May 2015

Newfoundland adventure cruise

MEDICINE ON THE MOVE

A new Vancouver Island drive Mango-lamb

Indian feast Why some people experience sound in colour

MAY 2015

Best MD apps: Introducing

KidSpeak

THE MANY FACES OF CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

CHENGDU

PLUS:

to know about IBS-C 10things Depression and women T H E N O VA R T I S C O P D P O R T F O L I O

SEEBRI, ONBREZ, ULTIBRO and BREEZHALER are registered trademarks.

Product Monographs available on request.

14SEE034E Š Novartis Pharmaceuticals Canada Inc. 2014

INTRODUCING FORXIGA FORXIGA is a reversible inhibitor of sodium-glucose co-transporter 2 (SGLT2) that improves glycemic control by reducing renal glucose reabsorption leading to urinary excretion of excess glucose1*† Over 193,000 patients have been prescribed FORXIGA worldwide combined across all indications

CONVENIENT, ONCE-DAILY DOSING1द RECOMMENDED STARTING DOSE: 5 mg

In patients tolerating 5 mg and who require additional glycemic control, dose can be increased to 10 mg

CAN BE TAKEN ANY TIME OF DAY

WITH OR WITHOUT FOOD

FORXIGA is indicated in monotherapy as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance.1 FORXIGA is also indicated in patients with type 2 diabetes mellitus to improve glycemic control in add-on combination with metformin, a sulfonylurea, or insulin (alone or with metformin), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control.1

2

Doctor’s Review •

DECEMBER 2013

In add-on combination with metformin, FORXIGA demonstrated significant reductions in A1c vs. placebo + metformin at weeks 24 and 1021,2** Adjusted mean change from baseline at week 24 (LOCF): -0.70% with FORXIGA 5 mg + metformin and -0.84% with FORXIGA 10 mg + metformin vs. -0.30% with placebo + metformin (p<0.0001) Adjusted mean change from baseline at week 102 (extension study): -0.58% with FORXIGA 5 mg + metformin and -0.78% with FORXIGA 10 mg + metformin vs. 0.02% with placebo + metformin (p<0.0001) In add-on combination with metformin, body weight results demonstrated with FORXIGA vs. placebo + metformin at weeks 24 and 102 (secondary endpoint)1,2** Adjusted mean change from baseline at week 24 (LOCF): -3.04 kg with FORXIGA 5 mg and -2.86 kg with FORXIGA 10 mg vs. -0.89 kg with placebo + metformin (p<0.0001) Adjusted mean change from baseline at week 102 (extension study): -3.38 kg with FORXIGA 5 mg + metformin and -2.81 kg with FORXIGA 10 mg + metformin vs. -0.67 kg with placebo + metformin FORXIGA is not indicated for weight reduction.

Clinical use: Not for use in pediatrics (<18 years).

temporary interruption of FORXIGA should be considered for patients who develop volume depletion until the depletion is corrected

In patients ≥65 years of age, a higher proportion had adverse events related to volume depletion and renal impairment or failure compared to placebo.

• Risk of hypoglycemia when used in combination with insulin or insulin secretagogues

Contraindications:

• Dose-related LDL-C increases; monitor LDL-C levels

• Patients with moderate to severe renal impairment, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, or end-stage renal disease

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

Relevant warnings and precautions:

• Increased risk of genital mycotic infections

• Not for use in type 1 diabetes or for the treatment of diabetic ketoacidosis

• Renal function should be assessed prior to initiation of FORXIGA and regularly thereafter

• Not for use in patients with active bladder cancer and use with caution in patients with a prior history of bladder cancer

• Not for use in pregnant or nursing women

• Not for use in patients concomitantly treated with pioglitazone

For more information:

• Not recommended for use in patients who are volume depleted; caution in patients for whom a FORXIGA-induced drop in blood pressure could pose a risk, or in case of intercurrent conditions that may lead to volume depletion; careful monitoring of volume status is recommended and

Please consult the Product Monograph at www.azinfo.ca/ forxiga/pm367 for important information relating to adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling 1-800-668-6000.

* Clinical significance unknown. † The amount of glucose removed by the kidney through this mechanism is dependent upon the blood glucose concentration and GFR. ‡ The efficacy of FORXIGA is dependent on renal function. Assessment of renal function is recommended prior to initiation of FORXIGA therapy and periodically thereafter. § In patients with evidence of volume depletion, this condition should be corrected prior to initiation of FORXIGA. ¶ Please see Product Monograph for complete dosing and administration information. ** Double-blind, placebo-controlled, 24-week study, with a 78-week, controlled, blinded extension period, of 546 patients with type 2 diabetes and A1c ≥7% and ≤10% and who were on a dose of metformin of ≥1500 mg/day. After a 2-week lead-in period, patients were randomized to dapagliflozin 2.5 mg, FORXIGA 5 mg, or 10 mg once daily or placebo. Mean baseline A1c values: FORXIGA 5 mg + metformin 8.17%, FORXIGA 10 mg + metformin 7.92% and placebo + metformin 8.11%. Mean baseline body weight: FORXIGA 5 mg + metformin 84.73 kg, FORXIGA 10 mg + metformin 86.28 kg and placebo + metformin 87.74 kg.

LOCF: last observation (prior to rescue for rescued patients) carried forward.

References: 1. FORXIGA Product Monograph. AstraZeneca Canada Inc., December 10, 2014. 2. Bailey C et al. Dapagliflozin add-on to metformin in type 2 diabetes inadequately controlled with metformin: a randomized, double-blind, placebo-controlled 102-week trial. BMC Medicine 2013;11:43.

02/16

FORXIGA® and the AstraZeneca logo are registered trademarks of AstraZeneca AB, used under license by AstraZeneca Canada Inc. © 2015 AstraZeneca Canada Inc.

NOW

M T inte Tr in nte tellllllix ixTM is indi in ndi d ca cate ted te d fo or th the e tr trea eatm tmen tm entt o en off majjor dep epre ress re ssiv ss ivve d diiso iso s rd rder er (MDD) MDD)) in ad MD dul ults ts.. ts

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Cons Co nssul nsul u t th t e pr prod oduc od uc u ct mo mono n gr no grap a h at www.t ap .tri tri rint ntel nt ellililxm el xmon onog on ogra og raph ra ph.c ph .c ca fo forr im mpo port rttan antt in i fo f rm rmat atio at ion io n ab bou ut cont co n ra r iin ndi d ca cati tion ti ons, on s, war a ni n ng gs an and d pr p ec ecau a ti au tion ons, on s, adv s, dver erse er se rea eact ctio ct io ons ns,, inte in nte tera ra act ctio ions io nss, do dosi sing si ng g ins n tr truc ucti uc tion o s, on s, a d co an ond diittio ons ns of cl clin inic in ical ic al use al se..

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TRINTELLIXTM is a trademark of Lundbeck Canada Inc.

Animals and islands we love Confession: I’ve never really cared for panda bears. As a kid, I was devoted to Winnie the Pooh and his ilk, and regarded pandas as, well, trying too hard. There’s a limit to cute and even as a six-year-old I felt they’d gone way over the line with that black and white shtick. One or two of my friends had stuffed pandas, but their proper place, it seemed to me, was as prizes at carnivals. “Knock over the stack of wooden milk bottles and win a panda!”

That was then, this is now. Giant pandas, as they’re called to distinguish them from the unrelated red panda, measure between 1.2 and 1.8 metres and are 60 to 90 centimetres at the shoulder. They weigh from 100 to 150 kilograms on average and have five fingers and a unique sesamoid-bone thumb, which they use to better grip the bamboo shoots that comprise 99 percent of their diet. As is well-known, they’re a severely threatened animal and everything must be done to save them — and it is.

The good news: the total panda population, though a scant 1864, is on the rise. The bears are being carefully nurtured at a remarkable urban facility in Chengdu, China, the subject of the cover story in this issue (page 32) written by managing editor Camille Chin.

Another article well worth reading is The Rock of ages (page 38) in which Cinda Chavich describes her adventures exploring Newfoundland outports and sites like the Viking settlement of L’Anse aux Meadows by ship and Zodiac. This is the season for such excursions and the article had me reaching for the phone to book a trip.

There’s no better way for a stranger to get a taste of the province, which, since 1949, we’ve been lucky to have as a part of the country. But remember, 10 days is only a hint of the flavour of the island; 10 years is likely not enough time to truly appreciate the uniqueness of the place.

A writer friend, who favoured socks and sandals, once planned to spend a summer in St. John’s pounding out a novel. He took the ferry from Cape Breton to Portaux-Basques and went into a bar for a beer. The bartender silently served him a Molson and then went to the jukebox and put on then popular song “It’s a strange, strange world we live in” at full volume. My friend caught the next ferry back to the mainland.

There are lots of other goodies in the issue including To read about a 10-day cruise around a newly opened spin around Vancouver Island (page 46), Newfoundland, turn to page 38. that other island which bookends the country.

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MAY 2015 • Doctor’s

Review

3

GLYCEMIC CONTROL WITH CONFIDENCE

GLYCEMIC CONTROL WITH

GLYCEMIC CONTROL WITH

ONGLYZA

KOMBOGLYZE®

®

Demonstrated long-term HbA1c reduction vs placebo, both in combination with metformin over 102 weeks HbA1c mean change from baseline:1*



At week 24: -0.7% for ONGLYZA + metformin (n=186) vs 0.1% for placebo + metformin (n=175, 95% CI -1.0, -0.6, p≤0.0001)



At week 102: -0.7% for ONGLYZA + metformin (n=31 observed, n=184 LOCF) compared to placebo + metformin (n=15 observed, n=172 LOCF)

The convenience of a fixed dose combination of saxagliptin with metformin2

KOMBOGLYZE is indicated for use: as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are already treated with saxagliptin and metformin or who are inadequately controlled on metformin alone.

Consult the product monograph at www.azinfo.ca/ komboglyze/pm566 for important information about:  Contraindications in type 1 diabetes mellitus, metabolic acidosis including diabetic ketoacidosis, history of lactic acidosis, renal disease or impairment, excessive alcohol intake, moderate and severe hepatic impairment, hypoxic states, stress conditions, severe dehydration, pregnancy, breastfeeding and radiologic studies involving iodinated contrast materials  The most serious warnings and precautions regarding lactic acidosis  Other relevant warnings and precautions regarding pancreatitis, risk of hypersensitivity, patients with congestive heart failure, reduced vitamin B12, use during surgical procedures, CYP 3A4 inducers, immunocompromised patients, rash and renal function  Conditions of clinical use, adverse reactions, drug interactions and dosing instructions The product monograph is also available by calling us at 1-800-668-6000.

AstraZeneca Canada Inc. Mississauga, Ontario L4Y 1M4

There have been no clinical efficacy studies conducted with KOMBOGLYZE tablets; however, bioequivalence of KOMBOGLYZE with coadministered saxagliptin and metformin hydrochloride immediate release tablets was demonstrated.

09/15

ONGLYZA is indicated in patients with type 2 diabetes mellitus to improve glycemic control in combination with: metformin when metformin used alone, with diet and exercise, does not provide adequate glycemic control.

Refer to the page in the bottom right icon for additional safety information and a web link to the product monograph discussing:  Contraindications in diabetic ketoacidosis, diabetic coma/ precoma and type 1 diabetes mellitus  Relevant warnings and precautions regarding patients with congestive heart failure, exposure to stress, CYP 3A4 inducers, lactose, risk of hypersensitivity, pancreatitis, immunocompromised patients, rash, pregnant or nursing women, moderate to severe renal impairment and ESRD  Conditions of clinical use, adverse reactions, drug interactions and dosing instructions In addition, the page contains the reference list relating to this advertisement.

Onglyza®, Komboglyze® and the AstraZeneca logo are registered trademarks of AstraZeneca AB, used under license by AstraZeneca Canada Inc. © 2014 AstraZeneca Canada Inc.

Seepage additional information on page XX See XX additional safety information 56 forsafety

contents

LEUNGCHOPAN / SHUTTERSTOCK.COM

MAY 2015

32 38

features 32

38

Capital wealth

regulars

Chengdu is developing fast, but everyone goes to Sichuan’s newest metropolis to meet its oldest residents — the pandas

by Camille Chin

9 LETTERS

The Rock of ages

11

A 10-day adventure cruise to Newfoundland’s far-flung corners for intrepid travellers who want to act like an early explorer

by Cinda Chavich

Second thoughts

PRACTICAL TRAVELLER The best gardens in the world, Japan’s most famous castle gets a facelift, men’s high heels at the Bata Shoe Museum in Toronto and more!

by Camille Chin

46

Going coastal on Vancouver Island A road trip around BC’s Pacific Marine Circle Route for seafood, microbrews and West Coast views

by Margo Pfeiff

52

Beyond butter chicken Spiced lamb with mango sauce plus more recipes from the bestselling author of Everyday Indian

by Bal Arneson

46

Coming in

June

•

Bolivia in all its glory from Lake Titicaca to the 6542-metre summit of Nevado Sajama

•

Summer in the Saguenay is adored

by Quebecers, reason enough to add it to your bucket list

•

Everything you didn’t know about The Scream, Norway’s most famous painting

•

A garden tour of Niagara-on-the-Lake, as famous for flowers as Shaw

MAY 2015 • Doctor’s

Review

5

BREATHE IT IN

Explore the possibilities.

Indication and clinical use: Symbicort® is indicated for the treatment of asthma in patients 12 years and older with reversible obstructive airways disease. In patients with asthma, there are two treatment approaches: Symbicort ® Maintenance Therapy, where Symbicort® is taken as regular maintenance treatment with a separate rapid-acting bronchodilator as rescue, and Symbicort Maintenance and Reliever Therapy (SMART®), where Symbicort® is taken as regular maintenance treatment and as needed in response to symptoms. Symbicort® should not be used in patients whose asthma can be managed by occasional use of a rapid onset, short duration, inhaled beta 2 -agonist or in patients whose asthma can be managed by inhaled corticosteroids along with occasional use of a rapid onset, short duration, inhaled beta 2 -agonist.

Contraindications: • Hypersensitivity to inhaled lactose Most serious warnings and precautions: Risk of asthma-related death: Long-acting beta 2 -agonists (LABA), such as formoterol, one of the active ingredients in Symbicort ®, may increase the risk of asthma-related death. This was found with salmeterol and is considered a LABA class effect. LABA may increase the risk of asthma-related hospitalization in pediatric and adolescent patients. It has not been established whether concurrent use of inhaled corticosteroids or other long-term asthma control drugs mitigates the increased risk of asthmarelated death from LABA. Therefore, when treating patients with asthma, Symbicort ® should only be used for patients not adequately controlled on a long-term asthma control medication, such as an inhaled corticosteroid, or whose disease severity clearly warrants the initiation of treatment with both an inhaled corticosteroid and LABA. Once asthma control is achieved and maintained, assess the patient at regular intervals, and do not use Symbicort ® for patients whose asthma is adequately controlled on low- to medium-dose inhaled corticosteroids.

Rescue medication: Inform patients to have rescue medication available at all times.

Recommended dosage: Do not exceed.

Use in adolescents: Periodic reassessment should be considered as severity of asthma may vary with age.

Other relevant warnings and precautions: • Treatment should not be stopped abruptly • Cardiovascular effects • Candidiasis • Hyperglycemia, hypokalemia • Enhanced effect of corticosteroids on patients with hypothyroidism and cirrhosis • Adrenal insufficiency in patients transferred from systemic steroid • Susceptibility or decreased resistance to infection • Paradoxical bronchospasm • Potential risk during pregnancy, labour, delivery or nursing • Control of asthma should be monitored For more information: Consult the Product Monograph at azinfo.ca/symbicort/pm796 for important information regarding adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling AstraZeneca Canada at 1-800-668-6000.

SY1180E

12/15

SYMBICORT®, SYMBICORT SMART®, TURBUHALER® and the AstraZeneca logo are registered trademarks of the AstraZeneca group of companies. © AstraZeneca Canada Inc. 2014

contents MAY 2015

15 15

BUDGET TRAVELLER Two ways to save: go to family camp in Ontario or hike the Rockies

by Roger White

17

BEST MD APPS An app to help physicians talk to sick kids

by David Elkins

19

TOP 25 The biggest medical meetings scheduled for this October

22

HISTORY OF MEDICINE The neurological condition that makes some people hear music and taste food in colour

by Rose Foster

26

DEPRESSION KEYPOINTS How women experience mental illness differently than men

by Mairi MacKinnon

31

26

IBS KEYPOINTS 10 things you need to know about IBS-C

by Dr Gabor Kandel

56

PHOTO FINISH With age, beauty

by Dr Lourene Roode MAY 2015 • Doctor’s

Review

7

LETTERS

Doctored up EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

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David Elkins

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Stephanie Gazo / Toronto

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Denise Bernier

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EDITORIAL BOARD

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

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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.

SECOND THOUGHTS I am a senior psychiatric resident and I enjoy reading Doctor’s Review. I find the travel articles inspiring and the general medicine updates very helpful for patient care. I would like to make some corrections to “Differential diagnosis of depression” in the March 2015 edition [page 28].

The article stated that those with dysthymia have mood symptoms that “do not meet DSM criteria for major depressive disorder (MDD).” This is not the case in DSM-5. The diagnosis of Persistent Depressive Disorder (Dysthymia) is essentially a consolidation of two constructs from the DSM-IV; dysthymic disorder and chronic major depressive disorder. In the DSM-5, those who have symptoms that meet criteria for major depressive disorder in the context of two or more years of low mood should be given the diagnosis of Persistent Depressive Disorder, with the appropriate specifier (e.g. “with persistent major depressive episode”).

Later in the article ADHD is listed as a part of the differential diagnosis for MDD. Although it is true that both conditions share criteria of concentration difficulties, ADHD is a neurodevelopmental disorder, which must also be accompanied by multiple other criteria that are distinct from MDD and are present prior to age 12. It will not present as an acute episode, but rather as part of a greater, lifelong problem.

One additional important diagnosis that must be considered in a patient with low mood is Adjustment Disorder.

This can present with attenuated depressive symptoms in the context of one or more life stressors. Screening should be done for situational or interpersonal stressors, including domestic abuse.

I recognize that doing a thorough psychiatric assessment and differential diagnosis is challenging for the average busy general practitioner. That being said, the initial time investment in finding the right diagnosis and collaborating to find the right treatment for this particular patient will pay off by minimizing the number of future visits for the same complaint, failed medication trials and suffering, as well as avoiding the prolonged wait for a psychiatric consultation.

Dr Sterling Sparshu Via email

DRAWING INTEREST [“Art for therapy’s sake,” History of Medicine, April 2015, page 29] was not only very informational, but put all the various tidbits I’ve found in my research together into one fluid article. I have been doing a research paper as well as considering art therapy as a profession going forward in my studies and this really helped me put it all together.

Thank you!

Samantha Via DoctorsReview.com MAY 2015 • Doctor’s

Review

9

Where can you turn for help in preventing

MENB?* Serogroup B has become the most common invasive meningococcal disease (IMD) serogroup to affect Canadians (2011).1 Percentage of reported IMD cases by age and serogroup, Canada (2007-2011)1,† AMONG INFANTS <1 year of age Other serogroups 21%

AMONG CHILDREN 1-4 years of age

AMONG ADOLESCENTS 15-19 years of age‡

Other serogroups 26%

B 79%

Other serogroups 34%

B 66%

B 74%

‡BEXSERO® is used in individuals 2 months through 17 years of age.

BEXSERO

®

BEXSERO ® is indicated for active immunization of individuals from 2 months through 17 years old against invasive disease caused by N. meningitidis serogroup B strains.

Refer to the page in the bottom right icon for additional safety information and for a web link to the Product Monograph discussing • Contraindications in individuals who are hypersensitive to the BEXSERO® vaccine or to any ingredient in the formulation or components of the container closure.

The first and only vaccine indicated for active immunization against invasive meningococcal disease caused by serogroup B strains.1,2,§

• Relevant warnings and precautions regarding temperature elevation following vaccination of infants and children (less than 2 years of age), postponement of the administration of BEXSERO ® in subjects suffering from an acute severe febrile illness, individuals with thrombocytopenia, hemophilia or any coagulation disorder that would contraindicate intramuscular injection, subjects with impaired immune responsiveness, not administering by intravascular, intravenous, subcutaneous or intradermal injection, not mixing with other vaccines in the same syringe, availability of appropriate medical

treatment and supervision in case of an anaphylactic event following administration of the vaccine, risk of apnoea in premature infants and need for respiratory monitoring, known history of hypersensitivity to latex, hypersensitivity to kanamycin, that protection against invasive meningococcal disease caused by serogroups other than serogroup B should not be assumed and that as with any vaccine, BEXSERO® may not fully protect all of those who are vaccinated.

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

*MenB: meningococcal disease caused by serogroup B. † In infants under 1 year of age, 21.6 out of 27.2 average reported IMD cases were caused by serogroup B, in children 1-4 years of age, 20.6 out of 28 average reported IMD cases were caused by serogroup B, in adolescents 15-19 years of age, 16.4 out of 25 average reported IMD cases were caused by serogroup B. §Comparative clinical significance is unknown.

References: 1. An Advisory Committee Statement (ACS), National Advisory Committee on Immunization (NACI). Advice for the use of the Multicomponent Meningococcal Serogroup B (4CMenB) Vaccine. April 2014. Available at http://publications.gc.ca/collections/collection_2014/aspc-phac/HP40-104-2014-eng.pdf. 2. BEXSERO ® Product Monograph. Novartis Pharmaceuticals Canada Inc. December 6, 2013.

BEXSERO is a registered trademark.

Product Monograph available on request.

Printed in Canada ©Novartis Pharmaceuticals Canada Inc. 2015 14BEX022E

Be informed. Be immunized.

55 See additional safety information on page xxxx

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

PHOTOS THIS PAGE © 2015 BATA SHOE MUSEUM, TORONTO, CANADA / RON WOOD

by

Another way men get high Toronto’s Bata Shoe Museum is celebrating its 20th anniversary year beginning this May. The downtown museum has a collection of 13,000 shoes spanning 4500 years. Many of the museum’s edgiest high heels are on display now through May 2016 — all of them belonged to men. Standing Tall: The Curious History of Men in Heels explores the fancy footwear from the early 1600s to today and why some men — from privileged rulers to “hyper-sexualized” rock stars — preferred them to flats. “When heels were introduced into fashion at the turn of the 17th century, men were the first to adopt them,” Elizabeth Semmelhack, the museum’s senior curator recently said. “And they continued wearing heels as expressions of power and prestige for over 130 years.” John Lennon’s original 1960s Beatle boots are on display as are platforms worn by Elton John in the 1970s. Adults $14.Thursdays from 5 to 8pm by donation. tel: (416) 979-7799; batashoemuseum.ca.

CLOCKWISE FROM TOP: This small boy’s shoe dates from the mid-17th century.

Toronto shoemaker Master John made these boots in 1973.

These silk shoes from the early 18th century are said to be papal.

MAY 2015 • Doctor’s

Review

11

WWW.JWPICTURES.COM

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

Wright this way

The first house that Frank Lloyd Wright designed in Southern California is now open for self-guided tours after a six-year, $4.5-million restoration. Built in LA between 1919 and 1921, the Hollyhock House’s floors, windows, doors, decorative moldings and paint colours have been brought back to their original state. Wright called the house’s architecture “California Romanza,” using a musical term that means “freedom to make one’s own form.” There’s a central garden and many interior spaces are connected to exterior ones. The rooftop terraces feature views of the LA basin and Hollywood Hills. The house was commissioned by Pennsylvanian oil heiress Aline Barnsdall in 1919 — and named for her favourite flower — who also wanted a theatre of her own to produce her avant-garde plays. A dormitory for actors, a studio for artists and two secondary residences were planned, but the contract was cancelled in 1921 because of cost.

Thursdays to Sundays. Adults US$7. tel: (323) 913-4031; barnsdall.org.

High tea, high up, high price Afternoon tea is an English institution and this summer you can have it high above London at The Shard. This June, the Renzo Piano-designed skyscraper is launching Sky-High Tea on the open-air sky deck of the building’s 72nd floor, which boasts dizzying views of St. Paul’s Cathedral, the Gherkin and Tower Bridge. A Fortnum & Mason picnic “Hamplerling” of classic finger sandwiches, scones, clotted cream, raspberry jam and the British grocer’s signature Royal Blend tea will cost £85 ($155) for two.

Panoramic views are included. Bookings are open now for the June 23to-September 8 season. theviewfromtheshard.com.

12

Doctor’s Review • MAY 2015

Japan’s new wings MARTIN METTE / SHUTTERSTOCK.COM

One of Japan’s most famous and well-preserved castles reopened in March following a more than five-year renovation. Guests can now take in the architecture of Himeji-jo Castle, which dates from the beginning of the Edo Period (1603-1868), sans scaffolding (the building’s exterior was repainted). The castle became Japan’s first UNESCO World Heritage Site in 1993. It consists of 74 structures, including a kitchen in the inner court in case the castle fell under siege and an attempt was made to starve its occupants. Among its many gates are mechanisms for dropping stones on intruders and, of course, there are holes in the walls for firing guns. But the castle is elegant, too. Its white plaster walls are evocative of an egret (shirasagi) with its wings spread, which gives the castle its nickname, Shirasagi-jo. At night, the entire castle is lit up so a visit after sunset is recommended. himeji-kanko.jp.

H FO OUS RS E AL E

New trains for thought Via Rail Canada packages are now available through the Amtrak Vacations program. The new partnership between the two rail services means that you can now plan trips to Canada and the US in one transaction. The Cross Canada itinerary, for example, visits Toronto and Niagara Falls before departing for Jasper/Banff and then Vancouver where travellers can then take off for any of the cities that Amtrak services in the US. The Capital to Capital tour includes Toronto, Niagara Falls, Ottawa and Montreal, then a transfer to an Amtrak station for NYC, Philly and Washington. tel: (800) 268-7252; amtrakvacations.com.

Affordable Muskoka Retreat 3-minute walk to Lake Muskoka • • • • • • • • •

Stunning, solidly built 4-season brick home 4 beds / 3 baths, Muskoka room and dry sauna Municipal water & sewer A nature lover’s paradise: ravine lot with natural gardens and hiking trails outside your doorstep Minutes drive to golf courses, provincial parks, music events, theatre performances and festivals Quiet cul-de-sac (close to town amenities) $90,000 in upgrades Lovingly cared for by physician Offered at $333,333

http://www.century21.ca/Property/100970555 Contact: jason.masotti@century21.ca / 1-647-891-0686

MAY 2015 • Doctor’s

Review

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

Plant yourself here

ANDREW M. ALLPORT / SHUTTERSTOCK.COM

Kirstenbosch Garden in Cape Town.

The 2015 International Garden Tourism Awards were presented in Toronto recently. Organizations were honoured for the development and promotion of the garden experience as a tourism attraction. The Garden of the Year award went to Kirstenbosch National Botanical Garden (sanbi.org/ gardens/kirstenbosch) in Cape Town, South Africa. Established in 1913, the 36-hectare garden graces the slopes of Table Mountain. The New Garden Experience of the Year award went to Dubai Miracle Garden (dubaimiraclegarden.com).

It opened in 2013 and is home to 150 million flowers. The Top 10 North American Gardens Worth Travelling For (listed alphabetically, not rank) are below. For more: gardentourism. blogspot.ca.

Butchart Gardens, Brentwood Bay, BC Chanticleer Garden, Wayne, PA Denver Botanic Gardens, Denver, CO Desert Botanical Garden, Phoenix, AZ Fairchild Tropical Botanic Garden, Miami, FL Huntington Botanical Gardens, San Marino, CA Jardín Botánico Culiacán, Culiacán, Mexico Longwood Gardens, Kennett Square, PA Montreal Botanical Garden, Montreal, QC Vallarta Botanical Gardens, Puerto Vallarta, Mexico

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Doctor’s Review • MAY 2015

LUKAS REBEC / SHUTTERSTOCK.COM

Dubai’s Miracle Garden.

BUDGET TRAVELLER by

R og e r Whi t e

Summer the way it used to be Summer is a time for family and friends, which possibly accounts for the huge popularity of cottages by a lake in Canada.

Not everyone has a cabin to call their own, of course. Many don’t choose to invest in a place that will be used only a few months a year. Find yourself stuck in the city? Here are a couple of ways to enjoy the great outdoors with those you love that won’t break the bank.

Haliburton Forest, ON. Porto, Portugal.

Go to family camp If you wax nostalgic for those halcyon days you spent at summer camp as a kid, here’s your chance to relive the experience.

And this time you can take your kids — and your dog! — with you.

At Camp Wanakita on Koshlong Lake near Haliburton Heights, ON you get your own cabin which accommodates from three to 12 people, and three squares a day. The washrooms and showers are in a separate building — this is camp after all — and the activities are endless. Biking, swimming, kayaking, canoeing, sailing, windsurfing, crafts, puppetry, yoga, jazz dance, archery and dozens of others; participation optional. And don’t forget the campfires, skits and talent night. So fun! So inexpensive!

Plastic covered foam mattresses, bring your own bedding and towels. Cell phone coverage is weak. Closest Wi-Fi is a 15-minute drive away. Rates for seven days: adults $556; youth 10-16 $400; kids 3-9 $375; under 3 free. You’re only permitted to stay a week. wanakita.ymcahbb.ca/family-camp-programs.cfm.

Consider aClaudia seven-dayMasciotra romp through the Rockies on a guided To trip that takes you from Banff to Jasper and back. Camp in spacious two-person tents, all meals and transportation For Doctor’s Review May 2015 issue between National Parks included. Take a different hike everyday to some of the most beautiful spots in the country. Distances Faxfrom a1-855-861-0790 vary few kilometres to an 18-kilometre circuit in Jasper that takes you up to a 2790-metre summit.

© OMTP

Take a hike All you need to bring is a sleeping bag and a daypack, everything else — tent, meals, park and camping fees — is supplied. Maximum of a dozen people on each trip. From $1395. timberwolftours.com/site/our-tours/best-of-banff-yoho-andjasper.html.

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Omnaris : Powerful allergic rhinitis relief with an excellent tolerability profile. ®

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Common adverse reactions (1%–10%) in 2 to 6 week clinical trials with SAR or PAR patients (≥12 years) for Omnaris and placebo include epistaxis (2.7% vs. 2.1%), nasal passage irritation (2.4% vs. 2.2%) and headache (1.3% vs. 0.7%).

Most common adverse reactions reported in a 52-week clinical trial of PAR in patients ≥12 years, OMNARIS vs. placebo, were epistaxis (8.4% vs. 6.3%), nasal passage irritation (4.3% vs. 3.6%) and headache (1.6% vs. 0.5%).

®

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Indications and clinical use: OMNARIS (ciclesonide nasal spray) is indicated for the treatment of seasonal allergic rhinitis, including hay fever, and perennial allergic rhinitis in adults and adolescents 12 years of age and older. ®

Contraindications: • Patients with tuberculosis Relevant warnings and precautions: • Patients who are on drugs that suppress the immune system are more susceptible to infections than healthy individuals • Patients should be examined periodically for changes or signs of adverse effects on the nasal mucosa (e.g. Candida albicans)

• Do not use in patients with recent nasal ulcers, nasal surgery, or nasal trauma until healing has occurred • Monitor for growth suppression in children and adolescents • Signs of adrenal insufficiency and withdrawal can accompany the replacement of a systemic corticosteroid with a topical corticosteroid; patients should be carefully monitored.

Rapid decreases in systemic corticosteroid dosages following long-term treatment may cause a severe exacerbation of symptoms • Monitor for hypoadrenalism in infants born to mothers taking corticosteroids • Use with caution, if at all, in patients with untreated local or systemic fungal or bacterial infections, viral or parasitic infections, or ocular herpes simplex

• Rare instances of wheezing, nasal septum perforation, cataracts, glaucoma, increased intraocular pressure have been reported with intranasal corticosteroid use For more information: For important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions and dosing information, please consult the product monograph at http://www. takedacanada.com /ca /omnarispm. The product monograph is also available by calling us at 1-866-295-4636.

REFERENCE: 1. OMNARIS (ciclesonide nasal spray) Product Monograph. Takeda Canada Inc., January 2, 2013. ®

COVERED BY MOST PRIVATE INSURANCE PLANS. ® Registered trademark of Takeda GmbH. Used under licence.

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Winning ways with kids Kidspeak is a great way to help young patients better understand their bodies and it helps explain how you intend to make them better — and you get to be Dr Cool in the bargain. A digital whiteboard lets you draw on organs to illustrate why they’re sick or in the hospital and what treatment is planned.

The app was created by the Child Life Specialists at Tucson Medical Center for Children and is geared towards pediatricians, GP/FPs and emergency medicine docs. The app is divided into three sections. The first features a virtual tour of the Tucson facility (only useful to those who use the facility). The other two parts are designed for any physician who treats those under age 16 regardless of where you practice. In addition to the whiteboard, there’s a 200-item glossary of common medical terms explained in easy to understand language.

Kidspeak has only been out for a few months, but your colleagues who have used it are enthusiastic. Dr Iltifat Husain, editor-in-chief of iMedicalApps. com, plans to use the app to explain disease pathology to parents and kids in a direct and simple way. “My favorite is the digital whiteboard section where you can draw on organ systems to show your pediatric population exactly what’s happening to their bodies,” said Dr Husain.

Another early physician-user posted this comment online: “I had a lot of fun playing around with Kidspeak and plan to use it with the pediatric patients I see in practice and their parents. Usually apps produced by medical centers have poor user interfaces and are buggy, but Tucson Medical Center should be proud of creating a health app that avoids these issues.”

The credit goes to the Child Life Specialists at the hospital with significant input from the Patient and Family Advisory Committee at Tucson Medical Center. One aim was to make procedures and equipment less frightening for children. To achieve this, the team included the sounds of an MRI scan, X-ray and ultrasound so they’ll be familiar when the time comes for the real thing.

Kidspeak by the Child Life Specialists at the Tucson Medical Center for Children Devices: iOS and Android Cost: Free Another new app worth considering: Canadian Guidelines on Sexually Transmitted Infections are now available as apps — search for CDN STI Guidelines — from the Public Health Agency of Canada, a sure sign that government agencies are embracing the new technology.

MAY 2015 • Doctor’s

Review

17

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doctorsreview.com/meetings access code: drcme

the top 25 medical meetings compiled by Camille Chin

Canada Charlottetown, PEI October 14-17 2015 Annual Meeting of the Canadian Society of Internal Medicine csim.ca/en/meetings-cme-2/annualmeetings/191-2015-national-meeting

Halifax, NS October 1-4

Montreal, QC October 6-9 45th Annual Meeting of the International Continence Society ics.org/2015

October 11-14 25th World Congress on Ultrasound in Obstetrics and Gynecology isuog.org/worldcongress/2015

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

Ottawa, ON October 1-3 8th Canadian Conference on Dementia canadianconferenceondementia.com

October 29 - November 1 Canadian Hospice Palliative Care Conference conference.chpca.net

NOVA SCOTIA TOURISM

61st Annual Meeting of the Canadian Fertility and Andrology Society cfas.ca

The Bluenose II tall ship in Halifax.

Quebec City, QC September 17-20

Vancouver, BC October 1-3

Toronto, ON September 25-27

October 4-9

2015 Annual Meeting of the Canadian Heart Rhythm Society chrsonline.ca/index.php/annual-meeting

7th Congress of the Canadian Sleep Society css-scs.ca/conference

65th Annual Conference of the Canadian Psychiatric Association cpa-apc.org XXI FIGO World Congress of Gynecology and Obstetrics figo2015.com

October 22-24

5th Annual Canadian Hypertension Congress hypertension.ca/en/chc

October 24-27

2015 Canadian Cardiovascular Congress cardiocongress.org

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

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!

MAY 2015 â&#x20AC;˘ Doctorâ&#x20AC;&#x2122;s

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doctorsreview.com/meetings access code: drcme

the top 25 medical meetings Around the world Barcelona, Spain October 1-3 54th Annual Meeting of the European Society for Paediatric Endocrinology espe2015.org

Berlin, Germany October 3-7 LISA A / SHUTTERSTOCK.COM

28th Annual Congress of the European Society of Intensive Care Medicine esicm.org/events/annual-congress

October 13-16 2015 Congress of the International Psychogeriatric Association ipa-online.org/wordpress/meetings-andeducation/annual-congress

Brisbane, Australia September 13-16 2015 World STI and HIV Congress worldsti2015.com

October 7-10 2015 Joint Annual Conference of the International Society for Pediatric and Adolescent Diabetes and the Australasian Paediatric Endocrine Group ispad.org/jointispad-apeg2015

Barcelona’s Casa Milà.

Budapest, Hungary September 17-20

Dundee, Scotland October 5-8

22nd World Congress on Controversies in Obstetrics, Gynecology and Infertility congressmed.com/cogi

17th Congress of the International Society of Addiction Medicine isamdundee2015.com

Copenhagen, Denmark October 7-11

London, England September 28-30

24th Congress of the European Academy of Dermatology and Venereology eadvcopenhagen2015.org

3rd World Congress on Interventional Therapies for Type 2 Diabetes wcitt2d.org

National Harbor, MD September 26-29 19th Annual Scientific Meeting of the Heart Failure Society of America hfsa.org/hfsa-wp/wp/upcoming-meetings

London’s Natural History Museum.

Prague, Czech Republic October 14-17 ALEXANDER TIHONOV / SHUTTERSTOCK.COM

26th Congress of the European Society for Paediatric Urology (joint meeting with the International Children’s Continence Society and Society for Pediatric Urology) jointmeeting2015.espu.org

San Diego, CA October 7-11 Fisherman’s Bastion in Budapest.

20

Doctor’s Review • MAY 2015

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A blending of the senses Synesthetes experience letters, music and even taste in colour — and there are more of them than you might think

I

Chromesthesia is a type of synesthesia in which sounds automatically evoke an experience of colour.

magine a world where letters and numbers have colours, where music takes forms, or names are accompanied by taste. This is the wonderful world

of synesthesia, a neurological phenomenon that mingles senses together. Maligned through much of history as a freakish disorder, synesthesia has, in recent years, been much more widely understood and is now even celebrated.

“It’s not a disorder,” says well-known neurologist and author Richard Cytowic.

“It’s a trait, like having blue eyes.” Not only is there nothing wrong with the synesthetic mind, it is in fact likely to possess a heightened capacity for memory and recall. And since sight, sound and movement already map to one another so closely, says Cytowic, there’s a little bit of synesthesia in all of us.

What’s the difference between someone who occasionally has an experience of one sense that triggers another — “This syrup tastes pink!” — and a real synesthete? Somewhere between two and four percent of the population is made up of synesthetes in which synesthetic associations are conscious, distinct, automatic and constant over time.

If an oboe has a mahogany-coloured sound, it always will. If the letter Q is turquoise, it will remain so for a lifetime, though another synesthete’s Q could be orange or green.

SEEING LIKE NABOKOV The Russian writer Vladimir Nabokov described his letter A as having “the tint of weathered wood,” R as “a sooty bag

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Doctor’s Review • MAY 2015

Arthur Rimbaud popularized the concept of grapheme synesthesia when he penned Voyelles in the 1870s.

being ripped” and the letter S as a “curious mixture of azure and mother-of-pearl.”

He mused on his “oatmeal N, noodlelimp L, and the ivory-backed hand-mirror of O,” steely X, thundercloud Z and huckleberry K, as well as what he calls “the green group” of alder-leaf F, the unripe apple of P and pistachio T (Speak Memory, 1966).

Nabokov was not the first writer to provide vivid colour imagery for letters.

The French Symbolist poets were the original artist-types who found the concept of synesthesia sexy. The earliest traceable medical reference to coloured hearing — “seeing colours upon hearing musical notes” — can be found in an

Individuals with spatial sequence synesthesia orient days of the week or months of the year around them in space.

1812 thesis by a German physician who went simply by the name of Sachs.

The father of 19th-century French poet Charles Baudelaire had an extensive collection of medical textbooks and there’s speculation that son Charles may have stumbled across this, or some similar reference, and been propelled into the flurry of inspiration which produced his famous poem Correspondances about the romantic intermingling of the senses.

In 1871, the same year that Gustav Fechner, the father of psychophysics, made records of 73 patients who reported having coloured letters, Arthur Rimbaud, Baudelaire’s contemporary, published his famous poem Voyelles. In it he declares that A is black, E is white, I is red, U is green and O is blue.

Though he has since been understood not to be a true synesthete, Rimbaud can be credited with popularizing the condition among the artist community of the day.

be victims of excessive use of LSD. But by the 1980s, as the cognitive revolution encouraged the study of consciousness, synesthesia experienced a renaissance that has been gathering momentum ever since.

That said, knowledge about the neurologic basis for synesthesia remains scant. The trait has been observed to be more prevalent in women, left-handed people, those on the autism spectrum and artists. The term synesthesia — from the Greek for “the joining of senses” — is derived from the theory that the brain

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FADING COLOURS The font of inspiration which artists, musicians, writers and researchers alike found in the exploration of synesthesia dried up with the rise of behaviourism in psychology when any mention of internal subjective experiences was verboten. More than 600 papers on the subject were published before 1940, but from 1940 to 1975, there were only 12.

Synesthesia’s long lapse into obscurity meant that when people with blended sensory associations reported seeing sounds and tasting colours in the mid-1960s, they were deemed “potheads and junkies” or were thought to

is firing two senses at once. Unlike most brains, which engage in the developmental process of pruning, the standard theory has it that synesthesia is caused by increased connectivity between adjacent brain regions which failed to prune normally.

Recent researchers have reframed the subject by suggesting that it isn’t a sensory perception which causes a colour association at all, but rather the meaning that we assign to that perception.

They suggest the term “ideasthesia,” meaning “sensing ideas” would be

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23

Russian writer Vladimir Nabokov described his letter A as having “the tint of weathered wood” and letter R as “a sooty bag being ripped” more accurate. In the past, colour associations were thought to be entirely random misfirings of the brain. This new way of understanding the phenomenon sees the associations between letters, numbers and colours in early childhood as a way for the forming brain to remember abstract concepts by anchoring them in familiar experiences. Tests which show that colour associations shift according to context — for example, an “S” shape will be perceived as having a different colour depending on whether it’s viewed as the letter ’s’ or the number 5 — confirm that the process is conceptual and not perceptual.

FISHER PRICE POWER An amusing discovery was made in 2009 about early childhood and the formation of synesthetic associations with alphabet colours. Two Stanford scientists, Drs Nathan Witthoft and Jonathan Winawer, observed a distinctive pattern in one synesthete’s letter colours, a particular cycling through red, orange, yellow, green and blue.

When asked about it, the synesthete pointed out a match between those colours and the colours on the Fisher Price alphabet magnets she’d had as a

In the Square Test, synesthetes can immediately distinguish the 2s from the 5s due to their colour difference.

Non-synesthetes have to look more closely.

kid. Could this be a direct example of sensory imprinting in early childhood which would confirm synesthetic associations as something more than random misfirings?

Dr David Eagleman, director of the Laboratory for Perception and Action at the Baylor College of Medicine, decided to try and find out. He collected data from 6588 synesthetes and came up with some conclusive results: six percent of the synesthetes had 10 or more letters that matched the magnet set, a statistic greatly surpassing chance.

Testing the hypothesis further, the lab found no one born before 1967 seemed to have imprinted on the toy, but a striking 15 percent of those born between 1975 and 1980 did have colours that matched the set, marking a direct correspondence with the heyday of Fisher Price letter-fridge-magnet marketing.

After 1990, when the magnet set went out of production, the percentage of magnet imprinting showed a decline.

Still more fodder for the “ideasthesia” concept can be found in what’s known as ordinal-linguistic-personification, or OLP synesthesia, in which ordered sequences like numbers or the alphabet are associated with personalities and genders. OLP synesthetes, for This boy, born in 1988, is an adult grapheme synesthete; 25 of his 26 letters match the colours of the Fisher Price alphabet set.

24

Doctor’s Review • MAY 2015

example, might perceive the letter B as a kindly woman in an apron or number 4 as a skater-punk in shades and a baseball cap. Pythagoras himself suggested genders for numbers though his pronouncement that even numbers were female and odd numbers were male was probably more theoretical than synesthetic. Some synesthetes position sequences like numbers or the calendar year in specific locations in space, yet another example of a conceptual fusion.

COLOUR DEMENTIA BRIGHT Linking words to colours could prove useful for the 96 percent of the population who aren’t synethetes. Dr Clare Jonas at the University of East London is currently training non-synesthetes to associate certain letters with certain colours to find out if people can remember coloured words more easily. So far the results look good. The hope is that synesthesia training could help patients recover from brain injuries or ward off cognitive decline in old age by enhancing visual mental imagery and memory performance.

Co-editor of The Oxford Handbook of Synesthesia Dr Julia Simner was recently awarded a grant to develop the fist test to identify synesthesia in children.

Synesthetes learn differently than other children, say some researchers, and would benefit from being acknowledged for their unique qualities. So while synesthetes of yore were mocked for their fanciful colour-rich pronouncements, the coming generations of word-tasters and colour-seers may enjoy special attention of a brighter, more magenta, more honey-tasting sort.

In major depressive disorder

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Nicole*, 37

For patients like Nicole...

Trust PRISTIQ

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

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

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

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

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

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

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

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D E PRE SSIO N K EY PO I NT S by

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Ruth Baruch, MD, FRCP(C)

Gender issues The female face of depression G . ender is a critical determinant of mental health and mental illness. … Gender differences occur particularly in the rates of common mental disorders — depression, anxiety and somatic complaints.

These disorders, in which women predominate, affect approximately one in three people in the community and constitute a serious public health problem.” — World Health Organization1

C .

linical depression is a major underlying cause of illnessrelated disability in women; in Canada and worldwide, twice as many women as men are affected.1-6 The gender disparity is multifactorial. Among the various causes, it is age-related, but the difference lessens with age. Women are prone to higher rates of depression than men throughout a good part of their lifetime, beginning in puberty and lasting until after menopause.2,5,7,8 Depression in women stems from a combination of genetic, biologic, psychologic and social factors. Causes unique to women include hormonal factors associated with reproductive cycles; depressive episodes are often linked to menstruation, pregnancy, the postpartum period, perimenopause and menopause. Psychosocial issues surrounding women’s complex roles/responsibilities as well as gender-related vulnerabilities are also critical components.2,5,8 Genetic factors: While not a prerequisite for developing the disorder, having a family history of depression puts women (as well as men) at greater risk. Genetic predisposition may also interact with environmental factors to increase the odds.5,6,8 Hormones: The impact of hormones on brain chemistry and mood, and the heightened sensitivity of some women to these hormonal fluctuations, contribute to the rise in depression at key periods during their lifetime.5,6,8 • Premenstrual dysphoric disorder (PMDD): Severe depression strikes some women up to two weeks before and one or two days into their menstrual period. Symptoms, including anxiety, irritability and mood swings, can be severe enough to hinder normal functioning and require treatment.5,6,8 • Perinatal depression: During pregnancy and after childbirth, women undergo hormonal changes and face lifestyle changes that can make them more susceptible to depression. While it is normal to feel somewhat “blue” after giving birth, more prolonged postpartum depression (PPD) can incapacitate some women. Typical symptoms include self-doubt, excessive crying, loss of pleasure and feelings of hopelessness and guilt.4-6,8 A previous history of depression can heighten a woman’s chances of developing PPD.6 Appropriate treatment

Ruth Baruch, MD, FRCP(C) is Medical Director of Community Service at the Toronto East General Hospital, University of Toronto

26

Doctor’s Review • MAY 2015

and adequate support are essential for the well-being of the child and the mother, especially since one episode of PPD increases the risk of a subsequent event.4,5 • Menopausal depression: While the transition between premenopause and menopause is relatively smooth sailing for some women, others have more difficulty coping with the symptoms and are at higher risk of depression. Once women reach menopause (a year after menstrual periods stop), depressive episodes are less common.5,6,8 • Other reproductive-related factors — such as infertility, miscarriage, oral contraceptives and hormone replacement therapy (HRT) — have been linked to depression.2 Comorbid medical conditions: Depression is associated with a variety of serious medical conditions, including heart disease, stroke, cancer, Parkinson’s disease, multiple sclerosis, HIV/AIDS, thyroid conditions and diabetes. Further, it may exacerbate symptoms and worsen outcomes related to these illnesses.6,8 Depression can also coexist with eating or anxiety disorders, which occur more frequently in women.6 As well, attention deficit hyperactivity disorder (ADHD) is frequently comorbid with depression in women, and often underdiagnosed.9,10 Psychosocial issues: Women may respond differently than men to difficult or traumatic life events (e.g. loss of a loved one, relationship problems). Stress and conflict arising from women’s many diverse roles and responsibilities (work, family, social) may make them more prone to suffering bouts of depression.

As well, women are more often victims of sexual/physical abuse, oppression, social inequality and lower socioeconomic status, all of which increase their susceptibility to depression.1,5,6,8

What does depression in women look like?

While the effect of depression is never identical from one individual to the next, there are some particular ways in which women’s experience is distinct from men’s.

• Women have more frequent depressive episodes; they also report more symptoms, and greater severity of symptoms, than men.8 • Problems most commonly expressed by women include anxiety/stress, extreme fatigue, sleeping too much, appetite/ weight increase, irritability, excessive crying, loss of interest (in habitual activities, relationships, sex) and more headache/ body pain.5,8,11 On the other hand, men’s reactions tend

OPENEYED / SHUTTERSTOCK.COM

more toward anger, aggression, substance use and selfdestructive behaviours.11 • Suicide attempts number three to four times higher in women suffering from depression than in men, although men are more often successful.4,8 • Women have higher rates of seasonal affective disorder (SAD) as well as chronic depression (dysthymia) than men.2,4,5

Treatment considerations Psychotherapy (e.g. cognitive behavioural therapy, interpersonal therapy) may be useful for women who are trying to conceive, pregnant women or breast-feeding mothers who do not wish to take medication.5 Antidepressants are equally effective in women and men, but women may experience more side effects.5 Newer firstline options (selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors and norepinephrine dopamine reuptake inhibitors) are associated with fewer adverse effects than older therapies.5,12 Antidepressants cross the placental barrier and may pose a small risk to the fetus during pregnancy, although studies vary.

On the other hand, not initiating or stopping treatment for depression is not without harm and may increase the risk of recurrence. Women and their doctors should weigh the risks and benefits to mother and child when considering the use of antidepressants during pregnancy.6,12 First-line antidepressants (in recommended doses) are associated with extremely low levels in infants who are breast-fed.6,12 There are no contraindications to taking antidepressants at the same time as HRT (used to alleviate menopausal symptoms).13 Tricyclic antidepressants may interfere with the effect of some oral contraceptives (e.g. increase of plasma levels and antagonism of antidepressant effects).13 As well, the herbal supplement St. John’s wort, sometimes used to treat mild to moderate depression, may reduce their effectiveness.6,13,14

Women are more likely to talk about it The higher rate of depression among women might also have to do with the fact that women are more open than men about discussing their emotions, and may be more likely to seek help from their primary care providers.1,15 When they do bring up

the subject, men’s description of emotional difficulties is often couched in terms of “stress” rather than depression.15 This may make depression more difficult to recognize in men.15 Interestingly, a recent study concluded that once the differences in the types of depressive symptoms experienced by men and women (e.g. men report more “nontraditional” symptoms) are accounted for, the gender discrepancies in the incidence of depression disappear.11 References 1. World Health Organization. Mental health: Gender and women’s mental health. www.who.int/mental_health/prevention/genderwomen. Accessed April 20, 2015.

2. Noble RE. Depression in women. Metabolism 2005;54(Suppl):49-52.

3. Canadian Psychological Association. “Psychology works” Fact sheet: Depression.

Ottawa, 2014. www.cpa.ca/docs/File/Publications/FactSheets/PsychologyWorks FactSheet_Depression.pdf. Accessed April 20, 2015.

4. Mood Disorders Society of Canada. What is depression? Fact sheet. www.mood disorderscanada.ca/page/resources Accessed April 20, 2015.

5. National Alliance on Mental Illness (NAMI). Women and depression Fact sheet.

Arlington, VA: NAMI, 2009.

6. National Institute of Mental Health (NIMH). Women and depression: Discovering hope. U.S. Department of Health & Human Services, National Institutes of Health.

NIH Publication No. 09 4779, 2009.

7. Patten SB, Kennedy SH, Lam RW et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. J Aff Disord 2009;117(Suppl 1):S5–S14.

8. Women’s College Hospital. Women’s Health Matters. Depression in women. www.womenshealthmatters.ca/health-centres/mental-health/depression/ depression-in-women. Accessed April 20, 2015.

9. Quinn PO, Madhoo M. A review of attention-deficit/hyperactivity disorder in women and girls: uncovering this hidden diagnosis. Prim Care Companion CNS Disord 2014;16:PCC.13r01596.

10. Nussbaum NL. ADHD and female specific concerns: a review of the literature and clinical implications. J Atten Disord 2012;16:87-100.

11. Martin LA, Neighbors HW, Griffith DM. The experience of symptoms of depression in men vs women. JAMA Psychiatry 2013:70:1100-06.

12. Lam RW, Kennedy SH, Grigoriadis S et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy.

J Aff Disord 2009;117(Suppl 1):S26–S43.

13. National Collaborating Centre for Mental Health (UK). NICE Clinical Guidelines, No. 91. Depression in adults with a chronic physical health problem: Treatment and management. Appendix 16: Table of drug interactions. British Psychological Society, 2010. www.ncbi.nlm.nih.gov/books/NBK82914/. Accessed April 20, 2015.

14. Ravindran AV, Lam RW, Filteau MJ et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. V. Complementary and alternative medicine treatments. J Aff Disord 2009;117(Suppl 1):S54–S64.

15. Wong ST, Manca D, Barber D et al. The diagnosis of depression and its treatment in Canadian primary care practices: an epidemiological study. CMAJ Open 2014; 2:E337-E342.

MAY 2015 • Doctor’s

Review

27

Trust in a name that has been available for 16 years: PrEFFEXOR® XR EFFEXOR XR (venlafaxine hydrochloride) is indicated for the symptomatic relief of: Major Depressive Disorder, Anxiety causing clinically significant distress in patients with Generalized Anxiety Disorder Social Anxiety Disorder (Social Phobia), Panic Disorder, with or without agoraphobia, as defined in DSM-IV

Recommended as a first-line agent for:1-3* •

Depression

•

General Anxiety Disorder

•

Social Anxiety Disorder

•

Panic Disorder

Help your patients taking EFFEXOR XR by offering payment assistance with Pfizer Strive Payment Assistance† * See respective guidelines for complete recommendations. † Pfizer Strive Payment Assistance is available in all provinces except Quebec. Availability and coverage vary by province.

Clinical use:

• Caution in patients operating machinery or engaging in tasks requiring alertness

Depression: Short-term efficacy has been demonstrated in placebo-controlled trials of up to 12 weeks. Efficacy in maintaining an antidepressant response for up to 26 weeks, following response to 8 weeks of acute treatment, was demonstrated in a placebo-controlled trial.

• Caution in patients with a history of myocardial infarction or unstable heart disease

Generalized Anxiety Disorder: Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. The effectiveness in long-term use has been evaluated for up to 6 months in controlled clinical trials.

• Risk of QTc prolongation, Torsade de Pointes (TdP)

Social Anxiety Disorder (Social Phobia): Efficacy was demonstrated in four 12-week, multi-centre, placebo-controlled, flexible-dose studies and one 6-month, fixed/flexible-dose study in adult outpatients.

Panic Disorder: Efficacy was established in two 12-week, placebo-controlled trials in adult outpatients. The efficacy in prolonging time to relapse for up to 6 months, in responders of a 12-week acute treatment, was demonstrated in a placebo-controlled trial.

The physician who elects to use EFFEXOR XR for extended periods should periodicallyre-evaluate the long-term usefulness of the drug.

Caution should be exercised in the elderly.

• Increases in heart rate may occur; caution in patients whose underlying conditions may be compromised – Caution in patients with cardiovascular disease or family history of QT prolongation, or in patients taking medicines known to increase QT interval, especially for patients with increased risk of QT prolongation • Caution in patients with diseases or conditions that could affect hemodynamic responses or metabolism • Risk of serum cholesterol elevations; monitor levels, especially during long-term treatment • Potential for changes in appetite and weight • Risk of hyponatremia and syndrome of inappropriate antidiuretic hormone (SIADH) secretion, usually in volume-depleted or dehydrated patients • Risk of bleeding; concomitant use with NSAIDs, ASA or other drugs affecting coagulation may add to the risk; caution in patients with a history of bleeding disorder or predisposing conditions

Contraindications: • In combination with Monoamine Oxidase Inhibitors (MAOIs) or within two weeks of terminating treatment with MAOIs. Most serious warnings and precautions: • Risk of potential association with behavioural and emotional changes, including self-harm: – Rigorous clinical monitoring for suicidal ideation or other indicator of potential for suicidal behaviour is advised in patients of all ages. This includes monitoring for agitation-type emotional and behavioural changes.

– Patients, families, and caregivers should watch for the emergence of unusual behavioural changes, depression worsening and suicidal ideation, especially during treatment initiation or change in dose/dose regimen.

• Discontinuation symptoms: dosage should be tapered gradually and the patient monitored.

• Bone fractures: increased risk of bone fractures have been shown with some antidepressants, including selective serotonin reuptake inhibitors/serotonin norepinephrine reuptake inhibitors (SSRIs/SNRIs).

• Caution in patients with a history of seizures; promptly discontinue if seizure develops • Risk of serotonin syndrome or neuroleptic malignant syndrome (NMS) – Careful observation if concomitant treatment with other agents affecting serotonergic and/or dopaminergic neurotransmitter systems is clinically warranted – Concomitant use with serotonin precursors is not recommended • Can cause mydriasis; caution in patients with raised intraocular pressure or narrow angle glaucoma • Treatment-emergent insomnia and nervousness • Mania/hypomania: caution in patients with a history or family history of bipolar disorder • Lactating women should not nurse their infants For more information:

Other relevant warnings and precautions:

Please consult the product monograph at www.pfizer.ca/en/our_products/ products/monograph/258 for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece.

• Risk of allergic reaction

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

• Hepatic and renal impairment: Dosage adjustments required.

• Risk of hypertension, including acute severe and sustained hypertension; monitor blood pressure regularly in all patients • Caution in the treatment of pregnant women, especially during the third trimester – Exposure late in the third trimester may result in discontinuation symptoms and complications requiring prolonged hospitalization, respiratory support and tube feeding

© 2014 Pfizer Canada Inc. Kirkland, Quebec H9J 2M5

References: 1. EFFEXOR XR Product Monograph, Pfizer Canada Inc., August 2013.

2. Lam R, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the management of major depressive disorder in adults. J Affec Disord 2009;117:S26-S43. 3. Swinson R, et al. Clinical Practice Guidelines Management of Anxiety Disorders.Can J Psychiatry 2006;51(suppl 2):S1-92S.

® Pfizer Inc, used under license Effexor ® Wyeth LLC., owner/ Pfizer Canada Inc., Licensee

CA0114EFX007E

Not indicated for use in children under 18 years of age.

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

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

IBS-C

CIC

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

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

Clinical use: Clinical studies of CONSTELLA did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.

CONSTELLA is contraindicated in children under 6 years of age and is not recommended for use in children between 6 and 18 years of age as the safety and efficacy of CONSTELLA in pediatric patients have not been established.

Contraindications: • Pediatric patients under 6 years of age • Patients with known or suspected mechanical gastrointestinal obstruction Most serious warnings and precautions: Children: Not recommended in children between 6 and 18 years of age

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

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

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

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

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

Dr Gabor Kandel

10 things you should know about IBS-C 1. IBS-C and CIC: two sides of the same coin?

6. Optimal management requires teamwork

Irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) are difficult to distinguish in at least 25 percent of patients, and a similar percentage may alternate between the two conditions. So you’re not the only one who sees a marked overlap between IBS-C and CIC.

Since IBS-C is a chronic condition, actively involve patients in management to ensure treatment adherence. Also, try to lower expectations and set realistic treatment goals to reduce symptoms, feel better and improve coping.

2. Abdominal pain is the hallmark of IBS-C

Adequate fibre intake increases bowel frequency and decreases straining, but can also increase gas and bloating. Over 25 g/day of fibre is likely to do more harm than good in IBS-C. However, soluble fibre, such as psyllium, oats and legumes, relieves constipation with less bloating than insoluble fibre, such as wheat bran.

IBS-C is defined as abdominal discomfort associated with altered bowel habits over at least three months, whereas CIC is diagnosed as unsatisfactory defecation with infrequent stools, difficult stool passage, or both, for at least three months.

A pragmatic way to distinguish constipation and IBS-C is to do a colonic lavage with polyethylene glycol. If symptoms persist, they’re probably due to IBS-C, meaning treatments focused solely on increasing bowel movements aren’t likely to help.

3. IBS-C is not a diagnosis of exclusion In the absence of alarm features (e.g. rectal bleeding), IBS-C and CIC are unlikely to be due to sinister disease, and exhaustive testing is unnecessary.

4. Your confidence in the IBS-C diagnosis is key It’s reasonable to order a few diagnostic tests to rule out organic disease. The biggest benefit works through you: if you’re confident in the diagnosis of IBS-C, you’ll be able to convince your patients there’s no serious illness, and start treating the real problem.

5. Red flags do warrant further investigation The classic alarm features are onset after age 50, rectal bleeding, weight loss, iron-deficiency anemia, symptoms at night, and family history of colorectal cancer, inflammatory bowel disease or celiac disease. Patients over 50 who’ve never had a colonoscopy should be screened for colorectal cancer because of their age. In women, early ovarian cancer symptoms, especially bloating due to ascites, may resemble IBS-C, so a pelvic exam and ultrasound may be warranted.

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

7. The wrong fibre might worsen IBS-C symptoms

8. FODMAPs may be to blame Small carbohydrates known as FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols), found in wheat and many other foods, may cause bloating in IBS-C by: (1) osmotic effects in the bowel, and (2) fermentation by colon bacteria, producing gas. If bloating and/or gas are the chief problem, it’s worth trying the low-FODMAP diet.

But it can be unhealthy if followed incorrectly, so consultation with a registered dietitian is recommended.

9. Patients may be reluctant to take medications, even if they work Many patients may resist medications, but if nothing else has worked, appropriate drug therapy may be their only hope.

Even when they find an effective medication, some people try stopping it, and the symptoms return. Emphasize that drugs for IBS-C only work while you take them.

10. Linaclotide is an effective option for IBS-C and CIC Among drugs for IBS-C and CIC, linaclotide (Constella) has the most convincing evidence for efficacy. The main side effect of linaclotide is diarrhea. Patients who get diarrhea should call their physician to decide together whether it’s severe enough to warrant stopping the drug. Often, patients are just startled by the abrupt increase in bowel movements.

If they’re comfortable with it, there’s no reason to stop.

Linaclotide has simplified the approach to constipation and IBS-C: if diet hasn’t worked, the next step is as simple as prescribing this drug.

MAY 2015 • Doctor’s

Review

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HUNG CHUNG CHIH / SHUTTERSTOCK.COM

There are 1864 giant pandas in China; 1246 of them live in the countryâ&#x20AC;&#x2122;s 67 panda nature reserves.

Capital wealth Chengdu’s economy is thriving, but the city’s real riches are its pandas and parks

by Camille Chin

seeing the shopping strip would be like going to NYC and not visiting Fifth Avenue; it’s lined with 700 shops.

Fourteen million people now live in Chengdu, which has been going through a decade of explosive economic growth. It’s a huge metropolis with glass skyscrapers, high-end shops and a new subway system. The 18-storey New Century Global Centre is the biggest complex in the world with 1.7 million square metres of useable floor space. It includes a Mediterranean-style shopping village, an Olympicsized ice rink and an entire beach resort: artificial sun, artificial sea breeze, artificial waves.

In 2013, Fortune magazine held its invite-only Global Forum in Chengdu for presidents of the biggest companies in the world and the city announced that 45 countries, including Canada, could visit visafree for 72 hours, a policy that only Beijing, Shanghai and Guangzhou share. (In March of this year, China’s foreign minister announced that Canadians can now get a 10-year, multiple-entry visa for travel to the country for stays of up to 180 days.)

Chengdu is, however, more than just big business and money. It’s also the gateway to some jawdropping UNESCO sites and it has pandas — just 15 kilometres north of the city.

In the nine years between 1974 and 1983, about 250 giant pandas starved to death in the Minshan and Qionglai Mountains, north and south of Chengdu.

Close to 200 cubs have been born at the Chengdu Panda Base since 1987.

HUNG CHUNG CHIH / SHUTTERSTOCK.COM

I

wasn’t surprised when my bus made an impromptu stop at Chunxi Road. Before I left for Chengdu in Western China, I read on a local website that going to the capital of the Sichuan Province and not

The Chengdu Zoo was able to save 63 and many were released back into the wild. Six of the animals were kept and, in 1987, they were the beginning of the Chengdu Research Base of Giant Panda Breeding (1375 Xiongmao Avenue; panda.org.cn; admission $12).

Known as the Chengdu Panda Base, it’s grown into a 100-hectare park that’s home to nearly 100 giant pandas that have been artificially breed. Fact: pandas don’t like to have sex. Females are keen only about once a year. Even panda porn and Viagra haven’t helped. No wonder there are only 1864 of these largely solitary creatures in the world.

MAY 2015 • Doctor’s

Review

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SEAN PAVONE / SHUTTERSTOCK.COM

The Anshun Bridge in Chengdu features a restaurant that has great views of the city.

There are 3000 travertine ponds in Huanglong and each reflects the colours of its surroundings differently.

Dragonair (dragonair.com) flies from Hong Kong to Chengdu daily. China Eastern Airlines (en.ceair.com) flies from Chengdu to Jiuzhaigou daily during the May-to-October peak season.

In Chengdu, I stayed at the Wangjiang Hotel (42 Xiashahepu Street; wangjianghotel.com; doubles from $325 a night), which is surrounded by a mini oasis of trees and Thai-inspired pavilions. Its 450 rooms are comfortable, the styling traditional.

The Buddha Zen Hotel (B6-6 Wenshufang Street; buddhazenhotel.com; doubles from $115) is more moderately priced. Itâ&#x20AC;&#x2122;s popular with travellers so book months before your trip.

The Holiday Inn Express Chengdu Gulou (72 Daqiang Street West; ihg.com/holidayinnexpress; doubles from $90) is an affordable option that gets good reviews.

Consider the New Jiuzhai Hotel (Zhanglong Town; english.ctrip.com; doubles from $255 in the fall) when in Jiuzhaigou. Its 329 rooms were renovated in 2009. I found it clean and modern.

Plus, there was free Wi-Fi. For more info on Chengdu, check out the China National Tourist Board site (cnto.org); Go Chengdu (gochengdu.cn) is also helpful.

CHINA NATIONAL TOURIST OFFICE

ORIENTATION

The 28-year-old research and conservation facility is one of the largest giant panda breeding centres in the world. About 600,000 people visit every year, some tiptoeing through the park as I did, desperate to spot a bear among all the gingko, magnolia and willow trees, bamboo forests, and manmade dens and caves. My first sighting was of a smallish-sized bear lying spread-eagle on his back in the grass catching some Zs. He was so fluffy, I actually wondered if he was real. I saw dozens of bigger pandas after that, slumped over chomping on bamboo (they eat about 40 kilos a day), and newborn babies, six or seven of them huddled together in big wooden cribs behind glass. I saw red pandas too!

Go in August or September if you want to see babies; avoid days that are over 25°C when pandas retreat into their air-conditioned caves.

(Note: four pandas at the Shaanxi Rare Wildlife Rescue and Breeding Center in Xian died of canine distemper this past January and February. Visitors at the Chengdu Panda Base are no longer allowed to hold pandas for photo-ops as a precaution.)

T

here are more giant pandas and also golden snub-nosed monkeys in the Huanglong Scenic and Historic Interest Area (huanglong.com; adults $40 during high season, April to November), a UNESCO World Heritage Site since 1992.

The national park isn’t in Chengdu, it’s about 300 kilometres northwest of it, but Chengdu is ground zero for 50-minute flights and bus tours to the site.

About 10,000 people arrive at the park daily to see the 5588-metre snow-capped peaks and cascading mineral pools formed by calcite deposits.

The 3.6-metre-long Huanglong Valley and the golden limestone that stretches throughout give the park its name: Huanglong means “yellow dragon.”

The Five-Coloured Ponds near the dragon’s “head” form the biggest cluster of travertine terraces, close to 700, and they’re hugely popular with tourists.

Don’t be surprised if Chinese women push you out of their frame when trying to pose for photos. I saw the littlest of ladies turn Incredible Hulk strong when attempting to take a selfie.

The altitude of Huanglong ranges from 3200 to 3600 metres so the air is thinner. You can take a cable car through the park ($24 round-trip) or hike along the boardwalk as I did, moving slowly because of the elevation and crowds. The hike took three hours.

Interestingly, among the hundreds of Chinese, were Tibetans dressed in traditional robes. Huanglong is in Songpan County in the eastern foothills of the Qinghai-Tibet Plateau.

The neighbouring Jiuzhaigou Valley National Park (jiuzhai.com; adults $42 during high season) contains nine Tibetan villages, which give the park its name; Jiuzhaigou means “nine-village valley.” Still, its

LEE SNIDER PHOTO IMAGES / SHUTTERSTOCK.COM

Luodai is one of the most well-preserved Hakka towns in China.

ANCIENT HISTORY The ancient town of Luodai, 30 kilometres east of Chengdu, is one of the largest and well-preserved Hakka towns in Western China. Founded during the Three Kingdoms Period (220 to 280 CE) some 1700 years ago, just under 25,000 people live there, over 85 percent of whom are Hakka, originally from northern China. A branch of the Han from the Henan and Shanxi provinces, the Hakka moved South in a handful of migrations beginning in the fourth century to avoid famine and warfare. Hakka means “guest.”

Luodai means “fallen or lost belt.” Liu Chan, the second and last emperor of the state of Shu Han during the Three Kingdoms Period, is said to have dropped his jade belt down an octagonal well in what was once the town’s market. I didn’t see the well — or the belt — when I was there, but I did visit the town’s narrow main street lined with buildings featuring Ming (1368-1644) and Qing (1644-1911) Dynasty architecture. Some of the fanciful structures were engraved with flowers and birds, many more featured generous lattice-work. They housed tiny shops selling inexpensive trinkets: jewellery, scarves and leather goods. I came away with a beaded bracelet — or three. There were also a handful of restaurants offering Hakka cuisine, which centres around salting, drying and curing to preserve food.

Luodai also consists of guildhalls, ancient testaments to the Hakka diaspora. The big Guangdong Guildhall is the one many travellers recommend. It was built in 1747 and features a yellow-tiled roof with gorgeous wavy eaves, but I didn’t have time for a visit. My own afternoon as a guest of the “guests” was over and I had to move on.

turquoise-coloured lakes and waterfalls are its most famous features. Like Huanglong, Jiuzhaigou’s popularity is understandable given the Chinese affinity for natural beauty, and the country’s many crowded and often smoggy east coast cities. The parks will also be popular with you.

Fall is a good time to visit when rainfall fills the pools. I visited in September and it was cool so bring warm and waterproof gear.

MAY 2015 • Doctor’s

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35

Contraindications: • Patients with severe hypersensitivity to milk proteins.

Most Serious Warnings and Precautions: Precautions • ASTHMA-RELATED DEATH: Long-acting beta2-adrenergic agonists (LABA) increase the risk of asthma-related death. Data from a large, placebo-controlled US study that compared the safety of another long-acting beta2-adrenergic agonist (salmeterol) to placebo added to usual asthma therapy, showed an increase in asthma-related deaths in patients receiving salmeterol. This finding with salmeterol is considered a class effect of LABA, including vilanterol, the active ingredient in BREO® ELLIPTA®.

• BREO® ELLIPTA® is only indicated for COPD. • The safety and efficacy of BREO® ELLIPTA® in patients with asthma have not been established. BREO® ELLIPTA® is not indicated for the treatment of asthma.

Other Relevant Warnings and Precaution: Precaution • BREO® ELLIPTA® should not be used to treat acute symptoms of COPD (i.e., as rescue therapy for the treatment of acute episodes of bronchospasm) and should not be initiated in patients with acutely deteriorating COPD. • 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®.

• Exacerbations may occur during treatment. Patients should be advised to continue treatment and seek medical advice if COPD 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 12-fold higher systemic exposure than seen in patients with COPD) inhaled fluticasone furoate/vilanterol was associated with dosedependent increases in heart rate and QTcF prolongation. Use with caution in patients with severe cardiovascular disease, especially coronary insufficiency, cardiac arrhythmias, 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.

• Endocrine and Metabolic effects: possible systemic effects include Cushing’s syndrome; Cushingoid features; and HPA axis suppression.

• Hypercorticism and adrenal suppression (including adrenal crisis) may appear in a small number of patients who are sensitive to these effects. Doses of the rapid onset, short duration, beta2 adrenoceptor agonist salbutamol, when administered intravenously, have been reported to aggravate pre-existing diabetes mellitus and ketoacidosis.

• 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: An increase in the incidence of bone fracture has been observed in COPD patients. Decreases in BMD have been observed with long-term administration of products containing inhaled corticosteroids.

• 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. 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.

® BREO and ELLIPTA are registered trademarks, used under license by GlaxoSmithKline Inc. BREO® ELLIPTA® was developed in collaboration with Theravance, Inc. © 2014 GlaxoSmithKline Inc. All rights reserved.

• 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 hypersensitivity 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. An increase incidence of pneumonia, and pneumonias resulting in hospitalization, has been observed with inhaled fluticasone furoate/vilanterol in COPD patients. In some incidences these pneumonia events were fatal. Physicians should remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of such infections overlap with the symptoms of COPD exacerbations. COPD 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. Patients should not stop therapy without physician supervision since symptoms may recur after discontinuation.

• 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% 1% from two 6-month placebo-controlled clinical studies of BREO® ELLIPTA® 100/25 mcg included: nasopharyngitis (9%); upper respiratory tract infection (7%); oropharyngeal candidiasis (5%); sinusitis (2%); bronchitis (1%); pharyngitis (1%); headache (7%); back pain (2%); COPD (2%); cough (2%); nausea (1%); ventricular extrasystoles (1%); and pyrexia (1%).

Dosage and Method of Administration: Administration The recommended dose of BREO® ELLIPTA® 100/25 mcg is one oral inhalation once daily, administered at the same time every day (morning or evening). 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.

• No dosage adjustment is required in patients over 65 years of age, or in patients with renal or hepatic impairment.

For More Information: Please consult the Product Monograph at http://gsk.ca/breo/en for important information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece.

The Product Monograph is also available by calling 1-800-387-7374.

To report an adverse event, please call 1-800-387-7374.

ONC e ve r

E

24 h y

BREO ELLIPTA ®

®

The first and only once-daily ICS/LABA combination for COPD.* BREO® ELLIPTA® (fluticasone furoate/ vilanterol) is indicated for the long-term oncedaily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema, and to reduce exacerbations of COPD in patients with a history of exacerbations.

BREO® ELLIPTA® is not indicated for the relief of acute bronchospasm in COPD. BREO® ELLIPTA® is not indicated for the treatment of asthma. BREO® ELLIPTA® is not indicated for use in children and should not be used in patients <18 years of age. *Comparative clinical significance is unknown.

fluticasone furoate / vilanterol

Practical once-daily dosing.

00416 12/14

The Rock of eeing the far-flung corners of Newfoundland has long been on my bucket list — and I’m not alone. Bouncing through the choppy water in a rubber Zodiac, clinging to the yellow nylon rope that snaked behind us, were intrepid travellers from across North America. It was a small, but eclectic group, the kind of 50-somethings and fit retirees who wanted to do something adventurous, and learn something new, while on vacation.

The cruise around the rugged shores of Canada’s most easterly — and arguably most unique — province ticked those boxes and more. Adventure Canada has been taking tourists into the Arctic and other corners of our country only accessible by small ship for decades.

Our vessel, the Clipper Adventurer (recently renamed Sea Adventurer), was comfortable, but the focus wasn’t spa treatments and midnight buffets.

Our fun was found hiking rough shores and experiencing outport life, and the ship had all the necessary amenities for that: an ice-strengthened hull for northern exploration and 10 Zodiacs to take us beyond the usual cruise ship ports.

While I’ve seen bits of Newfoundland before, notably the areas within a day’s drive of St. John’s, this was my chance to get around this massive province

Fort Amherst, near St. John’s, consists of a lighthouse and the remains of gun emplacements built during WWII.

ages

Hop from ship to shore for Vikings and fishing villages on a 10-day cruise around Newfoundland text and photos by Cinda Chavich

MAY 2015 â&#x20AC;˘ Doctorâ&#x20AC;&#x2122;s

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Whalers from France and Spain arrived on the shores of Red Bay 450 years ago to hunt the animals for their oil.

The 29-suite Fogo Island Inn was designed by Newfoundland-born and Norway-based architect Todd Saunders.

Lâ&#x20AC;&#x2122;Anse aux Meadows is the site of the excavated remains of an 11th-century Norse settlement.

Driver Aaju Peter (centre) is an Inuit activist and Order of Canada recipient; Michael Crummey (front right) is an award-winning author.

They call this “learning adventure travel,” but the company’s owner likened it to “floating summer camp” on one trip, to explore Gros Morne National Park, the first Viking settlements at L’Anse aux Meadows, and the early Basque whaling sites of eastern Labrador.

I set sail with 100 others, a third of them “staff” and many exceptional islanders like author Michael Crummey, actor and musician Daniel Payne, and archeologist/filmmaker Latonia Hartery. They regaled us with Newfoundland stories, songs and insights that helped bring our daily discoveries into focus.

Our 10-day adventure brought us to a new port every day. Officially, they call this “learning adventure travel,” but Matthew Swan, the company’s owner and master of goofy diversions, rightly likened it to “floating summer camp.” Our route ‘round The Rock may have been tame compared with some of their other Arctic adventures, but it was an unforgettable journey.

“I

n and out the Zodiac” was the game we played several times each day, bundled in outdoor gear, rubber boots and life vests.

Flying across the waves was great fun, like a crazy, bouncy carnival ride and sea salt exfoliation in one. Zodiacs were our lifeline from ship to shore and the reason we saw so much.

They zipped us across the open sea to wild beaches, up into narrow fjords, to archeological sites and lighthouses, then off to outport parties where locals played infectious reels and taught us to circle (square) dance, while our ship shimmered in the cove beneath a full moon.

The PA system woke us in our cabin every day, with local “culturalist” and outport mayor Tony Oxford strumming a daily ditty.

On one of our first mornings, the sun had broken over Fogo Island, but there was a gusty wind. Nevertheless, we scurried ashore to explore Fogo’s wonders.

Fogo Island is great for intrepid travellers with a bent for art and architecture. We hiked out to the Long Studio, one of the stunning retreats recently constructed by the local Shorefast Foundation to lure artists from around the world. The colourful cabins are contemporary renderings of the old salt cod-drying flakes and fishing “stages.” They’re scattered along the rocky shore in picturesque villages like Little Seldom, Joe Batt’s Arm and Tilting. In the latter, the local ladies had been cooking in the Parish Hall for hours before our arrival and we feasted on fried fish, partridge berry scones and molasses cake.

In the 1960s, filmmakers helped link the scattered populace by sharing their stories, a system that nurtured cooperative ideals that saved these secluded communities. Now millionaire entrepreneur and Fogo-ite Zita Cobb is hoping to make life on Fogo viable again with her artist-in-residence initiative and an upscale inn decked out in rugs and quilts stitched by local women, and furniture crafted by island boat builders. It’s all designed to attract the modern “geo-tourist” seeking undiscovered destinations, while preserving the outport life.

“It is a place to embrace and to be lived in for what it is,” said our guide, “an island halfway between the old world and the new.”

T

he next day, the water witch brought the nasty weather, our ship barely visible offshore in the driving rain as we motored to L’Anse aux Meadows. No doubt, the Vikings who settled here a 1000 years ago had days like this.

“My son, let me tell you something,” quipped Oxford as he commandeered our Zodiac. “I’ve wiped more saltwater out of my eyes than you’ve sailed over.”

We trudged the wet, grassy slopes to see the snorri (Viking ship) and three Norse-style sod buildings reconstructed next to the mounds where their longhouses, iron forge and workshops once stood. Discovered in 1960, L’Anse aux Meadows is the earliest confirmed Viking settlement in North America and a UNESCO World Heritage Site, proof that Norsemen arrived here 500 years before Columbus, completing the circle of human migration around the planet. Eventually they gave up on the place, perhaps too isolated and harsh for even a marauding Vikinger.

The storm kicked up and the ship moved forward, but also up, down and sideways as we crossed the Strait of Belle Isle to Labrador. I was getting queasy so I sipped lemon-ginger tea in the lounge, while expert Holly Hogan explained how the oxygen-rich Labrador Current affects marine life.

Chunks of floating ice in Iceberg Alley follow the current in May and June, as do the fish and whales that lured Basques from France and Spain to Red Bay in the early 1500s. Later, we hiked the trails where they rendered oil from the Bow Head whales they hunted, some 25,000 in 70 summers between 1530 and 1600.

MAY 2015 • Doctor’s

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Tilting on Fogo Island still consists of many fishing stages (shacks) on stilts next to clapboard homes.

The locals celebrate everything from blueberries to the arrival of big cruise ships with music.

T

here are no roads into many of these places — communities are linked by sporadic ferry service — so when a ship like ours arrives, with a hundred new faces on board, it’s a reason to gather local musicians and celebrate. I “put me hard shoes on for a scuff,” hopped a Zodiac and headed to the nearest hall.

These tiny towns are caches of island culture.

When musician Daniel Payne took to the stage, he recalled his great grandfather lending him his fiddle, so well-used there are grooves worn into the finger board. In Newfoundland, music goes “deeper than entertainment,” he explained. It draws people together and records the old stories in small communities.

Payne remembered Johnnie Formanger — “I had my 30th birthday the same year he had his 80th” — and 93-year-old Becky Bennett who “sang for five hours, four hours from memory, then one from the exercise book.”

“The music passed through these people,” he said. “It’s what makes our story, the different people who got together and carved out a life here.”

Every family has an outport story. Michael Crummey read Fishing on the Labrador one afternoon when we were out at sea. He told us about the 10,000 men and boys, including his grandfather, who sailed down the Labrador coast each summer, sent to the whaling stations to work, hacking away

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Doctor’s Review • MAY 2015

Under the 1992 moratorium, Newfoundland’s inshore fishermen are allowed an annual take of 3600 pounds of cod.

the blubber from the thick skin “as if pulling an old carpet from a hallway.” He painted a grim picture of boys ripped away from their families to earn money and men lost at sea, never to return home.

Loss was in the air when we motored into Brake’s Cove, an outport that was abandoned as part of former premier Joey Smallwood’s plan to amalgamate the far-flung population. There were 900 villages in the province in 1949, but the government decreed they would be consolidated into 300 “growth centres.”

I was sitting beside Joan Oxford, Tony’s wife, as our Zodiac headed into the sheltered bay. Joan’s grandparents lived there until 1968.

Brake’s Cove is now a pretty collection of summer cottages, but Joan still remembers the wrenching experience of leaving it. Returning that day opened an old wound.

“There’s so much emotion around it, I still can’t talk about it,” she said. Her grandmother’s house was floated out into the bay to be relocated further down the coast in Cox’s Cove. I walked up to the graveyard with her uncle Joe, who was more pragmatic about the move.

“We didn’t want to move — it seems crazy and it was, m’dear,” he said, as we stood next to a grove of stubby blue spruce, looking out across the glittering sea. “My great-grandfather Brake’s still here, all sodded over.”

Brake’s Cove was abandoned in 1949 when the government consolidated the province’s 900 villages into 300.

N

ewfoundland is a vast place — more than 110,000 square kilometres of rock and fjords, jutting further out into the wild Atlantic than any other corner of North America. It’s a world unto itself. To see all of its unique corners on one 10-day odyssey is miraculous.

When we finally disembarked in St. John’s, “swarving” around the steep streets on our sea legs, it seemed like we’d been away for a month, visiting a foreign land. I felt a little like an early explorer who’d discovered a part of Canada that few will ever have a chance to see.

We learned how to dress like a mummer and what sometimes seemed like a whole new language.

We feasted on partridge berries, tapped our toes to small-town fiddlers and walked in the footsteps of Vikings. We found rare birds, both feathered and not. We heard firsthand about the collapse of the cod fishery and marvelled at stoic Newfoundlanders who can still face hardships with good humour, grace and generosity.

Author Crummey offered an elegant summation: “Life is all about magic and loss and wonder and ruin.”

I saw it all on this adventure ‘round The Rock.

MORE ONLINE

The Clipper Adventurer was equipped with 10 Zodiacs to take passengers beyond regular cruise ship ports.

WE ALL SET SAIL Adventure Canada (tel: 800-363-7566; adventurecanada. com) has three Newfoundland cruises scheduled for the end of June. Prices range from US$1195 per person for a three-night sailing to US$3595 for a 10-night sailing, based on double occupancy. The Newfoundland Circumnavigation 2015 tour, June 24 to July 4, departs from St. John’s and includes all shipboard meals, Zodiac excursions, and entry and park fees.

A (fish) cake walk through Newfoundland. doctorsreview.com/features/cake-walk-newfoundland-cod MAY 2015 • Doctor’s

Review

43

Introducing

Introducing Nesina ; a new DPP-4 inhibitor for patients with type 2 diabetes. ®

Reimbursed by RAMQ as a medicament d’exception (prescribing codes available) Single entity DPP-4 inhibitors RAMQ reimbursement comparison*

Nesina

$2.10 UNIT PRICE

Treatment of type 2 diabetic patients:

Januvia

® †

REIMBURSED / CODE

$2.62 UNIT PRICE REIMBURSED / CODE

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

EN167

N/A

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

EN148

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

EN149

N/A

Onglyza

® †

Trajenta

®

$2.30 UNIT PRICE

†

REIMBURSED / CODE

N/A

®

$2.25 UNIT PRICE

†

REIMBURSED / CODE

N/A

N/A

N/A

EN148

N/A

N/A

EN149

N/A

N/A

* Comparative clinical significance has not been established. As per RAMQ List of Medications (Updated December 11, 2014). † Actual acquisition cost; prices do not include mark-up or dispensing fees.

N/A = Not Applicable.

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

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

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

Nesi ® na 2

5 Once mg Dail y

REFERENCE: 1. Nesina Product Monograph, Takeda Canada Inc. ®

© 2015 Takeda Canada Inc. All rights reserved. Nesina is a registered trademark of Takeda Pharmaceutical Company Limited and used under license by Takeda Canada Inc. JANUVIA Registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Used under license. ONGLYZA Registered trademark of AstraZeneca AB, used under license by AstraZeneca Canada Inc. TRAJENTA Registered trademark used under license by Boehringer Ingelheim (Canada) Ltd. ®

®

®

®

NES-2015-5E

Going coastal Going coa on Vancouver Island Seafood, microbrews and views along BC’s Pacific Marine Circle Route text and photos by Margo Pfeiff

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Doctor’s Review • MAY 2015

There are suites and yurts at the Soule Creek Lodge, which is perched high on the San Juan Ridge in Port Renfrew.

astal

Seafood, microbrews and views along Vancouver Island’s Pacific Marine Circle text and photos by Margo Pfeiff

rekking through a Tolkienesque rainforest of hanging vines and twisted tree trunks, I startle a bald eagle from its perch in a moss-draped hemlock. Moments later I freeze in mid-step, arms in mid-swing — a panic pose in response to spotting a bear crossing the trail in front of me. But the bruin has other priorities and when I cautiously reach the beach he is ambling away, noshing shoreline munchies delivered by last night’s high tide.

British Columbia is known for its easy access from cities to wilderness and Juan de Fuca Provincial Park alongside the far-flung outpost of Port Renfrew on Vancouver Island’s west coast is just that, a leisurely

two-hour drive from the tea shops and horse-drawn carriages of Victoria.

Until recently, Port Renfrew, lounging at the dead end of paved Highway #14, was off the map for anyone but avid fishermen and hikers heading for the starting point of the epic former shipwrecksurvivor rescue route, the 75-kilometre West Coast Trail. Then the BC government bought the rights to the notoriously rough logging road connecting Port

Fog pours across the road like heavy cream and we hike through a rainforest to the distant sounds of gentle surf Renfrew with Lake Cowichan. In 2009 that stretch was paved, completing the 290-kilometre Pacific Marine Circle Route around the southern tip of Vancouver Island.

Growing up in BC, Vancouver Island’s west coast always had a super-sized mystique as a remote and lush paradise of hefty salmon and halibut, broad beaches, secret coves offering surfers giant waves, and very, very tall trees. These days, once-secluded Tofino has become not only accessible, but a trendy foodie/spa destination and Port Renfrew is on its way to becoming the West Coast’s new kid on the block, though it’s still a sleepy village of 200 blinking wide-eyed at a new kind of wave — waves of visitors rolling in.

T

hey built the road and I have come. I love driving in circles especially when the circular road trip includes Britishflavoured culture, deserted beaches, bears, brews and gourmet retreats in the least expected locales.

I ferry across from Vancouver to Victoria with my cooler-carting, road-trip sage of a sister, Linda.

Since this is a coastal drive and we like our adventures to have themes, we decide to focus on seafood, local microbrews and nautical tunes.

For lunch we sit outside on Victoria’s harbourfront with gourmet fish tacos from the Red Fish, Blue Fish kiosk, then fill our cooler with Spinnaker, Canoe and Hoyne’s ales, lagers and porters, and bounce out of Victoria with Great Big Sea’s Newfoundland sea shanties blaring.

After a short stop to shoot pool at 17 Mile House, we head down the road to Sooke Potholes Provincial Park where a short hike leads into the wilderness and an idyllic swimming hole. Forgoing the artsy town’s small galleries, we head instead to Sooke Harbour House overlooking Whiffen Spit, an iconic seaside B&B and art gallery, and prowl their maze of hallways and stairways adorned with the best of local and aboriginal art.

Civilization drops away abruptly outside Sooke, replaced by the first of a string of beaches. We pass Point No Point Resort, a cluster of restored 1950s waterfront cabins where I once spent a winter stormwatching weekend, dining on creative local seafood in the high perch of their fine-dining restaurant as we were slammed by a dramatic gale. But on this calm day, fog pours across the road like heavy cream

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Doctor’s Review • MAY 2015

as we pull into the Sandcut Beach parking lot and hike towards the sea through a lush green tangle of rainforest to the distant sounds of fog horns and gentle surf.

Along the winding seaside route, we pick up fresh Dungeness crab, smoked salmon and oysters from roadside crab shacks. By the time we reach sandy China Beach, we have assembled the perfect picnic lunch and found the perfect place to eat it.

Sunshine has burned off the fog and revealed the distant jagged peaks of the Olympic Peninsula across the strait in Washington State.

China Beach is the start of the 48-kilometre seaside Juan de Fuca Marine Trail that skirts remote Mystic and Sombrio Beaches — surfers’ paradises where squatters once lived and rode waves until the land became part of the provincial park — part of a government plan to stitch together small parks and so stretch coastal Juan de Fuca Provincial Park all the way to Port Renfrew.

P

ort Renfrew is still a mellow mossy former logging outpost with an end-of-the-road feel. In late afternoon sun, we hike through a dripping forest towards Botanical Beach, the westernmost tip of the park, and hear a goose bump-raising rodent screech instantly drowned out by a feline snarl.

“Cougar, I think,” says a passing ranger after a moment’s consideration before heading off to restock the toilets.

The tidal pools along the beach are so rich with life that the University of Minnesota set up a marine study station here over 100 years ago in 1900. With one eye on a bear making its way down the beach, we count off Gooseneck barnacles, sea stars, chitons and anemones.

All that seafood makes us hungry so we turn towards our yurt for the night at Soule Creek Lodge perched up a steep mile-long gravel road on a ridge top with a panoramic 360-degree view.

Our trip’s biggest surprise arrives in the form of a remarkable three-course gourmet meal put together from local seafood and the lodge’s own garden. The place is run by a couple of colourful brothers who cut their rustic hospitality teeth in the wilds of an Alaskan camp.

“One of us would grill salmon on the barbecue,” says Jon Cash, “while the other kept bears at bay with a stick and pepper spray!”

There’s so much wildlife at the Botanical Beach that the University of Minnesota opened a marine station there in 1900.

The Sooke Harbour House has “foul-weather” gear for when conditions on the West Coast get wild.

The San Juan spruce is the largest spruce tree in Canada and the second largest in the world.

All of the 25 cabins at the Point No Point Resort have kitchens, fireplaces and oceans views.

The food is always local and organic at the Sooke Harbour House, and includes plenty of seafood. RIGHT: The Coastal Kitchen Café is open seasonally from May to September.

EAT, SLEEP, HIKE WELL You don’t want to miss Sooke Harbour House (1528 Whiffen Spit Road, Sooke; tel: 250-642-3421; sookeharbourhouse.com; doubles with breakfast from $230), the iconic and near mythic luxury waterfront B&B. It pioneered hyper-local dining and has become a foodie Mecca in the vein of Alice Waters’ Chez Panisse.

For a pleasantly retro stay, choose Point No Point Resort (10829 West Coast Road, Shirley; tel: 250646-2020; pointnopointresort.com; doubles from $140). The nicely restored 1950s era waterfront cottages are sure to please as is the dining room.

Sleep in yurt with a view at Soule Creek Lodge (6215 Powder Main Road, Port Renfrew; tel: 866277-6853 or 250-647-0009; soulecreeklodge.com; doubles from $145 in summer including full breakfast). And don’t forget the local gourmet dinner for $35 per person in the native-themed dining room: bring your own wine.

Drop into the Coastal Kitchen Café (17245 Parkinson Road, Port Renfrew; tel: 250-647-5545; facebook.com/pages/Coastal-Kitchen-Cafe/ 159495954099404) for casual, seafood-oriented comfort food in a popular-with-locals café.

The Juan de Fuca Trail (juandefucamarinetrail. com) winds along 48 kilometres of Tseaside wilderness trail on the southern coast of the island. Sections can be hiked between access beaches.

The few first growth forests that have been spared are a wonder to see and Avatar Grove (ancientforest guide.com) near Port Renfrew is a must.

For more info on the Pacific Marine Circle Route, go to the Hello BC website (hellobc.com/drivingroutes/19/pacific-marine-circle-route.aspx).

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Doctor’s Review • MAY 2015

A

fter a lazy morning of beachcombing, we dive into a bucket of fresh clams and fish and chips at the casual Country Kitchen Café before launching into our tall trees exploration. We start at Avatar Grove, a pocket of monster old-growth red cedars and Douglas firs discovered in 2010. The publicity of naming it after the lush landscape of Pandora in James Cameron’s movie, Avatar, seems to have worked: a steady stream of cars and even buses ply the eight-kilometre gravel road from town.

The trail is rough, but not difficult, through trees that were already 250 years old when Captain James Cook sailed past here in 1778. The highlight is dubbed “Canada’s Gnarliest Tree,” a dramatic red cedar 3.5 metres in diameter deformed with huge burls.

Other giants tower alongside the 60-kilometre former logging road to Cowichan Lake though reaching the biggest of them requires a 4WD. Cowichan Lake is a popular island vacation spot and the nearby town of Duncan is known for its 80 totem poles and a Saturday morning farmer’s market that showcases the produce, cheeses and wines from the adjoining Provence-like Cowichan Valley farmlands.

We take a short hike to stroll across the Kinsol Trestle, which, at 44 metres high, is one of the biggest wooden railway trestles in the world. Then we’re on the island’s east coast at the seaside village of Cowichan Bay. Surprisingly perhaps, in 2009 it was the first town to join in North America to become part of the “Cittaslow” slow food movement started in Italy a decade earlier. The spot still runs at a leisurely pace. This inspires us to settle into the local gastropub for fresh seared oysters and Philips Blue Buck Amber Ale. A short drive south, we hop a 20-minute ferry ride at Mill Bay across to Brentwood, a scenic shortcut back to Victoria via the Saanich Peninsula, a rural detour that takes us past the Sea Cider Farm and Cider House. Looking out across orchards and ocean, it’s the perfect place for one last sip before closing our circle route in downtown Victoria.

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

TURN TO

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

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

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

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

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

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

Safety and efficacy in pediatric populations have not been established.

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

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

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

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

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

Grilled prawns with garlic-fennel dip.

Beyond butter chicken Healthy Indian recipes from a bestselling-cookbook writer who lives in Vancouver by

Bal Arneson

photos by

W

Tracey Kusiewicz

hen Bal Arneson found out that many of her North American friends considered Indian food creamy, fattening and demanding to prepare, requiring a

long list of spices and lots of time to cook, she wrote Everyday Indian. It was her first cookbook and it focused on the food she grew up with in her tiny village in Punjab, India: fruits, veggies, legumes, and herbs and spices from her family garden — cream and butter were luxuries and used only on special occasions.

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Doctor’s Review • MAY 2015

Ayurvedic practitioners said that her recipes reflected their ancient principles for disease prevention and rejuvenation, and the book became a Canadian bestseller. The Vancouverite’s second cookbook, Bal’s Quick and Healthy Indian (Whitecap Books) is devoted to easy recipes and more wholesome ingredients.

GRILLED PRAWNS WITH GARLICFENNEL DIP It always feels good to serve something not only delicious, but healthy too. Garlic and fennel go very well together. Garlic contains allicin, which is known to have antibacterial, antiviral, antifungal and antioxidant properties.

For the dip 1 tbsp. (15 ml) grapeseed oil 10 garlic cloves, unpeeled ¼ c. (60 ml) sour cream 2 tbsp. (30 ml) flaxseed oil 1 tsp. (5 ml) ground fennel pinch salt pinch Spanish paprika For the prawns ¼ c. (60 ml) plain low-fat yogurt 1 tbsp. (15 ml) garam masala 1 tsp. (5 ml) fennel seeds, ground or kept whole 1 tsp. (5 ml) ground cardamom 1 tsp. (5 ml) Spanish paprika salt to taste 18 large raw prawns, heads removed, shelled and deveined 18 metal or wooden skewers 6 lime wedges

Serve with lime wedges and the garlic-fennel dip. Serves 4.

Suggested wine: 2006 Syrah by Nichol Vineyard. This wine has aromas of cherry and plum, and hints of roasted meat, with flavours of bright cherry and black pepper. Its velvety-soft finish pairs well with the fennel, cardamom and Spanish paprika in this recipe.

CAULIFLOWER AND CHICKPEA SOUP What’s great here is the combination of textures, particularly the puréed cauliflower with the whole chickpeas. The fenugreek and coriander add flavour.

You can prepare this soup for lunches.

For the cauliflower 5 c. (1.25 L) chopped cauliflower 3 c. (750 ml) water salt and pepper to taste For the chickpeas 1 tbsp. (15 ml) grapeseed oil 1 tbsp. (15 ml) finely chopped garlic

1 tsp. (5 ml) fenugreek seeds 1 tbsp. (15 ml) coriander seeds, crushed 1 tbsp. (15 ml) garam masala (recipe follows) ½ tsp. (2.5 ml) red chili pepper flakes salt to taste 14 oz. (398 ml) can chickpeas, drained and rinsed fresh mint leaves for garnish

Combine the cauliflower, water, salt and pepper in a large saucepan. Bring to a boil, then cover, reduce the heat and simmer until the cauliflower is tender, about 5 to 7 minutes. Let the mixture cool. Transfer the cauliflower and cooking liquid to a food processor and purée completely.

To prepare the chickpeas, heat the oil in a skillet over medium-high heat.

When the oil is hot, add the garlic, fenugreek seeds, coriander seeds, garam masala, chili pepper flakes and salt, and cook for 15 seconds. Add the chickpeas and cook for 1 minute.

To serve, ladle 1 cup (250 ml) of the puréed cauliflower into each soup bowl and top with 2 tbsp. (30 ml) of the chickpea mixture. Garnish each serving with mint leaves. Serves 4.

To make the dip, heat the oil in a skillet over medium-low heat. Add the garlic cloves and cook for 5 minutes, stirring regularly. Remove from the heat.

When the garlic is cool, remove the skins and mash the flesh with a fork.

In a medium bowl, combine the mashed garlic, sour cream, oil, ground fennel, salt and paprika. Whisk the mixture until it is thoroughly combined.

Refrigerate.

To make the prawns, combine the yogurt, garam masala, fennel seeds, cardamom, paprika and salt in a large bowl, and mix well. Add the prawns and stir to coat them with the mixture.

Cover and refrigerate for 20 minutes.

Preheat the barbecue to medium heat.

(If using wooden skewers, soak them in water for 30 minutes before using.)

Thread one prawn onto each skewer. Gently place the skewers on the preheated grill, turning frequently until the prawns are cooked, about 3 minutes.

Cauliflower and chickpea soup.

Suggested wine: 2008 Pinot Gris by Poplar Grove. The rich, luscious and mouth-filling pear, lemon and tropical fruit flavours complement the fenugreek, coriander and garam masala in the recipe.

Garam masala In India, there are many variations on garam masala. You can buy premade garam masala, but it’s so simple to make your own. ½ c. (125 ml) coriander seeds ½ c. (125 ml) cumin seeds ¼ c. (60 ml) black peppercorns ¼ c. (60 ml) curry leaves 3 whole cloves 2 black cardamom pods (kept whole) 2 cinnamon sticks, each 3 inches (8 cm) long 2 bay leaves

Preheat the oven to 325°F (160°C).

Combine all the ingredients in a bowl and mix well. Spread the mixture on a rimmed baking sheet and toast in the oven for 15 minutes. Allow to cool and remove the seeds from the cardamom pod, discarding the husk. Process the spice mixture to a fine powder in a grinder.

Store the masala in an airtight container in a cool place. It will keep well for three months. Makes about 1 cup (250 ml).

SPICED LAMB WITH MANGO SAUCE In this dish, cardamom, fenugreek and garam masala balance out the sweetness of the mango. You can also use raw sugar, but when mangoes are in Spiced lamb with mango sauce.

season, use them instead. This recipe also includes mango juice. Mangoes are a rich source of vitamin A and antioxidants.

3 1 1 1 1

tbsp. (45 ml) grapeseed oil medium onion, finely chopped tbsp. (15 ml) finely chopped garlic tbsp. (15 ml) finely chopped ginger tbsp. (15 ml) garam masala (recipe above) 1 tbsp. (15 ml) cumin seeds 1 tbsp. (15 ml) coriander seeds, crushed 1 tsp. (5 ml) ground turmeric salt to taste 2 tbsp. (30 ml) tomato paste 1 lb. (500 g) stewing lamb, cut into pieces 14 oz. (398 ml) can crushed tomatoes 1 c. (250 ml) mango juice 1 c. (250 ml) vegetable broth 2 medium green chilies, finely chopped 1 large ripe mango, peeled, pitted and cut into bite-sized pieces

Heat the oil in a deep skillet over medium-high heat. When the oil is hot, add the onion, garlic and ginger, and cook, stirring regularly, until the onion starts to soften and turn brown, about 4 minutes. Add the garam masala, cumin seeds, coriander seeds, turmeric and salt, and cook for 30 seconds. Add the tomato paste and cook for another 30 seconds. Add the lamb, then brown for 3 to 5 minutes, stirring occasionally.

Stir in the crushed tomatoes, mango juice, vegetable broth and green chilies, and bring the mixture to a boil. Turn the heat to low, cover the skillet and simmer, stirring regularly, until the lamb is soft, 45 minutes to 1 hour.

Add the mango pieces to the skillet, then turn the heat off. Cover the skillet and let it sit for 10 minutes before serving.

Serve with rice. Serves 4.

Suggested wine: 2008 Pink Elephant

by Elephant Island Orchard Wines. The currant and green apple aromatics of this wine play off the flavours of the cumin, coriander and mango juice. A great wine choice and a great pairing!

Recipes and photos from Bal’s Quick and Healthy Indian (Whitecap Books).

Indications and clinical use: BEXSERO ® is indicated for active immunization of individuals from 2 months through 17 years old against invasive disease caused by N. meningitidis serogroup B strains.

As the expression of antigens included in the vaccine is epidemiologically variable in circulating group B strains, meningococci that express them at sufficient levels are predicted to be susceptible to killing by vaccine-elicited antibodies.

Contraindications: • Hypersensitivity to the BEXSERO ® vaccine or to any ingredient in the formulation or components of the container closure.

Relevant warnings and precautions: • Temperature elevation following vaccination of infants and children (less than 2 years of age) • Administration of BEXSERO® should be postponed in subjects suffering from an acute severe febrile illness • Individuals with thrombocytopenia, hemophilia or any coagulation disorder that would contraindicate intramuscular injection • Subjects with impaired immune responsiveness • Do not inject intravascularly, intravenously, subcutaneously or intradermally

• Do not mix with other vaccines in the same syringe • Availability of appropriate medical treatment and supervision in case of an anaphylactic event following administration of the vaccine • Risk of apnoea in premature infants; need for 48-72 hours respiratory monitoring • Caution in subjects with known history of hypersensitivity to latex • Hypersensitivity to kanamycin • Protection against invasive meningococcal disease caused by serogroups other than serogroup B should not be assumed • As with any vaccine, BEXSERO® may not fully protect all of those who are vaccinated For more information: Please consult the Product Monograph at www.novar tis.ca / BexseroMonograph 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 Medical Information at 1-800-363-8883.

BEXSERO is a registered trademark.

Product Monograph available on request.

Printed in Canada ©Novartis Pharmaceuticals Canada Inc. 2014 13BEX017E Novartis Pharmaceuticals Canada Inc. Dorval, Québec H9S 1A9 www.novartis.ca T: 514.631.6775 F: 514.631.1867

Be informed. Be immunized.

BEX_7386_PI_DoctorsReview E01.indd 1

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advertisers index ACTAVIS SPECIALTY PHARMACEUTICALS Constella.....................................................................................30 AMERICAN SEMINAR INSTITUTE Corporate....................................................................................21 ASTRAZENECA CANADA INC. Forxiga.........................................................................IFC spread Komboglyze.................................................................................4 Symbicort.....................................................................................6 BOEHRINGER INGELHEIM (CANADA) LTD Spiriva Respimat.................................................................... OBC CANADIAN MEDICAL ASSOCIATION Corporate....................................................................................18 ELI LILLY CANADA INC. Corporate......................................................................................8 GLAXOSMITHKLINE BREO Ellipta........................................................................36, 37 LEO PHARMA INC. CANADA Dovobet Gel............................................................................IBC LUNDBECK CANADA Trintellix.......................................................................................2

NOVARTIS PHARMACEUTICALS CANADA INC. Bexsero.......................................................................................10 COPD Portfolio........................................................... Front cover PFIZER CANADA Effexor..................................................................................28, 29 Pristiq.........................................................................................25 Toviaz.........................................................................................51 SEA COURSES INC. Corporate....................................................................................15 TAKEDA CANADA INC. Nesina (Quebec only)............................................................44, 45 Omnaris......................................................................................16 WORKERS’ COMPENSATION BOARD Corporate....................................................................................23

FAIR BALANCE INFORMATION Bexsero.................................................................................... 55 Komboglyze............................................................................ 56 Symbicort.................................................................................. 7 MAY 2015 • Doctor’s

Review

55

P H OT O FI NI SH by

Dr L our e n e R ood e

With age, beauty ONGLYZA Contraindications:  Diabetic ketoacidosis  Diabetic coma/precoma  Type 1 diabetes mellitus Relevant warnings and precautions:  Not recommended for patients with congestive heart failure  Exposure to stress (e.g. surgery)  Interactions with potent CYP 3A4 inducers  Contains lactose  Risk of hypersensitivity  Discontinue if pancreatitis is suspected  Immunocompromised patients (consider monitoring lymphocyte count)  Rash (monitoring recommended)  Not recommended for pregnancy, should not be used by nursing women  Not recommended for patients with moderate to severe hepatic impairment (not recommended for patients with ESRD requiring hemodialysis)  Monitor renal function For more information: Please consult the product monograph at www.azinfo.ca/onglyza/pm664 for more information relating to adverse reactions, drug interactions, and dosing information not discussed in this piece.

The product monograph is also available by calling us at 1-800-668-6000.

After seeing this slot canyon in a winning photograph at the Calgary Stampede, I knew that I had to see it for myself. It’s called the Antelope Canyon and it’s located just south of the city of Page, close to the Utah-Arizona border on Navajo land.

The canyon is literally a slot formed by sandstone over the years. The amazing wave formations are in the most gorgeous orange, yellow and brown colour spectrum, and sunlight streams in from the sky, about 35 metres above.

What makes it even more amazing is taking pictures without a flash during what feels like dusk. The true colours that show up on the instant image of your digital SLR are utterly amazing.

I felt like I had died and gone to heaven during the brief hour we spent in this magnificent canyon! The waves were like a symphony in stone. It’s a must on any photographer’s bucket list.

The other canyon on my list was the Grand Canyon. You can’t go through this lifetime without seeing it. Was it ever grand.

MDs, submit a photo!

Please send photos along with a 150- to 300-word article to:

* Randomized, double-blind, placebo-controlled study of 24 weeks’ duration in patients with inadequate glycemic control (HbA1c ≥7.0% and ≤10.0%) on metformin alone. Saxagliptin baseline HbA1c 8.1% (n=186), FPG 9.9 mmol/L (n=187), PPG 16.4 mmol/L (n=155). Placebo baseline HbA1c 8.1% (n=175), FPG 9.7 mmol/L (n=176), PPG 16.4 mmol/L (n=135). Patients were required to be on a stable dose of metformin (1500 mg to 2550 mg daily) for at least 8 weeks to be enrolled in the trial. Patients who completed all visits during the initial 24-week study period without need for hyperglycemia rescue therapy were eligible to enter a controlled, double-blind, long-term study extension. Patients who received saxagliptin in the initial 24-week study period maintained the same dose in the long-term extension.

References: 1. Onglyza® Product Monograph.

AstraZeneca Canada Inc., June 30, 2014.

2. Komboglyze® Product Monograph. AstraZeneca Canada Inc., June 30, 2014.

Onglyza®, Komboglyze® and the AstraZeneca logo are registered trademarks of AstraZeneca AB, used under license by AstraZeneca Canada Inc. © 2014 AstraZeneca Canada Inc.

09/15

Doctor’s Review, Photo Finish, 400 McGill Street, 4th Floor, Montreal, QC H2Y 2G1.

editors@doctorsreview.com

56

Doctor’s Review • MAY 2015

AstraZeneca Canada Inc. Mississauga, Ontario L4Y 1M4

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

A Corticosteroid plus Vitamin D Analogue in one formulation.

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

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

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

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

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

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

For More Information Please consult the product monograph at www.leopharma.ca/dovobetgel_pm for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece.

The product monograph is also available by contacting LEO Pharma Medical Information at 1-800-263-4218.

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

www.leo-pharma.ca

DOV-007-15E

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

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

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

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

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

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

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

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

NEW

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

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