November-December 2015 by Doctor's Review

NOVEMBER / DECEMBER 2015

Darjeeling’s Rajah of tea Doctors in opera Colour in the artist’s eye Tablet wars The Middle East’s sweet eats

MEDICINE ON THE MOVE

MIAMI PASTEL ART DECO’S GREAT REVIVAL

PLUS

Depression rating scales AND

Eccentric patients

She’s a busy working mom who tries to manage her type 2 diabetes the best she can.

A type 2 diabetes add-on you and your

may agree on. New once-daily JARDIANCE™ is an oral SGLT2 inhibitor to improve glycemic control. Visit Jardiance.ca to learn more.

Indication and Clinical Use: Monotherapy: JARDIANCE™ (empagliﬂozin) is indicated for use as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance. Add-on combination: JARDIANCE™ is indicated in adult patients with type 2 diabetes mellitus to improve glycemic control, when metformin used alone does not provide adequate glycemic control, in combination with: • metformin, • metformin and a sulfonylurea, • pioglitazone (alone or with metformin), • basal or prandial insulin (alone or with metformin), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control. Important Limitation of Use: In combination therapy, use of JARDIANCE™ with insulin mix (regular or analogue mix) has not been studied. Therefore, JARDIANCE™ should not be used with insulin mix. Contraindications: • Patients with a history of hypersensitivity reaction to the active substance or to any of the excipients • Renally impaired patients with eGFR less than 45 mL/min/1.73m2, severe renal impairment, end-stage renal disease and patients on dialysis Relevant warnings and precautions: • Not indicated for use in patients with type 1 diabetes or for the treatment of diabetic ketoacidosis

• Patients should be assessed for diabetic ketoacidosis (DKA) immediately if non-speciﬁc symptoms of DKA occur (nausea, vomiting, anorexia, abdominal pain, excessive thirst, difﬁculty breathing, confusion, unusual fatigue, or sleepiness), regardless of blood glucose level. Discontinuation or temporary interruption of JARDIANCE™ should be considered. Caution should be taken when reducing a patient’s insulin dose • Not recommended for use in patients who are volume depleted • Use with caution in patients for whom a drop in blood pressure could pose a risk or in case of intercurrent conditions that may lead to volume depletion. Careful monitoring of volume status and electrolytes is recommended. Temporary interruption of JARDIANCE™ should be considered for patients who develop volume depletion until the depletion is corrected • The use of JARDIANCE™ in combination with a secretagogue or insulin was associated with a higher rate of hypoglycemia • Dose-related increases in LDL-C can occur with JARDIANCE™. LDL-C levels should be measured at baseline and monitored • JARDIANCE™ increases the risk of genital mycotic infections, particularly for patients with a history of genital mycotic infections • JARDIANCE™ increases the risk of urinary tract infections • Use with caution in patients with an elevated hematocrit • Not recommended in patients with severe hepatic impairment • Assessment of renal function is recommended prior to JARDIANCE™ initiation and regularly during treatment. Do not initiate JARDIANCE™ in patients with an eGFR <60 mL/ min/1.73m2

* Fictitious patient. May not be representative of all cases. CA/EMP/00019 | BI/EMP/00019 JARDIANCE™ is a trademark of Boehringer Ingelheim International GmbH, used under license.

• Monitoring of renal function is recommended prior to and following initiation of any concomitant drug which might have an impact on renal function • JARDIANCE™ must not be used during pregnancy or breastfeeding • Should not be used in patients <18 years of age • Use with caution in patients ≥65 years of age due to a greater increase in risk of adverse events, and because diminished efﬁcacy is expected in this population as older patients are more likely to have impaired renal function • Patients ≥75 years of age are at a higher risk of volume depletion. Prescribe with caution • Initiation of therapy in patients ≥85 years of age is not recommended • Patients receiving JARDIANCE™ will test positive for glucose in their urine For more information: Please refer to the product monograph at www.JardiancePM.ca for important information relating to adverse events, drug interactions, dosing, and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633.

Introducing

Florida then and now Long before the Art Deco revival in south Miami Beach got underway, I was a frequent visitor thanks to $10 flight passes offered to employees of Northeast Airlines, the outfit I worked for at the airport in Montreal. It was possible, in those days of simple pre-9/11 airline travel, to jump on a jet at 8:30pm on a Friday night, spend the weekend in Florida, return on a Sunday evening flight and be ready for another work week Monday morning. I stayed in many hotels in what was then predominately the Jewish section of town. The prices were low, the rooms spotless and you could nosh on bagel with lox and cream cheese just up the street at Wolfie’s (restaurant-ingthroughhistory.com/2011/03/ 27/famous-in-its-day-wolfies). The buildings in the area were grey and, with a few exceptions, seemed to have little to recommend them other than to keep out the rain. That was then and this is now. Most of the buildings have been restored to the way they were in the glory days of the ’20s and ’30s when they were first erected. Gerald Fitzpatrick offers a fine tour of the high points in his article, which begins on page 34. Elsewhere in the issue are two articles that are particularly “doctorly.” The first is a series of unusual afflictions presented by patients who were, themselves, unusual. Eccentric patients I have known, by Dr Nicholas Down, begins on page 45. The second is taken from the book Doctors in opera: an irreverent look at operatic medicine by the Scottish physician J. Ian S. Robertson. It examines the role of one Dr Grenvil in Verdi’s La Traviata and is one of 40 operatic performances in which physicians appear. Is opera one of your interests? If so, I’d be interested in hearing if you’d like more of such coverage in these pages. On an entirely dissimilar note, the Gadgets column takes a quick look at the very rapid rise of the use of mobile devices in medical practice, see Tablet wars, page 19. Do you use one? If so, I’d be grateful if you could let me know about your experience with it — something we’d share with other readers. Eccentric patients and operatic doctors notwithstanding, have a wonderful holiday season and do go south for a short break if the fancy takes you — that special architecture in south Florida could use a closer look. Happy days,

Visit

doctorsreview.com

facebook.com/doctorsreview

David Elkins, Publisher and editor delkins@parkpub.com

@doctorsreview

NOVEMBER / DECEMBER 2015 • Doctor’s

Review

heartburn

Because doesn’t give a hoot what time it is

DEXILANT : Demonstrated 24-hour heartburn relief 96% of 24-hour periods were heartburn-free ®

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

99% of nights were heartburn-free vs. 72% with placebo in patients maintaining healed EE with DEXILANT® 30 mg (median; p<0.00001, secondary endpoint)1,2†

DEXILANT® and Dual Delayed Release® are registered trademarks of Takeda Pharmaceuticals U.S.A., Inc. and used under licence by Takeda Canada Inc. Product Monograph available on request. Printed in Canada © 2015 Takeda Canada Inc.

Indications and clinical use: In adults 18 years and older, DEXILANT® is indicated for: • Healing of all grades of erosive esophagitis for up to 8 weeks • Maintenance of healed erosive esophagitis for up to 6 months • Treatment of heartburn associated with symptomatic non-erosive gastroesophageal reflux disease (GERD) for 4 weeks Other relevant warnings and precautions: • Symptomatic response does not preclude the presence of gastric malignancy • May slightly increase the risk of gastrointestinal infections such as Salmonella and Campylobacter and possibly Clostridium difficile • Concomitant methotrexate use may elevate and prolong serum levels of methotrexate and/or its metabolites • May increase risk of osteoporosis-related fractures of the hip, wrist, or spine. Use lowest dose and shortest duration appropriate • Patients >71 years of age may already be at high risk for osteoporosis-related fractures and should be managed carefully according to established treatment guidelines • Chronic use may lead to hypomagnesemia. For patients expected to be on prolonged treatment or concurrent treatment with digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), initial and periodic monitoring of magnesium levels may be considered • May interfere with absorption of drugs for which gastric pH is important for bioavailability • Co-administration of HIV protease inhibitors for which gastric pH is important for bioavailability (e.g., atazanavir, nelfinavir) is not recommended • Prolonged use may impair absorption of protein-bound Vitamin B12 and may contribute to development of cyanocobalamin deficiency • Should not be administered to pregnant women unless the expected benefits outweigh the potential risks • Should not be given to nursing mothers unless its use is considered essential. In this case nursing should be avoided

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

®1‡§

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

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

* Surgical, diagnostic or invasive procedures that require the interruption of anticoagulation therapy due to bleeding risk include: neurosurgery (intracranial or spinal surgery), cardiac surgery (coronary artery bypass or heart valve replacement), major vascular surgery (abdominal aortic aneurysm repair, aortofemoral bypass), major urologic surgery (prostatectomy, bladder tumour resection), major lower limb orthopaedic surgery (hip/knee joint replacement surgery), lung resection surgery, intestinal anastomosis surgery, selected invasive procedures (kidney biopsy, prostate biopsy, cervical cone biopsy, pericardiocentesis, colonic polypectomy or biopsies), other intra-abdominal surgery, other intrathoracic surgery, other orthopaedic surgery or other vascular surgery. surgery11 Consult respective product monographs for specific direction. 1. Verma Atul et al. 2014 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2014;30:1114-1130.

contents

KAMIRA / SHUTTERSTOCK.COM

NOVEMBER / DECEMBER 2015

features 34

South Beach by design

Eight “must-see” Art Deco buildings in Miami by Gerald Fitzpatrick

The operatic Dr Grenvil How good a doctor was he? by Dr J. Ian S. Robertson

Eccentric patients I have known Exploding foot syndrome plus more colourful complaints as told to one British MD by Dr Nicholas Down

Darjeeling’s tea Rajah A solo wander pays an informative visit by Bill Giebler

45 58

Sweet dreams Classic cakes and cookies that’ll transport you to the Middle East by Anissa Helou

58 NOVEMBER / DECEMBER 2015 • Doctor’s

Review

A Family Fun Adventure

Beaches Resort, Turks & Caicos January 9-16, 2016

Travel packages starting at $3550 Per person, based on double occupancy (Children $975)

A Tropical Paradise for Adults

Sandals Grande St. Lucian, Saint Lucia February 20-27, 2016

Travel packages starting at $2960 Per person, based on double occupancy (Adults only)

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Airway Intervention and Management in Emergencies (AIME) Update AIME Update: What’s new, what’s in, what’s out AIME Update: While this program is not a substitute for the hands-on experience of AIME, it is relevant to any clinician who may be responsible for airway management in emergencies regardless of experience.

Procedural Sedation and Analgesia • Blood and Blood Components • Adult Resuscitation • Pediatric Resuscitation • Seizures • Dizziness and Vertigo • Geriatric Trauma • Spinal Injuries • Thoracic Trauma • Forensic Emergency Medicine • Oral Medicine • Chronic Obstructive Pulmonary Disease • Hypertension • Peripheral Arteriovascular Disease • Pulmonary Embolism and Deep Vein Thrombosis • Plus many more Visit caep.ca/EM-Review for a complete list of course topics.

Highlights of this new course include: Case based ‘rapid fire’ interactive learning • Current issues and controversies • Review the ‘top 10’ airway articles • Customized AIME videos • Airway management pharmacology do’s and don’ts • Live demos using current airway equipment • Create your own customized airway ‘go-kit’ (and have it shipped to you) • Half day format • Plus many more

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To register and for more information go to caep.ca/sun

contents NOVEMBER / DECEMBER 2015

regulars 9

11 30

LETTERS Steamy issues

Rating scales by Mairi MacKinnon

PRACTICAL TRAVELLER The Ontario MD who was named the Wildlife Photographer of the Year, new non-stop flights from Canada, the best cruise ship of 2015 and more by Camille Chin

DEPRESSION KEYPOINTS

PHOTO FINISH A cruise back in time by Dr Arnold Wolf

GADGETS Tablet wars by David Elkins

TOP 25 The biggest medical meetings scheduled for spring 2016

HISTORY OF MEDICINE Was Van Gogh colour blind? by Rose Foster

Coming in

January • Rome on your own: a gender-neutral guide to the Imperial City • Trinidad, Cuba: the joys to be discovered outside Havana • Three special Caribbean treats: fine stays on lesser-known islands • Plan now for great spring hikes: 2016 gear and itinerary guide

19 NOVEMBER / DECEMBER 2015 • Doctor’s

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LETTERS

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

Steamy issues

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Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

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Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

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FULL OF HOT AIR? Can you really cook in a rice cooker [Full steam ahead, October 2015, page 53]?! I have a hard time believing that you can properly sauté sausage and make dumplings in a device that’s meant to steam. I’m curious if other readers have actually tried to do either and what the results were like. Dr Daphne Wilde Via email

EDITORIAL BOARD

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

MONTREAL HEAD OFFICE

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

INTIMATE MATTERS I do not have a medical background, but I read your article on depression and sex [“Open a dialogue on sex and depression,” Depression keypoints, October 2015, page 29] in my own doctor’s office with much interest. My husband suffered from depression for many years and I suspect it’s the reason we struggled in the bedroom. I didn’t know that his mental condition was the reason at the time, of course, but I wish I did because I often felt it was because of me. Thank you for addressing this issue. Olivia B. Via email

VIRTUAL REALITY I always read Doctor’s Review with interest and find it engaging and informative. I did want to correct an important error in the September issue. Doxy.me [“Free telemedicine comes to your iPhone,” Best MD Apps, September 2015, page 20] is a fun tool that is HIPAA compliant, but NOT suitable for use in Canada as our privacy laws have different requirements, including for example not sending any patient information (video or otherwise) via non-Canadian servers.

I can speak of this issue with authority, having had various health leadership roles including eHealth. I also helped co-write the BC Physician Privacy Toolkit with the Office of the Privacy Commissioner and the College of Physicians and Surgeons of BC. Last year until November 2014, I was CMO of Medeo, a Canadian telehealth startup that has the same tool as Doxy.me, but is 100 percent compliant for Canadian physicians to use (full disclosure: I am no longer working with or holding shares or options in Medeo). Dr Alexandra T. Greenhill Vancouver, BC

NOVEMBER / DECEMBER 2015 • Doctor’s

Review

For your adult patients with type 2 diabetes

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

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

BITRJ00110 CATRJ00110

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

C a mi lle C hi n

B:11”

S:10”

T:10.75”

Doctor gone wild A Canadian MD was named the Wildlife Photographer of the Year (WPY) this past September. Dr Don Gutoski, an accident and emergency physician from London, Ontario, beat out over 42,000 entries from 96 countries in a competition that’s now in its 51st year and one of the most prestigious in the world. Taken at Wapusk National Park in Cape Churchill, Manitoba where the range of the red fox and the more northern Arctic fox overlap, A Tale of Two Foxes took Dr Gutoski three hours to nab in -30°C temperatures. The picture will be on view at the Royal Ontario Museum (ROM) in Toronto, November 21 through March 20, 2016. The exhibit will also feature 100 short listed and winning images, including one by Connor Stefanison from Vancouver, BC and another by 10-year-old Josiah Launstein from Pincher Creek, Alberta. Dr Gutoski will be at the ROM on January 28, 2016 for a lecture and exclusive WPY tour. Adults $24; kids 4 to 14 $21. tel: (416) 586-8000; rom.on.ca.

TOP TO BOTTOM: A tale of two foxes by Dr Don Gutoski. Goose attack and Snowy scene by 10-year-old Josiah Launstein. NOVEMBER / DECEMBER 2015 • Doctor’s

Review

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

Putting down routes In September, WestJet announced new direct flights to London Gatwick beginning in May 2016. There will be non-stop service from St. John’s, Toronto, Winnipeg, Calgary, Edmonton and Vancouver. Interestingly, Air Canada rouge begins its direct flights to Gatwick from Toronto in May 2016 as well. A new Air Canada non-stop service to Lyon from Montreal begins in June 2016. Also new, Porter Airlines will fly to Florida for the first time with direct seasonal service to Orlando-Melbourne beginning December 2015 through April 2016.

A structural survey

TOP: Casa A, 2015 by Selgascano + Helloeverything (Madrid, Spain/ New York, US). RIGHT: House No. 11 (Corridor House), 2015 by Sou Fujimoto Architects (Tokyo, Japan).

Doctor’s Review • NOVEMBER / DECEMBER 2015

PHOTOS STEVE HALL

The Chicago Architecture Biennial, being called the largest international survey of contemporary architecture in North America, is on now until January 3, 2016. The event examines how we build, inhabit and shape our world, and how architects, designers, planners and policy makers are tackling today’s most pressing issues. Projects by over 100 architects and artists representing more than 30 countries are installed around the Windy City at places like the Chicago Cultural Center, Water Tower Gallery and Millennium Park. The Chicago Cultural Center features a full-scale house that can be built for less than $4000 by the Vietnamese architecture office Vo Trong Nghia Architects; the Swiss-based office Gramazio Kohler has collaborated with the MIT Self-Assembly Lab to make the first architectural construction built by robots using only rocks and thread. Most of the programming is free. For more events: chicagoarchitecturebiennial.org.

El Celler de Can Roca, Girona, Spain.

Help relieve her menopausal symptoms.

Mary Seguin BACKGROUND: Mary has a husband, 3 boys and works as a top advertising executive downtown. She is experiencing frequent hot flashes and has not had a period for 12 months. TREATMENT GOALS: To help reduce the frequency of hot flashes she experiences on a daily basis. TREATMENT: Mary’s doctor prescribed Premarin oral tablets at the lowest effective dose once daily with a concomitant progestin. A one-month follow-up was suggested to evaluate treatment.

DEMONSTRATED REDUCTION OF

HOT FLASHES.1* Premarin (0.625 mg) with MPA (2.5 mg) showed a 90% decrease from baseline in the mean daily number of hot flashes vs 50% for placebo at 12 weeks (p<0.05)1,2

EFFECTIVE RELIEF OF MENOPAUSAL AND POSTMENOPAUSAL SYMPTOMS, INCLUDING HOT FLASHES, VULVAR AND VAGINAL ATROPHY AND THE PREVENTION OF POSTMENOPAUSAL OSTEOPOROSIS WERE DEMONSTRATED.1 Indications and clinical use: Premarin (conjugated estrogens sustained release tablets) is indicated for the following: • Relief of menopausal and postmenopausal symptoms occurring in naturally or surgically induced estrogen deficiency states including vulvar and vaginal atrophy • Prevention of osteoporosis in naturally occurring or surgically induced estrogen-deficiency states - When prescribing solely for the prevention of post menopausal osteoporosis, Premarin should be considered in light of other available therapies and should only be considered for women at significant risk of osteoporosis. Non-estrogen medications should be carefully considered - For older women who are not experiencing any more acute symptoms of menopause, use in combination with a progestin should only be considered for women who failed on, or were intolerant of, non-estrogen medication • Hypoestrogenism due to hypogonadism, castration, or primary ovarian failure • Atrophic vaginitis • Vulvar atrophy (with or without pruritis) - When prescribing solely for the treatment of symptoms of vulvar and vaginal atrophy, topical vaginal products should be considered • Not indicated for use in pediatric patients (< 16 years of age) In patients with an intact uterus, Premarin should be prescribed with an appropriate dosage of a progestin for women with intact uteri, in order to prevent endometrial hyperplasia/carcinoma. Contraindications: • Liver dysfunction or disease • Known or suspected estrogen-dependent malignant neoplasia

• Endometrial hyperplasia • Known, suspected, or past history of breast cancer • Undiagnosed abnormal genital bleeding • Known or suspected pregnancy • Active or past history of confirmed venous thromboembolism or active thrombophlebitis • Active or past history of arterial thromboembolic disease • Partial or complete loss of vision due to ophthalmic vascular disease • Known thrombophilic disorders • Migraine with or without aura Most serious warnings and precautions: Risk of stroke and deep vein thrombosis: estrogen-alone therapy (mean age 63.6 years). Risk of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli and deep vein thrombosis: estrogen plus progestin therapy (mean age 63.3 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 women with pre-existing endocrine and metabolic disorders • May exacerbate endometriosis • May increase pre-existing uterine leiomyomata • Abnormal vaginal bleeding

*This randomized, double-blind, placebo-controlled trial evaluated the safety and efficacy of lower doses of conjugated equine estrogens (CEE) and medroxyprogesterone acetate (MPA) to relieve vasomotor symptoms (VMS) in postmenopausal women. A total of 2,673 healthy postmenopausal women 40 to 65 years of age with an intact uterus (mean age 53.3 years), including a VMS efficacy-evaluable population (n=241 at baseline), participated. Efficacy measures were frequency and severity of daily hot flashes. The baseline mean daily number of hot flashes was 10 for both groups.Eight treatment arms were evaluated for 13 cycles over a period of 1 year: CEE 0.625 mg/day; CEE 0.625 mg/MPA 2.5 mg/ day; CEE 0.45 mg/day; CEE 0.45 mg/MPA 2.5 mg/day; CEE 0.45 mg/MPA 1.5 mg/day; CEE 0.3 mg/day; CEE 0.3 mg/MPA 1.5 mg/day; or placebo. © 2015 Pfizer Canada Inc. Kirkland, Quebec ® Pfizer Inc., used under license H9J 2M5 PREMARIN ® Pfizer Canada Inc.

CA0115PRE003E

• Risk of gallbladder diseases • May exacerbate systemic lupus erythematosus • May induce or exacerbate anaphylactic reaction and angioedema symptoms • Risk of developing probable dementia (women >65 years) • May exacerbate epilepsy • Caution in patients with otosclerosis • May cause fluid retention • Risk of estrogen-induced hypocalcemia: Caution in individuals with hypoparathyroidism For more information: Please consult the product monograph at www.pfizer.ca/en/our_products/products/monograph/278 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. References: 1. Premarin Product Monograph, Wyeth Canada, December 1, 2014. 2. Utian W et al. Relief of vasomotor symptoms and vaginal atrophy with lower doses of conjugated equine estrogens and medroxyprogesterone acetate. Fertility and Sterility 2001;75(6):1065-1079.

0.3 mg

0.625 mg

1.25 mg

Holy men at a sacred site in Kathmandu, Nepal.

A Berber guide in the Sahara desert, Morocco.

LEO TAMBURRI / G ADVENTURES

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

A worldly experience

G ADVENTURES

Canadian tour operator G Adventures announced a new partnership with National Geographic in September. The adventure outfitter based in Toronto is celebrating its 25th anniversary year with the launch of National Geographic Journeys with G Adventures. Details on an initial collection of 70 “experiential” trips will be released on December 15 — with departures beginning January 5, 2016. All are intended to connect travellers with local people and cultures, while discovering places that are significant to National Geographic scientists and storytellers. Some events already planned for groups of 16 include the chance to sip homemade limoncello with a farmer at his lemon orchard in Italy; practice a centuries-old tradition of throwing pots at a women’s cooperative in Belize; or join a researcher on safari in South Africa to learn about a National Geographic-sponsored initiative to protect cheetahs and other big cats. tel: (888) 800-4100; gadventures.com/journeys.

Greece is chronically short of revenue so in October the country’s Central Archaeological Council approved plans to charge travellers more to enter the country’s main archeological sites and museums. Beginning January 1, 2016, admission to the Acropolis in Athens will likely increase from €12 to €20 (or about $18 to $30). Entry to the Knossos ruins in Crete, the ancient Minoan palace that’s considered Europe’s oldest city, will jump 150 percent from €6 to €15 ($9 to $22). The new full prices will be effective April to November; they’ll be reduced by 50 percent the rest of the year. The hikes will reportedly raise at least €21 million for the Greek government. According to the World Travel and Tourism Council, tourism accounted for seven percent of the country’s €11.8 billion Gross Domestic Product in 2014.

Doctor’s Review • NOVEMBER / DECEMBER 2015

Ruins of Knossos Palace.

VALENTYN 1961 / SHUTTERSTOCK.COM

Greece’s culture shock

Help her treat painful intercourse.

Natalia Pottier BACKGROUND: Natalia is a wife, mother and grandmother. She is experiencing vaginal dryness as well as painful intercourse. TREATMENT GOALS: To alleviate the atrophic vaginitis and dyspareunia she has been experiencing. TREATMENT: Natalia’s doctor prescribed Premarin Vaginal Cream at the lowest effective dose. A threemonth follow-up was suggested to evaluate treatment response.

THE ONLY CE CREAM INDICATED TO TREAT PAINFUL INTERCOURSE (DYSPAREUNIA)1* *Comparative clinical significance is unknown. CE=Conjugated Estrogen

TREATMENT OF DYSPAREUNIA, ATROPHIC VAGINITIS AND KRAUROSIS VULVAE.

Indications and clinical use: Premarin Vaginal Cream (conjugated estrogens, CSD) is indicated for the treatment of atrophic vaginitis, dyspareunia, and kraurosis vulvae. It has not been shown to be effective for any purpose during pregnancy and its use may cause severe harm to the fetus. It should be prescribed with an appropriate dose of a progestin for women with intact uteri in order to prevent endometrial hyperplasia/carcinoma. • Not indicated for use in pediatric patients (<16 years of age) Contraindications: • Liver dysfunction or disease • Known or suspected estrogen-dependent malignant neoplasia • Endometrial hyperplasia • Known, suspected, or past history of breast cancer • Undiagnosed abnormal genital bleeding • Known or suspected pregnancy • Active or past history of confirmed venous thromboembolism or active thrombophlebitis • Active or past history of arterial thromboembolic disease • Partial or complete loss of vision due to ophthalmic vascular disease • Known thrombophilic disorders • Migraine with or without aura

For more information: Please consult the product monograph at www.pfizer.ca/en/our_products/products/monograph/276 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.

Most serious warnings and precautions: Risk of stroke and deep vein thrombosis: estrogen-alone therapy (mean age 63.6 years). Risk of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis: estrogen plus progestin therapy (mean age 63.3 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 • May weaken and contribute to the failure of condoms, diaphragms, or cervical caps • Monitor blood pressure with hormone replacement therapy use • Caution in women with pre-existing endocrine and metabolic disorders • May exacerbate endometriosis • May increase pre-existing uterine leiomyomata • Abnormal vaginal bleeding • Risk of gallbladder diseases • May exacerbate systemic lupus erythematosus • May induce or exacerbate angioedema symptoms • Risk of developing probable dementia (women >65 years) • May exacerbate epilepsy • Caution in patients with otosclerosis • May cause fluid retention

References: 1. Premarin Vaginal Cream Product Monograph, Wyeth Canada, December 11, 2014.

CA0115PRE004E

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

Cruising for a win The Viking Star’s main pool and Wintergarden for afternoon tea (right).

The Viking Star has been named the best new cruise ship of 2015 by the editors of Cruise Critic. Described by the cruise review website as “a boutique hotel, homey and comfortable after a long day exploring in port,” Viking Ocean’s 930-passenger Star debuted this year as the river cruise company’s first venture into ocean cruises. It features an alfresco dining room, an Explorer’s Lounge with two-storey panoramic windows and a Nordic-style spa with “snow grotto.” The Star sails to Italy, Spain, Turkey, the UK, Sweden and Norway. Several more award winners follow. For more results (best dining, cabins etc.): cruisecritic.com/ editors-picks.

Ocean cruises: Best cruise line for families: Royal Caribbean International Best for luxury: Crystal Cruises Best for adventure: Un-Cruise Adventures Best shore excursions: Azamara Club Cruises Best value: Carnival Cruise Line

River cruises: Best new river cruise ship: S.S. Maria Theresa, Uniworld Boutique River Cruise Collection Best river cruise line: Uniworld Boutique River Cruise Collection Best itineraries: Viking River Cruises Best value: Emerald Waterways

February 20-‐March 2, 2016 • Tahi4 & Cook Islands • Geriatrics & Women’s Health

Doctor’s Review • NOVEMBER / DECEMBER 2015

March 13-‐20, 2016 • Exo4c Western Caribbean • Rehab Medicine, Gastroenterology & Psychiatry

July 16-‐28, 2016

• Iceland & Norway • Neurology, Cardiology, Psychiatry • & Technology in Medicine

COVERED ON MOST PRIVATE P L A N S

Picato® Gel is about treatment time in actinic keratosis. Picato® Gel (ingenol mebutate) is indicated for topical treatment of non-hyperkeratotic, non-hypertrophic actinic keratosis (AK) in adults. • Short duration dosing: once daily for 3 days on face/scalp or 2 days on trunk/extremities

• Local Skin Responses (LSRs)* are transient

and typically occur within 1 day of treatment and peak in intensity up to 1 week following completion of treatment. These effects typically resolve within 2 weeks on the face and scalp, and within 4 weeks on the trunk and extremities.

*LSRs included erythema, ﬂaking/scaling, crusting, swelling, vesiculation/pustulation, and erosion/ulceration Relevant Warnings & Precautions

For more information

• • • • • • • • • •

Please consult the product monograph at www.leo-pharma.ca/ picato_pm for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by contacting LEO Pharma Medical Information at 1-800-263-4218.

Severe Local Skin Responses (LSRs) Severe eye disorders Use on skin which is not healed Contact with skin outside the treatment area should be avoided Use near the eyes, inside the nostrils or ears or on the lips Must not be ingested Use in pregnant and nursing women Prevention of squamous cell carcinoma (SCC) has not been studied Re-treatment and treatment of more than one area Use in immunocompromised patients

www.leo-pharma.ca

PIC-006-15E

1. Picato® Gel product monograph. LEO Pharma Inc. January 30, 2013. ®Registered trademark of LEO Pharma A/S used under license and distributed by LEO Pharma Inc., 123 Commerce Valley Dr. E., Suite 400, Thornhill, Ontario L3T 7W8

GLYCEMIC CONTROL WITH CONFIDENCE

CARDIOVASCULAR SAFETY EVIDENCE

GLYCEMIC CONTROL WITH ONGLYZA

Primary safety endpoint: composite of time to ﬁrst occurrence of CV death, nonfatal myocardial infarction, or nonfatal ischemic stroke

•

Demonstrated long-term A1c reduction vs placebo, both in combination with metformin over 102 weeks

•

A1c mean change from baseline:1*

•

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

Demonstrated hazard ratio 1.00; 7.3% for ONGLYZA vs 7.2% for placebo when added to current background therapy or as monotherapy (95% CI: 0.89 to 1.12; p =0.986)1,2† – The study did not demonstrate the superiority of ONGLYZA compared with placebo when added to current background therapy, in reducing the primary endpoint

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

Hospitalization for heart failure occurred at a greater rate in the ONGLYZA group compared with the placebo group (3.5% vs 2.8%, respectively, HR 1.27; 95% CI: 1.07 to 1.51)1,2 – Subjects on ONGLYZA with a baseline history of congestive heart failure, especially those who also had renal impairment and/or MI, were at higher absolute risk for hospitalization for heart failure

ONGLYZA is indicated in patients with type 2 diabetes mellitus to improve glycemic control in combination with metformin, a sulfonylurea, metformin and a sulfonylurea (dual therapy), or premixed or long/intermediate-acting insulin (with or without metformin) when metformin, the sulfonylurea, dual therapy or premixed or long/intermediate-acting insulin (with or without metformin), used alone with diet and exercise, does not provide adequate glycemic control. Should not be used in pediatric populations.

KOMBOGLYZE is indicated for use as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus: • who are already treated with saxagliptin and metformin or who are inadequately controlled on metformin alone • in combination with a sulfonylurea (i.e., triple combination therapy) as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are already treated with saxagliptin, metformin and a sulfonylurea or who are inadequately controlled on metformin and a sulfonylurea alone • in combination with premixed or long/intermediate-acting insulin as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are already treated with saxagliptin, metformin and premixed or long/intermediate-acting insulin or who are inadequately controlled on metformin and premixed or long/intermediate-acting insulin alone Use with caution in geriatric populations. Should not be used in pediatric populations.

Convenience of a ﬁxed-dose combination with metformin3 There have been no clinical efﬁcacy studies conducted with KOMBOGLYZE tablets; however, bioequivalence of KOMBOGLYZE with coadministered saxagliptin and metformin hydrochloride immediate release tablets was demonstrated.

ONGLYZA®, KOMBOGLYZE® and the AstraZeneca logo are registered trademarks of AstraZeneca AB, used under license by AstraZeneca Canada Inc.

07/16

See additional safety information on page XX See page XX 61 for additional safety information

GA D GE T S by

Da vi d E l k i n s

Tablet wars In case you missed it, there’s a war going on between Amazon and Apple for your e-book and tablet business. Earlier this year, Apple fired the first shot and stopped accepting the full version of Amazon’s popular Kindle books on their mobile devices. iPhones and iPads will now only load the first 30 pages of a Kindle book even if Amazon’s site indicates that it has been sent to your Apple device. Neither company lets you know of the change in policy. If you’ve been used to reading Kindle books on your Apple device, including the popular iPad Mini 2 or the just launched iPad Air 2, you’re out of luck. Amazon would prefer it, of course, if you purchased one of their tablets to read their books on. In 2011, they launched the Fire tablet line and have been marketing it aggressively ever since. On September 17, the company launched a new seven-inch tablet in the US priced at just US$50, even offering the low-cost device in a family “six pack.” Though it’s clearly not a top-of-the-line tablet, it does have a decent screen and most of the bells and whistles, and it’s selling briskly in the US, the only country in which it’s offered so far. It’s not clear yet when it will come to Canada. In the meantime, you can find out all about it on Amazon’s US site where over 7000 customers have given it four stars out of five. This latest tablet entry adds confusion to an already crowded market. Portability is what makes tablets popular and many of them have found their way into the pockets of white lab coats. Initially, seven-inch models were the most popular, but of late bigger eight-inch-plus screens have had stronger sales. The newest mini models now have as much technology packed into them as their larger cousins. So which tablet would work best for a busy practitioner? Reviewers’ first choice in smaller tablets is almost universally the iPad Mini 2. Launched in 2013, it remains popular despite the arrival of the 3 and, this fall, the Mini 4. The only drawback is price. Canadian BestBuy stores offer the 16-gigabyte model for $321. When it comes to full-sized tablets the new iPad Air 2 is the model of choice. Says one reviewer reflecting the general consensus: “Everyone else really has their work cut out if the iPad Air 2 is going to be unseated from the number one spot.” At BestBuy the 16-gigabyte version is $541. Android users rank the 32-gigabyte Samsung Galaxy Tab S2 as their favourite. $500 at BestBuy. On the other hand, if all you really want is a reader for your Kindle e-books, the six-inch glare-free touchscreen model from Amazon for $80 will do just fine. The new Paperwhite at $140 has a better screen — it’s up to you to decide if it’s worth the extra $60.

NOVEMBER / DECEMBER 2015 • Doctor’s

Review

R E C O M M E N D E D F I R S T- L I N E

IN CHILDREN, ADOLESCENTS AND ADULTS 1*

ANYONE IN THE FAMILY CAN HAVE ADHD BIPHENTIN ®: FOR ADHD PATIENTS FROM 6-65 YEARS OLD 2 IN ADULTS: 3 Fast onset – similar to IR methylphenidate2† IN CHILDREN ≥6 YEARS OF AGE AND ADOLESCENTS: 3 Demonstrated improvements within one hour2‡ 3 Efficacy shown to last for 10 to 12 hours2§ Biphentin® is indicated for treatment of Attention-Deficit Hyperactivity Disorder (ADHD) in children 6-11, adolescents 12-18 and adults >18 years of age. Refer to the page in the bottom-right icon for additional safety information and a web link to the Product Monograph discussing: • Contraindications in patients with anxiety, tension, agitation, thyrotoxicosis, advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension or glaucoma. Motor tics or with family history or diagnosis of Tourette’s syndrome. Concomitant use of an MAO inhibitor or within a minimum of 14 days following discontinuation of an MAO inhibitor. Most Serious Warnings And Precautions: • Drug dependence/tolerance. Careful supervision is required during drug withdrawal. Other relevant warnings and precautions regarding risk of sudden

Flexible dosing – available in 8 strengths for dose optimization2¶

May be sprinkled on these soft foods: apple sauce, yogurt or ice cream2

cardiac death in Patients who are involved in strenuous exercise or activities or have a family history of sudden cardiac death, sudden death, screening for cardiovascular and cerebral vascular conditions, monitor blood pressure, long-term suppression of growth, Psychiatric effects: Not for treatment of depression; not for use in treatment or prevention of normal fatigue states; may exacerbate psychosis symptoms in patients with pre-existing psychotic disorder; Screen for risk of bipolar disorder in patients with comorbid depressive symptoms; monitor patients for signs of suicide related behaviour, monitor patients for new psychotic or manic episodes and aggressive behaviour, neurologic effects, ophthalmologic effects, Priapism, Associated with peripheral vasculopathy, including Raynaud’s phenomenon • Refer to conditions of clinical use, adverse reactions, drug interaction and dosing instructions in the Product Monograph

* Recommended first-line for uncomplicated ADHD in children, adolescents and adults by CADDRA (Canadian Attention Deficit Hyperactivity Disorder Resource Alliance).1 † Rapidly and extensively absorbed with peak blood levels obtained in 1 to 3 hours. The initial peak plasma concentration at 1.7 hours post-dose was similar to 1.8 hours for the immediate-release formulation when fasting.2 ‡ Improvements relative to placebo were noted within 1 hour on Biphentin® and persisted into the early evening in a doubleblind, placebo-controlled, crossover comparison of Biphentin® and IR methylphenidate in ADHD children and adolescents 6-15 years of age (n=17).2 § IOWA Conners’ Rating Scale and Conners’ Parent Rating Scale performed at approximately 10 and 12 hours, respectively, post-morning dose in two separate randomized, double-blind crossover studies vs. IR methylphenidate and placebo and vs. IR methylphenidate in children and adolescents ≥6 years of age.2 ¶ Biphentin® should be initiated at the lowest possible dose and titrated in weekly increments of 10 mg/day. Maximum daily dose of 1 mg/kg (not exceeding 60 mg/day) in children 6-12 years of age and adolescents. Maximum dose of 80 mg/day for adults.2 Biphentin® is a registered trademark of Purdue Pharma. © 2015 Purdue Pharma. All rights reserved.

62 See additional safety information on page XX

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Halifax, NS April 14-16, 2016 2016 Canadian Respiratory Conference crc.lung.ca/crc/home-accueil_e.php

79th Annual Scientific Meeting of the Canadian Association of Radiologists car.ca/en/education/annual-scientific-meeting/ 2016-asm.aspx

April 16-19, 2016 2016 Canadian Conference on Medical Education mededconference.ca

Ottawa, ON April 1-4, 2016 29th Annual Meeting of the Canadian Society for Immunology csi-sci.ca/scientificmeeting.aspx

Vancouver, BC April 6-9, 2016 7th National Biennial Conference on Adolescents and Adults with Fetal Alcohol Spectrum Disorder interprofessional.ubc.ca/adultswithfasd2016/ default.asp

April 14-16, 2016 36th Annual Scientific Meeting of the Canadian Geriatrics Society canadiangeriatrics.ca

JOSEF HANUS / SHUTTERSTOCK.COM

Montreal, QC April 14-17, 2016

A-maze-ing laughter by Yue Minjun at English Bay in Vancouver.

Around the world Baltimore, MD April 14-17, 2016

Boston, MA April 1-4, 2016

47th Annual Conference of the American Society of Addiction Medicine asam.org/education/live-and-online-cme/ the-asam-annual-conference

ENDO 2016 endocrine.org/endo-2016

April 30 - May 3, 2016 2016 Annual Meeting of the American Society of Pediatric Nephrology aspneph.com/educationmeetings.asp

April 15-21, 2016

Barcelona, Spain March 31-April 3, 2016

2016 Annual Meeting of the American Academy of Neurology aan.com/conferences

3rd World Congress on Controversies in Pediatrics congressmed.com/copedia

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

Chicago, IL April 14-16, 2016 2016 Summit of the Thrombosis and Hemostasis Societies of North America thsna.org/web/index.php

April 14-16, 2016 41st Annual Meeting of the Society for Sex Therapy and Research sstarnet.org/meeting.php

46425 MER15ZH096-Banner-3E-Merck_E2.indd 1

NOVEMBER / DECEMBER 2015 • Doctor’s

R2015-05-25 eview

11:11 PM

THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Dallas, TX April 15-17, 2016 18th Annual Meeting of the American Society of Interventional Pain Physicians asipp.org/meetings.htm

Istanbul, Turkey April 9-12, 2016

Jakarta, Indonesia April 8-10, 2016 6th Congress of the Asia Pacific Initiative on Reproduction aspire2016.org

Leipzig, Germany April 6-10, 2016

Lisbon’s Berardo Museum in the Belém district.

London, England April 26-29, 2016

autoimmunity.kenes.com

38th Charing Cross Symposium: Vascular and Endovascular Challenges Update cxsymposium.com

Lisbon, Portugal March 17-20, 2016

Malaga, Spain April 4-7, 2016

10th International Congress on Autoimmunity

10th World Congress on Controversies in Neurology comtecmed.com/cony/2016

PAOLO QUERCI / SHUTTERSTOCK.COM

26th European Congress of Clinical Microbiology and Infectious Diseases eccmid.org

New Orleans, LA April 2-5, 2016 41st Annual Conference of the American Society of Andrology andrologysociety.org

April 13-16, 2016 2016 Annual Meeting of the American Society for Colposcopy and Cervical Pathology asccp.org/2016annualmeeting

2016 World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases wco-iof-esceo.org

San Francisco, CA April 6-10, 2016 Obesity Medicine 2016 asbp.org/education/obesitymedicine.html

São Paulo, Brazil April 20-23, 2016 12th World Congress of the International Hepato-Pancreato-Biliary Association ihpba2016.com

The John Fitzgerald Kennedy Memorial in downtown Dallas.

Doctor’s Review • NOVEMBER / DECEMBER 2015

LINDA MOON / SHUTTERSTOCK.COM

Venice, Italy March 3-6, 2016 4th International Conference on Prehypertension, Hypertension and Cardio Metabolic Syndrome 2016.prehypertension.org

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

Treating chronic pain, our shared responsibility. As one of the leading pharmaceutical companies in Canada, Purdue Pharma is dedicated to ongoing research and development in the field of drug delivery and the use of pain medications. However, we also recognize that prescription drug abuse is a public health issue. A recent survey conducted by CAMH showed that 81% of students who use medicines non-medically obtain them from family or friends.1 Purdue Pharma, together with health authorities and the medical community, is actively working to reverse this trend so that the right medications get to the right patients. Through our educational programs and strong community partnerships, we are confident that we can continue to make great strides in addressing the use, abuse and diversion of pain medications. For more information on our products and our role within the community, please contact your Purdue Health Solutions Manager or visit www.purdue.ca.

1. Boak, A., Hamilton, H. A., Adlaf, E. M., & Mann, R. E. (2013). Drug use among Ontario students, 1977-2013: Detailed OSDUHS findings (CAMH Research Document Series No. 36). Toronto, ON: Centre for Addiction and Mental Health.

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

R os e F os t e r

Art and ocular disease Part two: why Van Gogh’s critics are wrong

Some argue that the blues in Van Gogh’s famous Starry Night suggest he was colour blind. Stanford’s professor of ophthalmology, Dr Michael Marmor, concedes that the painter had a host of mental and physical health afflictions, but colour blindness was very unlikely one of them.

rt critics in the 1800s had a scientific weapon up their sleeves when it came to attacking the painters whose florid and outrageous colour choices caused them so much disdain. Clearly, they asserted,

this perverse excess of incoherently selected hues could be chalked up to just one thing: daltonism. This was the early term for colour blindness, so named after the Englishman John Dalton who wrote the first scientific paper on the subject in 1798 after he realized that his own colour vision was congenitally compromised. Commenting on the work of Édouard Manet he wrote: “On soul and conscience, I believe that the pupils of Mr. Manet are afflicted with daltonism.” Only an affliction of the eyes could possibly explain the Impressionists’ bizarre palettes chorused the critics. Some complained about the preponderance of blue in paintings by Monet, Pissarro and others. One noted “green has practically disappeared from their palette, whereas blue dominates all their paintings (and) spoils everything.”

TOO BLUE? The excess of blue was, they decided, sufficient evidence to diagnose the painters with protanopia or deuteranopia, the two types of inherited colour vision deficiency which make green and red indistinguishable. The painters themselves mischievously played into the act. Camille Pissarro wrote to his son that, “We are affected by painters’ disease who see blue, which is daltonism.” American James Whistler, not an Impressionist himself, glimpsed a spot of blue paint on the sleeve of writer Stéphane Mallarmé’s jacket and commented, “He’s been to stay with the Impressionists!” It was the critics’ eyes — or rather, their judgments — which were in need of a diagnosis, and not those of the painters. Chromophobia, or fear of colour, was perhaps at play here. Contemporary artist NOVEMBER / DECEMBER 2015 • Doctor’s

Review

David Batchelder describes chromophobia as a phenomenon that lurks within much Western cultural and intellectual thought, apparent in the way Western culture seeks to make colour the property of some “foreign body” — the pathological, the vulgar or the infantile. When Western palettes first exploded into vibrant splotches of indescribable brilliance, critics took cover declaring the outburst a product of pathology. Interestingly, a similar approach has been used even recently in an attempt to “explain” painter Vincent van Gogh’s ecstatic, visionary use of colour. In 2011, Japanese colour designer Kazunori Asada had what he felt was a profound revelation about Van Gogh’s use of colour while viewing Starry Night and other famous works in a “Colour Vision Experience Room” designed to show normal-sighted people what it was like to have red-green colour blindness. “Under the filtered light,” he wrote, “I found these paintings looked different from the Van Gogh which I had always seen. […] [T]o me, the incongruity of colour and roughness of line had quietly disappeared. And each picture had changed into one of brilliance with very delicate lines and shades. This was truly a wonderful experience.” His argument that the great master of colour had been colour deficient was strangely compelling and caught on in some circles. But professor of ophthalmology at Stanford University, Dr Michael Marmor, says that while Van Gogh was most certainly plagued by a host of health afflictions both mental and physical, colour blindness is very unlikely to have been one of them. “He used vibrant greens in many paintings,” says the specialist, “and green is a dangerous colour for a colour blind person because it lies right between yellow and blue, and to their perception it actually greys out — it loses colour.” Dr Marmor also rejects the theory that Van Gogh’s affinity for yellow in his paintings came from “yellow vision,” caused by taking digitalis to treat supposed epilepsy. “He could not have taken enough of it to have that effect. It’s too toxic. He loved yellow throughout his career.” He isn’t the only one who disagrees with Asada. American ophthamologist Dr Bryan William Jones points out that Asada’s software for transforming normal colour vision into colour blind perception is more of a “gentle approximation” of what a true

Englishman John Dalton wrote the first scientific paper on the subject of colour blindness in 1798 and the condition became known as “daltonism.”

protanope would see, and one which leaves some reds and greens intact. Dr Jones uses his own software to filter Van Gogh’s paintings through a colour-blind lens more accurately, revealing that had he been colour blind, Van Gogh would not have been able to select the reds and greens necessary to distinguish tulip leaves from the blossoms, as he clearly does in Flowering Garden with Path. And who but a painter sensitive to the atmospheric differences between green and red could paint masterpieces like The Night Café and Woman Rocking a Cradle, one might ask. Outrageous myths about the eccentric painter abound: that the painter Gauguin was responsible for cutting off a portion of Van Gogh’s ear during a fencing match; that he was murdered; and finally, that he was colour blind. At least that one can be crossed off the list. Another good reason to believe that Van Gogh’s colour vision worked just fine is that the painter never mentioned any lack of perception when it came to colour. Artists notice these things.

BLISSFUL ENGRAVER Take the case of Charles Méryon (1821–1868) who was France’s most renowned engraver in the 19th century and who was colour blind. He discovered this early in his career as a painter, when he observed that, “There is no doubt that my sight is out of order and this causes certain colours to be confused by me,

The many layers in the lenses of EnChroma sunglasses filter out specific wavelengths of light such that the proper combination of cones is activated. This allows people with CVD to see shades of colour they have never seen before. For more: sitn.hms.harvard.edu/flash/2015/ from-kansas-to-oz-how-new-glasses-could-change-theway-the-colorblind-see-the-world.

Doctor’s Review • NOVEMBER / DECEMBER 2015

even though they are completely different for everyone else.” His close friend Philippe Burty, who was to publish the first important study of his work, noted that Méryon was, “unable to distinguish ripe strawberries from the leaves… on his palette he used red for yellow, rose pink for green, whilst he distinguished other colours like gold, cobalt and lapis lazuli with extreme precision.” During a voyage across the Pacific — the same environment from which painter Gauguin drew a paradise of colour 50 years later — Méryon produced a series of landscape drawings in black pencil. Soon after, he discovered engraving and renounced colour for good. The unequalled mastery he was able to achieve as an engraver, celebrated especially in scenes of Paris and its surrounds, may in fact be credited to his colour blindness, which allowed him to develop a heightened sensitivity to the subtleties of light and shadow. Upon viewing his etchings, writer Victor Hugo remarked, “The murmur of the universe traverses Méryon’s work and creates visions more from his etchings than his paintings.” Switching to sculpture or printmaking is apparently common among artists who find themselves with a colour-blind diagnosis, says contemporary artist Peter Milton. He counts himself among them, creating lush, extraordinarily intricate black-and-white prints which invoke a sense of mystery. Milton didn’t find

out he was colour blind until he had a show of his paintings at age 32 and one critic referred to how “warm and sort of pinky the landscapes were,” he says. “I was horrified.”

COLOUR GURU Milton had the good fortune to study art at Yale under Josef Albers, who literally wrote the book on colour, entitled Interaction of Color. Apparently Albers thought highly of Milton’s work, which continues to strike Milton as bizarre. “I’m the colour-blind person,” he says. “He’s the colour guru.” Would Milton correct his colour vision deficiencies (CVD) if he could? If he wanted to see the world the way the other 93 percent of men of European descent see it (7 percent of people born male are colour blind, while only .4 percent of those born female have the deficiency), a special pair of lenses could give him renewed colour vision. EnChroma glasses are reputed to help four out of five people who experience colour blindness. The glasses were originally designed to offer eye protection for surgeons using lasers. But when inventor Donald McPherson’s colour-blind friend put the glasses on, he saw a new range of colours for the first time. Milton, however, seems attached to his particular form of seeing. “I don’t miss colour,” he says and claims that it’s a disability that makes colour choices easier.

Influential physician leaders are not always in formal leadership positions CHALLENGE THE WAY YOU THINK ABOUT LEADERSHIP. Leadership training throughout your career is essential. In today’s complex environment, physicians need to be good collaborators, communicators and managers. These skills can be continually developed and help you in your everyday life.

5 reasons you should attend PMI physician leadership courses

*based on 2014-15 physician participant survey results.

cma.ca/lead Register for a 2016 course by Dec. 31, 2015, and SAVE $150. Promo code: EARLYBIRD** **some exceptions apply.

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1. Developed by the CMA specifically for physicians 2. Earn RCPSC and CFPC credits 3. A 98% participant satisfaction rate* 4. Flexible delivery options (online and face to face) 5. Network with colleagues from across Canada

Registered trademarks of the Canadian Medical Association used under licence

AndroGel速 is indicated for testosterone replacement therapy in adult males for conditions associated with a deficiency or absence of endogenous testosterone (hypogonadism). 1

AndroGel

速

TESTOSTERONE REPLACEMENT THERAPY (TRT) FOR MEN WITH HYPOGONADISM 1

Consult the Product Monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for important information on contraindications, warnings, precautions, adverse reactions, drug interactions, dosing and conditions of clinical use. The Product Monograph is also available by calling Mylan EPD at 1-844-596-9526.

References: 1. AndroGel速 Product Monograph. BGP Pharma ULC. January 28, 2015. 2. IMS Brogan, CompuScript, Testosterone Replacement Therapy, Molecular Level, National Data, MAT July 2015. Data on file, BGP Pharma ULC. 息 Mylan 2015. All rights reserved. 速 Registered Trademark Abbott Laboratories (USA), Licensed use by BGP Pharma ULC, Saint-Laurent, Quebec, H4S 1Z1

D E P R E S S I O N K E Y P OI N T S by

Mairi MacKinnon

Measuring patients’ sadness

Depression rating scales can guide decision-making and improve care

Reviewed by Corina Velehorschi, MD, FRCPC, DABPN, Adjunct Professor of Psychiatry, University of Western Ontario

T .

he Canadian Network for Mood and Anxiety Treatments (CANMAT) 2009 guidelines for management of major depressive disorder (MDD) in adults define successful therapy as full remission (vs simply response). Failure to achieve this target significantly raises the risk of relapse and worsens the prospect of a positive outcome.1 Measurement-based care facilitates resolution of depressive symptoms, prevents recurrence and improves individuals’ chances of enjoying full recovery. Symptom rating scales make up an important component of effective management.1-4 Response corresponds to a reduction of more than 50 percent in scores on these scales, while remission is equated with a score within the normal range.1

Considerations in clinical practice Primary care is the most common setting for the diagnosis and treatment of depression.5,6 A variety of validated rating scales are available to assist busy physicians with management of this prevalent condition.1,3,6 These include subjective (patient-rated) scales and objective scales (rated by the provider). Many of them can be accessed and downloaded online, free of charge. Choice of the right tool is important. Rating scales should be user-friendly (short, straightforward), reliable and suitable for the needs of diverse patient groups; they should take into account factors such as language, culture, age-appropriateness, cognitive status, comorbid conditions and suicide risk.3

Start with two quick questions CANMAT recommends screening for high-risk groups, such as patients with past or family history of depression, chronic medical conditions or other psychiatric conditions, individuals undergoing periods of psychosocial stress or hormonal challenge (menarche, perinatal, postpartum, perimenopausal), or those with unexplained physical symptoms, pain, fatigue and/ or insomnia.1 The two-quick-question method, adapted from the Primary Care Evaluation of Mental Disorders (PRIME-MD) diagnostic tool, affords an easy, effective way to start off casefinding: “In the last month, have you been bothered by little interest or pleasure in doing things?”; and “In the last month, have you been feeling down, depressed or hopeless?”1,3

Doctor’s Review • NOVEMBER / DECEMBER 2015

A “yes” to either of these questions indicates the need for further assessment to determine if the patient meets the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for MDD.

Symptom rating The following scales are recommended for the purposes of both screening and monitoring of depression in adults.1 The Brief Patient Health Questionnaire (PHQ-9) is a nine-item, self-report questionnaire designed to confirm a diagnosis of MDD. It also includes a severity scale that can be useful for regular monitoring of response to treatment.1,3 (See phqscreeners.com.) The 16-item Quick Inventory of Depressive Symptomatology, Self-Rated (QIDS-SR) is used mainly to assess severity of depressive symptoms (ids-qids.org). The current version of the Beck Depression Inventory (BDI-II) contains 21 self-report items formulated to assess and monitor depression in people aged 13 years and older. It has high sensitivity and specificity, and is valid and reliable for evaluation of depression severity.3 (The BDI is not in the public domain; you can order it online from pearsonassess.ca.) The Zung Depression Self-Rating Scale, a 20-item survey, is used in screening as well as for measuring severity for both clinical and research ends. (You can download the pdf at healthnet.umassmed.edu/mhealth/ZungSelfRatedDepression Scale.pdf.) Other outcome assessment tools that measure evolution from one treatment to the next and are validated to track changes include the Hamilton Depression Rating Scale (Ham-D) and the Montgomery Åsberg Depression Rating Scale (MADRS). The MADRS (psy-world.com/madrs.htm), based on clinical interviews, encompasses 10 questions ranging from general to specific, and permits precise rating of depression severity. The HAM-D (veterans.gc.ca/eng/forms/document/290) is available in clinician-rated versions as well as a shorter, sevenitem version suitable for clinical practice.

Functional assessment While symptom monitoring during treatment is key to measuring outcomes,1 improvements in symptomatic scales (which tell how a patient is “feeling”) might not necessarily reflect how the patient is “doing.” In conjunction with symptom rating scales, functional scales can be useful to tap into a patient’s ability to perform normal activities.4

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The Global Assessment of Functioning (GAF; see the DSM, Fourth Edition) is the standard measure of functional impairment and is often used for insurance purposes. The GAF provides information on activities of daily living, social functioning, concentration/persistence and degree to which symptoms affect work function.7 The Lam Employment Absence and Productivity Scale (LEAPS; available at workingwithdepression.psychiatry.ubc.ca) is a recently validated, 10-item self-rated tool that is very quick to complete. Based on common problems that impact most on work productivity, it can help steer decisions about patients’ ability to remain at work and follow their improvement over time.4

Population-specific scales The self-rated Geriatric Depression Scale (GDS) contains yes/no questions in a 15- or 30-item format and controls for somatic symptoms related to aging and comorbid illness (available at web.stanford.edu/~yesavage/GDS.html).3,8,9 It provides good specificity and predictability for diagnosis of MDD in elderly individuals who have no significant cognitive deficits. For those with moderate to severe impairment with dementia, the standard screening tool is the Cornell Scale for Depression in Dementia (CSDD).8,9 Interviews covering 19 questions can be conducted with the patient or a family member /caregiver. (Permission is required to use the CSDD: geropsychiatriceducation.vch.ca/docs/edu-downloads/ depression/cornell_scale_depression.pdf.) For women at risk of major depression during the postpartum period, the BDI as well as the more specific Edinburgh Postnatal Depression Scale (www.fresno.ucsf.edu/pediatrics/ downloads/edinburghscale.pdf) can be valuable in screening.6

Benefits for physicians and patients Rating scales can improve the efficiency of assessment and save time. Used in partnership with clinical observation and

judgment, they can provide important information about patients’ symptoms and functioning, help gauge treatment response and side effects, and guide decision-making along the patient’s journey. Many of the questionnaires can be completed by patients while they wait for the doctor’s visit or given to patients to bring back at their next appointment. Patients using them might be encouraged to report symptoms they might otherwise not mention, and ensuing discussions can be a stepping-stone to better communication with patients about their condition. In turn, this can increase patients’ involvement in their own care, improve adherence to treatment and, hopefully, contribute to better outcomes in the long run.1,3,4 References 1. Patten SB, Kennedy SH, Lam RW et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. J Aff Disord 2009;117(Suppl 1):S5–S14. 2. Guo T, Xiang Y-T, Xiao L. Measurement-based care versus standard care for major depression: A randomized controlled trial with blind raters. Am J Psychiatry 2015;172:1104-13. 3. Anderson JE, Michalak EE, Lam RW. Depression in primary care: Tools for screening, diagnosis, and measuring response to treatment. BCMJ 2002;44:415-9. 4. University of British Columbia Faculty of Medicine. The Lam Employment Absence and Productivity Scale (Leaps). http://workingwithdepression.psychiatry.ubc.ca/leaps/ the-lam-employment-absence-and-productivity-scale-leaps/ Accessed Oct. 30, 2015. 5. Wong ST, Manca D, Barber D et al. The diagnosis of depression and its treatment in Canadian primary care practices: an epidemiological study. CMAJ Open 2014; 2:E337-E342. 6. Sharp LK, Lipsky MS. Screening for depression across the lifespan: A review of measure for use in primary care settings. Am Fam Physician 2002;66:1001-9. 7. Bilsker D, Gilbert M, Samra J. Managing workplace mental health & occupational disability: Guidelines for physicians. CARMHA and BC Mental Health & Addiction, 2009. www.comh.ca/antidepressant-skills/work/resources/physicianguidelines/ Accessed Oct 20, 2015. 8. Wiese BS. Geriatric depression: The use of antidepressants in the elderly. BCMJ 2011;53:341-7. 9. Buchanan D, Tourigny-Rivard M-F, Cappeliez P et al. National guidelines for seniors’ mental health: The assessment and treatment of depression. Can J Geriatr 2006;9(Suppl 2):S52-S58. NOVEMBER / DECEMBER 2015 • Doctor’s

Review

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

“demonstrated improved functional outcomes”

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 preceeding 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 and 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.

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

She calls it

“helping her at work”*

Choose PRISTIQ:

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

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

For More Information: Please consult the product monograph at http://pfizer.ca/en/our_products/ products/monograph/226 for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001.

Count on

for powerful symptom relief

CA0115PRI005E

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 • Narrow angle glaucoma • Mania/hypomania • Serotonin syndrome or neuroleptic malignant syndrome-like reactions

SOUTH BEACH BY DESIGN

The US neighbourhood that has the greatest concentration of Art Deco buildings in the world by Gerald Fitzpatrick

FELIX MIZIOZNIKOV / SHUTTERSTOCK.COM

uch of Miami’s South Beach, especially parts of Ocean Drive, is tawdry and crassly

JORG HACKEMANN / SHUTTERSTOCK.COM

commercial. Restaurant tables fill the sidewalk for block after block, forcing hapless pedestrians along a narrow path where they run the gauntlet of smiling hostesses in clingy dresses waving menus at them. In late afternoon, add noise to the mix. A guy saunters by with a snake wrapped around his neck while a young woman offers Cuban cigars to passersby. At night, music and light shows pulse from huge TV monitors, and the trunks of palm trees ringed in lights sprout green neon fronds. A convertible cruises by with two selfie cameras attached to the windscreen. Welcome to Hedonism Central: Florida’s biggest non-stop happy hour. But in spite of what one Miami writer has called “a full blown cesspool of touristic masturbation,” South Beach boasts one of the most enchanting concentrations of distinctive architecture in the United States. The style that predominates is Art Deco, its story told in the new Art Deco Museum (1001 Ocean Drive; tel: 305-672-2014; mdpl.org; closed Mondays; 90-minute walking tours US$25), opened on Ocean Drive in October 2014 by the Miami Design Preservation League. Art Deco grew out of the Paris Exposition of 1925 and reflected the age it was born in: a time of new technology, flappers, short skirts, hot jazz and shocking dances. With clean geometric lines, zigzags, chevrons, sunbursts and plant life motifs, Art Deco was a reaction to the elaborate ornamentation

After years of neglect during the 1970s and early ’80s, Ocean Drive came roaring back with new restaurants in the late ’80s.

of the earlier Art Nouveau movement. The less extravagant style fitted leaner times and quickly spread around the world from New York to New Zealand. So when a 1926 hurricane razed much of Miami to the ground, it’s not surprising that Art Deco was in the minds of its rebuilders. What is surprising is how completely the style spread. Today, South Beach has the greatest concentration of Art Deco buildings in the world. This is partly because Miami Beach evolved in three distinct parts. The early developers of North and Central Beach catered to wealthy vacationers — and with few exceptions, their luxurious hotels openly excluded Jews for many years. NOVEMBER / DECEMBER 2015 • Doctor’s

Review

The developers of South Beach, on the other hand, aimed at a more modest clientele and allowed Jews in the small hotels and single-family homes that grew up south of Lincoln Road. The area became a seaside escape from dreary northern winters for the Jewish middle class; a place to bathe in the ocean and socialize with friends. After the stock market crash of 1929 others looking for a brief respite from hard times began to pour into more affordable South Beach and launched the Art Deco building boom that lasted until World War II. The uniqueness of South Beach comes not from outstanding individual buildings, but from the harmony of so many buildings of the same style built in a short period. A style based on central tenets — simplified “bas relief” ornamentation, a three storey building height and uniform lot setbacks, each building contributing to the overall effect. As Miami resident Leicester Hemingway (Ernest’s kid brother) wrote, it is “a style that smoothes everything out until you get the feeling that life was smooth. The buildings make you feel all clean and new and excited and happy to be there.”

GERALD FITZPATRICK

The Breakwater’s neon sign glows blue and orange at night, standing out in a city where doing so is no easy task.

Doctor’s Review • NOVEMBER / DECEMBER 2015

After World War II, development shifted to Middle Beach and Miami became a mecca for organized crime and illegal gambling. At one point it was said that every hotel on the beach had its own bookie. Throughout the 1950s and 1960s, South Beach remained a haven for retired middle class Jews, some referring to the area as “God’s waiting room.” But, by the 1970s, block after block of South Beach had fallen on hard times and most considered the pre-war Art Deco style old fashioned and not worth saving. Enter Barbara Capitman, a middle-aged widow who had moved to the area from New York in 1973. Captivated by the Art Deco buildings of South Beach, she spearheaded the formation of the Miami Design Preservation League in 1976 to help revitalize the area. At first, the League’s efforts met with limited success — and were not helped when Fidel Castro authorized the Mariel Boatlift in 1980. South Florida became flooded with Cuban refugees, many of them criminals, who began to displace many longtime residents of South Beach. However, the League persevered and in 1982 Miami Beach enacted its first historic preservation controls. Public awareness of the area’s unique architectural heritage was heightened by the success of the TV show Miami Vice, which used the Art Deco buildings of South Beach as a backdrop and brought tourists eager to see where scenes had been shot. But it was Barbara Capitman’s friend, interior designer Leonard Horowitz, who pushed South Beach into the spotlight in a way that years of political lobbying could never match. Horowitz designed a palette of tropical pastel colours to replace the dreary browns and beiges of the 1970s. The effect was astonishing. Building by building, newly painted white facades became accented with sea foam green, salmon pink, powder blue, turquoise and lavender. Horowitz came up with schemes for a whole block of buildings that made them look like confections. Katherine Maddox, writing in Vogue magazine, said the result was like “sinking into cotton candy.” Celebrating its centennial year of 2015, it’s clear that the revival of South Beach has been wildly successful. More and more Art Deco buildings are being given a new lease on life and South Beach has become a byword for “cool” around the world. The new Art Deco Museum and welcome centre has daily guided and self-guided walking tours and has an excellent map identifying over 100 Art Deco and other significant buildings. Here are just a few of them:

JORG HACKEMANN / SHUTTERSTOCK.COM

Throughout the 1950s and ‘60s, South Beach was a haven for retired Jews, some referring to the area as “God’s waiting room”

JIAWANGKUN / SHUTTERSTOCK.COM

The Carlyle was featured in 1983’s Scarface and The Birdcage in 1996.

This classic Hohauser building served as Jerry’s Famous Deli until becoming a Mexican bar earlier this year.

The Cardozo Hotel is owned by singer Gloria Estefan and her producer-husband Emilio.

Webster Hotel (1936) 1220 Collins Avenue

FELIX MIZIOZNIKOV / SHUTTERSTOCK.COM

Designed by Henry Hohauser, the former hotel is now a fashion boutique. The ornate plaques over the main entrance of the symmetrical facade are delicately accented in two shades of pink while neon strips add a further accent at night.

United States Post Office (1937) 1300 Washington Avenue

Essex House Hotel (1938) 1001 Collins Avenue

“Right over there,” said manager David Lopez, pointing just off the lobby of the Essex House Hotel, “is where Al Capone used to play cards in a game room with some of his cronies.” The Essex was another of Hohauser’s designs and is a good example of nautical Deco with porthole style windows, racing stripes along the sides and a mast-like tower bearing the hotel’s name. The lobby has a mural of the Everglades that was restored by the same artist that painted the original 50 years earlier.

Havana 1957 serves traditional Cuban cuisine like ham croquettes with plantain chips and fried yucca.

Breakwater Hotel (1939) 940 Ocean Drive

Across the street from the Clevelander, the hub of partying on the Beach, the Breakwater has the typical Art Deco features of symmetry and strong lines. At night, it becomes one of the most striking sights on the Beach with its towering central facade bearing its name lit up in blue and orange neon. Lots of action at street level.

Cardozo Hotel (1939) 1300 Ocean Drive

Also designed by Hohauser, the Cardozo with its curving facade is now a boutique hotel owned by Cuban-American singer Gloria Estefan and her husband Emilio.

MIAMI HOT SPOTS Each year more original Art Deco hotels are being restored offering a range of choice. We stayed at the Essex House Hotel (1001 Collins Avenue; tel: 305-534-2700; essexhotel. com; continental breakfast included). Our ground floor room was completely updated and we slept peacefully, superbly soundproofed from external noise. Avoid those waving hostesses on Ocean Drive and try one of the places like Havana 1957 (405 Española Way; tel: 305-503-3828; havana 1957.com) on Española Way between 14th and 15th Street. Havana 1957 serves traditional Cuban food and is good value. The Eleventh Street Diner (1065 Washington Avenue; tel: 305-534-6373; eleventhstreetdiner.com) is also recommended. But the classic place to dine is Joe’s Stone Crab Restaurant (11 Washington Avenue; tel: 305-673-0365; joesstonecrab.com) at the southern tip of Miami Beach. Joe’s is a Miami institution and has been serving stone crab here for 100 years. No reservations and likely a long wait — but it’s worth it.

JIAWANGKUN / SHUTTERSTOCK.COM

The post office is generally regarded as a “streamlined modern” version of Art Deco and has a central rotunda with a decorative cupola on top. Inside, the original fixtures are still in place. A three-panel painting includes the discovery of Florida by the Spanish explorer Ponce de León.

The uniqueness of South Beach comes from the harmony of so many buildings of the same style built in a short period 1450 Collins Avenue (1939)

Starting life as Hoffman’s Cafeteria, this classic Hohauser design has gone through a series of owners. A gay bar until 2002, it became Jerry’s Famous Deli until changing hands again in 2015. It’s now a Mexican restaurant/bar/club franchise. Through it all, it has retained its streamlined form of nautical Art Deco with a curving frontage and porthole-like shapes on its facade now accented in pale pink and turquoise.

McAlpin Hotel (1940) 1424 Ocean Drive

One of the finest Art Deco buildings on the Beach, the McAlpin Hotel is one of the most photographed. Designed by L. Murray Dixon, the symmetrical facade is divided into thirds with pink and turquoise accents. Five large “bris soleil” sunshades complete its perfection. Now operated as part of Hilton Grand Vacations Club, the McAlpin is a perfect complement to Hohauser’s earlier Crescent Hotel next door at 1420 Ocean Drive.

Carlyle Hotel (1941) 1250 Ocean Drive

Under restoration in early 2015, the Carlyle has the typical division into thirds, but more muted colour accents than some other buildings. Its facade has been the backdrop to movies such as 1983’s Scarface and it gave up its name for the setting of The Birdcage in 1996. There are many more buildings to look for. The Beach is a constantly changing dynamic area and the Miami Design Preservation League is now fully supported by the City of Miami Beach. The Ocean Drive entertainment area could quieten down a little if a recent proposal to change the last call in bars and patios from 5am to 2am goes through. There’s some incongruity, to put it mildly, between the gracious form of the Art Deco buildings above the ground floor and some of the activity taking place at street level, but if that’s what it takes to preserve the buildings then let the happy hour roll on. And make mine a gin and tonic, please.

GERALD FITZPATRICK

Pop into the post office on Washington Avenue to see a three-panel mural of explorer Ponce de León.

MORE ONLINE

The Webster is now home to a high-end fashion boutique for women and men.

The ex-industrial wasteland that’s now home to some of Miami’s hottest art. doctorsreview.com/features/miami-arts-district NOVEMBER / DECEMBER 2015 • Doctor’s

Review

Experience ANORO ELLIPTA ™

Indications and Clinical Use: ANORO™ ELLIPTA® (umeclidinium/vilanterol) is a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta2-agonist (LABA) indicated for the long-term once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema. ANORO™ ELLIPTA® is not indicated for the relief of acute deterioration of COPD. ANORO™ ELLIPTA® is not indicated for the treatment of asthma. The safety and efficacy of ANORO™ ELLIPTA® in asthma have not been established. ANORO™ ELLIPTA® should not be used in patients under 18 years of age. Contraindications: • Patients with severe hypersensitivity to milk proteins. Most Serious Warnings and Precautions: • ASTHMA-RELATED DEATH: Long-acting beta2-adrenergic agonists (LABA) increase the risk of asthma-related death. Data from a large placebo-controlled US study that compared the safety of salmeterol (SEREVENT® Inhalation Aerosol) or placebo added to patients’ usual asthma therapy showed an increase in asthma-related deaths in patients receiving salmeterol. This finding with salmeterol is considered a class effect of LABA, including vilanterol, one of the active ingredients in ANORO™ ELLIPTA®. The safety and efficacy of ANORO™ ELLIPTA® in patients with asthma have not been established.

Other Relevant Warnings and Precautions: • ANORO™ ELLIPTA® is not indicated for the treatment of acute episodes of bronchospasm (i.e., as rescue therapy), relief of acute deterioration of COPD or for the treatment of asthma. • ANORO™ ELLIPTA® should not be initiated in patients during rapidly deteriorating or potentially life-threatening episodes of COPD. • Patients should be instructed to discontinue regular use of short-acting beta2-agonists and to use them only for acute respiratory symptoms. • Exacerbations may occur during treatment. Patients should be advised to continue treatment and seek medical advice if COPD symptoms remain uncontrolled or worsen after initiation of therapy. • ANORO™ ELLIPTA® should not be used more often or at higher doses than recommended. ANORO™ ELLIPTA® should not be used in conjunction with other medicines containing a LABA or LAMA. • Headache or blurred vision may influence the ability to drive or to use machinery. • Anticholinergic Effects: Use with caution in patients with narrow-angle glaucoma or urinary retention. • Cardiovascular effects: ANORO™ ELLIPTA® should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, acute myocardial infarction, cardiac arrhythmias, and hypertension. Cardiovascular effects such as cardiac arrhythmias, may be seen after administration. Treatment may need to be discontinued. ANORO™ ELLIPTA® was associated with a dose-dependent increase in heart rate and QTcF prolongation in healthy subjects receiving steady-state treatment. Caution is recommended in patients with 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.

A once-daily LAMA/LABA dual bronchodilator for COPD.* • Endocrine and Metabolism: Use with caution in patients with convulsive disorders, thyrotoxicosis and patients who are unusually responsive to sympathomimetic amines. Use with caution in patients predisposed to low levels of serum potassium or patients with ketoacidosis or diabetes. • Respiratory: Treatment should be discontinued if paradoxical bronchospasm occurs and alternative therapy instituted if necessary. • Hypersensitivity: As with all medications, immediate hypersensitivity reactions may occur after administration of ANORO™ ELLIPTA®. Patients with severe milk protein allergy should not take ANORO™ ELLIPTA®. • Use during pregnancy, labour and in breastfeeding women should only occur if the potential benefit justifies the potential risk. Adverse Events: Adverse reactions reported at a frequency of ≥1% and greater than placebo include: pharyngitis, sinusitis, lower respiratory tract infection, diarrhea, constipation, pain in extremity, muscle spasms, neck pain and chest pain.

Recommended Dose: • The recommended dose is one inhalation of ANORO™ ELLIPTA® 62.5/25 mcg once daily. Dosing Considerations: • No dosage adjustment is required in patients over 65 years of age, in patients with renal impairment, or in patients with mild or moderate hepatic impairment. ANORO™ ELLIPTA® has not been studied in patients with severe hepatic impairment. For More Information: Please consult the Product Monograph at http://gsk.ca/anoro/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. *LAMA=Long-acting muscarinic antagonist [also known as a long-acting anticholinergic (LAAC)]; LABA=Long-acting beta2-agonist

ANORO and ELLIPTA are trademarks of Glaxo Group Limited, used under license by GlaxoSmithKline Inc. ANOROTM ELLIPTA® was developed in collaboration with Theravance, Inc. © 2015 GlaxoSmithKline Inc. All rights reserved. 00656 05/15

Dr Grenvil in Verdi’s La Traviata Just how good a doctor was he?

by Dr J. Ian S. Robertson

The excerpt which follows comes from Doctors in Opera: An Irreverent Look at Operatic Medicine by Scottish doctor J. Ian S. Robertson. As he explains in the preface, the account of this, and the more than 40 operas considered in the book, is derived mainly from the author’s own “often very free” interpretation of the scores, libretti on the sources on which they are based and on other publications on the subject.

physician in private practice might be expected to command some deference, both from patients and from the public. We encounter a person who initially appears to be just such a doctor in Verdi’s

La Traviata of 1853, composed to a libretto by Piave after both a novel and a play by Alexandre Dumas fils, La Dame aux camélias. One of the most prevalent diseases of the 19th century for which then there was no cure was consumption pulmonary tuberculosis. Many a Victorian literary, dramatic and operatic heroine died from that affliction. Violetta, the soprano courtesan of the Parisian demi-monde in La Traviata, is a typical sufferer. In the opera she is under the care of Dr Grenvil (bass). By the time of the last act, Violetta is dying of consumption. She has lost her good looks and most of her fortune, and she is lying in her bed in a shabby apartment, attended only by her faithful maid. It is early morning. Dr Grenvil arrives to examine his patient. Dr Grenvil comforts Violetta, although he observes, and warns the maid, that she is deteriorating rapidly. He says he will return later in the day.

J. Ian S. Robertson FRS, MD, FRCP is a retired Professor of Medicine with a BA in Opera Studies from the University of Manchester. He has written and lectured widely on the medical aspects of opera.

Doctor’s Review • NOVEMBER / DECEMBER 2015

Dr Grenvil does indeed return later, but despite his ministrations, Violetta dies. It is possible at this point to pursue a little medical research. Another 19th-century Parisian operatic heroine, Mimi, dies from pulmonary tuberculosis, but in the absence of a doctor. In Puccini’s La Bohème the time taken for Mimi to die in the last act, in a recording conducted by Thomas Beecham wherein Mimi is sung by Victoria de Los Angeles, is 19 minutes. In Leoncavallo’s version of La Bohème, as conducted by Heinz Wallberg and with Mimi sung by Lucia Popp, the heroine lasts a mere 14 minutes. By contrast, in La Traviata, where a doctor is in attendance, the patient, Violetta, as sung for example by Ileana Cotrubas in a performance conducted by Carlos Kleiber, takes 25 minutes to die. So is demonstrated the beneficial therapeutic value of a doctor, even for a disease which was then devoid of effective drug treatment. This analytical approach is nowadays termed “evidencebased medicine,” a method with some fervent advocates. Hence Dr Grenvil can perhaps lay claim to a measure, albeit modest, of therapeutic effectiveness. It remains necessary to explain the rather odd life that Dr Grenvil leads in the opera La Traviata. In Acts I and II, Dr Grenvil appears to be a physician in very lucrative private practice, since he seems able to af-

DREW FARRELL

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

ford to attend the expensive parties at which the courtesans entertain their aristocratic clients, or “protectors,” as those wealthy patrons were usually termed. Even so, in those first two acts Dr Grenvil’s actions are by no means professional, and include gambling and heavy drinking. And then, in Act III, we find this same Dr Grenvil plodding around the streets of Paris at seven o’clock in the morning doing his house calls, a circumstance seemingly at odds with what had earlier appeared as a highly remunerative private practice. The distinguished musicologist and critic Ernest Newman’s view of the matter was that Verdi had been obliged to engage the services of a bass singer to perform the role of Dr Grenvil in Act III. Thus saddled with that singer, Verdi thought that he might as well provide employment for him also in Acts I and II, and so in those first two acts Dr Grenvil is invited to various lavish, if louche, parties. Newman’s explanation seems, however, to be wrong. In 2008, Scottish Opera staged a new production of La Traviata, directed by David McVicar,

and the matter was gone into more carefully. In 2003, David McVicar had directed a play, Camille, by Neil Bartlett, concerning the same tale. The character Dr Grenvil is seemingly based on the activities of a real person, Dr Koreff, who is depicted in that play. Dr Koreff apparently did once obtain a genuine medical qualification. He practiced homeopathy and mesmerism, and attached himself to the Parisian demi-monde. According to one account (there are many inconsistencies), Dr Koreff was officially disbarred from medical practice for performing an illegal abortion, although he continued as a quack, and treated venereal disease in both the courtesans and their clients. Despite the numerous uncertainties, this information concerning Dr Koreff does seem to provide a more likely explanation for the way Dr Grenvil is presented in Verdi’s opera. Excerpted from Doctors in Opera: An Irreverent Look at Operatic Medicine by Dr J. Ian S. Robertson (Scottish Opera, 2012).

One of the most prevalent diseases of the 19th century was consumption pulmonary tuberculosis and many operatic heroines died from the affliction NOVEMBER / DECEMBER 2015 • Doctor’s

Review

Eccentric patients I have known What doctor hasn’t wanted to write a book about their practice? by Dr Nicholas Down

Family medicine can be a challenge, no doubt about it. It also has its lighter moments — and some puzzling ones as well. Here are a few such patient encounters taken from the diary of a British physician. He’s collected them in a book-length manuscript, Unclaimed Ashes: Reflections on the Art of General Practice, which is currently making the rounds with publishers.

WORMS, YOU SAY, MRS HODNETT?

ALL ILLUSTRATIONS COMPLOT / SHUTTERSTOCK.COM

This morning Nel, one of my receptionists, came into my office with an apprehensive smile on her face. She was carrying a large jar filled with water and, swimming around in it languidly, was a worm. Apparently, a Mrs. Hodnett had come in saying she’d found it in the toilet and could she be infected she wondered. Apparently the toilet was only used by her and one other, the gardener. I was pretty convinced that it was an earthworm and told her so, but Nel said that my partner Bob was convinced otherwise and that we should send it to the lab for analysis. Later in the day the lab rang with a confident and slightly amused diagnosis of an earthworm.

Born in Uganda, Nicholas Down graduated in 1980 from the London Hospital Medical College. In 1985, after post-graduate training, he became one of three partners in a small practice in the southeast of England. He practiced there as a family doctor until 2012 when he left medicine, immigrated to upstate New York, opened a studio and gallery, and became a full-time painter (nicholasdown.net). His work is widely held by collectors.

A SUSPECTED CASE OF EXPLODING FOOT Returning to a mountain of paperwork after a short holiday, I came across a letter from Hector Muriel, which asked me if I had heard of exploding foot syndrome. He had attached a cutting from a newspaper in which the comedian Warren Mitchell gave a detailed description of his symptom patterns. Hector was convinced that he, in turn, was suffering from the condition and it took a while to reassure him that it was extremely unlikely. NOVEMBER / DECEMBER 2015 • Doctor’s

Review

MULTI-COLOURED STOOL ATTACK This evening I had a long baffling conversation with Billy Herring about the colour of his stools, which had turned green and orange on different days of the week. He also told me that he was now convinced that he was suffering from mercury poisoning from his fillings and was considering having them all replaced. Most baffling of all, was the fact that as he came in to my office, he told me that his father had died last week and yet, Billy seemed curiously detached about it all. I fear for Billy, who at 39, is obsessed with abstruse and strange conditions that may or may not afflict him and, in particular, I believe he spends an inordinate amount of time researching such things on the Internet. Today, he brought me two stool samples, one green, the other orange and wants me to have them tested for mercury.

“That man had the cheek to ask me how my prostate was in the street. How dare he?” THE BARON’S SENSITIVE STOMACH Baron Grunwald was in a somewhat exuberant mood this evening. He told me he had felt so much better last week when I had given him some tablets for his upset tummy that he’d gone out to have a curry. Unfortunately his symptoms flared up the following morning. “Now Doctor,” he said. “What is to be done? What do I eat?” I examined his large corporation and found him to be a little distended. As on our previous meetings he was wearing a collection of thick gold bangles around his wrist and his neck was festooned with a collection of gold religious symbols. Today, he sported a canary yellow jumper and yellow cord trousers. He had a very loud presence to say the least. “Now you’ll never guess what I bought from Harrods last week,” he said with a broad smile. I looked non-plussed. “A Shar Pei puppy!” he said with a flourish of his wrist. My jaw dropped. “And guess how much it cost?” I suggested £2000, but of course I didn’t have a clue. “Five thousand pounds,” he proudly declared. As it turned out, his two Burmese cats were extremely jealous of the sevenweek-old pup and had immediately pounced on it intent on tearing it to shreds. “So I rang the manager in tears,” he said. “You see I practically live in Harrods, they know me so well. The manager said of course you can bring it back.” He got up to leave. “Thank you so much,” he said, walking briskly out to his bright yellow Ferrari, parked in the practice car park like a gleaming jewel.

Doctor’s Review • NOVEMBER / DECEMBER 2015

A NOT SO SERIOUS COUGH Some months later the Baron made an appointment because, he said, he was worried about his cough. “Please don’t let it be pneumonia, I don’t want to die,” he pleaded in a plaintive tone. He had started himself on some Augmentin yesterday that he’d hoarded some time ago and today, he wanted more. After I had examined him and reassured him fully that his cough was not pneumonia he turned to the subject that was really bothering him. “This erection business,” he said. “What are we going to do?” Earlier I had referred him to a specialist in Harley Street and matters had taken a rather ugly turn when, a week later, the Baron had bumped into his consultant outside Harrods. “That f***ing man,” he said. “He had the cheek to ask me how my prostate was in the street. How dare he?” And there was something else. He wanted to show off his new Piaget watch, which he had just bought at Asprey’s that week. “You mustn’t tell my wife,” he said with a conspiratorial wink. “But guess how much it cost.” I hazarded a figure, which was, of course, ludicrously low. “Twenty thousand,” he said, flourishing the thing like a matador waving away a bull.

Linaclotide is now included in the latest:

AGA

American Gastroenterological Association guideline for IBS-C1

ACG

American College of Gastroenterology monograph for IBS-C and CIC2

CONSTELLA® (linaclotide) is indicated for the treatment of irritable bowel syndrome with constipation (IBS-C) in adults and chronic idiopathic constipation (CIC) in adults.3 For more information: Please consult the Product Monograph at www.actavis.ca/NR/rdonlyres/94008767D103-460E-B854-766C324A3CE8/0/CONSTELLA_ProductMonograph.pdf for important contraindications, warnings, precautions, adverse reactions, food interactions, dosing information and conditions of clinical use. The Product Monograph is also available by calling Actavis Specialty Pharmaceuticals at 1-855-892-8766. References: 1. Weinberg DS, et al. American Gastroenterological Association Institute guideline on the pharmacological management of irritable bowel syndrome. Gastroenterology 2014;147:1146-8. 2. Ford AC, et al. for the Task Force on the Management of Functional Bowel Disorders. American College of Gastroenterology monograph on the management of irritable bowel syndrome and chronic idiopathic constipation. Am J Gastroenterol 2014;109:S2-S26. 3. CONSTELLA® (linaclotide) Product Monograph, Forest Laboratories Canada Inc., May 12, 2014. CONSTELLA® is a registered trademark of Ironwood Pharmaceuticals, Inc. used under license by Allergan, Inc. or its affiliates. © 2015 Allergan. All rights reserved.

See page [XX] 49 for additional safety information CGE-JA1-DRR.indd 1

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9/11/15 10:17 AM Logos Relinked to Master na Page Count NOVEMBER / DECEMBER 2015 •for DBinding octor’Checked s Review

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KILL THAT CHICKEN I saw Howard Jenkins again and, as usual, he was accompanied by his wife Winifred. After I had checked him over again and reviewed his angina she looked at me conspiratorially and said, “I wouldn’t advise you to keep chickens unless you’ve got a lot of time,” and then added dismissively, “Oh well, we’ve taken up too much of your time already so you mustn’t let me ramble on.” I smiled and asked her to tell me what she meant. “Well my father was a farmer and we kept chickens and I was in charge of looking after them. One day I had to walk a mile to have one of them killed. On the way, I let it peck around in the grass and I never saw it again. We don’t eat meat, do we Howard, what with the way they treat animals these days.” I listened to her and as usual found myself shaking my head after she’d left at the surreal way in which she engages me in conversations like this.

I fear for Billy who is obsessed with abstruse and strange conditions that may or may not afflict him YES, WE HAVE NO BANANAS Benjamin Brightlington is a large 1.9-metre-tall asthmatic with an intense distaste for anything to do with Europe. He has told me this on many occasions, believing that the EU is a conspiracy to deflower Great Britain of all its power. One time he had regaled me with a story about a grocer who had dared sell a pound of bananas and had received a court hearing as a result. Benjamin had contributed some money to a fund that had been set up to help the poor fellow. It was called the Metric Martyr’s Fund50 — a British Advocacy Group that campaigned vigorously on behalf of those who wished to use any unit of measurement they chose. Today though, I was concerned that he really did need to lose weight and that he might be developing diabetes. I asked him to tell me what sort of food he was used to eating. “Well I was very good at Christmas really. I had a Jam Roly-Poly and pudding and custard and one of my friends gave me some chocolate fudge. Then we went up to the RAC club where we had spotted dick and custard (a traditional English suet pudding, one portion alone would be about 600 calories) but other than that I’ve been very good,” he said, looking slightly perplexed when he saw the expression on my face. I introduced the idea of low glycemic foods. “Does that mean I can’t have tinned ravioli or custard then?” he asked. After I had explained in some detail about the hazards of such foods his attention seemed to wander and so I asked him what had happened to the grocer in court. “Oh, we lost the case,” he said with a shrug. “The only people who win these days are the lawyers and what it means is that the laws of this country are completely subordinate to Europe. The chap owes about £200,000 in costs and he’s only a small shopkeeper selling bananas and things like that.”

Doctor’s Review • NOVEMBER / DECEMBER 2015

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

IBS-C

CIC

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

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

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

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

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

速

The first and only analgesic combining the efficacy of oxycodone with the benefits of oral naloxone in one tablet.1,2* Adults: TARGIN速 (oxycodone hydrochloride/naloxone hydrochloride) is a controlled release tablet having a dual therapeutic effect. The oxycodone component in TARGIN速 is indicated for the management of pain severe enough to require daily, continuous, long-term opioid treatment, and that is opioid-responsive and for which alternative treatment options are inadequate. The naloxone component in TARGIN速 is indicated for the relief of opioidinduced constipation (OIC).

Demonstrated comparable analgesic efficacy to oxycodone CR.1† In a 12-week study of patients with chronic back pain, the average pain experienced over the last 24 hours was comparable between TARGIN® and oxycodone CR (secondary endpoint)

In drug abuse studies, TARGIN® demonstrated reduced systemic drug-liking relative to oxycodone, when administered intranasally or intravenously.1‡§ ‡ The clinical significance of these results has not yet been established.

Refer to the page in the bottom-right icon for additional safety information and a web link to the Product Monograph iscussing: • Contraindications in patients with known or suspected mechanical gastrointestinal obstruction or any known condition that affects bowel transit; rectal administration; suspected surgical abdomen; mild, intermittent or short duration pain that can be managed with other pain medications; management of acute pain; management of perioperative pain; acute asthma or other obstructive airway, and status asthmaticus; acute respiratory depression, elevated carbon dioxide levels in the blood, and cor pulmonale; acute alcoholism, delirium tremens, and convulsive disorders; severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury; MAO inhibitor use; pregnancy, labour and delivery, breast-feeding; opioid-dependent patients and for narcotic withdrawal treatment; moderate to severe hepatic impairment • The most serious warnings and precautions regarding limitations of use; addiction, abuse, and misuse; life-threatening respiratory depression; accidental exposure; neonatal opioid withdrawal syndrome; administration including must be swallowed whole; 40/20 mg tablets for opioid-tolerant patients only; use by patient only; not for patients with constipation not related to opioid use; patients currently taking oral oxycodone; conversion from other opioids/opioid preparations; maximum dosage • Other relevant warnings and precautions regarding use of 5/2.5 mg tablets for titration and dose adjustment; do not consume alcohol; dose reduction or change in opioid may be required in hyperalgesia; peritoneal carcinomatosis; potential diarrhea; marked withdrawal symptoms if abused; withdrawal symptoms after abrupt discontinuation; dependence/tolerance; not approved for managing addictive disorders; use cautiously in patients receiving other CNS depressants; increased respiratory depression in patients with head injuries; use cautiously in patients with pre-existing cardiovascular conditions; psychomotor impairment; administer with caution and at reduced dosage to debilitated patients, and patients with Addison’s disease, cholelithiasis, hypotension, hypothyroidism, mild hepatic impairment, myxoedema, renal impairment, toxic psychosis, prostatic hypertrophy or urethral stricture; disposal of Targin® • Conditions of clinical use, adverse reactions, drug interactions, dosing instructions and storage under lock and key * Naloxone is for the relief of opioid-induced constipation (OIC). † Multicentre, randomized, 12-week, double-blind, double-dummy, parallel-group study. Patients (N=322) with moderate to severe chronic non-cancer pain (including musculoskeletal and neuropathic pain) requiring opioids (oxycodone equivalent to 20-50 mg/day), who were also experiencing opioid-induced constipation (OIC) were randomized to TARGIN® (dose range of 20/10-50/25 mg/day) or oxycodone CR. Average pain over the last 24 hours was estimated using the Pain Intensity Scale, a 0 [no pain]-10 numeric rating scale (NRS). Constipation was measured using the Bowel Function Index (BFI) score (0-100, with higher scores indicating poor bowel function).1,3 § Studies conducted in dependent or non-dependent recreational opioid users. The studies included both subjective and objective measures. Collectively for these studies, the subjective results that were produced were supported by similar results in objective measures.Solutions contained a 2:1 ratio by weight of oxycodone HCl to naloxone HCl. If abused parenterally or intranasally by individuals dependent on opioid agonists, Targin is expected to produce marked withdrawal symptoms – because of the systemic opioid receptor antagonist characteristics of naloxone by these routes – or to intensify withdrawal symptoms already present.1

Controlled release oxycodone/naloxone HCl tablets

At first flush A solo wander through India for a lesson on the processing of Darjeeling tea by Bill Giebler

CHINA PAKISTAN NEPAL

Makaibari INDIA

BANGLADESH

INDIA

“Flush” refers to tea’s separate plucking seasons, each known for its distinctive colour and flavour.

PAVEL SVOBODA / SHUTTERSTOCK.COM

t looks like a dance floor, a three-square-metre section of smooth wood among the

rough planks that make up most of the flooring, all surrounded by giant locomotive-like drying machines. I’ve been waiting at the cool, dark packing station just inside the front door of the tea factory, and alternately in the warm April Sunday morning sun just outside, for my packing shift. Packing represents the final step handled here at the factory, completing my education in the processing of my favourite tea. At 1400 metres above sea level in the Himalayan foothills of India’s Darjeeling region, I’m at the 150-year-old Makaibari tea factory (makaibari.com) perched on a slope just below the town of Kurseong. I’m just over a week into my physical travels across northern India, but a dozen weeks into the personal journey that began with giving notice on a 20-year career, and planning my solo wander across a land that has existed in my mind as a magical and challenging destination, no more or less real than Narnia or Brigadoon.

NOVEMBER / DECEMBER 2015 • Doctor’s

Review

In any case, here I am, one man interested in experiencing each step of tea processing as my own process unfolds, far from home After an hour of waiting, four large full tins of finished tea from the sorting room — carried twoladies-at-a-time — are dumped on the shiny floor, filling the air with the rich, dark vegetal scent of black tea leaves. A man, barefoot, wearing grey dress pants, a white T-shirt and, amusingly, a Starbucks baseball cap, shovels and sweeps the tea into a single well-blended mountain of the finest grade Makaibari Estate, First Flush Darjeeling Tea. We wait, he and I, for the inspector to ensure the quality of the grade, and then begin filling 20-kilo foil-lined brown paper bags, one scoop at a time into the chute engineered into an upper corner of each bag. Easy at first, it becomes very difficult once the bag is over half full and has to be repeatedly shaken and shifted — the entire bag lifted and dropped — in order for the tea to settle and make room for more. We’ve been joined by a woman, swiftly scooping tea and maneuvering the large bags with an urgency and

confidence that compensates for her diminutive size and arms that are, at their widest, the size of my wrists. “She filled two in the time it took you to fill one,” the foreman teases after watching my slow struggle with the process, “and then finished yours off for you.” It’s not true! I started two different bags, handing one off to each of them for the challenging final touches. It is true, though, that each of them has done twice the work I have. He smiles. “She says you should only get half pay.” Packing is the only part of the process that — as far as I’ve witnessed — employs both genders. The gender roles are strong; each stage of the process (plucking, withering, rolling, firing, sorting) is handled either by men or by women, never both. The process begins and ends with women, and the distinction can be drawn along the lines of precision. If the work is delicate enough that human hands are involved, they must be women’s hands. The gross handling of larger actions (and larger machines) is done by men. In any case, here I am, one man interested in experiencing each step of tea processing as my own process unfolds, far from home.

PAVEL SVOBODA / SHUTTERSTOCK.COM

T FAMILY TIES The Makaibari Homestay Programme (makaibari.com/en/sustainable-tourism/ homestay-makaibari.aspx) connects travellers with a family in a village that’s close to the tea estate. In addition to lodging, three meals are provided daily, which gives guests the opportunity to taste traditional dishes made with local organic produce. The homestay programme is run by Volunteer in Makaibari, an independent self-help group managed by Makaibari’s youth wing. Profits are shared between the ladies of the community who participate in the programme and the host families.

Doctor’s Review • NOVEMBER / DECEMBER 2015

ea is both art and science. It is the careful, methodical refinement of a bulk raw material that is pure potentiality. If handled correctly, it can become a brilliant and universally captivating expression of this potential. It is a delicate and manystaged process, however. When it’s harvested, how — and how quickly — it’s processed, the precision of brewing, etc. all affect the degree to which the essence is optimally revealed. I see this clearly from my position here on the tea estate, surrounded by dramatic hills carpeted with hundreds of acres of what many consider the world’s finest tea. The drama of the place comes from the geography, the grade. Simply put: it is steep. These are young mountains, the Himalayas, and that must explain their boldness. These foothills burst out of the plains below with such urgency that a flat surface is nearly impossible to find. On a clear night, I can easily see Siliguri, a plains city only 35 kilometres down Pankhabari road, yet more than 1200 metres below me. The roads attempt to follow the ever-ascending ridges, and this is where the towns are. The tea villages and fields are in the startling, swooping valleys. That’s where I’ve spent these last several days, above nearly vertical fields of the robust little shrub, Camellia sinensis, in a village homestay just down the

Darjeeling’s infrastructure has been unable to cope with the ever-expanding population, but the city is still a colourful and lively place.

SANTIBHAVANK P / SHUTTERSTOCK.COM

Each stage of tea processing is handled either entirely by men or by women — never both, except for packing.

T PHOTOGRAPHY / SHUTTERSTOCK.COM

The Himalayas’s tea villages and fields are in the mountains’s swooping valleys.

road from the factory, the oldest one in the region, still processing tea today the same way they have for more than a century. “Makaibari” is stencilled in white paint — each letter about a metre tall — on the green corrugated tin roof of the rugged old building. Truly unchanged for well over 100 years, even the machinery inside is pre-1900. The factory opened in 1859, not coincidentally the same year tea production began in the region. Mechanization came in the next few decades, and that’s about it. The rest has happened day in and day out with very few changes over the next dozen decades. The place is run by the vital and eccentric Swaraj Kumar Banerjee, the “Rajah of Darjeeling Tea,” a man in his early 60s, greying hair around his sharp, handsome Bengali face, and often a somewhat devious smile like a child with a secret. Known simply as “Rajah” Banerjee, he is the fourth generation Banerjee to run the estate, and the man responsible for bringing organic agriculture to India’s tea lands, indeed changing the way things are done outside the factory in the fields.

R .

ajah and I were crouched in the dirt outside of his office one afternoon as he counted types of uncultivated flora growing between the bushes. “...three, four, five...” Then turning to me, “You have a brother? Same genetic make-up, same cultural upbringing... right?” I agreed on all counts. “Tell me, placed in a room together, facing, talking, how long would it take before you had a disagreement?” “Two hours?” I considered. “I bet it’s more like 15 minutes, but ok.” He resumed plucking fronds and flowers, all in reach from his squatting position between bush and building, all voluntary growth, “...six, seven, eight...” He stopped at 15. “This,” he declared, handing me the bouqueted cluster of flora, “is what happens naturally.” He was referring to the stability of a complex ecosystem versus

Makaibari was the first tea estate in the world to be certified organic in 1988.

Doctor’s Review • NOVEMBER / DECEMBER 2015

the fragility of genetic homogeneity, like brothers or chemical-dependent mono-crops. “This is what creates sustainability: diversity!” Diversity is subtext, however, as are the words mulch and dung and compost. To distill Banerjee’s ever-ready lecture to a single word it would be: soil. “Healthy soil is healthy mankind,” is his mantra. The result is better tea, healthier workers and a product that just might be reproducible for another 150 years, and then another after that. Days later in his home, in a smoke-filled living room with two enormous taxidermied tigers and two very alive German Shepherds, I sipped sparkling wine with Banerjee and his wife, and their daughter-in-law and six-year-old grandson visiting from Bangalore. “My father was one of the greatest hunters in India,” he proclaimed as I inspected the very large, catatonic, dusty creatures. “He took down 86 such beasts in his day.” I was glad to hear this placed him among the best of hunters, the notion that this might be an average performance made my stomach turn. “I think he might be singlehandedly responsible for putting these on the endangered species list,” I said. He smiled, accepting the jab, but was unapologetic about the contradiction. This man with his impressive legacy in organic agriculture and fair trade business practices, this champion of biodiversity, remained very proud of his family’s legacy as well — even those elements that depleted the local tiger population. It’s Makaibari’s environmental record that intrigued me into coming here. That and the ad hoc homestay volunteer program. A love of tea, too, factors in, particularly Darjeeling’s lighter body, golden-brown liquor, floral astringency and tannic bitterness. But I come without substantial expertise on the beverage, and my work here is not directly related to tea. I’m volunteering among the villagers — many employed by the tea company, but experts, each, in a single process, not a finished product — thus I’m not substantially progressing my tea knowledge save for a few shifts on the factory floor. My expertise on the topic of timing and handling comes from an uncanny sense of fellowship as we, leaves and I, are plucked from our framework and set on course to re-organize ourselves into something new. In fact, that is precisely my work here. The story for both of us begins after the roots and branches have been well established. After the various feats, cultural and agricultural, that brought us to this point of readiness. Reprinted with permission. The article appears on TravelersTales.com and BestTravelWriting.com under the title The Tea in Me. It won the Grand Prize Gold Award for Best Travel Story of 2014 in the Eighth Annual Solas Awards sponsored by Travelers’ Tales.

PAAB

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Wheat berry and nut porridge with aniseed (Snayniye).

Sweet dreams

Classic confections that’ll transport you to the Middle East recipes by

Anissa Helou

photos by

Linda Pugliese

nissa Helou was, perhaps, destined to write Sweet Middle East. Born and raised in Beirut, her last name, Helou, means “sweet” in Arabic. Her latest

cookbook contains 64 recipes for the myriad of treats sold in speciality shops, hawked by street vendors and made in home kitchens throughout the Middle East and North Africa. There,

Doctor’s Review • NOVEMBER / DECEMBER 2015

most everyone has a serious penchant for all things sugary. Every important occasion, rite of passage or religious event has a specific sweet associated with its celebration, and sweets are an

essential part of the region’s hospitality, ever-present in homes to offer to guests. Here, we bring you our favourites from the cookbook for you to make and offer your guests this winter.

WHEAT BERRY AND NUT PORRIDGE WITH ANISEED (SNAYNIYE) Sinn means “teeth” in Arabic — snayniye is prepared to celebrate babies’ first teeth and the beginning of their ability to eat proper food. The porridge is not given to the baby, but is offered to friends and family. Hulled wheat is used here, but you can also use barley. The soft, chewy texture of the cooked wheat offers a lovely contrast to the crunch of the soaked nuts, the whole enhanced by the fragrant waters. This delightful sweet snack also makes a delectable breakfast. Soak the nuts the night before you want to make this.

SYRIAN SEMOLINA AND NUT CAKE (H’RISSEH) Nabak is a little Syrian town not far from Damascus that’s famous for its h’risseh. The name of this cake is confusing as it also describes a Lebanese savoury dish, a kind of porridge made with wheat and meat. In Syria, however, there’s no mistaking the name for any thing but this delectable syrupy sponge cake topped with mixed nuts. This irresistible dessert is very simple to prepare. 1¼ c. (310 ml) semolina flour (regular, not fine) 6 tbsp. (90 g) unsalted butter, at room temperature

¼ c. (60 ml) superfine sugar 1½ c. (375 ml) whole-milk yogurt ¼ tsp. (1.25 ml) baking soda 1 tsp. (5 ml) tahini ¹⁄³ c. (50 g) blanched almonds ¹⁄³ c. (50 g) hulled unsalted pistachios ¹⁄³ c. (50 g) walnut halves ¹⁄³ c. (50 g) unsalted cashews 1½ c. (375 ml) fragrant sugar syrup, at room temperature (instructions follow)

Put the semolina, butter and superfine sugar in a mixing bowl, and work together using a spatula until well blended. Add the yogurt and baking soda, and mix until you have a firm batter. Using the tahini, grease a 10-inch (25-cm) round cake pan with sides about 1¾ inch (4.5 cm) high. Spread the batter evenly across the prepared pan.

²∕³ c. (100 g) blanched almonds ²∕³ c. (100 g) walnuts ¹⁄³ c (50 g) pine nuts 1¼ c. (250 g) hulled wheat berries 1½ tsp. (7.5 ml) ground aniseed 1 c. (250 ml) organic cane sugar 2 tbsp. (30 ml) orange blossom water 2 tbsp. (30 ml) rose water

Place the almonds, walnuts and pine nuts in three separate small bowls and pour in enough water to cover. Let soak overnight. If you have the patience, peel the soaked walnuts, discarding the skins. Rinse the wheat berries and put them in a large saucepan. Add 1 quart (1 L) water and place over medium heat. Bring to a boil; lower the heat and let simmer for 1 hour, or until the wheat berries are completely tender and have opened up a little. The cooking water should be a thick broth. Add the ground aniseed, sugar, orange blossom water and rose water, and stir until the sugar has dissolved. Drain and rinse the nuts, keeping them separate. Divide the wheat berries among six individual bowls. Scatter the nuts over the top and serve hot, warm or at room temperature. Serves 6.

Syrian semolina and nut cake (H’risseh).

NOVEMBER / DECEMBER 2015 • Doctor’s

Review

Flatten it gently with the back of a spoon. Cover with plastic wrap, taking care not to let the plastic touch the top of the batter, and let rest in a cool place for 3 hours. Preheat the oven to 400°F (200°C) for about 20 minutes. Scatter the nuts all over the surface of the batter and bake until the cake is golden, 40 minutes. Remove from the oven and pour the syrup all over. Don’t worry if the cake looks as if it’s swimming in the syrup; it will absorb it all. Let the cake stand for 30 minutes to soak up the syrup. It may seem like too much syrup, but the cake needs it all. Of course, if you lack the Middle Eastern sweet tooth, you can decrease the amount. Store in an airtight container at room temperature for up to 1 day. Serves 8 to 10.

Fragrant sugar syrup 2 c. (500 ml) superfine sugar 1½ tsp. (7.5 ml) freshly squeezed lemon juice 1/2 c. (125 ml) water 1 tbsp. (15 ml) rose water 1 tbsp. (15 ml) orange blossom water

Put the sugar, lemon juice and water in a saucepan, and place over medium heat. Bring to a boil, stirring occasionally to help the sugar dissolve. Boil for 3 minutes, and then add the rose water and orange blossom water. Mix well and remove from the heat. Let cool before using unless the recipe instructs otherwise. Store in the refrigerator for up to 2 weeks. Bring to room tem perature before using. Makes about 1½ cups (375 ml).

CORNES DE GAZELLE (KA’B AL-GHAZAL) These almond-filled cookies are baked until just set but not coloured so that they remain delicate, breaking as soon as you bite them and then melting in your mouth. Even though every self-respecting Moroccan cook knows how to make cornes de gazelle — French for “gazelle’s horns” — they are often purchased from specialists. The pastries are normally offered at the end of fancy dinner parties known as diffa (from diyafa, meaning “hospitality” in Arabic), or served throughout the day alongside mint tea. For the almond filling 3¾ c. (500 g) blanched almonds ¾ c. (180 ml) superfine sugar ¼ c. (60 ml) orange blossom water 2 tbsp. (30 g) unsalted butter, at room temperature 6 to 8 small grains mastic (see box right), crushed in a small mortar with a pestle to yield ½ tsp. (2.5 ml) powdered mastic For the pastry 1½ c. (375 ml) unbleached all-purpose flour 2 tbsp. (30 g) unsalted butter, melted, plus more for rolling out the pastry 6½ tbsp. (100 ml) water

Cornes de gazelle (Ka’b al-ghazal).

Doctor’s Review • NOVEMBER / DECEMBER 2015

Put the almonds in a medium heatproof bowl. Pour in enough boiling water to cover and soak for 30 minutes. Drain the almonds and dry them well on a clean kitchen towel. In a food processor, working in batches if necessary, process the almonds and superfine sugar to a very fine paste, about 2 minutes, scraping down the sides of the bowl as needed. Transfer to a large bowl. Add the orange blossom water, butter and mastic; mix with your hands until you have a homogeneous paste. Cover with a clean kitchen towel and set aside. Put the flour in a large, shallow mixing bowl and make a well in the centre. Add the melted butter and slowly add the water as you gradually

stir the butter into the flour with your hand or a spatula. (Some cooks use orange blossom water instead of regular water, but that makes for very fragrant pastries). Knead the mixture in the bowl for 15 minutes, or until a smooth, malleable dough forms. Divide the filling into 40 pieces, rolling each piece between the palms of your hands into a 2-inch (5-cm) ball. Shape each ball into a cylinder about 4 inches (10 cm) long, with tapering ends. Set aside. Preheat the oven to 400°F (200°C). Line two baking sheets with parchment paper or silicone baking mats. Smear your pastry board or work surface, rolling pin and hands with melted butter. Divide the dough in half and shape each half into a rectangle measuring about 4 by 8 inches (10 by 20 cm). Roll out one half, turning it over once or twice, into a very thin strip about 5 inches (12.5 cm) wide and 20 inches (50 cm) long. Carefully stretch the dough with your hands to thin it out a little more and lengthen it to about 25 inches (60 cm). With the dough positioned perpendicular to the counter’s edge, place a piece of filling along a short end, about 1 inch (2.5 cm) away from the edge.

Fold the 1-inch (2.5-cm) edge tightly over the filling and pinch the filling, bending it at the same time to form a crescent with a thin triangular body and pointed ends; it should be a little wider than the initial cylinder of filling and flat on the bottom. Press the edges of the dough together and cut using a fluted pastry wheel, following the shape of the crescent and keeping very close to the edge of the filling. The crescent should measure about 4 inches (10 cm) wide by 1¼ inch (3 cm) high. Prick it with a toothpick in several places on both sides and set on a prepared baking sheet. Form more cornes de gazelle in the same way; you should have enough to make 20 crescents. Space them about 1 inch (2.5 cm) apart on the baking sheet. Bake until barely coloured, 15 to 20 minutes. Let the pastries cool a little and then carefully transfer them to a wire rack to cool completely. While the first batch is baking, begin forming the second lot, and bake and cool in the same way. Store in an airtight container at room temperature for up to 5 days. Makes 40 cookies. Recipes and photos from Sweet Middle East: Classic Recipes from Baklava to Fig Ice Cream (Chronicle Books, 2015).

MASTIC (MISKEH) Mastic is a dried resin that seeps out of the bark of the Pistacia lentiscus (the same genus as pistachios), an evergreen tree native to the Mediterranean basin. There are two kinds of dried mastic: clear, tiny grains called dahtilidopetres (flintstones) and the larger, spotted soft ones known as kantiles (blisters). The latter is the coarser grade. It is normally used for chewing — the resin is a natural chewing gum — while the finer grade is used in cooking. These days, however, it’s becoming more difficult to purchase “flintstones.” Some mastic grains are very large. The grains used in the gazelle horns recipe should be smaller than half the size of a cannellini bean. Reserve a small mortar and pestle that you use only for mastic so as to not corrupt the flavour, and crush the grains on demand. If you crush more than you need, wrap your mortar with plastic wrap and keep until you next need the mastic, or transfer to a jar for storage. You can keep it in the refrigerator, but it’s not necessary. Mastic will keep for up to 1 year. Editor’s note: Mastic is sold in Middle Eastern and Greek stores, usually in bottles. The grains look like little golden opaque crystals. Its flavour has been described as slightly piny or like cedar. Some cooks omit it entirely if it’s too difficult to find.

ONGLYZA Contraindications:  Diabetic ketoacidosis  Diabetic coma/precoma  Type 1 diabetes mellitus Relevant warnings and precautions:  Caution in patients with history of congestive heart failure, especially in patients who also have renal impairment and/or history of myocardial infarction  Exposure to stress (e.g. surgery)  Interactions with potent CYP3A4 inducers  Contains lactose  Risk of hypersensitivity  Discontinue if pancreatitis is suspected  Immunocompromised patients (consider monitoring lymphocyte count)  Rash (monitoring recommended)  Not recommended for pregnancy, should not be used by nursing women  Not recommended for patients with moderate to severe hepatic impairment  Caution in patients with severe renal impairment; not recommended for patients with ESRD requiring hemodialysis  Monitor renal function For more information: Please consult the Product Monograph at www.azinfo.ca/onglyza/pm664 for more information relating to adverse reactions, drug interactions and dosing information not discussed in this piece. The Product Monograph is also available by calling us at 1-800-668-6000. KOMBOGLYZE Contraindications:  Type 1 diabetes mellitus  Metabolic acidosis including diabetic ketoacidosis  History of lactic acidosis  Renal disease or impairment  Excessive alcohol intake  Moderate and severe hepatic impairment  Hypoxic states  Stress conditions  Severe dehydration  Pregnancy and breastfeeding  Radiologic studies involving iodinated contrast materials Most serious warnings and precautions: Lactic acidosis can occur due to metformin accumulation during treatment. Patients should be cautioned against excessive alcohol intake as it can potentiate the effect of metformin on lactic acidosis. Other relevant warnings and precautions:  Discontinue if pancreatitis is suspected  Risk of hypersensitivity  Caution in patients with history of congestive heart failure, especially in patients who also have renal impairment and/or history of myocardial infarction  Reduced vitamin B12 (monitor hematologic parameters)  Suspend therapy for surgical procedures  Interaction with potent CYP3A4 inducers  Immunocompromised patients (consider monitoring lymphocyte count)  Rash (monitoring recommended)  Monitor renal function For more information: Please consult the Product Monograph at www.azinfo.ca/komboglyze/pm566 for more information relating to adverse reactions, drug interactions and dosing information not discussed in this piece. The Product Monograph is also available by calling us at 1-800-668-6000. MI = myocardial infarction * Randomized, double-blind, placebo-controlled study of 24 weeks’ duration in patients with inadequate glycemic control (A1c ≥7.0% and ≤10.0%) on metformin alone. ONGLYZA baseline A1c 8.1% (n=186), FPG 9.9 mmol/L (n=187), PPG 16.4 mmol/L (n=155). Placebo baseline A1c 8.1% (n=175), FPG 9.7 mmol/L (n=176), PPG 16.4 mmol/L (n=135). Patients were required to be on a stable dose of metformin (1500 mg to 2550 mg daily) for at least 8 weeks to be enrolled in the trial. Patients who completed all visits during the initial 24-week study period without need for hyperglycemia rescue therapy were eligible to enter a controlled, double-blind, long-term study extension. Patients who received ONGLYZA in the initial 24-week study period maintained the same dose in the long-term extension. † Double-blind, placebo-controlled study in 16,492 patients with type 2 diabetes with A1c ≥6.5% and ≤12% who had either established CVD (n=12,959, defined as a history of atherosclerosis event, involving the coronary, cerebrovascular or peripheral vascular system) or multiple risk factors for vascular disease (n=3533, age [men ≥55 years and women ≥60 years] plus ≥1 additional risk factor of dyslipidemia, hypertension, or active smoking), including patients with moderate (n=2240) or severe (n=336) renal impairment. Patients were randomized to placebo (n=8212) or ONGLYZA (5 mg or 2.5 mg for patients with moderate or severe renal insufficiency) once daily (n=8280). The primary safety (non-inferiority) and efficacy (superiority) endpoint was a composite endpoint consisting of the time to first occurrence of any of the following major adverse CV events (MACE): CV death, nonfatal myocardial infarction, or nonfatal ischemic stroke. Subjects were followed for a median duration of 2.1 years. References: 1. ONGLYZA Product Monograph. AstraZeneca Canada Inc., February 25, 2015. 2. Scirica BM et al. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus. N Engl J Med. 2013;369:1317-26. 3. KOMBOGLYZE Product Monograph. AstraZeneca Canada Inc., May 14, 2015.

07/16

NOVEMBER / DECEMBER 2015 • Doctor’s

Review

ÉP

ONCE DAILY Controlled release methylphenidate hydrochloride capsules

ONCE DAILY

Controlled release methylphenidate hydrochloride capsules

PRODUCT OF CANADIAN RESEARCH

10 mg 10 mg

1515 mg mg 20 mg2030mg mg

40 mg 30mg mg 50 40

60 mg 5080 mg mg mg

60 mg

80 mg

Indications & Clinical Use: Biphentin® is indicated for treatment of Attention-Deficit Hyperactivity Disorder (ADHD) in children 6-11, adolescents 12-18 and adults >18 years of age. Biphentin® is indicated as an integral part of a total treatment program for ADHD that may include other measures (psychological, educational, social) for patients with this syndrome. Drug treatment may not be indicated for all patients with this syndrome. Effectiveness for more than 4 weeks has not been systematically evaluated in placebo-controlled trials. Physicians electing to use Biphentin® for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient. Should not be taken by children under 6 years of age. No data is available for patients >65 years of age. Contraindications: • Anxiety, tension, agitation, thyrotoxicosis, advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension or glaucoma • Motor tics or with family history or diagnosis of Tourette’s syndrome • Concomitant use of an MAO inhibitor or within a minimum of 14 days following discontinuation of an MAO inhibitor Most Serious Warnings And Precautions: • Drug dependence/tolerance. Careful supervision is required during drug withdrawal Other Relevant Warnings And Precautions: • The risk of sudden cardiac death should be considered although incremental risk of adverse cardiac events has not been confirmed • Patients who are involved in strenuous exercise or activities; are using other stimulants or medications for ADHD; or have a family history of sudden cardiac death • Cardiovascular – sudden death and pre-existing structural cardiac abnormalities or other serious heart problems • Screen for cardiovascular and cerebral vascular conditions before initiating treatment and monitor for new conditions during treatment • Monitor blood pressure at appropriate intervals especially in patients with pre-existing conditions that may result in hypertension • Long-term suppression of growth: Carefully monitor patients requiring long-term therapy. Interrupt treatment in patients not growing or gaining weight as expected • Psychiatric effects: Not for treatment of depression; not for use in treatment or prevention of normal fatigue states; may exacerbate psychosis symptoms in patients with pre-existing psychotic disorder; screen for risk of bipolar disorder in patients with comorbid depressive symptoms; monitor patients for signs of suicide-related behaviour; monitor patients for new psychotic or manic episodes and aggressive behaviour • Neurologic effects: Discontinue if seizure frequency rises • Ophthalmologic effects • Priapism • Associated with peripheral vasculopathy, including Raynaud’s phenomenon • Not for use in pregnant women unless the potential benefit outweighs the risk to the fetus. A risk to the suckling child cannot be excluded • Patients with an element of agitation may react adversely; discontinue therapy if necessary • Patients should be cautious when driving or operating machinery • Drug interactions For more information: Please consult the Product Monograph at http://www.purdue.ca/files/Biphentin-PM-EN.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-387-5349. References: 1. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Third Edition, Toronto ON; CADDRA, 2011. http://www.caddra.ca/pdfs/caddraGuidelines2011.pdf. Accessed September 26, 2013. 2. Biphentin® Product Monograph, Purdue Pharma, March 4, 2015 or such later date as posted at www.purdue.ca.

Doctor’s Review • NOVEMBER / DECEMBER 2015

Clinical Use TARGIN® is not indicated as an as-needed (prn) analgesic. Not recommended for use in patients <18 years of age. Select dose cautiously in elderly patients, usually starting at the low end of the dosing range. Contraindications: • Known or suspected mechanical gastrointestinal obstruction or any known condition that affects bowel transit • Rectal administration • Suspected surgical abdomen • Mild, intermittent or short duration pain that can be managed with other pain medications • Management of acute pain • Management of perioperative pain • Acute asthma or other obstructive airway, and status asthmaticus • Acute respiratory depression, elevated carbon dioxide levels in the blood, and cor pulmonale • Acute alcoholism, delirium tremens, and convulsive disorders • Severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury • MAO inhibitor use • Pregnancy, labour and delivery, breast-feeding • Opioid-dependent patients and for narcotic withdrawal • Moderate to severe hepatic impairment Most Serious Warnings And Precautions: Limitations of use: Should only be used in patients for whom alternative treatment options are ineffective, not tolerated, or would be otherwise inadequate to provide appropriate management of pain. Addiction, abuse, and misuse: Assess patient risk prior to prescribing; monitor all patients regularly; store TARGIN® securely. Life-threatening respiratory depression: May occur with TARGIN® use. Monitor patients for respiratory depression, especially during initiation or following dose increases. Must be swallowed whole. Cutting, breaking, crushing, chewing, or dissolving TARGIN® can lead to rapid release and absorption of a potentially fatal dose of oxycodone. Accidental exposure: Serious medical consequences, including death, may occur, especially in children. Neonatal opioid withdrawal syndrome: Can result from prolonged maternal use during pregnancy. Administration: Must be swallowed whole. Broken, chewed, dissolved, or crushed tablets could lead to rapid release and absorption of a potentially fatal dose of oxycodone. Do not administer rectally. 40/20 mg tablets: For opioid-tolerant patients only. Medication sharing: Patients for whom TARGIN® is prescribed should not give TARGIN® to anyone else. Constipation: Not for patients with constipation not related to opioid use. Patients currently taking oral oxycodone: Switch to TARGIN® based on an equivalent oxycodone dose. Conversion from other opioids/opioid preparations: Initiate at the lowest available strength, provide adequate rescue medication, with dose titration to achieve satisfactory pain relief with acceptable side effects. Maximum dosage: Single doses should not exceed 40/20 mg. Maximum daily dose is 80/40 mg. Other Relevant Warnings And Precautions: • 5/2.5 mg tablets are intended for titration and dose adjustment • Do not consume alcohol • An oxycodone dose reduction or change in opioid may be required in hyperalgesia • Use in peritoneal carcinomatosis • Potential diarrhea • Marked withdrawal symptoms if abused rectally, intravenously or intranasally • Withdrawal symptoms after abrupt discontinuation of therapy • Dependence/tolerance • Not approved for managing addictive disorders • Use cautiously in patients receiving other CNS depressants • Increased respiratory depression in patients with head injuries • Use cautiously in patients with pre-existing cardiovascular conditions • Psychomotor impairment: Advise patients that TARGIN® may impair mental and/or physical ability required for the performance of potentially hazardous tasks especially when starting TARGIN®, when dose has been adjusted, and receiving other CNS-active drugs. Patients should be advised not to drive a car or operate machinery unless they are tolerant to the effects of TARGIN® • Administer with caution and at reduced dosage to debilitated patients, and patients with Addison’s disease, cholelithiasis, hypotension, hypothyroidism, mild hepatic impairment, myxoedema, renal impairment, toxic psychosis, prostatic hypertrophy or urethral stricture • Disposal and security: Unused or expired TARGIN® should never be thrown into household trash, where children and pets may find it. Return to pharmacy for proper disposal. Should be kept under lock and out of sight and reach of children and pets. Adverse Events: Adverse events often observed with other drugs with opioid-agonist activity were also seen with TARGIN®. The most frequently observed were nausea, which tends to reduce with time, as well as constipation, diarrhea, fatigue, headache and hyperhidrosis. For more information: Please consult the Product Monograph at http://www.purdue.ca/files/2014-08-05_Targin-pm-mktg-eng.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-387-5349. Targin® is a registered trademark of Purdue Pharma. © 2015 Purdue Pharma. All rights reserved. 1. TARGIN® Product Monograph, Purdue Pharma, August 2014. 2. Purdue Pharma, letter on file, September 25, 2014. 3. Simpson K et al. Fixed-ratio combination oxycodone/naloxone compared with oxycodone alone for the relief of opioid-induced constipation in moderate-to-severe noncancer pain. CMRO. 2008;24(12):3503-3512. NOVEMBER / DECEMBER 2015 • Doctor’s

Review

P H OT O FI NI S H by

Dr A r nold Wolf

A cruise back in time

advertisers index ACTAVIS SPECIALTY PHARMACEUTICALS Constella............................................ 47, 49 AMERICAN SEMINAR INSTITUTE Corporate ................................................ 23 ASTRAZENECA CANADA INC. Forxiga................................................. IBC Komboglyze/Onglyza............................. 18 BOEHRINGER INGELHEIM (CANADA) LTD Corporate..................................................4 Inspiolto Respimat...............................OBC Jardiance...............................................IFC Trajenta................................................... 10 CANADIAN ASSOCIATION OF EMERGENCY PHYSICIANS Corporate..................................................6 CANADIAN MEDICAL ASSOCIATION Corporate............................................ 8, 27 GLAXOSMITHKLINE Anoro................................................ 40, 41 LEO PHARMA INC. CANADA Picato...................................................... 17 MERCK CANADA INC. Zenhale.................................................... 21 MYLAN AndroGel.......................................... 28, 29 PFIZER CANADA Premarin............................................ 13, 15 Pristiq................................................ 32, 33 PURDUE PHARMA CANADA Analgesic Portfolio.................................. 24 Biphentin............................................. 5, 20 Targin................................................ 50, 51

These people are Italian emigrants bound for Canada. The photo was taken in 1967 onboard the Cristoforo Colombo of the now defunct Italian Line. The ship travelled from Venice via Sicily to Halifax and New York. The young man in the centre could be found singing at all times throughout the sections of the ship allowed for tourist class passengers. At the time, ships still had cabin class and first class accommodations. One day, I was lucky to take a snapshot of this group, to which everybody agreed. One wonders where they are now.

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

editors@doctorsreview.com

Doctor’s Review • NOVEMBER / DECEMBER 2015

SEA COURSES INC. Corporate................................................ 16 TAKEDA CANADA INC. Dexilant................................................. 2, 3 Nesina (Quebec only).............................. 44

FAIR BALANCE INFORMATION Biphentin................................................. 62 Komboglyze............................................ 61 Targin..................................................... 63

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

CONVENIENT, ONCE-DAILY DOSING1‡§¶ RECOMMENDED STARTING DOSE: 5 mg

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

CAN BE TAKEN ANY TIME OF DAY

WITH OR WITHOUT FOOD

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

Clinical use: Not for use in pediatrics (<18 years). In patients ≥65 years of age, a higher proportion had adverse events related to volume depletion and renal impairment or failure compared to placebo. Contraindications: • Patients with moderate to severe renal impairment, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, or end-stage renal disease Relevant warnings and precautions: • Not for use in type 1 diabetes or for the treatment of diabetic ketoacidosis • Not for use in patients with active bladder cancer and use with caution in patients with a prior history of bladder cancer • Not for use in patients concomitantly treated with pioglitazone • Not recommended for use in patients who are volume depleted; caution in patients for whom a FORXIGA-induced drop in blood pressure could pose a risk, or in case of intercurrent conditions that may lead to volume

depletion; careful monitoring of volume status is recommended and temporary interruption of FORXIGA should be considered for patients who develop volume depletion until the depletion is corrected • Risk of hypoglycemia when used in combination with insulin or insulin secretagogues • Dose-related LDL-C increases; monitor LDL-C levels • Increased mean hemoglobin/hematocrit and frequency of patients with abnormally elevated values of hemoglobin/hematocrit • Increased risk of genital mycotic infections • Renal function should be assessed prior to initiation of FORXIGA and regularly thereafter • Not for use in pregnant or nursing women For more information: Please consult the Product Monograph at www.azinfo.ca/forxiga/pm367 for important information relating to adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling 1-800-668-6000.

* Clinical significance unknown. † The amount of glucose removed by the kidney through this mechanism is dependent upon the blood glucose concentration and GFR. ‡ In patients with evidence of volume depletion, this condition should be corrected prior to initiation of FORXIGA. § The efficacy of FORXIGA is dependent on renal function. Assessment of renal function is recommended prior to initiation of FORXIGA therapy and periodically thereafter. ¶ Please see Product Monograph for complete dosing and administration information. Reference: 1. FORXIGA Product Monograph. AstraZeneca Canada Inc., December 10, 2014.

02/16

NEW once-daily combination COPD therapy

grounded in long-term maintenance

INSPIOLTO RESPIMAT 速 TM

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

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

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

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