March 2017

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

MARCH 2017

Finest Irish golf The art of being Dutch Thai basil chicken tonight!

MEDICINE ON THE MOVE

WIN

THIS MONTH’S

GADGET PAGE 15

Montreal

CELEBRATES!

Joys of solo practice Treatment-resistant depression

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 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., January 27, 2016. 2. Data on file HZA106827. 3. Data on file HZA106829.

BREO and ELLIPTA are registered trademarks of Glaxo Group Limited, used under license by GSK Inc. BREO® ELLIPTA® was developed in collaboration with Theravance, Inc. © 2017 GSK Inc. All rights reserved.

01933 12/16

AN ICS/LABA COMBINATION

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 beta -adrenergic agonist 2

* 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.

My old hometown Montreal knows how to party. In 1967 it led the world in celebrating Canada’s 100th anniversary. This year, it will help the country mark its 150th at the same time as the city stages a huge summer-long party for its own 375th. Read all about it in Managing Editor Camille Chin’s article on page 38 — and seriously consider adding Montreal to your 2017 travel plans.

I grew up in Montreal and in some ways it’s been a strange journey. For almost a hundred years following Confederation, the city was the economic engine of the country, the place to invest, the place to be. It represented the national aspiration of a single country made up of two founding nations. For much of my young life, my friends and I considered the Montreal Canadiens the best hockey team in the world, and we weren’t wrong.

The French/English character of the city makes it a unique place in North America. The latest numbers set the population at 1.75 million: 57 percent French, 18.5 percent English with 56 percent reporting they are bilingual.

Montreal doesn’t aspire to be New York, L.A., Miami, San Francisco or — good heavens — Toronto. It likes being itself and if that means taking a few economic hits, it’s a small price to pay. These days the infrastructure is a mess of “under construction-ness.”

Thirty-storey condos are few and far between. What you will find are affordable places to live in a variety of neighbourhoods including street after street of brick duplexes in NDG, two- and three-floor walk-ups in the Plateau and farther east to the Olympic Stadium, and new lofts along the Lachine Canal where they join other lofts converted from factories. Old Montreal, that visitor magnet, now hosts new five- and six-floor condos along the waterfront that gaze across to Habitat 67, McGill graduate Moshe Safdie’s lasting contribution to world architecture.

In the end though, what makes the city is attitude. It’s a place where the food at lunch is more important than the deal, where leisure time is more valued than work time, where style and content share common ground, where live and laugh and let live comes with the DNA. Don’t fret! There’s more to this issue than Montreal.

You’ll find Anita Draycott’s ultimate golf tour of Ireland on page 26, Robb Beattie’s reveal on the pleasures of Dutch life in Groningen on page 32.

Happy trails,

Indications and Clinical Use: Monotherapy: JARDIANCE® (empagliflozin) is indicated for use as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance.

Add-on combination: JARDIANCE® is indicated in adult patients with type 2 diabetes mellitus to improve glycemic control, when metformin used alone does not provide adequate glycemic control, in combination with: • metformin, • pioglitazone (alone or with metformin), • metformin and a sulfonylurea, • basal or prandial insulin (alone or with metformin), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control.

Add-on combination in patients with established cardiovascular disease: JARDIANCE® is indicated as an adjunct to diet, exercise and standard care therapy to reduce the incidence of cardiovascular death in patients with type 2 diabetes mellitus and established cardiovascular disease who have inadequate glycemic control.

Important Limitation of Use: Use of JARDIANCE® with insulin mix (regular or analogue mix) has not been studied. Therefore, JARDIANCE® should not be used with insulin mix.

Contraindications: • Patients with a history of hypersensitivity reaction to the active substance or to any of the excipients • Renally impaired patients with eGFR less than 45 mL/min/1.73m2, severe renal impairment, endstage renal disease and patients on dialysis Most Serious Warnings and Precautions: Diabetic Ketoacidosis: Clinical trial and post-market cases of diabetic ketoacidosis (DKA), a serious, life-threatening condition requiring urgent hospitalization, have been reported in patients on JARDIANCE® and other sodium-glucose co-transporter 2 (SGLT2) inhibitors. Some cases of DKA have been fatal. A number of these cases have been atypical with blood glucose values below 13.9 mmol/L (250 mg/dL) • Patients should be assessed for DKA immediately if non-specific symptoms of DKA occur (difficulty breathing, nausea, vomiting, abdominal pain, confusion, anorexia, excessive thirst, unusual fatigue, or sleepiness), regardless of blood glucose level, and JARDIANCE® should be discontinued immediately • JARDIANCE® should not be used for the treatment of DKA or in patients with a history of DKA • Not indicated, and should not be used, in patients with type 1 diabetes Other Relevant Warnings and Precautions: • Not recommended for use in patients who are volume depleted • Use with caution in patients for whom a drop in blood pressure could pose a risk or in case of intercurrent conditions that may lead to volume depletion. Careful monitoring of volume status and electrolytes is recommended. Temporary interruption of JARDIANCE® should be considered for patients who develop volume depletion until the depletion is corrected • Caution should be observed in patients at high risk for cerebrovascular accidents • In clinical situations known to predispose to ketoacidosis (e.g., major surgical procedures, serious infections and acute serious medical illness), consider temporarily discontinuing JARDIANCE® • Use caution in patients at higher risk of DKA • Use caution when reducing the insulin dose in patients requiring insulin • The use of JARDIANCE® in combination with a secretagogue or insulin was associated with a higher rate of hypoglycemia • Dose-related increases in LDL-C can occur with JARDIANCE®. LDL-C levels should be measured at baseline and monitored • JARDIANCE® increases the risk of genital mycotic infections, particularly for patients with a history of genital mycotic infections • JARDIANCE® increases the risk of urinary tract infections • Use with caution in patients with an elevated hematocrit • Not recommended in patients with severe hepatic impairment • Assessment of renal function is recommended prior to JARDIANCE® initiation and regularly during treatment. Do not initiate JARDIANCE® in patients with an eGFR <60 mL/min/1.73m2 • Monitoring of renal function is recommended prior to and following initiation of any concomitant drug which might have an impact on renal function, JARDIANCE® must be discontinued if eGFR falls below 45 mL/min/1.73m2 • JARDIANCE® must not be used during pregnancy or breastfeeding • Should not be used in patients <18 years of age • Use with caution in patients ≥65 years of age due to a greater increase in risk of adverse events, and because diminished efficacy is expected in this population as older patients are more likely to have impaired renal function • Patients ≥75 years of age are at a higher risk of volume depletion. Prescribe with caution • Initiation of therapy in patients ≥85 years of age is not recommended • Patients receiving JARDIANCE® will test positive for glucose in their urine For more information: Please refer to the product monograph at www.JardiancePM.ca for important information relating to adverse events, drug interactions, dosing, and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633.

For important safety information on SGLT2 inhibitors and the risk of DKA, please refer to http:// www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2016/58404a-eng.php.

References: 1. JARDIANCE Product Monograph. Boehringer Ingelheim, September 12, 2016. 2. Boehringer Ingelheim (Canada) Ltd. Data on File. Medical Letter. September 6, 2016.

David Elkins, publisher and editor delkins@parkpub.com

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JARDIANCE® is a registered trademark of Boehringer Ingelheim International GmbH, used under license.

CA/EMP/00086 BI/EMP/00086

NEW INDICATION

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

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

JARDIANCE® is not recommended for use in patients who are volume depleted.

Due to its mechanism of action, JARDIANCE® causes diuresis that may be associated with decreases in blood pressure. Caution should be exercised in patients for whom an empagliflozin induced drop in blood pressure could pose a risk, such as patients with known cardiovascular disease, patients on antihypertensive therapy (particularly loop diuretics), elderly patients, patients with low systolic blood pressure, or in case of intercurrent conditions that may lead to volume depletion (such as gastrointestinal illness).

Careful monitoring of volume status is recommended.

Temporary interruption of JARDIANCE® should be considered for patients who develop volume depletion until the depletion is corrected.

CV=cardiovascular; T2D=type 2 diabetes. *Comparative clinical significance is unknown.

You don’t compromise on patient care.

So why compromise on your network?

Power your business with Bell, Canada’s fastest, as ranked by PCMag 2016, and largest network1.

Download X-rays and patient files at amazing speeds and access medical references anywhere on your mobile device. Plus, our reliable connections, strong LTE signals and amazing in-building coverage make it easier for you to contact staff and patients. The right network makes all the difference for your business.

Visit a Bell store • 1 888 832-7224 • bell.ca/therightnetwork Current as of Feb 10, 2017. Available within network coverage areas available from Bell Mobility where technology permits; see bell.ca/coverage. One-time connection ($15) and SIM card charges ($10) may apply. 9-1-1 government monthly fee in Alta.: $0.44, N.B.: $0.53, N.L.: $0.75, N.S.: $0.43, P.E.I.: $0.70, Que: $0.46, Sask.: $0.62. Taxes extra. Other conditions apply. If you end your Commitment Period early, a Cancellation Fee applies; see your Agreement for details. Subject to change without notice. (1) As ranked by PCMag. Reprinted from www.pcmag.com with permission. © 2016 Ziff Davis, LLC. All Rights Reserved. Largest network based on total square km of coverage on the shared LTE network available from Bell vs. Rogers’ LTE network. See bell.ca/LTE for details.

contents GUILHEM VELLUT / FLICKR

MARCH 2017

38

Classic Montreal smoked meat sandwich, fries and a pickle at Schwartz’s on the Main.

features

26

Golf and food as God intended

26

44

Portmarnock, Royal Portrush, Portstewart and more — a roundup of the best true links courses and fine dining in and around Northern Ireland

by Anita Draycott B:11” T:10.75”

S:10”

32

38

Holy basil chicken fried rice and street-style fried bananas plus more recipes from the BC-based YouTube star

by Pailin Chongchitnant

regulars

Groningen: what’s old is new again From hip markets to historic monuments, a jaunt through the Dutch bicycle-only town popular with students and in-the-know visitors

by Robb Beattie

Montreal turns 375!

Giant marionettes, symphonies on the mountain, huge digital projections and parties all over town — come celebrate

by Camille Chin

Authentic Thai

8

LETTERS Name that neighbourhood

9

PRACTICAL TRAVELLER Robots at London’s Science Museum, bison return to Banff National Park, hackers hit a hotel in Austria and more

by Camille Chin

44

32

MARCH 2017 • Doctor’s

Review

5

VYVANSE®*

st

The 1 & only medication in Canada indicated for the treatment of moderate to severe Binge Eating Disorder in adults1,2† Limitation of Use for Binge Eating Disorder (BED): Serious cardiovascular (CV) events have been reported with this class of sympathomimetic medications.

The BED clinical trials were not designed to assess CV safety.

Given the higher CV risk associated with obesity, the BED population may be at a higher risk.

The safety and effectiveness of VYVANSE for the treatment of obesity have not been established.

VYVANSE is not indicated or recommended for weight loss.

Consider a conversation with your patients who you believe may be suffering with Binge Eating Disorder.

In addition to your clinical assessment, ask: • • • • •

Have you eaten an abnormally large amount of food in a short period of time?

Did you have a sense of lack of control over eating during the episode?

Are you distressed about the binge eating?

Do you feel disgusted or guilty?

Do you eat alone because you are embarrassed?

VYVANSE (lisdexamfetamine dimesylate capsules) is indicated for the treatment of Moderate to Severe Binge Eating Disorder (BED) in adults.3 Recurrent episodes of binge-eating are characterised by: • consuming an abnormally large amount of food in a short period of time and sense of lack of control over eating during the episode • marked distress about the behavior • feeling disgusted or guilty, or eating alone because of embarrassment.

Limitation of Use for BED: Prescribers should consider that serious cardiovascular (CV) events have been reported with this class of sympathomimetic medications.

The BED clinical trials were not designed to assess CV safety. While there is an accumulation of safety data with VYVANSE use in the Attention Deficit Hyperactivity Disorder (ADHD) population, this is of limited relevance regarding CV risk in the BED population. Given the higher CV risk associated with obesity, the BED population may be at a higher risk.

The safety and effectiveness of VYVANSE for the treatment of obesity have not been established.

VYVANSE is not indicated or recommended for weight loss. Use of other sympathomimetic drugs for weight loss has been associated with serious cardiovascular adverse events.

Consult the product monograph at www.shirecanada.com/vyvpm/en for important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions, and dosing. The product monograph is also available by calling Shire Pharma Canada ULC at 1-800-268-2772.

References: 1. Shire Pharma Canada ULC. Data on file. 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. 3. VYVANSE Product Monograph. Shire Pharma Canada ULC, September 30, 2016. † Moderate BED is defined as 4-7 binge-eating episodes per week. Severe BED is defined as 8-13 binge-eating episodes per week.

*VYVANSE is a registered trade-mark used under licence from Shire LLC. © 2017 Shire Pharma Canada ULC. All rights reserved.

CDA/PRMCDA/VYV/16/0047 72604-01-2018-E

contents MARCH 2017

14

regulars

14

GADGETS AND GEAR Easy-make ice cream

by David Elkins

17

TOP 25

9

The best conferences scheduled for this summer

20 DEPRESSION KEYPOINTS

Individual treatment resistant strategies

by Dr David Desjardins

23

48

PHOTO FINISH Cheeky monkey

by Dr Bruno Tremblay

HISTORY OF MEDICINE An interview with “ideal medicine” activist Dr Pam Wible

by Tilke Elkins

Coming in

23

April

Free as a bird in Nepal Get your adventure on and let a vulture be your guide to paragliding Walks in the English countryside Come along with this Canadian doctor as she explores enchanting paths that are close to London Finland is 100!

Celebrate the Finns and their wonderful little-known country — we have so much in common Vancouver’s new Chinese chefs Call it Chinese nouvelle, the classic rules are changing and old Saltwater City is in the vanguard MARCH 2017 • Doctor’s

Review

7

LETTERS

Name that neighbourhood

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

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

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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, Parkhurst Publishing Ltd., 3 Place Ville Marie, 4th floor, Montreal, QC H3B 2E3.

Subscription rates: One year (12 issues) – $17.95 Two years (24 issues) – $27.95* One year U.S. residents – $48.00 *Quebec residents add PST. All prescription drug advertisements appearing in this publication have been precleared by the Pharmaceutical Advertising Advisory Board.

8

Doctor’s Review • MARCH 2017

ARTISTS IN RESIDENCE I was intrigued by the article by Theo Sands, “Cognitive decline in famous painters” [Medicine and the Arts, January 2017, page 21]. In particular though, it was the photo on page 23 of Marc Chagall that really struck me. I think I recognize the home in the photo and I wonder if you or Mr. Sands could let me know the source of this photo or how to find out? It would be amazing if this is indeed the house of friends of mine (one of whom is also an MD) near Lisbon!

Dr Denise Marshall Via email

Editor’s note: The photo (above) of Marc Chagall (pictured left) and Jean Vincent de Crozals (right) was taken by Dr Cyrille de Crozals in 1951. We got the photo from Wikimedia Commons, but the location isn’t specified.

A MIXED BAG I read the article “The doctor’s got a new bag” [Gadgets and Gear, January 2017, page 14] and opted to purchase a bag from rucksackbag.com.

Despite ordering and paying for a bag, I received an e-mail noting that the bag I selected was out of stock (though it still didn’t specify that on their website).

After choosing yet another bag, the same thing happened. I ended up

selecting one of the alternate bags and I enquired about whether the bag could be left on my porch. I also asked whether there would be customs fees.

I e-mailed multiple times with no response until finally, this morning, I received an e-mail that I was receiving a refund. I was, on one hand, relieved, as I was starting to wonder if the company is a scam. I even got the dispute number from VISA. On the other hand, I still don’t have a bag for performing house calls!

Dr Chase Everett McMurren Via email

Editor’s note: Sorry to hear about the difficulty you had in trying to purchase the bag.

Careful steps are taken to ensure gadget suppliers are trustworthy. This supplier will be contacted and a suitable remedy requested.

We want to hear from you!

Send your comments and questions to: Doctor’s Review, Parkhurst Publishing Ltd., 3 Place Ville Marie, 4th Floor, Montreal, QC H3B 2E3.

Or email us at editors@doctorsreview.com.

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

C a mi lle C hi n

Kodomoroid, a Japanese android who reads the news.

FAR RIGHT: Automaton monk, attributed to Gianello Torriano, Spain, circa 1560.

How long ago do you think the first robot was made: 20 years ago… 50…100? It’s one of the questions that the new Robots exhibit in London answers. Turns out that we’ve been fascinated with mechanised humans for 500 years and the blockbuster exhibit, on now until September 3 at the Science Museum, has 16 moving robots and 100 artifacts to prove it, including an amazing 16th-century mechanised monk from Spain. The T-800 Terminator from, yes, the movie, is also there as is Kodomoroid from Japan. Every 20 minutes she reads robot-related news. The show focuses on why robots exist — religious beliefs, the industrial revolution, dreams about the future — rather than on how they work, and provides insight into our ambitions and desires to make things that resemble us (delusion, fear, hope…).

Tickets are date and time-stamped: adults £15 ($25); kids 8 to 16 £13 ($21). beta.sciencemuseum.org.uk/robots.

MARCH 2017 • Doctor’s

SMITHSONIAN INSTITUTION

© PLASTIQUES PHOTOGRAPHY / COURTESY OF THE SCIENCE MUSEUM

Our obsession with robots

Review

9

© PLASTIQUES PHOTOGRAPHY / COURTESY OF THE SCIENCE MUSEUM

Visitors looking at iCub, the world’s smartest robot toddler.

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

Taiwan for the win

LITTLEAOM / SHUTTERSTOCK.COM

Gozo Island, Malta.

10

Doctorâ&#x20AC;&#x2122;s Review â&#x20AC;˘ MARCH 2017

Ecuador.

AMMIT JACK / SHUTTERSTOCK.COM

Dreaming of living and working abroad? A new survey by InterNations, a resource for expats with 2.5 million members, revealed that Taiwan is the best place to work and play overall.

The island nation 180 kilometres east of China took the top spot ahead of 67 other destinations. More than 14,000 expats took part in the survey representing 174 nationalities and 191 nations.

The survey considered things like climate and weather, medical care, availability/cost of housing, childcare and education, job security, work-life balance, transportation, wellbeing and safety, the friendliness of locals and more. Taiwan ranks particularly high in work satisfaction, quality of medical care and friendliness. Malta came in second overall; it ranks high in good weather, feeling welcome, ease of making friends and where expats are most in love with each other. Finland (32nd overall) scored extremely high in education; Canada is 12th overall. For more, including infographics of the most interesting results: internations.org/expat-insider.

T. DALLAS / SHUTTERSTOCK.COM

Taipei, Taiwan.

TOP EXPAT DESTINATIONS OVERALL 1. Taiwan 2. Malta 3. Ecuador 4. Mexico 5. New Zealand 6. Costa Rica 7. Australia 8. Austria 9. Luxemburg 10. Czech Republic

ALBERT LOZANO / SHUTTERSTOCK.COM

A new kind of DARREN BAKER / SHUTTERSTOCK.COM

hotel virus Hooves on

home soil

When was the last time you got an actual, old-school key to access your hotel room? A four-star hotel in Austria is scrapping electronic room cards, and reverting to traditional locks and keys after their computer system was hacked by ransomware at the beginning of their busy ski season. New room cards for guests checking in at the Romantik Seehotel Jaegerwirt couldn’t be issued for about 24 hours until €1500 in Bitcoins was paid to the thieves. Other guests couldn’t re-enter their rooms if they left. What’s more, this was the fourth time the Austrian hotel in the Alps was hacked; they finally went public with the news to warn other accommodations. This past summer, several hotel operators in the US admitted that their point-of-sale terminals had been compromised by malware; it exposed customer names, payment card numbers, expiration dates and verification codes.

Sixteen plains bison were returned to Banff National Park in February. It’s the first time in over 100 years that bison have been in the park.

Thirty million once grazed there, but overhunting almost left them extinct. In the early 1900s, the Canadian government bought one of the last herds and kept them in a protected paddock in Alberta. Park officials say the animals, mostly pregnant two year olds, are adapting to their new home, the remote Panther Valley on the eastern side of the park. Their health and movements will be monitored as will their survival rates and how well they withstand predation from wolves and bears. In summer 2018, they’ll be released into a larger area where they can search for food.

The goal of this five-year project is to re-establish a wild population and also to help conservation nationally and internationally. For more: pc.gc.ca/ eng/pn-np/ab/banff/plan.aspx.

MARCH 2017 • Doctor’s

Review

11

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

ROCKY MOUNTAINEER

Singled out

ROCKY MOUNTAINEER

Single people often get the short-end of the stick — on Valentine’s Day and on travel supplements. Now, Rocky Mountaineer, which chugs through Western Canada and the Canadian Rockies and offers 65 vacation packages, has announced its first-ever promotion for solo travellers. Go Solo sees single travellers pay the same per-person rate of a double-occupancy booking, which, depending on journey length, hotel stay, additional excursions and the time of travel, may amount to a savings of several hundred dollars.

The promo is available now until May 15 on GoldLeaf and SilverLeaf packages of five days or more that depart in April or May 2017. To book: (877) 460-3200; rockymountaineer.com.

12

Doctor’s Review • MARCH 2017

NOW AVAILABLE WITHOUT A PRESCRIPTION!

FLONASE® Allergy Relief is the same intranasal corticosteroid (INS) that has been trusted by doctors and pharmacists for nearly 20 years.1 FLONASE® Allergy Relief is the first and only over-the-counter (OTC) INS indicated to treat nasal and ocular symptoms of seasonal and perennial allergic rhinitis, without a prescription.1-3 It is available for OTC* use in adults 18 years of age and older.2

VISIT FLONASEPROFESSIONAL.CA FOR MORE INFORMATION. FLONASE® Allergy Relief (fluticasone propionate aqueous nasal spray 50 mcg) is indicated for the treatment of the symptoms associated with seasonal allergic rhinitis including hay fever, and perennial rhinitis; and the management of sinus pain and pressure symptoms associated with allergic rhinitis.

References: 1. Data on file. GSK group of companies. 2016. 2. FLONASE® Allergy Relief Product Monograph. GlaxoSmithKline Consumer Healthcare Inc. August 23, 2016. 3. Nasacort Allergy 24HR/Nasacort AQ Product Monograph. Sanofi-Aventis Canada Inc. December 11, 2013.

Please consult the product monograph at flonaseprofessional.ca or by calling 1-866-994-7444 for information relating to adverse reactions, drug interactions, and dosing information.

GlaxoSmithKline Consumer Healthcare Inc. Mississauga, Ontario L5N 6L4 ©2017 GSK group of companies. All rights reserved.

* BTC in Quebec, Schedule II.

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

D a v i d Elk i n s

Ice cream season cometh When I was a kid one of my favourite things to do with my Dad was make ice cream. That said, it wasn’t an unfettered joy. It involved creating an egg custard with sugar and cream and eggs which had to be heated on the stove and constantly stirred to keep the eggs from curdling. Sometimes, despite the sincerest form of stirring, they still curdled.

That made my father angry but he was a good-natured, forgiving man at heart and we’d begin the delicate process again.

Once complete, the mixture was put in the refrigerator to cool as we prepared the ice cream maker — ­ an old time affair consisting of a wooden pail into which a metal container was placed and surrounded with ice and salt.

After the custard was added, a geared crank was fitted on and turned until the ingredients miraculously became the most wonderful ice cream ever.

The cranking did, however, take some time with frequent stops to add more ice and salt. A messy process. We usually did it on the kitchen floor on a stack of newspapers to soak up the water from the melting ice. The cranking seemed endless to my 10-year-old self. I had to bite my tongue to keep from asking, “Is it ready yet, Dad?” every two minutes or so. That risked getting on his nerves — especially if it was a hot day and he was wearing one of his white nylon go-towork shirts. Truth be told he’d sweat like a horse and curse like a sailor until the delicious nectar was ready to be served.

Since then everything about homemade ice cream has changed except the marvellous taste. A wide range of electric contraptions are available that will take the effort out of cranking, but I’ve remained

Win one of two Donvier Manual Ice Cream Makers by entering the Gadget of the Month contest at doctorsreview.com a purist. I like my ice cream hand cranked.

Fortunately there are also new frozen dessert recipes that leave out the eggs and the threat of salmonella and yet still taste scrumptious. Ben and Jerry’s have a book of ice cream recipes that includes this one: Sweet Cream Base #2, which consists of 2 cups (500 ml) heavy whipping cream, ¾ cup sugar (180 ml) and ²⁄³ cup (160 ml) half-and-half.

Simple enough but my own favourite recipe is even simpler. It uses yogurt chilled to 40 degrees and added directly to the canister. The Donvier Manual Ice Cream Maker also does away with ice and salt entirely! Instead you put the metal container in the freezer for a couple of hours, add the ingredients and you’re off to the races. To turn the yo-

gurt into a firm, scoopable delight takes about 30 minutes with cranking stops every four or five minutes to let the mixture rest. It can be a bonding group experience if performed around the dinner or picnic table.

My daughter and her partner have come up with a tasty enhancement: reduce a saucepan of pomegranate juice over medium heat until it becomes a syrup and pour over a scoop that has been sprinkled with pomegranate seeds — a visual and flavour extravaganza.

You can find the one-quart Donvier Manual Ice Cream Maker at better kitchen shops or order it from Amazon. ca. $50 or $58 with Ben and Jerry’s Homemade Ice Cream and Dessert Book by Ben Cohen.

CONGRATULATIONS! The winner of a leather and canvas rucksack is Dr Judith Shindman, a GP from Toronto.

MARCH 2017 • Doctor’s

Review

15

CV EVENTS HAPPEN.

COULD YOUR PATIENTS BE AT RISK? RECOMMEND COVERSYL® PROVEN TO REDUCE CV RISK IN HYPERTENSIVE AND/OR POST-MI PATIENTS WITH STABLE CAD.1

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.

Indication and clinical use not discussed elsewhere: COVERSYL® is indicated for the reduction of CV risk in patients with hypertension or post-MI and stable CAD. Use in children is not recommended.

Most serious warnings and precautions: • Pregnancy: When used in pregnancy, ACE inhibitors can cause injury or even death of the developing fetus. When pregnancy is detected, COVERSYL® should be discontinued as soon as possible.

Contraindications: • Pregnant women, women planning to become pregnant or nursing women.

• Patients with a history of hereditary/idiopathic angioedema or angioedema related to previous treatment with an angiotensin converting enzyme (ACE) inhibitor.

• Patients with hereditary problems of galactose intolerance, glucose-galactose malabsorption or the Lapp lactase deficiency.

• Concomitant use with aliskiren-containing drugs in patients with diabetes mellitus (type 1 or 2) or moderate to severe renal impairment (glomerular filtration rate (GFR) < 60 mL/min/1.73 m2).

Other relevant warnings and precautions: • Head and neck, and intestinal angioedema • In patients with stable coronary artery disease • Hypotension • In patients with aortic stenosis/ hypertrophic cardiomyopathy • Dual blockade of the renin-angiotensin system (RAS) in patients other than patients with diabetes mellitus (type 1 or 2) or moderate to severe renal impairment (GFR < 60 mL/min/1.73 m2) • Neutropenia/agranulocytosis/ thrombocytopenia/anemia • Hepatic failure • Anaphylactoid reactions • Nitritoid reactions – gold • Peri-operative considerations

CV: cardiovascular; MI: myocardial infarction; CAD: coronary artery disease 1. COVERSYL® Product Monograph. Servier Canada Inc., October 23, 2014.

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.

• Impaired renal function • In hypertensive patients with congestive heart failure • In hypertensive patients with renal artery stenosis • Proteinuria • Hyperkalemia • Respiratory (cough) • Dermatological reactions • In geriatrics • In patients with impaired liver function • In diabetic patients For more information: Please consult the Product Monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for more information relating to adverse reactions, drug interactions and dosing information which have not been discussed here.

The Product Monograph is also available by calling us at 1-800-363-6093.

Please visit www.servier.ca/references/ Coversyl_EN.pdf to access the study parameters and reference list.

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Ottawa, ON September 14-16 2017 Annual Conference of the Canadian Psychiatric Association cpa-apc.org

Quebec City, QC August 20-23 150th Annual Meeting of the Canadian Medical Association cma.ca/En/pages/upcoming-annual-meetings. aspx

August 23

Toronto, ON September 13-16

Canada Aviation and Space Museum in Ottawa.

© CTC

2017 Annual Meeting of the Canadian Medical Protective Association cmpa-acpm.ca/annual-meeting

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

31st Annual Scientific Meeting of the Canadian Association of Radiation Oncology caro-acro.ca/meetings___education/annual_ scientific_meetings.htm

August 6-10

Vancouver, BC July 14-16

September 7-10

22nd World Congress on Heart Disease cardiologyonline.com/wchd2017

93rd Annual Meeting of the Western Section of the American Urological Association wsaua.org 18th Congress of the International Headache Society ihc2017.com

September 14-16

CLAUDIO DIVIZIA / SHUTTERSTOCK.COM

63rd Annual Meeting of the Canadian Fertility and Andrology Society cfas.ca/annual-meeting/future-meetings

Berlin’s House of the Cultures of the World arts venue.

Berlin, Germany July 8-13 26th Biennial Congress of the International Society on Thrombosis and Haemostasis isth2017.org

Boston, MA July 27-30 3rd World Congress on Thyroid Cancer thyroidworldcongress.com

Chicago, IL July 6-9 13th World Congress of Pediatric Dermatology wcpd2017.com

July 17-18

Around the world

14th World Congress on Neurology and Neurological Disorders neuro.conferenceseries.com

Bangkok, Thailand August 2-5

Gold Coast, Australia August 7-8

11th Congress of the International Society for Hemodialysis ishd2017.org

4th National Eating Disorders and Obesity Conference eatingdisordersaustralia.org.au

Barcelona, Spain August 26-30

Hong Kong, China August 4-6

ESC Congress escardio.org/congresses-&-events/esc-congress

15th Urological Association of Asia Congress uaa-congress.org MARCH 2017 • Doctor’s

Review

17

THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Kuala Lumpur, Malaysia July 6-9 11th International Symposium on Pediatric Pain ispp2017.org

Liverpool, England August 30-September 3 20th International Congress of the International Society for Psychological and Social Approaches to Psychosis isps2017uk.org

MIGEL / SHUTTERSTOCK.COM

London, England July 16-20 2017 International Conference of the Alzheimer’s Association alz.org/aaic

Lyon, France July 7-9 3rd International Neonatology Association Conference 2017.worldneonatology.com

MEDICAL QUIPS Come again?

Doctor: “Nurse, get me my auriscope.”

Flustered young nurse: “But doctor, I don’t even know your star sign.”

Jalan Alor food street in Kuala Lumpur.

Portland, OR July 10-13 Basic Cardiovascular Sciences Scientific Sessions 2017 professional.heart.org/professional

San Diego, CA June 9-13 77th Scientific Sessions of the American Diabetes Association professional.diabetes.org/meeting/scientificsessions/77th-scientific-sessions

August 4-6 34th Annual Primary Care Summer Conference scripps.org/events/34th-annual-primarycare-summer-conference-august-4-2017

To register and to search 2500+ conferences, visit doctorsreview.com/meetings San Francisco, CA July 26-29 15th Symposium on Cochlear Implants in Children ci2017sf.org

Snowbird, UT July 9-12 35th Annual National Neurotrauma Symposium nationalneurotraumasociety.org/ symposium/2017-symposium

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!

18

Doctor’s Review • MARCH 2017

DE PRESSIO N K EY PO I NT S by

David Desjardins, PhD

Treatment-resistant depression A common clinical problem requiring an individualized treatment approach

M .

ajor depressive disorder (MDD) ranks among the most debilitating diseases affecting modern society with a disease burden surpassing that of cancer or diabetes in some countries.1 In Canada, over 1.5 million people experience a major depressive episode (MDE) each year, and the lifetime prevalence in the general population is approximately 11.3%.2 A combination of factors contribute to the burden including occupational costs, increased utilization of healthcare resources, and diminished quality of life.

In Canada alone, the annual economic burden is estimated to be upwards of C$51 billion.3 Several organizations, including the Canadian Network for Mood and Anxiety Treatments (CANMAT), recommend secondgeneration antidepressants as the first-line treatment option for moderate or severe MDD.4 Unfortunately, a large proportion of patients fail to respond to pharmacologic treatment. In STAR*D clinical trail only 36.8% of patients achieved remission after their first treatment.5 With each subsequent treatment, remission rates dropped further. In fact, one third of patients never remitted after four consecutive treatments.

Treatment-resistant patients are a major challenge in terms of their own well-being and economic cost to the country. It is imperative that they receive optimal care and are counselled appropriately.6

Roadblocks to recovery Treatment-resistant depression (TRD) is most commonly defined as the failure to improve despite two or more trials with antidepressants.7 When assessing a patient with depression who has failed to respond to treatment, there are several important factors to consider before initiating subsequent treatments.

One is whether the diagnosis is correct. Other medical disorders may present with depressive symptoms, including hypothyroidism, inadequately controlled diabetes mellitus, and others.

To avoid diagnostic errors, it is essential to ensure a thorough and accurate medical history has been taken. Existing comorbid physical or psychiatric disorders (e.g., chronic pain, substance abuse) can also worsen prognosis. If such comorbid conditions are identified and treated successfully, the prognosis for these patients can significantly improve.8 A third factor to consider is poor adherence, which is common in all medical conditions, and occurs in up to 20% of patients with depression.9 Lastly, it is important to ensure that treatments are optimized, as there is evidence that many patients receive sub-therapeutic doses and/or undergo treatment for a suboptimal duration.

A clinician’s toolkit The 2016 CANMAT guidelines recommend two broad treatment strategies for patients with an inadequate response to first-line antidepressants: switching and adjunctive strategies.4 Switching, whether within or between classes, is the most common strategy used by clinicians to treat TRD. However, it is not necessarily the most effective option. Indeed, analyses have failed to convincingly demonstrate the superiority of either option over the other.10 The best treatment plan will ultimately depend on individual patient factors, as outlined in Table 1. A switching strategy should be considered if a patient had an inadequate response to a single antidepressant that was properly optimized in terms of dose and duration. If a patient has not responded to two or more antidepressants, adjunctive treatments should be considered instead.4,6 Switching is also appealing in the setting of poor tolerance or complete non-response (<25% improvement).

Table 1. Factors to consider when choosing between switching and adjunctive strategies Consider switching when...

Consider an adjunctive medication when...

• The patient has not responded to their first antidepressant • The initial antidepressant is tolerated poorly • There is no response to the initial antidepressant • There is time to wait for a response • The patient prefers switching

• The patient has not responded to ≥2 antidepressants • The initial antidepressant is tolerated well • There is partial response to the initial antidepressant • There is less time to wait for a response • The patient prefers to add on another medication • There are symptoms or side effects to the initial antidepressant that can be targeted

Modified from Kennedy SH et al; CANMAT 2016. Can J Psychiatry. 2016;61(9):540-60.

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Doctor’s Review • MARCH 2017

Step-by-step road to remission One accepted predictor of future response is early improvement, defined as >20% to 30% reduction from baseline on a depression rating scale after 2 to 4 weeks.4 As such, when treating patients with an inadequate response, CANMAT recommends first increasing the antidepressant dose for non-improvers at 2 to 4 weeks, if tolerated, or switching to another antidepressant if not.

If early improvement is still not observed, then switching or adjunct therapy should be initiated based on the patient factors previously described (Table 1). In addition, the adjunctive use of psychological and neurostimulation treatments can be considered. Once early improvement is achieved, treatment should be continued for 6 to 8 weeks. If remission is not achieved after this period, the dose can be increased if tolerated and not already maximized. In those who do enter remission, CANMAT recommends treatment maintenance for 6 to 9 months, or for 2 or more years in those with risk factors for recurrence (e.g., comorbid psychiatric conditions). Patients with chronic and resistant depression who respond poorly despite a systematic, sequential approach should be counselled on whether to continue active treatment or switch to a management approach focused on improving quality of life and functioning.

Treatment resistant, not treatment immune Why is it that some patients respond to initial treatment, whereas others pass through multiple trials without ever entering remission? A likely reason is the heterogenicity of the disease — the symptoms, severity, and course of the disease can vary greatly in patients who all meet the definition of MDD.6 Social factors and psychiatric and medical comorbidities will also vary from patient to patient. Thus, it is not that patients with TRD are

incapable of responding to treatment, but rather that they have not yet been matched to a treatment that fits their individual psychopathology. This is a useful mindset to have, especially since both patient and clinician can become pessimistic about the prognosis after several rounds of failed therapy. Clinicians should focus on individualizing treatment and involving the patient in treatment decisions. Although many patients with TRD will not enter remission, adopting a patient-centric, systematic approach offers the best chance of overcoming this debilitating illness.

References 1. Mrazek DA, Hornberger JC, Altar CA, et al. A review of the clinical, economic, and societal burden of treatment-resistant depression: 1996-2013. Psychiatr Serv.

2014;65(8):977-87.

2. Lam RW, McIntosh D, Wang J, et al; CANMAT Depression Work Group. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 1. Disease Burden and Principles of Care. Can J Psychiatry. 2016;61(9):510-23.

3. Lim KL, Jacobs P, Ohinmaa A, et al. A new population-based measure of the economic burden of mental illness in Canada. Chronic Dis Can. 2008;28:92-98.

4. Kennedy SH, Lam RW, McIntyre RS, et al; CANMAT Depression Work Group.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. Can J Psychiatry. 2016;61(9):540-60.

5. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report.

Am J Psychiatry 2006;163:1905-17.

6. Ionescu DF, Rosenbaum JF, Alpert JE. Pharmacological approaches to the challenge of treatment-resistant depression. Dialogues Clin Neurosci. 2015;17(2):111-26.

7. Haddad PM, Talbot PS, Anderson IM, et al. Managing inadequate antidepressant response in depressive illness. Br Med Bull. 2015;115(1):183-201.

8. Bair MJ, Robinson RL, Eckert GJ, et al. Impact of pain on depression treatment response in primary care. Psychosom Med. 2004;66:17-22.

9. Roberson AM, Castro VM, Cagan A, et al. Antidepressant nonadherence in routine clinical settings determined from discarded blood samples. J Clin Psychiatry.

2016;77:359-362.

10. Gaynes BN, Dusetzina SB, Ellis AR, et al. Treating depression after initial treatment failure: directly comparing switch and augmenting strategies in STAR*D. J Clin Psychopharmacol. 2012;32:114-119.

MARCH 2017 • Doctor’s

Review

21

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

PRISTIQ 50 mg demonstrated significant improvements in functional outcomes from baseline vs. placebo, as measured by the Sheehan Disability Scale (SDS).2† Work score: PRISTIQ -2.9 (n=156), placebo -2.2 (n=148), p=0.01 Family life score: PRISTIQ -3.0 (n=163), placebo -2.2 (n=160), p=0.002 Social life score: PRISTIQ -3.2 (n=163), placebo -2.3 (n=160), p=0.003 Clinical use: • PRISTIQ is not indicated for use in children under the age of 18 • The short-term efficacy of PRISTIQ has been demonstrated in placebo-controlled trials of up to 8 weeks • The efficacy of PRISTIQ in maintaining an antidepressant response for up to 26 weeks, following response during 20 weeks of acute, open-label treatment, was demonstrated in a placebo-controlled trial Contraindications: • Concomitant use with monoamine oxidase inhibitors (MAOIs) or within the preceding 14 days • Hypersensitivity to venlafaxine hydrochloride Most serious warnings and precautions: Behavioural and emotional changes, including self-harm: SSRIs and other newer antidepressants may be associated with:

•

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

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

•

For more information: Please consult the Product Monograph at http://pfizer.ca/ pm/en/Pristiq.pdf for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece.

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

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

References: 1. PRISTIQ Product Monograph, Pfizer Canada Inc., October 26, 2016. 2. Boyer P, et al. Efficacy, safety, and tolerability of fixed-dose desvenlafaxine 50 and 100 mg/day for major depressive disorder in a placebo-controlled trial.

Int Clin Psychopharmacol 2008;23:243-253. 3. Sheehan DV. Sheehan Disability Scale in: Rush AJ, Pincus HA, First MB, et al. eds. Handbook of psychiatric measures. Washington, DC: American Psychiatric Association; 2000:113-115.

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

CA0116PRI017E

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

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

T i lk e Elk i n s

Is solo practice the way of the future?

An interview with US “ideal medicine” activist Dr Pam Wible

A

pioneer in the movement seeking to re-humanize medicine, Dr Pamela Wible, a family physician based in Eugene, Oregon, is a passionate advocate

for relationship-based medical care. In 2005, she reached a personal nadir as a doctor after realizing how many in her profession had died of suicide. Having been suicidal herself given the deplorable working conditions physicians face and the poor “big-box medicine” delivered to patients, she called nine town meetings where she asked her community, “What does your ideal medical clinic look like?” After reviewing the 100 pages of notes she had compiled, she opened a clinic within a month.

She did it without outside funding; it met 90 percent of the community’s criteria.

To view one of Dr Wible’s TED Talks, search “How to get naked with your doctor” on YouTube.

Dr Wible describes her clinic as “a sanctuary, a safe place, a place of wisdom where we can learn to live harmlessly, listen with empathy, and learn without judgment.” Her clinic has sofas in the waiting room, no front counter and no staff. There are purple robes for patients and free massages. Dr Wible answers her own phone, schedules appointments and takes patient vitals. She also submits insurance claims without the help of a billing clerk. She avoids unnecessary tests and procedures, and makes 85 percent of diagnoses simply by listening to the patient. Appointments usually last 30 minutes to an hour during which there’s ample time to build what Dr Wible calls “a complete human relationship.” No one is turned away for lack of funds, and though she gives patients her home phone number and accepts calls 24/7, her phone barely rings because she’s able to handle her patients’ issues comprehensively during office visits. She works three half days a week, and makes more in take-home pay than she did when she worked four long days at a big clinic.

In addition to her belief that vulnerability, joy and humour are keys to success in medicine, Dr Wible has business smarts. In her old job, 74 percent of her earnings went into overhead: receptionists and staff, rent, elaborate computer systems and other MARCH 2017 • Doctor’s

Review

23

Dr Wible strives to make her practice “a place where doctor and patient listen with empathy and learn without judgment.”

“unnecessary” technology. In her current practice, start-up costs were only 3K, which covered furniture, decor, first and last month’s rent, an exam table and supplies. She already owned her only two crucial pieces of technology: a laptop and a stethoscope. Her total annual overhead is now just 10 percent, allowing her to keep 90 percent of her earnings.

Dr Wible has abandoned the white coat and favours Levis because she believes people value authenticity over authoritarianism. “The patriarchal medical model is obsolete,” she says.

Physicians and other health professionals can download a free guide to opening their own ideal medical clinic on her website idealmedicalcare.org.

To view one of Dr Wible’s TED Talks, search “How to get naked with your doctor” on YouTube.

DR: What would you say is the essential difference between medical care as currently practiced and “ideal medical care?”

PW: Most doctors have been funneled into assembly-line medical clinics

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that are production driven. Ideal medical care is relationship driven. Patients are seen as whole human beings and not just body parts. The most progressive clinics place the end user in charge of designing their own ideal clinics.

DR: Do you think that ideal medical care could be practiced everywhere?

Even in high-speed, high-stress, understaffed locations and in hospitals?

PW: Absolutely. Ideal clinics are most aligned with the traditional way medicine has always been practiced for centuries. Assembly-line medicine is a recent failed phenomenon. There are hundreds of ideal clinics all over America.

I’ve also been hired to create communitydesign ideal hospitals. The basic concepts are scalable and can be applied successfully to all health care facilities.

DR: How does practicing ideal medicine affect earnings?

PW: I have been able to triple my income per patient working just one quarter of the time. When I worked at a big-box medical clinic my overhead was 74 percent. When I opened my own ideal clinic my overhead was seven

percent. What does that mean for you?

Well, here comes a patient who is bringing you $100 for a medical visit.

And guess how much you get to keep if your overhead is 74 percent? You get to keep $26 (before tax). Here’s your income for seeing one patient at the big-box clinic: $26. How does that sound? But if you see the same patient at your ideal clinic, you’ll end up with a nice income of $93. What do you prefer: an income of $26 or $93?

DR: If all doctors used your model wouldn’t we have a shortage of doctors?

PW: That’s a great question. If all doctors limited their practice to a smaller panel of patients, whether fulltime or part-time, would there be enough docs to take care of all the patients? The Ideal Medical Movement actually inflates the physician workforce by decreasing the burden on each doc. Here’s how: 1) Less per-patient burden on the health-care system. More comprehensive care visits help patients be more selfreliant so that one 30-40 minute visit

“Physicians have a high suicide rate.

They are searching for any exit strategy, especially from primary care” may be worth four shorter rushed visits. Patients don’t need to be seen as frequently. Patients also feel more confident knowing that they have a stable relationship with an accessible doctor.

They don’t get anxious about getting in. There’s no hoarding of perceived scarce resources that is what desperate patients do when they can’t get the services they need.

2) Inflates the physician workforce.

Physicians are retiring early, searching for niche specialties, or leaving medicine as a profession because they can’t stand the current model. Physicians also have a high suicide rate. They are searching for any exit strategy, especially from primary care. In my last employed practice, three women in their prime left medicine completely because it was “undoable.” In a humane ideal-medical care model, we can attract these physician drop-outs back to the office. We can get our early retirees back to work. We will also recruit more physicians. In the first two years of my new practice, I’ve had three patients tell me that they plan to pursue medicine as a career!

I’ve inadColour: 1/3 page horizontal

vertently served as a recruitment centre for physicians! This never happened in the assembly line!

3) Embraces other health-care professionals. It’s time to work together with other health-care professionals, rather than have adversarial relationships. Let’s work with NPs, PAs, naturopaths, chiropractors, massage therapists and any other accredited and certified health-care professionals who have our patient’s best interests at heart. Share the workload!

The Ideal Medical Care Movement renews hope and a sense of purpose in our physicians, ultimately inflating the physician workforce. Shortage of physicians in primary care has more to do with onerous and unnecessary regulations, absurdly complex bureaucracy, and disproportionately low reimbursement in primary care compared with more lucrative specialties. Let us deal squarely with the real issues that undermine primary care. The ideal practice model is the saviour of primary care medicine.

DR: What are some first steps that a doctor steeped in the current

system can take to begin to practice ideal medical care? Is opening an ideal clinic the only answer?

PW: Physicians must practice in alignment with their highest values, the dreams that brought them to medicine in the first place. Docs must break free of their victim mindset. Meet other docs who have opened relationshipdriven clinics. There are many physicians practicing medicine in fulfilling solo and independent practices. Ideal is a relative term. Ideally the “ideal” clinic would be designed by the patients and physician in collaboration.

DR: Since you opened your ideal clinic, have you noticed physiological changes in your patients’ health, as compared to your patients at the big clinic?

PW: YES! Relaxed and better blood pressures. They are actually excited to come to the doctor and some tell me that it’s the highlight of their day!

DR: What are some invigorating challenges that you face currently in your work? uu CONTINUED ON PAGE 47

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Portmarnock near Dublin Airport measures 7365 yards from the back tee and thereâ&#x20AC;&#x2122;s always a stiff breeze.

Golf and food as God intended An Irish version of the best of the good life

by Anita Draycott

here are about 160 genuine links courses in the world and almost a third of them are in Ireland. How’s that for the luck of the Irish?

The main reason golf addicts cross the Atlantic is the lure of those links, but for pampered North American swingers, the first encounter with a true links course may come as a bit of a shock. No wallto-wall fairways, yardage markers or cart girls.

“Buggies,” as carts are called in Ireland, are few and far between.

Links courses are meant to be walked, either shouldering your bag or pushing a “trolley.” Better still, hire a caddie, not just for judicious advice on quirky bounces, but also for local colour. Expect to lose plenty of balls in the rough and to taste the salt in the invigorating air. Links courses were created in the main by Mother Nature, carved through dunes linking land and sea. This is golf as it was meant to be played.

On my first trip to Ireland, I tossed my clubs in the “boot” of a rental car, opened the left front door and realized the steering wheel was on the right. Jet lag may have had something to do with it.

Driving on the “wrong” side of the road can be stressful. On my most recent trip, I put the driving and planning into the capable hands of Carr Golf (carrgolf.com). Joe Carr, the company’s late founder, was one of Ireland’s greatest golf heroes with over 40 championships including three British Amateur titles. Today, Joe’s son, Marty, operates the business, named winner of Golf Digest’s Editors’ Choice Award as 2016’s “Best Tour Operator.”

Royal County Down is ranked number one by Golf Digest’s 2016/17 “World’s 100 Greatest Golf Courses.”

Our foursome, having played in Ireland before, decided to hit a combination of top ranked links and some lesser-known gems. Carr booked tee times, caddies, hotels, sightseeing and provided a coach to ferry us around.

Portmarnock and Royal County Down Nothing cures jetlag like a round of golf in a stiff wind.

That’s just what we encountered at Portmarnock’s Old Course, 15 minutes out of Dublin Airport. From the back tees Portmarnock measures 7365 yards, but its length and difficulty are determined by the constantly changing force and direction of the wind. Pot bunkers abound and the rough is long and fierce.

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Portmarnock proved to be a worthy warm-up to Northern Ireland’s Royal County Down, ranked number one on Golf Digest’s 2016/17 “World’s 100 Greatest Golf Courses.”

“It’s one of those rare courses where you could feel a perfect handshake between the hand that created the land and the hand that shaped it into a golf course,” wrote Tom Coyne, author of A Course Called Ireland. Narrow ribbons of fairways wind their way through daunting sand dunes surrounded by beautiful, yet penal, gorse and shaggy bunkers.

The crown jewel was originally laid out in 1898 by the legendary Old Tom Morris from St. Andrews.

The parsimonious County Down Committee commissioned Old Tom to travel from Scotland “for a sum not to exceed £4 to advise on a second nine holes.”

If this is a once in a lifetime round for you, I suggest you shell out £50 for a senior caddie. Most are crafty characters who can help you navigate the slick greens, blind tee shots and other idiosyncrasies.

I knew my caddie, Brender, and I would get along when he suggested I play the “jubilee tees” on several of the fairways requiring long carries over expanses of gorse. “Where are they?” I asked.

“Wherever we want them to be,” he replied with a wink. Royal County Down is tough for the pros; for a high handicapper, such as myself, it’s downright humbling.

For many, hole number nine is golf ecstasy. You launch your ball over a high hill covered in gorse down to the fairway 80 yards below! Royal County Down can be exhilarating or excruciating, but you’ll never forget it.

Bad weather at Royal Portrush can blow your ball right off the tee.

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Giant’s Causeway is a big Northern Ireland attraction whether you play golf or not.

Royal Portrush What an Irishman calls a “bit of a breeze and a mist,” I would call a gale-force wind and a torrential downpour. The morning we arrived at Royal Portrush on Northern Ireland’s Causeway Coast I wondered if we should start building an ark.

“Should we wait until it clears a bit,” I suggested to the starter. “It’s looking pretty good now,” he responded as my umbrella blew inside out. OK, we decided, we’ll play this gem designed by Harry Colt come hell and high water. When my ball blew off the tee Rory, my shivering caddie, remarked, “I’m glad it’s you playing in this wind and not me.”

Portrush has made renovations on its championship Dunluce Links in preparation for hosting the 2019 Open. The notorious Calamity Corner (now the 16th instead of the 14th) requires a precise drive over an enormous chasm on the right. Purgatory follows.

Aim your blind drive for a striped pole and pray.

GOOD FOOD, FUN AND PLACES TO STAY It’s fitting that the world’s top ranked Royal County Down sits beside the landmark Slieve Donard Resort and Spa (hastingshotels.com/slieve-donardresort-and-spa). The sprawling Victorian edifice offers grand views of the Irish Sea, especially from the bubbling vitality pool in the spa. Breakfast in the Oak Restaurant is a sumptuous buffet. It was here that I discovered porridge is far better when you add fresh cream and a wee dram of Irish whisky.

For dinner, try the rump of local lamb with dreamy celeriac or fillet of hake and wild mushrooms.

Non-golfers can relax at the spa, stroll the beach or take a hike into the Mountains of Mourne.

After rounds at Royal Portrush and Portstewart, the inviting smoky smell of a peat fire lures visitors into the snug Bushmills Inn (bushmillsinn.com).

Fortify yourself with an Ulster fry breakfast, then head to The Giant’s Causeway, a World Heritage Site and geological marvel. You can hike among the 40,000 six-sided basalt columns formed by cooling lava about 60 million years ago. Legend has it that Irish giant Finn MacCool built the Causeway as stepping stones to his sweetheart on Hebrides Island in Scotland.

Nearby, I recommend the tour with samples at Old Bushmills, the world’s oldest licensed distillery, where they’ve been producing the “water of life” since 1608.

We broke up the drive from the Causeway Coast to Rosapenna in County Donegal with a stop in Londonderry.

Après golf activities at the Rosapenna Hotel & Golf Resort (rosapenna.ie) include various indoor pools and spa treatments. Walkers and cyclers can take various trails around Sheephaven Bay. Named after golfing legend Harry Vardon, the restaurant specializes in local lobster, scallops, crabs — and spectacular sunsets.

After our round at Enniscrone, we visited Kilcullen’s Bath House, circa 1912. Visitors steep in deep

Mount Falcon Estate is within an hour’s drive of no fewer than 12 golf courses.

“Arizona” a Harris hawk, receives a raw chicken leg after each successful flight.

Victorian tubs filled with hot sea water dosed with fresh seaweed, known for its natural curative powers to reduce stiffness and make the skin silky soft.

You can also add on a massage.

Mount Falcon Estate (mountfalcon.com) is within an hour’s drive of 12 golf courses, including Enniscrone. Golf pro Mark O’Meara likes to fish for wild salmon on the banks of the River Moy where Mount Falcon has exclusive angling rights.

Originally a baronial lodge, the 19th-century estate was renovated and reopened in 2006. Guests can stay in the manor house or in fully-equipped rental lodges, ideal for golf groups.

Chef Willimont of the Kitchen Restaurant serves innovative dishes using produce from the estate’s own gardens. You might feast on turnip and horseradish soup, salmon with a gin and beet purée, and cassis, elderflower and apple cobbler. Sip your nightcap in the lively Boathole Bar. I recommend taking a “hawk walk” with Jason Deasy, the resident master falconer. We ventured into the woods with Deasy, his dog Chili and Arizona, a Harris hawk tethered to Jason’s glove. Deasy demonstrated how to call and release Arizona. Each time Arizona performed his takeoff and landing ritual, he received a reward of a raw chicken leg tucked into the palm of our sturdy leather gauntlets so he was a bit lazy about hunting for critters, which was fine with me. It’s thrilling enough to have such a powerful “terminator” with wingspans of up to 1.8 metres, razor-sharp beaks and powerful talons at the end of your arm. Sure and begorrah, it makes golf seem rather tame.

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

• • •

*

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

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

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

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

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

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

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

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

Clinical use:

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

Contraindications: •

•

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

Most serious warnings and precautions:

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

Other relevant warnings and precautions: • • • • • • • • • •

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

For more information:

Please consult the product monograph at www.lilly.ca/ TrulicityPM/en for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling us at 1-888-545-5972.

Reference: 1. Trulicity Product Monograph. Eli Lilly Canada Inc., August 4, 2016. †

Clinical significance has not been established.

‡

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

§

26-week, randomized, open-label, parallel group, multicentre, active-controlled, phase III non-inferiority study. Patients received either 1.5 mg Trulicity once weekly (n=299; baseline A1c 8.1%) or 1.8 mg liraglutide once daily (n=300; baseline A1c 8.1%). Treatment was added to background therapy with metformin Ű PJ GD\ $OO Q YDOXHV UHIHU WR LQWHQW WR WUHDW SRSXODWLRQ Primary endpoint was change in A1c from baseline to week 26 between once-weekly Trulicity and once-daily liraglutide.

TRULICITY is a trademark owned by or licensed to Eli Lilly and Company, its subsidiaries or affiliates. © 2017, Eli Lilly and Company. All rights reserved.

PP-DG-CA-0016

Game of Thrones was filmed on the jagged Antrim on the beach below the Portstewart Golf Club.

Portstewart and Rosapenna Minutes west of Portrush, the Strand Course at Portstewart Golf Club, founded 1894, is a sight for sore eyes. From the elevated first tee you have splendid views of the jagged Antrim coast, and if the sun shines, as it did for us, you will be blessed. Game of Thrones was filmed on the beach below.

Rosapenna overlooking Sheephaven Bay has been challenging golfers since 1893 when Old Tom Morris created nine holes among the dunes. About a century later, a newer Strand nine replaced the old front nine resulting in a wonderfully schizophrenic blend of ancient and modern links. Number 17 is a long par-three with a punchbowl green set against the dunes. Just beyond the 18th green stands a lifesize statue of Old Tom himself. Bring your camera for a selfie.

The Dunes at Enniscrone For our grand finale, we tackled The Dunes at Enniscrone, established in 1918. At 7033 yards, it’s a rollicking romp over towering dunes and serene valleys with grand views of Killala Bay. Scoring well here requires precise aim on the tumultuous fairways. The yardage book describes the 17th as “just like the 17th at Sawgrass except more natural — 150 yards of terror, especially when the wind blows! So take good aim, take good care and good luck. If it all fails, enjoy the view!”

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The city thrives on students, bicycles, cafĂŠs and fashion-forward shops.

Groningen: whatâ&#x20AC;&#x2122;s new again Founded in 950, the compact Dutch city has lots to teach the 21st century

by Robb Beattie

It’s true I could have been more cautious. I didn’t have to gawk over my shoulder at the photogenic market square behind me or look up past a horizon of steeples to find the landmark bell tower.

Still, the real problem, as everyone explained later, was that I had unwittingly crossed the line.

The line in question was painted in white across the cobblestones. One side was sidewalk; the other was dedicated to traffic, which, in this car-free city centre, consisted of crowds of cyclists speeding along in rush-hour throngs. It took one oblivious step into the surging herd of pedals to confirm I was as bad a jaywalker as I would be a rodeo clown.

Once the bikes were untangled, and apologies and handshakes exchanged, I took great care not to cross the line again.

The iconic Martini Tower has, for 500 years, soared above a church said to house John the Baptist’s arm.

old is

C

harming, vibrant and full of interest, the city of Groningen isn’t just Holland’s cycling

headquarters. Located 180 kilometres north of Amsterdam in the province of the same name, this lively centre of 200,000 people is both rich with history and a youthful university town buzzing with contemporary culture. Founded in the year 950, Groningen is compact and easily walkable — if you watch where you’re going, that is — and exudes the MARCH 2017 • Doctor’s

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The Groninger Museum occupies three post-modern pavilions that seem to float on the canal. LEFT: Like so many Dutch cities Groningen is laced with canals, many through older, cobblestoned residential areas.

Groningen exudes the sense of urbane wellbeing the Dutch have specialized in since the country essentially invented the bourgeoisie sense of urbane wellbeing the Dutch have specialized in since the country essentially invented the bourgeoisie during the Golden Age of the 17th century.

Filled with outdoor cafés, venerable churches, funky galleries, shops, clubs and whole epochs of architecture, the picturesque city also has a reputation for intriguingly juxtaposing the old and the new.

Its main art museum, for instance, looks like a luridly painted flotilla of avant-garde shipwrecks and sits partially immersed in a historic canal. And while Groningen obviously enjoys its student ambience — 55,000 young people go to colleges here and local bars literally never close — it also easily retains the elegance and airs of the wealthy independent city-state it once was. For that, you only have to look to the heritage that’s perennially on view in the stately centre ringed by waterways and chock-a-block with impressive buildings dating back to the medieval era.

This was where I began a morning jaunt with a steaming cup of Dutch cocoa. Any point in central

HOTELS IN GRONINGEN The Asgard Hotel (asgardhotel.nl; doubles from $139 a night) is located in the museum district of Groningen close to the Grote Markt. Hotel Prinsenhof (prinsenhof-groningen.nl; doubles from $200 a night) is housed in a 15th-century building metres from Martini Tower.

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Groningen is minutes from the Diepenring canal system that surrounds the city like a spider web glistening with houseboats and intersected by bridges, many of which split open to accommodate water traffic larger than the paddle boards, kayaks and ducks that regularly ply the placid channels. It’s possible to take a three-kilometre canal cruise around the city centre (you can rent canoes too), but I decided to wander in the vicinity of the Grote Markt, one of two large downtown squares — the other is Vismarkt, the fish market — that at weekends transform from empty expanses of cobblestone into a caravanserai of food trucks and produce stalls.

Looming over the Grote Markt is Groningen’s most enduring symbol, the 500-year-old, 97-metretall church spire known as the Martini Tower.

Named after St. Martinus, a Roman who converted at the Crucifixion, the church is said to house John the Baptist’s arm and offers public access (€3) up the 250 steps to the bells on top.

Instead of viewing the relics, I headed into the constellation of shopping streets and merchant alleys that radiate off the square. Herestraat is the main pedestrian commercial boulevard and I eventually found my way to Folkingestraat near Vismarkt, which I’d heard was the best place to buy anything to eat, wear or show off in the Netherlands. I explored its treasure trove of gourmand delicacies and sophisticated design stores before ending up in OudeKijk in’t Jatstraat, an area of trendy boutiques and friendly, stylish cafés and brasseries.

Dutch Art for goodness’ sake

by Ed White Groningen is a two-hour drive north of Amsterdam and three from Rotterdam and The Hague. Amsterdam is a wonderful place, no doubt, and so is the rest of Holland. Think museums. Yes, you must visit Amsterdam’s dazzling collection of Dutch masters at the Rijksmuseum. Modern art at the Stedelijk Museum belongs on your list for Cézanne, Chagall, Kandinsky, De Kooning, Koons, Malevich, Matisse, Mondrian, Picasso, Pollock — the list goes on and on. And of course, you can’t miss the city’s Van Gogh Museum, but then what?

The Hague, less than an hour from Amsterdam by train, doesn’t always get the attention it deserves.

You could even be forgiven for thinking it wasn’t in Holland at all. Fact is, it’s home to the Dutch parliament and a host of international organizations including the UN’s International Court of Justice. The city also hosts a couple of museums well worth seeing.

Your first stop should be The Mauritshuis (or Maurice House).

Here you’ll find the Dutch Masters you thought were in Amsterdam, but aren’t, including Vermeer’s Girl with a Pearl Earring, his View of Delft, Rembrandt’s The Anatomy Lesson of Dr Nicolaes Tulp and Frans Hals’s Laughing Boy — each of them among the most famous Dutch paintings.

You also absolutely must take in The Gemeentemuseum Den Haag (The Municipal Museum). Go for the works of favourite son Mondrian, the biggest anywhere, and the works of many of his contemporary moderns. The print collection is also first rate.

Now’s your chance to see the North Sea suburb of Scheveningen and the Museum Beelden aan Zee with its fine modern sculptures. Half hidden in sand dunes, the modern building is a delight. Stroll among the sculptures on the terrace with its broad view of the sea. After art-ing up, hang out along the beach, season permitting, take a dip, then relax in one of the many excellent seaside cafes.

WILLEM DE KOONING FOUNDATION / STEDELIJK MUSEUM

NIK BRUINING / SHUTTERSTOCK.COM

Groningen also boasts many leisurely parks and fine public gardens, some established centuries ago.

Just north of the centre is the majestic Noorderplantsoen, a serene oasis of paths and serpentine ponds with a name that must mean “Northern plant zone” if there’s any merit to my highly questionable theory that Dutch is basically English misheard underwater. Equally bucolic are the city’s Gasthuizen (guest houses), walled compounds of homes built around courtyards that were the gated communities of the Middle Ages. Still privately occupied, the verdant interior courtyards are open for polite public viewing; the largest one is in the Pelsterstraat between the markets.

After a lunchtime snack of regional favourites — the eierbal, a meatball containing a boiled egg, washed down with Bax, one of the foamy local suds — I set off to what is undoubtedly the city’s most flamboyant attraction. The screamingly post-modern Groninger Museum (groningermuseum.nl; adults €18) is housed in three zanily hued pavilions that seem to float in the canal opposite the main railway station.

Designed by a trio of famous “po-mo” starchitects, its canary yellow tower, silver cylinder and deconstructivist blue box are a perfect prequel to the bizarre, ornate galleries and cutting-edge art inside.

I was lucky enough to arrange a chat with the museum’s affable director, Andreas Blühm, in a “job lounge” lit by pendulous sconces that looked either like breasts or prophylactics; as Andreas slyly pointed out, it was presumably “the designer’s method of gauging sexual orientation.” The Groninger Museum is currently featuring a massive retrospective of the sculptor Auguste Rodin. His masterpiece, The Thinker, is in the show, which runs until the end of April.

Tired out by the day’s wandering, I was revived by dinner, a superbly presented six-course meal, complete with paired wines, at Eetcafé Schuitendiep (eetcafeschuitendiep.nl), a restaurant dedicated to affordable gastronomy. By the last truffle, there was no chance I was going pub-crawling down Poelestraat off the Grote Markt, by all accounts a lubricious tribute to the Netherland’s celebrated liberalism.

I needed a good night’s sleep to prepare myself for the coming morning’s trip to rural Groningen landscapes of peat bogs, flower meadows and terps, artificial hills long ago raised above sea level. Not to mention Groningen’s Wadden Sea coast. After the Alps, it’s the biggest untouched wilderness in Western Europe, with millions of breeding seabirds. If you’re so inclined, at low tide you can walk for hours over the sand bars and mud flats. And also visit the baby seal rescue and rehabilitation centre at Pieterburen.

I carefully followed the white median line over pavements and cobblestones back to my hotel and to bed lulled by a silence scarcely broken by the distant sounds of a squeaky bike or two.

New LIXIANA®:

Helping patients along the journey of stroke prevention in AF LIXIANA® (edoxaban) is indicated for: › Prevention of stroke and systemic embolic events in patients with atrial fibrillation (AF), in whom anticoagulation is appropriate. › Treatment of venous thromboembolism (VTE) (deep vein thrombosis [DVT], pulmonary embolism [PE]) and the prevention of recurrent DVT and PE.

In the prevention of stroke and systemic embolic events in AF (primary composite endpoint), LIXIANA® 60 mg (30 mg dose-reduced):* • Demonstrated NON-INFERIORITY vs. warfarin

› Event rate of 1.18% vs. 1.50% per year seen with LIXIANA® 60 mg (30 mg dose-reduced*) vs. warfarin (mITT – on-treatment†)‡,1,2 HR (97.5% CI): 0.79 (0.632, 0.985); p<0.0001 for non-inferiority§

• Component scores (% per year) seen with LIXIANA® 60 mg (30 mg dose-reduced*) vs. warfarin‡ › First ischemic stroke: 0.87 vs. 0.93 HR (95% CI): 0.94 (0.75, 1.19)

› First hemorrhagic stroke: 0.26 vs. 0.49 HR (95% CI): 0.53 (0.36, 0.78)

› First systemic embolic events: 0.05 vs. 0.08 HR (95% CI): 0.62 (0.26,1.50)

• Significantly LOWER rates of MAJOR BLEEDING events demonstrated vs. warfarin

› Adjudicated event rate of 2.75% vs. 3.43% per year seen with LIXIANA® 60 mg (30 mg dose-reduced*) vs. warfarin (mITT – on-treatment†)‡,¶,1,2 HR (95% CI): 0.80 (0.71, 0.91); p=0.0009

Bleeding: LIXIANA® increases the risk of bleeding and can cause serious, potentially fatal bleeding. LIXIANA®, like other anticoagulants, must be used with caution in patients with increased risk of bleeding. Patients at high risk of bleeding should not be prescribed LIXIANA®. Should severe bleeding occur, treatment with LIXIANA® must be discontinued and the source of bleeding investigated promptly. Close clinical surveillance is recommended throughout the treatment period, especially in the presence of multiple risk factors for bleeding.

ASA: acetylsalicylic acid; CI: confidence interval; CrCL: creatinine clearance; HR: hazard ratio; mITT: modified intent-to-treat; NSAID: nonsteroidal anti-inflammatory *In the study, patients receiving verapamil, quinidine, or dronedarone concomitantly with LIXIANA® had their dosing regimens halved. The recommended dose of LIXIANA® is 30 mg once daily in patients with concomitant use of P-gp inhibitors other than amiodarone and verapamil. †mITT population included only subjects who received at least one dose of study drug; the on-treatment period was the period during which the subject took study drug unless the patient had early drug discontinuation(s), in which case the on-treatment period included the 3 days following drug discontinuation(s). ‡Event rate (%/yr) is calculated as number of events/subject-year exposure. §The two-sided p-value is based on the non-inferiority margin of 1.38. ¶A major bleeding event (the primary safety endpoint), as defined by ISTH (International Society of Thrombosis and Haemostasis), was a clinically overt bleeding event that met one of the following criteria: fatal bleeding; symptomatic bleeding in a critical site such as retroperitoneal, intracranial, intraocular, intraspinal, intra-articular, pericardial, or intramuscular with compartment syndrome; a clinically overt bleeding event that caused a fall in hemoglobin of at least 2.0 g/dL (or a fall in hematocrit of at least 6.0% in the absence of hemoglobin data), when adjusted for transfusions (1 unit of transfusion = 1.0 g/dL drop in hemoglobin). **Please see Product Monograph for complete dosing and administration information.

® Registered trademark of Daiichi Sankyo Co., Ltd. Used under license.

© 2017 Servier Canada Inc.

1x

DAILY

Convenient one pill, once-daily dosing, taken with or without food**

Clinical use Not recommended for use in children < 18 years.

Contraindications › Clinically significant active bleeding, including gastrointestinal bleeding › Lesions or conditions at increased risk of clinically significant bleeding, e.g., recent cerebral infarction (hemorrhagic or ischemic), active peptic ulcer disease with recent bleeding, patients with spontaneous or acquired impairment of hemostasis › Hepatic disease associated with coagulopathy and clinically relevant bleeding risk › Concomitant treatment with any other anticoagulant, including: » unfractionated heparin (UFH), except at doses used to maintain a patent central venous or arterial catheter; » low molecular weight heparins (LMWH), such as enoxaparin and dalteparin; » heparin derivatives, such as fondaparinux; and » oral anticoagulants, such as warfarin, dabigatran, apixaban, rivaroxaban except under circumstances of switching therapy to or from LIXIANA® › Pregnancy › Nursing women Most serious warnings and precautions Premature discontinuation: PREMATURE DISCONTINUATION OF ANY ORAL ANTICOAGULANT, INCLUDING LIXIANA®, INCREASES THE RISK OF THROMBOTIC EVENTS. To reduce this risk, consider coverage with another anticoagulant if LIXIANA® is discontinued for a reason other than pathological bleeding or completion of a course of therapy.

INR: Although LIXIANA® therapy will lead to an elevated INR, INR is not a valid measure to assess anticoagulant activity of LIXIANA®. INR is only calibrated and validated for vitamin K antagonists (VKA) and should not be used for any other anticoagulant, including LIXIANA®.

Peri-operative spinal/epidural anesthesia, lumbar puncture: Risk of epidural or spinal hematoma is increased by use of indwelling catheters or concomitant use of drugs affecting hemostasis. Indwelling epidural or intrathecal catheters must be removed ≥ 5 hours prior to the first dose of LIXIANA®. Risk may also be increased by traumatic or repeated epidural or spinal puncture.

If traumatic puncture occurs, administration of LIXIANA® should be delayed for 24 hours.

Other relevant warnings and precautions › Concomitant use of drugs affecting hemostasis may increase the risk of bleeding, such as aspirin, P2Y12 platelet inhibitors (i.e. clopidogrel, prasugrel, and ticagrelor), other antithrombotic agents, fibrinolytic therapy and chronic NSAIDs; long-term concomitant use is not recommended › Concomitant use with UFH is not recommended except at doses used to maintain a patent central venous or arterial catheter › Concomitant use of low dose (≤ 100 mg/day) ASA or thienopyridines (clopidogrel) and NSAIDs increased rates of clinically relevant bleeding › Not recommended in patients with prosthetic (mechanical or biological) heart valves or those with hemodynamically significant rheumatic heart disease, especially mitral stenosis › Not recommended in patients with severe hepatic impairment; caution in patients with mild to moderate hepatic impairment › A specific anticoagulant reversal agent for LIXIANA® is not commercially available › Not recommended in patients with severe renal impairment (CrCL ≤ 30 mL/min). Patients who develop acute renal failure while on LIXIANA® should discontinue treatment. › Peri-operative/procedural considerations › Following an invasive procedure or surgical intervention, restart LIXIANA® as soon as adequate hemostasis has been established and the clinical situation allows › Not recommended for prevention of VTE in patients who have undergone elective total knee or hip surgery › Not recommended as an alternative to UFH in patients with PE who are hemodynamically unstable or may receive thrombolysis or pulmonary embolectomy › Not recommended for treatment and/or prevention of VTE in patients with active cancer For more information Please consult the Product Monograph at https:// health-products.canada.ca/dpd-bdpp/index-eng. jsp for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece.

The Product Monograph is also available by calling us at 1-800-363-6093.

Please visit www.servier.ca/references/ LIXIANA_EN.pdf to access the study parameters and reference list.

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

Servier Canada Inc. 235, boulevard Armand-Frappier, Laval, QC H7V 4A7

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Montreal turns 375 Š EVA BLUE / TOURISM MONTREAL

Giant marionettes, concerts on the mountain, haunting digital projections and more to celebrate the cityâ&#x20AC;&#x2122;s big birthday this year

by Camille Chin

Old Montreal and Place Jacques-Cartier will be more happening than ever this summer when they welcome some of the city’s biggest birthday events.

MARCH 2017 • Doctor’s

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39

Cité Mémoire’s large-scale video projections bring Montreal history to life in the city’s oldest neighbourhood.

GIANTS ON THE STREET

© JEAN-FRANÇOIS GRATTON / SHOOT STUDIO

Giant, 15-metre-tall marionettes with eyes that blink, and lungs that rise and fall, may sound creepy, but you’ll still want to see the biggest show on earth when it arrives in North America for the first time ever this spring. Based in Nantes, France, the street theatre company Royal de Luxe transforms city streets around the world into its stage, acting out stories and ancient legends with puppets made of poplar wood.

The marionettes are suspended by cranes; a crew of 20 to 40 people control each one. An entirely new The Giants production will be unveiled at a secret location for Montreal’s 375th “to meet the people of Canada.” Catch it if you can — founder Jean-Luc Courcoult doesn’t pack his puppets for just anywhere. His giants only go where performances are free and where there’s a narrative to connect the puppets to the people.

MOVING PROJECTIONS Old Montreal is full of characters. Sometimes they rise from the cobblestone ground, other times they creep out of leafy trees. I saw two men in overalls rappelling down a tall old building. At night. In the dead of winter. The characters are large-scale animated projections in honour of people who have made invaluable contributions to the city: Charles McKiernan (1835–1889) of Joe Beef’s Tavern who advocated for the working class and refused service to no one “whether English, French, Irish, Negro, Indian;” Éva Circé-Côté (1871–1949), a feminist who wrote under a male pseudonym and established the city’s first public library in 1903; baseball legend Jackie Robinson who played for the Montreal Royals in 1946. Suzanne, who appears on the Old Port’s Clock Tower, is a poetic tribute to Leonard Cohen’s famous song. Launched in May 2016 and screened on the city’s most historic brick walls, Cité Mémoire is the largest ever installation of its kind in the world. Michel Lemieux and Victor Pilon worked on the 23 projections for five years. A free app with historical contexts and soundtracks is available in four languages. Connect via the free MTL Wi-Fi.

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Doctor’s Review • MARCH 2017

© PASCAL VICTOR-ARCOMART

Mid-May to Mid-March until 2019

Giant moveable marionettes from France will make their Canadian debut with a production created for the city’s birthday.

© SUSAN MOSS / TOURISM MONTREAL

May 19 to 21

Nineteen parks will host La Grande Tournée, which will showcase the people and merchants outside the downtown core.

NEIGHBOURHOOD BLOCK PARTIES May 12 to September 17 La Grande Tournée du 375e will be the block party to end all block parties. Part open-air circus, gourmet food fest and impromptu art show, it’ll descend on a different neighbourhood park for 19 consecutive weekends beginning in May. The event is an easy way to hobnob with locals and discover boroughs outside downtown and Old Montreal. La Grande Tournée is presented, for free, by Cirque Éloize, which, like Cirque du Soleil, is a Quebec-based nouveau cirque troupe. They’ve performed almost 4000 times in 50 countries, and will set out to amaze audiences each Saturday night. Bakers, cheese makers and microbrewers will introduce visitors to their borough’s specialties; some homeowners have volunteered their porches and windows for art exhibits. Before you leave, check out the futuristic postal truck. Mail a postcard to yourself and it’ll be delivered in 25 years — just in time for Montreal’s 400th.

BRIDGE OF LIGHTS May 17 onwards Beginning in May, the Jacques-Cartier Bridge will be a barometer of Montreal’s energy for the next 10 years.

The 87-year-old structure that connects the Island of Montreal to the suburbs of the South Shore is a landmark and it’s getting gussied up with 2807 lights for the city’s 375th as well as Canada’s 150th as a nation.

The colour of the sky, traffic, events (a Habs win or loss?) and the city’s overall vibe will determine the movement, speed and intensity of the lights in real time.

The $39.5 million price tag is controversial. This year also marks the 50th anniversary of Montreal’s Expo67

The Biosphere and Jacques-Cartier Bridge will be illuminated with lights that change in colour and intensity.

World’s Fair. The US pavilion’s colossal geodesic dome by architect Buckminster Fuller is still an architectural feat. It’s currently the Biosphere museum and is lit up now, and will be for the next 20 years.

MARCH 2017 • Doctor’s

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Three of the city’s best orchestras will come together in Mount Royal Park for a spectacular concert featuring 300 musicians.

A LITTLE NIGHT MUSIC

ART FOR PEACE May 29 to October 27 It’s only fitting that downtown’s Sherbrooke Street will be lined with 67 works of art to commemorate the 50th anniversary of the World’s Fair in Montreal, Expo67. Sixty-two nations participated, 50 million people visited, making it the most successful World’s Fair of the 20th century. The theme was Man and His World, and the values of humanism, tolerance and openness will again be at the forefront in 2017.

Appropriately so. Stretching for one kilometre, La Balade pour la Paix will feature large-scale sculptures, installations and photographs by contemporary artists

Regardless of your taste in music, there are few things better than open-air concerts, particularly when they’re free. The Montréal Symphonique will bring together 300 musicians from the city’s best orchestras — the Orchestre Symphonique de Montréal, the Orchestre Métropolitain and the McGill Symphony Orchestra — for the first time ever. Simon Leclerc will direct; he once led LA’s Paramount Pictures Orchestra for TV shows like Star Trek: Voyager and Star Trek: Enterprise.

The concert’s theme is the seasons and it’ll take place at the foot of the city’s favourite four-season playground, leafy Mount Royal Park. On concert day, explore the mountain’s glorious Chalet du Mont-Royal, a make-work project during the Great Depression.

There are magnificent high ceilings, exposed wood beams and industrial-sized chandeliers inside; the Kondiaronk belvedere and semicircular plaza outside features unrivalled views of downtown.

Art installations and flags will line Sherbrooke Street beginning at the MMFA.

from around the world. It’ll begin at the new Michal and Renata Hornstein Pavilion for Peace at the Montreal Museum of Fine Arts (MMFA) and end at the McCord Museum just after the McGill campus.

The flags of Canada’s 13 provinces and territories as well as those of 200 countries will fly high over the street.

IN HONOUR OF LEONARD COHEN November 9 to April 1, 2018

Leonard Cohen will be honoured at the MAC by artists he inspired.

When 82-year-old Leonard Cohen died last November, hundreds of Montrealers gathered outside his home at 28 Rue Vallières to mourn, sing and read his poetry.

He was buried in an unadorned pine box next to his mother and father in the neighbourhood of Outremont. A year later, the Musée d’art contemporain de Montréal (MAC) will host Leonard Cohen: A Crack in Everything ($15) compiled exclusively for the city’s 375th. It’ll consist of new works by artists who were inspired by Cohen’s style and recurring themes. After the exhibit, explore his old stomping grounds: his family home at 599 Belmont Avenue where he once brought Joni Mitchell in the ’60s; The Main Deli Steakhouse on St. Lawrence Blvd., which he frequented with sculptor Mort Rosengarten; the lovely Sailors’ Church in the Old Port, the backdrop to his debut single “Suzanne.”

For more details: 375mtl.com and joinmontreal375.tourisme-montreal.org.

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Doctor’s Review • MARCH 2017

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Holy basil chicken fried rice.

Authentic Thai

Recipes from the self-made YouTube star and co-host of One World Kitchen on TV’s Gusto channel recipes by

Pailin Chongchitnant

photos by

P

David Tam

ailin Chongchitnant is a native Thai who currently lives in Vancouver. When she was 12, her parents sent her to New Zealand to learn English. She went

to high school in Bangkok, university in BC, culinary school in San Francisco.

Le Cordon Bleu in San Fran was a dream come true and the beginning of her journey as a culinary educator (she holds a bachelor’s degree in nutritional sciences and is training to be a cooking teacher).

While abroad, she frequented many good Thai restaurants, but more often than not, she left disappointed, even

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Doctor’s Review • MARCH 2017

angry, because Thai food was misrepresented. Then one day, her brother Eddie suggested that she start her own cooking show on — where else? — YouTube. Hot Thai Kitchen was born; Eddie was her cameraman.

Fast-forward seven years to the release of Pailin’s first cookbook, also Hot Thai Kitchen. Running a good 100 pages, Part One is extensive, breaking

down key ingredients, flavours, how Thais eat, how to construct a Thai meal, the structure of Thai curries, salads, soups etc., beverage pairings and more.

In Part Two, she shares must-make recipes with vegetarian and vegan options like the mushroom and mint salad featured here. To cook up more, see her new YouTube show, Pailin’s Kitchen, or One World Kitchen, which she co-hosts on TV’s Gusto channel.

MIXED MUSHROOMS AND MINT SALAD (LAAB HED RUAM) Laab: a type of Northeastern Thai salad Hed: mushroom Ruam: mix

This dish is savoury, herbaceous and incredibly healthy. Feel free to use any types of your favourite mushrooms; the more varieties, the more beautiful this salad will look. Sautéing the mushrooms is quick and convenient, but if the weather permits, grill them for extra smokiness.

mixing bowl. Repeat with the remaining types of mushrooms and add them all to the mixing bowl. (If you notice a lot of liquid pooling at the bottom of the bowl, pour it off before adding the other ingredients in the next step).

While the mushrooms are still warm, add the shallots and lemongrass; toss to mix. When ready to serve, add the lime juice, soy sauce, seasoning sauce, chili flakes, mint, cilantro, green onions, sawtooth coriander and toasted rice powder; toss to mix. Taste and adjust seasoning.

Serve the salad with sticky rice, which you can use to soak up the juices.

Also serve with some crisp lettuce leaves, which you can use to make little bitesized wraps. Serve warm or at room temperature. Serves 4 as an appetizer, 2 as an entrée.

Note: Good mushroom choices are shimeji (beech), enoki, oyster, chanterelles, morels and maitake. You can use crimini mushrooms, but keep in

mind that they give off a lot of liquid and shrink significantly when cooked.

To toast the rice powder, add to a small sauté pan over medium-high heat.

Move the grains constantly, until they turn a deep golden-brown, about 5 minutes.

Don’t skimp on the toasted rice powder because without meat, the lime’s acidity can feel a bit aggressive and the nuttiness of the toasted rice powder will be your only counterweight. You can also try making laab with crumbled tofu.

HOLY BASIL CHICKEN FRIED RICE (KAO PAD GAPRAO GAI KAI DAO) Kao: rice Pad: stir-fry Gaprao: holy basil Gai: chicken Kai dao: fried egg

as needed vegetable oil 12 oz. (375 ml) mushroom mix of your choice (see note) pinch of salt ¼ c. (60 ml) shallots, short juliennes 2 tbsp. (30 ml) lemongrass, very thinly sliced 3 tbsp. (45 ml) lime juice 1-1½ tbsp. (15-22.5 ml) soy sauce ½ tbsp. (7.5 ml) seasoning sauce, such as Golden Mountain or Maggi to taste roasted chili flakes or regular chili flakes ½ c. (125 ml) mint, large leaves chopped, small leaves left whole ¼ c. (60 ml) cilantro, chopped 1-2 green onions, chopped 4 leaves sawtooth coriander or extra cilantro, chopped 1½ tbsp. (22.5 ml) toasted rice powder (see note)

Heat a little oil in a wok or a large sauté pan over medium-high heat. Add one type of mushroom, season with a pinch of salt and cook, stirring occasionally, until they are cooked and have browned slightly. Transfer to a large

Mixed mushrooms and mint salad.

MARCH 2017 • Doctor’s

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45

The predecessor of this dish, pad gaprao, is a stir-fry of holy basil and ground meat served over rice and usually with a fried egg on top — unquestionably one of the most popular lunch items in Thailand.

Instead of serving the rice beside the stir-fry, some restaurants throw it all into a fine fried rice like this version here. If you’re tempted to skip the fried egg, please reconsider. You don’t have to fry the egg Thai-style if you want to conserve some oil: a sunny-side-up or an over-easy egg will do.

For the rice 6 oz. (180 g) chicken, ground, or other ground meats 1 tsp. (5 ml) soy sauce

Street-style fried bananas.

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Doctor’s Review • MARCH 2017

as needed oil for frying eggs 2 eggs, room temperature 2 tbsp. (30 ml) vegetable oil 2-3 garlic cloves, chopped 2-5 Thai chilies, finely chopped 5 long beans, ½-inch (1.25-cm) pieces on a bias ¹⁄³ c. (80 ml) onion, small dice 1 spur chili or ¼ red bell pepper, short julienne 1½ c. (375 ml) cooked rice 1 tsp. (5 ml) granulated sugar 1 c. (250 ml) holy basil, Thai basil or regular basil For the sauce 1 tbsp. (15 ml) oyster sauce 2 tsp. (10 ml) soy sauce

1 tsp. (5 ml) fish sauce 1 tsp. (5 ml) seasoning sauce Golden Mountain 1 tsp. (5 ml) black soy sauce

Combine the ground chicken and 1 teaspoon (5 ml) of soy sauce in a bowl and mix thoroughly. Let sit in the fridge while you prepare the other ingredients.

In a wok or small frying pan, add about ½ inch (1.25 cm) of oil. Heat over medium-high heat until very hot, but not smoking. Crack an egg into the centre of the pan; the egg white should bubble excitedly right away. If you like a medium to well-done yolk, lower the heat so the white doesn’t brown too quickly. As the egg cooks, baste the top of it with the hot oil. Once the edges of the egg white are browned and crispy, and the yolk done to your liking, remove and drain on a paper towel. Repeat with the remaining egg. Note: the egg should be floating on top of the oil; if parts of it stick to the pan, let it cook for a minute before gently nudging it off with a spatula.

Grease a small bowl generously with cooking oil, then add all the sauce ingredients to the bowl. (Greasing the bowl helps the thick sauce slide out more easily.)

Heat the 2 tablespoons (30 ml) oil in a wok or a large sauté pan over mediumhigh heat. Add the garlic and Thai chilies; stir until the garlic starts to turn golden brown. Add the chicken and cook until it is 70 percent done. Add the long beans, onion and spur chili; toss to mix well. Add the rice, followed by the sauce mixture and sugar. Toss until the rice is evenly coated in the sauce, pressing down on rice lumps to break them apart. When the sauce has been completely absorbed (the rice should look dry), turn off the heat and stir in the basil just until it is incorporated. Taste and adjust the seasoning.

Transfer to a plate, top with one fried egg per portion. You can use prik nam pla (a condiment of fish sauce and chilies) to season the egg, but it’s also great on the rice. Serves 2.

Tip: Mushy or clumpy fried rice is the most common fried-rice issue. Using cold rice helps, but the most important factor is that the rice is not cooked with too much water.

STREET-STYLE FRIED BANANAS (GLUAY KAG) Gluay: banana Kag: people of South Asian descent

Thai restaurants overseas often serve some sort of battered-and-fried bananas with ice cream, which is delicious, but not actually a Thai dish — not in that form. The idea of frying bananas comes from this street snack. It’s not so much a dessert as it is a mildly sweet snack, perfect for a 3 o’clock refuel or even breakfast. Most gluay kag vendors also sell fried sweet potato and taro using the same batter, so you can add those to your mix. ½ tbsp. (22.5 ml) white sesame seeds 1 ¾ c. (180 ml) rice flour ¼ c. (60 ml) granulated sugar ½ tsp. (2.5 ml) salt ½ tsp. (2.5 ml) baking powder ¹⁄³ c. (80 ml) shredded coconut, unsweetened, fresh, frozen or dried (see note) ¹⁄³ c. (80 ml) water 6 Namwa bananas or 2 sweet plantains (see note) As needed oil for frying

Toast the sesame seeds in a dry sauté pan over medium heat, stirring constantly until golden brown, about 5 minutes. Let cool on a plate.

In a medium-sized mixing bowl, whisk together the toasted sesame seeds, rice flour, sugar, salt and baking powder until well combined. Add the shredded coconut and mix well. Add the water and stir until combined. The batter should be thinner than pancake batter, but slightly thicker than crepe batter.

Peel and cut the bananas lengthwise into ¼-inch- (1.25-cm-) thick pieces. If using plantains, peel and cut them into 3 sections, then slice each section horizontally into ¼-inch- (1.25-cm-) thick pieces.

Add about 1½ inches (3.75 cm) of oil to a pot and heat to about 325°F (170°C).

Dip the bananas into the batter and fry for about 5 minutes, until they are a deep pretzel-brown colour. Maintain the frying temperature below 350°F (180°C).

When done, drain on a paper towel or rack. (Based on your first batch, you

can decide if you want a thicker or thinner coating by adding more flour or water.) If you have leftover batter, drizzle it into the oil and fry it up into crispy, munchy bits.

Let cool just until the coating becomes crisp, then serve immediately.

Makes 24 pieces.

Note: If using dried shredded coconut, let it rehydrate in 2 tablespoons (30 ml) of hot water for 10 to 15 minutes before using.

Namwa bananas are traditionally used because they hold their shape when cooked. Choose ones with just a trace of green left on the skin. Sweet plantains also work. Choose ones whose skins have turned at least 60 percent black so they will be sweet. Regular bananas aren’t an option because they turn mushy when fried for a long time.

Crispiness: We’re frying at a slightly lower than normal temperature because this allows you to fry the bananas for longer, allowing the batter enough time to dry out and become crispy. The right temperature should take you about 4 to 5 minutes to achieve the desired deep-brown colour.

Some people fry them at a lower temperature for even longer to dry out the bananas. This prolongs the crispiness because there is less moisture around to soften the coating. This is a fine method if you need to make these a few hours before serving, but the bananas won’t be as plump.

HISTORY OF MEDICINE

Excerpted from Hot Thai Kitchen by Pailin Chongchitnant. ©2016 Pailin Chongchitnant. Recipe photos by David Tam. Published by Appetite by Random House®, a division of Penguin Random House Canada Limited. Reproduced by arrangement with the Publisher. All rights reserved.

ELI LILLY

uu CONTINUED FROM PAGE 25

PW: Balancing patient care with leading the Ideal Medical Care Movement, and dealing with the medical student and physician suicide crisis. I run an unofficial suicide hotline for physicians out of my home. I also host physician retreats multiple times per year in which I help colleagues heal from the trauma of medical training and launch their own ideal clinics.

DR: Have you seen a shift in medical culture since you opened your clinic in 2005? Do you think that the success of vulnerability researcher Brené Brown’s work (ted.com/talks/ brene_brown_on_vulnerability) is a sign of a changing social climate in our broader culture?

PW: Absolutely. People are ready for real healing and deep authentic relationships with one another. They are less tolerant with hierarchy and artificiality. I welcome anyone who wants to enjoy medicine again to reach out. Contact me at IdealMedicalCare.org.

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PHOTO FINISH by

D r B r u n o T r e mb la y

Cheeky monkey

This picture was taken in China in 2010. It cost $1 to have your picture taken with three monkeys. While it was being taken, it felt like the monkey in the middle was pooping on my hand, but thankfully, it was just the shells of the peanuts he was eating. What a relief!

MDs, submit a photo!

Please send a high-resolution photo along with a 150- to 300-word article to:

editors@doctorsreview.com

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Doctorâ&#x20AC;&#x2122;s Review â&#x20AC;˘ MARCH 2017

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• 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.

Simple, once-daily dosing with one 5 mg dose.2* – Independent of ethnicity,† BMI,‡ mild or moderate hepatic impairment,§ and renal function.||

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Please refer to the product monograph at www.TrajentaPM.ca for important information about: • Contraindications in patients with type 1 diabetes or diabetic ketoacidosis.

• Relevant warnings and precautions regarding congestive heart failure, patients using insulin, hypoglycemia, glycemic control, use in patients with severe hepatic insufficiency, pancreatitis, hypersensitivity reactions, use in immunocompromised patients, use in patients with End Stage Renal Disease (ESRD) or on dialysis, skin monitoring, use in special populations (e.g., pregnant and nursing women), hepatic function (should be assessed before starting treatment and periodically thereafter), and interactions with strong inducers of P-gp or CYP3A4 (monitoring recommended).

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

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References: 1. Boehringer Ingelheim (Canada) Ltd. Data on File. s00042091-01.

2. Boehringer Ingelheim (Canada) Ltd. Trajenta® Product Monograph. May 14, 2015.

Trajenta® is a registered trademark of Boehringer Ingelheim International GmbH, used under license.