or severe renal impairment (creatinine clearance <30 mL/min), including patients on dialysis Most serious warnings and precautions: Thyroid C-cell tumours: Exenatide extended-release causes an increased incidence of thyroid C-cell tumours at clinically relevant exposures in rats compared to controls. It is unknown whether BYDUREON causes thyroid C-cell tumours, including MTC, in humans. Patients should be counselled regarding the potential risk for MTC and informed of symptoms of thyroid tumours. Routine monitoring of serum calcitonin or thyroid ultrasound is of uncertain value for early detection of MTC in patients treated with BYDUREON. Acute pancreatitis, including fatal and non-fatal hemorrhagic or necrotizing pancreatitis: patients should be observed carefully for signs and symptoms of pancreatitis; if suspected, discontinue and initiate appropriate management; if confirmed, BYDUREON should not be restarted. Other relevant warnings and precautions: Not for use in type 1 diabetes or for the treatment of diabetic ketoacidosis Should not be used in combination with PrBYETTA® (exenatide), other glucagon-like peptide-1 (GLP-1) agonists or dipeptidyl peptidase-4 (DPP-4) inhibitors Not studied with warfarin; frequent INR monitoring recommended in patients taking warfarin Plasma levels decline over 10 weeks after discontinuation; choice of other medicinal products and dose selection should be considered accordingly Must not be administered by intravenous or intramuscular injection Heart rate increase; caution in patients with a history of ischemic heart disease or tachyarrhythmias Prolongation of heart rate-corrected PR interval of the electrocardiogram; caution in patients with underlying structural heart disease, pre-existing conduction system abnormalities, ischemic heart disease, cardiomyopathies and history of atrial fibrillation Increased risk of hypoglycemia in combination with sulfonylureas Not recommended in patients with severe gastrointestinal disease Serious hypersensitivity reactions, including anaphylaxis and angioedema; discontinue if a reaction is suspected, assess for other potential causes and institute alternative treatment for diabetes Potential for antibody development; discontinue if there is worsening glycemic control or failure to achieve targeted glycemic control and alternative antidiabetic therapy should be considered Serious injection site reactions Caution in patients with moderate renal impairment and in renal transplant patients; assess renal function prior to initiation and periodically thereafter, as appropriate Not for use in pregnant or nursing women; women of childbearing potential should use contraception during treatment For more information: Please consult the Product Monograph at www.azinfo.ca/bydureon/pm293 for important information relating to adverse reactions, drug interactions and dosing information that has not been discussed in this piece. The Product Monograph is also available by calling 1-800-668-6000. References: 1. BYDUREON Product Monograph. AstraZeneca Canada Inc., October 30, 2015. 2. Diamant M et al. Exenatide once weekly versus insulin glargine for type 2 diabetes (DURATION-3): 3-year results of an open-label randomised trial. Lancet Diabetes Endocrinol 2014;2:464-73.

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

01/17

Doctor’s Review • MARCH 2016 Notes supplémentaires

Introducing

Sam does it on Sunday, and only on Sunday

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

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

BYDUREON

Titrated insulin glargine

-1.48%

-1.32%

p=0.047

• BYDUREON was associated with fewer hypoglycemic events1*†

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

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One injection, ONCE A WEEK

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

Alluring Alsace Great beauty, food, wine and two wonderful neighbours text and photos by Dr Philippe Erhard

Eguisheim’s houses offer visitors colour at every turn from pastel shutters to glorious flowers.

little winding road took us along rolling hills, covered with vineyards, where Alsace wine is produced. At the next turn, we saw a village. From a distance, it seemed impenetrable with houses tight together

circling a church steeple. As we got closer, we learned that we had arrived in Eguisheim (ot-eguisheim.fr), which was named France’s favourite village in 2013

Philippe Erhard is a family physician in Winnipeg. He grew up in the Besançon-Belfort region, near the border with Germany and Switzerland, and is well acquainted with the charms of the Alsace region. He’s the author of Being: A Hiking Guide Through Life.

by the television program Le Village préféré des Français. Illuminated by the late morning sun, it was utterly enchanting with its narrow, twisting streets and facades of medieval timbered houses. The explosion of harmonious pastel colours was amazing. Blue, green, pink, white, even orange houses and shutters competed with a blast of red geraniums everywhere. This is where Walt Disney came to get inspiration for his movies and we had the distinct feeling of walking into a fairy tale. MARCH 2016 • Doctor’s

Review

CLOCKWISE FROM ABOVE: The delightful village square opens onto stairs that lead up to a castle and a church. Savoury meats and cheese may be a “heart attack on a plate,” but what a way to go! The facades of medieval timbered buildings speak to the long history of the region. Storks grace the church roof in Eguisheim.

Doctor’s Review • MARCH 2016

We had the distinct feeling of walking into a fairy tale From a distance, the village looked compact, but once inside, it was surprisingly spacious. At the centre, a large sunny square with a babbling water fountain featured a wall covered with flowers and stairs that led up to a castle and church. From the roof of the church, storks flew in and out of a large nest and circled the village above a view that has remained unchanged for over 1000 years. A legend says that storks bring babies, and if you want a brother or sister, you just need to put a piece of sugar on the windowsill and those majestic birds will look after the rest.

FLOWERY FIELDS FOREVER It would be a crime to leave this little piece of paradise too quickly so we sat outdoors at a restaurant to absorb the beauty. A glass of wine was the perfect introduction to the local food. When the waitress brought large platters of savoury smoked meat and tasty potatoes cooked with cheese, I wondered if this plethora of calories and fat was not designed to make us go to the real paradise sooner than we wished. My wife called our meals “a heart attack on a plate,” but everything was so good, and if that was the key to heaven, so be it! And, after all, burning calories was easy here. After lunch, we crossed the village and took a trail that climbed up the mountain through vineyards toward the three towers of a castle that was destroyed in 1466. As we climbed, the village below looked just like a toy. Meadows of wild flowers succeeded the orderly vines and we soon found ourselves in a deep forest. The trail climbed steeply. It was dark and mysterious and seemed to go on endlessly. When I least expected it, we arrived in a flowery field which led to where a cliff dominated the ruined castle. Despite its age and partial destruction, it still stood proudly over the valley and plain that extends all the way to the Black Forest in the east and the Alps in the south. From here, a wooden sign pointed to a trail that led to an old convent on the left, another castle on the right and straight ahead to the summit. Arriving at the top was not only a pleasure for the eyes with its vast and varied vistas, but also an auditory delight with its summer ode of chirping birds, crickets and the crisp ring of cow bells. But Alsace is not only about hiking in rural settings. Large cosmopolitan cities are around the corner. Strasbourg (otstrasbourg.fr), the official seat of

the European parliament, is famous for its historical centre and gothic cathedral — both classified as World Heritage Sites by UNESCO. Colmar (tourisme-colmar.com), located on the wine route, is well known for its preserved old town, its scenic canals called “la petite Venice” and its stunning Unterlinden Museum, the most visited outside Paris. Germany and the Black Forest with the beautiful city of Freiburg and the spa town of Bad Krozingen as well as Switzerland are just a short and easy drive away. And don’t miss the drive along the wine route with its picturesque villages and attractive restaurants. Choose one of those villages and experience life like a local by renting an apartment, where you’ll be able to cook your own food bought at lively farmers markets. The Gîtes de France website (gites-defrance.com) offers apartments available by the week. Getting to Colmar is easy. Basel’s airport is only 30 minutes away and it’s just a 90-minute drive from Zurich. Make sure to rent a car so you can explore all the treasures of the region. Bon voyage!

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France at its

Narrow lanes wind up through Dordogneâ&#x20AC;&#x2122;s traditional white and yellow stone buildings in the pretty village of Beynac.

most enchanting The Dordogne region in the southwest overwhelms with beauty, history — and confit text and photos by Jeremy Ferguson

here is in us, I believe, a sublimated thirst for beauty, and when we engage it fully, we drink it in with the ferocity of the dying man at the oasis. Twenty-five years ago, I found such a place. Here was

beauty in fields of poppies and sunflowers, beauty in ancient stone, beauty in the play of light, beauty in the cloudscapes, beauty on the table. Welcome to the Dordogne, that landlocked département of southwest France, and I’m wondering why it took me so long to return. I have become something of a flâneur in my geezerhood, one who wanders with no particular destination and a certain anticipation of wonder. Balzac defined flânerie as the “gastronomy of the eye.”

The département sprawls across the French southwest on the banks of the Dordogne River itself, which rushes out of the Massif Central, then drifts westward among limestone cliffs, forest dappled green-and-gold, splendidly preserved medieval villages and gauntlets of feudal castles. It is easily the longest and loveliest river in France. The French honour their countryside. The purity of it can stagger a Canadian accustomed to strip malls, McDonald’s, Burger King and Starbucks.

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Many castles were ravaged in the Hundred Years’ War, which raged on for closer to 300 years as France and England battled for ownership of southwest France. Then it happened all over again in the unspeakably brutal Wars of Religion in the 16th and 17th centuries. So we stand at the foot of Beynac village, gazing 200 metres up at its magnificent fortress perched against a flared sky. The French had Château de Beynac (beynac-en-perigord.com/en/the-fortress.html). Across the river on its promontory, Château de Castelnaud (castelnaud.com), the English stronghold, glowers at its ancient enemy. One wonders if the English caused the most damage by catapulting their puddings at Beynac’s battlements. Some of these castles are the property of onepercenters from as far off as Texas and Tokyo, but there are still plenty to visit. I prefer castles from a distance. It was their formidable exteriors, after all, that were calculated to impress friends and intimidate the foe. Not for me, the fussy interiors.

I was persuaded to enter the château dedicated to this amazing woman; I’d been a fool for not visiting earlier

he exception is Château des Milandes (milandes.com), which was built by the owners of Castelnaud when they finally sought a more genteel lifestyle in 1489. The trappings of defense gave way to elegant gardens, ivy-covered turrets, choruses of gargoyles and sumptuous apartments. The château’s most remarkable owner, however, was a profoundly modern woman. Josephine Baker was a black American, born in a St. Louis slum, who found her destiny in the racially tolerant France of the 1920s. At the Folies Bergère at age 20, she dazzled Paris with her melodious voice, magical smile and lithe brown body, belting out le jazz hot wearing nothing more than a string of artificial bananas. She was the 20th century’s first real sex symbol. Ernest Hemingway called her “the most beautiful woman there is, there ever was, or ever will be.” I was persuaded to enter the château on learning it was no wax museum, but an intricate space dedicated

Doctor’s Review • MARCH 2016

CLOCKWISE: Château de Beynac sits high on a rocky promontory 200 metres above the Dordogne River. Falconry was popular in the Middle Ages and there are birds of prey on display at the Château des Milandes in summer. Built in the 15th century, the Château des Milandes was restored by entertainer Josephine Baker in the late 1940s. Replicas of old trading boats are used for river cruises in La RoqueGageac. La Roque-Gageac’s golden yellow houses line the river and feature traditional perigord roofs.

Château de Castelnaud changed hands seven times between the French and English as each fought to control the region. BELOW: Lascaux is famous for its Paleolithic cave paintings.

DORDOGNE UNDERGROUND Long the Dordogne’s single tourism juggernaut, the Lascaux Caves (lascaux.culture.fr) consist of some of the world’s most astonishing Paleolithic art. More than 17,000 years ago, our prehistoric ancestors used the region’s network of limestone caves as art galleries. They painted brilliantly by any standards, orchestrating a fluid ballet of hunters and wildlife on cave walls. Lascaux 2, the cave so painstakingly and perfectly replicated in 1983, and since seen by 10 million visitors, is giving way to Lascaux 4, scheduled to open at Le Centre International de l’Art Parietal Montignac-Lascaux (projet-lascaux. com) this fall. “Lascaux 2 shows us how the art looks,” director Guillaume Colombo told Doctor’s Review, “but Lascaux 4 tells what it means.” Colombo says the new exhibition represents a whole new take on Cro-Magnon man and his capacity for technically brilliant art. “It will,” he says, “broaden our interpretation of Cro-Magnon art to link with history, archeology, the humanities and even cuisine.” The new complex constructs the original cave in its totality (Lascaux 2 contains only a part). It occupies 6.4 hectares, its design recalling a half-buried rift in the earth.

The visitor’s journey unfurls over seven zones; a clever device based on Wi-Fi and RIFD tech nology serves as tour guide. One zone deciphers the cave art and provides a historical, cultural and symbolic context. Highlights include a 3D, multi-screen film that gives viewers the feeling they can actually touch the art and a workshop in which you’re encouraged to create art with the tools and techniques of Paleolithic artists. A major ambition is to bridge the gap and between modern and cave art. For more on Dordogne’s castles and most beautiful villages, visit North of the Dordogne (northofthedordogne.com). For more on travel to the region, visit Rendez Vous en France (rendezvousenfrance.com).

to the life of this amazing woman. I’d been a fool for not visiting earlier. Milandes comes with unusual perks: it has an honest little brasserie in the garden, the chanteusechatelaine’s voice floating through the linden trees. For a modest price, we ate a very good lunch of foie gras, confit of duck with green salad and potatoes Sarladaise laced with garlic, and dessert of walnut tart. There was, too, at no charge, one of those eyeopening raptor shows, in which birds of prey, from barn owls to American bald eagles, demonstrate their predatory prowess. But it is the rooms, 24 of them, detailing Baker’s life, that own the memory. Here are glamorous posters, vintage photographs, film clips, documents and dazzling costumes bringing Baker, who died in 1975, to life. An image of the ravishingly mischievous young vamp nearly stops the heart. We see the mature Baker receiving the Legion of Honour for her work as a spy under the noses of the Nazis in WWII. Here, see Josephine Baker, civil rights activist. There, see the elderly woman forced from her beloved château — her “Sleeping Beauty” castle — and compelled to live on charity.

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How to find a holiday rental in France. doctorsreview.com/features/inside-story

streets and alleys dusted in time. I expected D’Artagnan, Cyrano de Bergerac and Quasimodo to fly from the shadows. Such a thing makes a flâneur’s day. And would I ever write a story without talking about food? The Dordogne used to be Périgord of yore and it remains the pinnacle of gastronomie chosen by the French themselves. Mention the Dordogne even in Paris and a Frenchman will smack his lips in Dolby Sound. The Dordogne’s giants are foie gras, truffles and confit de canard. They assume religious proportions. A great chef once described foie gras as “the cocaine

The Dordogne drifts among limestone cliffs and gauntlets of feudal castles — it’s easily the loveliest river in France

here was another château to discover this time: the devastated Château de Commarque (commarque.com), a 12th century wreck now under restoration. It recalls the old irony: a ruin is more spellbinding than the original, just as an aging actor easily steals the audience from a muscled pretty boy. And the peppering of Les plus beaux villages de France (france-beautiful-villages.org): Monpazier is a classic bastide, a fortified village, its arcaded square prompting visions of somersaulting jesters and jugglers. Domme sits high on a crag, its Dordogne panorama supreme. La Roque-Gageac occupies a finger of land between the Dordogne and steep cliffs, and of cuisine.” Once denounced as the work of the devil, turns to gold at dusk. Saint-Cyprien hosts a boisterous the truffle is as cherished as it is expensive: the largeststreet market twice a week. Saint-Léon-sur-Vézère ever Périgord black truffle, weighing 1.3 kilos, sold sits on one of the most exquisite stretches of the river for about $2000 in 2013. as it flows through the Vézère Valley. But humble me, I’d happily trade these grandiThe town of Sarlat is tourism central. It lists ose delicacies for the vastly more affordable confit, more registered historic buildthe juicy duck thigh preserved ings per square kilometre than in crinolines of its own fat and any city in Europe. I’ve wangently roasted. We do this in dered its medieval heart a dozCanada with our native Pekin en times, a stroll through the or Long Island duck, and it’s 14th century, all ochre-hued decent enough, but here in the stone, tilted streets and halfDordogne, we have the timbered buildings with steep French Moulard duck, a hy“Discharge status: alive, slate rooftops. brid that has three times the but without my permission.” But this time, I found myflavour. Did I say something ... self on the less explored, far about beauty on the plate? “Skin: somewhat pale, but side of the central Rue de la With potatoes fried in duck fat present.” République. I wandered into a and garlic, it’s in itself a reason warren of tiny residential to return.

MEDICAL QUIPS From patient charts

MARCH 2016 • Doctor’s

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Under Irish sk A sojourn in County Kerry’s shimmering green

PATRIK KOSMIDER / SHUTTERSTOCK.COM

by Robb Beattie

A County Kerry lighthouse along the Wild Atlantic Way, a 2500-kilometre tourist trail Doctor’s Review • MARCH 2016 on Ireland’s western seaboard.

ies

t’s a blustery afternoon in County Kerry on Ireland’s wild southwest coast, a lonely place of seabirds, storms and tides long regarded as the edge of the world. Visiting scenic, windswept Valentia Island,

T MARCH 2016 • Doctor’s

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TOURISM IRELAND

“They say painters go mad here trying to capture the sky’s changes” I’ve reached the end of what has to be Europe’s last road, a country lane that dwindles to a track by the time it crests a high, bare hill overlooking the immensity of the Atlantic. Below me, 180-metre cliffs fall into a swirling grey and black sea the consistency of liquid marble. In every direction, there are views of islands and high treeless peninsulas that rise from the waves like the domed backs of whales, sloping seamlessly up from the ocean to long smooth hilltops gleaming with sheep-cropped grass.

Doctor’s Review • MARCH 2016

Over the wind, I hear a tractor stopping behind me. A dapper man and his friendly sheepdog emerge from the cab to check on a flock grazing the dizzy edges of the sandstone cliffs. Morrish O’Donaghue is a sixth-generation Valentia farmer, old enough to remember drying peat, the turf dug from bogs that was once Ireland’s principal fuel. While we talk, the sky flits through an operatic show of light and shadow. The interplay of sun, mist and passing storms colour the sea jet black and then copper.

A circular path descends to the sea on one of the Skellig Rocks where a pivotal scene in The Force Awakens was shot.

BILDAGENTUR ZOONAR / SHUTTERSTOCK.COM

RICHARD SEMIK / SHUTTERSTOCK.COM

The single street in the village of Portmagee on the beautiful, windswept island of Valentia.

Walkers descend a steep path on one of the spectacular Skellig Rocks off the coast of County Kerry.

PATRYK KOSMIDER / SHUTTERSTOCK.COM

The 15th-century Ross Castle overlooks Lough Léin and is a bed-and-breakfast accommodation.

“They say painters go mad here trying to capture the changes,” ventures Morrish as a cloud briefly targets us with pellets of rain that sting like bees and taste of sea salt. “But it’s a bit more interesting than the dullness of sunshine, don’t you think?” Evidently, many visitors agree with Morrish. This southwest corner of Ireland is a popular destination. Fortified by ample precipitation, County Kerry’s shimmering green landscapes are one of the main reasons Ireland is known as the “Emerald Isle.” Compact and simple to get around, Kerry is also still rustic enough that it’s easy to avoid the high-season crowds and get off on your own to enjoy its secluded beaches and panoramic valleys of misty fields and constant rainbows. No guarantees, but summer is said to be the dry season. “Bring an umbrella,” says Morrish.

spend most of my weeklong visit in the county’s south along the bottom of the Wild Atlantic Way (wildatlanticway.com), a tourist trail that runs the 2500 kilometres of Ireland’s western seaboard. Heading off from the lively hub of Killarney, I circle the “loop drive” called the Ring of Kerry, exploring the hilly Iveragh Peninsula and its fringe of islands that include small Valentia. “Now don’t fret. Kerry’s not a big place and I haven’t lost an O’Connell from Boston yet!” quips the Killarney tour guide at the gateway to the national park of the same name and headquarters for the vacationing Irish-American diaspora. The stately mid-sized town is a mix of kitsch and character, and the 10,300-hectare park is made for hikers, cyclists, anglers and boaters. Once an estate, MARCH 2016 • Doctor’s

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The Skelligs, which sit 12 kilometres off the Kerry coast, can be reached by boat, weather permitting.

DOIN OAKENHELM / SHUTTERSTOCK.COM

The puffins, who winter near Michael’s Monastery on the peak of the eponymous Skellig, leave in June.

DAVID ALEKSANDROWICZ / SHUTTERSTOCK.COM

Local farmers spray paint their sheep as a way to identify ownership.

TOURISM IRELAND

KANUMAN / SHUTTERSTOCK.COM

Michael’s Monastery was built, stone on stone, by hermit monks in the fifth century and many of their huts are still standing.

Whether you’re in a pub sipping a pint or a café eating potato pancakes, this is a land where easy conversation and wit always win the day it features three picture-perfect lakes in a valley silk, sitting in a café eating boxty (potato pancakes) ringed by the rugged high country Kerry folk call or almost anywhere at all, this is a land where easy mountains — the tallest peaks reach about 900 meconversation and wit always win the day. tres. The park offers peaceful drives in jaunties, horse-drawn carts, which I take to clop past herds of finish my circle of the Iveragh Peninsula at a deer and arrive at Ross Castle (ross-castle.com), a sheepdog demonstration at the 150-year-old 15th-century keep whose turrets look over Lough Léin Kissane Farm (kissanesheepfarm.com) in barren to the gorse-clad heights opposite. Moll’s Gap. After the dogs show off their Just an hour west by car, the Iveragh Peninsula skills, son Noel gravely explains another tradiseems more remote, its narrow roads weaving along tion. “Local farmers spray paint sheep as a kind of iridescent green ridges that slope steeply to a hazy sea. Celtic graffiti; we call it shephart,” he explains. I’d Thousands of years of history roll by as I pass fields say he was pulling my leg were it not for the fourcontaining smaller versions of Stonehenge called legged works of art standing about. Clearly the Kis“standing stones” and the ruins of Iron Age forts sanes have a sense of humour: the farm’s motto is and early Christian churches. “man can’t live on scenery alone.” There’s sense, At the hamlet of Portmagee, I stop to learn about though, to this apparent madness — the paint is the remarkable Skellig Rocks (skelligexperience.com), used to identify ownership. 12 kilometres offshore. In the fifth century, Skellig Further south in the ruin-filled Sheen Valley, anMichael, the larger rock, became the unlikely abode other farmer, Stephen “Mike Dan” O’Sullivan, pours of hermit monks who built still-standing stone huts me poteen (moonshine whiskey) from his grandmother on its pinnacle among the sea and bird colonies of Molly Gallivan’s still (“the recipe is based on the puffins and gannets. kick of her donkey”) and reveals the ergonomic way Now a UNESCO World Heritage Site and a to dig peat: “As you jam down the spade, think of truly spectacular item for any bucket list, the Skelligs the wretch who stole your first love.” are reached from Portmagee by a choppy 45-minute But perhaps the last word goes to the softly spoken boat ride May through September, weather permitting. Jim Kennedy, a kayak outfitter and national chamOn landing, visitors climb the 600 vertigo-inducing pion who takes me night kayaking on Lough Hyne, steps to the monastery to absorb its otherworldly a saltwater lagoon connected to the ocean by a narrow beauty and to photograph the teeming bird life, espetidal channel. Well-studied for its unusual marine life, cially the colourful puffins who are in residence until the Lough has a secret ingredient: a tiny species of June. The pivotal scene in Star Wars’ latest, “The Force phytoplankton that is bioluminescent after dusk. I keep Awakens,” was shot at the apex of Skellig Michael. dipping my hand into the water to watch the evanescent Back on the single street of Portmagee, the Holblue lights trail my fingers like submerged fireflies lywood talk is low key except for occasional punning before their sparkling glow fades away in the current. cries in the pub of “May the fáilte be with you,” fáilte “It’s best in July and August, on still evenings being the Irish word not for force but for “welcome.” with no moon,” Jim informs me. “You come out Over the rest of the week, I and it’s like paddling through hear more Irish spoken in the stars. You can hear the echoes villages, a language of hard of everything that ever was. rhythms that contrasts with Even the noises of the sea are peoples’ lilting accents in Englike laughter or music.” He lish. What is constant is the smiles, says, “Irish fairy munative charm, a quality familsic, that is,” and then expertly iar to those who have met the pilots away, the eddies behind “While in ER, Eva was examined, country’s inhabitants, none of his kayak leaving a flickering x-rated and sent home.” whom have ever heard of a short blue trail in the dark. ... chat, let alone one without jokes “Patient has two teenage children, or a drink. Whether you’re in For more info on travel to the but no other abnormalities.” a dark-oak pub sipping a pint region, visit Tourism Ireland of stout that goes down like (tourismireland.com).

MEDICAL QUIPS From patient charts

MARCH 2016 • Doctor’s

Review

Thrills on

Cabot Cliffs Cape Breton’s new true links course doesn’t open until June but it’s already considered one of the world’s best by Anita Draycott

Cape Breton’s newest seaside links sensation wasn’t ranked the number one golf course in Canada, if not North America, I’d eat my putter. Lucky for me, I was right. Golf Digest named Cabot Cliffs the “Best New Course in America” for 2015, third in its list of “America’s 100 Greatest” and number 93 on its list of “World’s Greatest Courses.” What’s more, the magazine described it as “The second coming of Cypress Point,” located on California’s Monterey Peninsula in Pebble Beach. This is remarkable considering that Cabot Cliffs is only six months old and doesn’t officially open to the public until this June. When its older sister course, Cabot Links, opened in 2012, it too caused a buzz as Canada’s first and only true links course. Although there seems to be no definitive definition of what a true links course is, there are some common characteristics. This is the original type of golf course design, dating to the origins of the game, found in such venerable tracts as St. Andrews and Turnberry. Scotland, Wales, England and Ireland boast most of the planet’s links. Formed more by Mother Nature than man, the original links along the coast of Scotland were the game’s crucibles, where golf as we know it was born. Traditionally, they were built on sandy, unarable oceanfront land exposed to the salt and wind. Some links have minimal views of the sea and are as flat as pancakes; others run alongside the ocean with towering dunes. In the hearts and minds of golf purists, they are the only real and true courses — all others are imitations. The vast majority of those that call themselves links are not. Authentic links make up less than one percent of all the courses on earth, yet this small collection includes nearly half of the best courses in existence. Whatever your definition of links golf, there’s little doubt that both Cabot Links and Cliffs are the real McCoy. They occupy a sandy coastal site that drains exceptionally well, resulting in firm, fast fairways. Trees are few and far between allowing them to be scoured by wind. There are plenty of deep pot bunkers and, in almost all cases, approaches to greens are unobstructed, promoting bump-and-run shots. Greens are firm and hard to hold with lofted shots.

Golfers might have to play Cabot Cliffs’ 16th hole a few times before the intimidation of the tee shot subsides.

ALL PHOTOS COURTESY CABOT LINKS UNLESS OTHERWISE NOTED

fter playing a sneak preview round at Cabot Cliffs last summer, I vowed that if

MARCH 2016 • Doctor’s

Review

“We’ve seen a lot of golf courses, but I don’t think I’ve ever seen a prettier sight than this one right here” How fitting that the game that was born in Scotland traversed the ocean and took root in Inverness, Cape Breton, which was first settled by Highland Scots in the 1800s and is still a place with strong Celtic traditions. The folks who own Cabot Links, Toronto-born Ben Cowan-Dewar and Mike Keiser of the highly ranked Bandon Dunes in Oregon, hired the acclaimed team of Bill Coore and Ben Crenshaw to design their second course. Global Golf Post described Cabot Cliffs as “Pebble Beach on steroids.” The maximum green fee for Cabot Cliffs, however, is $185 for resort guests and $215 for non-resort players from June to October 2016 — Pebble Beach’s rates hover around US$500. Commenting on his design of Cabot Cliffs, Coore remarked “the greatest curse in life is extreme potential.” His partner added, “We’ve seen a lot of golf courses, but I don’t think I’ve ever seen a prettier sight than this one right here. Right on the Gulf of St. Lawrence, it’s got gorgeous undulations and the movement of the ground is graceful.”

The resort has three restaurants: Panorama (pictured), the Cabot Bar and the new Cabot Public House.

Indeed, the fairways tumble and twist down from a forested glade high above the sea. They meander up and over dunes, cross meadows and ravines, and skirt ragged cliffs. There’s an empathetic harmony between the golf course design and the rollicking terrain, an ebb and flow with endless sea views. And although there’s no lack of “wow” factor, a romp over Cabot Cliffs feels natural. There’s a rhyme, a reason and a natural rhythm to this masterpiece.

played with Cabot’s Golf Professional Emeritus, Joe Robinson, one fine afternoon last July. The temporary clubhouse was a yurt and the practice facility was still in the works, but the course was in remarkably good condition considering it had been open for just one week. Standing on the first tee at Cabot Cliffs, inhaling the briny air, watching the russet fescue swaying in the breeze, I wondered if maybe I’d been transported to Scotland. A round island that I spotted out in the Gulf looked like Ailsa Craig at Turnberry on Scotland’s west coast. It was uncanny.

Cabot Cliffs’ number six is akin to something golfers might see in the British Isles: the green is situated in the bowl of a group of dunes.

“Is Mike Keiser so rich that he can afford to tow the Ailsa Craig across the Atlantic Ocean?” quipped another golf writer. No, the locals call this Ailsa clone Margaree Island (its real name is Sea Wolf). There isn’t a weak hole at Cabot Cliffs and there are many you’ll never forget. Number six, a parthree, 186-yard gem resembles something you’d play in the British Isles. The green is positioned in the bowl of a cluster of dunes that brought memories of the Dell at Lahinch in County Clare, Ireland. But what differentiates Cabot Cliffs from typical Old World links courses is that along with the ocean, fescue, craggy bunkers and dunes, you’ll encounter a forest starting on the spectacular seventh hole, plus the most intimidating tee shot on the course with a forced carry that looks longer than it really is. On the par-three 14th, a huge rock outcropping surrounded by bunkers to the right of the green stands ready to deflect any errant shots. The designers could have bulldozed this rocky attraction out, but wisely opted to make it an integral part of the design. The most photographed parts of Cabot Cliffs are the green at 16 and the tees at 17, both located on the

jagged, windswept promontory. Number 17 is a cliff-hanging driveable par-four. Once you tee off over the chasm, the roll of the fairway propels your Titleist towards the green. Birdie this one and you’ll be on cloud nine. I think the first course, Cabot Links, is now even better due to new routing. The first four holes were previously numbers six to nine. Actually, the present routing was in the original plan. Now the first hole offers a gentler handshake to your round and if you only want to play nine holes, you finish back at the clubhouse. In keeping with true links traditions, Cabot Links is planted from tees-to-greens with 100 percent fescue. Drop your first putt and you’ll be rewarded with the sound of it clinking into a tin cup. You don’t have to hire a caddy, but I highly recommend doing so the first time you play both tracks. Our caddies, Steve and Keith, locals from Inverness, gave us lots of valuable tips, especially about how to negotiate the cleverly contoured greens. They also provided local colour. Commenting on one of my badly struck shots, Keith remarked, “That’s what we call a MARCH 2016 • Doctor’s

Review

There are 48 rooms at the Cabot Links Lodge, each with sweeping ocean views and golf course vistas.

mother-in-law. It looked good leaving, but didn’t go far enough!” Unless you have a medical condition, you do have to walk both courses. And what a joy that is, especially numbers five and six that play around MacIsaac’s Pond where lobster and crab boats bob in the harbour. Numbers 14 to 16 play right along the beach. With luck, you’ll spot dolphins or whales while you practice your bumps and runs, plus every other shot in the book. Number 14, a nod to the famed seventh at Pebble Beach, is a short,100-yard, par-three with a downhill pitch to a peninsula green jutting into the water. Panorama’s seafood chowder consists of lobster, scallops, haddock, bacon and potatoes.

he philosophy at Cabot is similar to that at Bandon Dunes. Nothing supersedes the fantastic golf experience. That said, guests enjoy well-designed rooms with floor-to-ceiling windows overlooking Cabot Links and the Gulf of St. Lawrence. Stenciled on every door are clever quotes by famous golfers. Mine, by Harry Vardon, read, “Don’t play too much golf. Two rounds a day are plenty.” The heavenly Beltrami bed linens are custom-made for the resort in Italy. Amenities such as walk-in rain showers, l’Occitane toiletries and Nespresso coffee machines all add up to a top-notch resort experience.

Gaelic musical traditions flourished in Cape Breton throughout the 1800s, and can be heard at festivals and in pubs.

ANITA DRAYCOTT

From Halifax Airport, it’s a three-hour drive to Cabot Cliffs (cabotlinks.com/golf/cabot-cliffs). From Sydney Airport, it’s a two-hour drive. The resort can arrange for transportation to and from the airports in its eleven-passenger Mercedes Sprinters. Fifteen minutes away, the Glenora Distillery (glenoradistillery.com) produces North America’s single malt whisky (only whisky distilled in Scotland can be called scotch). They have a good dining room and a lively pub where you can sample drams from their various vintages and enjoy fiddle music most nights. The new Downstreet Coffee Company (15844 Central Avenue) on the main street of Inverness, serves baked goods, soups, sandwiches and some specialty items like truffle and olive oils. It’s a great spot to mingle with the locals over an espresso and scone. You can also buy a fresh baguette and fixings to take a picnic to the beach. For golf deals and packages, try Golf Cape Breton (golfcapebreton.com). For more on travel to the region, visit Destination Cape Breton (cbisland.com).

PAUL MCKINNON / SHUTTERSTOCK.COM

LINKS TO THE LINKS

The coastline of the Gulf of St. Lawrence hugs the left of Cabot Link’s medium length, par four, 15th hole.

There’s an empathetic harmony between the golf course and the rollicking terrain, an ebb and flow with endless sea views In addition to the 48 rooms, 14 new two- and four-bedroom villas are for sale. These units will also be available for rent. Each is equipped with state-ofthe-art kitchens and bathrooms. The management team intends to make Cabot Links a world-class golf destination where everything, including the cuisine, scores a “ten out of ten.” They’re obviously doing things right; at the 2014 Canadian Tourism Awards, Cabot Links took the “VISA Canada Traveller Experience of the Year” prize. John Haines and Tracy Wallace, Cabot’s husband/ wife chef team, both born in nearby Antigonish, are committed to the owners’ lofty mandate. John was trained in the classical French style. Tracy is self-taught and brings a more modern dynamic to her dishes. She also loves foraging for local ingredients, something she learned from her grandmother. They make everything from scratch and butcher every piece of fish caught daily in the Gulf of St. Lawrence. Meat

and poultry are sourced locally and most produce comes from their spring-fed garden. Everything is good, but some dishes are outstanding. The award-winning chowder will never go off the menu. Some guests, including yours truly, request it for breakfast. The lobster ravioli is so rich and decadent, it should be illegal. Go for it. Panorama is the main restaurant, but you can enjoy casual fare until the wee hours at the recently opened Cabot Public House. They bought a Moretti Forni, the Italian “Lamborghini” of pizza ovens. Specialties include thin crust Italian-style pizzas and local craft beers. At the end of a memorable day on the links, tucking into some fabulous seafood in the Panorama restaurant, watching the sun slide into the St. Lawrence while the last golfers sink their putts on number 18, is about as good as it gets. The folks at Cabot Links deliver golf as it was meant to be played and life as it was meant to be lived. MARCH 2016 • Doctor’s

Review

INDICATION: ZENHALE® is indicated for the treatment of asthma, in patients 12 years of age and older with reversible obstructive airway disease. CLINICAL USE: ZENHALE® is not indicated for patients whose asthma can be managed by occasional use of a rapid-onset, short-duration, inhaled beta2-agonist, with or without inhaled corticosteroids. ZENHALE® is not indicated for the relief of acute bronchospasm. Contraindications: • Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required • Patients with untreated systemic fungal, bacterial, viral or parasitic infections, active tuberculous infection of the respiratory tract, or ocular herpes simplex • Patients with cardiac tachyarrhythmias Most serious warnings and precautions: Asthma-Related Death: Long-acting beta2-adrenergic agonists (LABA), such as formoterol, may increase the risk of asthma-related death. This is based on salmeterol data, and this finding with salmeterol is considered a class effect of the LABA, including formoterol. Available data from controlled clinical trials suggest that LABA increase the risk of asthma-related hospitalization in pediatric and adolescent patients. There are inadequate data to determine whether concurrent use of inhaled corticosteroids or other long-term asthma control drugs mitigates the increased risk of asthma-related death from LABA. ZENHALE® should only be used for patients not adequately controlled on a longterm asthma control medication, such as an inhaled corticosteroid or whose disease severity clearly warrants initiation of treatment with both an inhaled corticosteroid and LABA. Once asthma control is achieved and maintained, assess the patient at regular intervals and do not use ZENHALE® for patients whose asthma can be adequately controlled on low or medium dose inhaled corticosteroids.

Other relevant warnings and precautions: • Should not be stopped abruptly • Serious adverse event risk due to adrenal insufficiency and unmasking of pre-existing allergy in patients transferred from systemically active corticosteroids • Risk of systemic effects of inhaled corticosteroids o Hypercorticism, adrenal suppression, growth retardation in children/ adolescents, reduced bone mineral density, osteoporosis, fracture, cataracts, glaucoma • Risk of dose-dependent bone loss • Should not be used with another LABA • Do not exceed recommended dose • Small increase in QTc interval reported • Caution with cardiovascular conditions • Oropharyngeal candidiasis • Potentially serious hypokalemia • Diabetic patients • Rare systemic eosinophilic conditions • Enhanced effect of corticosteroids in patients with cirrhosis or hypothyroidism • Risk of immunosuppression • Immediate hypersensitivity reactions may occur • Not for rapid relief of bronchospasm or other acute episode of asthma • Serious asthma-related adverse events and exacerbations may occur; seek medical advice if symptoms remain uncontrolled or worsen • Possible paradoxical bronchospasm • No adequate studies in pregnant/nursing women • Risk of labour inhibition • 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/Zenhale-PM_E.pdf for important information relating to adverse reactions, drug interactions, and dosing/administration information which have not been discussed in this advertisement. The Product Monograph is also available by calling us at 1-800-567-2594.

. Printed in Canada

Member of Innovative Medicines Canada

Soybean products (from left to right): tofu, edamame, tempeh.

The whole truth Beans, nuts and seeds for breakfast, lunch and dinner recipes by

Nettie Cronish

and

Cara Rosenbloom

photos by

Mike McColl

arch is Nutrition Month and March 16 is the seventh anniversary of Dietitians Day so there’s no better time to bring you recipes from Nourish

by registered dietitian Cara Rosenbloom and chef and culinary instructor Nettie Cronish. The new cookbook by the Ontario-based writers features 100 dishes with a bean, nut or seed in every recipe as well as plenty of whole, unprocessed foods. Whole foods are as close to nature as they can be — they haven’t been highly altered or had other ingre-

dients added to them. They’re recommended to help control an assortment of conditions including obesity, high cholesterol, hypertension, diabetes, heart disease, dementia and cancer. The cookbook isn’t designed exclusively for vegetarians, but a lot of the dishes, including our favourites below, are veggie-based. MARCH 2016 • Doctor’s

Review

APRICOT GINGER GRANOLA

¹⁄³ c. (80 ml) 2-percent milk 1 tsp. (5 ml) smoked paprika 4 tsp. (20 g) unsalted butter, divided

This batch of granola features the surprising warm spice of candied ginger. Make sure to let the granola cool completely on the baking sheet; the ingredients adhere to each other as they cool, giving you those tell-tale clusters of true granola. 3 c. (750 ml) large flaked rolled oats 1 c. (250 ml) unsalted pistachios, chopped 1 c. (250 ml) raw unsalted pumpkin seeds ½ c. (125 ml) sesame seeds ½ c. (125 ml) raw unsalted sunflower seeds ¼ tsp. (1.25 ml) ground cinnamon ½ tsp. (2.5 ml) ground cardamom ½ tsp. (2.5 ml) pure vanilla extract ½ c. (125 ml) extra virgin olive oil ½ c. (125 ml) pure maple syrup ½ c. (125 ml) finely chopped dried apricots ¼ c. (60 ml) chopped crystallized ginger

Preheat the oven to 325°F (160°C). Line a large rimmed baking sheet with parchment paper. In a large bowl, stir together the oats, pistachios, pumpkin seeds, sesame seeds, sunflower seeds, cinnamon and cardamom. In a small bowl, combine vanilla, olive oil and maple syrup. Stir to combine. Add to the oat, nut and seed mixture.

Apricot ginger granola.

Turn the mixture onto the baking sheet and spread in an even layer. Bake until fragrant and golden brown, about 25 to 30 minutes. Remove from the oven and let cool completely on the baking sheet. Stir in the apricots and ginger once the granola is cool, about 20 minutes. Store in an airtight container for 3 to 4 weeks. Makes 8 cups (2 L). Tip: If you prefer a toned-down sweetness in your breakfast bowl, cut the maple syrup in this recipe to a ¼ cup (60 ml). To serve, you can use this granola as part of trail mix, atop Greek yogurt, in parfaits, sprinkled on salad or as cereal with added milk. NUTRIENTS PER SERVING Serving size: ¼ cup (60 ml) granola 136 calories, 8 g fat, 1 g saturated fat, 2 mg sodium, 13 g carbohydrates, 2 g fibre, 5 g sugars, 4 g protein. Good source of magnesium.

BROCCOLI PATTIES If you’re not a fan of ordinary pancakes and maple syrup, you’ll love this delicious savoury pancake, complete with a yogurt dipping sauce. It’s an excellent addition to any brunch table and they freeze well too.

Broccoli patties.

Doctor’s Review • MARCH 2016

4 c. (1 L) broccoli florets 1 tbsp. (15 ml) flaxseeds, finely ground 3 tbsp. (45 ml) water 1 onion, diced 1 small hot chili pepper, seeded and diced or ½ tsp. (2.5 ml) chili powder 2 garlic cloves, minced ¼ c. (60 ml) extra virgin olive oil ²⁄³ c. (160 ml) whole grain wheat flour 1 tbsp. (15 ml) finely chopped fresh dill ¼ tsp. (1.25 ml) sea salt 1 large egg

Yogurt dipping sauce 1 c. (250 ml) plain 2-percent Greek yogurt 1 tbsp. (15 ml) fresh lemon juice ½ tsp. (2.5 ml) hot sauce ¹⁄8 tsp. (0.5 ml) sea salt ¹⁄8 tsp. (0.5 ml) freshly ground black pepper sprinkling of chopped fresh dill

Set a collapsible steamer basket in a large pot. Add enough water to reach the bottom of the steamer basket. Bring to a boil over high heat. Place the broccoli in the steamer basket, cover and steam for 3 to 5 minutes or until tender. Set aside. Place the ground flax in a small bowl. Add water. Stir well. Allow to stand for 3 minutes. Put the steamed broccoli, onion, chili and garlic in a food processor, and pulse on and off to coarsely chop (do not purée the vegetables). Alternatively, chop by hand. Transfer the chopped ingredients to a large mixing bowl and stir in the oil, flour, dill and salt. Add the ground flax mixture, egg, milk and paprika. Mix thoroughly with a wooden spoon. In non-stick skillet, heat 1 teaspoon (5 g) of butter over medium heat. Using ¼ cup (60 ml) of batter for each pancake, add three ¼ cup (60 ml) amounts in a frying pan large enough to allow the patties to be far enough apart so that they don’t touch. Cook over medium heat for 3 to 4 minutes. Flip the patties and cook the other side for 3 minutes. Transfer to a hot platter to keep warm. Add 1 teaspoon (5 g) of butter to the skillet for each new batch. To serve, mix all of the ingredients for the yogurt dip together and spoon 1 teaspoon (5 ml) on top of each pancake. Serves 6. Tip: Savoury yogurt is so trendy right now so there’s a little extra in this recipe for you to keep in the fridge. You can use it as a dip for crackers or vegetables, a sauce for fish, or add cucumbers and olives and enjoy it as is, right out of the bowl. That’s how it’s served at Sohha, a savoury yogurt stand in New York City’s Chelsea Market.

NUTRIENTS PER SERVING Serving size: 2 patties with 2 teaspoons (10 ml) yogurt 256 calories, 16 g fat, 4 g saturated fat, 150 mg sodium, 22 g carbohydrates, 3 g fibre, 3 g sugars, 7 g protein. Excellent source of folate and vitamin D.

ASIAN VEGETABLE NOODLE SOUP Colourful and hearty, this soup is surprisingly simple to make. 6 c. (1.5 L) no-salt-added vegetable broth, divided 1 leek, thinly sliced (white and pale green parts only) 2 garlic cloves, minced 1 tbsp. (15 ml) minced ginger 2 tbsp. (30 ml) sodium-reduced tamari 2 tsp. (10 ml) white miso paste 2 4-inch (10-cm) squares of kombu 1 carrot, grated 1 celery stalk, thinly sliced 3 stalks bok choy, diagonally sliced 1 c. (250 ml) broccoli florets 1 red pepper, julienned 1 c. (250 ml) thinly sliced mushrooms ½ c. (125 ml) peas (fresh or frozen) 3 oz. (90 g) buckwheat soba noodles, broken into 1-inch (2.5-cm) pieces (about ¾ c. or 180 ml) 12 oz. (350 g) tofu, cubed (½ inch or 1.25 cm)

In a large pot, bring 1 cup (250 ml) vegetable broth to a boil. Add the leek, garlic and ginger, and simmer for 3 minutes. Stir in remaining broth, tamari, miso and kombu. Cover and bring to a boil for about 10 minutes. Remove the kombu. Add the carrot, celery, bok choy, broccoli, red pepper, mushrooms, peas, noodles and tofu. Simmer for about 10 minutes or until the noodles are softened. Serves 6. A note about umami: Have you heard of umami? It’s considered to be the fifth taste, after salty, sour, bitter and sweet. It’s best described as “savoury” and one great way to get this flavour is to add seaweed to your foods. Kombu has that unique umami flavour and using more umami-rich foods (tomatoes, Parmesan cheese and mush-

Asian vegetable noodle soup.

rooms also have it), can reduce your reliance on salt in many recipes. NUTRIENTS PER SERVING Serving size: 1¹⁄³ cups (330 ml) soup 209 calories, 6 g fat, 1 g saturated fat, 498 mg sodium, 27 g carbohydrates,

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3 g fibre, 9 g sugars, 14 g protein. Excellent source of vitamin C. Good source of folate, magnesium and iron. Recipes and photos from Nourish: Whole Food Recipes Featuring Seeds, Nuts and Beans (Whitecap Books, 2016).

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MERCK CANADA INC. Zenhale.................................................. 4, 5 MARCH 2016 • Doctor’s

Review

Contraindications: • Patients with severe hypersensitivity to milk proteins. • In the primary treatment of status asthmaticus or other acute episodes of asthma. Most Serious Warnings and Precautions: • ASTHMA-RELATED DEATH: Long-acting beta2-adrenergic agonists (LABA), such as vilanterol, increase the risk of asthma-related death. Physicians should only prescribe BREO® ELLIPTA® for patients not adequately controlled on a long-term asthma control medication, such as an inhaled corticosteroid, or whose disease severity clearly warrants initiation of treatment with both an inhaled corticosteroid and a LABA. Once asthma control is achieved and maintained, assess the patient at regular intervals and do not use BREO® ELLIPTA® for patients whose asthma can be adequately controlled on low- or medium-dose inhaled corticosteroids. Other Relevant Warnings and Precautions: • BREO® ELLIPTA® should not be used for the relief of acute symptoms of asthma (i.e., as rescue therapy for the treatment of acute episodes of bronchospasm). • Patients who have been taking a rapid onset, short duration, inhaled bronchodilator on a regular basis (e.g., q.i.d) should be instructed to discontinue the regular use of these drugs and use them only for symptomatic relief if they develop acute symptoms while taking BREO® ELLIPTA®. • BREO® ELLIPTA® should not be initiated in patients with acutely deteriorating asthma, which may be a life-threatening condition. • Exacerbations may occur during treatment. Patients should be advised to continue treatment and seek medical advice if symptoms remain uncontrolled or worsen after initiation of therapy. • BREO® ELLIPTA® should not be used more often than recommended, at higher doses than recommended, or in conjunction with other medicines containing a LABA, as an overdose may result. • Caution in patients with cardiovascular disease: vilanterol can produce clinically significant cardiovascular effects in some patients as measured by an increase in pulse rate, systolic or diastolic blood pressure, or cardiac arrhythmias such as supraventricular tachycardia and extrasystoles. In healthy subjects receiving steady-state treatment of up to 4 times the recommended dose of vilanterol (representing a 10-fold higher systemic exposure than seen in patients with asthma) inhaled fluticasone furoate/vilanterol was associated with dose-dependent increases in heart rate and QTcF prolongation. Use with caution in patients with severe cardiovascular disease, especially coronary insufficiency, cardiac arrhythmias (including tachyarrhythmias), hypertension, a known history of QTc prolongation, risk factors for torsade de pointes (e.g., hypokalemia), or patients taking medications known to prolong the QTc interval. • Effects on Ear/Nose/Throat: localized infections of the mouth and pharynx with Candida albicans have occurred. • Endocrine and Metabolic effects: possible systemic effects include Cushing’s syndrome; Cushingoid features; HPA axis suppression; growth retardation in children and adolescents; decrease in bone mineral density. • Hypercorticism and adrenal suppression (including adrenal crisis) may appear in a small number of patients who are sensitive to these effects. • Adrenal insufficiency: particular care should be taken in patients transferred from systemically active corticosteroids because deaths due to adrenal insufficiency have occurred during and after transfer to less systemically available inhaled corticosteroids. • Bone Effects: decreases in BMD have been observed with long-term administration of products containing inhaled corticosteroids. • Effect on Growth: orally inhaled corticosteroids may cause a reduction in growth velocity when administered to children and adolescents. • Monitoring recommendations: serum potassium levels should be monitored in patients predisposed to low levels of serum potassium. Due to the hyperglycemic effect observed with other beta-agonists, additional blood glucose monitoring is recommended in diabetic patients. Monitoring of bone and ocular effects (cataract and glaucoma) should be considered in patients receiving maintenance therapy. Patients with hepatic impairment should be monitored for corticosteroid effects due to potentially increased systemic exposure of fluticasone furoate. • Use with caution in patients with convulsive disorders or thyrotoxicosis and in those who are unusually responsive to sympathomimetic amines. • Hematologic effects: may present with systemic eosinophilic conditions, with some patients presenting clinical features of vasculitis consistent with Churg-Strauss syndrome. Physicians should be alerted to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. • Hypersensitivity effects: immediate hypersensitivity reactions have occurred after administration, and patients should not be re-challenged with BREO® ELLIPTA® if it is identified as the cause of the reaction. There have been reports of anaphylactic reactions in patients with severe milk protein allergy with other inhaled dry powder drug products containing lactose.

• Immune effects: greater susceptibility to infections. Administer with caution and only if necessary in patients with active or quiescent tuberculosis infections of the respiratory tract; chronic or untreated infections such as systemic fungal, bacterial, viral, or parasitic; or ocular herpes simplex. Chickenpox and measles can have a more serious or even fatal course in susceptible patients using corticosteroids. In such patients who have not had these diseases or been properly immunized, particular care should be taken to avoid exposure. • Ophthalmologic effects: glaucoma, increased intraocular pressure, and cataracts. Close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts. • Respiratory effects: paradoxical bronchospasm may occur with an immediate increase in wheezing after dosing. This should be treated immediately with a rapid onset, short duration inhaled bronchodilator. BREO® ELLIPTA® should also be discontinued immediately, the patient assessed, and alternative therapy instituted if necessary. The incidence of pneumonia in patients with asthma was uncommon. Patients with asthma taking BREO® ELLIPTA® 200/25 mcg may be at an increased risk of pneumonia compared with those receiving BREO® ELLIPTA® 100/25 mcg or placebo. • Drug interactions: caution should be exercised when considering coadministration with inhibitors of cytochrome P450 3A4; inhibitors of P-glycoprotein (P-gp); sympathomimetic agents; beta-adrenergic receptor blocking agents; non-potassium sparing diuretics (i.e., loop or thiazide diuretics); drugs that prolong the QTc interval (e.g., monoamine oxidase inhibitors and tricyclic antidepressants); xanthine derivatives; and acetylsalicylic acid. Adverse Events: Adverse reactions reported at a frequency of ≥1% and more common than placebo in one clinical study of BREO® ELLIPTA® 100/25 mcg included: nasopharyngitis, oral candidiasis, upper respiratory tract infection, headache, dysphonia, oropharyngeal pain, epistaxis. Adverse reactions reported at a frequency of ≥1% in another clinical study of BREO® ELLIPTA® 200/25 mcg and BREO® ELLIPTA® 100/25 mcg also included the following additional adverse reactions: influenza, bronchitis, sinusitis, respiratory tract infection, pharyngitis, cough, rhinitis allergic, abdominal pain upper, diarrhea, toothache, back pain, pyrexia, muscle strain. Dosage and Method of Administration: The recommended dose of BREO® ELLIPTA® 100/25 mcg or 200/25 mcg is one oral inhalation once daily, administered at the same time every day (morning or evening). Do not use more than once every 24 hours. The starting dose is based on patients’ asthma severity. For patients previously treated with low- to mid-dose corticosteroid-containing treatment, BREO® ELLIPTA® 100/25 mcg should be considered. For patients previously treated with mid- to high-dose corticosteroid-containing treatment, BREO® ELLIPTA® 200/25 mcg should be considered. After inhalation, patients should rinse their mouth with water (without swallowing). If a dose is missed, the patient should be instructed not to take an extra dose, and to take the next dose when it is due. Dosing Considerations: • For optimum benefit, advise patients that BREO® ELLIPTA® must be used regularly, even when asymptomatic. • Once asthma control is achieved and maintained, assess the patient at regular intervals and do not use BREO® ELLIPTA® for patients whose asthma can be adequately controlled on low-or medium-dose inhaled corticosteroids. • No dosage adjustment is required in patients over 65 years of age, or in patients with renal or mild hepatic impairment. • Caution should be exercised when dosing patients with hepatic impairment as they may be more at risk of systemic adverse reactions associated with corticosteroids. Patients should be monitored for corticosteroid-related side effect. For patients with moderate to severe hepatic impairment, the maximum daily dose is 100/25 mcg. For More Information: Please consult the Product Monograph at http://gsk.ca/breo/en for important information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374. References: 1. BREO® ELLIPTA® Product Monograph, GlaxoSmithKline Inc., August 26, 2015. 2. Data on file HZA106827. 3. Data on file HZA106829.

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

01258 01/16

AN ICS/LABA COMBINATION

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

DAY & NIGHT

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

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

BREO® ELLIPTA® (fluticasone furoate/vilanterol) 100/25 mcg and BREO® ELLIPTA® 200/25 mcg are indicated for the once-daily maintenance treatment of asthma in patients aged 18 years and older with reversible obstructive airways disease. BREO® ELLIPTA® is not indicated for patients whose asthma can be managed by occasional use of a rapid onset, short duration, inhaled beta2-agonist or for patients whose asthma can be successfully managed by inhaled corticosteroids along with occasional use of a rapid onset, short duration, inhaled beta2-agonist. BREO® ELLIPTA® is not indicated for the relief of acute bronchospasm. BREO® ELLIPTA® 200/25 mcg is not indicated for COPD. ICS=inhaled corticosteroid; LABA=long-acting beta2-adrenergic agonist * A 12-week treatment, multicenter, randomized, double-blind, placebo-controlled, parallel group study to compare the efficacy and safety of BREO® ELLIPTA® 100/25 mcg, fluticasone furoate (FF) 100 mcg, and placebo administered once daily in the evening in subjects with persistent bronchial asthma (N=609). † ITT population, FEV1 data (mL) of BREO® ELLIPTA® vs. placebo, respectively: 5min: 495 vs. 224, 15min: 516 vs. 267, 30min: 530 vs. 252, 1hr: 546 vs. 271, 2hr: 561 vs. 264, 3hr: 538 vs. 216, 4hr: 537 vs. 212, 5hr: 536 vs. 222, 12hr: 494 vs. 126, 16hr: 502 vs. 245, 20hr: 525 vs. 228, 23hr: 517 vs. 237, 24hr: 508 vs. 260. ‡ A 24-week treatment, multicenter, randomized, double-blind, parallel group study to compare the efficacy and safety of BREO® ELLIPTA® 200/25 mcg administered once daily each evening with FF 200 mcg administered once daily each evening and fluticasone propionate (FP) 500 mcg administered twice daily in subjects with persistent asthma (N=586). § ITT population, FEV1 data (mL) of BREO® ELLIPTA® vs. FF 200 mcg, respectively: 5min: 465 vs. 326, 15min: 466 vs. 338, 30min: 472 vs. 348, 1hr: 478 vs. 343, 2hr: 505 vs. 343, 3hr: 483 vs. 340, 4hr: 478 vs. 343, 5hr: 487 vs. 351, 12hr: 441 vs. 274, 16hr: 470 vs. 322, 20hr: 454 vs. 335, 23hr: 431 vs. 371, 24hr: 446 vs. 372.

NEW once-daily combination COPD therapy

grounded in long-term maintenance

INSPIOLTO RESPIMAT 速 TM

tiotropium + olodaterol inside Delivered by RESPIMAT 速 SMI (soft mist inhaler)1-3

INSPIOLTO RESPIMAT (tiotropium bromide monohydrate and olodaterol hydrochloride) is a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta2-adrenergic agonist (LABA) indicated for the long-term, once-daily maintenance bronchodilator treatment of airflow obstruction in patients with Chronic Obstructive Pulmonary Disease (COPD), including chronic bronchitis and emphysema. References: 1. INSPIOLTOTM RESPIMAT速 Product Monograph. Boehringer Ingelheim (Canada) Ltd., May 28, 2015. 2. Data on file. Boehringer Ingelheim (Canada) Ltd., 2015. 3. Decramer M, Vestbo J, Bourbeau J et al. Global strategy for the diagnosis, management, and prevention of COPD (updated 2015). Global Initiative for Chronic Obstructive Lung Disease, Inc. 2015.

Please consult the product monograph at www.boehringer-ingelheim.ca/content/ dam/internet/opu/ca_EN/documents/humanhealth/product_monograph/ InspioltoRespimatPMEN.pdf for conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions and dosing. The product monograph is also available by calling us at 1 (800) 263-5103 Ext. 84633. NEW tiotropium bromide monohydrate & olodaterol hydrochloride

InspioltoTM is a trademark and Respimat速 is a registered trademark used under license by Boehringer Ingelheim (Canada) Ltd.