November-December 2016 by Doctor's Review

NOVEMBER / DECEMBER 2016

An agnostic visits Israel Memories of Christmas markets Empress Hotel makeover Holiday desserts to die for Organic caviar

MEDICINE ON THE MOVE

WIN

A FABULOUS

BLENDER PAGE 14

Glorious Andalusia 10

things about

Emily Carr

Depression self-help

Type 2 diabetes can be heartbreaking.

According to the Canadian Diabetes Association (CDA):1, 2 Patients with type 2 diabetes are at increased risk for cardiovascular mortality. Diabetes can reduce life expectancy by about 12 years. The BI and Lilly Diabetes Alliance is committed to the heart health of your type 2 diabetes patients.

References: 1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Vascular protection in people with diabetes. Can J Diabetes. 2013;37 Suppl 1:S100-4. 2. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Screening for the presence of coronary artery disease. Can J Diabetes. 2013;37 Suppl 1:S105-9. Member of Innovative Medicines Canada

On the road again I lived in southern Spain for a year long enough ago that Franco was still in power. Memories of the Civil War, more than 30 years before, still marred the country like an open wound. Guardia Civil, the regime’s enforcers, had a post in every town and uniformed soldiers with automatic rifles patrolled the streets after dark. That was then, this is now. I visited most recently last June and found the region full of hope, evolving opportunity and, on the surface at least, plain old-fashioned fun, despite some of the choppy economic waters the country has been through in the past few years Organic caviar from Riofrio. along with the rest of southern Europe. The Spanish are skilled at the art of living — come good times or bad. You can read about a few of my adventures in Travels in Andalusia beginning on page 46. There’s one, though, that’s not covered there: Riofrio, an organic caviar farm in the hills east of Granada. That’s right, organic caviar. It’s the only such spot in the world. The roe comes from sturgeon and Acipenser Naccari trout, an indigenous breed no longer found in the wild. The fish grow to maturity in icy, pure, spring-fed water that flows out of the Sierra Nevada mountains. That maturity is a long time coming. It takes seven to nine years to even determine the sex of the fish and so separate the valuable eggproducing females from the, ah, let’s say, uncommercial males. The wait continues until the females spawn at 14 or 15 years. Ultrasound is used to tell when the eggs are ready, the sturgeon is cut open and, voilà, a cache of some of the finest caviar on earth. Nothing is done to the dark grey roe except to mix it with salt and pack it into the iconic 120-gram Riofrio cans that sell for €280 each, approximately €2000 a kilo. I had the privilege of tasting some — superb — but don’t take my word for it. You can watch as British chef, Gordon Ramsey, comes to his own conclusion at http:// bit.ly/2dVYTkL. There’s a lot more to savour in the issue, of course, including agnostic Anita Draycott’s take on some of the holy places in Israel beginning on page 28. Continuing the seasonal theme, wander through some of Europe’s most entrancing Christmas markets with writer Josephine Matyas who finds the experience caught up with her own bittersweet memories of Christmases past. This is a combined November/December issue. Look forward to seeing you in the New Year to begin the celebration of Canada’s 150th. Happy days,

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David Elkins, publisher and editor delkins@parkpub.com

@doctorsreview

NOVEMBER / DECEMBER 2016 • 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

contents NOVEMBER / DECEMBER 2016

46 COVER: LIQUID STUDIOS / SHUTTERSTOCK.COM

features

Travels in Andalusia Sunshine, fine food — and so much more — whet the appetite for history from the Costa del Sol to Córdoba and back by David Elkins

Sweet somethings Easy cakes and cookies for the holidays plus an elaborate chocolate pear trifle that you can make in stages and still woo your guests by Anna Olson

Israel, pray tell An agnostic becomes a “believer” while exploring the sacred splendours of the Holy Land from ancient Jaffa to hip Tel Aviv by Anita Draycott

Europe for the holidays The best Christmas markets in France, Germany and Switzerland for traditional ornaments, wooden toys and paper cones filled with chestnuts by Josephine Matyas

42 The Empress’s new clothes BC’s Fairmont Empress gets a full makeover, but is her fresh look — and new menu — worth all the millions? by Jeremy Ferguson

Coming in

January

• Timbuktu by car: about as exotic a road adventure as they come • Anguilla for music and so much more: the tiny Caribbean island comes into its own • Ottawa for the sesquicentennial: 150 years old and looking better than ever • Short walks from Heathrow: a family doctor shows how to make the most of a stopover

NOVEMBER / DECEMBER 2016 • Doctor’s

Review

Standing by you and your patients with a variety of treatments

With the Pﬁzer Strive card, your patients can receive savings* on their Pﬁzer brand medication such as:

• Tell your patients to visit pfizeroriginal.ca and download the Pfizer Strive card • You can also order Pfizer Strive cards for your patients at physiciansonline.ca/ physician or by calling 1-866-794-3574

Encourage your patients to ask for original Pﬁzer brands at the pharmacy. * Payment assistance is available for patients taking LIPITOR, NORVASC, CADUET, ACCUPRIL and ACCURETIC. Amount will vary by province. Pﬁzer Strive is available in all provinces except Quebec.

Inderal-LA remember to specify

If you want your patients to receive the INDERAL-LA brand.

CA016LI003E

For patients taking

contents NOVEMBER / DECEMBER 2016

regulars 7

LETTERS What’s brewing?

PRACTICAL TRAVELLER A home for Black History, why Montreal and Calgary are hot, hot, hot plus art meets science at London’s beautiful new Wonderlab by Camille Chin

GADGETS The best blender for your morning smoothies by David Elkins

TOP 25 The biggest medical meetings scheduled for next April and May

21 21

MEDICINE AND THE ARTS 10 things you need to know about Emily Carr by Tilke Elkins

DEPRESSION KEYPOINTS Teach your patients more about how to help themselves by Dr Erin Michalak and Eva Chanda

NOVEMBER / DECEMBER 2016 • Doctor’s

Review

Choose Alvesco first. Demonstrated effective symptom control with an excellent safety profile. ®

1,2

Indications and clinical use: Alvesco is indicated for the prophylactic management of steroid-responsive bronchial asthma in adults, adolescents, and children 6 years of age and older.

• Immunosuppressant drugs • May cause eosinophilic conditions • May cause candidiasis • As with other inhalation therapy, paradoxical bronchospasm may occur Contraindications: • Caution in systemic steroid replacement by inhaled steroid • Untreated fungal, bacterial or tuberculosis • Patients with hypoprothrombinemia in infections of the respiratory tract conjunction with acetylsalicyclic acid • Primary treatment of status asthmaticus or other acute episodes of asthma or in patients • Systemic effects of inhaled corticosteroids may occur, particularly at high doses for with moderate to severe bronchiectasis prolonged periods Relevant warnings and precautions: • Monitor HPA axis function and effects • Patients with hypothyroidism on the eye • Patients with cirrhosis and/or severe hepatic impairment ®

ALVESCO is a registered trademark of Takeda GmbH, used under licence. The AstraZeneca logo is a registered trademark of AstraZeneca AB, used under license. © AstraZeneca Canada Inc. 2016. ®

For more information: For important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, drug interactions and dosing, please consult the product monograph at http://www.azinfo.ca/alvesco/pm258/. The product monograph is available by calling AstraZeneca Canada at 1-800-668-6000. REFERENCES: 1. Alvesco (ciclesonide inhalation aerosol) Product Monograph. Takeda Canada Inc. December 17, 2012. 2. Lougheed MD et al. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012;19(2):127-164. ®

LETTERS

EDITOR

David Elkins

What’s brewing?

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

OFFICE MANAGER

Denise Bernier

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

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

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None of the contents of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means, without prior permission of the publishers. ISSN 0821-5758 Canadian Publications Mail Sales Product Agreement No. 40063504 Post-paid at St. Laurent, QC. Return undeliverable Canadian addresses to: Circulation Department, 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.

BREWHAHA I believe that the first pub to brew and sell its own beer was at Horseshoe Bay — Troll’s? — in 1982 [Sails and ales, October 2016, page 34]. Spinnakers was second. I perpetuated the myth of Spinnakers until I found out about Troll’s. I was surprised that Greg Evans didn’t mention Frank Appleton’s contribution to BC’s brewing revolution. Brett Via DoctorsReview.com

HEADPHONE SOUND OFF One more way that Apple Inc. [“Headsets without wires,” Gadgets, October 2016, page 17] is making more money from their customers! Andries Via DoctorsReview.com

No lines to choke you make listening privately safe now. Ilmar Via DoctorsReview.com

RECIPE REVIEW I’ve made the gnocchi, squash and kale recipe twice [Weeknight winners, October 2016, page 50], and I just love it. The gnocchi was so moist and soft. And the recipe is so easy and healthy. I told my daughter and I will most definitely make it again. Anna J. Via email

TRAILER TALK We’ve been researching the Airstream Basecamp so I was very excited to see the Happier Camper [“A camper that you can customize,” Practical Traveller, September 2016, page 13]. The

Happier Camper costs $10,000 less than the Basecamp and can be hauled by a regular-sized car, which is so fantastic. Thanks for covering it. Dr A. Marcus Via email

CHIN CHIN My sister brought a bottle of Prosecco to Thanksgiving dinner. I remember reading that it’s becoming more popular in your Venice article [Flavours of the Veneto, September 2016, page 38] so I was happy to try it. I was even happier that I knew something about it and could talk about it! Liz Fowler Montreal, QC

AIRBNB MEETS FRANK LLOYD WRIGHT I came across an article about another Frank Lloyd Wright house that you can rent. It’s in Virginia Beach, owned by a lovely couple in their 90s and a room costs only $150 a night. I read about it in the New York Times and it’s available for rent on Airbnb. Lynn Montreal, QC

NOVEMBER / DECEMBER 2016 • Doctor’s

Review

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

VISIT FLONASEPROFESSIONAL.CA FOR MORE INFORMATION.

FLONASE® Allergy Relief (fluticasone propionate aqueous nasal spray 50 mcg) is indicated for the treatment of the symptoms associated with seasonal allergic rhinitis including hay fever, and perennial rhinitis; and the management of sinus pain and pressure symptoms associated with allergic rhinitis. Please consult the product monograph at flonaseprofessional.ca or by calling 1-866-994-7444 for information relating to adverse reactions, drug interactions, and dosing information. 1. GSK data on file. 2013. 2. FLONASE® Allergy Relief Product Monograph. GlaxoSmithKline Consumer Healthcare Inc. August 2016. 3. FLONASE® Product Monograph. GlaxoSmithKline Inc. Dec. 10, 2015. *Provincial exclusions may apply.

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

ALAN KARCHMER / NMAAHC

COLLECTION OF THE SMITHSONIAN NATIONAL MUSEUM OF AFRICAN AMERICAN HISTORY AND CULTURE

Black history gets a home The National Museum of African American History and Culture is the 19th and newest museum of the Smithsonian Institution. It opened in Washington, DC this past September. The lead designer was David Adjaye, the son of a Ghanaian diplomat who has visited all 54 independent nations of Africa. The lead architect was Philly-born Philip Freelon, who worked on the National Center for Civil and Human Rights in Atlanta and the Museum of the African Diaspora in San Francisco. The museum’s main entrance is a porch — porches have architectural roots in Africa and throughout the African Diaspora. Its exterior is wrapped in a bronze-coloured metal lattice, homage to the intricate ironwork that was crafted by enslaved African Americans in Louisiana, South Carolina and elsewhere. The museum has collected more than 36,000 artifacts; 3500 are displayed chronologically from the Atlantic slave trade to the Obama presidency: an auction block and a statue of Thomas Jefferson standing in front of a wall of bricks listing the names of slaves he owned to banners from President Obama’s 2008 campaign and posters from the Black Lives Matter movement. “Community” galleries share the stories of African-Americans in the military and sports; “Culture” galleries, the arts, music, film and television. Free, but advanced, timed-entry passes are unavailable through March 2017. nmaahc.si.edu. NOVEMBER / DECEMBER 2016 • Doctor’s

Review

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

International growth Calgary International Airport, recently renamed YYC Calgary International Airport, has a new terminal for travellers going to and from the US and international destinations. It opened on October 31 and adds about 186-square-metres or 34 football fields to the airport, doubling its current size. There are 24 new aircraft gates, two common-use lounges, and 50 new restaurants and shops. A new Connections Corridor, featuring eight moving walkways, links the new and existing terminal; alternatively, a 10-passenger shuttle transports travellers between the concourses. From 2000 to 2015, passenger volumes at the airport grew to almost 15.5 million from just over 8 million. yyc.com.

Luther’s legacy

Next year marks the 500th anniversary of the Protestant Reformation and Germany is celebrating Martin Luther: monk, professor and church reformer. Born in Eisleben, Luther is famous for his 95 theses attacking the Catholic Church’s practice of selling “indulgences” to absolve sins, which gave birth to the Reformation. When Pope Leo excommunicated Luther in 1521, Luther hid in Eisenach for the next year, where he began translating the New Testament into German, which took 10 years to complete. There are eight routes in Germany that feature 36 authentic Luther sites — the castle church where he nailed his 95 theses to the door in 1517, Wartburg Castle where he translated some of the New Testament — and also a host of exhibits and festivals scheduled for throughout 2017. Details are at germany.travel/en/specials/luther/luther.html where you can download the Luther 2017 brochure.

Doctor’s Review • NOVEMBER / DECEMBER 2016

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The Luther Room at Wartburg Castle in Eisenach.

THIS PAGE: PLASTIQUES PHOTOGRAPHY

Wonderlab’s Chemistry Bar and Friction Slides (below).

A new scientific wonder The Science Museum in London opened Wonderlab: The Statoil Gallery in October, and kids big and small will love it. It was designed by the UK-based Muf Architecture/Art and combines science with craft and design. There are 50 exhibits across seven zones that focus on incredible phenomena that happens around us every day. The most popular include a chemistry lab where kids can play mad scientist and order live experiments; three big colourful slides — one in artificial grass, another in fibre glass, the last in timber like the lanes of a bowling alley — for learning about friction; a giant rotating model of the solar system that visitors can ride to find out more about the seasons. There are free, 20-minute shows in the timber-and-redquilted auditorium: Live Wire! (about circuits and how your home is powered); Flash! Bang! Wallop! (the chemistry of explosions); The Rocket Show (about how Newton’s Laws of Motion get rockets into space and back again). Admission to the Science Museum is free; a day pass to Wonderlab is £8 ($13) for adults, £6 ($10) for kids four to 16. sciencemuseum.org.uk.

NOVEMBER / DECEMBER 2016 • Doctor’s

Review

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

Gardens by design Visiting Amsterdam between March 23 and May 21 next year? You may want to visit the famed Keukenhof gardens (actually located in Lisse between Amsterdam and The Hague). The garden’s theme for 2017 is Dutch Design and, this past October, gardeners began planting some of the seven million flower bulbs that will bloom next spring. One flower mosaic will depict a Mondriaan painting with Gerrit Rietveld-designed chairs. The mosaic will cover 250-square-metres and be planted in two layers to ensure a longer bloom period. It’ll consist of 80,000 tulips, muscari (grape hyacinth) and crocuses. Keukenhof’s 32 hectares feature 15 kilometres of footpaths and attracts over a million visitors every year. Adults €16 ($23); kids four to 11 €8 ($12). keukenhof.nl.

To Montreal by the millions

Doctor’s Review • NOVEMBER / DECEMBER 2016

Montreal was incredibly hot this year — weather and otherwise. The city is on track to receive 10 million visitors for the first time ever by the end of 2016. According to numbers gathered by Tourisme Montréal, the city welcomed 10 percent more travellers between January and June compared to the same period last year. Year-to-date tourism from Spain increased 17 percent, Germany 18 percent and France 21 percent, but the absolute biggest increase came from China — up by 205 percent. Air Canada and Air China launched direct flights between Montreal and Beijing in September 2015, the first non-stop trans-Pacific link between Montreal and Asia. Direct flights between Montreal and Shanghai will begin in February 2017.

GADG ETS by

D a vid El kin s

Smoothie search! Blenders are important — and they get more important everyday. Healthier ways are sweeping the nation. More exercise and better eating habits are at the top of the list and the healthiest mornings these days start with smoothies. You can’t make a smoothie without a decent blender and blenders collectively have a problem: they frequently breakdown. The morning ritual at our house is often interrupted by an odd whirr, a faint smell of smoke, then silence. Our breakfast combination of bananas, blueberries, walnuts, sunflower and pumpkin seeds, and yogurt has come to a grinding stop. The ingredients in the container look like a half-eaten meal, most unappetizing before 8am. Fortunately, after a two or three minute pause, the machine kicks itself back to life, and resumes churning out our day-launching drink. And the mechanical failure is forgotten — until tomorrow. This is our third blender in as many years. My search for the perfect replacement ended with the Ninja BL660. It combines good design with 1000 watts of power — enough so it could be used commercially — and at a price that won’t break the bank. It comes with two 16-ounce containers with lids so you can easily tote a smoothie off to work or school. The machine’s sharp six blades thoroughly blend fruit and leafy vegetables in little more than five seconds. For cool drinks, the big 72-ounce container handles ice with ease.

Win a Ninja BL660 blender by entering the Win the Gadget of the Month contest at doctorsreview.com A minor drawback is that cleaning is no easier than any other blender. The blades are so sharp you stick your hand down there at your own peril. The preferred method is to add a cup of water and a few drops of detergent and give it a whirl, or leave the job to a dishwasher. There are a few caveats. If you’re looking for super-smooth results you might be better served by a Vitamix or similar machines that are priced at $400 on up. If greens are your thing, the individual cups do a better job than the six-cup

unit. The company makes over a dozen different blenders so if you decide on a model other than the BL660 make sure you scan the reviews for details on the one you choose. User comments suggest customer service ranges from superlative (replacements quickly offered) to average. You can find the Ninja BL660 at a Canadian Tire or order it online. $189. canadiantire.ca Amazon.ca currently offers it at a slightly lower price. Shop around, prices vary and sales are frequent.

CONGRATULATIONS! The winner of Black + Decker’s 12V MAX Lithium Drill/Driver is Dr Arthur Vasquez, a family physician from Richmond, BC. 14

Doctor’s Review • NOVEMBER / DECEMBER 2016

Binge Eating Disorder is a cycle of

Binge. Distress. Repeat.

In a study of over 24,000 people across 14 countries, the lifetime prevalence of Binge Eating Disorder (BED) was estimated to be 1.9%, affecting about 1 in 52 adults.2* Though its exact cause is unknown, BED may have a neurobiological basis.3-6 Now recognized as a distinct disorder in the DSM-5, BED is defined as eating large amounts of food in short time periods with a perceived lack of control. During these episodes (occurring one or more times a week for 3 months), patients may eat extremely fast, to the point of physical discomfort, or with no physical hunger. They may eat alone due to shame, feel distress or self-disgust afterwards, and may hide these symptoms, even from you. BED is not associated with compensatory behaviour as in bulimia nervosa.1 Identifying and accurately diagnosing adults with BED is the first step to helping them.

Learn to recognize it. You can help. * Based on lifetime prevalence rates of BED among adults over the age of eighteen across 14 countries. Prevalence and correlates of eating disorders from nationally representative samples (or those representative of urbanized areas) via face-to-face surveys (n=24,124) were assessed using the WHO Composite International Diagnostic Interview. References: 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013. 2. Kessler RC, et al. The prevalence and correlates of binge eating disorder in the WHO World Mental Health Surveys. Biol Psychiatry 2013;73(9):904–14. 3. Manwaring JL, et al. Discounting of various types of rewards by women with and without binge eating disorder: evidence for general rather than specific differences. Psychol Rec 2011;61(4):561-82. 4. Balodis IM, et al. Divergent neural substrates of inhibitory control in binge eating disorder relative to other manifestations of obesity. Obesity 2013;21(2):367-77. 5. Davis CA, et al. Dopamine for “wanting” and opioids for “liking”: a comparison of obese adults with and without binge eating. Obesity 2009;17(6):1220-5. 6. Wang GJ, et al. Enhanced striatal dopamine release during food stimulation in binge eating disorder. Obesity 2011;19(8):1601-8. © 2016 Shire Pharma Canada ULC. All rights reserved. CDA/NPRMCDA/NBU/16/0014 66653-05-2017-E

CV EVENTS HAPPEN.

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

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

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

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

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

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

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

COVERSYL® is a registered trademark of Servier Canada Inc.

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

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Toronto, ON April 25-28, 2017 2017 WADEM Congress on Disaster and Emergency Medicine wadem.org

May 10-13, 2017

Vancouver, BC April 20-23, 2017 6th World Congress on ADHD: from Child to Adult Disorder adhd-congress.org

May 17-20, 2017 13th World Congress on Endometriosis endometriosis.ca/world-congress/wce2017

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Pri-Med CANADA pri-med.ca

El Caminito in the La Boca neighbourhood, Buenos Aires.

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

Around the world

Boston, MA April 22-28, 2017

Amsterdam, Netherlands April 19-23, 2017

69th Annual Meeting of the American Academy of Neurology aan.com/conferences/2017-annual-meeting

2017 International Liver Congress ilc-congress.eu

May 3-5, 2017 27th Conference of the European Wound Management Association ewma.org/ewma-conference/2017

XII International Congress of Dermatology icd2017.com.ar

Florence, Italy April 1-4, 2017 25th European Congress of Psychiatry epa-congress.org

April 19-22, 2017 18th Congress of the World Association for Dynamic Psychiatry wadp2017.org

Baltimore, MD May 1-3, 2017

Las Vegas, NV April 20-22, 2017

6th World Intracranial Hemorrhage Conference worldich.org

19th Annual Meeting of the American Society of Interventional Pain Physicians asipp.org/meetings.htm

Barcelona, Spain May 3-6, 2017

Lausanne, Switzerland May 5-6, 2017

2017 Combined Annual Meetings of the European Pediatric Orthopedic Society and the Pediatric Orthopedic Society of North America eposna.posna.org

EuroGUCH 2017: the Annual Meeting of the ESC Working Group wp1.euroguch.com

CTC

May 14-18, 2017 15th Conference of the International Society of Travel Medicine istm.org/cistm15

Buenos Aires, Argentina April 18-22, 2017

The Age of Dinosaurs at the Royal Ontario Museum in Toronto.

NOVEMBER / DECEMBER 2016 â&#x20AC;˘ Doctorâ&#x20AC;&#x2122;s

Review

THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Madrid, Spain May 18-20, 2017 15th World Congress of the European Association of Palliative Care eapc-2017.org

May 23-27, 2017

New Orleans, LA April 6-9, 2017 48th Annual Conference of the American Society of Addiction Medicine asam.org/education/live-online-cme/the-asamannual-conference

Prague, Czech Republic April 23-26, 2017 85th Congress of the European Atherosclerosis Society eas2017.com

MEDICAL QUIPS Yet another breakthrough Medical researchers have discovered a new disease that has no symptoms. It is impossible to detect, and there is no known cure. Fortunately no cases have been reported thus far.

Downtown Seoul from the Buddhist Bongeunsa Temple.

San Diego, CA May 6-9, 2017

Vienna, Austria April 22-25, 2017

2017 Annual Clinical and Scientific Meeting of the American Congress of Obstetricians and Gynecologists acog.org

27th European Congress of Clinical Microbiology and Infectious Diseases eccmid.org

San Francisco, CA May 6-9, 2017 2017 Pediatric Academic Societies Meeting pas-meeting.org

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Introducing

Introducing Nesina (alogliptin): a new DPP-4 inhibitor for patients with type 2 diabetes. Pr

Reimbursed by RAMQ as a médicament d’exception (prescribing codes available) Treatment of type 2 diabetic patients:

CODE

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

EN167

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

EN148

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

EN149

DPP-4 = Dipeptidyl peptidase-4

As per RAMQ List of Medications and Codes des médicaments d’exception (Updated July 24, 2015).

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

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

REFERENCE: 1. NESINA Product Monograph, Takeda Canada Inc., November 7, 2014. ®

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

ME D I C I N E A N D T H E A R T S by

T i lk e Elk i n s

10 things you need to know about Emily Carr

The Group of Seven recognized a kindred spirit in works such as this one titled Odds and ends and embraced Emily Carr “as one of us.”

Emily Carr loved animals and kept a vast menagerie of pets from birds to horses.

1. Radio (not art!) made her a household name Painter and Canadian icon Emily Carr had to wait a lifetime for the nationwide recognition that eventually came her way. She was first introduced to a broad Canadian audience in 1940 at age 68, not as a painter, but as a writer, when CBC Radio broadcast stories from her book Klee Wyck, a chronicle of a summer spent with West Coast First Nations people in Ucluelet in 1899 when she was 27. The book was written mostly in bed, as Carr was recovering from a 1937 heart attack. By then she had all but stopped painting. In 1941, she received a Governor General’s Award for non-fiction for Klee Wyck, which is still considered a significant volume in Canadian literary history. NOVEMBER / DECEMBER 2016 • Doctor’s

Review

ME D I C I N E A N D T H E A R T S

2. Klee Wyck was heavily edited Emily Carr is best known for the observations that she made of the West Coast First Nations people. Her paintings of totem poles and wooden villages set against the majestic brooding coastal rainforests have become quintessential Canadian images. Carr was born and raised in Victoria, BC in a society that was “more English than the English.” Her perspective on the First Nations people she met was certainly a product of the culture she knew, but which she also worked hard to distinguish herself from. The result was a predictably colonialist attitude — one that believed the First Nations cultures were dying — coupled with a deep appreciation for First Nations people and their art. She strongly opposed the residential schools saying “Why should native people send their children away to become ashamed of their people’s tradition?” These viewpoints were lost to the public, however, when the passages in Klee Wyck where she openly criticizes missionary attitudes towards native people were slashed from the manuscript by Ira Dealworth, her editor.

3. She brought Fauvism and Post-Impressionism to Western Canada Until 1912, when Carr exhibited 70 of her boldly coloured canvases from her time in France in a Vancouver gallery, no one in the city had heard of Fauvism. Carr had moved to France in 1910 to study “the French style” with modernist painter Henry Gibbs whose use of vibrant colour and distortion shocked and delighted her. Returning to Canada, she travelled north to recapture the art of the Haida, Gitxsan and Tsimshian in her new Post-Impressionist style. This style Emily’s home in Victoria, BC is preserved as a Provincial and National Historic Site.

Doctor’s Review • NOVEMBER / DECEMBER 2016

would evolve in time to become more and more her own, though she never crossed the line into abstraction. She did form a friendship with Mark Tobey, an abstract expressionist from Seattle, but said of herself, “I was not ready for abstraction. I clung to earth and her dear shapes, her density, her herbage, her juice. I wanted her volume and I wanted to hear her throb.” She found affinity with American landscape visionary artist Charles Burchfield, whose 1930’s solo show she visited in NYC used lines to indicate sound and motion. On the same trip, she met with painter Georgia O’Keeffe, who may have inspired Carr to further develop her own visual language by encouraging her to practice making large charcoal drawings, just as O’Keeffe had famously done in 1916.

4. Canada rejected her Modernist paintings Carr hoped that her bright new canvases depicting native West Coast scenes would be of value to her country. After several painting trips north where she completed many of what would eventually become her best-known works, such as Big Raven and Tanoo, she organized an exhibit and gave lectures about the native villages she had visited. Those interested in the ethnographic value of her paintings claimed that they were not realistic enough, while others simply didn’t warm to her style or her subject matter. Although she did receive some positive reaction, she decided that there was not enough enthusiasm to support her career in Vancouver. She vowed to stop making and teaching art, and moved back to Victoria where she built a rooming house she called The House of All Sorts with the remainder of her inheritance and virtually abandoned her paintbrush for the following 15 years to become a landlord, cook and housecleaner.

5. She suspended her chairs from the ceiling Life with tenants was not easy. When she could, Carr would retreat to an attic room upon whose ceiling she had painted an eagle in the Haida style, its proud head a reminder to keep her spirit intact. Claiming that she favoured an uncluttered space, she attached the parlour chairs to pulleys and kept them hoisted out of the way, though some believed this was a tactic to discourage visitors. Having made a strategic career decision not to marry when she was in her 30s, she sought company in a menagerie of creatures. She bred English sheepdogs, raising 350 puppies before she decided running a kennel was too much work. When she closed the kennel, she traded her last dog for a Javanese monkey named Woo who, along with her yellow-and-green Panama parrot, a Persian cat named Adolphus, a couple of white rats, a chipmunk, a budgie, hens, rabbits and three Brussels Griffons, became the source of much merriment.

Carr first visited aboriginal villages in 1898, at age 27, and said later that her time in one of them, Ucluelet, “made a lasting impression on me.” She painted War Canoes on a later visit after she had studied in France which is reflected in her brighter palate.

6. The Group of Seven told her “you are one of us” Her painting drought blessedly ended when her work came to the attention of Marius Barbeau, a prominent ethnologist at the National Museum in Ottawa. In 1927, Barbeau persuaded Eric Brown, Director of Canada’s National Gallery, to visit Carr, and from there, everything changed for her. Brown immediately invited her to bring 26 of her oil paintings to be exhibited in Canadian West Coast Art: Native and Modern at the National Gallery. She travelled to Ottawa where she met the Group of Seven who were astounded by the originality and modernity of her work and immediately welcomed her into their ranks, telling her, “You are one of us.” Of particular significance was the mentorship of Lawren Harris, who introduced her to European symbolism and encouraged her to immerse herself in her connection with the Canadian wilderness and give up painting the art of another culture.

7. She thinned her paint with gasoline In the next few years, Carr’s relationship to her materials evolved from the use of charcoal sketches and traditional oil paint on canvas to an oil-on-paper medium. She bought big stacks of cheap manila paper and mixed her oil colours into white house paint she thinned with gasoline. The result gave her inexpensive materials she could experiment with and a paint that was as fluid and fast-drying as watercolour. She rented “some tumbledown shack too lonesome to be wanted

by summer campers” and disappeared into the woods with her dogs and monkey. In 1933, she purchased a camper van she called “the Elephant,” which further increased her freedom. She remarked on the joys of her travelling home upon noticing its contrast with her House of All Sorts: “[The] van was so much nearer the big outside, just a canvas and a rib or two, and then the world. And the earth was more yours than this little taxed scrap which is under your name.”

8. Her heart failed her Carr considered herself a sturdy person. She travelled fearlessly by boat and through wilderness, and even claimed to have been the first woman in Victoria to ride cross-saddle. But her health was not perfect. In 1899, just before she left for five years of painting study in England, she had to have one of her big toes amputated after it was damaged in a carriage accident. The slow-to-heal amputation combined with the pressures to either be successful as an artist or get married may have contributed to her complete breakdown in 1903. She spent the following year in a sanatorium in Suffolk, under strict orders not to paint. Her next trip to Europe was similarly clouded by ill health. She contracted diphtheria just before she left for Paris in 1910 and spent her first few weeks in the city in bed. In her 40s, she suffered an unsuccessful gallbladder operation, and in 1937, she had the first of three heart attacks, the last of which resulted in her death in 1945 at age 73. Around the time of the heart attacks, she also had several major strokes. When her health declined, she once again gave up painting — but this time writing was there to take its place. uu CONTINUED ON PAGE 55 NOVEMBER / DECEMBER 2016 • Doctor’s

Review

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

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

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

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

CA0115PRI005E

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

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

D r Er i n M i c ha la k

and

Eva Chanda, MSc

Depression self-management Keeping patients on the road to recovery Reviewed by Erin Michalak, PhD, an Associate Professor and Network Lead of the Collaborative Research Team to study psychosocial issues in Bipolar Disorder (CREST.BD), Department of Psychiatry, University of British Columbia.

t’s no secret that successful treatment of depression is challenging in clinical practice. Even in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) “real-world” clinical trial, the largest of its kind, about one-third of patients failed to achieve remission after four different levels of treatment, involving either medication switching, or augmentation with another medication or cognitive therapy.1 Recurrence is also common, with a rate of 85% after 15-year prospective followup.2 An added complication is that, in both primary and psychiatric care, around 50% of patients with depression stop antidepressant therapy prematurely (within 6 months of starting),3 making it even harder to achieve and sustain remission. Increasingly, depression is being recognized and managed as a chronic disease.2

Empowered patients, better outcomes So what can clinicians do to keep patients motivated and on track? The key is self-management: actively engaging patients through various activities to promote health, treatment adherence, and monitoring of physical, emotional and psychosocial status.4 But many patients need help to implement self-management successfully. A growing number of authorities worldwide, including the 2016 updated Canadian Network for Mood and Anxiety Treatments (CANMAT) depression treatment guidelines, are promoting “supported self-management” (SSM), an essential, evidence-based component of depression care.5 SSM lowers reliance on healthcare providers, increases empowerment and self-efficacy, and is associated with fewer depression symptoms, improved functioning, and possibly lower relapse/recurrence rates.2 For some patients with mild depression, SSM can even be a first-line alternative to antidepressants, offering a better riskbenefit ratio at lower cost.6

Help patients help themselves SSM for depression should include the following elements:6 1. Self-management guidance: a workbook or, increasingly, an interactive website, to learn about depression and its management, including coping skills based on principles of cognitive-behavioural therapy (CBT) (Table 1) 2. Effective coping skills: behavioural activation (increasing positive activities to improve mood), cognitive restructuring (recognizing negative depressive self-talk, replacing it with more fair, realistic interpretations), and problem solving (systematically assessing problems, identifying useful actions, and implementing them to work toward solutions)

3. Encouragement and coaching: by the physician, and also by allied health professionals (e.g. psychologists, nurses, occupational therapists), peer support workers and groups, family and friends The latest buzzword in depression management, and a key component of SSM, is measurement-based care (MBC), which uses rating scales to monitor outcomes and support clinical decisions. The 2016 CANMAT guidelines recommend using MBC to monitor not only symptoms, but also functioning, side effects and quality of life. Overburdened clinicians can rest assured that patient-rated scales are quicker than, and correlate well with, clinician-administered scales.5 With a few steps, MBC can be integrated into even the busiest practice (Table 2).

Table 1. Web resources for patient self-management • MoodFx (www.moodfx.ca): a free, mobile-friendly web tool developed by the Mood Disorders Centre at UBC Hospital; allows patients to screen for and track depression symptoms, set reminders to check symptoms regularly and before appointments; print, email or show results to doctor on mobile device, and view progress over time with simple charts (English, French) • Antidepressant Skills Workbook (www.comh.ca/antidepressantskills/adult): a free self-management guide from Simon Fraser University; contains an overview of depression and its management, and step-by-step instructions on changing patterns that trigger depression; online and downloadable versions (English, French, Punjabi, Chinese, Vietnamese, Farsi) and audiobook versions (English, French) • Living Life to the Full (www.llttf.com): an interactive web course teaching CBT-based life skills (English)

Table 2. Practice tips for measurement-based care • Use patient-rated scales. • Have ready-to-use copies of scales in the office. • Have patients complete scales in the waiting room, or in an exam room while seeing another patient. • Use a monitoring summary sheet in the chart. • Configure a monitoring dashboard in your electronic medical record (EMR). • Use tracking apps and web sites (for tech-savvy patients). References 1. Gaynes BN, Warden D, Trivedi MH, et al. Psychiatr Serv. 2009;60(11):1439-1445. 2. Houle J, Gascon-Depatie M, Bélanger-Dumontier G, Cardinal C. Patient Educ Couns. 2013;91(3):271-279. 3. Sansone RA, Sansone LA. Innov Clin Neurosci. 2012;9(5-6):41-46. 4. Trivedi MH, Daly EJ. Dialogues Clin Neurosci. 2008;10(4):377-384. 5. Lam RW, McIntosh D, Wang J, et al. Can J Psychiatry. 2016;61(9):510-523. 6. Bilsker D, Goldner EM, Anderson E. Can J Psychiatry. 2012;57(4):203-209. NOVEMBER / DECEMBER 2016 • Doctor’s

Review

Trust in a name that has been available for 16 years: PrEFFEXOR® XR EFFEXOR XR (venlafaxine hydrochloride) is indicated for the symptomatic relief of:1 Major Depressive Disorder, Anxiety causing clinically significant distress in patients with Generalized Anxiety Disorder, Social Anxiety Disorder (Social Phobia), Panic Disorder, with or without agoraphobia, as defined in DSM-IV

Recommended as a first-line agent for:2-3* •

Depression

•

General Anxiety Disorder

•

Social Anxiety Disorder

•

Panic Disorder

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

Clinical use: Depression: Short-term efficacy has been demonstrated in placebo-controlled trials of up to 12 weeks. Efficacy in maintaining an antidepressant response for up to 26 weeks, following response to 8 weeks of acute treatment, was demonstrated in a placebo-controlled trial. Generalized Anxiety Disorder: Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. The effectiveness in long-term use has been evaluated for up to six months in controlled clinical trials. Social Anxiety Disorder (Social Phobia): Efficacy was demonstrated in four 12-week, multi-centre, placebo-controlled, flexible-dose studies and one 6-month, fixed/flexible-dose study in adult outpatients. Panic Disorder: Efficacy was established in two 12-week, placebo-controlled trials in adult outpatients. The efficacy in prolonging time to relapse for up to six months, in responders of a 12-week acute treatment, was demonstrated in a placebo-controlled trial. The physician who elects to use EFFEXOR XR for extended periods should periodically re-evaluate the long-term usefulness of the drug. Caution should be exercised in the elderly.

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

Not indicated for use in children under 18 years of age. Contraindications: • In combination with Monoamine Oxidase Inhibitors (MAOIs) or within two weeks of terminating treatment with MAOIs. Most serious warnings and precautions: • Risk of potential association with behavioural and emotional changes, including self-harm: – Rigorous clinical monitoring for suicidal ideation or other indicator of potential for suicidal behaviour is advised in patients of all ages. This includes monitoring for agitation-type emotional and behavioural changes. – Patients, families, and caregivers should watch for the emergence of unusual behavioural changes, depression worsening and suicidal ideation, especially during treatment initiation or change in dose/dose regimen. • Discontinuation symptoms: dosage should be tapered gradually and the patient monitored. • Bone fractures: increased risk of bone fractures have been shown with some antidepressants, including selective serotonin reuptake inhibitors/serotonin norepinephrine reuptake inhibitors (SSRIs/SNRIs). • Hepatic and renal impairment: dosage adjustments required.

• Caution in patients with a history of seizures; promptly discontinue if seizure develops. • Risk of serotonin syndrome or neuroleptic malignant syndrome (NMS). – Careful observation if concomitant treatment with other agents affecting serotonergic and/or dopaminergic neurotransmitter systems is clinically warranted. – Concomitant use with serotonin precursors is not recommended. • Can cause mydriasis which may trigger an angle-closure glaucoma attack. • Treatment-emergent insomnia and nervousness. • Mania/hypomania: caution in patients with a history or family history of bipolar disorder. • Lactating women should not nurse their infants. For more information: Please consult the Product Monograph at www.pfizer.ca/pm/en/Effexor.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-463-6001.

Other relevant warnings and precautions: • Risk of allergic reaction. • Risk of hypertension, including acute severe and sustained hypertension; monitor blood pressure regularly in all patients. • Caution in the treatment of pregnant women, especially during the third trimester.

References: 1. EFFEXOR XR Product Monograph, Pfizer Canada Inc., July 2016. 2. Lam R, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the management of major depressive disorder in adults. J Affec Disord 2009;117:S26-S43. 3. Swinson R, et al. Clinical Practice Guidelines Management of Anxiety Disorders.Can J Psychiatry 2006;51(suppl 2):S1-92S.

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

CA0116EFX004

– Exposure late in the third trimester may result in discontinuation symptoms and complications requiring prolonged hospitalization, respiratory support and tube feeding.

Israel, pray tell An agnostic goes on a pilgrimage to the Holy Land and shares all the sites loved by Jews, Christians and Muslims

ROSTISLAV AGEEV / SHUTTERSTOCK.COM

by Anita Draycott

Jerusalemâ&#x20AC;&#x2122;s Old City is home to the Dome of the Rock, Church of Our Lady of the Spasm and Al-Aqsa Mosque (pictured this page, left to right).

aiting to board our flight from Toronto to Tel Aviv, my husband and I were surrounded by an excited group of young Canadian Jews en route to Israel courtesy of Birthright Israel. The program was founded by two philanthropists who believed that it was the birthright of all young Jews (aged 18 to 26) to visit their ancestral homeland. Since 1999, Birthright Israel has sent more than half a million kids to the Holy Land. For most, this was their first trip. Mine too. True confessions: I am an agnostic and my Sunday School Bible lessons are long behind me. A trip to Israel was not at the top of my bucket list. I was confused and overwhelmed by the wars, politics and religious conflicts. Israel, however, was number one on my husband’s wish list and that’s why we found our-

selves at the Ben Gurion Airport looking for our guide. Enter Motti Saar (mottitour.com), the man whose enthusiasm for his country turned me into a “believer.” Saar introduced himself as a true sabra, Hebrew for prickly pear cactus. Think tough and feisty on the outside and really sweet inside. I met a lot of sabras in Israel and I must say that the moniker suits. Jesus was born in Bethlehem and died in Jerusalem, but it was around the Sea of Galilee that his ministry

NOVEMBER / DECEMBER 2016 • Doctor’s

Review

Jesus is believed to have delivered his “Sermon on the Mount” on this hill overlooking the Sea of Galilee.

ALL PHOTOS BY ANITA DRAYCOTT EXCEPT OTHERWISE NOTED

Architect Antonio Barluzzi designed the Church of the Beatitudes as an octagon in homage to Jesus’s eight blessings.

The Scots Hotel was originally a hospital built by a Scottish surgeon who saw treating the sick in the Holy Land as his calling.

was forged and most of his activities outlined in the New Testament took place. We began our journey in Tiberias at The Scots Hotel (scotshotels.co.il) overlooking the Golan Heights. The hotel, once a hospital, is owned by the Church of Scotland, which explains why the kilted fellow who checked us in offered us hot cider spiked with a wee dram. After a bountiful Israeli buffet breakfast, we made a pilgrimage past orchards of oranges, bananas, mangos, olives and avocados to the Mount of Beatitudes where Jesus gathered his disciples and gave his “Sermon on the Mount” in which he pronounced the eight blessings. Nearby, Jesus is thought to have fed the multitudes with a couple of fish and a few loaves of bread. Well-tended gardens lead up to a simple church by Italian architect Antonio Barluzzi. Its octagonal shape is an homage to the eight beatitudes; the hole in the middle of the dome represents eternity. It’s a lovely place to contemplate this landscape of earthly delights. Later, we met up with Captain David for a cruise around the Sea of Galilee. His boat is a replica of the fishing vessels (feluccas) used in Jesus’ times — except his has a motor. We tried our luck casting the nets for St. Peter’s fish (tilapia), but with no luck.

Doctor’s Review • NOVEMBER / DECEMBER 2016

Dinner was at Magdalena (facebook.com/magdalena. restaurant) in Migdal, birthplace and home of Mary Magdalene. Here, chef Yousef Hanna has resurrected Arabic cuisine to gourmet heights. Our feast included cauliflower with roasted red peppers, lamb chops and pine nut dumplings, wild hickory served with garlic confit and caramelized onions. All this washed down with a crisp white wine from the Golan Heights.

ext stop, Tel Aviv where biblical tales and a hip cosmopolitan vibe go hand in hand. We stayed at the Brown TLV Urban Hotel (browntlv.com), minutes from the beach, bohemian Neve Tzedek quarter and trendy Rothschild Boulevard. We strolled along Rothschild Boulevard to the Social Club (socialclub.co.il) where brass railings, leather banquettes and a noisy crowd gave it a Manhattan feel. The waitress brought a parade of starters (mezes). We devoured plates of cheese, charcuterie, Israeli salad (finely chopped tomatoes, cucumbers and onion), hummus, stuffed peppers and fried eggplant. “Pace yourself,” advised Saar. “Those were just the starters. We Israelis live to eat.” The next morning Saar led us to the bustling Carmel market. In a country that is mainly desert, the Israelis have created a remarkable irrigation system

The Al-Bahr Mosque is said to be the oldest in Jaffa and used to have a special entrance for the faithful who arrived by boat.

The 91 shops and restaurants at the upscale Sarona Market in Tel Aviv specialize in gourmet food and drink.

The stalls at Carmel’s Market in Tel Aviv are filled with locally grown dates and mini pyramids of multi-coloured olives.

The Israelis have created a remarkable irrigation system and are now producing mangos, pomegranates, prickly pears and more so that the once barren patches of sand are now producing mangos, pomegranates, prickly pears and more. Did you know that cherry tomatoes were invented in Israel? Also, thanks to an investment by Baron Edmond de Rothschild, there are more than 200 wineries in this land of more than milk and honey. As we munched on locally-produced dates and olives, Saar gave us a tour and a bit of a history lesson. Jaffa is one of the world’s most ancient port cities, dating back to the Bronze Age. At the beginning of the 20th century, a large number of Jewish immigrants landed there. In the spring of 1909, a group of these immigrants, fed up with Jaffa’s noisy and unsanitary neighbourhoods, bought some uninhabited sand dunes north of Jaffa, divided the property into parcels of land and voilà, Tel Aviv, nicknamed “The Big Orange” — a variation on New York’s Big Apple and the Jaffa orange — was born. Believed to be founded by Japheth, son of Noah,

Jaffa is one of the oldest towns in Israel. Disciples Peter and Simon lived there and you can visit St. Peter’s Church and the home of Simon the Tanner. Today, the Old City perched high on a hill overlooking the sea is a marvellous hodgepodge of twisting lanes full of art galleries, boutiques and restaurants. Don’t miss the Ilana Goor Museum (ilanagoormuseum.org), an 18th-century house where the Israeli sculpture artist resides and works. Back in Tel Aviv, foodies have to visit Sarona Market, the upscale eating emporium. Craft beer from the Golan Heights, popsicles made with ouzo and grapefruit, halvah spiked with chilies, cheese soused with truffle oil, celebrity chef restaurants and so much more vie for your shekels here. “We can make shekels out of nothing,” said Saar. “Despite all the wars and strife, see what we have accomplished. Imagine what we could do without one arm tied behind our back!” NOVEMBER / DECEMBER 2016 • Doctor’s

Review

The Muslim Quarter is the largest of Jerusalem’s neighbourhoods and home to 22,000 residents.

The Dead Sea is 10 times saltier than oceans so nothing can live in this body of water.

For a few shekels, Issa will let you mount Shushi for a photo with the Judean Desert as the backdrop.

C .

aesarea, north of Jaffa on the Mediterranean Coast, deserves a few hours visit. It was founded by Herod the Great in 22 BCE, but is a posh real estate area today that boasts Israel’s only golf course. We saw a stone tablet inscribed with the name of Pontius Pilatus, the Roman prefect who ordered Jesus’ crucifixion. It’s also here that the Apostle Paul was imprisoned and where Peter baptized the centurion Cornelius. King Herod encouraged culture and horseraces, and the ancient amphitheatre is so well preserved, it’s still used for concerts. The following day we headed south toward the Dead Sea. Saar pointed out the cave where the Dead Sea Scrolls were found by a Bedouin shepherd who stopped to rest in 1947. The shepherd took what he thought was a piece of leather to a shoemaker in Bethlehem to have a pair of sandals made. The shoemaker took the leathery parchment to an antiquity store where the scrolls were declared to be one of the major archeological finds of the 20th century. Today more than 50,000 pieces from 900 biblical scrolls have been uncovered. Most are housed in the Israel Museum in Jerusalem. At Masada, we took the cable car up to Herod’s magnificent palace atop an isolated plateau on the western shore of the Dead Sea. This was the site of

Doctor’s Review • NOVEMBER / DECEMBER 2016

the last Jewish stand against the Romans in 73 CE when 967 defenders, realizing they had no chance, committed mass suicide. In 2001, Masada was declared a UNESCO World Heritage Site. To wash off the doom and gloom, we took a dip in the briniest place on earth. The Dead Sea is 10 times saltier than oceans so nothing can live in this body of water. At the Premier Spa Resort (dead-seapremier.com), we paid a few shekels for towels, locker room facilities and beach chairs. Saar instructed us to wade out to knee deep and lie on the water, which is so buoyant, you can just float without any need to kick or paddle. It was a bit like lying on jello.

“. I

could not conceive of a small country having so large a history,” wrote Mark Twain after his visit to the Holy Land in 1867. Jerusalem, Israel’s capital, embodies this impression. Jerusalem’s golden stones are saturated with history, sanctified by pilgrim prayers and scarred by wars. At every turn, you’ll find shrines and lessons in the co-existence of Judaism, Christianity and Islam. Jerusalem has been a place of turmoil since King David pronounced it Capital of Israel around 1000 BCE. In 638 CE, it was conquered by Muslims who built their Dome of the Rock over the site of the Temple.

In 73 CE, 967 Jewish zealots chose to commit suicide at Masada rather than to fall into the hands of the Romans.

Muslim Israelis Mahmoud and his wife Alia are EatWith hosts, a global program that connects people through food.

The Way of the Cross is believed by many to follow the path that Jesus walked, carrying his cross, on the way to his crucifixion.

On Friday, just before sunset, we visited Judaism’s holiest shrine, the Western Wall where the devout sing, dance and insert written prayers into the cracks of the otherwise known Wailing Wall. “You can call God from anywhere in the world,” kidded Saar, “but you’ll only be charged for a local call from the Western Wall.” The New Testament tells of Jesus’ final, fateful week in Jerusalem starting with his triumphal entry of what we now call Palm Sunday, the crucifixion on Good Friday and the Resurrection on Easter Sunday. Most visitors will follow the Via Dolorosa or 14 stations of the “Way of the Cross.” The last five stations are in the Church of the Holy Sepulchre that most Christians venerate as the site of the death, burial and resurrection of Jesus. All Kosher establishments in Jerusalem close from Friday sunset to Saturday sunset so after the Via Dolorosa we spent Saturday morning strolling the warren of souks in the Muslim Quarter where a heady aroma of burning incense, spices and coffee filled the air. If you want a hookah pipe or some gifts of the Magi (gold, frankincense and myrrh), this is the place to pick up souvenirs. We stayed at the Mont Zion Hotel (mountzion.co.il) with lovely gardens framing views of the Hinnom Valley below. After a dip in the pool, I succumbed to

the Turkish baths for detoxifying steam followed by a massage. Jerusalem can’t compare with Tel Aviv on the food scene, but we enjoyed crispy calamari and fun cocktails at Chakra (chakra-rest.com). We also haggled for halva at the boisterous Mahane Yehuda Market. Our “last supper” was back in Jaffa at a private home, part of a program called EatWith Israel (eatwith.com/list/israel). Muslim Israelis Mahmoud and his wife Alia greeted us in their lush garden and escorted us to the dining room where the table was set with a groaning board of Middle Eastern dishes: moussaka, pastries stuffed with cheese and spinach, meatballs in tahini, baba ganoush, salads galore, homemade pickles, a casserole of roasted eggplant and basmati rice. We washed this down with rose water and sage tea. Alia and Mahmoud produce such feasts several times a week in a kitchen the size of my desk. Over this amicable repast, we learned that every home and hotel in Israel must have a bomb shelter. Saar also showed us the app on his phone that warns of rocket launches. Despite what we hear in the news, EatWith is a terrific example of how many Arabs and Jews live peacefully side-by-side. And to that I can only add salaam/shalom (peace). For more info on travel to the region, visit the Israel Ministry of Tourism (goisrael.com). NOVEMBER / DECEMBER 2016 • Doctor’s

Review

FROM THE GSK COPD PORTFOLIO...

INCRUSEÂ&#x2122; ELLIPTAÂ® (umeclidinium) is indicated for the long-term once-daily maintenance bronchodilator .,! .(!). *" %,5 *1 * -.,/ .%*) %) + .%!).- 1%.$ $,*)% * -.,/ .%0! +/'(*) ,3 %-! -! %) '/ %)# chronic bronchitis and emphysema. INCRUSEÂ&#x2122; ELLIPTAÂ® is not %) % .! "*, .$! ,!'%!" *" /.! !.!,%*, .%*) *" Â&#x2122; ELLIPTAÂ® should not be used in patients <18 years of age. BREOÂ® ELLIPTAÂ® 5 /.% -*)! "/,* .! 0%' ).!,*' ( # %- %) % .! "*, .$! '*)# .!,( *) ! %'3 ( %).!) ) ! .,! .(!). *" %,5 *1 * -.,/ .%*) %) + .%!).- 1%.$ $,*)% * -.,/ .%0! +/'(*) ,3 %-! -! %) '/ %)# $,*)% ,*) $%.%- ) *, !(+$3-!( ) .* ,! / ! !2 !, .%*)- *" %) + .%!).- 1%.$ $%-.*,3 *" !2 !, .%*)- BREOÂ® ELLIPTAÂ® is not %) % .! "*, .$! ,!'%!" *" /.! ,*) $*-+ -( $! - "!.3 ) !"4 3 %) +! % .,% patients younger than 18 years have not been established. BREOÂ® ELLIPTAÂ® ( # %- not %) % .! "*, + .%!).- 1%.$ $!,! %- )* %.%*) ' !)!4 . *" .$!

( # *-! *(+ ,! .* .$! ( # *-! ) .$!,! %- +*.!).% ' %) ,! -! ,%-& *" +)!/(*)% ) systemic corticosteroid-related adverse reactions. Please consult the Product Monograph for INCRUSEÂ&#x2122; ELLIPTAÂ® . #-& %) ,/-! !) ) Â® ELLIPTAÂ® . #-& ,!* !) "*, %(+*,. ). %)"*,( .%*) ,!' .%)# .* *) %.%*)- *" '%)% ' /-! *)., %) % .%*)- 1 ,)%)#- precautions, adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monographs are also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374. $,*)% * -.,/ .%0! +/'(*) ,3 %-! -! *)# .%)# (/- ,%)% ). #*)%-. '-* &)*1) - '*)# .%)# ).% $*'%)!,#% %)$ '! *,.% *-.!,*% '*)# .%)# !. 2-adrenergic agonist.

01633 09/16

100/25 mcg for COPD

LAMA

Europe for

The cities and Christmas markets along the Rhine River that still revel in the food and crafts of days gone by by Josephine Matyas

The off-kilter architecture and winding cobblestone streets in Colmarâ&#x20AC;&#x2122;s Old Town are straight out of a storybook.

the holidays T

he first year you face a major holiday as an adult orphan it’s like the ground beneath

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you tilts. Suddenly, you are the generation of oldsters, the keeper of the holiday-traditions flame. The box of treasured family ornaments, the tabletop crèche and the festive linens now live on the shelf in your storage closet. This is that Christmas for me. I am now that oldster. The cartons of family decorations were divvied up between siblings. We have stepped up to our new roles as nurturers of the customs knowing that — one day — they will be passed along to those who follow us. My parents were refugees from post-war Europe. They escaped with only what they could carry and — almost certainly — that didn’t include wooden carved nutcrackers and boxes of Christmas ornaments. What eventually made it into our holiday collection was found in Canada. The boxes were filled with a fusion of North American-style Santas and reindeeremblazoned baubles as well as more traditional European-style decorations, including a carved and painted wooden Svaty Miklas (Saint Nicholas) and elegant, painted glass ornaments from specialty shops. I was hoping the Christmas markets scattered up and down the Rhine River would caress the senses of my childhood. My journey was to inhale the heady scent of gingerbread, to find small potato pancakes sizzling in vats of bubbling fat and to marinate in a setting where neon signs are verboten and the old-fashioned is celebrated. I was looking to find my footing.

NOVEMBER / DECEMBER 2016 • Doctor’s

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The markets along the Rhine River are connected by train. For info: Rail Europe (raileurope.ca).

Stuttgart Strasbourg Obernai

FRANCE

GERMANY

Colmar

Freiburg

Basel

SWITZERLAND

Zürich

or Johann Wanner, Christmas — ornaments, specifically — is a love affair. He never handles the glass decorations in his Christmas House shop (johannwanner.ch) without first pulling on the white cotton gloves favoured by curators. Wanner is an ornament eccentric, something fuelled by a wish “to preserve the Christmas of my childhood.” The low shelving in his shop in the northern Swiss city of Basel (myswitzerland.com/en-ca/basel. html) is filled with thousands of handmade, delicate globes, glass ornaments, twisted glass icicles and tree toppers. Most are carefully arranged by colour. He’s been collecting since 1969. “My wife is related to Thomas Edison,” Wanner explains. “And that allowed me to start this business when an aunt died and there was a small fortune left.” Johann Wanner observes Christmas all year-round, but Basel rolls out two main Christmas markets during the month of December. I begin with the largest of the two, at Barfüsserplatz (basel.com/en/christmasin-basel/christmas-market), in a square ringed by a soaring cathedral and medieval buildings. There are lights twisted around the bare branches of chestnut trees, rows of small wooden chalets, shelves stacked with artisan pottery, knitted hats and sheepskin slippers. Pop-up restaurants dole out cheese fondue, raclette, sausages, thick waffles and thin crepes. Butter cookies and chocolates round out an astronomical calorie count. The air is fragrant with the heady smell of mulled wine.

The Marktplatz in Basel is home to fruit and veggie stands that are open year-round, including the holidays.

Johann Wanner has been collecting glass ornaments since 1969 and his shop in Basel is filled with handmade globes.

Doctor’s Review • NOVEMBER / DECEMBER 2016

JOSEPHINE MATYAS

D .

ownstream, a former walled city is home ground to five different German Christmas markets. The half-timbered houses of Colmar (tourisme-colmar.com), in the Alsace region of northeastern France, sit along the edges of its winding canals, the water channels that give it the nickname Little Venice. The slightly off-kilter architecture and the pleasing bends in the narrow waterways are almost certainly the design model for the romanticized tabletop Christmas models they sell in department stores back home —

LAWRENCE GOH / SHUTTERSTOCK.COM

The Christmas Market in Obernai is known for its gastronomic treats, but kids visit for the carousel rides.

JOSEPHINE MATYAS

Small booths in Freiburg sell handmade crafts of cloth and wood, and stars made of heavy shiny paper.

the ones with miniature lights to make it look as though someone is home, tossing another log onto the wood fire blazing away in the tiny hearth. The Germans are a practical folk who leave little to chance. The front doors of many Colmar homes and shops are dressed up with an ancient Celtic symbol, encircled by a crown of pine twigs, to ward off evil before Christmas. “Until the 19th century, people were superstitious,” says local guide Stéphane Reitter. “There were symbols on a house for fertility or success, or a cross to protect the home from evil or disease. The Advent pine twigs and the twisted bretzel are like extra insurance against evil.” Evil successfully banished, there’s an undeniable storybook appeal to Colmar’s markets (noel-colmar. com). The city’s medieval alleyways and homes are decked out in greenery and mood-setting, twinkling lights. The old city has Alsatian roots — for hundreds of years, the Franco-German border was highly contested, flip-flopping back and forth across the Rhine River. It’s a Christmas markets bonanza, with distinct markets that sell tree ornaments, toys, crafts and antiques, local foie gras, brandy, gingerbread and traditional Christmas cakes. Obernai (tourisme-obernai.fr) is a very small French town 50 kilometres north of Colmar. “This is a dynamic little town,” says Vivianne Beller who grew up in Massachusetts, hopped the pond (for love), and now guides visitors around her adopted home in the Alsace. But this is not a town that lives off tourism. The surrounding hills are blanketed with vineyards and orchards. For the holiday season, the Christmas market in the village’s central square is all about food and the forest. The small booths are well stocked with mulled wine, snails, oysters, chestnuts, foie gras, local cheese and fruit liqueurs. In the Alsace, there is a very long tradition of honouring someone through aromas, with spices often imported through the main markets in nearby Strasbourg. “It tells us of Christmas past,” says Vivianne. “Christmas is a collection of aromas for the Alsatians. Gingerbread and hot spiced wine, which is like gingerbread for adults.” The modest houses of Obernai are decorated with handmade garlands of fresh green intertwined with small, white lights. Outdoor cafés are open — despite fat snowflakes softly falling — and each chair has a thick blanket to keep diners warm. Church bells mark the hours, but nothing seems rushed. “Christmas is about solstice. The central element of Christianity is that light beats dark,” says Vivianne. “That’s why the tradition is to make our own light, candles and fires. We celebrate here on December 24. That is when the big meal happens, the gifts and midnight mass. There is a special Yule log tradition. The wooden log is burned in a ceramic stove to heat the home while the family is at church. By tradition, the ashes are scattered in the fields, to represent fertility.” NOVEMBER / DECEMBER 2016 • Doctor’s

Review

Help protect your patients from invasive disease caused by Neisseria meningitidis serogroup B strains (MenB). BEXSERO® is indicated for active immunization of individuals from 2 months through 17 years old against invasive disease caused by N. meningitidis serogroup B strains. As with any vaccine, BEXSERO® may not protect all vaccine recipients. BEXSERO® is not expected to provide protection against all circulating meningococcal serogroup B strains.

BEXSERO

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

1,2*

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

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

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

Infants and children (less than 2 years of age): • local reactions – tenderness, erythema, induration, pain, swelling • systemic reactions – change in eating habits, fever ≥38 °C, irritability, unusual crying, sleepiness, vomiting, diarrhea, rash

Freiburg was full of holiday staples like roasted chestnuts and crispy potato pancakes topped with apple sauce or sour cream.

Children (aged 2 years through 10 years): • local reactions – pain, tenderness, erythema, induration, swelling • systemic reactions – change in eating habits, sleepiness, diarrhea, irritability, unusual crying, arthralgia, vomiting, headache, rash, fever ≥38 °C Adolescents and adults (11 years or older): • local reactions – pain, erythema, induration • systemic reactions – malaise, headache, muscle and joint pain, nausea, myalgia

The primary series can also be given at 2, 3 and 4 months of age, but the immune response to the NHBA antigen is lower. With both schedules, a fourth dose (booster) is required in the second year of life between 12 and 23 months of age. It is preferred this dose be given early in the second year of life, whenever possible. Unvaccinated infants aged 6 months through 11 months: The vaccination schedule consists of three doses each of 0.5 mL with an interval of at least 2 months between the first and second dose. A third dose is required in the second year of life with an interval of at least 2 months between the second and third dose. The need for further booster doses has not been established. Unvaccinated children aged 12 months through 23 months: The vaccination schedule consists of two doses, each of 0.5 mL, with an interval of at least 2 months between doses. The need for a booster dose after this vaccination schedule has not been established. Children aged 2 years through 10 years: The vaccination schedule consists of two doses, each of 0.5 mL, with an interval of at least 2 months between doses. The need for a subsequent dose after this immunization schedule has not been established. Individuals aged 11 years through 17 years: The vaccination schedule consists of two doses, each of 0.5 mL, with an interval of at least 1 month between doses. The need for a subsequent dose after this vaccination schedule has not been established. Administration: BEXSERO should be given by deep intramuscular injection, preferably in the anterolateral aspect of the thigh in infants or in the non-dominant deltoid muscle region of the upper arm in older subjects. ®

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

For more information: Please consult the Product Monograph at myg.sk/bexseroPM for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling Medical Information at 1-800-387-7374. To report an adverse event, please call 1-800-387-7374. *Comparative clinical significance is unknown. References: 1. BEXSERO Product Monograph. December 11, 2015. 2. An Advisory Committee Statement (ACS), National Advisory Committee on Immunization (NACI). Advice for the use of the Multicomponent Meningococcal Serogroup B (4CMenB) Vaccine. April 2014. ®

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JOSEPHINE MATYAS

Recommended dose and dosage adjustment: Infants aged 2 months through 5 months: The recommended immunization series consists of four doses, each of 0.5 mL. The primary infant series consists of three doses, given at 2, 4 and 6 months of age, followed by a fourth dose (booster).

reiburg’s Christmas market (weihnachtsmarkt. freiburg.de) is as much a social meeting place as a spot of seasonal commerce. The city sits on the edge of the Black Forest in southwest Germany, in a region that’s renowned for its namesake foods: Black Forest Cake, Black Forest cured ham. And the holiday market doesn’t skimp on calories. It is here that I find the potato pancakes of my childhood, topped with homemade applesauce or dollops of thick sour cream. There are paper cones filled with chestnuts that speak to me of peeling the roasted skins and tasting the warm, soft nut inside. This is my Christmas comfort food. The city’s market is in Cathedral Square in the shadow of the main cathedral. Legendary for its tall spire and famous stained-glass windows, it’s been called “the loveliest tower in Christendom.” Like many of the other markets across Europe, this one is a collection of small wooden booths with a heavy emphasis on the foods and crafts of days gone by. There are handmade ornaments of glass, cloth and wood, illuminated decorative stars made of heavy shiny paper, knitted mittens and small jars of preserves. By the end, there have been a string of markets. With each one, I’ve found something I can hold on to; something to connect me in an essential way to the Christmas traditions of my childhood. I’ve found my footing with roasted chestnuts, with crispy potato pancakes, with the smell of gingerbread and cookies made with insane amounts of butter and ground nuts. These are not things that get packed away in boxes and stacked in storage closets. But they are just as much a part of my Christmas traditions. They are what I came to find. Now, in my new role as keeper of the flame, I will nurture these traditions and pass them along. NOVEMBER / DECEMBER 2016 • Doctor’s

Review

Cherry wood ceilings and detailed moldings honour the storied past of Restaurant Q, while the finishes add a modern twist.

The Empress’s new clothes The grande dame of West Coast hotels struts her stuff after a makeover by Jeremy Ferguson

he Empress is one of Canada’s grandes dames, the westernmost of the railway palaces that include Quebec City’s Château Frontenac and Alberta’s Château Lake Louise. She’s 108 years old and she’s

just undergone a whole lot more than a facelift. This Empress has shed her crinolines, put on her dancing shoes and waltzed into the 21st century. Vancouver real estate titan Nat Bosa and his wife Flora purchased her for an undisclosed figure in 2014. The Victoria hotel’s value had been estimated at about $90 million — the average price of a Vancouver bungalow if the current trend holds. Last spring marked the completion of phase one of a $30-million, seven-month-long restoration.

“Not a renovation,” stresses a hotel spokesperson, “a restoration.” Victoria traditionalists were more than upset. Noting the sudden disappearance of signature greenery and the massive interior construction, they let forth a squall of righteous outrage. Particularly irksome to Victoria’s pukka sahib set, who rained furious letters on the local Times Colonist, was the closing of the Bengal Lounge, a room with a Bengal tiger skin splayed on the wall and an ersatz NOVEMBER / DECEMBER 2016 • Doctor’s

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Doctor’s Review • NOVEMBER / DECEMBER 2016

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Indian buffet. Animal lovers decried the skin as a loathsome memento of an era in which killing a magnificent animal passed for masculinity. The controversy evaporated, conveniently, when the tiger skin was allegedly stolen. Doctor’s Review was invited to inspect the premises. First off, the new landscaping is just fine. The landmark weeping sequoias and ivies had been neglected beyond repair. Replacing the old vines is Boston Ivy. It turns colour like autumn leaves. Renovations on 245 rooms and suites are complete. They’re up-to-date with air-conditioning (at last), walk-in showers, in-room coffee machines, wallmounted TVs and soft contemporary tones that embrace natural light. The second phase of the restoration, begun last month, highlights an airy new lobby, renovated spa and another 229 guest rooms. It’s slated for completion next June, with total costs in the vicinity of $40 million. The Fairmont Gold Lounge and Terrace spoil the expense-account set with a private check-in desk and lounge, smoked salmon breakfasts and complimentary pre-dinner hors d’oeuvres. Its terrace, previously devoted to a row of flagpoles, presents a superlative Inner Harbour view. The Royal Suite costs a mere $12,995 per night. Food and drink facilities were designed by San Francisco’s Puccini Group, whose way with casual opulence can be seen in ultra-luxe hotel properties including the Four Seasons Resort Orlando and the St. Regis Monarch Beach. The Lobby Lounge, now a bright and cheerful space, offers the veddy English tea ritual at $75 per person. It serves 500,000 cups of tea and 120,000 scones annually. Pilgrims check off their bucket lists. But the Empress, happily, is more than a tea party. Walk into the Q Bar and let your eyes pop: behold the giant white quartzite bar, sculptural lighting and antique mirrored panels. Expect innovative cocktails: Northwest Collins marries the celebrated local gin with a sweetened fir sprig. Local craft beers garner just attention. Live music provides a jaunty air seven nights a week. The signature restaurant is also called simply Q. Casual’s the word. Goodbye to the baronial Empress Room, in which powdered wigs and knee britches might have gone unnoticed. Gone are the plump drapes, upholstered walls and dress code. The new look, a riff on the Paris brasserie, brings intimacy to the 88-seat space. Diners are advised to pay attention to the beams above. Their superlative look is an ingenious deception. They’re made of plaster and horsehair, and painted to resemble mahogany, perfectly. The menu adheres to a regional trend: the purity of Pacific Northwest raw materials showcasing the produce of Vancouver Island and the hotel’s own rooftop garden. Let the ingredients sing without distraction, runs the mantra.

The hotel serves 500,000 cups of tea and 120,000 scones annually — pilgrims check off their bucket lists Q’s stated objective is to be the best regional restaurant in the Pacific Northwest. It was instantly that in Victoria, a provincial capital starved for quality restaurants, but Vancouver and Seattle need not shudder just yet. The fare that emerges from the lauded hotel kitchen makes no apologies for its simplicity. Blow the horns: here’s Pacific Northwest in the nude and flaunting it. Out, out, tournedos Rossini. Begone, sauces and spices. Begone, fusion devils. The seafood bar menu ranges from oysters to a $70 seafood tower, with storeys of oysters, Dungeness crab, prawns, octopus and salmon, all from a kitchen famed for purchasing the best of everything. The playful “Keep It Going” label bunches appetizers and mains together, perhaps confusingly. Here we have blue-cheese-and-tomato salad, grilled avocado Caesar salad, poached halibut, butter-basted ling cod, beef tenderloin. Among desserts, the imaginative choice is fir-infused blackberry clafoutis with Salt Spring Island goat’s milk yogurt sorbet. But chocoholics may go off menu with the ultra-rich Empress Cake, a chocolate hazelnut layer cake with a chocolate crown.

The old tea lounge (opposite page) is now the Q Bar, which has a vibrant menu of signature cocktails, an extensive wine list and local craft beer.

Some of this works beautifully. Certainly the briny bivalves. Saltspring Island mussels are probably the finest in Canada. Tenderloin from Alberta’s Black Apron ranch with crispy fingerling potatoes might tempt a vegan back to meat-and-taters. But there’s a damning tendency to overcook here and beautiful hunks of prime beef are seen on their way back to the kitchen. Some dishes almost make it. The octopus poke (pronounced pok-ay and based on the Hawaiian raw fish salad) of marigold petals, tomato, taro chips and sea asparagus is masterful. But the giant Pacific octopus, BC’s great cephalopod, is ruined in a soy-based marinade. Note to kitchen: please respect our octopus. And some simply don’t. Tagliatelle is generously topped with Dungeness crab and mussels, but the noodles are tasteless and the crab generous in all but flavour. Q has talent and promise, but at this writing, has a marathon distance to go. The wine list follows the Pacific Northwest bias with a laudable selection of BC wines by glass or bottle. The big names — Mission Hill, Blue Mountain, Tinhorn Creek, Laughing Stock — deliver the goods from a wine region still unknown to many foreigners. Of course, the Europeans are here, too. And how about the 1998 Tâche Romanée-Conti at $20,000? But hey, this is a casual resto. It’s only décor. For more info on the hotel and restoration, go to the Fairmont Empress website (fairmont.com/empressvictoria). For more info on travel to the region, visit Tourism Victoria (tourismvictoria.com).

Scones and pastries are served during afternoon tea in the new lobby lounge.

Phase two of the hotel’s restoration project is ongoing through June 2017.

Travels in Anda Sunshine, fine food — and so much more — whet the appetite for history

RAFAEL RAMIREZ LEE / SHUTTERSTOCK.COM

by David Elkins

Reflecting pools, like this large one lined with myrtle hedges, add to the exotic sense of romance in Granada’s Alhambra.

alusia omas, a charming young man with an infectious sense of humour, has taken the group on a full tour of the Olive and Olive Oil Visitor Centre in Úbeda, Jaén province, Spain. He’s patiently explained both old and new methods of growing olives and extracting the “juice,” proper care and storing, and how to identify a good olive from a “less good” one: a fresh grassy taste in the mouth, peppery flavour in the throat. Now it’s late, almost an hour after the 8pm closing, and the questions just won’t stop. “Yes, it’s a perfect cooking oil. Keep the temperature under 180°C and I’ll bet anyone €5 it’ll never smoke.” Should you go by the date on the bottle? “No, go by the taste.” Can you use olive oil as a shampoo? “Ask my friend downstairs. He knows all about beauty care. He’ll

sell you something for your face and your hair. And here’s another idea. It’s time for dinner.” This Andalusian traveller’s tale starts in the middle. I began in Málaga a few days ago, visited Granada and will end back on the coast three days from now after calling in at nearby Baeza and a stop in Córdoba. Jaén is chock-a-block with UNESCO World Heritage castles, churches and forts, and still has room for the largest protected natural area in Spain — and 65 million olive trees. Spain produces twice as much olive oil as Italy and accounts for 40 percent of the world’s supply.

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Despite the many visitors, there is a palpable hush in the enormous hall — people have been praying here daily for 800 years

Doctor’s Review • NOVEMBER / DECEMBER 2016

mikvah, which, scholars believe, was used by Jewish women as a cleansing pool prior to the Jews 16thcentury expulsion. On the spring equinox, a beam of light streams in from a concealed opening to illuminate the pool. The effect is magical.

his part of Spain has a long and complicated history. Here’s an extremely brief summary to help to get your bearings. After the long erosion of the Roman Empire, the Visigoths crossed the Rhine in 410 and occupied the Iberian Peninsula frequently duking it out with local fiefdoms until the Arabs invaded in 711. They invaded from North Africa a little more than a century after the beginning of Islam in Medina and Mecca. With significant support from the Berbers, they established themselves in Andalusia where they tolerated Christians and Jews though they didn’t much care for the Visigoths. The building of the great mosque in Córdoba began in 785, but it was not to be a peaceful kingdom. A long succession of sultans/despots, some with allegiance to Damascus, others nominally subservient to Baghdad, fought among themselves. Not a year went by without skirmishes, battles and, among the ruling classes, assassinations and murders. Nor did the Europeans go quietly into that good night. The Arab conquest created the conditions for a state of virtually permanent warfare in the Iberian Peninsula. In scale and intensity, this exceeded anything to be found elsewhere in Western Europe. Writes Roger Collins in Caliphs and Kings: Spain, 796-1031: “Visigoths, Franks and Vikings staged endless raids from the north occupying territory on the Iberian Peninsula for a month or two or a few years only to be overthrown. And let’s not forget the Crusades.” Córdoba fell to the Christians in 1236 as part of the first re-conquest. A church, which was replaced with a nave in the 16th century, was built in the centre of the mosque. Muslims have been forbidden to pray there ever since. It remains a place of exclusive Christian worship today. This may seem a long way around but a bit of history would have been a bit of a help to me when I first entered the magnificent building. Over 800 red and white carved stone columns and arches stretch off into the dim spiritually evocative light. Despite the many visitors, there is a palpable hush in the enormous hall. People have been praying here daily for 800 years. That said, the cathedral plunked down in the middle and punched through the roof comes as a bit of a shock. There’s an elegance to the Moorish

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But now it’s time to eat. You could be forgiven for assuming Cantina la Estación (cantinalaestacion. com) is just another tapas bar. You could even be forgiven for thinking it’s not in Úbeda at all. The dining room resembles a 19th-century dining car on a train — estación means “station” in Spanish. Curtains line each side of the narrow room and are drawn back to reveal large “windows” —LCD screens that play videos of what you’d see from an express train speeding through the Spanish countryside. Quite an effect! The creativity extends to the menu. There’s been a food revolution in Spain over the last decade. Spanish chefs are among the most innovative on the planet and Montserrat Nieto de la Torre, the owner and head chef, is one of them. The food is glorious from traditional paper-thin jamón to innovative hummus and red peppers, and on through vegetables, seafood, beef and pork dishes prepared using olive oil and local herbs. Each dish is melt in the mouth delicious. Úbeda and nearby Baeza are noted for their Muslim-Jewish-Christian history and the magnificent Renaissance architecture of native son Andrés de Vandelvira. Another local, Francisco de los Cobos y Molina, became secretary to Carlos I, the grandson of Ferdinand and Isabella who expelled the last of the Arabs from Europe in 1492. In the same year, the royal couple financed Christopher Columbus on his voyage to the “New World” which soon made the country the wealthiest in the world. De los Cobos is said to have received one percent of all the gold and silver shipped back from the Americas. He established a family fortune which, through a foundation, still funds his private mausoleum, the magnificent Chapel of El Salvador. It’s just one of the historic buildings on the central Plaza de Santa Maria which it shares with the remarkable 16th-century Palace de las Cadenas. The square also houses a parador (parador.es/en/ paradores/parador-de-ubeda), an intriguing place to stay while you’re in town. For cozier accommodation, book into the Hotel Nueve Leyendas (hotelnueveleyendas. com) down the street. The owners are huge fans of Gordon Lightfoot! This is scarcely dipping into the glories of the area, but if you fancy dipping into some truly special water, visit the old 15th-century synagogue around the block. It was rediscovered three years ago during the renovation of a small apartment building. In the basement workers broke through a floor that covered seven steps down to a deep pool of water, a

DAVID ELKINS

The 16th-century Chapel of El Salvador and the Palace de las Cadenas (left) are just two of Úbeda’s eight UNESCO World Heritage sites.

Sixty-five million olive trees grow on the hills of Jaén province.

Thinly sliced jámon and spicy meats are the first course in many a fine meal.

FOTOMICAR / SHUTTERSTOCK.COM

JASON ROTHE / SHUTTERSTOCK.COM

FRANCK BOSTON / SHUTTERSTOCK.COM

At the spring equinox, light pours into a sacred pool deep in the cellar of Úbeda’s recently re-discovered 15th-century synagogue.

In the years following the re-conquest of the great mosque of Córdoba in 1236, the nave of a cathedral (far left) was punched through the roof.

NOVEMBER / DECEMBER 2016 • Doctor’s

Review

Málaga is today a glittering place of elegant plazas, peaceful parks and one of the finest seaside esplanades in Europe stones that the festooned and gilded Renaissance structure simply cannot achieve. The cultural clash between the two civilizations could not be more arresting — or more poignant. Córdoba has been a large and vibrant city for over 1300 years so there’s lots to see. Continuing on the religious theme, Jews will want to visit the old quarter where Maimonides, the great 12th-century philosopher, was born. Another reason to explore the twisting streets and shops of this part of town is the excellent Restaurant el Churrasco (elchurrasco.es). Select your seafood from the case in the lobby, they’ll serve it to you cooked to perfection in one of the upstairs rooms.

glimpse of the huge variety of food grown in this southern European cornucopia call in at the Mercado Atarazanas. Start the morning with churros (fried pastry), fruit and coffee, go on to tapas for lunch and, once the sun goes down, head for the big terrace of El Pimpi (elpimpi.com), adjacent to the recently uncovered Roman Amphitheatre. Delicious food is kept coming by a squad of white-shirted waiters. Plan to spend your last night here to catch the full flavour of the city. Every night is party night, one that often ends on the beach, a short stroll away across the park, where the big cruise ships all come in. If you’re lucky, there’ll be fireworks.

ravels in Andalusia these days begin in Málaga on that portion of the western Mediterranean called the Alboran Sea. It’s a city that has transformed itself in the last decade, greatly helped by Spain’s membership in the EU — over 700,000 Britons alone came here to live. What was once a work-a-day port, albeit with a history pre-dating Roman times, is, today, a glittering place of elegant plazas, marble by-ways, peaceful parks and one of the finest seaside esplanades in Europe. Begin with the big sites, the Alcazaba, the old Moorish fort, and the Gibralfaro castle with its overflowing gardens. In the city centre take a gander at the vast Renaissance cathedral locals call La Manquita, or the one-armed woman, in reference to its missing south tower. Next the museums; there are now more than 30 to visit. The coloured glass cube of the Pompidou Centre (centrepompidou-malaga.eu), the first so named outside France, sits conveniently on the harbour. One absolute must-see is the Picasso Museum (museopicassomalaga.org) on a small plaza beside the artist’s childhood home. The restored palace offers well-curated selections of paintings, sculptures and ceramics that don’t overwhelm with too many works as they often do in bigger Picasso shows. If you have the time and inclination call in at the new Collection of the Russian Museum (coleccionmuseoruso. es) affiliated with the Hermitage in St. Petersburg. Bored with high art? There’s an Auto Museum (museoautomovilmalaga.com) next door. For the rest of your time here take a couple of days to wander about. The shopping is varied and interesting especially for Spanish-made leather goods to chess sets to fashion-forward clothing. For a

BEAUTY AND INTRIGUE AT THE ALHAMBRA

Doctor’s Review • NOVEMBER / DECEMBER 2016

The accompanying article describes highlights along a circle route in southern Andalusia with never more than a couple of hours on the road between stops. What isn’t mentioned is Granada’s Alhambra. Granada is an ancient town at the foot of the 3478-metre Sierra Nevada. Ferdinand and Isabella, the royal couple who defeated the Arabs in 1492 and sent Christopher Columbus off to discover the Americas, are buried in the cathedral here. That’s reason enough to call in yet the 8000 visitors a day come mostly to marvel at the vast Moorish palace of the Alhambra, which was the last Arab foothold in Europe that sits on a promontory above the city. Read about it before your visit if you like, but while you’re there, simply find a few quiet places to sit and contemplate the glory of what has been. Dream of the lives of sultans, queens, princes and princesses. Wives and lovers. Betrayed and betrayer. Cast your mind to a rising new moon in a navy sky, a canopy of stars, air heavy with the perfume of 10,000 flowers, secret liaisons sealed with kisses, alliances made in a throne room only to end on some far off field of battle. American writer Washington Irving indulged in just such a reverie inspired by his stay in the palace in 1828 and wrote about it in Tales of the Alhambra. Consider taking a copy with you when you dine at Restaurant Mirador de Morayma (miradordemorayma.com) in the ancient Moorish quarter, the Albayzín, overlooking the Alhambra high up on the opposite bank of the Darro. Ask for the balcony room overlooking the palace. Go on a full moon.

DAVID ELKINS

The shadows of swifts streak across a sunny wall at Granada’s Alhambra Palace.

The Alhambra sits on a promontory on the opposite bank of the Darro River from Granada’s ancient Arab quarter, the Albayzín.

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PABKOV / SHUTTERSTOCK.COM

DEBI GOODWIN

Many of Málaga’s strolling streets in the old town have been paved with elegant grey marble.

DEBI GOODWIN

The Pompidou Centre in Málaga’s harbour is the Centre’s only foray outside Paris.

Today Málaga’s harbour is ringed by esplanades to welcome visitors from some NOVEMBER / DECEMBER 2016 Doctor s Review of •the 180+ ’cruises that call in every year.

Pfeffernüsse cookies.

Sweet somethings Desserts for your loved ones from one of Canada’s favourite pastry chefs recipes by

Anna Olson

photos by

Ryan Szulc

Doctor’s Review • NOVEMBER / DECEMBER 2016

Mike McColl

n Bake with Anna Olson, the Food Network Canada TV host begins with one simple question: “do you like to bake?” “Success,” she continues,

“stems from that simple ‘yes’.” For MDs that have answered in the affirmative, the author of seven bestselling cookbooks has more than 125 recipes in her latest publication. And, because Olson also thinks that “baking is about sharing” —and, in fact, the key moti-

and

vator sometimes — we’ve selected three of her recipes for you and your holiday guests. The cookies and syrup cake are categorized as “simple” in the book; the trifle “sensational” or slightly more complex, that is, a recipe for special occasions.

Blood orange syrup cake.

PFEFFERNÜSSE COOKIES These little gems have a lovely spicy character that comes not just from traditional baking spices, but also from black pepper. They’re great at holiday time as an addition to a cookie tin mix. They’re also perfect to make ahead and freeze. Prep: 25 minutes Bake: 16 minutes 6 tbsp. (90 ml) honey 6 tbsp. (90 ml) granulated sugar ¼ c. (60 ml) packed dark brown sugar ¼ c. (60 g) unsalted butter, melted 1 large egg 1 egg yolk 2 c. (500 ml) all-purpose flour ¾ tsp. (3.75 ml) baking soda ½ tsp. (2.5 ml) ground cinnamon ½ tsp. (2.5 ml) ground cardamom ½ tsp. (2.5 ml) anise seed ½ tsp. (2.5 ml) ground allspice ½ tsp. (2.5 ml) ground cloves ½ tsp. (2.5 ml) ground black pepper ¼ tsp. (1.25 ml) salt icing sugar, for rolling the baked cookies

Preheat the oven to 325°F (160°C). Line two baking trays with parchment paper. In a large mixing bowl, whisk the honey with both sugars, the melted butter, egg and egg yolk. Sift the flour, baking soda, spices and salt over the sugar mixture, and stir until evenly blended (the batter will be dense). Use a small ice cream scoop or two teaspoons to scoop up the batter. Shape it into balls between the palms of your hands, place the balls on the prepared trays, leaving 2 inches (5 cm) between each, and bake for 14–16 minutes, until the cookies are lightly browned. Cool the cookies on the tray on a cooling rack and then roll them in icing sugar to coat them completely. The cookies will keep for up to 1 week in an airtight container or can be frozen for up to 3 months. Makes about 3½ dozen cookies. Note: Ground anise seed really gives Pfeffernüsse cookies their distinctive taste and can usually be found at European food shops. If you don’t have ground anise seed, you can leave it out. (Crushed fennel seed as a substitute was too strong-tasting.)

BLOOD ORANGE SYRUP CAKE Cornmeal and ground almonds give this cake its structure and great texture without the use of wheat flour. Soaking the cornmeal in hot milk plumps it up, so there isn’t the coarseness you might find in a traditional cornmeal-based cake. GLUTEN FREE

Prep: 20 minutes Bake/cook: 45 minutes For the cake 1 c. (250 ml) milk ½ c. (115 g) unsalted butter 1 c. (250 ml) cornmeal 1 c. (250 ml) granulated sugar 4 eggs at room temperature 2 tsp. (10 ml) finely grated blood orange zest 1 c. (250 ml) ground almonds 2 tsp. (10 ml) baking powder (gluten-free, if necessary) ¼ tsp. (1.25 ml) salt pinch ground cinnamon

butter has melted. Place the cornmeal in a large mixing bowl and pour the milk-butter mix over it, whisking by hand as you add it (it will thicken up quickly). Whisk in the sugar and add the eggs one at a time, whisking after each addition. Stir in the zest. In a separate bowl, stir the ground almonds with the baking powder, salt and cinnamon, and add this to the batter, stirring until blended. Pour the batter into the prepared pan and bake for about 45 minutes, until a tester inserted in the centre of the cake comes out clean. To make the syrup, bring the blood orange juice and sugar to a full boil over medium-high heat. While the cake is still hot from the oven, poke holes in it with a bamboo skewer and then spoon the syrup over it (the syrup will soak in quickly). Allow the cake to cool to room temperature in the pan on a cooling rack before serving. The cake will keep, in an airtight container or wrapped in plastic wrap, at room temperature for 3 days. Do not refrigerate. Makes one 9-inch (23-cm) cake. Serves 12.

For the syrup ½ c. (125 ml) blood orange juice (about 2 oranges) ½ c. (125 ml) granulated sugar

DOUBLE CHOCOLATE PEAR TRIFLE

Preheat the oven to 350°F (180°C). Grease a 9-inch (23-cm) springform pan. Heat the milk and butter in a saucepan over medium-low heat until the

There are a lot of steps to make this trifle, but one reason trifle is perfect for a special occasion is that you can make it ahead of time. The chocolate cake, custard and vanilla-poached pears can

NOVEMBER / DECEMBER 2016 • Doctor’s

Review

Double chocolate pear trifle.

be made 1 to 2 days ahead, and you can assemble the trifle a day in advance of serving it. Prep: 2 hours Bake/cook: 75 minutes plus chilling For the cake 1½ c. (375 ml) cake and pastry flour 1¹⁄³ c. (330 ml) granulated sugar ½ c. (125 ml) Dutch process cocoa powder ¾ tsp. (3.75 ml) baking soda ¼ tsp. (1.25 ml) salt ½ c. (115 g) cool unsalted butter, cut into pieces ½ c. (125 ml) hot, strongly brewed coffee ½ c. (125 ml) milk 1 tsp. (5 ml) pure vanilla extract 2 eggs, at room temperature For the pastry cream 2 c. (500 ml) milk

1 vanilla bean, seeds only, or 2 tsp. (10 ml) vanilla bean paste 6 egg yolks 6 tbsp. (90 ml) granulated sugar ¼ c. (60 ml) cornstarch 3 oz. (90 g) white chocolate, chopped 2 tbsp. (30 g) unsalted butter, cut into pieces For the pears 5 Bartlett pears 3 c. (750 ml) water 3 c. (750 ml) granulated sugar ¼ c. (60 ml) fresh lemon juice 1 vanilla bean, seeds only, or 1 tbsp. (15 ml) vanilla bean paste For the ganache and assembly 4 oz. (120 g) bittersweet couverture/ baking chocolate, chopped 1½ c. (375 ml) whipping cream, divided 2 tbsp. (30 ml) granulated sugar 1 tsp. (5 ml) pure vanilla extract dark chocolate shavings, for garnish

Doctor’s Review • NOVEMBER / DECEMBER 2016

Preheat the oven to 350°F (180°C). Line a 17- x 11-inch (43- x 28- cm) baking tray with parchment paper, but do not grease the pan. To make the cake, sift the flour, sugar, cocoa powder, baking soda and salt into a large mixing bowl or the bowl of a stand mixer fitted with the paddle attachment. Add the butter, cutting it in (if using a large bowl, use electric beaters) until the mixture is a fine crumble (like fine breadcrumbs) and no large pieces of butter are visible. Stir the hot coffee, milk and vanilla together, and add it all at once to the flour mixture, blending on medium speed until smooth. Break the eggs into a small dish, stir them with a fork, and then add them to the batter, again blending on medium just until smooth (the batter will be very fluid). Pour the batter into the prepared pan, spreading it evenly, and bake for 25 minutes, until a tester inserted in the centre comes out clean. Cool in its pan. To make the pastry cream, heat the milk with the vanilla bean seeds in a saucepan over medium heat until just below a simmer. In a bowl, whisk the egg yolks, sugar and cornstarch together. Place the white chocolate and butter in a bowl, placing a fine mesh sieve over top. Gradually whisk the hot milk into the egg mixture and then return it all to the saucepan. Whisk this constantly over medium heat (switching to a spatula to get into the corners) until thickened and glossy, 2 minutes. Pour this immediately through the sieve, whisking it through if needed, and stir in the white chocolate and butter. Place a piece of plastic wrap directly onto the surface of the custard, cool to room temperature, and then chill until ready to use. To make the pears, peel, halve and core the pears, and remove the stems. Bring the water, sugar, lemon juice and vanilla bean seeds up to a full boil in a saucepan over medium-high heat. Add the pears. Place a piece of parchment paper cut to fit the saucepan (called a cartouche) directly on the surface of the liquid to cover the pears. Return the liquid to a gentle simmer over medium heat and simmer for 10 minutes. Remove the saucepan from the heat and let the pears cool to room temperature

in the syrup before chilling until ready to assemble. To make the ganache, place the chocolate in a small bowl. Heat ½ cup (125 ml) of the whipping cream to a simmer in a saucepan over medium heat and pour this over the chocolate. Gently stir the mixture until the ganache is smooth and cool to room temperature. Whip the remaining 1 cup (250 ml) of cream with the sugar and vanilla, and chill until ready to assemble. Have ready a 12-cup (3-L) trifle bowl or glass vessel. Turn the chocolate cake out onto a cutting board, peel away the parchment paper, and cut three or four layers of cake the size of your trifle bowl. Remove the pears from the vanilla syrup (saving the syrup) and cut them into ½-inch (1-cm) slices, saving one intact pear half for the top of the trifle. Start by placing a layer of cake in the bottom of the bowl. Brush this generously with vanilla syrup and top with a layer of white chocolate pastry cream. Drizzle the cream with a little chocolate ganache and arrange some pear slices over top. Repeat this with the cake, syrup, cream and pear until the cake layers are used, finishing with a layer of pear slices. Top this with the whipped cream and chocolate shavings. Slice the final pear half so that it fans out from the stem end and place this on top. Chill the trifle until ready to serve. The trifle can be prepared and assembled up to a day in advance. Serves 12 to 16. Recipes and photos from Bake with Anna Olson (Appetite by Random House, 2016).

MEDICAL QUIPS From patient charts Patient’s medical history has been unremarkable with only a 40-pound weight gain in the past three days.

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MEDICINE AND THE ARTS uu CONTINUED FROM PAGE 23

9. HER PAINTINGS (FINALLY!) SELL FOR MILLIONS Though she is now widely considered one of Canada’s best artists, Carr’s reputation was slow to build. Most Americans, even art aficionados, fail to recognize her name. But a few significant shows in the last decade have given her a boost. In 2001, Carr, O’Keeffe, Kahlo: Places Of Their Own at the Museum of New Mexico in Santa Fe incorporated Carr into the North American tradition of ruggedly individual women artists. Then, in 2012, seven of her most illustrious paintings were selected for dOCUMENTA (13), the prestigious international art showcase held every year in Kassel, Germany. Carr was the first Canadian ever accorded this posthumous honour. Her work was also brought (at last!) to an English audience at the venerable Dulwich Picture Gallery in South London around the same time as the Kassel show. To top it all off, in 2013, The Crazy Stair (also known as The Crooked Staircase) became the third most expensive Canadian artwork sold at auction when it went for $3.39 million.

10. NATURE WAS THE FOCUS OF HER LIFE Throughout her life, her relationship with nature remained a constant source of nourishment. She was an avid reader of Ralph Waldo Emerson and kept a copy of Walt Whitman’s Leaves of Grass with her at all times. A journal entry from March 1934 is reminiscent of the great transcendental American poet. Carr writes: “Dear Mother Earth! I think I have always specially belonged to you. I have loved from babyhood to roll upon you, to lie with my face pressed right down onto you in my sorrows. I love the look of you and the smell of you and the feel of you. When I die I should like to be in you uncoffined, unshrouded, the petals of flowers against my flesh and you covering me up.” NOVEMBER / DECEMBER 2016 • 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 a short- or long-acting muscarinic antagonist (SAMA or LAMA), e.g. ipratropium, tiotropium, glycopyrronium, aclidinium. • 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. • Drug interactions: Avoid co-administration with other anticholinergics. Caution should be exercised when considering the co-administration with inhibitors of cytochrome P450 3A4; drugs that prolong the QTc interval (e.g. monoamine oxidase inhibitors and tricyclic antidepressants); betaadrenergic receptor blocking agents; and non-potassium-sparing diuretics (i.e. loop or thiazide diuretics). 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 and maximum 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

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

01445 04/16

M Y R BE T R IQ is the ®

C O V E R E D I N 8 O U T O F 10 P R O V I N C E S W I T H S P E C I A L A U T H O R I Z AT I O N*

Help your OAB patients fight the urge

dispensed OA B medication prescribed by Canadian urologists

1†

Proven efficacy in OAB with symptoms of urgency, urgency incontinence and urinary frequency.2

Consider MYRBETRIQ (mirabegron): A potent and selective β-3 adrenoceptor agonist for OAB2‡ ®

Indication and clinical use: • MYRBETRIQ® (mirabegron) is indicated for the treatment of overactive bladder (OAB) with symptoms of urgency, urgency incontinence and urinary frequency • Safety and efficacy in pediatric patients have not been established Contraindications: • Severe uncontrolled hypertension (SBP ≥180 mm Hg and/or DBP ≥110 mm Hg) • Pregnancy Relevant warnings and precautions: • Serious adverse events of neoplasm • Serum ALT/AST increase with/without bilirubin increase and Stevens-Johnson syndrome • Dose dependent QTc prolongation, elevated blood pressure, elevated heart rate • Caution in patients with risk factors for torsade de pointes or patients taking medications known to prolong the QT interval • Interaction with CYP2D6 substrates • Caution in patients with clinically significant bladder outlet obstruction or taking antimuscarinics for OAB * MYRBETRIQ® is eligible for formulary coverage with special authorization in Alberta, Saskatchewan, Manitoba, Ontario, Quebec (http://www.ramq.gouv.qc.ca/en/regie/legal-publications/Pages/list-medications.aspx)§, New Brunswick, Newfoundland and Labrador, and Nova Scotia. Please refer to the respective formularies for coverage information. †Comparative clinical significance is unknown. ‡Clinical significance is unknown. §For treatment, as monotherapy, of vesical hyperactivity in persons for whom oxybutynin is poorly tolerated, contraindicated or ineffective.

MYR B ETR IQ ® is a trademark of Astellas Pharma Canada, Inc.

• Caution in patients with moderate hepatic impairment; not recommended in severe hepatic impairment • In patients with glaucoma, ophthalmological examinations should be performed regularly • Angioedema of the face, lips, tongue and/or larynx has been reported. If involvement of tongue, hypopharynx or larynx occurs, discontinue MYRBETRIQ® and initiate appropriate therapy and/or measures • Caution in patients with severe renal impairment; not recommended in end stage renal disease • Should not be used during nursing For more information: Please consult the Product Monograph at http://www.cmsastellas.ca/uploads/pdf/2016-06-02%20 Myrbetriq%20English.pdf for more information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-888-338-1824. References: 1. IMS Health (April 2016). Canadian CompuScript (April 2015 – March 2016). 2. Astellas Pharma Canada, Inc. MYRBETRIQ® Product Monograph, June 2, 2016.