May 2017 by Doctor's Review

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CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

MAY 2017

Castles with secrets

Lobsters are coming! Family time on PEI

Sustainable eating You can get too much sleep

WIN

THIS MONTHâ&#x20AC;&#x2122;S

GADGET PAGE 14

Indications and clinical use: 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. 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 beta2adrenergic 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 betaagonists, 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

Find out if it’s a fit for your asthma patients.

Covered by all provincial formularies (special authorization)*

untreated infections such as systemic fungal, bacterial, viral, or parasitic; or ocular herpes simplex. Chickenpox and measles can have a more serious or even fatal course in susceptible patients using corticosteroids. In such patients who have not had these diseases or been properly immunized, particular care should be taken to avoid exposure. • Ophthalmologic effects: glaucoma, increased intraocular pressure, and cataracts. Close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts. • Respiratory effects: paradoxical bronchospasm may occur with an immediate increase in wheezing after dosing. This should be treated immediately with a rapid onset, short duration inhaled bronchodilator. BREO® ELLIPTA® should also be discontinued immediately, the patient assessed, and alternative therapy instituted if necessary. The incidence of pneumonia in patients with asthma was uncommon. Patients with asthma taking BREO® ELLIPTA® 200/25 mcg may be at an increased risk of pneumonia compared with those receiving BREO® ELLIPTA® 100/25 mcg or placebo. • Drug interactions: caution should be exercised when considering coadministration with inhibitors of cytochrome P450 3A4; inhibitors of P-glycoprotein (P-gp); sympathomimetic agents; beta-adrenergic receptor blocking agents; non-potassium sparing diuretics (i.e., loop or thiazide diuretics); drugs that prolong the QTc interval (e.g., monoamine oxidase inhibitors and tricyclic antidepressants); xanthine derivatives; and acetylsalicylic acid. Adverse Events: Adverse reactions reported at a frequency of ≥1% and more common than placebo in one clinical study of BREO® ELLIPTA® 100/25 mcg included: nasopharyngitis, oral candidiasis, upper respiratory tract infection,

headache, dysphonia, oropharyngeal pain, epistaxis. Adverse reactions reported at a frequency of ≥1% in another clinical study of BREO® ELLIPTA® 200/25 mcg and BREO® ELLIPTA® 100/25 mcg also included the following additional adverse reactions: inﬂuenza, bronchitis, sinusitis, respiratory tract infection, pharyngitis, cough, rhinitis allergic, abdominal pain upper, diarrhea, toothache, back pain, pyrexia, muscle strain. Dosage and Method of Administration: The recommended dose of BREO® ELLIPTA® 100/25 mcg or 200/25 mcg is one oral inhalation once daily, administered at the same time every day (morning or evening). Do not use more than once every 24 hours. The starting dose is based on patients’ asthma severity. For patients previously treated with low- to mid-dose corticosteroid-containing treatment, BREO® ELLIPTA® 100/25 mcg should be considered. For patients previously treated with mid- to high-dose corticosteroid-containing treatment, BREO® ELLIPTA® 200/25 mcg should be considered. After inhalation, patients should rinse their mouth with water (without swallowing). If a dose is missed, the patient should be instructed not to take an extra dose, and to take the next dose when it is due. Dosing Considerations: • For optimum beneﬁt, advise patients that BREO® ELLIPTA® must be used regularly, even when asymptomatic. • Once asthma control is achieved and maintained, assess the patient at regular intervals and do not use BREO® ELLIPTA® for patients whose asthma can be adequately controlled on low- or medium-dose inhaled corticosteroids.

• No dosage adjustment is required in patients over 65 years of age, or in patients with renal or mild hepatic impairment. • Caution should be exercised when dosing patients with hepatic impairment as they may be more at risk of systemic adverse reactions associated with corticosteroids. Patients should be monitored for corticosteroid-related side effect. For patients with moderate to severe hepatic impairment, the maximum daily dose is 100/25 mcg. For More Information: Please consult the Product Monograph at gsk.ca/breo/en for important information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374. *Quebec Code RE41: For treatment of asthma and other reversible obstructive diseases of the respiratory tract, in persons whose control of the disease is insufficient despite the use of an inhaled corticosteroid (ramq.gouv.qc.ca/en/regie/ legal-publications/Pages/list-medications.aspx)

02012 02/17

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Gone fishin’ — and lobsterin’ My uncle Don taught me to fish in Tidnish, Nova Scotia. He came from there and went back every summer with his wife, my auntie Do, and their three kids. They rented a cabin back from the shore and most days we kids would just run around being kids, playing in the woods and fields, and generally getting up to whatever was worth getting up to. My father was not the fishing type. He preferred driving the back roads with my mother looking for antiques, that and out of the way places with seafood on the lunch menu. The year I turned 11, my uncle said it was high time I learned to fish and so one morning he outfitted me with a bamboo pole and a line with a hook on it, and we set off into the bush to find a trout stream that he remembered as a kid. It wasn’t much of a forest, mostly saplings no more than an inch or two thick, but they grew so tightly together weaving your way through was a bit of a chore. After an hour or so we finally found it. It wasn’t much to look at either: a stream no more than six or 10 feet wide hedged in with trees so close to the water you couldn’t get the rod out to where it mattered without getting your feet wet. It was a gloomy day, cold for the season, and raining lightly. I thought of my parents in a warm car looking forward to a tasty lunch. Uncle Don showed me how to worm up and get the line in and BAM, I immediately got a strike and pulled in a rainbow trout about eight to 10 inches long. The fish was hooked and so was I. We fished the morning away, had a sandwich beside the stream and kept on fishing until three in the afternoon. We came home with 13 fine looking fish, which the family polished off for dinner along with new potatoes and peas. One of the best meals I can remember. Now you might have thought that with such an auspicious start I would have gone on to fishing as an important part of my life but it wasn’t to be. Over the next few years, I went lake fishing a couple of times with a friend whose parents had a cottage on Brome Lake in Quebec’s Eastern Townships, but bites were few and when we did catch something it always turned out to be a perch or sunfish – not great eating. Truth be told, I found the whole enterprise boring in the extreme. And there was another gustatory high that summer in the Maritimes when I was 11 that did stick with me. Our two families took a couple of days and went camping at Cavendish Beach in PEI. We all went over on a ferry and had dinner at a church lobster supper. The ultimate unmatchable east coast dining experience! To read about another family experience of more recent vintage turn to Dr Sonali Garland’s “PEI by the senses” which begins on page 24. There’s lots more for you in this issue including a summer and winter sojourn in Finland, a tour of some storied castles in Europe and, don’t forget, the lobsters are coming. Happy trails,

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David Elkins, publisher and editor delkins@parkpub.com

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MAY 2017 • Doctor’s

Review

CV EVENTS HAPPEN.

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

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

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

Contraindications: • Pregnant women, women planning to become pregnant or nursing women. • Patients with a history of hereditary/idiopathic angioedema or angioedema related to previous treatment with an angiotensin converting enzyme (ACE) inhibitor. • Patients with hereditary problems of galactose intolerance, glucose-galactose malabsorption or the Lapp lactase deficiency. • Concomitant use with aliskiren-containing drugs in patients with diabetes mellitus (type 1 or 2) or moderate to severe renal impairment (glomerular filtration rate (GFR) < 60 mL/min/1.73 m2).

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

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

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

COVERSYL® is a registered trademark of Servier Canada Inc.

• Impaired renal function • In hypertensive patients with congestive heart failure • In hypertensive patients with renal artery stenosis • Proteinuria • Hyperkalemia • Respiratory (cough) • Dermatological reactions • In geriatrics • In patients with impaired liver function • In diabetic patients For more information: Please consult the Product Monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for more information relating to adverse reactions, drug interactions and dosing information which have not been discussed here. The Product Monograph is also available by calling us at 1-800-363-6093. Please visit www.servier.ca/references/ Coversyl_EN.pdf to access the study parameters and reference list.

contents MAY 2017

COVER: © TOURISM PEI / HEATHER OGG

features

PEI by the senses An MD takes a family vacation in the Maritimes that includes beaches, parks, clam digging — and lots and lots of food by Dr Sonali Garland

The stuff of fairy tales Europe has hundreds of castles, but these six have design, character and history that sets them apart by Camille Chin

Creating a sustainable kitchen Roasted carrot sesame hummus, savoury bread pudding with greens plus more recipes to use up the staples in your fridge by Cinda Chavich

Helsinki cool and hot A romp through the capital via the city’s best cafes, saunas and national parks as Finland gets set to turn 100 by Karen Burshtein

contest! Win a seven-day “CME Away” holiday at Sandals Barbados!

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MAY 2017 • Doctor’s

Review

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

2.6x

Change from baseline (L)

0.25

greater improvement

in FEV1 at endpoint (p <0.05)

0.20

0.15

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

0.10

0.05

0.00 0

6 Time (weeks)

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

Adapted from Bousquet et al., 2000.1

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

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

See additional safety information on page xx 47

contents regulars MAY 2017

LETTERS Europe love

PRACTICAL TRAVELLER Measles makes a comeback, a 14,000-year-old village is discovered in BC, plus why is the whole world in NYC? by Camille Chin

GADGETS The perfect pens and cuff links for any MD by David Elkins

TOP 25 The best conferences scheduled for October

MEDICAL TRANSITIONS A brief review of menopause by David Elkins

HISTORY OF MEDICINE How temperature affects the amount of hours you sleep by Tilke Elkins

PHOTO FINISH An English keep by Dr Peter Hughes

DEPRESSION KEYPOINTS CANMAT Guidelines for the Management of Major Depressive Disorder by Alison Palkhivala

15 Coming in

June

Be the first to cruise the Ganges The storied river now offers the chance to sail it like a maharaja Free as a bird in Nepal Let a vulture be your guide to paragliding Japan undercover An inspiring visit to the country’s little visited Oki Island A doctor does New Zealand Travel with a Halifax OB/GYN and his wife on a two-month retirement spree

MAY 2017 • Doctor’s

Review

LETTERS

Europe love

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

OFFICE MANAGER

Denise Bernier

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

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

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

ENGLAND BY FOOT Thank you for Dr Wrigley’s article on her walking trip through London’s countryside [“Paths to happiness,” I Prescribe a Trip to England, April 2017, page 30]. I’ve been tempted to embark on a solo holiday myself and her account was inspirational. She wrote with so much wit, which was also a delight. I’m now considering taking on a trip like this more seriously and hoping to bring it into fruition this September. Dr. S. Lordon Via email

TECH ON TWO WHEELS

Here are some online comments we received about the lighted turn-signal cycling gloves and the GPS system for your bike [Gadgets, March 2017, page 14]: I am a keen biker so the Garmin would be super on our training rides. Dr Aileen Comerton

J’aimerais beaucoup tourner avec style avec les gants lumineux! Dr Serge Bruneau

TV COME TRUE I was interested to see something on the Oresund Bridge in your magazine [“Denmark to Sweden by bike (and boat),” Practical Traveller, April 2017, page 10]. I binged on Netflix this winter and watched a Danish/Swedish detective series called The Bridge. The main female detective had Asperger’s Syndrome, which added an interesting aspect to the show. It was interesting to be transported to northern Europe every night and thought the bridge was beautiful. Dr John Riley Toronto, ON

Doctor’s Review • MAY 2017

SUCH A LOT OF FLOWERS Appreciated the photos of gardens around the world [The joys of spring, April 2017, page 40]. My partner and I had just returned from Italy where we did a driving tour south of Rome. Many, many of the roads were full of red poppies, so gorgeous. We were able to have two picnics in fields surrounded by flowers. Now if only the flowers in Manitoba would hurry up and bloom. L. P. St. Boniface, MB

DOCTOR LIKES HER BRAND NEW BAG The winner of the leather and canvas tote [Gadgets, January 2017, page 14] writes: The bag is great! I’m sure that there will be a line-up in our house to use it. Many thanks. Dr Judith Shindman Toronto, ON

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

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

C a mi lle C hi n

KRIS KRĂ&#x153;G / FLICKR.COM

The present-day Heiltsuk First Nation resides in Bella Bella, BC.

North Americaâ&#x20AC;&#x2122;s ancient history Excavations north of Vancouver Island are causing a rethink of the way North America was first peopled, that is, across a land bridge that connected modernday Siberia to Alaska. Archeologists have recently discovered an ancient settlement on Triquet Island, 500 kilometres northwest of Victoria, BC, that is three times as old as the Great Pyramid of Giza. It suggests that humans entered North America along the coast. An old hearth, tools for lighting fires, fishhooks and early spears have been unearthed. Tiny charcoal flakes from a fire pit were painstakingly recovered and sent for carbon dating, which revealed the remnants are more than 14,000 years old. The findings support the oral history of the Heiltsuk Nation which has long maintained that its people inhabited the area for generations. According to the Heiltsuk, the island was one of the few ice-free places during the last ice age when glaciers covered much of North America.

Bella Bella

Triquet Island

Vancouver Island

Victoria

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

Measles’ big comeback Anyone headed to Europe should make sure their measles vaccinations are up to date. More than 559 measles cases were reported on the continent in January 2017 alone; 474 of those cases were reported in seven of the 14 endemic countries (France, Germany, Italy, Poland, Romania, Switzerland and Ukraine) with the largest outbreaks occurring in Italy and Romania. “With steady progress toward elimination over the past two years, it is of particular concern that measles cases are climbing in Europe,” Dr Zsuzsanna Jakab, the WHO’s regional director for Europe, said in March. According to Dr Theresa Tam, Canada’s interim chief public health officer, there have been 10 confirmed cases of measles in Canada so far this year, all related to travel. Those who need to update their protection should get their shots six weeks before travelling, she said. euro.who.int/en/media-centre.

Ireland by two wheels

Ireland’s newest off-road walking and cycling route opened in March, and it’s the country’s longest at 46 kilometres. The Waterford Greenway in southeast Ireland begins, as you might assume, in Waterford, the country’s oldest city, founded by Vikings in the 9th century, and ends in Dungarvan, a coastal town with a pretty harbour. The route crosses 11 bridges, three tall viaducts and a long, 400-metre, brick-lined tunnel. The Greenway was a former railway line that opened in 1878 and closed 50 years ago on March 25, 1967. It was considered one of the most scenic routes in the country. Travellers can rent bikes and helmets from a handful of companies along the way. Go to Visit Waterford (visitwaterfordgreenway.com) for a list and maps. The Greenway will become part of the Atlantic Coast Route of EuroVelo, a long-distance cycling network connecting areas in Europe.

Doctor’s Review • MAY 2017

Reginald’s Tower is a circular defense tower set in Waterford’s historic Viking Triangle.

PHOTO BY ERNEST MAYER / COLLECTION OF THE WINNIPEG ART GALLERY

Picasso, Villa de California by photographer Arnold Newman, 1956. BELOW: Picasso’s Femme assise, 1927.

Picasso and his muses in Manitoba

Picasso (1881-1973) will be in Manitoba this summer. Two concurrent exhibits May 13 through August 13 at the Winnipeg Art Gallery will highlight the Spanish-born artist’s work. Drawn from art museums across the country, Picasso in Canada will feature 30 pieces spanning five decades. It’ll include iconic images of five of Picasso’s lovers. Picasso: Man and Beast, The Vollard Suite of Prints is a collection of 100 etchings and drypoints with the themes of love and lust, identity and inspiration. Picasso developed the Suite during his affair with model and muse MarieThérèse Walter. The Suite is named after Ambroise Vollard, the art dealer and print publisher who gave Picasso his first Paris exhibit in 1901, and who also commissioned the etchings. Adults $12; students $8; kids under 5 free. wag.ca.

MAY 2017 • Doctor’s

Review

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

A small world in NYC The whole world is in NYC. It’s a teeny tiny version of the world, sure, but landmark parts of North America, South America, Europe, the Middle East, Asia and Russia are all there with unimaginable amounts of detail. The $40-million project that is Gulliver’s Gate features 300 miniatures: Cambodia’s Angkor Wat (pictured below), India’s Taj Mahal, Machu Picchu in Peru, Jerusalem’s Western Wall and more, all with itty bitty people from monks to zombie mummies to The Beatles. Constructed at a scale of 1:87, some of the models have movable and interactive parts, sound and light. Seven design teams based in workshops around the world created the miniatures either by hand from wood or using computers, 3D printers and laser cutters. The exhibit opened on April 4 in a huge space in the old New York Times building on West 44th Street in Times Square. Adults aged 13 to 64 US$36 (or US$31 online); kids three to 12 US$27 (US$22 online). gulliversgate.com.

Doctor’s Review • MAY 2017

SALINE

XLEAR

THERE IS A DIFFERENCE BETWEEN

RINSING AND CLEANING Stop recommending an incomplete solution for nasal and sinus issues. Recommend something that works better than saline. Simple saline solutions alone do little more than rinse out

shown to significantly reduce bacterial adhesion.

2.5%

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Writing with the right symbol – or not Confession time again: I have an unhealthy relationship with pens. Ballpoint, rollerball, fountain — bring ‘em on, I love them all. Not surprisingly, I never attended a pen show I didn’t like. These are terrific events. If you have even a mild obsession with writing instruments, you’ll find yourself transported. Manufacturers’ representatives attend with all their wares and lay them out on big display tables. Plenty of pads of paper are supplied for testing whatever catches your eye. I tried out dozens from lowly plastic work-a-day numbers to high-end masterpieces of fine craftsmanship, such brands as Caran d’Ache, Mont Blanc, Montegrappa, Dupont, Visconti and so on. Pens can cost thousands, even tens of thousands. These are art objects to be admired and passed on to succeeding generations. When it comes to putting pen to paper, the starting point for a good fountain pen is a gold nib. I’m blessed with two such pens: one with a 14-carat nib, the other, a gift, with an 18-carat nib. I prefer the stiffer 14-carat, but it’s a matter of finding a model that feels balanced in the hand, writes smoothly and has dependable ink flow — most important. Fountain pens add elegance and class to anything you write and are by far the instrument of choice for personal correspondence, especially that to do with

Win the Caduceus pens and the Asclepius cuff links by entering the Gadget of the Month contest at doctorsreview.com

love or poetry. For the rest of the time it’s ballpoint and rollerball territory, and no matter how finely crafted the pen, the only thing that matters is the refill. I’ve recently started to use a Schmidt Easy Flow 9000M made in Germany ($5.95). It fits any pen that takes a Parker-Type refill and it’s a joy: smooth, never blotches and the black ink writes in more of a dark grey tone which I like. At the show, I also came across a pen with a handsome Caduceus clip.

Aware that not all DR readers approve of the use of Caduceus as a medical symbol back in the office (doctorsreview.com/ history/medicines-odd-confusion-oversymbols), I searched the net to find a pen sporting a rod of Asclepius. All I could find was a British fountain pen at €550, which was a gadget too rich by the column’s modest standards. So it was back to Caduceus and Penscanada. com who offer the pens shown here, the choice for this month’s gadget. “Buffed and polished to a glass-like finish,” each come in a velvet pouch along with a Certificate of Authenticity. $39.95. bit.ly/2oPBR0v. For those who believe Asclepius is the only way to go, consider a neat, but not gaudy pair of unisex cuff links. $37.55. bit.ly/2qbxKQ6.

CONGRATULATIONS to Dr Rebecca Kennedy, a family physician from Pointe Claire, QC and to Dr Dave Mohomed, an internist from Simcoe, ON. Each wins a Donvier Manual Ice Cream Maker. 14

Doctor’s Review • MAY 2017

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme

©CTC

The Provencher Bridge in Winnipeg.

Canada Calgary, AB September 9-11

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Canadian Stroke Congress strokecongress.ca

Ottawa, ON September 15-17

Montreal, QC October 22-24

2017 Annual General Meeting and Educational Sessions of the Federation of Medical Women of Canada fmwc.ca/2017agm

2017 Annual Conference of the Canadian Association of Pediatric Health Centres caphcevents.org/conf2016/index

September 17-19 37th Annual Conference of the Canadian Academy of Child and Adolescent Psychiatry cacap-acpea.org

September 20-23 2017 Canadian Hospice Palliative Care Conference conference.chpca.net

October 29-31 2017 Canadian Conference on Global Health csih.org/en/events/canadian-conference-globalhealth

©CTC

Quebec City, QC October 28-29

Toronto’s Kensington Market.

October 11-14 2017 Annual Scientific Meeting of the Canadian Society of Allergy and Clinical Immunology csaci.ca/annual-scientific-meeting

October 12-14 7th Annual Canadian Hypertension Congress hypertension.ca/en/chc

White Point Beach Resort, NS October 12-15 11th International Forum on Pediatric Pain pediatric-pain.ca/ifpp

Winnipeg, MB October 19-21 46th Annual Scientific and Educational Meeting of the Canadian Association on Gerontology cagacg.ca

Vancouver, BC October 21-24 2017 Canadian Cardiovascular Congress cardiocongress.org

13th Annual CADDRA ADHD Conference caddra.societyconference.com

Victoria, BC October 18-22

Toronto, ON October 1-4

87th Annual Meeting of the American Thyroid Association thyroid.org/87th-annual-meeting-ata

Critical Care Canada Forum criticalcarecanada.com

MAY 2017 • Doctor’s

Review

NEW

VIACORAM

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

Contraindications Patients who are hypersensitive to the active ingredients of this drug, to any ingredient in the formulation or component of the container, to any other angiotensin converting enzyme inhibitor (ACE-inhibitor), or to any other dihydropyridine derivatives • Patients with renal impairment (creatinine clearance < 60 ml/min) • Patients with a history of hereditary/ idiopathic angioedema, or angioedema related to previous treatment with an ACE-inhibitor • Pregnant women or planning to become pregnant • Nursing women • Patients with mitral valve stenosis and left ventricular outflow tract obstruction (e.g. aortic stenosis, hypertrophic cardiomyopathy) • Patients with heart failure • Concomitant use of angiotensin converting enzyme (ACE) inhibitors, including VIACORAM®, with aliskiren-containing drugs in patients with diabetes mellitus (type 1 or 2) or moderate to severe renal impairment (GFR < 60 ml/min/1.73 m2) • Patients with hereditary problems of galactose intolerance, glucose-galactose malabsorption, or the Lapp lactase deficiency as VIACORAM® contains lactose • Patients with extracorporeal treatments leading to contact of blood with negatively charged surfaces • Patients with bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney •

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

•

• •

• • •

•

Risk of anaphylactoid reactions during desensitization or membrane exposure (hemodialysis patients) Risk of nitritoid reactions in patients on therapy with injectable gold Patients undergoing major surgery or during anesthesia with agents that produce hypotension Black patients vs. non-black patients Not recommended in patients with a recent kidney transplantation Risk of changes to renal function in susceptible patients; potassium and creatinine should be monitored in these patients Risk of cough Dermatological reactions Not indicated for the initiation of treatment in the elderly (> 65 years) patients; not recommended in pediatrics (children < 18 years of age) Patients with diabetes treated with oral antidiabetic agents or insulin, glycemic control should be closely monitored during the first month of treatment with VIACORAM® Patients with unilateral or bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney Sexual function/reproduction

For more information Please consult the Product Monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/indexeng.jsp for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-363-6093.

VIACORAM® (perindopril arginine/amlodipine) is indicated for the treatment of mild to moderate essential hypertension in patients for whom combination therapy is appropriate. VIACORAM® 3.5 mg/2.5 mg is indicated for initial therapy in patients with mild to moderate essential hypertension. VIACORAM® is not indicated for switching therapy from the individual drugs currently on the market (perindopril as erbumine or arginine salt, amlodipine). VIACORAM® is not indicated for the initiation of treatment in elderly patients (> 65 years of age). There is not sufficient clinical experience to justify the use in these patients. VIACORAM® is not indicated in pediatric patients < 18 years of age. The efficacy and safety have not been studied in this population.

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Mariahilfer shopping street in Innsbruck, Austria.

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Around the world Berlin, Germany October 8-12 17th World Congress of Psychiatry wpaberlin2017.com

Brisbane, Australia October 18-21 9th World Congress of Melanoma worldmelanoma2017.com INDICATED IN INITIAL THERAPY

3.5 mg Perindopril arginine / 2.5 mg Amlodipine

Chicago, IL September 16-19 2017 National Conference and Exhibition of the American Academy of Pediatrics aapexperience.org

Dallas, TX September 16-19 *Comparative clinical significance unknown. Reference: VIACORAM® Product Monograph. Servier Canada Inc. February 17, 2016. VIACORAM® is a registered trademark of Servier Canada Inc.

21st Annual Scientific Meeting of the Heart Failure Society of North America meeting.hfsa.org

Guadalajara, Mexico October 11-14 Servier Canada Inc. 235, boulevard Armand-Frappier Laval, QC H7V 4A7 1-888-902-9700

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48th Union World Conference on Lung Health guadalajara.worldlunghealth.org

Innsbruck, Austria October 18-21

43rd Annual Conference of the International Society for Pediatric and Adolescent Diabetes 2017.ispad.org

Lisbon, Portugal September 11-15

53rd Annual Meeting of the European Association for the Study of Diabetes easd.org

Ljubljana, Slovenia October 12-15

2017 European Academy of Pediatrics Congress and Masterclass 2017.eapcongress.com

Nice, France September 20-22

13th International Congress of the European Union Geriatric Medicine Society eugms.org/2017.html

Rotterdam, The Netherlands October 15-18

10th World Congress on the Developmental Origins of Health and Disease dohad2017.org

Venice, Italy October 15-17

12th International Congress on Innovations in Coronary Artery Disease from Prevention to Intervention iccadcongress.com MAY 2017 • Doctor’s

Review

TATIANA POPOVA / SHUTTERSTOCK.COM

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

THE TOP 25 MEDICAL MEETINGS

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

T i lk e Elk i n s

The search for a perfect sle New research suggests shorter, deeper sleeps depend on temperature

“S

leep is the new sex” was an off-the-cuff declaration that appeared widely in the media in the early 2000s. People found it funny because, true or not, it rang

true for many. With one in three North Americans experiencing some form of insomnia and many more burning the candle at both ends, sleep seemed a luxury, a pleasure greater than even the sacred pinnacle of bodily delights. And when it comes to overall health, good sleep is more important than good sex. Abstinence lacks the health risks associated with sleep deficits: heart disease, obesity, depression, lack of mental clarity, accidents in the work place and on the road.

Sleep disruptions in intensive care units caused by light and noise can lead to an increase in sepsis.

Doctor’s Review • MAY 2017

Sleep science, and especially sleep medicine, is young. Rapid Eye Movement (REM) sleep — the kind of sleep that occurs at intervals during the night and is characterized by rapid eye movements, more dreaming and bodily movement, and faster pulse and breathing — was discovered just half a century ago. Only in the past 25 years has there been an organized study of sleep through organizations like the US-based Sleep Research Society and the Canadian Sleep Society and others. Though the function of sleep still retains some of its mystery, current ideas suggest that it clears the brain of compounds that build up during the day and is also a time when short-term memories are moved to long-term storage. Mice die after about 20 days without sleep. Though no humans have volunteered for these sorts of studies, an American high school student named Randy Gardner tried to break the record for the longest time awake in the 1960s, ending the experiment after 11 days and 24 minutes with slurred speech and an expressionless appearance. The Guinness Book of Records was so alarmed by the effects on Gardner that they stopped listing records for voluntary sleep deprivation. In October 2010, 28-year-old L.A. celebrity photographer Tyler Shields claimed to have gone 40 hours without sleeping, but his feat has been largely written off as an unproven publicity stunt.

eep DEATH BY LACK OF SLEEP Sepsis was the cause of death for the mice who died of sleep deprivation, reinforcing data from sleep studies of humans whose immune systems begin to fail when they don’t get enough sleep. Disruption of sleep in intensive care units due to environmental light and noise as well as patient care interactions has been found to lead to an increase in sepsis. Lack of sleep also interferes with the effectiveness of vaccines, resulting in the production of half as many antibodies than when in a well-rested state. On the other hand, some members of the medical establishment seem to doubt the dangers of sleep deprivation. In the US, despite a mounting number of studies that point to the dangers to patients of depriving doctors who treat them of sleep, the maximum allowable workday for firstyear medical students just rose from 16 to 28 hours. Powerhouses in politics and entertainment have also served as poor examples of sleep hygiene, instead bragging about how little sleep they need — their “sleep machismo” number. Current US president Donald Trump may be among what’s known as the “sleepless elite,” the one to three percent of the population that requires very little sleep owing to a genetic mutation. Margaret Thatcher, Jay Leno and Barack Obama are also famously short sleepers, requiring less than six hours a night. How do you know for sure if you’re among the sleepless elites

Fully one in three Canadians are believed to suffer from insomnia yet sleep research is a new discipline that began only 25 years ago.

or just under-slept? If you have the opportunity to sleep more than six hours and you take it to pick up an extra hour or two of shut-eye, then you are probably a regular human. True members of the “sleepless elite,” are those who have a tiny mutation in a gene called hDEC2. They never sleep more than a few hours, even if they have ample opportunity, and are characterized by sunny dispositions and a lack of need for naps and are often thin.

co-director of research at the Scripps Clinic Sleep Center in La Jolla, California says the eight-hour figure was derived from population studies showing sleep averages. He asserts that people who report sleeping 6.5 to 7.5 hours per night live the longest, though he admits that the reasons why have yet to be proven, let alone whether the habits of those people would be healthy for everyone. Dr Kripke claims that sleeping too much may be just as damaging

One to three percent of the population requires very little sleep So what about the rest of us? Is the prescribed seven to nine hours really necessary? And where did the holy grail of virtuous sleepers — the magic number eight — originate? The classic teaching that adults need seven or eight hours of sleep seems to be supported with scant evidence. It is probably a relic from the late 18th century, when industrialization was running factory workers ragged and a Welsh social reformer named Robert Owen stepped in to save them from the 16-hour work day by declaring, “Eight hours labour, eight hours recreation, eight hours rest.” Sleep expert Dr Daniel Kripke,

to one’s health as sleeping too little, saying that an 8.5 hour sleep schedule could be worse for you than getting a mere five hours of shut-eye a night.

SEVEN HOURS OF SHUT-EYE BEST? Sleeping less than seven hours in a 24-hour cycle may be more natural than we’ve been conditioned to think. It isn’t just fast-living urbanites who are out for six or so hours a night. According to a recent study, individuals in existing hunter-gatherer societies in Africa and MAY 2017 • Doctor’s

Review

South America spend about seven or eight hours a night in bed, but they only sleep five to seven of those hours — on the low end of what urbanites sleep. Most of us have been trained to believe that if we’re under the seven-hour mark we must have insomnia and are doomed to poor health. But insomnia and other health problems are generally unheard of in the groups studied — the Hadza in Tanzania, the San in Namibia, and the Tsimane in Bolivia. Meanwhile, the Canadian media fusses and frets about its nation’s sleep deficit, insisting that 60 percent of Canadian adults feel tired most of the time, on an average of 6.9 hours of sleep per night, with 30 percent of people sleeping less than six hours. Why do people living in contemporary society seem to need so much more sleep than hunter-gatherers?

COLD ENOUGH FOR YOU? The answer may have to do not with time but with temperature. While we imagine that people who live without electricity go to sleep as soon as the sun sinks below the horizon, in reality these groups wait for the temperature to drop at night and don’t retire until about three hours after sunset, and get up in the morning at the coolest time of day, right before sunrise. This temperature cycle is mimicked by our own bodies during sleep when our core temperatures cool. So while light plays a significant role in regulating our circadian rhythms, and has been the focus of sleep specialists who recommend darkening rooms for sleep and exposure to blue light in the day, the newest research

MEDICAL QUIPS Therapist talk #1 I used to think I was indecisive, but now I’m not too sure.

Doctor’s Review • MAY 2017

The Hadza in Tanzania and other hunter-gatherer societies sleep only five to seven hours though they lie down for about eight hours a night.

suggests temperature may be even more significant. Following the environment’s temperature rhythm more closely and naturally could be a key to improving sleep for people in cities. Sleep specialists are now advising that the optimum temperature for sleep is 19˚C and recommend breathable bedclothes that can be easily removed. Sticking arms and legs out from under the covers is also an acceptable cooling technique, they say. And that old

pumps fluid into a pad on your forehead and so cools the brain. The process is called frontal cerebral thermal transfer and the device has been tested and approved by the FDA with a proposed release date some time in the latter half of this year. In randomized controlled studies, the cooling caps were found to both reduce brain metabolism during sleep, especially in the frontal cortex, and also to reduce the wearer’s core temperature, further

An FDA-approved device reduces brain metabolism by cooling the head chestnut your grandma taught you about taking a hot bath before bed? Counter-intuitively it’s the cooling you experience when you get out of the hot water that helps you sleep better. Temperature as a treatment for sleep has been taken a step further by a US company that says it has a cure for insomnia. Sleep specialist and founder of the Cereve Sleep System, Eric Nofzinger, suggests that insomniacs have too much metabolic activity in the frontal cortex — activity which can be slowed by gently cooling the region. The product he’s developed consists of a soft plastic cap that you wear in bed at night that’s connected to a software-controlled bedside device that continuously

deepening sleep. The cooler the setting, the more effective the device is at allowing those with insomnia to sleep like normal sleepers.. Before recommending possible remedies to your sleep-concerned patients it’s best for them — and for you — to first figure out how much sleep you need to feel rested. And there’s a simple way to do that. Go camping for a few days, ideally in winter or on cool spring or fall nights. Multiple studies have shown that even a single weekend spent in cool weather — without the use of electric light or devices after sundown — can be enough to significantly recalibrate circadian rhythms and help you sleep longer and more deeply.

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

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

•

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

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

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

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

References: 1. PRISTIQ Product Monograph, Pfizer Canada Inc., October 26, 2016. 2. Boyer P, et al. Efficacy, safety, and tolerability of fixed-dose desvenlafaxine 50 and 100 mg/day for major depressive disorder in a placebo-controlled trial. Int Clin Psychopharmacol 2008;23:243-253. 3. Sheehan DV. Sheehan Disability Scale in: Rush AJ, Pincus HA, First MB, et al. eds. Handbook of psychiatric measures. Washington, DC: American Psychiatric Association; 2000:113-115.

CA0116PRI017E

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

DE PRESSIO N K EY PO I NT S by

A li son Pa lkhi va la

Burden and diagnosis Highlights of the 2016 CANMAT guidelines for the management of major depressive disorder

M .

ajor depressive disorder (MDD) is among the most common medical conditions faced by Canadian clinicians. In this country, it has an estimated annual prevalence of 4.7% and lifetime prevalence of 11.3%. It is also the second leading cause of disability worldwide, carrying with it a high economic and occupational burden. In the fall of 2016, the Canadian Network for Mood and Anxiety Treatments (CANMAT) updated its practice guidelines for the management of MDD. Diagnostic criteria for the condition are based on the DSM-V (Table 1). In addition to these symptoms, sleep, cognition, and physical symptoms should also be taken into account.

Management of MDD Management of MDD is divided into two phases: 1. Acute: Lasting about eight to 12 weeks, the major goal of therapy in the acute phase is full symptom remission and return to premorbid psychosocial functioning. Even residual symptoms should be treated when possible as their presence contributes to the risk of relapse. 2. Maintenance: During this long-term phase of care, the primary goal of therapy is prevention of recurrence. To achieve this, some patients will need to remain on therapy, while others do well by addressing healthy life strategies, personality vulnerabilities, and long-term self-management. Special consideration should be given to the risk of suicide. Risk factors include personal or family history of past attempts or self harm, symptoms of hopelessness, anxiety, impulsivity, or psychosis, stressful life events, history of legal problems, and being an older man or sexual minority. When symptoms are mild, first-line treatment consists of psych education, self-management, and psychological treatments. Some patients with mild MDD may also benefit from pharmacological treatments. Moderate-to-severe MDD is typically best treated with psychotherapy combined with pharmacotherapy. Brain stimulation and complementary/alternative approaches can be considered in resistant cases or as a component of ongoing maintenance care.

Psychological treatments First-line psychotherapeutic options for the acute phase of therapy are cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), and behavioural activation (BA). Second-line recommendations include computer-based and telephonedelivered psychotherapy.

Doctor’s Review • MAY 2017

Table 1: DSM-5 symptom criteria for major depressive episode Five (or more) of the following symptoms occurring most of the day, nearly every day, present during the same two-week period, and representing a change from previous functioning; at least one of the symptoms is either (1) or (2): 1. Depressed mood (in children and adolescents, can be irritable mood) 2. Markedly diminished interest or pleasure in all, or almost all, activities 3. Significant weight loss/gain (without dieting) or appetite change 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness, or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, or indecisiveness 9. Recurrent thoughts of death or suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide Note: Do not include symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations. Adapted from American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).

Both CBT and mindfulness-based cognitive therapy (MBCT) are good options during the maintenance phase of therapy. Take into account patient preference and treatment availability when selecting therapy.

Pharmacotherapy Second-generation antidepressants, including the serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) remain the mainstay for pharma cologic care for MDD. There is still a role for older agents, including tricyclic antidepressants (TCAs) and MAO inhibitors, however. (Table 2). Relative differences among the medications are small, so consider patients’ individual needs and preference when making a selection (Table 3). When prescribing SSRI medications, two potential serious adverse events that can occur are an increase in suicidal ideation and attempts among adolescents, necessitating close monitoring, and prolongation of the corrected QT interval (QTc), a surrogate marker for Torsade de Pointes (TdP) arrhythmia.

Table 2. Pharmacological management of MDD First-line

Second-line Third-line

SSRIs TCAs e.g., Citalopram e.g., Amitriptyline Escitalopram Clomipramine Fluoxetine Fluvoxamine Sertraline Paroxetine

MAO inhibitors

SNRIs Quetiapine Reboxetine e.g., Desvenlafaxine Duloxetine Milnacipran Venlafaxine Agomelatine Trazodone Bupropion Moclobemide

citalopram from paroxetine or reboxetine, to escitalopram from citalopram, to fluoxetine from milnacipran, to mirtazipine from an SSRI or venlafaxine, to paroxetine from fluoxetine, and to sertraline from fluoxetine). Combining two antidepressants is not recommended, but adjunctive treatment with another class of medication can be helpful. Atypical antipsychotics have the most consistent evidence for efficacy in this regard. The decision to switch antidepressants or add an adjunctive therapy should be individualized (Table 4). Antidepressant therapy should be continued for 6 to 9 months following symptomatic remission. Those with risk factors for recurrence, however, should stay on therapy for 2 years or more. When discontinuing therapy, taper the dose slowly over several weeks in order to avoid discontinuation symptoms.

Table 4. Considerations when choosing between switching to another antidepressant monotherapy or adding an adjunctive medication

Mirtazipine Selegiline

Circumstances favouring switching

Circumstances favouring adjunctive medication

Vortioxetine Levomilnacipran*

First antidepressant trial

≥ 2 antidepressant trials

Vilazodone*

Poorly tolerated side effects to initial antidepressant

Initial antidepressant well-tolerated

No response (< 25% improvement) to initial antidepressant

Partial response (> 25% improvement) to initial antidepressant

More time to wait for a response (less severe, less functional impairment)

Less time to wait for a response (more severe, more functional impairment)

Patient prefers to switch to another antidepressant

Patient prefers to add on another medication

Specific residual symptoms or side effects to the initial antidepressant that can be targeted

*Approved since last CANMAT guideline update in 2009

While warnings by regulatory agencies about QTc prolongation have been limited to citalopram, escitalopram, and quetiapine, its association with specific antidepressants and doses remains unclear. In patients without other risk factors for arrhythmia, the risk is considered low. Evaluate response to and tolerability of antidepressant therapy 2 to 4 weeks after initiation. If poor tolerability is a problem, consider switching drugs. If response is absent or inadequate, ensure therapy is optimized in that the maximum therapeutic dose has been reached and patients are adhering to therapy. Consider re-evaluating the diagnosis and addressing other treatment issues that may be affecting the response. If response remains suboptimal, the addition of psychotherapy and/or brain stimulation therapies can be beneficial. Another option is switching to an antidepressant with evidence of superior efficacy (e.g., to agomelatine from sertraline, to

Table 3. Factors to consider in selecting an antidepressant Patient factors

Medication factors

Clinical features and dimensions

Potential interactions with other medications

Comorbid conditions

Comparative efficacy

Response and side effects with previous antidepressants

Comparative tolerability

Patient preference

Simplicity of use Cost and availability

Brain stimulation and complementary/ alternative approaches A trial of repetitive transcranial magnetic stimulation (rTMS) is a first-line option for patients with MDD who have failed at least one antidepressant trial. Electroconvulsive therapy (ECT) remains a solid second-line treatment option and can be considered first-line in certain circumstances. Transcranial direct current stimulation (tDCS) and vagus nerve stimulation (VNS) are third-line options. Other brain stimulation therapies remain investigational. Alternative and complementary treatments for MDD include exercise, light therapy, St. John’s wort, omega-3 fatty acids, SAM-e, and yoga. These can be used as first- or second-line treatments in mild-to-moderate MDD. Other physical treatments and natural health products have less evidence but may be considered third-line. While most alternative health products are well-tolerated, evidence of efficacy, especially long-term, is lacking, and care should be given to avoid possible drug-drug interactions. MAY 2017 • Doctor’s

Review

I PRES CR I B E A TRIP TO... PRINCE EDWARD ISLAND

PEI by the senses An MD reminisces about her favourite sights, smells, sounds and food during a family vacation in the Maritimes by Dr Sonali Garland

along with our two teenagers, then 14 and 16, took a weeklong family vacation on this island province last July and it was truly a feast for the senses.

EVAN GARLAND

THE SIGHTS

Cabot Beach on Malpeque Bay is the largest park in western PEI.

Dr Sonali Garland is a family physician hospitalist at Joseph Brant in Burlington, Ontario. She is busy planning her family’s next travel and food adventure. They know better than to ask her any questions.

Doctor’s Review • MAY 2017

The colours of PEI seem to be more vibrant than anywhere else. From the rich red soil to the intense green of the ubiquitous potato plants, your eyes will be treated to a colour palette like no other. And it seems like no matter where you are on the island, you’ll always catch a glimpse of the deep blue ocean. Take an easy hike through Cabot Beach Provincial Park (tourismpei.com/provincial-park/cabot-beach) and you’ll be rewarded with a view from atop red cliffs overlooking the Atlantic. Skip some stones along its red beach, but be warned — that red sand really seems to stay with you. For more heart-stopping sights, PEI National Park (tourismpei.com/pei-national-park) at Greenwich boasts an extensive trail system and a floating boardwalk that lead to vistas of the spectacular dune system and pristine white sand beaches.

THE SCENTS At the PEI Preserve Company (preservecompany.com), you’ll smell the handmade artisan preserves as soon as you walk in. Our favourite: strawberry with Grand Marnier. Located in New Glasgow, the retail space and restaurant are surrounded by the fivehectare Gardens of Hope. These lovingly attended gardens were created by owners Bruce and Shirley McNaughton as a space for Islanders and visitors to

EVAN GARLAND

f you are looking for a way to stretch your holiday dollar and would like to be treated to some true Maritime Hospitality, look no further than beautiful Prince Edward Island. My husband and I,

The PEI Preserve Company in New Glasgow is surrounded by the five-hectare Gardens of Hope.

relax. An onsite Respite Cottage is available for weeklong stays to those suffering from life-threatening illnesses. It’s also available to caregivers. The cottage is available year-round, sleeps up to seven and is wheelchair accessible. Elsewhere on the island, if you’re lucky, you’ll catch whiffs of wild roses carried along a salty ocean breeze. And, of course, there’s nothing like the smell of freshly caught fruit of the sea — lobsters, mussels, clams and oysters — being brought in by proud fishers around the island. But more on that later.

Dr Garland (pictured left) and her family were kitted out with snorkels and wetsuits for the Giant Bar Clam Dig.

THE SOUNDS At Basin Head Beach in Red Point Provincial Park (tourismpei.com/provincial-park/red-point) you can enjoy the music of the “Singing Sands.” Thought to be a phenomenon created by the special shape of the grains of sand and their high silica count, walking barefoot in the sand at varying speeds and pressure produces a music like no other. For music of a different sort, try one of the island’s many ceilidhs (pronounced “kay-lee”). Loosely translated as “kitchen party,” they’re great examples of island music, dance and lore in the Scottish and Acadian tradition. The King’s Playhouse (kingsplayhouse. com) in Georgetown and the Ross Family Ceilidh (rossfamily.ca) are good bets. Like any great house party, space is limited, so plan to get there at least a half hour before the show to get tickets at the door.

THE FOOD PEI is fast becoming a Canadian culinary destination. Everywhere you go, the pride and hard work of its farmers, fishers and chefs is evident in their offerings. One of the hottest meal tickets on the island is The Feast, the evening meal at The Inn at Bay Fortune (innatbayfortune.com). PEI ambassador and celebrity chef Michael Smith, and his artist/musician wife, Chastity, purchased the Inn in 2015 and have lovingly MAY 2017 • Doctor’s

Review

EVAN GARLAND

The trail network in PEI National Park includes a floating boardwalk and towering parabolic dunes.

One of the hottest meal tickets on the island is The Feast, a family-style dinner at The Inn at Bay Fortune.

EVAN GARLAND

If you’re lucky, you’ll get a photo op with the owners of the inn, Chef Michael Smith and his wife Chastity.

DIY PEI

Doctor’s Review • MAY 2017

A visit to Malpeque Oyster Barn for the large oyster platter is a “must” when in PEI.

EVAN GARLAND

If you’re considering a road trip, it’s an easy 15-hour drive along the TransCanada Highway from Toronto, 12 hours from Ottawa and 10 hours from Montreal. Air Canada (aircanada.com) offers daily non-stop flights from Toronto and Montreal. WestJet (westjet. com) flies non-stop from Toronto four times weekly. Vacation Rental by Owner (vrbo.com) allows you to browse many types of rental properties by region, number of beds and price. Alternatively, Tourism PEI (tourismpei.com/pei-bed-and-breakfastinn) has a comprehensive list of inns and B&Bs on the island. PEI also has an extensive network of campgrounds including nine within provincial parks. Campsite settings can range from deep woods to waterfront and beach. Consider booking well in advance for coveted oceanfront locations.

renovated it into a five-star food and accommodation destination. The 19-hectare property includes a certified organic farm and aromatic herb garden, walking trails, fire pits for open-air cooking and extensive flower gardens. The on-site restaurant produces the nightly meal as well as a gourmet breakfast for overnight guests. Its name, Fireworks, comes from the eight-metre,

Your afternoon will start with a scenic boat ride to a deserted island where you will be taught by Perry and his crew how to harvest giant clams; snorkels, wetsuits, water socks and rakes are provided. After a satisfying beach cookout with the fruits of your labour, you’ll board the boat again to haul up lobster, crab and mussel lines, and learn about the art of sea farming. A retired fisherman himself, Perry peppers this

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Chef Michael’s Feast The Feast begins in the early evening with a welcome by staff (Chef Michael, if you’re lucky) and a number of food stations both indoors and out where guests are encouraged to wander, eat and drink, and get to know each other as well as the proud members of Michael’s “Fire Brigade.” These young, enthusiastic chefs have been handpicked from across the country to be part of the Farm-to-Fork experience that is championed at the Inn. At 7pm, guests are moved inside to the lovely screened-in porch overlooking the sloping gardens and Fortune Bay. The many courses are served family-style at butcher-block tables. Each plate is accompanied by a heartfelt explanation of the produce and process. The whole experience takes three to four hours, but flies by. Don’t be surprised if you feel like you’ve made lifelong friends with your tablemates by the end. Tickets for the Feast are booked months in advance and priority is given to overnight guests, so consider reserving soon.

Seafood and more For another unique island experience, consider booking the “Giant Bar Clam Dig” with Perry Gotell from Tranquility Cove Adventures (www.tcpei.ca).

11:04 AM

Other favourite food experiences to try: as-freshas-you-can-get oysters from Malpeque Oyster Barn (facebook.com/malpequeoysterbarn). Try a dozen large oysters with their house-made mignonette. The young, award-winning shuckers are happy to talk to you about their trade as they prepare your platter. Other offerings include their famous PEI mussels in a homemade broth. Don’t try to get the recipe from your server: it’s a well-guarded secret. At Rick’s Fish and Chips (ricksfishnchips.com), grab a brown paper bag filled with their signature Cajun-spiced mussels or order a fabulous fish and chips and sit at a picnic table overlooking St. Peter’s Bay. Wash it down with an icy soda or, better yet, a local craft beer. If you visit PEI in the middle of July, try to get tickets to the Village Feast (villagefeast.ca). A collaboration between local farmers, artisans and volunteers, the Village Feast serves a locally-sourced, gourmetcalibre meal to over 1000 people in an open-air setting in the small town of Souris. Besides funding a number of local children’s charities, the feast has helped Farmers Helping Farmers (farmershelpingfarmers.ca) build nine cookhouses in Kenya, which have served over a million hot meals to school children to date. At the end of our week in PEI, my family and I were sad to leave this beautiful island where we had feasted on such incredible sights, sounds, scents and food. But as proud Canadians we were pleased and surprised to learn that we have such a world-class tourism destination in our own backyard. MAY 2017 • Doctor’s

Review

FOR THE TREATMENT OF MOD

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

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

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

NEW

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

ERATE TO SEVERE VASOMOTOR SYMPTOMS

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

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

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

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

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

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STRENGTHEN CANADA’S DIVERSE & MULTILINGUAL HEALTHCARE COMMUNITY

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ME D I C AL T R A N S I T I ON S by

David Elkins

A brief review of menopause Common symptoms and recommendations Recommendations for patients and physicians SOGC guidelines, sogc.org/wp-content/uploads/2014/09/ gui311CPG1409Eabstract.pdf

Patients Diet. Eating well is important. An ideal daily diet would include seven servings of fruit and vegetables, six of grain, three of milk and alternatives, and two of meat and fish or equivalents.

Six most reported symptoms Hot flashes or flushes can range from mild to severe. Results from a decreased supply of estrogen, which is gradual in some and abrupt in others. More than half of women report this symptom.

Night sweats caused by hot flashes at night, they range from mild to severe. Cool rooms promote better sleep. Could have other medical implications.

Irregular periods, the most common are hormonal imbalances during perimenopause. Most occur in women in their mid-40s. Pregnancy or other medical conditions could also be responsible.

Loss of libido caused by hormonal imbalance, commonly an androgen deficiency. Other causes include vaginal dryness, depression or side effects of medication.

Vaginal dryness in which vaginal tissue becomes dryer and less soft, which can lead to itchiness and irritation. Caused by a fall in estrogen levels, it can be emotionally difficult and should be treated promptly.

Mood swings, again caused by hormonal imbalances, the swings can, in some cases be severe, fatigue is often an underlying cause. The most effective way of reducing mood swings is to target the hormonal imbalance. Other symptoms include: weight gain, bloating, incontinence, irritability, anxiety, osteoporosis and others.

Salt. Reduced sodium intake. Vitamins. D and calcium supplements. Weight. Maintain a healthy weight. Exercise. Moderate to vigorous aerobic exercise of 150 minutes a week.

Physicians A waist circumference of 88 cm or more is associated with diabetes, heart disease and hypertension, and should be part of the initial assessment.

Tobacco use is a strong negative. Patients should be advised to quit with treatment offered to those willing to do so.

Blood pressure should be controlled. If the systolic blood pressure is ≥ 140 mmHg and/or the diastolic blood pressure is ≥ 90 mmHg, a specific visit should be scheduled for the assessment of hypertension.

Lipid-profile screening for those age 50 or over and for those with additional risk factors.

A cardiovascular risk assessment using the Framingham Risk Score should be completed every three to five years for women aged 50 to 75.

A history of past pregnancies should be taken as it can predict and increase risk for cardiovascular disease and may suggest the need for further screening.

Hormone therapy. Physicians should offer hormone therapy, estrogen alone or combined with a progestin, as the most effective therapy for the medical management of menopausal symptoms only after the risks for cardiovascular disease and breast cancer have been thoroughly assessed — see the SOGC guidelines. MAY 2017 • Doctor’s

Review

The stuff of fairy tales

Six of Europe’s most breathtaking castles, each with a spectacular story to tell by Camille Chin

A SHOW OF WEALTH Peles¸ Castle is over the top. Commissioned in 1873 by King Carol I of Romania who was said to be absorbed with the prestige of the dynasty he founded and who reportedly wore the crown in his sleep, the castle sits high in the Carpathian Mountains near Sinaia, 65 kilometres from Brasov, and absolutely oozes Neo-Renaissance luxury. It was the very first castle in Europe to have electricity and central heating, an elevator and a vacuum (“carpet sweepers” were invented in the 1860s, powered vacuums around the 1890s). The castle’s 160 rooms are bedazzled with Murano crystal chandeliers, Cordoba leather-covered walls and Iraqi rugs. There are also 4000 European and Oriental pieces dating from the 15th to the 19th centuries. Closed Mondays in summer. Adults $10; kids $5. There’s an additional $10.50 fee to take pictures. Rich. romaniatourism.com/castles-fortresses.html.

Doctor’s Review • MAY 2017

A LEGACY OF WIVES (AND MISTRESSES) PHILOPHOTOS / SHUTTERSTOCK.COM

Château de Chenonceau is unofficially called the Château des Dames (or Ladies Castle) because its design was the vision of many women. French noblewoman Katherine Briçonnet oversaw its major revamp in the Renaissance style beginning around 1515 when her husband was away at war. King Francis I seized the château in 1535 for unpaid debts to the Crown, but when his son, Henry II, ascended to the throne in 1537, he gifted the castle to his mistress, Diane de Poitiers. The lovely arched bridge above the Cher River in France’s Loire Valley was all her idea. When Henry II died, the Queen, Catherine de’ Medici, drove Diane out of the château. She kept the arched bridge however and built a 60-metre-long ballroom on top of it with 18 windows, a chalk-and-slate checkerboard floor, and exposed joist ceiling. Revenge. Diane’s bedroom is on the ground floor, Catherine’s on the first. Both are equally exquisite. Adults from $20; kids from $15. chenonceau.com.

Conwy Castle

POLAND

UNITED KINGDOM Ksia˛z˙ Castle

GERMANY

Chenonceau Castle

FRANCE

Neuschwanstein Castle

Predjama Castle

DENNIS JARVIS / FLICKR.COM

SLOVENIA

ROMANIA Peles¸ Castle

HITLER’S HOUSE Don’t judge this castle by its exterior. It’s pink and blue and so obviously celebrates the Easter egg, but its history is deep. Really deep. Built in the late 13th century for a Polish prince whose name, by all accounts, was Bolko I the Strict, Ksia˛z˙ Castle, in the city of Walbrzych, 80 kilometres from Wroclaw in southwestern Poland, changed hands a few times until Konrad I von Hoberg bought it for an undisclosed sum in the early 1500s. The castle remained in the Von Hoberg family for more than 400 years, and was continuously enlarged and remodelled in a mishmash of styles, until the Nazis seized it in 1941 as a future residence for Hitler. The Nazis built a bunker for Hitler underneath it; forced labourers from the Gross-Rosen Concentration Camp dug more bunkers and also a huge network of tunnels — to exactly what end remains unknown. Adults from $12; kids from $9. ksiaz.walbrzych.pl/en/turystyka.

THE GOLIATH

S-F / SHUTTERSTOCK.COM

MARIUSZ SWITULSKI / SHUTTERSTOCK.COM

Edward I was the King of England from 1272 to 1307. The first part of his reign was dominated by invasions of Wales, which he conquered in 1282. Conwy Castle in the Snowdonia region of northwest Wales was commissioned by him in 1283 as one of the key fortresses in his “Iron Ring” of structures to contain — and humble and intimidate — the rebellious Welsh. It’s a goliath and the absolute finest and best preserved fortress from medieval times. In addition to curtain walls of coarse dark stone, the rectangular castle has eight massive towers. Its battlements look out across the mountains and sea, down to the roofless shell of the outer ward’s original Great Hall. From there, you can admire Conwy’s other glory: its circuit of town walls guarded by 22 towers. Adults $14; kids $10. conwy.com/place/conwy-castle.

MAY 2017 • Doctor’s

Review

HOME OF THE HUNTED

Doctor’s Review • MAY 2017

YURY DMITRIENKO / SHUTTERSTOCK.COM

ROKA / SHUTTERSTOCK.COM

According to Guinness World Records, Predjama is the largest cave castle on the planet. Located in Slovenia’s Carniola (Notranjska) region, 65 kilometres from Ljubljana, it was implanted into the gaping mouth of a 123-metre-tall cliff more than 800 years ago. The defiant structure has over a dozen rooms, including an armoury and dungeon, but the small bathroom located high on an outside wall is by far the most famous. Erazem Lueger, a 15th-century noble knight or dastardly robber-baron, depending on your point of view, was crushed by a cannonball in 1483 while he did his business on the “throne.” Lueger had been hiding in the castle from the Habsburg Army for an entire year. He used a secret passage to get food and water before being betrayed by a servant who literally raised a flag to reveal his whereabouts. Adults $18; kids $11. postojnska-jama.eu/en/tickets/ predjama-castle.

A LABOUR OF LOVE King Ludwig II of Bavaria ascended to the throne in 1864 when he was 18. A reluctant ruler, he avoided governmental responsibilities, favouring the countryside instead. He’s been described as creative, introverted, even shy. He spent his wealth on art, music — and castles, beginning construction on three within a decade. A dramatic Romanesque fortress with towers, turrets and all kinds of fairy tale twinkle, Neuschwanstein was built high on a hill in southern Germany. It was designed to be a retreat, “holy and unapproachable” in the King’s own words. But Ludwig wasn’t a complete loner. He was close friends (and arguably in love) with composer Richard Wagner. He was devoted to Wagner’s operatic works and the castle’s interior walls are illustrated with the medieval myths that inspired his music. Ironically, Neuschwanstein now hosts 1.4 million tourists every year. Adults $19; kids under 18 free. neuschwanstein.de.

Helsinki cool

The beautiful green-domed Lutheran cathedral dominates Helsinkiâ&#x20AC;&#x2122;s Senate Square and the cityâ&#x20AC;&#x2122;s skyline.

and hot

There’s more to Finland than saunas and cloudberry cake, but that’s an excellent start by Karen Burshtein

LAURI ROTKO / VISIT HELSINKI

ears ago, a violinist friend attended a Sibelius Festival in Helsinki, Finland, the

home country of the celebrated composer. Finland: it sounded so distant, dark and cold. It’s unforgivable for a Canadian to apply the same stereotypes to a country as others do to mine so for some perspective I rewatched the Helsinki segment of Jim Jarmusch’s Night on Earth, a favourite movie. It cemented my idea of the city. Then, surprisingly, years later, I was going to Finland myself. Would Helsinki match my evermore cartoonish vision: a cold, mysterious city lurking in the shadow of its Russian neighbour, full of silent expressionless people who are obsessed with reindeer meat and, inexplicably, mid-century modern design? Well, it was winter when I visited: dark at 3pm. As I strolled the square underneath the imposing Helsinki Cathedral, I watched people shopping at the outdoor Christmas market where vendors in little wooden huts sold everything from long-handled knives to handmade birch sauna soap. Everyone was MAY 2017 • Doctor’s

Review

COMMA IMAGE OY

Formerly a working-class neighbourhood, Kallio is now lined with boutiques, cafés, bars and more.

Would Helsinki match my evermore-cartoonish vision: a cold, mysterious city full of silent people obsessed with mid-century modern design? caught up in the festive atmosphere as if their lives depended on it and then I realized that with SAD, it probably did. I immediately understood why Yuletide Christmas was a northern European invention. You needed something cheery to survive winter. And yet, I came to love Helsinki.

he city is accessible, compact and very easy to get around, despite neighbourhood names that sound as intimidating as an Ikea instruction sheet: Punavuori, Kallio and Vallila. Locals, for all their so-called reserve, were as approachable and helpful as any I’ve met. These are people who are generally at ease in their skin. It’d be

Doctor’s Review • MAY 2017

hard not to be with all the fresh air, forests and famous cradle-to-grave social system. In winter, warm and inviting cafés were a gift, and I participated in Finnish high-coffee consumption at iconic cafés like the 19th-century Café Ekberg (cafeekberg.fi) as well as Café Aalto (cafeaalto.fi) in the Academic Bookshop designed by famous Finnish architect Alvar Aalto. I also had cups at Good Life Coffee (goodlifecoffee.fi) and Café Kokko (cafekokko. com) in Kallio, what’s become a hip neighbourhood in the city’s eastern end. I checked out some of the city’s excellent museums. Among my favourite were the Design Museum (designmuseum.fi), and the interactive Helsinki City Museum (helsinginkaupunginmuseo.fi), which focuses

EETU AHANEN / VISIT HELSINKI

There are only 5.4 million Finns, but about 3.3 million saunas.

Löyly’s wooden exterior will eventually turn grey and the sauna will resemble a rock on the shoreline.

on the everyday lives of the people of Helsinki. The latter has become such a hit since it opened last May that locals come to hang out in the common spaces like its living room. Though it was full of families with young kids when I was there, I noticed the same thing I did walking through the city streets: a pervasive silence. This is one of the quietest big cities you’ll ever visit, even among the hustle and bustle of pre-Christmas shopping. And yet Finns seek out a place with even more peace and quiet: the sauna. It’s said that there is one sauna for every 1.5 people. They used to be public places until every apartment building and now, very often, every apartment unit, even studio, is built with a sauna. But the idea of the public sauna is coming back. You find them in the most unlikely of places like the business lounge at Helsinki airport and in one car of the Ferris wheel that dominates the port area. Even Burger King opened a branch last year with a sauna in it. The hottest sauna news — excuse the pun — is Löyly (loylyhelsinki.fi/en), which opened on the southern tip of the Helsinki peninsula last year. The building is stunning: a hexagon-shaped wood struc-

FINNAIR OYJ

JOEL PALLASKORPI / LÖYLY

All Finnair aircraft feature dishware by the Finnish design house Marimekko.

ture overlooking the sea. It combines key aspects of Finnish identity all in one: saunas, great minimalist design and a window to nature. I decided to walk the 30 minutes from my hotel to Löyly because I was told the route was through the Ullanlinna neighbourhood, which has a huge concentration of Art Nouveau architecture. That idea didn’t take long to flop. I lost the race against the setting sun, couldn’t see the buildings. The winds rose and snow started to blow the rest of the way, which was along the frigid harbourfront. The sauna certainly hit the spot. After warming my bones, I was expected to complete the authentic experience by dipping into the frigid Baltic. I was going to, outside again in my swimsuit, but the path and stairs to the sea were icy, so I went for the bucketof-ice-water-dumped- over-me option instead, repeating the cycle of heat and cold until I felt as relaxed as a puddle of mellow. Heading back, this time by bus, all I could think about was having a hot bowl of soup under the comfort of my bed’s duvet. I found packages of ready-made gourmet soups MAY 2017 • Doctor’s

Review

Built in the mid-18th century, Suomenlinna is one of the biggest sea fortresses in the world.

at a supermarket next to my hotel. Alas, I could not decipher what each one was, thanks to packaging more high design than practical visual info and, of course, Finnish-only labels. Finnish is a notoriously tricky language, closest to Hungarian, and I found it impossible to pick out familiar looking words or roots. A local walking by kindly translated. Lohikeitto, Finnish salmon soup, won. I microwaved it there, crossed the street to my hotel and was eating the delicious soup in my room within minutes. It was one of those nothing moments that became a special travel memory.

froze again the next morning on a visit to Suomenlinna (suomenlinna.fi), a 17th-century Swedish maritime fortress, a short ferry ride from the city. My guide showed me around the UNESCO World Heritage Site complete with ancient cannons and tombs of military heroes. He told tales of Finland’s later Russian period and the fallout of soldiers who used vodka as tonic water. Eventually, my toes couldn’t take the cold anymore and I asked if we could continue “the tour” from the comfort of

Doctor’s Review • MAY 2017

a cozy café. We did, over cardamom cinnamon buns and hot coffee, at Samovarbar, Suomenlinna’s charming café housed in a wooden Russian-period villa. Helsinki’s magic and mystery remained with me, but I saw a whole other city when I visited a short period later, this time in summer. It was a city heated up in more ways than one. Here were people celebrating summer quite the way Canadians do, relishing every second of it. The sun was so astonishingly bright that it felt like afternoon when you got up from dinner. I set off to reacquaint myself with the city, although it was more like getting to know a new city, so different was winter and summer Finland. I attended the hip Flow Festival (flowfestival.com) with its hot music lineup and art in venues like an old sheet metal factory. I visited the Löyly sauna again, this time exploring its expansive terrace overlooking the sea where locals were splashing each other with champagne, I assumed, in a giddy appreciation of warmer weather. I followed that with a visit to Allas Sea Pool (allasseapool.fi), diving into the seawater swimming pool on the shore of Kaivopuisto.

SATU_M_N / FLICKR.COM

JUSSI HELLSTEN / VISIT HELSINKI

The best cafés in the city used to be measured by the size of their cinnamon rolls.

JUSSI HELLSTEN / VISIT HELSINKI

Opened in 1919, the Central Railway Station is a gem among Helsinki’s art nouveau buildings.

Hossa has been designated a national park as part of Finland’s centenary celebrations.

I set off to reacquaint myself with the city, although it was more like getting to know a new city, so different was winter and summer Finland Despite some undiplomatic jabs in the past (most famously by Italy’s raunchy former Prime Minister Berlusconi), Helsinki is becoming a foodie destination on par with its Nordic neighbours. At trendy new café El Fant (elfant.info), I partook in the produce that stars in summertime. A salad of fresh summer peas tasted like a treat, while lakkakakku (cloudberry cake) was bursting with so much yellow fruit, it was surely a health food. At Shelter (shelter.fi), an inviting new restaurant located in an old warehouse at Katajanokka Harbour, I had salted whitefish in ginger buttermilk. Finland’s well-known lakes, forests of birch, spruce and pine, and northern lights, may be a harder sell for Canadians who have all of the above. If not, a trip

focused on Helsinki doesn’t mean you have to deprive yourself of Finland’s natural beauty, an abundance of which is within minutes of the city. I took easy day trips from the gorgeous Eliel Saarinen-designed Helsinki Central Railway Station for serene forest walks, once to the nearby island of Emäsalo, once through the thick forests of Nuuksio National Park. Another day, I signed up for a foraging workshop that ended with a picnic lunch of nettles. There was so much to do that, even in the nightless summer, I wished there could be more hours in the day. For more on Finland’s centennial celebrations, check out suomifinland100.fi. For more info on travel to the capital, go to Visit Helsinki (visithelsinki.fi). MAY 2017 • Doctor’s

Review

Creating a sustainable kitchen Recipes to help you use up what’s in your refrigerator and pantry, and in turn reduce your “foodprint” at home recipes by

Cinda Chavich

recipes photos by

n The Waste Not, Want Not Cookbook, food and travel writer Cinda Chavich reveals some hardto-swallow numbers. Every year, producers,

manufacturers, retailers and consumers around the world, toss and waste 1.3 billion metric tonnes of food, enough to feed 3 million people. Individually, Stats Can indicates that’s 122 kilograms per Canadian, with 51 percent of the waste occurring at home.

Doctor’s Review • MAY 2017

DL Acken

What’s more, Conservation Group Oceana, a group of foundations focused solely on oceans, reported in 2014 that global bycatch accounts for 40 percent of the world’s total catch of fish per year. Scientists say that will lead to a complete collapse of the

world’s fisheries within the next 30 years. Is there anything a consumer can do besides feel utter despair? Beyond bleak realities, The Waste Not, Want Not Cookbook published by TouchWood Editions, has 140 ideas on how home cooks can use up all of the stale bread, slightly wrinkly produce, and leftover roasts, bones and carcasses in their kitchen. The recipes that follow are suggestions on how to eat up staples: apples, carrots, red peppers and bread. The cookbook also includes tips on how to store and preserve food to make things last longer, and how to cook once and create three different meals.

ROASTED CARROT SESAME HUMMUS

loin medallions, too. Add a rustic mash of yellow-fleshed potatoes on the side. 4 boneless, skinless chicken breasts salt and freshly ground black pepper 2 tbsp. (30 ml) all-purpose flour 2 tbsp. (30 ml) olive oil 2 tbsp. (30 ml) butter 2 onions, thinly sliced 2 Granny Smith apples, peeled, cored and sliced 1 tbsp. (15 ml) minced fresh rosemary 2 c. (500 ml) apple cider

Season the chicken breasts with the salt and pepper, and then dredge in the flour, shaking off any excess. In a nonstick sauté pan, heat the oil and butter over medium-high. When

sizzling, add the chicken. Cook for about 5 minutes per side, until the chicken is nicely browned. Remove from the pan and set aside. Add the onions to the pan, stirring up any browned bits. Cook until the onions are soft and starting to brown. Add the apples and rosemary to the pan, tossing to combine. Add the cider and bring to a boil. Simmer for 5 minutes, until the liquid is reduced by half. Return the chicken to the pan and cook together for about 5 minutes, until the chicken is cooked through and the apples are saucy. Season with additional salt and pepper to taste. Serve the chicken topped with the sauce. Serves 4.

GEORGE PARRILLA / FLICKR.COM

A creamy, nutty spread to use up old carrots and serve as a dip with pita bread, crackers or crudités. 4 medium carrots, roasted 1 c. (250 ml) cooked chickpeas (or canned chickpeas, rinsed and drained) ¹⁄³ c. (80 ml) tahini ¼ c. (60 ml) extra-virgin olive oil ¼ c. (60 ml) water 2 tbsp. (30 ml) fresh lemon juice 1 tsp. (5 ml) Asian chili paste 2 large garlic cloves, chopped (about 1 tbsp. / 15 ml) 1 tbsp. (15 ml) chopped fresh cilantro 1 tsp. (5 ml) dried mint ¼ tsp. (1.25 ml) ground cumin ¼ tsp. (1.25 ml) ground coriander sea salt, to taste

Combine all of the ingredients in a blender or food processor and whirl to a chunky or smooth purée. Serves 4–6. Tip: To roast the carrots, cut into chunks, toss with olive oil and salt, and roast in the oven at 400°F (200°C) for 20 minutes.

CHICKEN BREASTS WITH APPLE AND ROSEMARY An easy way to include apples in a main dish. This recipe works perfectly with boneless pork chops or pork tender-

Dips and salsas are a great way to use up produce. Pictured here: roasted carrot sesame hummus (and also chimichurri).

MAY 2017 • Doctor’s

Review

MOUHAMMARA This Syrian red pepper and walnut spread is simple, but addictive. It may take a trip to a Middle Eastern grocer for pomegranate molasses, but the results are worth it. Serve with sliced baguette or pita bread, and make extra to freeze (and give away in little jars as hostess gifts). If you have a stash of frozen roasted red peppers, they’ll work well here. 3 tbsp. (45 ml) extra-virgin olive oil 1 small onion, minced 3 garlic cloves, minced ²⁄³ c. (160 ml) ground walnuts 4 red bell peppers, roasted and peeled 2 hot red peppers, roasted and peeled 3 tbsp. (45 ml) fresh lemon juice (from 1 lemon)

Pictured from top: chimichurri, mouhammara and guacamole.

Doctor’s Review • MAY 2017

1 tbsp. (15 ml) pomegranate molasses ground cumin, for dusting (optional)

In a saucepan over medium-low, heat the oil. Add the onion and garlic, cover and sweat for 15 minutes until very tender. Add the walnuts to the pan, increase the heat and toast for 3 minutes, stirring constantly. Transfer to a food processor along with the red bell peppers, hot peppers, lemon juice and pomegranate molasses, and purée until smooth. Chill the purée overnight. To serve, spoon into a bowl, drizzle with more olive oil, and dust lightly with cumin if desired. Serve with pita bread. Makes 2 cups (500 ml).

SAVOURY BREAD PUDDING WITH SALMON AND GREENS This is classic comfort food and a mother recipe that works with all kinds of leftovers. As long as you have cheese, eggs, milk and fresh herbs, feel free to use any other cooked vegetables, meats or fish that you have on hand. Make it the night before and bake it for brunch, or whip it together after work for a fast family dinner with salad on the side. 2 tbsp. (30 ml) olive oil 1 medium onion, chopped or thinly sliced 2 garlic cloves, minced 4 c. (1 L) bread cubes (about

2-inches / 5-cm; slightly stale French bread is the best) 2 to 3 tbsp. (30 to 45 ml) chopped fresh dill 3 c. (750 ml) chopped fresh spinach or chard 2 c. (500 ml) grated cheese (Gruyère, Gouda, Fontina, etc.), divided 4 eggs, lightly beaten 1 c. (250 ml) milk ½ tsp. (2.5 ml) salt ½ tsp. (2.5 ml) freshly ground black pepper 1 (7½ oz. / 235 ml) can sockeye salmon, drained

In a large nonstick sauté pan over medium, heat the olive oil and slowly cook the onion until soft and caramelized. This will take 30 minutes. Add the garlic halfway through cooking. In a large bowl, toss the caramelized onion with the bread cubes, dill and spinach. Mix in 1½ cups (375 ml) of the grated cheese. Whisk together the eggs, milk, and salt and pepper. Pour this mixture evenly over the bread cubes and stir until most of the egg mixture has been soaked up by the bread.

Preheat the oven to 350°F (180°C). Lightly rub a deep, 8-inch (20-cm) round or oval casserole dish with olive oil. Layer half of the bread mixture in the dish. Break the salmon into chunks and spread evenly on top, then finish with the remaining bread cubes. Sprinkle with the remaining ½ cup (125 ml) of cheese. Bake the casserole, uncovered, for 45 minutes, until the pudding is golden brown and crisp on top. Cool for 5 minutes before serving. Serves 4. Recipes © Cinda Chavich, 2015, The Waste Not, Want Not Cookbook. Reprinted with permission from TouchWood Editions.

MEDICAL QUIPS Therapist talk #2 My therapist says I have a preoccupation with vengeance. We’ll see about that.

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

advertisers index BC INTERIOR HEALTH AUTHORITY Recruitment............................................... IBC BOEHRINGER INGELHEIM (CANADA) LTD Trajenta....................................................OBC GLAXOSMITHKLINE Breo Asthma .........................................IFC, 1 MERCK CANADA INC. Asmanex........................................................6 PFIZER CANADA INC. Duavive.................................................. 28, 29 Pristiq...........................................................21 SEA COURSES INC. Corporate.....................................................11 SERVIER CANADA INC. Coversyl.........................................................4 Viacoram......................................................16 XLEAR INC. Xlear nasal spray..........................................13

FAIR BALANCE INFORMATION Asmanex......................................................47 Duavive........................................................27 Viacoram......................................................17

• Caution when used with acetylsalicylic acid

in hypoprothrombinemia

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

receiving corticosteroids

• Monitoring of: HPA axis function and haematological status

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

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

MAY 2017 • Doctor’s

Review

PHOTO FINISH by

D r P e t e r H u g he s

An English keep When my wife and I lived in the UK, Orford Castle in Suffolk was one of our favourite day trips. Our young sons used to love running up and down the stone staircases, and exploring its dark passages and hidden chambers. For a building that’s more than 800 years old, the interior layout is remarkably sophisticated. The master bedroom, for instance, has a stone urinal built into the wall that drains directly outside into the moat. The rooftop features an open-air space where visitors can sit and take in the view. The five-storey structure — one part royal residence and one part fortress — was built between 1165 and 1173 by Henry II. It’s located on the east coast of England, about two hours northeast of London. During the Second World War, the British government made use of its 27-metre height by installing a radar dish atop one of its three rectangular towers to detect Luftwaffe bombers flying in across the North Sea. Orford Castle is now maintained by English Heritage and during the summer months it’s open to the public seven days a week. For this photo, I borrowed my wife’s camera, a Canon EOS Rebel T1i. It was taken with a shutter speed of 1/100 sec at f10, with a focal length of 18mm. The yellow flowers in the foreground nicely capture the mood of an English summer afternoon.

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

editors@doctorsreview.com

Doctor’s Review • MAY 2017

Physician Opportunities

Rural Incentives* ~ Relocation Support* ~ Diverse Practice Options

The choice is yours! Choose the community that fits your lifestyle. Choose the Southern Interior of BC. Choose Interior Health! Interior Health has fantastic permanent practice opportunities in both rural and urban settings available. Discover the rewards of employment in Canada by contacting us today. Whether itâ&#x20AC;&#x2122;s for the communities, the friendly people or the endless outdoor adventures right out your back door, come and experience the many reasons you will love living here.

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For your adult patients with type 2 diabetes

Equipped for glycemic control.

~5 million patient-years of experience.1

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.

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

BMI = body mass index. * Please see the Product Monograph for complete dosing and administration information. † No dose adjustment is required based on race. Race had no obvious effect on the plasma concentrations of linagliptin based on a composite analysis of available pharmacokinetic data. ‡ No dose adjustment is required based on BMI. § Use of Trajenta® in patients with severe hepatic insufficiency is not recommended. || Use of Trajenta® in patients with ESRD (eGFR <15 mL/min/1.73 m2) and those on dialysis should be with caution.

Please refer to the product monograph at www.TrajentaPM.ca for important information about: • Contraindications in patients with type 1 diabetes or diabetic ketoacidosis. • Relevant warnings and precautions regarding congestive heart failure, patients using insulin, hypoglycemia, glycemic control, use in patients with severe hepatic insufficiency, pancreatitis, hypersensitivity reactions, use in immunocompromised patients, use in patients with End Stage Renal Disease (ESRD) or on dialysis, skin monitoring, use in special populations (e.g., pregnant and nursing women), hepatic function (should be assessed before starting treatment and periodically thereafter), and interactions with strong inducers of P-gp or CYP3A4 (monitoring recommended). • Conditions of clinical use, adverse reactions, drug interactions and dosing recommendations. The product monograph is also available by calling 1-800-263-5103 ext. 84633. References: 1. Boehringer Ingelheim (Canada) Ltd. Data on File. s00042091-01. 2. Boehringer Ingelheim (Canada) Ltd. Trajenta® Product Monograph. May 14, 2015. Trajenta® is a registered trademark of Boehringer Ingelheim International GmbH, used under license.