May 2016 by Doctor's Review

MEDICINE ON THE MOVE

MAY 2016

low fare tips

CRUISE into

SUMMER

BC houseboating PEC partying Dalmatia coasting Peruvian delicacies

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

PLUS:

Korean kimchi

WIN

THIS MONTH’S

GADGET PAGE 15

Glucosamine update Guide to youth depression

heartburn

Because doesn’t give a hoot what time it is

DEXILANT : Demonstrated 24-hour heartburn relief ®

96% of 24-hour periods were heartburn-free

99% of nights were heartburn-free

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

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

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

‡§

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

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

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

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

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

Houseboating ain’t what it used to be. If you doubt it, have a gander at Home sweet houseboat, page 42. The craft that writer Margo Pfeiff boarded for a four-day sail around BC’s Okanagan Shuswap Lake was more like a luxury multi-level condo than the tin can I piloted through Ontario’s Thousand Islands with my parents-in-law 20 years ago. It was a wonderful bonding family trip. In those pre-Internet days, we swam and fished and read and, after dinner, played board games and went to bed an hour after sunset. That was then and this is now. Named Where’s my cheque?, the behemoth in which Ms. Pfeiff plied the BC waters is three-storeys high, sleeps 16, has a fully-equipped kitchen, a fireplace, a hot tub and a twisting waterslide from the top deck. Of an evening you can entertain yourself by watching TV or listening to the satellite radio. That said, the one thing any houseboat trip shares, regardless of how down-market or luxe, is freedom. Leaving the dock with a fully-stocked larder means you are entirely independent for as long as the food holds out. Relax and let the world go by, nobody can get you. It’s a wonderful feeling. This issue has something along the same lines for land Confit of guinea pig served with yucca lubbers in the east. A visit to Prince Edward County, a short cream and sprouts at Maido in Lima. ferry ride from Kingston, ON, page 36, offers many on-shore delights not unlike those in the Okanagan. Enchanting scenery, wineries, gourmet eateries, beaches and, in June, the great Canadian Cheese Festival. It’s hard not to have a good time in PEC and Lin Stranberg tells you how to make the most of it. Speaking of food, you’ll want to read Lima’s food revolution, page 50, but only do so on a full stomach or you’ll find the goodies writer Cinda Chavich describes will send you running to the kitchen in search of sustenance. The chefs in Peru’s capital offer a remarkably diverse and tasty table. Indigenous fruit and vegetables grown from sea level to 2500 metres with the Pacific at the doorstep means there’s scarcely any food stuff on earth that’s not available here and creative preparation thrives. Indeed, the town at the foot of the Andes is home to seven of the world’s top 50 restaurants. And there’s more! Don’t forget the kimchi. I love Korean food and have always been enchanted by the many tiny dishes with their huge variety of savoury pickled veggies. A couple of years ago, I tried my hand at turning a head of savoy cabbage into kimchi. It worked! Now I always keep a jar in the fridge and you can too. Turn to Korean fire (and fermentation), page 56. Summer’s coming. Let the good times roll, laissez les bons temps rouler!

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David Elkins, publisher and editor delkins@parkpub.com

@doctorsreview

MAY 2016 • Doctor’s

Review

CINDA CHAVICH

Live life at large

For your adult patients with type 2 diabetes

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

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

BITRJ00110 CATRJ00110

contents MAY 2016

42 COVER: TYLER OLSON / SHUTTERSTOCK.COM

10 ways to get the cheapest seat on your next flight Timing, websites and strategies to snag the best deal among ever-shifting fares by David Elkins

CINDA CHAVICH

features 50

The dreamy Dalmatian Coast The marble streets of Dubrovnik and beautiful beaches of coastal Croatia: one MD’s summer vacation by Dr David Wood

Lima’s food revolution The acclaimed chefs and indigenous ingredients behind some of the hottest restaurants on the planet by Cinda Chavich

The best farms, markets, wineries and nature trails in one of Ontario’s top touring regions by Lin Stranberg

Home sweet houseboat Calling all captains! Sail an apartment on floats through BC’s Okanagan Sicamous Lake this summer by Margo Pfeiff

Prince Edward County: what to know before you go

DAVID WOOD

Korean fire (and fermentation) The best-ever kimchi recipe plus more food with funk from Koreatowns across the US by Deuki Hong and Matt Rodbard

MAY 2016 • Doctor’s

Review

Helping you support your patients on ALESSE.

An effective oral contraceptive and a trusted choice in Canada for 18 years.1

New Box Design. Same Formula. DUAL INDICATION: CONCEPTION CONTROL AND TREATMENT OF MODERATE ACNE VULGARIS.2 HELP YOUR PATIENTS SAVE ON ALESSE! Encourage them to visit Alesse.ca, enroll and download the Pfizer Strive Payment Assistance card.* Alesse (levonorgestrel 100 mcg and ethinyl estradiol 20 mcg tablets) is indicated for conception control and the treatment of moderate acne vulgaris in women ≥14 years of age, who have no known contraindications to oral contraceptive therapy, desire contraception and have achieved menarche. Consult the product monograph at http://www.pfizer.ca/pm/en/ALESSE.pdf for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The product monograph is also available through our medical department. Call us at 1-800-463-6001. * Pfizer Strive Payment Assistance is available in all provinces except Quebec. Availability and coverage vary by province.

References: 1. Alesse NOC. Health Canada, 1997. 2. Alesse Product Monograph, Pfizer Canada Inc., September 18, 2015.

® Pfizer Inc., used under license ALESSE ® Wyeth LLC, owner; Pfizer Canada Inc., Licensee

CA0115ALS016E

Alesse makes sense

contents MAY 2016

regulars

LETTERS

The Caribbean, France plus disabling the cable

PRACTICAL TRAVELLER Bruce Munro lights up Uluru in Australia, Harry Potter arrives at Universal Studios Hollywood, Motel 6 gets an upgrade and more! by Camille Chin

The biggest medical meetings happening this fall

HISTORY OF MEDICINE Dr Henry Heimlich choked by his ambition by Rose Foster

CROSS CURRENTS IN OSTEOARTHRITIS Glucosamine guidelines by Eva Chanda

GADGETS A top-of-the-line car charger and the Hori Hori garden tool by David Elkins

TOP 25

DEPRESSION KEYPOINTS Spot and treat signs of youth depression by Mairi MacKinnon

PHOTO FINISH Brooklyn links by Dr Fredericka Abcarius

Coming in

June

• Anita Draycott picks her 10 favourite golf courses in Canada and the US • Take a four-day hike around central Oregon’s stunning Three Sisters • History of Medicine: mental illness among political leaders

COVERED BY MOST PRIVATE INSURANCE PLANS

• Treatment options in the co-morbidity of anxiety and depression • You haven’t seen Italy until you’ve seen Sicily

TRINTELLIX® is a registered trademark of Lundbeck Canada Inc.

MAY 2016 • Doctor’s

Review

Notes supplémentaires

ÉPREUVE

03F

LETTERS

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

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EDITOR

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ian one lucky physic Campo will send venue. and Casa de ican Republic renowned Domin Doctor’s Review a holiday at this and a guest for

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier for two receives airfare The winning MD t and four nights aboard Air Transa ion. A $5800 value! modat “Elite” accom hectares: g Life” set on 2833 Enjoy “The Sportin designed Dog, 90 holes the of Teeth • golf the by Pete Dye courts on championship • play tennis ack horseb • ride • shoot skeet paddle board and kayak sail, • swim, dive, at Minitas Beach abs and glutes at the on your • spin, work

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

fitness centre ants in a palate — six restaur • please your ting venues variety of fascina appetite at more. Whet your And so much o.com.do casadecamp

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

OFFICE MANAGER

test box Click on the con review.com. e drcme to participate. cod n. Enter at doctors winter vacatio t. Use access for a glorious issue, just in time in the top righ in the October

dates may apply. 4, 2016; other blackout reservation. 2015 to January credit to an existing of December 20, not be applied as valid for the period package value may to availability. Not 1, 2016, subject for cash and estimated 2015 to October Prize is not redeemable from October 1, prize after expiration. This prize is valid made to redeem extension will be Absolutely no date

The winner will

be announced

Denise Bernier

CONGRATULATIONS!

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

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

MONTREAL HEAD OFFICE

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

WINNING WORDS Dr Steve Choi was the winner of the Doctor’s Review all-inclusive trip to Casa de Campo. He visited the luxury resort with his wife in March and shares these highlights: 1. Enjoying a fresh breakfast every morning with a great view of the golf course and the Caribbean Sea. 2. Getting around in a golf cart was fun — I don’t golf and never used one before this trip! 3. The food, drink and service were fantastic. 4. Relaxing on the well-kept beach. 5. Visiting the Altos de Chavón replica village with great vistas. Dr Steve Choi Oakville, ON

ANTENNA LOVE Here are a few of the online comments we received about the Winegard HDTV Indoor Antenna [Gadgets, March 2016, page 20]: How innovative. Building height and mountains might be an issue. Dr R. Friesen

Very interesting. How can I know if it works in Québec city? Dr France Landry

Editor’s note: Get one at a local supplier with a return policy and try it out. If it doesn’t work, take it back.

Doctor’s Review • MAY 2016

The winner of a Winegard Flatwave Amplified HDTV Indoor Antenna is Dr David W. Jones, a family physician from Burnaby, BC.

Great idea. Can’t wait to try one! Dr Bill Tillmann

It is innovative. Dr Michael Lai

Sounds like a great gadget to try. Thanks for the review. Dr Daniel Beytell

MEMORIES OF ALSACE [Dr Philippe Erhard] should work for France Tourism! Alsace is a jewel filled with history, vineyards and unforgettable magic [“Alluring Alsace,” I Prescribe a Trip to, March 2016, page 31]. Thanks for sharing your memories of this very special paradise! Dr JoAnne Christie Via DoctorsReview.com

Wow! [Dr Erhard] truly captured the charm, beauty and spirit of Alsace. I want to return to this magnificent setting! Dr Lynn Lambert Via DoctorsReview.com

DISPENSED NAIL FUNGUS TREATMENT IN CANADA*

A transungual topical shown to achieve

†

complete and mycologic

cure of nail fungus ONCE-DAILY •

Complete cure achieved in 18.8% of patients vs. 3.5% with vehicle (52 weeks, p<0.001) ‡

•

Mycologic cure achieved in 55.3% of patients vs. 16.8% with vehicle (52 weeks, p <0.001) (secondary endpoint) §

Indicated for the topical treatment of mild to moderate onychomycosis (tinea unguium) of toenails without lunula involvement due to Trichophyton rubrum and Trichophyton mentagrophytes in immunocompetent adult patients.

CLINICAL USE:

Safety and efficacy in patients under 18 or over 75 have not been studied. Greater sensitivity of some older individuals (≥ 65) cannot be ruled out.

CONTRAINDICATIONS: •

Hypersensitivity to efinaconazole or any excipients of JUBLIATM or container component

RELEVANT WARNINGS AND PRECAUTIONS:

Patients with a history or clinical signs of immunosuppression, HIV infection, uncontrolled diabetes, other toenail infection except Candida, toenail infection to the matrix, only lateral toenail disease, severe plantar tinea pedis • Concomitant use of other antifungal therapy and daily use of JUBLIATM for more than 48 weeks • For topical use only, and only on toenails and immediately adjacent skin • Flammable – keep away from heat or flame • Sensitivity reaction or severe irritation • Pregnant and nursing women •

valeantcanada.com JUBLIATM is a trademark of Valeant Pharmaceuticals International, Inc. or its affiliates. Valeant Canada LP, 2150 St-Elzéar Blvd. West, Laval, Quebec H7L 4A8 © 2016 Valeant Canada LP. All rights reserved.

FOR MORE INFORMATION:

Please see Product Monograph on the Health Canada website (http://webprod5.hc-sc.gc.ca/ dpd-bdpp/index-eng.jsp) for important information on adverse reactions, drug interactions and dosing. Product Monograph is also available by calling 1-800-361-4261. * Source: IMS Brogan CompuScript Audit, December 2015. † Clinical significance is unknown. ‡ Two identical 48-week, randomized, double-blind, vehicle-controlled trials with 4-week post follow-up in 1,601 patients (1,198 JUBLIATM, 403 vehicle) with 20-50% clinical involvement of area of target great toenail, without dermatophytomas or lunula (matrix) involvement. Patients not excluded for concomitant Candida infection. Complete cure defined as 0% clinical involvement of target toenail plus mycologic cure. § Defined as a negative fungal culture and a negative potassium hydroxide examination of target toenail sample. REFERENCE: JUBLIATM Product Monograph, October 2013.

Trintellix is indicated for the treatment of major depressive disorder (MDD) in adults.

Consult the product monograph at www.trintellixmonograph.ca for important information about contraindications, warnings and precautions, adverse reactions, interactions, dosing instructions, and conditions of clinical use. The product monograph is also available by calling 1-800-586-2325. TRINTELLIXTM is a trademark of Lundbeck Canada Inc.

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

THIS PAGE FIELD OF LIGHT, ULURU, BRUCE MUNRO 2016 / PHOTOS MARK PICKTHALL

C a mi lle C hi n

Australia’s light year

TOP TO BOTTOM: Team members had to individually construct each handcrafted solar stem. Stems glow purple, blue, red and yellow.

British-artist Bruce Munro conceived the idea for Field of Light while visiting Uluru, also known as Ayers Rock, in central Australia in 1992. Since then, he’s created Field of Light installations in London, Edinburgh, Mexico and throughout the US. April 1 saw the realization of Munro’s largest and first solar-powered work in the very place that inspired it. There are more than 50,000 slender stems crowned with frosted-glass spheres in an area the size of four football fields at Ayers Rock Resort. The spheres “bloom” as darkness falls. “Field of Light was one idea that landed in my sketchbook and kept on nagging at me to be done,” said Munro. “I saw in my mind a landscape of illuminated stems that, like the dormant seed in a dry desert, quietly wait until darkness falls, under a blazing blanket of southern stars, to bloom with gentle rhythms of light,” he said. “Field of Light is a personal symbol for the good things in life.” The exhibit, named Tili Wiru Tjuta Nyakutjaku or “looking at lots of beautiful lights” in local Pitjantjatjara, closes on March 31, 2017. Adults from $35; kids two to 15 $25. ayersrockresort.com.au. MAY 2016 • Doctor’s

Review

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

Harry Potter in Hollywood

ZACK LIPP 2015 UNIVERSAL STUDIOS

The Wizarding World of Harry Potter opened on April 7 at Universal Studios Hollywood capping a five-year revamp of the park. (The Wizarding World at Universal Orlando opened in 2014.) The new attraction features cobblestone streets and snow-capped roofs, merchants at work and a train conductor who welcomes arrivals. Its signature ride is the 3D-HD Harry Potter and the Forbidden Journey in which riders wear Quidditchinspired 3D goggles as they spiral and pivot 360-degrees along an elevated track while experiencing moments shared by Harry and his friends in the classrooms and corridors of Hogwarts. Another big ride is the Flight of the Hippogriff, Universal Hollywood’s first outdoor rollercoaster. At Ollivanders, Makers of Fine Wands since 382 BC, you can buy your own wand. Online park tickets start at US$89 for kids ages 3 to 9; US$95 for ages 10 and up. universalstudioshollywood.com.

TOP: Hogwarts Castle at night. RIGHT: Madam Puddifoot’s Tea Shop.

Doctor’s Review • MAY 2016

ILYAS KALIMULLIN / SHUTTERSTOCK.COM

Moscow’s Bolshoi Theatre.

Glacier National Park in Montana’s Rocky Mountains.

Culture cruise Silversea Cruises recently launched a new collection of sailings called Exclusively Yours — Enriched Voyages. Scheduled to begin late this summer through early fall, they combine “culture and travel” with special programs designed to make trips richer and “more exclusive.” Milan-based Accademia Teatro alla Scala will perform opera shows on three different sailings to the Mediterranean; two solo ballet performers from the State Academic Bolshoi Theatre of Russia will take the stage on an August 31 Mediterranean cruise; six different sailings through the Caribbean, South America, Europe and Asia will feature culinary demos and dinners, some hosted by chefs from the Relais & Châteaux group of luxury hotels, and winery excursions. Card enthusiasts have not been overlooked: they can compete in the first-ever Silversea bridge tournament on a Barcelona to Fort Lauderdale cruise this November. silversea.com.

MAY 2016 • Doctor’s

Review

PR A CTICA L T RAVEL L ER

TV come true

A modern motel upgrade

Motel 6 rooms may not look the way you remember them. Seventy-five percent of them have been renovated and now feature bright orange, turquoise or lime green accent walls and blankets, contemporary furniture, wood-effect flooring, flat-screen TVs and new bathrooms. By the end of 2017, all 1330 locations throughout Canada and the US will be revamped. For more pics and a map of renovated properties: motel6.com/en/renovations.html.

The Financial District in San Francisco.

Doctor’s Review • MAY 2016

VACCLAV / SHUTTERSTOCK.COM

California for a price Headed to the US for a working vacation? If San Francisco is in the agenda, expect to spend a lot of cash. According to Business Travel News, the City by the Bay is the most expensive destination for corporate travel in the US — the average perdiem for a hotel, rental car and food was US$547.34 in 2015. The other cities to top the 32nd Annual Corporate Travel Index are New York (US$523.05), Boston (US$502.69), Seattle (US$418.88) and Washington, D.C. (US $411.10). Want a working vacation on the cheap? Go to Norfolk, Virginia where accommodation, transportation and three meals a day averaged US$248.15. Caracas, Venezuela is the most expensive worldwide (US$1702.44), the result of an inflationary spiral, followed by London (US$553.58), Muscat, Oman (US$515.23), Geneva (US$496.81) and Zurich (US$484.46). Last year Calgary ($282.22) ranked as the most expensive city in Canada. businesstravelnews.com/corporate-travel-index-2016.

LUXURY RESORT & VILLAS

SHOOTING CENTER

PRIVATE BEACHES

CHAMPIONSHIP GOLF BY PETE DYE POLO & EQUESTRIAN CENTER

EXCEPTIONAL RESTAURANTS & LOUNGES

JIM COURIER TENNIS CENTER

OFFSHORE FISHING

CULTURAL EXCURSIONS

CASADECAMPO.COM.DO / GOLF golf@ccampo.com.do 1-855-681-0158

LA ROMANA, DOMINICAN REPUBLIC

“GOLF IS NOT A FAIR GAME, SO WHY BUILD A COURSE FAIR?” - PETE DYE

GA D GE T S by

D a v i d Elk i n s

Car and garden top-of-the-line CAR CHARGER You had to dash out early for a conference at a convention centre near the airport. You made it and the congress was worthwhile but, in your haste, you forgot to charge your cell phone and now you can’t remember where you parked your car. Lucky you have a ZUS. The device remembers where you parked when you last turned your engine off and it will charge two devices at a time twice as fast as other car chargers. ZUS was launched with a Crowdfunder campaign with the aim of being the best car charger-car locator combo on the market. The stylish body is made from high-grade German Bayer polycarbonate, and metal parts are coated with titanium to keep the device cool and meet US military high-temperature standards. There are some downsides. Maximum charging results require the OEM charging cables supplied with most devices, not after-market generics. Also, ZUS is not compatible with Qualcomm Quick Charge technology, which comes with the newest Android phones. To use the ZUS locator, you install an app on your phone which, when opened, points in the direction of your car and tells you roughly how far away it is. It does not require cell service to do this. It can also keep track of the time remaining on a parking meter. Users report the locator works well in open parking lots, but can run into trouble in those underground. $48 at amazon.ca; nonda.co/products/nonda-zus-smart-car-charger.

MEDICAL QUIPS Blood battle Phlebotomist: I’m here to draw some blood. Patient: But I just received blood yesterday. Phlebotomist: You didn’t think you’d get to keep it, did you?

Win the ZUS car charger or the Hori Hori knife by entering the Win the Gadget of the Month contest online at doctorsreview.com

GARDEN DIGGER A Hori Hori knife is a cross between a knife and a trowel. Many gardeners find it the most useful tool in their repertoire. The tool originated in Japan for use with bonsai trees and has been adopted with a vengeance by gardeners all over the world. Essentially, it’s a heavy 30-centimetre knife with a serrated edge on one side and sharpened edge on the other. It’s used for everything from weeding to transplanting, dividing perennials, deadheading and trimming. Very handy. One user calls it a farm-to-table device since he uses it in the garden and then takes it inside to carve the roast. All Hori Horis are not created equal. This one, from Lee Valley, gets raves all around. It has a hardwood handle, graduations on the slightly curved extra-sharp blade and comes with a belt sheath. Made in Japan. Stainless-steel. $44; leevalley.com. MAY 2016 • Doctor’s

Review

10 ways to get the cheapest seat on your next flight With a little knowledge and some patience you can fly away smiling by David Elkins

1. BEST TIME TO BOOK? You may have heard that there is a “best time” to book to get the lowest fare. I’ve heard suggestions that Tuesday late afternoon is the best time, or Wednesday, or Sunday night. I’ve been told airlines adjust their fares every Monday. I don’t know if that’s a fact or not and it really doesn’t matter. Airlines have large staffs that set fares based on the total revenue a given flight is bringing in. The task is to generate the most dollars per flight. If a plane has unsold seats, fares are adjusted downward to try to sell them. Demand for seats goes up and down: there are cancellations and new bookings all the time, which is why prices fluctuate so much. In one sense, it works the same way as the stock market.

Doctor’s Review • MAY 2016

2. IT’S A CARP SHOOT As a passenger, there’s no surefire way to predict prices on a given flight. If you find a good fare, grab it. It may be gone tomorrow or even an hour later. The fare jockeys make adjustments 24/7. I worked in an airline reservation office back in the day. We had no control over prices, but did have full control over how many seats were sold. Like today’s fare managers, our object was to keep each flight as full as possible. We did this using a card system, one for each seat. You could tell at a glance when a flight was filling up simply by glancing at the thickness of the cards. We also knew from experience which times of the week, month and year were likely to be full — Friday and Sunday nights, Monday mornings, around holidays and so on. Few people flew on Saturdays. How things have changed. It’s now one of the most popular days of the week. Some flights were in heavy demand. For example, flights to Florida before the winter holidays could fill up in minutes. At times like these, we’d put passengers on a waiting list and tell them we’d call if anything

opened up. In the meantime, we slavishly counted cards and searched for duplicates. People had a habit of booking multiple flights just in case they changed their plans. It was a kind of a game; they overbooked, we tried to weed them out. That was then and this is now, but the objectives are the same: keep the planes as full as possible without overbooking them. It can be a delicate art and that’s why it’s worth checking often. If you can, book with a carrier (or online service) that guarantees they’ll give you the lowest fare available at the time of your flight.

VAZZEN /SHUTTERSTOCK.COM

3. SIGN UP FOR ALERTS Use a service that alerts you when fares drop. At Airfarewatchdog (airfarewatchdog.com), for example, you can search for the lowest return fare between two airports, and they’ll give you the fare at the time of your inquiry and then send you an e-mail if the fare drops. A couple of caveats: sites like these only scan for fares from major carriers and do not cover special promotions. Also, smaller carriers, which often do have substantially lower fares, aren’t listed (see the next item for more). That said, if your dates are reasonably certain, sign up for alerts from more than one provider. Do it judiciously or your e-mail box will quickly be filled to overflowing with alerts you don’t need. Get even quicker fare updates on Twitter: follow @airfarewatchdog.

4. COMPARE ALL FARES For a quick view of the lowest fares by date, go to Google Flights (google.ca/flights). It’s very useful since you can see at a glance day-to-day price variations and plan your trip accordingly. Google listings are as complete as you can get for larger carriers. The company now owns ITA Software (itasoftware.com/ solutions/qpx), which charts all major airline fares. The site is well worth a visit for a quick overview of fares and for a better understanding of why fares are what they are. One caution: the site does not list smaller carriers, which often do offer lower fares — WestJet, Porter and Air Transat in Canada and Southwest, JetBlue and Alaska (who have just purchased Virgin America) in the US. It does, however, list smaller airports across the continent, some of which offer such service. Knowing where smaller airports are located is a service in itself.

5. SEARCH THE SMALLEST In the US, it may pay to go directly to the airline’s own site to book such carriers as Spirit and Allegiant. When booking, be sure to check the extras tacked on to the fare: baggage charges, seat-selection tariff and even penalties if you don’t arrive to check in with a boarding pass you’ve printed out yourself.

The other thing to check is the cost of getting to your destination from these smaller airports. In some cases, ground transportation can be as much as the airline ticket.

6. USE AN ONLINE SERVICE Use online services such as Expedia, Kayak, Orbitz and Travelocity, and make sure you check several. They do not all offer the same prices, especially on international flights. For example, last fall Travelocity offered flights to Ireland that were $100 less than were available on the other online booking sites. You couldn’t even match the fare booking directly with the airline itself.

7. REDEEM POINTS Use your frequent flyer points and sign up for special promotions on airlines you’re likely to use. Check the rules and regulations carefully, all programs are not created equal. Same goes for points given by credit cards and other purchase linked cards like Air Miles.

8. BOOK DIRECT It’s always worth checking with the airline directly. Lower fares are often available through special promotions that are never offered except through an airline. Another reason: you may find it easier to deal directly, especially if you have to change your plans. In some cases, they will allow you to make those changes without a penalty, something that will simply not happen if you’ve booked through a third party.

9. BOOK TWO ONE-WAYS Check both one-way and return fares. You can often use different carriers going out and coming back to save money.

10. SEE A TRAVEL AGENT Though not as popular as they were before so many of us began to make our own bookings on the Internet, agencies can still be very useful. They know the industry, have daily dealings with carriers and are in a strong position to ferret out the best price — and to know a great deal when they see one. They also, of course, take all the inconvenience out of making bookings on your own. A single phone call is all it takes and they do the rest. Not all fares are created equal. There’s great pleasure in knowing you’re sitting in the lowest cost seat on the plane. Go for it. MAY 2016 • Doctor’s

Review

Make your travel dreams come true Go to doctorsreview.com/meetings to search 2500+ top world conferences Access code: drcme

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Calgary, AB September 18-22

22nd World Congress for the International Association for Child and Adolescent Psychiatry and Allied Professions with the 36th Annual Conference of the Canadian Academy of Child and Adolescent Psychiatry iacapap2016.org

Halifax, NS October 23-25

2016 Annual Conference of the Canadian Association of Paediatric Health Centres conference.caphc.org

21st International Congress on Palliative Care palliativecare.ca

October 20-22

XXVII Annual Meeting and Scientific Conference of the International Society of Addiction Medicine and Canadian Society of Addiction Medicine csam-smca.org/events

October 22-25

2016 Canadian Cardiovascular Congress cardiocongress.org

October 26-29

2016 Annual Meeting of the Canadian Society of Internal Medicine csim.ca/annual-meetings Bota Bota spa in Old Montreal.

Montreal, QC October 18-21

Ottawa’s Convention Centre and Rideau Canal.

Ottawa, ON October 24-26

Quebec City, QC September 30-October 1

6th Conference on Recent Advances in the Prevention and Treatment of Childhood and Adolescent Obesity interprofessional.ubc.ca/obesity2016

25th Annual Scientific Meeting of the Canadian Academy of Geriatric Psychiatry cagp.ca/conferences

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

Toronto, ON October 30-November 2 Critical Care Canada Forum criticalcarecanada.com

Vancouver, BC October 26-29 45th Annual Meeting of the Child Neurology Society childneurologysociety.org/meetings/future-cnsannual-meetings

MEDICAL QUIPS What is a double-blind study?

TOURISME MONTREAL / SID LEE

Two orthopedists reading an electrocardiogram.

MAY 2016 • Doctor’s

Review

THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Around the world Amsterdam, Netherlands October 12-15

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8th International Meeting of the International Society of Vascular Behavioural and Cognitive Disorders vascog2016.nl

Barcelona, Spain October 20-22 4th World Congress on Controversies, Debates and Consensus in Bone, Muscle and Joint Diseases congressmed.com/bmjd

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

Geneva, Switzerland October 21-25 6th Congress of the European Academy of Paediatric Societies paediatrics.kenes.com

São Paulo’s Hotel Unique.

Liverpool, England October 26-29

San Antonio, TX October 21-24

47th Union World Conference on Lung Health liverpool.worldlunghealth.org

US Psychiatric and Mental Health Congress psychcongress.com/psychcongress

New Orleans, LA October 26-30

São Paulo, Brazil October 23-26

ID Week 2016 idweek.org

XX World Congress of the International Society for the Study of Hypertension in Pregnancy isshp.org/meeting/isshp-xx-world-congress

Hyderabad, India October 26-29

Prague, Czech Republic September 28-October 1

10th World Stroke Congress wsc.kenes.com

15th World Congress on Menopause imsociety.org/world_congress.php

Valencia, Spain October 26-29

42nd Annual Conference of the International Society for Pediatric and Adolescent Diabetes 2016.ispad.org

A street vendor in Hyderabad.

Vienna, Austria August 31-September 3

16th World Congress on Cancers of the Skin wccs2016.com

October 15-19

United European Gastroenterology Week ueg.eu/week

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Yokohama, Japan September 26-30

Doctor’s Review • MAY 2016

16th World Congress on Pain iasp-pain.org

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

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

R os e F os t e r

A man and his manoeuvre Heimlich choked by his ambition

resident Ronald Reagan was nearly felled by a peanut. A vitamin pill almost took down pop icon Cher. And former New York Mayor Ed Koch

was reputed to have narrowly escaped death by watercress. What saved them? A procedure so simple a child can perform it, so familiar everyone’s heard of it: the Heimlich manoeuvre. Most Canadians have seen the “First Aid for Choking” posters that have appeared on restaurant walls since the ’70s detailing the mechanics of the Heimlich manoeuvre: stand behind the choking victim, wrap your arms around them, place a fist one hand above

Heimlich believes that forces are conspiring to erase the manoeuvre from collective memory — he may have a point Dr Henry Heimlich demonstrates his manoeuvre on Johnny Carson while appearing on The Tonight Show in April 1979.

Doctor’s Review • MAY 2016

the bellybutton, clasp it in the other fist, and pull inwards and upwards. Many have performed the manoeuvre themselves, or know someone whose life was saved by it. The Good Samaritan tool is not an ancient relic from medical history, but rather reported to be the inspiration of Henry Heimlich, a man who is alive and well today at age 96. And although his name is a household word, Heimlich believes that forces are conspiring to erase it from collective memory. He may have a point. Below the rosy surface of a procedure that has unquestionably snatched many a soul from “café cardiac,” as it was once known, lies a raging family feud and an unresolved medical debate. Evidence of an official cooling off towards the Heimlich legacy can be found in revised language about the procedure, which has been renamed “abdominal thrusts” by both the American and Canadian Red Cross. In 1974, when Dr Heimlich developed the procedure, people were so eager to learn from him that he was able to circumvent the fact-based medical realm and popularize his manoeuvre based entirely on anecdotal evidence. Choking claimed thousands of lives each year and no one knew how to stop the death toll. Doctors fiddled with near-useless inventions such as the Throat-E-Vac, a minisuction device intended to suck the food obstruction from a person’s throat, and the ChokeSaver, a 23-cm-long pair of plastic tweezers meant to do the same, but the dubious products did not catch on. For years, incidents of public choking had been misinterpreted as cardiac arrests.

Dr Edward Patrick (far right) claims to have collaborated with Dr Heimlich (centre) on the manoeuvre.

In 1963, a Florida coroner named Robert Haugen published an article casting light on the so-called heart-attacks that were claiming the lives of thousands of restaurant goers every year. Examining the airways of several of the deceased, he located “steak in four cases, beef in two, ham fat in one, kippered herring in one, and broiled lobster in another” and pronounced death by asphyxiation. He dubbed the phenomenon “the café coronary.”

SURGEONINVENTOR In 1969, Dr Heimlich, then director of surgery at the Jewish Hospital in Cincinnati, had spent his career thus far saving and improving lives with inventions, both his own and those of others. In the mid-50s, he began to employ a surgery that allowed people with severe esophageal damage to swallow food. In 1963, he invented a “flutter valve” which allows blood to be drained from a chest cavity so that a collapsed lung can re-expand. He was eager to address the problem of choking. As a thoracic surgeon, he knew that lungs contained a substantial amount of air at the moment of choking and he hoped to use that air to expel the object lodged in the larynx. In the animal lab at his hospital, he partially anesthetized a 17-kilogram beagle and lodged a cuffed endotracheal tube in the dog’s larynx. First, he pressed on the dog’s chest with no results. Next he pushed up on the diaphragm and found that he could compress the lungs that way. To his de-

light, the tube flew out. He replicated the experiment, this time with chunks of hamburger meat, on three other dogs. Still, the doctor had no way of knowing whether his technique would work on humans. His solution? He convinced the editor of Emergency Medicine, a journal that did not require its articles to be peer-reviewed, to permit him to print his proposal for the anti-choking treatment in its pages. Readers were urged to attempt the method should an emergency choking event arise and report their results to him. Dr Heimlich then sent a copy of the article to Arthur Snider, the Chicago Daily News’s nationally syndicated science writer. Just a week later, Dr Heimlich got what he was hoping for: in Washington state, a retired restaurant owner had used the procedure to prevent his neighbour from choking to death. More news articles ensued and anecdotal evidence continued to pour in. Before long, the American Red Cross was recommending that the manoeuvre be used alongside slaps to the back. At Heimlich’s urgings, the slaps to the back, which Heimlich called “death blows,” insisting that they lodged food even farther into the throat, were dropped from the recommendations. By 1986, Heimlich’s manoeuvres were widely recognized in North America as the single most effective way to save a person from death by choking. In recounting this story, Dr Heimlich never mentions his colleague, Dr Edward Patrick, who claims to have collaborated with him on the manoeuvre and its popularization for more than two decades. Though Dr Heimlich sticks

resolutely by his assertion that he and he alone came up with the method, Dr Patrick says that the two developed it together. Over the years, Dr Patrick says he was a tireless promoter of the manoeuvre and was instrumental in gaining public acceptance.

BAD OLD DAD Dr Patrick isn’t the only person to have challenged Dr Heimlich’s claim to fame. Since 2002, Dr Heimlich’s son Peter, and his wife Karen, have dedicated much of their time to defaming his dad. Peter Heimlich has accused his father of medical fraud and quackery as well as carrying out horrific experiments on human subjects. Peter admits that it was a private family conflict that prompted him to go digging for dirt, but that what he found there was so shocking that he felt an “ethical responsibility” to broadcast it to the world. Heimlich the Younger says that the fame his father received from the manoeuvre made him hungry for more attention. In an attempt to further dominate the field of emergency response procedures, Peter says his father declared that the Heimlich manoeuvre could be used for a range of other conditions including stopping asthma attacks, curing cystic fibrosis and clearing water from the lungs of drowning victims. The latter claim was particularly heinous, says Peter, as it has been demonstrated that use of the Heimlich manoeuvre on a drowning victim can delay resuscitation efforts and induce vomiting, resulting in aspiration pneumonia. MAY 2016 • Doctor’s

Review

NEW

VIACORAM

En route towards BP control.

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

3.5 mg / 2.5 mg

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

mg mg perindopril arginine/ amlodipine

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

mg mg perindopril arginine/ amlodipine

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

Available in three dosage strengths perindopril arginine/ amlodipine

7 /5

14 /10

INDICATED IN INITIAL THERAPY

3.5mg Perindopril arginine / 2.5mg Amlodipine

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

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

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

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

These inflated claims were not the only dodgy business Dr Heimlich cooked up, says Peter, who has devoted an obsessively researched and detailed website to what he sees as his father’s iniquity. Perhaps the most egregious of his father’s activities is his involvement in malaria therapy, a theory that posits that injecting people who have AIDS, or even cancer, with malaria and letting the illness run its course for three weeks before stopping it with medication will kill the AIDS virus and eliminate cancer. When Dr Heimlich was denied permission to conduct malaria therapy research on human subjects in the US, he set up labs in Mexico, Africa and China, and received generous funding from Hollywood stars. Dr Heimlich remains publicly passionate about malaria therapy, though his overseas research came to a halt years ago, in part due to his son’s agitating. The doctor is dismayed that ER organizations, including Red Cross Canada, have demoted the significance of the Heimlich manoeuvre and now refer to it simply as “abdominal thrusts.” But he takes comfort in the stories that continue to roll in of what he dubs “Heimlich Heroes,” people of all ages who have experienced the joy of saving a life. No one can argue with him about that. Incidentally, the manoeuvre has never been used in Australia. The general belief Down Under is that its risks outweigh its benefits. The primary injury associated with the manoeuvre is gastric rupture, but other injuries include lacerated liver, fractured sternum, aortic valve cusp rupture and aspiration of stomach contents. The Aussies also contend that chest thrusts (resus.org.au/faq/choking) have been proven to be not only less risky, but more effective, and seem puzzled that so much of the world has embraced a procedure with so little scientific backing as the Heimlich manoeuvre. Canada, the US and the UK have taken a different route. The most common advice in the case of a choking victim is to first use five sharp back slaps and, if they don’t dislodge the object, only then go on to “abdominal thrusts.” The Red Cross continues to support the thrusts if only because people find them easy to remember.

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

Review

CR OSS CUR R E N T S I N O S T E OA R T H R I T I S by

Eva Chanda, MSc

Osteoarthritis: improving patient s

O .

steoarthritis (OA) affects over 10% of Canadians aged 15 and older, rising in incidence with age. It presents a management challenge for physicians and is a major cause of pain, disability and reduced quality of life for patients. According to Statistics Canada, 66% of Canadians with OA report using over-the-counter (OTC) remedies for their condition and 39% manage with prescription medications.1 What products are they taking — and are they using them appropriately? A 2013 study of nearly 1000 people in the US from the National Institutes of Health Osteoarthritis Initiative (OAI) provides some insight into medication use by patients with knee OA. The most popular therapy was glucosamine, taken by 40% of participants. OTC nonsteroidal anti-inflammatory drugs (NSAIDs) were the most common analgesics, used by 27%, followed by 14% taking acetaminophen and 8% receiving prescription NSAIDs (Figure 1).2

The glucosamine challenge The widespread use of glucosamine in the OAI study suggests that many patients will seek out glucosamine on their own and some will find it helpful. Clinical trials of glucosamine, mainly in knee OA, have had conflicting results, but the evidence-based Natural Medicines Comprehensive Database (NMCD; naturaldatabase.therapeuticresearch.com) has rated glucosamine as “likely effective” for OA pain.3 In terms of safety, NMCD considers glucosamine “likely safe,” while several systematic reviews have consistently found it is very safe, with adverse events comparable to placebo.3-6

FIGURE 1. Self-reported patient use of medications for knee OA

Glucosamine is available in three forms: glucosamine sulfate, glucosamine hydrochloride and N-acetylglucosamine, which can all be obtained in capsule, tablet, liquid and powder formulations. Glucosamine is often sold in combination with chondroitin, another joint matrix building block, but this may be unnecessary. The NMCD has found no reliable evidence that the combination is better than glucosamine alone, and less evidence for chondroitin alone than for glucosamine; it classifies chondroitin as “possibly effective” and “likely safe.” The typical glucosamine dosage in trials is 1500 mg taken orally once daily or in three divided doses.7 However, with almost 66% of Canadian seniors taking 5 or more medications,8 patients considering glucosamine may already have a heavy pill burden. Another option is powder formulations, which can be mixed with food or beverages for greater ease of dosing. Those choosing pills should look for once-daily products containing 1500 mg per capsule/tablet. If tolerability of 1500 mg all at once is a problem, they can try 500 mg 3 times a day. Patients should also be aware that glucosamine products on the market can vary wildly in chemical potency. A University of Alberta study found that, among 13 samples of 500-mg glucosamine sulfate capsules commercially available in Canada, the actual percentage of free glucosamine base, compared to the stated amount, ranged from 108% to 41% (Figure 2). The authors noted that glucosamine is unstable and therefore must be complexed with salts, which may dilute the active ingredient if calculated incorrectly.9 In contrast, N-acetylglucosamine is extremely stable, even at 37°C for up to 12 days.10 Most glucosamine supplements are derived from crustacean shells, so people with known shellfish allergies are advised to avoid these products. However, shellfish-free vegetarian-sourced glucosamine supplements are available as an alternative for those with allergies or dietary restrictions.11

Rethinking acetaminophen

*For more than ½ of days in previous month; OTC=over-the-counter; NSAID=nonsteroidal antiinflammatory drug Data from: Kingsbury SR, et al. How do people with knee osteoarthritis use osteoarthritis pain medications and does this change over time? Data from the Osteoarthritis Initiative. Arthritis Res Ther. 2013;15(5):R106.

Doctor’s Review • MAY 2016

Acetaminophen is still guideline-recommended as a first-line pharmacologic treatment for OA, but with reservations, due to growing evidence of lower efficacy and more adverse effects than previously thought.12,6 A recent, extensive network metaanalysis concluded that acetaminophen is clinically ineffective for OA pain at any dose.13 A systematic review found that, even at standard analgesic doses (≤4 g/day), acetaminophen showed a dose-response relationship with AEs typically associated with NSAIDs: cardiovascular, renal and gastrointestinal (GI) adverse events, as well as increased mortality.14 Patients taking acetaminophen must not exceed 4 g/day and should be cautioned not to take combination products that may contain acetaminophen, such as OTC cold remedies.15,12

self-management FIGURE 2. Differences in potency between glucosamine products in Canada

macologic and pharmacologic approaches, with education, weight loss (if overweight or obese) and exercise forming the core set of interventions recommended for all patients.12,6,18,19

Exercise and weight loss benefits

Data from: Aghazadeh-Habashi A, Jamali F. The glucosamine controversy, a pharmacokinetic issue. J Pharm Pharmaceut Sci 2011;14:264–73.

Glucosamine alternative to NSAID Physicians are well aware of the risk of adverse events with NSAIDs, but what about patients? Reassuringly, the OAI medication use study suggests OA patients are using NSAIDs largely as recommended.2 One area of concern is NSAID use by patients over the age of 75. In the OAI, prescription NSAIDs were uncommon in this age group, used by less than 3%, compared to 10% of those under 65, and 6% of 65–74-year-olds. This prescribing pattern is in line with recommendations discouraging NSAIDs in patients at risk for adverse events due to comorbidities, including advanced age. However, older people continued to take OTC NSAIDs at virtually the same rates as their younger counterparts, putting themselves at risk for serious side effects.2,12 Older seniors should be encouraged to consult with their physicians on less-toxic alternatives to oral NSAIDs. One option for hand and knee OA is topical NSAIDs, which offer pain relief comparable to oral NSAIDs, with a far lower risk of GI and other systemic adverse events.16 The 2012 American College of Rheumatology (ACR) guidelines recommend topical NSAIDs instead of oral forms for hand and knee OA in patients 75 and older.15 Glucosamine may also be an appealing alternative to NSAIDs. A recent head-to-head study of glucosamine + chondroitin (GC) versus celecoxib in 606 patients with knee OA and moderate-tosevere pain found that GC was noninferior to celecoxib, offering comparable efficacy in improving pain, function, stiffness and joint swelling after 6 months, with good safety and tolerability.17 Basic management of OA involves a combination of nonphar-

Patients and physicians alike tend to underestimate the benefits of exercise in managing OA. A 2015 Cochrane review concluded that land-based exercise improves pain, physical function and quality of life in knee OA, with benefits lasting at least 2–6 months after a formal program, and a treatment effect comparable to that of NSAIDs (but without the adverse effects).20 Obesity is a major modifiable risk factor for the development and progression of OA. Even modest weight loss can be helpful, since every kilogram of weight lost translates to a 4-kg decrease in the load on an arthritic knee with each step taken.21 Weight loss of >5% over 20 weeks reduces disability and, to a lesser extent, pain in knee OA.22 OA self-management education programs are strongly recommended, based on high-quality evidence for benefits in pain and physical function.19 Successful OA management requires individualized treatment and active involvement of informed, empowered patients. References 1. Macdonald K V, Sanmartin C, Langlois K, Marshall DA. Symptom onset, diagnosis and management of osteoarthritis. Stat Canada. 2014;25(9):10-17. 2. Kingsbury SR, Hensor EMA, Walsh CAE, Hochberg MC, Conaghan PG. How do people with knee osteoarthritis use osteoarthritis pain medications and does this change over time? Data from the Osteoarthritis Initiative. Arthritis Res Ther. 2013;15(5):R106. doi:10.1186/ar4286. 3. Natural Medicines Comprehensive Database. Natural Medicines in the Clinical Management of Osteoarthritis. Clin Manag Ser. http://naturaldatabase.therapeuticresearch.com/ce/ceCourse.aspx?s=ND&cs=&pc=16-104&cec=1&pm=5. Accessed April 22, 2016. 4. Towheed TE, Maxwell L, Anastassiades TP, et al. Glucosamine therapy for treating osteoarthritis. Cochrane database Syst Rev. 2005;(2):CD002946. doi:10.1002/14651858.CD002946.pub2. 5. Wandel S, Jüni P, Tendal B, et al. Effects of glucosamine, chondroitin, or placebo in patients with osteoarthritis of hip or knee: network meta-analysis. BMJ. 2010; 341:c4675. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=294157 2&tool=pmcentrez&rendertype=abstract. Accessed February 11, 2016. 6. (UK) NCGC. Osteoarthritis. Care and Management in Adults. Clin Guidel CG177. 2014;(February). doi:http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0068962/ pdf/PubMedHealth_PMH0068962.pdf. 7. University of Maryland Medical Center. Glucosamine. 2015:1-6. http://umm.edu/ health/medical/altmed/supplement/glucosamine. Accessed April 12, 2016. 8. Proulx J, Hunt J. Drug Use among Seniors on Public Drug Programs in Canada, 2012. Healthc Q. 2015;18(1):11-13. https://secure.cihi.ca/estore/productFamily. htm?locale=en&pf=PFC2594. 9. Aghazadeh-Habashi A, Jamali F. The glucosamine controversy, a pharmacokinetic issue. J Pharm Pharm Sci. 2011;14(2):264-273. 10. Hrynets Y, Ndagijimana M, Betti M. Studies on the Formation of Maillard and Caramelization Products from Glucosamine Incubated at 37 °C. J Agric Food Chem. 2015;63(27):6249-6261. doi:10.1021/acs.jafc.5b02664.

uu CONTINUED ON PAGE 61 MAY 2016 • Doctor’s

Review

DE PRESSIO N K EY PO I NT S by

Mairi MacKinnon

Depression in youth

Be on the lookout, early treatment is imperative Reviewed by Jeffrey S. Habert, MD, CCFP, FCFP, Assistant Professor, University of Toronto Dept. of Family and Community Medicine

Y .

outh has been associated with greater risk of mental health problems and social stress, and is often the time when mental illnesses, including depression, begin to manifest.1-5 According to recent Canadian community health surveys, 12-month rates of mood disorders were highest in the age group from 15 to 24 years (5.3% of males and 9.0% of females met the criteria for depression).6 Depression in younger people affects psychosocial development and academic and social functioning. Further, it heightens the risk for specific problems such as eating disorders, alcohol/ substance use and suicide.1,4,5 Data from a 2012 survey showed that 15- to 24-year-olds (especially males) had the highest 12-month rates of substance use disorders (11.9%).6 In 2009, suicide ranked as the second leading cause of death (after accidents) in 15- to 34-year-old Canadians.7 Early treatment and support are essential, as mental health issues can continue to plague people throughout their lives (worse overall health, psychosocial/functional impairment as well as diminished quality of life).1,3,5 Increased awareness among family physicians of the symptoms and behavioural issues related to depression in younger people can help to improve diagnosis and treatment.5,8

• unusual antisocial and/or disruptive behavior • physical symptoms like delayed puberty (pointing to a possible eating disorder), unexplained weight loss or gain, fatigue, headaches, stomach aches • alcohol and/or drug use2,4,8 When making the diagnosis of depression, one should rule out other causes such as medical conditions (e.g. diabetes, hypothyroidism), medication effects, coexistent substance abuse or comorbid mental conditions (attention-deficit hyperactivity disorder, anxiety or bipolar disorder).4,5,8

Ask pointed questions Canadian Network for Mood and Anxiety Treatment guidelines recommend the PHQ-9 (Patient Health Questionnaire-9) for case-finding and monitoring.9 A modified version for adolescents, designed to evaluate the frequency (e.g. not at all, several days, more than half the days, nearly every day) and severity of symptoms over the previous two weeks or longer, can be found at www.integration.samhsa.gov. Examples of questions include: • Feeling down, depressed, irritable or hopeless? • Feeling bad about yourself — or feeling that you are a failure, or that you have let yourself or your family down? • Trouble concentrating on things like school work, reading or watching TV? • Thoughts that you would be better off dead or of hurting yourself in some way?

Adolescent turmoil or depression?

Campus crisis

Depression in younger people is frequently unrecognized or underestimated in healthcare settings, especially in the absence of serious physical symptoms.5 Adults (parents and physicians) may confuse symptoms with the “normal” ups and downs or oppositional behaviour typical of adolescence. Also, young people often do not talk about their troublesome moods or feelings, or may not attribute these to something requiring attention.2,4,8 While diagnostic criteria for depression are the same across age groups, symptoms in adolescents may present more on the spectrum of anger, irritability, trouble with social interaction and disruptive behaviour. Things to look for include: • intense mood swings • loss of interest in usual pastimes • low self-esteem, excessive self-consciousness or self-blame (being overly critical or hard on oneself, feeling others criticize you) • disturbance of sleep/eating habits • difficulties concentrating (avoidance or inability to complete school work)

Transition to university can be particularly challenging. In recent years, the incidence as well as the severity of mental health issues among college/university students has increased signifi-

Doctor’s Review • MAY 2016

Depression and suicide risk in Aboriginal communities

cantly. Possible contributing factors are: academic and financial pressure, wider accessibility of postsecondary education, higher female-to-male ratio (women are more prone to depression than men), technology “addiction” (may be detrimental to social/ coping skills) and unhealthy lifestyle choices.10 A 2012 Queen’s University report highlighted an increased demand for counselling at Canadian schools over the previous eight years, with a shift in primary focus to crisis intervention: 92% of counselling centres reported more students with psychological issues, 89% a spike in the severity of problems, and 97% a rise in the number of students on medication.11 The following table presents figures from the Canadian Consortium Reference Group of the American College Health Association-National College Health Assessment II Spring 2013 survey (representing 34,039 respondents from 32 Canadian institutions).12

Students reporting depressive symptoms or treated for depression within the last 12 months12

Males Females Total

Felt hopelessness Had trouble functioning due to depression Felt exhausted (not from physical exertion) Considered suicide Attempted suicide Diagnosed or treated for depression

47% 56.6% 53.8% 33.3% 39.4% 37.5% 79.2% 90.7% 86.9% 8.9% 9.6% 9.5% 1.0% 1.4% 1.3% 6.7% 11.4% 10.0%

Depression is treatable Recognition of the problem and early treatment with medication and possibly psychotherapy (i.e. cognitive behavioural therapy)13 are imperative to obtain remission as soon as possible and optimize response. Strong support — from family, psychologist, school and community — is also paramount. Emphasis should be on self-care: basics include maintaining good sleep, nutrition and exercise habits, engaging in pleasurable activities and learning to identify/confront negative thinking and behaviour.2,5 References 1. Public Health Agency of Canada. The Chief Public Health Officer’s report on the state of public health in Canada, 2011. Chapter 3: The health and well-being of Canadian youth and young adults. Government of Canada, 2011. 2. Children, youth, and depression. Ottawa, Canadian Mental Health Association, 2014. 3. Child Trends Data Bank (2015). Young adult depression. www.childtrends.org/ 4. Child Mind Institute. Major depressive disorder. childmind.org/guide/majordepressive-disorder

Young people between the ages of 15 and 24 years make up 18.2% of the Aboriginal population in Canada.14 While the incidence of depression and suicide varies across Aboriginal peoples (living on or off reserves), it is generally much higher than among other Canadians.15 • Suicide and self-injury are the prime causes of mortality for First Nations youth and adults up to 44 years of age.16 • The suicide rate among First Nations youth aged 15 to 24 years is five to six times higher than among non-Aboriginal youth: 126/100,000 for males (vs 24/100,000 for non-Aboriginal Canadians), and 35/100,000 for females (vs 5/100,000 for nonAboriginals).15,16 • Suicide among Inuit youth ranks 11 times higher than the national average; 29% of youth in Nunavut have made at least one attempt.15,16 Aboriginal people often do not trust mainstream approaches to medicine and may not seek help for depression from conventional Western channels even when available. Among those who do, non-response and discontinuation rates are high. These statistics point to the need for culturally sensitive treatment programs that reflect the holistic beliefs and values of Aboriginal communities and individuals related to healing.16

5. Guidelines and Protocols Advisory Committee. Anxiety and depression in children and youth: Diagnosis and treatment. British Columbia Medical Association, 2010. 6. Pearson C, Janz T, Ali J. Health at a glance — Mental and substance use disorders in Canada. Statistics Canada, 2013. Catalogue no. 82-624-X. 7. Navaneelan T. Health at a glance — Suicide rates: An overview. Statistics Canada, 2012. Catalogue no. 82-624-X. 8. CANMAT CME. Diagnosing depressive disorders. Depression in adolescents. www.canmat.org/cme-depression-depression-in-adolescents.php 9. 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. 10. Flatt AK. Suffering generation: Six factors contributing to the mental health crisis in North American higher education. College Quarterly 2013;16. 11. Principal’s Commission on Mental Health. Student mental health and wellness. Queen’s University, 2012. 12. American College Health Association. ACHA-NCHAII Canadian Reference Group Executive Summary Spring 2013. Hanover, MD: American College Health Association, 2013. 13. 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. 14. Statistics Canada. Aboriginal peoples in Canada: First Nations people, Métis and Inuit. Government of Canada, 2015. 15. Bellamy S, Hardy C. Understanding depression in Aboriginal communities and families. Prince George: National Collaborating Centre for Aboriginal Health, 2015. 16. Health Canada. First Nations and Inuit health: Mental health and wellness. Government of Canada, 2015. MAY 2016 • Doctor’s

Review

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

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

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

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

CA0115PRI005E

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

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

The dreamy Dalmatian Coast A summer sojourn through Dubrovnik and the stunning islands of the Adriatic Sea text and photos by Dr David Wood

George Bernard Shaw was enchanted with Dubrovnik and described it as “the pearl of the Adriatic.”

he sun drenched Dalmatian Coast of Croatia is one of the most spectacular destinations in Europe. The sparkling Adriatic Sea is dotted with numerous islands, picturesque fishing ports and medieval

David Wood was born in Charlottetown, but grew up in Halifax where he works as a GP. He and his wife Nina share a passion for travel and have visited Africa, Singapore, Malaysia, Thailand, Australia and New Zealand.

towns, framed by the coastal mountains. “Those who seek paradise on earth must come to Dubrovnik,” wrote playwright George Bernard Shaw. Often referred to as the Pearl of the Adriatic, Dubrovnik is the most stunning city on the coast. Formerly known as the Republic of Ragusa, it maintained its independence while most of Dalmatia was MAY 2016 • Doctor’s

Review

ruled by Venice. For centuries it rivalled Venice with its merchant fleet of 700 ships and built towering ramparts to protect its medieval core. The twokilometre wall, now protected by UNESCO, forms a perimetre around the Old Town. Cool drinks and ice cream are available everywhere for refreshment. One charming place we enjoyed was Cool Drinks Bavia, a little bar perched over the sea, literally located through a hole in the wall. The Old Town has some nice museums, a Rector’s Palace and, of course, an ancient cathedral complete with a treasury of relics. The best way to enjoy Dubrovnik is to amble along the marble streets, sample the fabulous fare in the many cafés and restaurants, and cool off in the crystal clear Adriatic. In the evening, the Old Town’s main square bursts with live music and everyone comes out to enjoy the open-air concerts. If you want to indulge, take a tramcar up the mountain and have dinner while you watch the Old Town light up in the setting sun. We stayed at the Villa Argentina (adriaticluxury hotels.com/en/grand-villa-argentina), which I would highly recommend. While a little pricier than the average hotel, it’s perched on a cliff and offers spectacular views. The sea swimming is wonderful and there’s also a seaside swimming pool. There are multiple lounge areas and the al fresco dining space looks out over the water. It’s captivating!

FINE WINE

Good seafood and Italian risotto are on the menu at the restaurants that dot Korcula’s shoreline.

overlooking the 915-metre hills on the opposite shore. Many of the streets are free of cars and relaxing to wander. The shoreline is dotted with cafés, bars and restaurants — lots of good seafood and Italian risotto. Its cathedral boasts a masterpiece by the Venetian painter Tintoretto as well as a bronze sculpture by the Croatian master Mestrovic. If you like local cultural dances, the Moreska sword dance is worth seeing on Thursday evenings in summer. It commemorates the clash between Christians and Moors in an attempt to free a young kidnapped girl.

Our next stop was on the Peljesac Peninsula, an hour’s drive north of Dubrovnik. This is the heart of some of the best wine making in Croatia and we visited two wineries. At the Frano Milos Estate (milos.hr), we had a tour and tasting with Ivan Milos. The winery makes fabulous big reds from the plavac mali grape, which is closely related to zinfandel, and also a very nice rosé. The samples were generous and the wine is affordable. The Grgic Winery (grgic-vina.com) was founded by Miljenko Grgich who immigrated to California in Two ferry rides brought us up to the spectacular sun the 1960s and established a successful winery in the soaked Makarska Coast backed by 1800-metre karst Napa Valley. His success inmountains. The town is very spired him to return to Croatia pretty, ringed with beaches after the war in the 1990s. He and nice restaurants, but very makes a beautiful crisp white crowded. posip — the grapes are grown We headed to the island of on the islands where it’s cooler Brac. Ferries leave Makarska — and a big delicious red plavac fairly regularly for the one-hour mali. Many of the red grapes trip. Here, we went to the town Asian vegetable noodle soup. are grown at Dingac known for of Bol to enjoy the most famous producing the best in Croatia. “Any sign of the trapped miners, beach in Croatia, Zlatni Rat From the town of Orebic, chief?” (golden horn). A one-kilometreit’s a 15-minute ferry ride to the long sea walk connects the island of Korcula. Korcula’s town and beach, and there is a walled old town sits on a point regular shuttle boat service as

IN THE BOL

MEDICAL QUIPS Patient during colonoscopy

Doctor’s Review • MAY 2016

Lamb cooked under the “bell” was one of the best meals Dr Wood (front), his wife Nina (far right), and their friends had in Croatia.

If you want to indulge, take a tramcar up the mountain and have dinner while you watch the Old Town light up in the setting sun Over a dozen crystalline lakes tumble into each other via a network of waterfalls in Plitvice Lakes National Park.

well. We stayed at the Zlatni Rat Beach Resort (zlatniratbeach.com), which is ideally situated for a beach vacation. The beach is a swimmer’s paradise, and windsurfers and kite boarders abound. We had one of our best meals in Bol. It happened by chance, after finding a pub overlooking the harbour for lunch. Afterwards, we were offered something off the menu if we returned for dinner: lamb cooked under the “bell.” This turned out to be an incredibly delicious dish with lamb and roasted veggies bathed in a garlic-infused sauce that was so tasty we soaked up every last drop with bread and washed

it all down with a good bottle of Dingac red. The restaurant was improbably named The Moby Dick, but this is a tourist town, and the staff were all locals. An hour ferry ride north from Brac is the cosmopolitan city of Split. With a population of 265,000, Split is the largest city and port on the Dalmatian Coast. This amazing place takes you back in time to the Roman era of Emperor Diocletian, who built his retirement palace here in 280 CE. During the Middle Ages, this vast complex became a refuge for citizens from the invading barbarian tribes from the north. uu CONTINUED ON PAGE 61 MAY 2016 • Doctor’s

Review

“fine, fine, thanks.”

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

ZENHALE® is indicated for the treatment of asthma, in patients 12 years of age and older with reversible obstructive airway disease.1

in patients transferred from systemically active corticosteroids, risk of systemic effects of inhaled corticosteroids, risk of dose-dependent bone loss, use with another long-acting beta2-agonist, exceeding the recommended dose, small ® ZENHALE is not indicated for patients whose asthma can be managed by occasional increases in QTc interval, caution with cardiovascular conditions, oropharyngeal use of a rapid-onset, short-duration, inhaled beta2-agonist, with or without inhaled candidiasis, potentially serious hypokalemia, diabetic patients, rare systemic corticosteroids. ZENHALE® is not indicated for the relief of acute bronchospasm. eosinophilic conditions, enhanced effect of corticosteroids in patients with cirrhosis Refer to the page in the bottom-right hand icon for additional safety information and or hypothyroidism, risk of immunosuppression, immediate hypersensitivity reactions, a web link to the product monograph discussing: relief of acute asthma episodes, serious asthma-related adverse events and • Contraindications in the primary treatment of status asthmaticus or other acute exacerbations, paradoxical bronchospasm, pregnant and nursing women, risk of episodes of asthma where intensive measures are required in patients with untreated labour inhibition, and monitoring of: HPA axis function and haematological status systemic fungal, bacterial, viral or parasitic infections, active tuberculous infection periodically during long term therapy, use of short-acting inhaled bronchodilators, of the respiratory tract, or ocular herpes simplex and in patients with cardiac bone and ocular effects, height of children and adolescents tachyarrhythmias • Conditions of clinical use, adverse reactions, drug interactions and • The most serious warnings and precautions regarding the risk of asthma-related death dosing/administration instructions • Other relevant warnings and precautions regarding abrupt discontinuation, serious adverse event risk due to adrenal insufficiency and unmasking of pre-existing allergy The Product Monograph is also available by calling us at 1-800-567-2594.

Do you have patients you suspect are unsure about how to help manage their asthma? Talk to them about their treatment plan.

5 minutes post-dose on Day 1

Significant difference in serial FEV1 (0-1 h) was demonstrated for ZENHALE® vs. ADVAIR DISKUS† (FP/S-DPI)‡ (200 mL vs. 90 mL, respectively, p<0.001)

Adapted from Bernstein DI, et al. 2011.2

Consider ZENHALE® In a non-inferiority study comparing ZENHALE® 200/10 mcg and ADVAIR DISKUS† (FP/S-DPI) 250/50 mcg in patients (≥12 years) with uncontrolled persistent asthma,

ZENHALE® 100/5 (2 inhalations BID) demonstrated:2‡

• Statistically significant faster onset-of-action on Day 1 compared with ADVAIR DISKUS† (FP/S-DPI) 250/50 (1 inhalation BID) (secondary endpoint) - Least squares mean increase in FEV1 from baseline at 5 minutes post-dose on Day 1 = 200 mL vs. 90 mL, respectively, p<0.001 (baseline LS mean trough FEV1 values were 2.31 and 2.39 L in the MF/F-MDI and FP/S-DPI groups, respectively) • ZENHALE® 200/10 mcg demonstrated non-inferiority to ADVAIR DISKUS† (FP/S-DPI) 250/50 in FEV1 AUC0–12 h at Week 12 (LOCF): Mean change in FEV1 from baseline to Week 12 = 3.43 vs. 3.24 L X h, respectively (95% CI -0.40, 0.76)2

References: 1. ZENHALE® Product Monograph. Merck Canada Inc. October 21, 2014. 2. Bernstein DI, et al. Efficacy and onset of action of mometasone furoate/formoterol and fluticasone propionate/salmeterol combination treatment in subjects with persistent asthma. Allergy Asthma Clin Immunol. 2011; 7:21 LOCF = last observation carried forward. FEV1 = forced expiratory volume in 1 second. MDI = metered dose inhaler. FP/S = FLUTICASONE PROPIONATE/SALMETEROL. DPI = dry powder inhaler. MF/F = MOMETASONE FUROATE/ FORMOTEROL. ‡ This was a 12-week, multicentre, randomized, open-label, evaluator-blind, active-controlled, non-inferiority and safety study of patients 12 years of age and older with uncontrolled persistent asthma previously treated with medium-dose ICS with or without a LABA (n=722). The effects of ZENHALE® (MDI) and ADVAIR DISKUS† (FP/S-DPI) combination therapies were compared. The study was designed to assess the non-inferiority of ZENHALE® 200/10 compared with ADVAIR DISKUS† (FP/S-DPI) 250/50 in their effect on lung function as measured by the change from baseline (mean of 2 predose measurements on Day 1) to Week 12 (last observation carried forward [LOCF]) in area under the curve (AUC) in FEV1 measured serially over 0-12 hours postdose (FEV1 AUC0-12 h). As a key secondary assessment, the study was also powered to assess whether ZENHALE® was superior to ADVAIR DISKUS† (FP/S-DPI) in onset of action (ie, change from baseline in FEV1 at 5 minutes postdose on Day 1) if lung function non-inferiority was demonstrated. ZENHALE® was administered as 2 inhalations, twice daily. ADVAIR DISKUS† (FP/S-DPI) was administered as 1 inhalation, twice daily.2 †All trademarks are properties of their respective owner(s). ® MSD International Holdings GmbH. Used under license. © 2016 Merck Canada Inc. All rights reserved.

Printed in Canada

Member of Innovative Medicines Canada

See additional safety information on page 63 xx

Let the fun begin at Sandbanks Provincial Park.

Prince Edward What to know before you go by Lin Stranberg

ometimes you want to be in the heart of the action, even when you’re trying to get away from it all. The beautiful countryside of Ontario’s Prince Edward County (PEC) gives visitors a buzz

with its wineries, great food, vibrant creative culture and highly photographable locations. Just a few hours drive from Montreal, Ottawa and Toronto, and a free 15-minute ride from Kingston on the Glenora Ferry (prince-edward-county.com/glenoraferry-free), the area is one of the best made-in-Canada touring spots you’ll find — one of those rare places that

Doctor’s Review • MAY 2016

draws big-city exiles in droves, resulting in an appealing mix of country comforts and urban sensibilities. The County, formerly known as the Bay of Quinte area, is a wine-growing region on a headland at the eastern end of Lake Ontario. Technically, it became an island in 1889 when the Murray Canal opened the lake to the Trent-Severn Waterway.

County LIN STRANBERG

Picnic PEC ranks as one of the best food trucks in the country.

Food trucks, boutique wineries, farm-to-fork dining, hiking and cycling, PEC is made for easy unwinding. Nothing requires much organizing and self-guided tour routes are just a click away. You can enjoy fabulous local food and wines while meandering down quiet country roads on the Taste Trail (tastetrail.ca), visit artists’ studios and galleries on the Arts Trail (artstrail.ca) or hike the nature trails of Sandbanks Provincial Park (ontarioparks. com/park/sandbanks) with its hill-sized sand dunes and balmy beaches. Hop and barley farms have morphed into vine-

LIN STRANBERG

VALESTOCK / SHUTTERSTOCK.COM

Feast your eyes on infinite shades of green all over PEC.

yards and wineries with a younger personality and provenance than their Niagara Peninsula cousins. Some offer woodland hikes and other extras like the Loft Art Gallery at Karlo Estates (karloestates.com), worth a stop just to try their distinctive white port. Although PEC is a great getaway any time of year, June may be the ideal month to go. Feast your eyes on the infinite shades of green rolling out on both sides of the Loyalist Parkway and treat yourself to some of the culinary delights the County is known for that run the gamut from down-home to sophisticated. Pick up a sandwich, gluten-free if that’s your MAY 2016 • Doctor’s

Review

French comestibles in Maison Depoivre’s cupboard.

fancy, at Schroedter’s Farm Market (schroedtersmarket. com). Or drop in down the road to shop the artful display of fine olive oils and French comestibles at Maison Depoivre (maison-depoivre.ca), a boutique B&B and gourmet shop by French émigrés Vincent Depoivre and Christophe Doussot who fell in love with the County and moved to Canada in 2012.

he marquee event in June is the Great Canadian Cheese Festival (cheesefestival. ca), an annual County happening that’s the biggest cheese show in North America. It’s scheduled for June 5 and 6 this year and will be held at the 19th-century Crystal Palace at Picton Fairgrounds. The focus is on artisanal and farmstead cheeses, and on makers rather than mongers, so you’ll get to sample a dazzling variety of cheeses and connect with the people who actually produce them. A bite of brie here, a taste of cheddar there, and soon you’ve fallen in love with the stuff. At the 2015 event, we met established producers like Albert Borgo of Quality Cheese (qualitycheese. com) from Vaughan, Ontario; celebrated talents like Jean Morin of Quebec’s Fromagerie du Presbytère (fromageriedupresbytere.com) and young up-and-comers like Shep Ysselstein and his wife Colleen Bator who

Doctor’s Review • MAY 2016

The Drake’s happy restaurant deck.

started up Gunn’s Hill Artisan Cheese (gunnshill cheese.ca) on the family farm near Woodstock. Debra Amrein-Boyes from Agassiz, BC, told us why many of her Farm House Cheeses (farmhousecheeses.com) were intensely yellow — it’s the beta carotene in her cows’ diet! If you book ahead, you can choose activities like a cheese seminar, tasting program, cooking with cheese class, local cheese tour or an informal Saturday night of food and drink. The big ticket, and by far the hardest to come by — they sell out way in advance — is the Saturday night dinner prepared by celebrity chef Jamie Kennedy (ryanktaylor.com/clients/ jamiekennedy), long time local food advocate and County ambassador, at his nearby farm. You don’t have to be a cheese lover to have a good time. There are all kinds of other offerings including

LIN STRANBERG

Take in the Canadian Cheese Festival, June 5-6.

LIN STRANBERG

Cheese pleases all over the county.

GARY BLAKELEY / SHUTTERSTOCK.COM

The 1887 Crystal Palace at the Picton Fair Grounds.

LIN STRANBERG

If you bring your bike, ride the road to Sandbanks and hike the high dunes once youâ&#x20AC;&#x2122;re there

Help protect your patients from invasive disease caused by Neisseria meningitidis serogroup B strains (MenB). 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 with any vaccine, BEXSERO® may not protect all vaccine recipients. BEXSERO® is not expected to provide protection against all circulating meningococcal serogroup B strains.

BEXSERO

The first and only vaccine for active immunization against meningococcal disease caused by serogroup B strains

1,2*

For more information about BEXSERO ®, please contact GSK Medical Information at 1-800-387-7374. Indications and clinical use: • Protection against invasive meningococcal BEXSERO is indicated for active immunization disease caused by serogroups other than of individuals from 2 months through 17 years serogroup B should not be assumed old against invasive disease caused by • As with any vaccine, BEXSERO may not N. meningitidis serogroup B strains. fully protect all vaccine recipients • Anxiety-related reactions, including As the expression of antigens included in vasovagal reactions (syncope), the vaccine is epidemiologically variable hyperventilation, or stress-related reactions in circulating B strains, meningococci that may occur in association with vaccination as express them at sufficient levels are predicted a psychogenic response to the to be susceptible to killing by vaccine-elicited needle injection antibodies. • Administration of BEXSERO should be Contraindications: postponed in subjects suffering from an • BEXSERO should not be administered acute severe febrile illness to individuals with hypersensitivity to • Temperature elevation may occur following this vaccine or to any ingredient in the vaccination of infants and children (less than formulation or components of the 2 years of age). Antipyretic treatment can container closure. be initiated according to local Relevant warnings and precautions: treatment guidelines • The vaccine is not expected to provide • Availability of appropriate medical treatment protection against all circulating strains of and supervision in case of an anaphylactic meningococcal serogroup B strains event following administration of the vaccine ®

• Risk of apnea in premature infants; consider respiratory monitoring for 48-72 hours • Caution in subjects with known hypersensitivity to latex • Vaccine use in kanamycin-sensitive recipients has not been established • Individuals with thrombocytopenia, hemophilia or any coagulation disorder that would contraindicate intramuscular injection • The expected immune response may not be obtained after vaccination of immunosuppressed patients

Adverse events: The most frequent (these may affect more than 1 in 10 people) local and systemic adverse reactions after vaccination with BEXSERO observed in clinical trials were: ®

Infants and children (less than 2 years of age): • local reactions – tenderness, erythema, induration, pain, swelling • systemic reactions – change in eating habits, fever ≥38 °C, irritability, unusual crying, sleepiness, vomiting, diarrhea, rash Children (aged 2 years through 10 years): • local reactions – pain, tenderness, erythema, induration, swelling • systemic reactions – change in eating habits, sleepiness, diarrhea, irritability, unusual crying, arthralgia, vomiting, headache, rash, fever ≥38 °C Adolescents and adults (11 years or older): • local reactions – pain, erythema, induration • systemic reactions – malaise, headache, muscle and joint pain, nausea, myalgia Recommended dose and dosage adjustment: Infants aged 2 months through 5 months: The recommended immunization series consists of four doses, each of 0.5 mL. The primary infant series consists of three doses, given at 2, 4 and 6 months of age, followed by a fourth dose (booster). The primary series can also be given at 2, 3 and 4 months of age, but the immune response to the NHBA antigen is lower. With both schedules, a fourth dose (booster) is required in the second year of life between 12 and 23 months of age. It is preferred this dose be given early in the second year of life, whenever possible. Unvaccinated infants aged 6 months through 11 months: The vaccination schedule consists of three doses each of 0.5 mL with an interval of at least 2 months between the first and second dose. A third dose is required in the second year of life with an interval of at least 2 months between the second and third dose. The need for further booster doses has not been established. Unvaccinated children aged 12 months through 23 months: The vaccination schedule consists of two doses, each of 0.5 mL, with an interval of at least 2 months between doses. The need for a booster dose after this vaccination schedule has not been established. Children aged 2 years through 10 years: The vaccination schedule consists of two doses, each of 0.5 mL, with an interval of at least 2 months between doses. The need for a subsequent dose after this immunization schedule has not been established. Individuals aged 11 years through 17 years: The vaccination schedule consists of two doses, each of 0.5 mL, with an interval of at least 1 month between doses. The need for a subsequent dose after this vaccination schedule has not been established. Administration: BEXSERO should be given by deep intramuscular injection, preferably in the anterolateral aspect of the thigh in infants or in the non-dominant deltoid muscle region of the upper arm in older subjects. ®

Separate injection sites must be used if more than one vaccine is administered at the same time. The vaccine must not be injected intravenously, subcutaneously or intradermally and must not be mixed with other vaccines in the same syringe. BEXSERO must not be mixed with other medicinal products.

Hop and barley farms have morphed into vineyards with a younger personality than their Niagara Peninsula cousins wines, beers and ciders, meats, preserves, tapas and crafts. The live music is certain to be wonderful, there are food trucks and dairy farm animals for the kids, including a water buffalo. The County has hotels and B&Bs galore. At the top of everyone’s list these days is the Drake Devonshire Inn (drakedevonshire.ca; doubles from $279 a night in summer), a breakout country hit known as “the Drake by the lake” from indie hotelier Jeff Stober of Toronto’s Drake Hotel. Fresh, cool and playful, this is Prince Edward County’s hip retreat of choice. With only 11 rooms and two suites, it’s pretty well sold out every weekend from here to eternity, but you can usually book lunch or dinner on the deck or in the restaurant under soaring ceilings of Douglas fir. It oversees the shoreline and offers unbroken Lake Ontario views. Head Chef Matty deMille’s kitchen plays up the Drake vibe, artfully simple with a twist of fun. After dinner, stay for a game of ping-pong or a beanbag toss on the lawn. Whether you’re a day-tripper or book in for a few days, if you live within a day’s drive of Prince Edward Country make a point of visiting soon. It’s sure to be one of the summer’s highlights. For more info on travel to the region, visit Prince Edward County Tourism (prince-edward-county. com).

For more information: Please consult the Product Monograph at myg.sk/bexseroPM 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 1-800-387-7374. To report an adverse event, please call 1-800-387-7374. *Comparative clinical significance is unknown. References: 1. BEXSERO Product Monograph. December 11, 2015. 2. 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. ®

MEDICAL QUIPS Chart notes vegetable “She doesAsian indeed havenoodle fear soup. of frying and mental problems she attributes to deep-fat fryers.”

01403 04/16

MAY 2016 • Doctor’s

Review

Home sweet houseboat A slow cruise along BCâ&#x20AC;&#x2122;s Shuswap Lake aboard a decked-out three-storey watercraft that you sail yourself text and photos by Margo Pfeiff

Wild Rose Bay is a secluded and rarely visited park because of its distance from the highway.

need your captain and co-captain, please,” said Sharon Thomson. I hauled my friends, Cheryl and Louise, from in front of a mirror in Waterway Houseboats’ nautical-themed gift shop where they were doubled-over with laughter posing in pirate and sailor caps. MAY 2016 • Doctor’s

Review

Askew’s Foods carries over 900 local products and will stock your boat’s fridge and cupboards before your trip.

The group’s overnight on Marble Point began with driving metal stakes into the ground to anchor the boat.

Land excursions included an afternoon of tastings at some of North America’s most northerly wineries.

Herald Provincial Park is a popular day-use area for swimming, fishing and nature walks to sites like Margaret Falls.

“It’s a man cave on floats,” Cheryl announced. “Some guy made a wish list of everything he wanted and strapped it onto two pontoons.” After two hours of instruction and a mini test drive, Louise glided our hefty houseboat away from the dock in Sicamous, BC towards a Canadian Pacific Railway bridge that swung open to allow our threestorey-tall Where’s My Cheque? to pass into Shuswap Lake where we would spend the next four days exploring some of its 1000 kilometres of shoreline. Shuswap is an H-shaped lake in the less-touristed northeastern corner of British Columbia’s Okanagan region, a 90-minute drive from the bustling wine-country hub of Kelowna. Tiny Sicamous, perched on a narrow natural channel between Mara and Shuswap Lakes, officially calls itself “Canada’s Houseboat Capital” and has three rental companies with 160 boats of various sizes sleeping from 10 to 30 to prove it. Ours was a 20-metre-long, four-metre-wide Genesis 60 that could bed 16, making it spacious for just four of us, including my sister Linda who made the five-hour drive up from Vancouver with our friends Cheryl and Louise. As we glided towards Marble Point, our overnight destination, we prowled our floating apartment. It came complete with a full kitchen, queensized beds, a fireplace, flat screen TV, satellite radio and stereo system, two barbecues to grill any trout you pull in using the fish-finder, a hot tub with a wet bar on Deck 2, and a crazy spiral tube slide departing from Deck 3. “It’s a man cave on floats,” Cheryl announced. “Some guy made a wish list of everything he wanted in life and strapped it onto two pontoons.”

hile Captain Louise — with 17 years of coastal BC commercial fishing experience under her belt — first drove the houseboat bow up onto the pebble beach in the early afternoon, Cheryl and I hopped ashore with a sledgehammer to drive metal stakes into the ground to secure two ropes from the rear of the craft to hold it in position for the night. We were an active quartet of 50-somethings anxious to launch our onboard toys to explore the lake’s four long, sprawling arms. Wobbling atop a standup paddleboard, I spotted a small bear foraging the shore as my sister paddled a kayak alongside me. We joined the others in the hot tub afterwards, sipping rum-laced Dark and Stormys that would become our trip’s signature cocktail, and watched bald eagles soar above.

My keen-cook sister, having volunteered as voyage chef, commandeered the galley’s granite island to make dinner. The previous day we had stopped at DeMille’s Farm Market (demillesfarmmarket.com) in the nearby main town of Salmon Arm for the region’s renowned local fruits and vegetables like “hand-snapped asparagus” and fresh cherries. Our next stop had been Askew’s Foods (askews foods.com), a grocery store that carries over 900 local products from cheese and charcuterie makers to artisanal bakers. We steered our overloaded cart to the checkout, informing the clerk we were houseboating. The next morning, our groceries were loaded into the craft’s spacious fridge, freezer and cupboards an hour before our departure. It’s also possible to order online, then simply walk onto a fully-stocked boat. Don’t want to cook the first night? Bahama John’s Seafood and Rib Shack (bahamajohnsrestaurant.com) in Sicamous will make sure a Southern/Bahamian meal is on board before you set sail. Several outfitters will even speedboat catered meals to you out on the water. With fresh salmon on the grill, we cracked open a frosty local Celista Ortega and watched the last rays of sun from the second-deck dining table as three other boats anchored down the beach, creating a tranquil little houseboat village.

ouseboating is a new activity for the four of us and like many people, we have long associated it with its 1980s and ‘90s reputation of loud music and all-night stag parties. That has largely changed with a new generation of active houseboaters who don’t want to binge or sit on the boat all day. “We can easily pick a party group and we direct them to Neilson Beach,” Sharon had told us. Otherwise, it’s mostly groups of families and friends coming for the solitude, spending time on the water and doing the many activities you can tap into by just pulling ashore. On the toy menu for hire were powerboats for waterskiing and wake-boarding, fishing gear and mountain bikes to launch on easy-access lakeside trailheads that are also perfect for hiking. You could dock at Hyde Mountain Golf Course and putt the afternoon away or scuba dive off Copper Island. Houseboat weddings are on the rise as are annual events like multi-day salmon-viewing floats during spawning season in the famed Adams River, and mushroom hunting and cooking classes during a local Fungi Festival in September. MAY 2016 • Doctor’s

Review

White-cap wind had stirred up overnight and made our 30-kilometre cruise to the region’s main town of Salmon Arm, population 18,000, a slow sail in our bulky houseboat the next morning. “It’s like steering a cardboard box with a toothbrush,” Louise muttered through clenched teeth as she coaxed Where’s My Cheque? into the Salmon Arm Wharf. A short stroll and we were on the main streets of this folksy town, dropping in at the art gallery, boutiques and second-hand bookstores before settling into lunch at the Shuswap Pie Company (shuswap piecompany.ca), which was justifiably featured on the Food Network’s You Gotta Eat Here for their madefrom-scratch pies like steak and stout using organic Back Hand of God Stout brewed by Crannóg Ales in nearby Sorrento. Dessert was luscious local fruit pie, cherry and peach. Afterwards, Byron Noble of Noble Tours (noble adventures.net; wine tasting or hiking tours from $99 per person) whisked us off in a van for an afternoon of tastings at some of the region’s half-dozen little-known wineries that are North America’s most northerly, offering cool-climate white wines including Ortega, Siegerrebe, White Bacchus and Kerner, and reds including locally-grown Marechal Foch. We sipped our way from the Swiss family-run Larch Hills to Sunnybrae with its views and vintage photos of the family’s five generations of local farming, stocking up along the way. Then we popped in to sample cheeses on the farm at Grass Root Dairies before finishing up at the stylish log winery of Recline Ridge, which scooped 24 medals in Northwest wine competitions in 2014. The winery is actually accessible by houseboat, just a short walk up a hill from the beach.

he next morning the lake was a millpond as we headed eastward past a community called Canoe and across Salmon Arm to Herald Provincial Park (env.gov.bc.ca/bcparks/explore/parkpgs/ herald). Dropping stakes, we brewed a second cup of coffee before hiking amid cedar and firs and old downed trees lying scattered like mossy pick-up sticks until we reached the bridal-veil spray of Margaret Falls. Herald Park is one of many spots where you can hook into 103 hiking and mountain biking routes that cover a network of more than 800 kilometres of trails overseen by the Shuswap Trail Alliance (shuswaptrails.com), accessible by houseboat from lakeside trailheads. After spreading a lunch of local goodies on a picnic table overlooking the lake, watching kayaks paddle by and snow geese pass overhead on a major migratory flyway, Louise let loose three blasts of the horn as we backed offshore and sailed again. Houseboating is slow cruising at a leisurely top speed of six kilometres per hour. We passed waterfront cottages,

Doctor’s Review • MAY 2016

coves, beaches and lighthouses at the base of rocky cliffs with hidden petroglyphs. As we approached Cinnemousun Narrows where the four arms of the lake meet, a floating corner store awaited those who craved a slice of hot pizza or needed to stock up on supplies or kitschy souvenirs. We passed through the Narrows, made a left turn and prowled the waterfront, choosing our own private beach on Wild Rose Bay. We worked the waterslide until we were dizzy from spinning then lit a beach fire after dinner. I swam before breakfast the next day, paddled before lunch and took in some sun on the top deck in the afternoon. We watched ospreys overhead and a beaver swimming in the lake. Sizable trout leapt clear out of the water and we regretted not having rods. No one pulled in alongside us and we saw only distant houseboats chugging on the lake. We were grateful we came in June, shoulder season which, along with May and September, is quieter with fewer house and power boats than the July/August high summer season. In late afternoon we once again pulled up stakes and puttered off on our floating cottage… with a different view every day.

Captain Louise piloted the boat and you can too after a two-hour course and mini test drive.

Shuswap Lake is one of the most popular recreational water destinations in BC.

NAVIGATION NOTES

The colourful Artists House Heritage B&B is within minutes of the houseboat docks.

You can choose from six houseboat models at Twin Anchors: the smallest sleeps up to six, the largest up to 24.

Fly to Kelowna International Airport. Greyhound (greyhound.ca) runs several buses daily on the two-hour, 100-kilometre ride to Sicamous for $30 one way per person. Or catch a Noble Adventures (nobleadventures.net) one-hour 15-minute personal shuttle for $60 per person one way with a three-person minimum. Waterway Houseboat Vacations (waterway houseboats.com) offers various-sized boats that sleep 10 to 30. Rent for three-day weekends (from $1365), four-day mid-weeks (from $1335) or seven days (from $1985). Pilot the boat yourself or request a captain. The houseboat season runs from May 1 to September 30; May, June and September are quieter with lower rates. Sheets and towels supplied on request. For more on rates, go to waterwayhouseboats.com/plan-yourholiday/rates-at-a-glance. There are two other houseboat companies in the area: Twin Anchors (twinanchors.com) and Bluewater (bluewaterhouseboats.ca). Artists House Heritage B&B (artistshouse.ca; from $100 per night) is a funky, art-filled heritage house run by a charming artist owner. It over足looks Shuswap Lake and is within minutes of the houseboat docks. Full breakfast included. For more info on travel to the region, visit Shuswap Tourism (shuswaptourism.ca) and Destination British Columbia (hellobc.com).

BuTrans : The first and only pain treatment with 7-day dosing:1,2 ®

• A low starting dose (5 mcg/h) with ﬂexible dosing (5/10/20 mcg/h).1

Refer to the page in the bottom-right icon for additional safety information and a web link to the Product Monograph discussing: • Contraindications in ileus; suspected surgical abdomen; mild, intermittent or short duration pain that can otherwise be managed; management of acute pain; management of perioperative pain; acute asthma or other obstructive airway and status asthmaticus; acute respiratory depression; alcoholism, delirium tremens and convulsive disorders; severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury; MAO use; pregnancy, labour and delivery or breast-feeding; opioid-dependent patients and for narcotic withdrawal treatment; myasthenia gravis; severe hepatic insufﬁciency • The most serious warnings and precautions regarding limitations of use; addiction, abuse, and misuse; life-threatening respiratory depression; accidental exposure; neonatal opioid withdrawal syndrome; dosage initiation: doses higher than 5 mcg/h in opioid-naïve patients; maximum dosage: 20 mcg/h every 7 days; serum concentrations; depot formation; transdermal use; dependence/tolerance; and overdose • Other relevant warnings and precautions regarding unintentional increase in drug exposure including application of external heat; acute abdominal conditions; hypotensive effects; concomitant use of CYP3A4 inhibitors or inducers; not approved for managing addictive disorders; hepatic, biliary and pancreatic disease; application site skin reactions, neurologic considerations; psychomotor impairment with caution in activities requiring mental alertness; chronic pulmonary disease; special risk groups; disposal of BuTrans® • Conditions of clinical use, adverse reactions, drug interactions and dosing instructions

Adults: BuTrans® (buprenorphine transdermal patch) is indicated for the management of pain severe enough to require daily, continuous, long-term opioid treatment, and that is opioid-responsive and for which alternative options are inadequate. See additional safety information on page 62 xx

Lima’s bohemian Barranco district is home to cafes, art studios and historic buildings like Iglesia la Santísima Cruz. INSET LEFT: Huancaina sauce is made with queso fresco cheese, garlic and local Amarillo pepper, and served with potatoes at Casa Moreyra. INSET RIGHT: Rare rib eye in tempura crust is just one of the PeruvianJapanese concoctions that Chef Tsumura dishes up at Maido.

Lima’s

food revo

olution

The Peruvian capital is now one of the best places on earth to dine text and photos by Cinda Chavich

ima was not always an A-list destination and it still has its struggles. After decades

MAY 2016 • Doctor’s

Review

of violent civil war, the country is finally enjoying peace and stability. There are still great disparities in this city of nearly 10 million, but on the gastronomic side, there’s no place like it. I’ve been in Lima for just 48 hours and already I’ve consumed 65 creative courses — four ambitious tasting menus from a quartet of the city’s most celebrated chefs. Lima is the latest mecca for food lovers. In 2015, new spots were named to the San Pellegrino World’s 50 Best Restaurants list including Central (#4), Astrid y Gastón (#14) and Maido (#44), with Malabar (#7) already among the 50 Best Latin American restaurants. And I’m determined to taste it all.

From Astrid y Gastón’s Casa Moreyra (clockwise, this page): a rillette of cuy (guinea pig) on purple corn; Chef Diego Muñoz in the kitchen; fish on roasted cauliflower puree with red quinoa and baby peas; cold Peruvian coffee topped with warm foamed milk and lucuma truffles rolled in cocoa.

The Peruvian food revolution started with chef Gastón Acurio, a mentor to many of the current crop of top chefs and a promoter of all things Peruvian. His elegant flagship restaurant, Astrid y Gastón, was one of the first to break through more than 20 years ago. Now with dozens of restaurants around the world, he’s a local celebrity known as “the king of Peruvian cuisine.” Some even suggest he should be the country’s next president. His wife, Astrid Gutsche, is the queen of cocoa, working with small Peruvian communities to develop top quality chocolate, and creating the amazing finales to your meals — think chocolate spheres filled with cinnamon-scented sweet potato ice cream in a toffee sauce with salty Andean corn. Whether it’s this upscale molecular gastronomy, a modern take on Peruvian-Chinese food (aka Chifa) at Madam Tusan, his famed cevicheria La Mar, or the rustic anticuchos and causa at his casual, Creole-inspired Panchita restaurant, Acurio has built an empire by celebrating Peru’s varied traditions and flavours.

curio’s head chef, Diego Muñoz, greets us on the colonnaded balcony of Casa Moreyra (astridygaston.com) in San Isidro, yet another Acurio property. The elegant 17th-century hacienda and national monument was recently restored and re-imagined to house the establishment. Like the modernized décor, the multi-course menu is both avant-garde and rooted in Peruvian tradition. “It’s a chance to showcase our culture,” says Muñoz. “Biodiversity in Peru is huge — it’s one of the strengths of our cuisine — and there are so many amazing different cultures here that have influenced us. I’m here discovering my own country.” Below us, in the hacienda’s original courtyard, a glass-walled kitchen houses their “science lab” where local plants, roots, tubers and other indigenous foods are investigated.

Doctor’s Review • MAY 2016

From the deep fried arracacia root chips to the frozen orb of frizzled leek and artichoke, a rillette of cuy (guinea pig) set on purple corn and razor clam escabeche, a series of small starters begin the tasting

“Biodiversity in Peru is huge — it’s one of the strengths of our cuisine — and there are so many cultures here that have influenced us” menu. By the time we finish the spiral-cut avocado ceviche in “tiger’s milk,” a lime and chili marinade used to cure raw fish, rustic golden huancaina sauce ground tableside in a stone batan with potatoes roasted in a simulated pachamanca oven smoking in the middle of the table, five desserts followed by chocolate and lucuma truffles with a cold Peruvian coffee topped with warm foamed milk, I’ve counted 30 courses. Dining in Lima is serious business.

From Central (counterclockwise, this page): river snails, gamitana and sangre de grado; the restaurant’s open kitchen behind glass; Chef Virgilio Martínez and his collection of wild indigenous ingredients foraged from the Andes to the Amazon.

hef Virgilio Martínez is slight and soft spoken, with the lithe body of a dancer or marathon runner beneath his long denim apron, and the measured speech of an intellectual. The large, modern kitchen of his award-winning restaurant, Central (centralrestaurante.com.pe), sits behind a wall of glass, an appropriate setting for his creative cooking that combines both culinary and performance art, plates inspired by Peru’s unique terroir. From below sea level to the 3900-metre Andean plateau, Martinez gleans his ingredients and ideas from the land. And so tonight we dine on lettuce, scallops and granadilla, foraged at “0 metres;” wild yacon root, smoked duck, fig-like zapote fruit and peppery nasturtium from the high altitude rain forest (860 metres); lucuma, cacao and chaco clay (an edible medicinal mineral that’s part of indigenous diets) from the Green Highlands (1050 metres), and tunta (dried Andean potatoes, 3900 metres) on his 11-course Mater Ecosystems menu. Martinez is one of the most celebrated of the new Peruvian chefs. He combines classic French and modern molecular technique with an almost scientific approach to Peru’s vast array of indigenous ingredients. He studied cooking at Le Cordon Bleu in Ottawa and London after attending law school, and honed his restaurant chops as executive chef for Astrid y Gastón locations in Bogotá and Madrid.

MAY 2016 • Doctor’s

Review

“Different altitudes, different ecosystems, different ingredients,” he says, as we tour the kitchen, a space that is literally open to the sky, encircled by an open walkway that leads to a rooftop garden. He points out the drying cabinet, where wild-crafted herbs hang in bunches, and a massive white board, covered with sticky notes and photos, where the menu at Central evolves daily. Ascending the wide staircase in the sleek, modern dining room, we reach his laboratory where the

From Maido (top to bottom): Chef Mitsuharu Tsumura posing for a selfie with a patron; deconstructed ceviche and tiger’s milk crumble topped with raw fish and avocado; bonito tuna tartare with crispy potato and quail egg.

collection of plants, leaves, roots and bark he’s gathered from the Andes to the Amazon are dried, preserved and catalogued. It’s all part of his Mater Inciativa, a project to “link the cultural and biological diversity of Peru with the culinary experience,” he says. The chef speaks of scientists and villagers, local lore and ancient history, when he describes the process of creating the odd and inventive dishes that have been laid before me. In this hyper-local world of food foraging, there are roots and herbs with traditional medicinal value and others with properties and flavours yet to be discovered. It’s late, and though there is much more to explore, the team of waiters do their best to explain all of the unusual ingredients on the plate, whether it’s the juicy yacon, reminiscent of Asian pear, or the fuchsia flower petals of sangre de grado. It’s an intellectual pursuit as much as a meal.

t Maido (maido.pe), chef Mitsuharu Tsumura laughs easily and exudes hospitality. He is the face of Nikkei cuisine, a melding of Peruvian and Japanese flavours that’s evolved naturally here over a century and is now on the cutting edge of what diners in Lima love. Tsumura, or Micha as he’s known to his friends, and his convivial restaurant have rocketed to the top of the food world’s radar with a #14 nod on the World’s 50 Best Restaurants list. Why is this traditional Peruvian/Japanese food suddenly so popular? Perhaps it’s the connection with Nobu, the famed Japanese chef who opened his first sushi bar in Lima in 1973, or the endorsement of top chefs like Spain’s Ferran Adrià, who now serves his own version of Nikkei at Pakta in Barcelona (they both write forwards in Micha’s massive new book, Nikkei es Peru). Or maybe it’s just because Micha does it so well. At an epic 16-course Nikkei Experience lunch in this contemporary space, there is nary a misstep — just tiny, beautiful bite, after beautiful bite. Each little plate is a study in colour and texture. The Japanese sensibility, be it brought to cuy san, confit of guinea pig, tossed with soy and sugar and deep fried, then served with yucca cream and sprouts; a perfect ball of rare rib eye in an ethereal tempura crust; a single prawn with tobiko and quinoa cracker in a slurry of corn chichi; or the tiger’s milk of ceviche turned into a cold citrusy crumble with liquid nitrogen and topped with raw fish and avocado. “Traditionally Nikkei is comfort food,” says Micha, stopping to pose for a selfie with a satisfied customer. “It’s a Peruvian stew with steamed rice or a Japanese ceviche, the citrus just added at the last minute. We’ve taken it to the next step.” For more on Peruvian tastes, including a list of foods to try, go to doctorsreview.com.

Doctor’s Review • MAY 2016

TOP ROW: Take a food tour with Da Lima Gourmet and learn how to shake up a pisco sour, make ceviche as well as sample cacao.

Street vendors in the city centre sell everything from marinated beef heart and grilled “mystery meat” hot dogs to desserts like mazamorra morada (sweet purple corn pudding) and arroz con leche (Peruvian rice pudding).

FOOD FIESTAS Get your Limeñan culinary legs with a walking tour of foodie hot spots with Da Lima Gourmet Co. (limagourmetcompany.com; from US$40). It’s a food tour and a city tour rolled into one, and includes a visit to a local food market to sample exotic fruits, sip an addictive lucuma smoothie, shake up a perfect pisco sour and even create a DIY ceviche lunch. The weather in Lima is warm and dry year round, but if you want to eat well, plan your trip to coincide with Mistura (mistura.pe, website in Spanish only), Latin America’s largest food fest, scheduled for September 2 to 11 this year. The outdoor event features demonstrations from top local and visiting chefs, tastings of Peruvian specialties from cacao to ceviche, popular street food vendors, entertainers, and farmers at the Gran Mercado offering hundreds of varieties of potatoes, chili peppers, exotic fruits and colourful corn. Download the festival app from their website for daily updates.

The catch grilled cheese.

Napa cabbage kimchi.

KOREAN FIRE (and fermentation) A classic kimchi recipe plus spicy specialties for an Asian feast

recipes by

Deuki Hong

and

Matt Rodbard

photos by

n Koreatown, chef Deuki Hong and food writer Matt Rodbard explain that “Korean food is never, ever, a boring time.” Bright, bubbling, oftentimes

funky and spicy, Korean mealtime is almost always a feast with a parade of complimentary small plates called banchan. There are nearly two million people of Korean heritage living in the US, with nearly 230,000 living in Canada. The Koreatown cookbook consists of 100 of the best recipes from Koreatowns across the US as well as stories and portraits of cooks, grocers and ice cream makers. The book’s images were captured “live” in the over 125 bars, markets and restaurants that Hong and Rodbard visited. Our favourites follow.

Doctor’s Review • MAY 2016

Sam Horine

NAPA CABBAGE KIMCHI (Baechu kimchi) Napa cabbage: the granddaddy of all kimchi. There are literally thousands of different kimchi recipes tied to the seasons, but this is the kimchi that people think of when they hear the word kimchi. Traditionally, napa kimchi is made in the late autumn (October through December) to prepare for the famously harsh Korean winter. The tradition is called kimjang and back in the day entire

communities got together to make it in large batches. We’re talking as many as 100 heads of cabbage at a time, with recipes passed down village to village, generation to generation. But you can certainly make yourself a batch any time if you can find plump and healthy napa cabbage. For the cabbage 12 c. (3 L) water 1 c. (250 ml) coarse sea salt 1 large napa cabbage (2 to 3 lb. / 1 to 1.5 kg) For the rice flour paste 2 tbsp. (30 ml) sweet rice flour 1 c. (250 ml) water For the marinade 1 small onion, roughly chopped ½ c. (125 ml) roughly chopped, peeled Asian pear 2-inch (5-cm) knob of ginger, roughly chopped 6 garlic cloves, minced 4 Korean red chili peppers, trimmed and cut in half ¼ c. (60 ml) water ½ c. (125 ml) salted fermented shrimp ¼ c. (60 ml) sugar ½ c. (125 ml) rice flour paste 1 c. (250 ml) coarsely ground gochugaru (Korean red chili flakes) 1 bunch scallions, green parts only, thinly sliced 1 carrot, grated ½ c. (125 ml) peeled and grated daikon radish

In a large container, combine 12 cups (3 L) of cold water and the sea salt. Cut the napa cabbage head lengthwise, then into quarters. Place in the salt water and brine for 6 hours at room temperature. The brining step both adds flavour and opens the cabbage’s pores, allowing the marinade to soak in. Rinse in cold water and have a little bite. If you would prefer it saltier, brine for another 6 hours to overnight. Once the cabbage is brined, make the rice flour paste. In a small saucepan over medium-high heat, continually whisk the sweet rice flour and 1 cup (250 ml) water until it reaches a boil. Keep whisking for 2 minutes until it reaches a pudding-like consistency.

Remove from heat, transfer to a container and refrigerate until cool. Combine the onion, Asian pear, ginger, garlic, chili peppers and ¼ cup (60 ml) water in a food processor and run until smooth, then transfer to a large bowl. Add the shrimp, sugar, rice flour paste, gochugaru, scallion greens, carrot and daikon, and combine well. Drain the brined cabbage, rinse each piece well in cold water and place them in a very large bowl. While wearing plastic gloves, toss the cabbage with the marinade, coating well. Transfer to clean, large glass jars or clean plastic containers with lids that fit snugly. You can cut the cabbage to fit if you want, or keep the leaves whole and pack them tightly in the jars. Affix the lids, though not too tightly, and place the jars in a cool, dark and dry space, and allow to ferment for 1 day. (Heads up: the fermentation process may cause some kimchi juice to bubble over, so place the jars in a plastic bag.) When done, refrigerate for 5 to 7 days or until the kimchi has reached your desired level of funk. It will keep up to a month in the refrigerator to enjoy eaten directly from the container, or longer for use in further cooking. Makes about 2 quarts (2 L).

SPICY CLAM SOUP (Jogaetang) It’s late. You need something to make you feel right again, but you don’t want that volleyball-in-your-gut feeling the next morning. For many Koreans, the answer is jogaetang — a light, satisfying clam soup that is often served at pojangmachas (a tented street wagon) on a portable butane burner and paired with beer and soju. In a good pot of jogaetang, the clear broth evokes the essence of the sea, so it’s a little briny, but not in an overpowering way. Heat from the jalapeños can be adjusted to your liking, but it shouldn’t overpower the dish either. The name of the game is balance and resetting the palate for the next round of drinks and snacks. 2 lbs. (1 kg) littleneck clams in the shell, scrubbed 3 c. (750 ml) water 1 4 × 4-inch (10 x 10-cm) square of kombu 1 garlic clove, sliced 1 jalapeño pepper, sliced, with seeds 1 Korean or Anaheim chili pepper, sliced sea salt, to taste 1 scallion, cut into 2-inch (5-cm) pieces, for garnish (optional)

Buying the cabbage Look for cabbage that appears healthy and fresh; remove the outer few layers if anything is browned. The remaining leaves should be tightly packed. The paste and marinade Next make the rice flour paste (an important binder) and the marinade, which includes an essential ingredient: salted fermented shrimp called saeujeot. While many recipes call for fish sauce, the salted shrimp add a pronounced flavour that is just too good to omit. Kimchi is alive and always changing Kimchi is all about personal taste, and some like their kimchi fresh, while others like it older and funkier. Our suggestion is to make a large batch (6 to 8 heads) and store it in several jars to sample after different time periods (five days, 10 days, two months etc.). But if you’re new to the kimchi making process, start small with the recipe here and scale up later.

MAY 2016 • Doctor’s

Review

Soak clams in cold water for 1 hour. This will rid them of sand and sediment. Lift the clams from the water, leaving the grit behind. In a large saucepan, bring 3 cups (750 ml) of water and the kombu to a boil over high heat. Boil for 3 minutes and remove the kombu. Add clams, garlic, jalapeño and Korean chili pepper, and boil for 4 minutes, or until the clam shells open. If there are stubborn closed clams, remove the opened clams to a bowl and continue to cook the unopened clams

Spicy clam soup.

for a few more minutes. If they still don’t open, discard them. Add salt to taste. Divide the soup in bowls with the clams, garnish with scallions and serve immediately. Serves 4.

SWEET SOYBRAISED CHICKEN (Andong Jjimdak) This Andong jjimdak is inspired by the version served at Yet Tuh in Doraville, Georgia. The sauce is the key, which is

based around the union of soy sauce, sugar, rice syrup, sake and oyster sauce. A handful of dried red chili peppers gives the sweetness a distinct kick. Andong is a city located in eastcentral Korea and some have traced the roots of this dish to a section of Andong Gu Market called Chicken Alley. It is there, they say, the dish was conceived in the 1980s as a way of competing with (or possibly joining) the growing Korean fried chicken craze that still remains today. Seoul food blogger Joe McPherson calls Chicken Alley the “beating heart of the best jjimdak in the world,” while adding not to wear a white shirt while enjoying the messy, transportive dish. 2 lbs. (1 kg) chicken thighs or legs salt and black pepper ¹⁄³ c. (80 ml) soy sauce, plus more to taste 2 tbsp. (30 ml) mirin ¼ c. (60 ml) sugar, plus more to taste 1 tbsp. (15 ml) Korean rice or corn syrup 1 tbsp. (15 ml) oyster sauce 1 tbsp. (15 ml) sake 1½ tbsp. (22.5 ml) sesame oil 2 tbsp. (30 ml) vegetable oil 2 russet potatoes, peeled and cut into large dice 1 medium carrot, cut into large dice 1 medium onion, cut into large dice 4 scallions, trimmed 8 garlic cloves, minced ½ c. (125 ml) roughly chopped cabbage 8 dried Korean or Anaheim chili peppers 1½ c. (375 ml) chicken stock 1 c. (250 ml) dried sweet potato noodles, soaked in water for 30 minutes and drained sesame seeds, for garnish

MEDICAL QUIPS Reading error “Be careful about reading Asian vegetable noodle soup. health books – you might die of a misprint.” — Mark Twain

advertisers index AMERICAN SEMINAR INSTITUTE Corporate................................................ 21 BOEHRINGER INGELHEIM (CANADA) LTD Inspiolto Respimat...............................OBC Trajenta.....................................................2 GLAXOSMITHKLINE Bexsero.................................................... 40 Breo Ellipta......................................64, IBC HEALTH NETWORK NORTHERN TERRITORY LTD. Corporate................................................ 11 LUNDBECK Trintellix................................................ 5, 8 MERCK CANADA INC. Zenhale.............................................. 34, 35 PFIZER CANADA INC. Alesse........................................................4 Pristiq...................................................... 30 PURDUE PHARMA BuTrans..........................................3, 48, 49 SEA COURSES INC. Corporate................................................ 10 SERVIER CANADA INC. Viacoram................................................. 24 TAKEDA CANADA INC. Dexilant.................................................IFC VALEANT CANADA Jublia.........................................................7 XLEAR INC. Xlear nasal spray...................................... 13

FAIR BALANCE INFORMATION

Sweet soy-braised chicken.

Lightly season the chicken thighs all over with salt and pepper. In a small bowl, combine the soy sauce, mirin, sugar, rice syrup, oyster sauce, sake, sesame oil and 1 teaspoon (5 ml) black pepper. Set a large, high-sided sauté pan or Dutch oven on high heat and add the vegetable oil. Once the oil is lightly smoking, add the chicken, skin side down, and sear for 3 minutes, or until lightly browned. Flip and sear the other side for another 3 minutes, or until lightly browned. Add the potatoes, carrot, onion, scallion, garlic, cabbage and dried chilies along with the soy sauce mixture and 1 cup (250 ml) of chicken stock.

Bring to a boil and lower heat to gently simmer for 20 minutes or until the vegetables are tender and the chicken is cooked through. Stir in noodles. Add more stock if needed to keep the dish saucy. Remove from heat. Taste and adjust seasoning with salt, pepper, soy sauce and sugar; you’re looking for a balance of sweet, salty and spicy. Serve with sesame seeds. Serves 4 to 6.

Bexsero.................................................... 41 BuTrans................................................... 62 Viacoram................................................. 25 Zenhale................................................... 63

Excerpted from Koreatown. © 2016 Matt Rodbard and Deuki Hong. Photographs © 2016 Sam Horine. Published by Clarkson Potter Publishers, an imprint of the Crown Publishing Group, a division of Penguin Random House. Reproduced by arrangement with the publisher. All rights reserved. MAY 2016 • Doctor’s

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D r F r e d e r i c k a Ab c a r i u s

Brooklyn links I love New York. This sounds like an ad campaign, but the city just evokes emotion. On my last visit, I chose to see it from a different point of view. I made my way to Brooklyn then walked back into the city across the famous Brooklyn Bridge. Great experience, lovely views. This picture was taken with the most simple, but impressive point-and-shoot of all, the iPhone 6S.

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

editors@doctorsreview.com

MEDICAL QUIPS What’s the difference between a GP and a specialist? vegetable noodle soup. One treatsAsian what you have, the other thinks you have what they treat.

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Doctor’s Review • MAY 2016

CROSS CURRENTS IN OSTEOARTHRITIS uu CONTINUED FROM PAGE 27 11. Heller L. Another vegetarian glucosamine launched in US. NutraIngredients-USA. 2008:8649. http://www.nutraingredients-usa.com/ content/view/print/8649. Accessed April 14, 2016. 12. McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthr Cartil. 2014;22(3):363-388. doi:10.1016/j.joca.2014.01.003. 13. da Costa BR, Reichenbach S, Keller N, et al. Effectiveness of nonsteroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: a network meta-analysis. Lancet. 2016. doi:10.1016/S0140-6736(16)30002-2. 14. Roberts E, Delgado Nunes V, Buckner S, et al. Paracetamol: not as safe as we thought? A systematic literature review of observational studies. Ann Rheum Dis. 2016;75(3):552-559. doi:10.1136/annrheumdis-2014-206914. 15. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012;64(4):465-474. doi:10.1002/ acr.21596. 16. Derry S, Moore RA, Rabbie R. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane database Syst Rev. 2012;9:CD007400. doi:10.1002/14651858.CD007400.pub2.

I PRESCRIBE A TRIP TO CROATIA uu CONTINUED FROM PAGE 33

Subsequently, the palace became incorporated into the town, with the buildings being converted into homes, cafés, shops and restaurants. Diocletian’s mausoleum has ironically been converted into a cathedral (Diocletian ruthlessly persecuted Christians). A cathedral tower built in the seventh century can be scaled on a rickety staircase for a spectacular view of the city and port. There are several nearby beaches and parks, but a must-see is the Mestrovic Gallery (mestrovic.hr, website in Croatian only). Ivan Mestrovic was a protégé of the French sculptor Rodin a century ago and became the pre-eminent sculptor of the Balkans. His home overlooking the sea was built to showcase his amazing works of art.

INLAND PLEASURES Transportation is generally quite easy. We travelled by car and availed ourselves of the excellent Croatian ferry service, Jadrolinija (jadrolinija.hr). I should mention that it’s also becoming popular to stay on small tour boats holding 30 to 40 people to tour the Dalmatian Coast from Zadar to Dubrovnik without having to transfer from hotel to hotel. It’s an appealing option and something we may do in the future. Zadar is a pleasant port city of 75,000 and in the Middle Ages it was a main base for the Byzantine fleet. The Church of St. Donat, built in the ninth century, is one of the finest examples of Byzantine

17. Hochberg MC, Martel-Pelletier J, Monfort J, et al. Combined chondroitin sulfate and glucosamine for painful knee osteoarthritis: a multicentre, randomised, double-blind, non-inferiority trial versus celecoxib. Ann Rheum Dis. 2016;75(1):37-44. doi:10.1136/annrheumdis-2014-206792. 18. Bruyère O, Cooper C, Pelletier JP, et al. An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: A report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arthritis Rheum. 2014;44(3):253-263. doi:10.1016/j.semarthrit.2014.05.014. 19. Fernandes L, Hagen KB, Bijlsma JWJ, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis. 2013;72(7):1125-1135. doi:10.1136/annrheumdis-2012-202745. 20. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee. Cochrane database Syst Rev. 2015;1:CD004376. doi:10.1002/14651858. CD004376.pub3. 21. Messier SP, Gutekunst DJ, Davis C, DeVita P. Weight loss reduces knee-joint loads in overweight and obese older adults with knee osteoarthritis. Arthritis Rheum. 2005;52(7):2026-2032. doi:10.1002/ art.21139. 22. Christensen R, Bartels EM, Astrup A, Bliddal H. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta-analysis. Ann Rheum Dis. 2007;66(4):433-439. doi:10.1136/ard.2006.065904.

architecture in Dalmatia. Zadar would become Zara under the Venetians, and after Napoleon in 1815, the Austrians took over until the end of World War I. Plitvice Lakes National Park (np-plitvicka-jezera. hr) is inland from the coast, north of Zadar. Breathtaking and serene, the park is a UNESCO World Heritage Site and not to be missed. The series of terraced lakes is connected by beautiful waterfalls spilling over the karst (white limestone) and linked by a network of trails, boardwalks and boats. To see the park’s main section, you need six to seven hours and a good pair of walking shoes. However, the paths are wide and the walking is not arduous. A shuttle bus takes you up to the top, then you traverse the lakes and spectacular waterfalls on footpaths and boardwalks. At the end of the first series of lakes and falls, a pleasant 20-minute boat ride takes you to a lunch stop with a variety of tasty food and beverages. Continue on after lunch and you’ll find that there are more trails and footbridges past cascading falls and a large cave, ending with the Great Falls, the highest in Croatia at 78 metres. We travelled to Dalmatia in July, which guaranteed hot sunny weather. Most days averaged around 35°C, which was great for beaching, but a lot of people might find this too hot for touring. June and September have more moderate temperatures so, depending on your availability and personal preference, I would prescribe a trip to Dalmatia any time from May through October. For more info on travel to the region, visit Croatia Tourism (croatia.hr). MAY 2016 • Doctor’s

Review

Clinical Use BuTrans® is not indicated as an as-needed (prn) analgesic. Elderly patients should be dosed cautiously and initiated on the lowest available BuTrans® strength. Use of BuTrans® is not indicated in patients <18 years old. Contraindications: • Ileus • Suspected surgical abdomen • Mild, intermittent or short duration pain that can otherwise be managed • Management of acute pain • Management of peri-operative pain • Acute asthma or other obstructive airway and status asthmaticus • Acute respiratory depression

• Alcoholism, delirium tremens and convulsive disorders • Severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury • MAO use • Pregnancy, labour and delivery or breast-feeding • Opioid-dependent patients and for narcotic withdrawal treatment • Myasthenia gravis • Severe hepatic insufficiency

Most Serious Warnings And Precautions: Limitations of use: Should only be used in patients for whom alternative treatment options are ineffective, not tolerated, or would be otherwise inadequate to provide appropriate management of pain. Addiction, abuse, and misuse: Assess patient risk prior to prescribing; monitor all patients regularly; store BuTrans® securely. Life-threatening respiratory depression: May occur with BuTrans® use. Monitor patients for respiratory depression, especially during initiation or following dose increases. Placing the patch in the mouth, chewing it, swallowing it or using it in any way other than indicated may cause choking or overdose that could result in death. Accidental exposure: Serious medical consequences, including death, may occur, especially in children. Neonatal opioid withdrawal syndrome: Can result from prolonged maternal use during pregnancy. Dosage: Initiation: Doses higher than 5 mcg/h should not be used in opioid-naïve patients; Maximum: 20 mcg/h every 7 days. Serum concentrations: Decline gradually. Patients who experienced serious adverse events should be monitored for at least 24 hours after BuTrans® removal or until the adverse reaction has subsided. Depot: Formation of a subcutaneous depot of buprenorphine results in continued exposure after patch removal. If the patch is removed prior to peak buprenorphine exposure, buprenorphine plasma levels may continue to increase after patch removal. Transdermal: BuTrans® patches are intended for transdermal use on intact skin only; use on compromised skin can lead to increased exposure to buprenorphine. Dependence/Tolerance: BuTrans® has potential for abuse, dependence of the opiate type, and diversion. Overdose: Primary management should be reestablishment of adequate ventilation with mechanical assistance of respiration, if required. Naloxone may not be effective in reversing any respiratory depression produced by buprenorphine. starting BuTrans®, when the dose has been adjusted, and Other Relevant Warnings And Precautions: when receiving other CNS-active drugs. Patients should be • Unintentional increase in drug exposure including application advised not to drive a car or operate machinery unless they of external heat are tolerant to the effects of BuTrans® • Acute abdominal conditions • Chronic pulmonary disease • Hypotensive effects • Special risk groups: Adrenocortical insufficiency; CNS • Concomitant use of CYP3A4 inhibitors or inducers depression or coma; high-risk debilitated patients; • Not approved for managing addictive disorders myxedema or hypothyroidism; prostatic hypertrophy or • Hepatic, biliary and pancreatic disease urethral stricture; and toxic psychosis • Application site skin reactions • Disposal and security: After use, fold patch in half. Never • Neurologic considerations throw BuTrans® into household trash, where children and • Psychomotor impairment: Advise patients that BuTrans® pets may find it. Return to pharmacy for proper disposal. may impair mental and/or physical ability required for the Should be kept under lock and out of sight and reach of performance of potentially hazardous tasks especially when children and pets Adverse Events: The most common adverse effects in six randomized titration-to-effect placebo-controlled clinical trials with BuTrans® were anorexia, application site erythema, application site reactions, asthenia, constipation, dizziness, dry mouth, headache, hyperhidrosis, insomnia, nausea, somnolence and vomiting. For more information: Please consult the Product Monograph at http://www.purdue.ca/files/2014-08-05-butrans-pm-eng-final-tpd-clean..pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-387-5349. References: 1. NBuTrans® Product Monograph, Purdue Pharma, August 2014. 2. Purdue Pharma, letter on file, August 9, 2011. BuTrans® is a registered trademark of Purdue Pharma. © 2014 Purdue Pharma. All rights reserved.

Doctor’s Review • MAY 2016

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

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

. Printed in Canada

Member of Innovative Medicines Canada MAY 2016 • Doctor’s

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

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

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

01258 01/16

AN ICS/LABA COMBINATION

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

DAY & NIGHT

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

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

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

NOW ON SEVERAL PROVINCIAL

FORMULARIES

(SPECIAL AUTHORIZATION)*

once-daily combination COPD therapy

grounded in long-term maintenance INSPIOLTO RESPIMAT TM

速

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

1,2

INSPIOLTO RESPIMAT (tiotropium bromide monohydrate and olodaterol hydrochloride) is a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta2-adrenergic agonist (LABA) indicated for the long-term, once-daily maintenance bronchodilator treatment of airflow obstruction in patients with Chronic Obstructive Pulmonary Disease (COPD), including chronic bronchitis and emphysema.

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

* Provincial coverage: Ontario3, British Columbia4, PEI5, and New Brunswick6. See respective formulary listings for criteria details. Clinical criteria for Ontario Limited Use (LU) Code 459: For the long-term treatment of patients with moderate to severe chronic obstructive pulmonary disease (COPD-see notes below) who have had an inadequate response to a long-acting bronchodilator (i.e., long-acting beta-2 agonist (LABA), or long-acting muscarinic antagonist (LAMA)). Note: COPD disease severity is based on spirometry, symptoms, and disability (see classification information below). Classification COPD Stages - Symptoms and disability: Mild: Shortness of breath from COPD when hurrying on the level or walking up a slight hill. Moderate: Shortness of breath from COPD causing the patient to stop after walking approximately 100m (or after a few minutes) on the level. Severe: Shortness of breath from COPD resulting in the patient being too breathless to leave the house, breathless when dressing or undressing (MRC 5), or the presence of chronic respiratory failure or clinical signs of right heart failure. Classification by impairment of lung function: COPD stage and spirometry (post bronchodilator) FEV1 predicted: Mild: Greater than or equal to 80 percent. Moderate: 50 to 79 percent. Severe: 30 to 49 percent. Very severe: Less than 30 percent.

References: 1. INSPIOLTOTM RESPIMAT速 Product Monograph. Boehringer Ingelheim (Canada) Ltd., May 28, 2015. 2. From the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2016. Available from: http://www. goldcopd.org/. 3. Ontario Drug Benefit Formulary/Comparative Drug Index. Ministry of Health and Long-Term Care. Accessed on March 24, 2016. 4. British Columbia Pharmacare Formulary. Ministry of Health, Accessed on April 14, 2016. 5. PEI Pharmacare Formulary. Ministry of Health and Wellness. Accessed on April 14, 2016. 6. New Brunswick Prescription Drug Program Formulary. Department of Health. Accessed April 14, 2016.

(tiotropium bromide monohydrate & olodaterol hydrochloride)

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