October 2015 by Doctor's Review

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

OCTOBER 2015

A doctor takes you soaring Aging artists’ eyesight Handy home gadgets Depression and sex Rice steamer meals

MEDICINE ON THE MOVE

LAST CHANCE: Caribbean contest extended

FALL

GETAWAYS Shoulder-season savings Explore Philly’s countryside Stretch your short holiday

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

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

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

CAN BE TAKEN ANY TIME OF DAY

WITH OR WITHOUT FOOD

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

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

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

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

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

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

Contraindications:

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

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

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

Relevant warnings and precautions:

• Increased risk of genital mycotic infections

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

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

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

• Not for use in pregnant or nursing women

• Not for use in patients concomitantly treated with pioglitazone

For more information:

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

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

* Clinical significance unknown. † The amount of glucose removed by the kidney through this mechanism is dependent upon the blood glucose concentration and GFR. ‡ The efficacy of FORXIGA is dependent on renal function. Assessment of renal function is recommended prior to initiation of FORXIGA therapy and periodically thereafter. § In patients with evidence of volume depletion, this condition should be corrected prior to initiation of FORXIGA. ¶ Please see Product Monograph for complete dosing and administration information. ** Double-blind, placebo-controlled, 24-week study, with a 78-week, controlled, blinded extension period, of 546 patients with type 2 diabetes and A1c ≥7% and ≤10% and who were on a dose of metformin of ≥1500 mg/day. After a 2-week lead-in period, patients were randomized to dapagliflozin 2.5 mg, FORXIGA 5 mg, or 10 mg once daily or placebo. Mean baseline A1c values: FORXIGA 5 mg + metformin 8.17%, FORXIGA 10 mg + metformin 7.92% and placebo + metformin 8.11%. Mean baseline body weight: FORXIGA 5 mg + metformin 84.73 kg, FORXIGA 10 mg + metformin 86.28 kg and placebo + metformin 87.74 kg. LOCF: last observation (prior to rescue for rescued patients) carried forward. References: 1. FORXIGA Product Monograph. AstraZeneca Canada Inc., December 10, 2014. 2. Bailey C et al. Dapagliflozin add-on to metformin in type 2 diabetes inadequately controlled with metformin: a randomized, double-blind, placebo-controlled 102-week trial. BMC Medicine 2013;11:43.

02/16

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

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

Poetry before the fall

Jane Austen in her fine novel Persuasion sets the tone quite perfectly. “Her pleasure in the walk must arise from the exercise and the day, from the view of the last smiles of the year upon the tawny leaves and withered hedges, and from repeating to herself some few of the thousand poetical descriptions extant of autumn — that season of peculiar and inexhaustible influence on the mind of taste and tenderness — that season which has drawn from every poet worthy of being read some attempt at description, or some lines of feeling.”

ELENA ELISSEEVA / SHUTTERSTOCK.COM

If fall is here can winter be far behind? Well, no, not in Canada. Indeed in some parts of the country flying snow has already replaced tumbling leaves. Autumn is the season of poetry. This time of year, balanced between the warm months and the coming cold, brings out the best in poets. October weather fluctuates almost as much as human emotions do and we have a plethora of fine poetry to illustrate the point.

Rilke adds a darker note: “At no other time (than autumn) does the earth let itself be inhaled in one smell, the ripe earth; in a smell that is in no way inferior to the smell of the sea, bitter where it borders on taste, and more honeysweet where you feel it touching the first sounds. Containing depth within itself, darkness, something of the grave almost.” — Rainer Maria Rilke, Letters on Cézanne And now a lighter take: “October, baptize me with leaves! Swaddle me in corduroy and nurse me with split pea soup. October, tuck tiny candy bars in my pockets and carve my smile into a thousand pumpkins. O autumn! O teakettle! O grace!” — Rainbow Rowell, Attachments Canadian writers delight in the season, of course. “Oh, Marilla,” she exclaimed one Saturday morning, coming dancing in with her arms full of gorgeous boughs, “I’m so glad I live in a world where there are Octobers. It would be terrible if we just skipped from September to November, wouldn’t it? Look at these maple branches. Don’t they give you a thrill — several thrills?” — L.M. Montgomery, Anne of Green Gables And Yoko Ono takes a broader view; let’s give her the last word. “Spring passes and one remembers one’s innocence. Summer passes and one remembers one’s exuberance. Autumn passes and one remembers one’s reverence. Winter passes and one remembers one’s perseverance.” — Yoko Ono Autumn is for lovers, past and present, enjoy it as you will.

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David Elkins, Publisher and editor delkins@parkpub.com

@doctorsreview OCTOBER 2015 • Doctor’s

Review

Experience ANORO ELLIPTA ™

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

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

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

Recommended Dose: • The recommended dose is one inhalation of ANORO™ ELLIPTA® 62.5/25 mcg once daily. Dosing Considerations: • No dosage adjustment is required in patients over 65 years of age, in patients with renal impairment, or in patients with mild or moderate hepatic impairment. ANORO™ ELLIPTA® has not been studied in patients with severe hepatic impairment. For More Information: Please consult the Product Monograph at http://gsk.ca/anoro/en for important information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374. *LAMA=Long-acting muscarinic antagonist [also known as a long-acting anticholinergic (LAAC)]; LABA=Long-acting beta2-agonist

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

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

contents SHUTTERSTOCK.COM

OCTOBER 2015

features 30

The thrill of flying gliders

A family physician describes his lifelong obsession with the sport by Dr Réal Le Gouëff

Take it in the shoulder season Now’s the time for some of the best travel deals all year by Josephine Matyas

Full steam ahead Complete meals that you can make in a rice cooker by Diane Phillips

Pennsylvania Dutch treat A day trip through Philly’s countryside among Amish farms, art museums and estate gardens by Cherie DeLory

Make short getaways last longer 10 ways to stretch your time away from your practice by David Elkins

Coming in

November • Enjoy retro Miami: visit some of the finest Art Deco buildings in North America • Bye, bye Britain: an ex-GP tells how the NHS pushed him out of practice and the country • Was Van Gogh colour blind and other revelations on how health has affected art • Finally meet Swaraj Kumar Banerjee the “Rajah of Darjeeling Tea” • How e-books came of age and birthed the under $70 colour tablet

OCTOBER 2015 • Doctor’s

Review

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

A type 2 diabetes add-on you and your

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

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

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

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

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

Introducing

contents OCTOBER 2015

regulars 11

LETTERS California love, Cambodia, Croatia and more

PRACTICAL TRAVELLER The new pedestrian tunnel under Lake Ontario, the airport that’ll make travel to the Eastern Caribbean easier, LA’s $140-million museum opens its doors and more! by Camille Chin

BUDGET TRAVELLER Deals in Canada and the US for a fall or winter getaway by Camille Chin

GADGETS

21 21

TOP 25 The biggest medical meetings scheduled for spring 2016

HISTORY OF MEDICINE How painters and other visual artists are affected by ocular disease by Rose Foster

Clever gizmos to eliminate everyday irritants by David Elkins

DEPRESSION KEYPOINTS Approaches to talking to depressed patients about sex by Mairi MacKinnon

contest! 47

PHOTO FINISH A small fortune by Dr Hans Berkhout

CASA DE CAMPO CONTEST EXTENDED UNTIL NOVEMBER 15 Enter now for your chance to win!

OCTOBER 2015 • Doctor’s

Review

For your adult patients with type 2 diabetes

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

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

BITRJ00110 CATRJ00110

LETTERS

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

California love, Cambodia, Croatia and more

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

MONTREAL HEAD OFFICE

400 McGill Street, 4th Floor Montreal, QC H2Y 2G1 Tel: (514) 397-8833 Fax: (514) 397-0228 Email: editors@doctorsreview.com www.doctorsreview.com

TORONTO SALES OFFICE

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

AN EYE FOR AN “I” While I’m pleased that your publication decided to highlight a region of Croatia where I was born [Croatia underfoot, September 2015, page 34], your multiple references to Italian influences on Istria are with fault. Istra not “Istria” is the proper name of this region. Dr Joseph Grbac Via DoctorsReview.com

Editor’s note: We’re delighted you enjoyed the article. We indeed used the English spelling of Istria throughout rather than the Croatian Istra.

SOMETHING FISHY Why does the recipe for the cioppino [Fish for compliments, July/August 2015, page 52] say to cut the crab into six pieces, while the recipe for preparing the crab says to take the meat out of the crab after it is cooked? Dr David Spence Via DoctorsReview.com

Editor’s note: Sorry for the confusion. The instructions on how to cook and prepare crab were independent of the cioppino recipe in the Ocean Wise cookbook. The crab (in its shell) should be cut into six pieces.

WORDS TO LIVE BY I was delighted to see the article on Robinson Jeffers [A man of his word, July/August 2015, page 38]. I recall when I was an impressionable 20 year old travelling through Big Sur, California and becoming acquainted with the work of the poet. One of his quotes had a lasting impression on me and became a motto for my life. He was obviously very interested in stones and I remember the quote to this day, 40 years later. The mysticism of stone Which failure cannot cast down Nor success make proud Dr Michael Clarfield Toronto, ON

MISTAKEN IDENTITY I would like to point out that the picture on page 13 of the July/August edition of Doctor’s Review [“The world’s centres of attraction,” Practical Traveller] is not Angkor Wat. I have seen this picture many times and it is almost always mislabelled as Angkor Wat. Angkor Wat looks like this (see photo above). I know because I have been there. The picture in Doctor’s Review is of Ta Prohm, another temple worthy of seeing in Cambodia along with Angkor Thom, Banteay Srei and others. Cambodia is one of the most fascinating countries. Dr E.S. d’Archangelo Vancouver, BC OCTOBER 2015 • 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 • Systemic effects of inhaled corticosteroids other acute episodes of asthma or in patients 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 ®

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.takedacanada.com/ca/alvescopm. The product monograph is also available by calling us at 1-866-295-4636. 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. ®

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

C a mi lle C hi n

IWAN BAAN

ELIZABETH DANIELS

IWAN BAAN / PHOTOS THIS PAGE COURTESY THE BROAD AND DILLER SCOFIDIO + RENFRO

The Broad unveiled

LA’s new The Broad Museum is so dramatic you’ll either love it or hate it. The US$140-million facility was designed by the New York firm Diller Scofidio + Renfro to house the private, modern and contemporary art collection of founders Eli and Edythe Broad. The Broads made their billions from real estate and the 1998 sale of the mutual fund company SunAmerica. Located on Grand Avenue across from the Frank Gehry-designed Walt Disney Concert Hall, the three-storey museum features a bone-white honeycomb exterior of fiberglass-reinforced concrete panels and an oculus window. Described as the “veil” by Elizabeth Diller, it covers the “vault” of art inside. Also inside: a 32-metre-long escalator and a cylindrical glass elevator in the otherwise spare cave-like lobby. Both take guests to the second floor where art is (visibly) stored; the third floor is for exhibits. More than 250 works culled from the Broads’ 2000-piece collection are on display for the inaugural show. Free, but reservations recommended. tel: (213) 232-6200; thebroad.org. OCTOBER 2015 • Doctor’s

Review

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

The twin island nation of Antigua and Barbados inaugurated a new passenger terminal at V.C. Bird International Airport in August. The US$97-million facility will serve as the gateway to the Eastern Caribbean. The terminal features 14 gates and four loading bridges. There are 46 check-in counters, 15 self-check-in kiosks, more immigration and security positions, and a modernized baggage-handling system. The departure lounge features free Wi-Fi, but there are less than a dozen power outlets for recharging. The terminal can handle 1800 passengers an hour —authorities hope to attract three million passengers annually by 2030, up from 860,000 at the old terminal. vcbia.com.

TAVI / SHUTTERSTOCK.COM

The Caribbean opens up

JULE BERLIN / SHUTTERSTOCK.COM

Sir Walter Scott’s Abbotsford House in the Scottish Borders.

The UK’s new tracks The Borders Railway began service in September. It’s the longest new domestic train line to be built in the UK for over a century. It connects Edinburgh to Tweedbank in the Scottish Borders via the district of Midlothian and takes 55 minutes from beginning to end. It follows the old Waverly Route, closed in 1969, consists of seven new stations and 48 kilometres of new track. Station highlights include the Rosslyn Chapel (near the Eskbank station), which was featured in The Da Vinci Code; the National Mining Museum Scotland (near Newtongrange station) where visitors can see the largest steam engine in the country; and Abbotsford House (Tweedbank station) where novelist and poet Sir Walter Scott hosted the likes of Oscar Wilde and Charlotte Brontë. The diesel train is expected to carry 650,000 passengers a year. From £5.30 to £16 roundtrip. For info: bordersrailway.co.uk. For tickets: scotrail.co.uk.

Doctor’s Review • OCTOBER 2015

El Celler de Can Roca, Girona, Spain.

Super Indian debuts in Denver Fritz Scholder didn’t consider himself an Indian, but he became known as a leader of the New American Indian Art movement. Born in Breckenridge, Minnesota in 1937 (he died in 2005), his paternal grandmother was a member of the Luiseño tribe of Mission Indians. Though he defied the label “Native American artist” throughout his career, he’s perhaps best known for his Indian series, started in 1967 and controversial because he depicted Native Americans with national clichés like American flags, beer cans and cats. Super Indian: Fritz Scholder, 1967–1980, on now through January 17, 2016 at the Denver Art Museum, begins with the Indian series and ends with his 1980 Indian Land paintings. Scholder’s work echoes figurative and pop art influences; central elements are vibrant colour, energetic brushwork and a focus on the figure. The exhibit will travel to the Phoenix Art Museum in February 2016 and the Nerman Museum of Contemporary Art in Overland Park, Kansas in June 2016. Adults US$13; under 18 free. tel: (720) 865-5000; denverartmuseum.org. OCTOBER 2015 • Doctor’s

Review

COURTESY WILLIAM J. O’CONNOR © ESTATE OF FRITZ SCHOLDER

JACQUELYN PHILLIPS © ESTATE OF FRITZ SCHOLDER

CLOCKWISE FROM LEFT: Hollywood Indian, 1973. American Portrait with Flag, 1979. Matinee Cowboy and Indian, 1978.

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

Flight at the end of the tunnel

There’s a new underwater pedestrian tunnel in Toronto. Built 10 storeys below Lake Ontario, it stretches for 260 metres and connects the city’s mainland with the Billy Bishop City Airport on Toronto Islands. The entire journey via four moving sidewalks and “one of the longest escalator systems in Canada” takes six minutes. The old ferry takes 90 seconds, but only makes the trip every 15 minutes. The tunnel cost $82.5 million — in 2009 the Port Authority estimated that it would cost $20 million. It was funded using a P3 model (public-private partnership) and through the $20 airport improvement fee included in the cost of travellers’ flights. Rob Ford is taking full credit for the project, which was secured under his administration in 2011. portstoronto.com/airport.aspx.

Doctor’s Review • OCTOBER 2015

Watch your step

MARQUES / SHUTTERSTOCK.COM

The rural parts of the Camino de Santiago will soon be guarded by five mounted police. An American tourist who was inspired to walk the pilgrimage trail after watching the 2010 movie The Way went missing in April and was found dead in September. Denise Thiem’s last known location was the northern Spanish town of Astorga where she emailed a British pilgrim to say she was going to walk west to El Ganso. It was the last anyone heard from her and since then other pilgrims have shared previously unreported accounts of threats and harassment. Last year, close to 240,000 pilgrims were certified as having completed the Camino. The most popular route begins in France’s St. Jean Pied de Port; the route ends in Spain at the Cathedral of Santiago, the resting place of St. James.

BUDGET TRAVELLER

C a mi lle C hi n

deals for a fall or winter getaway Dallas’s Hilton Anatole.

Chicago, IL The Fairmont Chicago is offering a Weekend Escape Package for a special fall or winter getaway. When you book two nights at the luxury hotel Friday, Saturday or Sunday through March 31, 2016, the third night is free. Under this deal, three-night weekend stays are said to start at US$477. When we searched for a three-night, November 6-to-9 stay, it cost US$558 plus tax — not necessarily cheap, but a substantial savings when you consider it would normally cost US$837. The hotel is half a block from Millennium Park and one block from the famed Michigan Avenue. tel: (312) 565-8000; themillenniumparkhotel.com/special-offers/weekend-escape.

Dallas, TX The Stay and See Dallas Package at the Hilton Anatole starts at US$114 a night on select dates through the rest of 2015 and includes parking, breakfast for up to four people daily, an in-room movie and Wi-Fi, popcorn and soda. What’s better — standard rooms sleep four. A search at the end of September revealed that November 22-23 and 29-30 as well as Dec 11-13, 20-21 and 25-28 should get you that price. The chic hotel is located in the Dallas Design District and features a three-hectare sculpture park and 1000-piece art collection. The hotel received a 2015 TripAdvisor Certificate of Excellence Award. tel: (214) 748-1200; hiltonanatolehotel.com/special-offers.

San Diego, CA

BOOK NOW!

During the entire month of October, kids stay, eat and play for free throughout San Diego. There are 100-plus offers to choose from, but one of the best is complimentary admission to more

June 19-‐July 1, 2016

July 9-‐16, 2016

• Bal1c Capital Ci1es • Cardiology, Neurology & Gastroenterology

• Greece & Turkey • Emergency Medicine

than 40 museums for kids 12 and under (with one paying adult) — San Diego Air and Space Museum, Birch Aquarium at Scripps, New Children’s Museum, San Diego Museum of Art. Entrance is also free at the San Diego Zoo and Safari Park for kids 11 and under, a US$38 value. sandiego.org/promotions/kids-free.aspx.

Whistler, BC

BOOK NOW!

The winter 2015/16 season will mark Whistler Blackcomb’s 50th anniversary and to celebrate the resort is offering several ski savings — many that have to be booked by November 15. One limited-time deal is a five-night, four-day, lift-and-lodging package that will save you up to 40 percent. Another five-night, four-day package includes free accommodation and lift tickets for one kid 12 and under with one paying adult (based on two people in a hotel room). Buying at least two days of lift tickets three days in advance is another offer that will save you up to 40 percent. whistlerblackcomb.com/purchase/deals-packages.

September 24-‐October 8, 2016 • A Guide to a Healthy Heart: • Mediterranean & Israel • Cardiology & Endocrinology

OCTOBER 2015 • Doctor’s

Review

GLYCEMIC CONTROL WITH CONFIDENCE

CARDIOVASCULAR SAFETY EVIDENCE

GLYCEMIC CONTROL WITH ONGLYZA

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

•

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

•

A1c mean change from baseline:1*

•

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

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

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

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

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

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

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

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

07/16

See additional safety information on page XX See page XX 51 for additional safety information

GA D GE T S by

R og e r W hi t e

Quick fixes for daily irritants Here’s an encouraging thought: there are thousands of ordinary people out there trying to solve life’s small — but frequent — irritants. Here are four examples; perhaps one will make life a little easier for you. BAG LIGHT Tired of rummaging around in your medical case, gym bag, purse, backpack and so on. Here’s a solution: a bright, motion-sensitive light that sits in there and comes on automatically when you open looking for something and goes off after you close up. Called the SOI, it measures 8.4 centimetres in diameter and weighs only 48 grams. handtaschenlicht.com. Available at amazon.com, US$35; amazon.ca, $75. MULTIPLE DEVICE CHARGING STATION Does your family run around the house looking for a place to recharge their phones, music players, tablets and so on? Charge Hub takes a single electrical outlet and will charge up to seven devices simultaneously. A snazzy blue light under the hockeypuck sized device makes it easy to find even in the dark. Put a couple in convenient locations and make life is easier for everyone. thechargehub.com, US$59.95. DIRTY TOUCH SCREENS CLEANED Thirty years ago surgeon Dr Stanley Taub invented a silicon drape to hold instruments while operating. Recently, using a similar material, he came up with a roller that easily cleans any touch screen. The iRoller is about half the width of a full-sized tablet; the device easily removes fingerprints, smudges, smears and even bacteria. Washes clean under cold water faucet. sktproductions.com. Available at amazon.com, US$20; amazon.ca, $47. FUZZ-BALL BUSTER Many garments — especially woolen ones — look great when they’ve just been cleaned, but soon acquire a landscape of “pills” especially in places that get the most wear. Short of picking at them individually, they’re devils to get off. Enter Gleener’s Ultimate Fuzz Remover. The simple device, about the size of a large hairbrush, has three interchangeable attachments that clean up clothes in a jiffy regardless of pill size. gleener.com. Available at bedbathandbeyond.ca, $20.

OCTOBER 2015 • Doctor’s

Review

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

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

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Banff, AB March 4-6, 2016 61st Annual Scientific Assembly of the Alberta College of Family Physicians acfp.ca/what-we-do/annual-scientific-assembly

March 13-16, 2016

Edmonton, AB February 18-20, 2016 2016 Scientific Meeting of the Canadian Pediatric Endocrine Group interprofessional.ubc.ca/CPEG2016/default.asp

Montreal, QC February 26-29, 2016

CANADIAN GUILD OF CRAFTS

ACC Rockies acclakelouise.com

The Canadian Guild of Crafts in Montreal.

Around the world

Canadian Digestive Diseases Week cag-acg.org/cddw

Amsterdam, Netherlands March 9-11, 2016

Vancouver, BC March 11-12, 2016 PSBC’s 2nd Biennial Conference: Healthy Mothers and Healthy Babies, Advances in Clinical Practice and Research Across the Continuum interprofessional.ubc.ca/healthymothers healthybabies2016/default.asp

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

10th European Breast Cancer Conference ecco-org.eu

Barcelona, Spain March 31-April 3, 2016

Fort Lauderdale, FL March 3-6, 2016 2016 Annual Meeting of the American Glaucoma Society americanglaucomasociety.net/meeting

3rd World Congress on Controversies in

Hyderabad, India March 2-5, 2016

Pediatrics congressmed.com/copedia

17th International Congress on Infectious Diseases isid.org/icid

Chicago, IL March 9-12, 2016

Las Vegas, NV February 27-March 1, 2016

2016 Annual Assembly of the American Academy of Hospice and Palliative Medicine aahpm.org/meetings/assembly

Fourth International Congress on Cardiac Problems in Pregnancy 2016.cppcongress.com

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

OCTOBER 2015 • Doctor’s

R2015-05-25 eview

11:11 PM

THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Lisbon, Portugal February 18-20, 2016 4th Systemic Sclerosis World Congress web.aimgroupinternational.com/2016/ sclerosiscongress

March 17-20, 2016

Los Angeles, CA March 4-7, 2016 2016 Annual Meeting of the American Academy of Allergy, Asthma and Immunology annualmeeting.aaaai.org

Madrid, Spain March 12-15, 2016

The Sonoran Desert in Phoenix, AZ.

24th European Congress of Psychiatry epa-congress.org

Prague, Czech Republic March 4-5, 2016

Miami, FL March 10-13, 2016

17th European Congress: Perspectives in Lung Cancer imedex.com/lung-cancer-congress-europe

2016 Annual Meeting of the American Medical Women’s Association amwa-doc.org/future-amwa-meetings

San Diego, CA March 19-22, 2016

Milan, Italy February 3-6, 2016

2016 SGO Annual Meeting on Women’s Cancer sgo.org/education/annual-meeting-on-womenscancer

9th International Conference on Advanced Technologies and Treatments for Diabetes attd2016.com

Doctor’s Review • OCTOBER 2015

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

3rd International Conference on Nutrition and Growth nutrition-growth.kenes.com

32nd Annual Meeting of the American Academy of Pain Medicine painmed.org/annualmeeting

Washington, DC March 4-8, 2016 ANTON IVANOV / SHUTTERSTOCK.COM

Epidemiology and Prevention: Lifestyle and Cardiometabolic Health 2016 Scientific Session my.americanheart.org/professional/Sessions/ EPILifestyle/EPILifestyle-Scientific-Sessions_ UCM_316904_SubHomePage.jsp

Eleventh World Congress on Brain Injury internationalbrain.org/news/save-date-eleventhworld-congress-2016

Vienna, Austria March 17-19, 2016

Palm Springs, CA February 18-21, 2016

Phoenix, AZ March 1-4, 2016

The Hague, Netherlands March 2-5, 2016

74th Annual Meeting of the American Academy of Dermatology aad.org/meetings/2016-annual-meeting

The Binnenhof complex in The Hague, Netherlands.

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

TOM ROCHE / SHUTTERSTOCK.COM

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

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

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

IN CHILDREN, ADOLESCENTS AND ADULTS 1*

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

Flexible dosing – available in 8 strengths for dose optimization2¶

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

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

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

52 See additional safety information on page XX

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

R os e F os t e r

Ocular disease and its effect on art Part one: the eyes of Monet, Cassatt, Degas and O’Keeffe

Monet’s bilateral cataracts caused his paintings to become muddied.

“M

onet is only an eye,” painter Paul Cézanne said famously, “but what an eye!” Towards the end of his life, Claude Monet’s luminous canvases took on a somber, muddied look. Was the Impressionist

master turning into an Expressionist? Was he, perhaps, infusing his work with the cynicism and the woes of old age by darkening his palette? Zealous fans have balked at the idea that the colours in these works might have been determined by something other than pure inspiration, but among ophthalmologists, the evidence speaks for itself: by his 70s, Monet’s bilateral cataracts had become browner than the muddy water on the bottom of the Seine.

Monet’s progressive inability to distinguish between blues and greens is well documented. Writing of it himself post-cataract surgery, when the cat was out of the bag, he admits his despair: “I no longer perceived colours with the same intensity, I no longer painted light with the same accuracy. Reds appeared muddy to me, pinks insipid, and the intermediate or lower tones escaped me. What I painted was more and more dark, more and more like an ‘old picture,’ OCTOBER 2015 • Doctor’s

Review

In 1977, at age 90, O’Keeffe observed, “I can see what I want to paint. The thing that makes you want to create is still there” and when the attempt was over and I compared it to former works, I would be seized by a frantic rage and slash all my canvases with a pen knife.”

FEAR OF THE KNIFE In spite of this violent frustration, he was terrified to face the scalpel and postponed surgery for years. Cataract removal was not a new procedure — the first documented surgical removal of a cataract from the eye occurred in Paris more than a century earlier — but one of his colleagues, ex-pat American painter Mary Cassatt, was not one of the procedure’s success stories. Cassatt, well loved for her depictions of women and children in a simple style influenced by Japanese ukiyo-e prints, began to lose her sight to cataracts in 1900, when she was 56. By 1910, she had given up printmaking, which required a level of detail she couldn’t muster. Assessing the toll that the artistic life had on the rest of her colleagues, she proclaimed, “Nothing takes it out of one like painting. I have only to look around me to see that, to see Degas a mere wreck, and Renoir and Monet, too.” By this time, Degas had joined Monet in the descent into blindness, and Renoir had such bad arthritis that paintbrushes had to be forced into his gnarled hand by assistants. Radium inhalation therapy, all the rage in the early 1900s, didn’t seem to fix Cassatt’s sight, so, in 1917, After two unsuccessful cataract operations, American impressionist Mary Cassatt gave up painting entirely in 1917.

she agreed to cataract surgery in her right eye. It didn’t work, in fact, her vision worsened, in part due to a subsequent opacity of the posterior lens capsule in the same eye. Anticipating the forthcoming operation on her left eye, she wrote, “I look forward with horror to utter darkness and then an operation which may end in as great a failure as the last one.” Sadly, she was right. After a 1919 operation on her left eye, she never painted again. Monet must have had a convincing eye doctor, because in 1923 he agreed to cataract surgery in one eye. Success! Suddenly, the world was returned to him. Blues, greens, pinks and purples flooded back into his “blue” eye while his other eye continued to perceive yellowed tones. He began to paint with new fervour, completing some of his best-known paintings in the three following years before his death. Legend has it that he may even have acquired a form of ultraviolet super-vision. A documented case of a retired Air Force officer who underwent cataract surgery in 2011 and wound up able to perceive the low end of the visible light spectrum suggests that there could be a grain of truth in the story. Post-operative, the Impressionist master is said to have visited his paintings where they hung in museum collections and obsessively tried to “correct” the colours when no one was watching. Monet clearly thought that poor vision compromised his work. His colleague, Edgar Degas, was not so sure. He first noticed eye problems at age 36 when he was stationed as a national guardsman in the Franco-Prussian war in 1870, perceiving a blind spot in his right eye when he tried to aim a rifle. By 1890, his retinal disease — probably macular degeneration — had begun to deteriorate the vision in his left eye as well.

THE MIND’S EYE Art historians have observed the decline in the level of detail in Degas’ images as his vision worsened, as well as an increased coarseness to his brush strokes. His work would have appeared differently to him than it does to those with good vision, they say — strokes would have been blurred and smoothed. And they cite his gradually building preference for oil pastels and sculpture as evidence that oil paint had become too hard for him to handle. But the visual challenges Degas faced did not necessarily compromise the power of his work, some critics insist. “What his draftsmanship lost in fullness of realistic description and refinement of execution it gained

in grandeur and expression,” says Columbia University art historian Theodore F. Reff. And while PierreAuguste Renoir commenting on the state of Degas’ vision, proclaimed after the death of his friend in 1917, “It is fortunate for him …any conceivable death is better than living the way he was,” Degas himself took a more philosophic approach to his near-blindness — “I am convinced that these differences in vision are of no importance. One sees as one wishes to see. It’s false, and it is that falsity that constitutes art,” he said of his failing sight. The beautiful “falsity” made possible by these great pioneers of vision who had to contend with changing eyesight in the course of their lives literally changed the way subsequent generations perceived the world. These painters were the first to actively identify an inner sight, a longing to convey beauty beyond the confines of what had been considered literal perception. By loosening the adherence to “correct” colours and allowing lines to blur and merge, they opened the door to an artistic hunger for new visions which gave birth to Fauvism, Cubism, Surrealism, Abstract Expressionism, and the rest of art history as we know it. Degas’s acceptance of his ocular eccentricities, then, were perhaps an acknowledgment of the insignificance of the eye in the service of inner sight, a monumental proclamation in his time.

O’KEEFFE’S INFIRMITY Modernist painter Georgia O’Keeffe might have agreed. She too suffered from macular degeneration and was discouraged by her failing sight. In 1972, she completed

The top row (A,B,C) shows three Degas paintings done between 1885 and 1910; the bottom row (D,E,F) shows the same paintings blurred to Degas’ quality of eyesight at the time he painted them. BELOW: Georgia O’Keeffe, shown here in her younger days, later suffered from macular degeneration and did not paint unassisted after age 87.

her last unassisted oil painting, The Beyond. A year later, a young potter named Juan Hamilton knocked on her door looking for a job. He became her closest friend, teaching her to work with clay and infusing her creative practice with new life. In 1977, at age 90, she observed, “I can see what I want to paint. The thing that makes you want to create is still there.” Though she was almost blind, she began to paint again, with assistance, using abstract watercolour forms that activated the page from edge to edge and she continued to realize her lifelong goal to “fill space in a beautiful way.” Sky Above Clouds/ Yellow Horizon is one such work, powerful in its simplicity. Stay tuned for part two: Was Van Gogh colour blind? OCTOBER 2015 • Doctor’s

Review

In major depressive disorder

“I felt down and

overwhelmed nearly every day.” Nicole*, 37

For patients like Nicole...

Trust PRISTIQ

for powerful

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

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

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

• Increases cholesterol and triglycerides (consider measurement during treatment) • Hyponatremia or Syndrome of Inappropriate Antidiuretic Hormone (SIADH) with SSRI/SNRI • Potential for GI obstruction • Abnormal bleeding with SSRI/SNRI • Interstitial lung disease and eosinophilic pneumonia with venlafaxine • Seizures • Narrow angle glaucoma • Mania/hypomania • Serotonin syndrome or neuroleptic malignant syndrome-like reactions For more information Please consult the product monograph at http://www.pfizer.ca/en/our_products/ products/monograph/226 for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001. Reference: PRISTIQ Product Monograph, Pfizer Canada Inc., July 3, 2013.

CA0113PRI023E

Count on

for powerful symptom relief

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

Mairi MacKinnon

Open a dialogue on sex and depression Chances are if you don’t ask, patients won’t tell

D .

ecreased sexual interest and satisfaction are common in both women and men with major depressive disorder (MDD). This can be due to the depression itself and/or to its treatment. Symptoms include reduced libido, impaired arousal and difficulties achieving orgasm.1-3 Sexual dysfunction can significantly lower self-esteem and quality of life and is also a foremost cause of non-adherence to therapy, which puts patients in jeopardy of depression relapse.1,3 Unfortunately, sex is a subject patients (and sometimes physicians) tend to shy away from, so problems often remain hidden or underestimated. The good news is that, once properly assessed, sexual problems related to depression can usually be treated. Talking openly to patients about their sexual difficulties and working with them on ways to manage them can boost their confidence and compliance and go a long way to improving outcomes.3,4

Symptom or side effect? Many factors — medical, psychosocial, interpersonal and neurobiologic — can contribute to sexual problems in people suffering from MDD. Medications used to treat depression are also sometimes to blame. Antidepressants work by altering the functioning of neurotransmitters, resulting in heightened mood. But they also affect nerve pathways that regulate sexual function, and are linked to sexual dysfunction in up to 60% of patients.3,4 The rate of sexual side effects varies with the type and dose of the antidepressant used; frequency associated with first-line antidepressants is highest for selective serotonin reuptake inhibitors and slightly lower for serotonin norepinephrine reuptake inhibitors.2,3 It can be difficult to distinguish whether problems are symptoms of depression or side effects of treatment. Assessing sexual function at baseline, before prescribing therapy, is important, and can assist in deciding on the best antidepressant for individual patients as well as in monitoring for side effects that arise during the course of therapy.3 One obstacle to adequate assessment and treatment of sexual dysfunction in MDD is that patient reports are often unreliable. Besides being embarrassed to bring up their sexual problems, many patients may be unaware of the sexual side effects related to their antidepressants.2,3 A frank approach works best. Include direct questions about sex when inquiring about patients’ mood, interest in normal activities, etc. Providing questionnaires and validated rating scales can also help break the ice and guide the discussion.3

Management strategies Treatment-related sexual dysfunction does not generally resolve on its own.2,5 Pharmacologic interventions include: • reducing the antidepressant dose (while watching for signs of relapse) • switching to another effective but lower-risk antidepressant • adding another agent to counteract sexual side effects or to enhance sexuality.2,3 Non-pharmacologic methods can also be tried. Recommended strategies for MDD such as psychotherapy and relaxation techniques, along with specific sex therapy, can be useful. Exercise before sexual activity has also been reported to improve genital arousal in women.3 Finally, healthy life habits — e.g. weight control, sleep hygiene, smoking cessation/abstinence and stress management — are advised for all patients with depression.5,6

Taking charge Therapy for depression targets elimination of symptoms, return to full normal functioning and quality of life, and prevention of recurrence.6 Engage your patients in frank discussions about sexual side effects related to depression and/or its treatment. Involve them in finding the medication or combination of medications as well as other management strategies that work best for them. Above all, make sure patients understand the importance of sticking with their treatment plan in order to ensure their long-term recovery. References 1. Kennedy SH, Rizvi S. Sexual dysfunction, depression, and the impact of antidepressants. J Clin Psychopharmacol 2009;29:157-64. 2. Lam RW, Kennedy SH, Grigoriadis S et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy. J Aff Disord 2009;117(Suppl 1):S26–S43. 3. Poulin M-J. Managing sexual dysfunction in MDD: Depression-related causes and antidepressant-related causes. www.peervoice.com/clinical-approachessexual-dysfunction-major-depressive-disorder. Accessed September 14, 2015. 4. Depression Health Center. Sexual problems and depression. WebMD, 2014. www.webmd.com/depression/guide/sexual-problems-and-depression. Accessed September 14, 2015. 5. BCGuidelines.ca. Major depressive disorder in adults: Diagnosis & management. British Columbia Ministry of Health, 2013. 6. Patten SB, Kennedy SH, Lam RW et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. J Aff Disord 2009;117(Suppl 1):S5–S14. OCTOBER 2015 • Doctor’s

Review

I P R E S C R I B E A TRIP TO... A GLIDING CLUB

Up, up and away …in a shiny soaring machine

Ridge flying in Saint-Auban, a commune in the Alps, with instructor Yanik Gendron.

lying gliders is, frankly, fabulous. It’s hard to convey the thrill of soaring silently as a bird and gazing down on the earth below. With Mother Nature’s help, you can enjoy that feeling for many

Dr Réal Le Gouëff graduated in family medicine from the University of Montreal and now practices in Saint-Michel-des-Saints, Quebec, northeast of Montreal. He joined the Montreal Soaring Club in 1977 and has been seriously devoted to gliding since 1996.

Doctor’s Review • OCTOBER 2015

hours of fun. Like sailing, it’s a sport in perfect harmony with nature. Canada is a great place for gliding. There are gliding clubs across the country, which you can find through the Soaring Association of Canada (sac. ca). Some clubs even offer RV camping which leads to an interesting social life with new friends, great

ALL PHOTOS COURTESY RÉAL LE GOUËFF

by Dr Réal Le Gouëff

Like to experience the sport? Most gliding clubs offer introductory rides parties and evenings around campfires swapping gliding stories. For kids considering a career as a pilot, gliding offers terrific benefits: they can learn to fly on the cheap and Transport Canada will credit them with a number of flying hours toward a future pilot licence.

The author and his instructor, Alain Laprade, in a flight near Hawkesbury, ON.

GETTING UP THERE In most cases, gliders are towed up to a given altitude and released to fly on their own. Some gliders, though, have small engines to enable them to take off without a tow. In other cases, engines are designed just to sustain flight. In the photo (right), I’m flying with my co-pilot Alain Laprade above Hawkesbury, ON. We’re in a unique motor glider with an engine that can be retracted into the fuselage when its work is done and allow us to take full advantage of this gracious, highperforming craft. You don’t need supernatural skills to be a glider pilot. When I was learning to fly, I was very anxious to know if I was going to make it. I asked my instructor what he thought of my chances. He looked at me with ice cold eyes, waited a few seconds, and as I was almost having a nervous breakdown awaiting a devastating comment, he got closer and asked me in the most severe manner, “Do you know how to ride a bicycle?” Choked with apprehension, I answered with an almost inaudible, “Yes.” He burst out laughing and shouted, “Well then don’t worry, you’ll be able to fly a glider, no problem!”

GLIDING HIGH In terms of performance, it’s almost unbelievable what these machines can do. For instance, a reasonably good glider, released at an altitude of 2000 metres, can travel about 60 kilometres and the best ones can do a lot more. As you might imagine, many factors come into play which effect performance. You need to use strategies taking into account the terrain, the weather, the winds, your location and the best time of the day to take you where you want to go. The idea is to fly where you wish during a day of gliding always with the goal of returning to the home field at flight’s end. On the other hand, you can simply stay close to the gliding club’s home field. One of the beauties of

FLOATING ON AIR There are essentially three ways of flying gliders. In thermal flying, you search for an updraft, frequently found under a cloud, and climb in for as long as you can. You then look for another one and so on. The idea is to cover as much distance as possible in a single-day outing. The MSC record is about 750 kilometres. Wave flying occurs in specific areas and can allow you to cover great distances and go to very high altitudes. The world wave flying distance record is over 3000 kilometres in a single day. Given the high altitudes involved, you must dress warmly and will require oxygen. I personally have been to 6705 metres, but you can go much higher. Mountain flying uses a mountainside warmed up by the sun to create an upward moving air mass. Ridge flying is a variation which involves flying close to a mountain when an air current (wind) is blowing on it, exactly as you might surf a wave going over a rock under the water. OCTOBER 2015 • Doctor’s

Review

Gliders parked in Saint-Auban waiting for pilots to take them up.

the sport is that you can gear it to the amount of challenge you’re ready for on any given day. If you’re the solitary kind, you can use a single seat glider and go your own way. More social types fly two seaters and enjoy the benefit of a co-pilot on board to share the experience. Gliding is not as expensive as you might think. Despite the fact that we are most of the time flying expensive rented machines, it ends up being cheaper

and more engaging than many other summer sports. And if you really get in to it, you can always buy your own glider. A second-hand reasonably good machine will be less expensive than the average ordinary new car. Like to experience the sport? Most the gliding clubs offer introductory rides. They’ll help you see for yourself what gliding is all about and will introduce you to a new world which you just might find is as addictive as it’s been for me.

THE (PRETTY REASONABLE) COST OF SOARING Gliding costs can be compared to those of skiing or golf. At the Montreal Soaring Club or MSC (montrealsoaring.com), a half hour flight typically costs $120 or $450 for a five-flight plan — the kind of green fees or lift ticket prices you might pay. Typically this is how someone begins the sport. If you find it’s for you, an annual club membership comes in at $1200. Each tow will set you back $33 at the MSC with another $0.10 a minute ($6 an hour) to rent a gilder. That means a full eight hours of flight comes in at less than $100. True devotees buy their own glider. A used one can be purchased for US$10,000-15,000 (go to bit.ly/1LD9h5G to browse some for sale). Buying a craft is not quite as simple as kicking tires. Here’s a document that tells you pretty much everything you need to know: bit.ly/1QMEzvw — it will either light a fire under your wings or quash the dream entirely.

Doctor’s Review • OCTOBER 2015

Step into the cockpit of a two-seater Duo Discus Turbo.

Introducing

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

Nesina is reimbursed by RAMQ as a medicament d’exception and prescribing codes are available for all indications reimbursed. ®

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. ®

NES-2015-6E

Take it on the Why the months between the high and low season may be the best time to travel by Josephine Matyas

EKATERINE POKROVSKY / SHUTTERSTOCK.COM

here are those who simply can’t wean themselves from booking vacation travel at peak times. They endure lineups in airports, restaurants, museums and theme parks, and bear the brunt of surly service from overstretched wait staff. When the credit card bill arrives in the mail, it’s time for the smelling salts. “There must be a better way,” they plead. The good news is there is a much better way. Travelling in what tourism insiders call “the shoulder season” is a breath of fresh air: tourist hordes are blissfully absent, wait times shrink, prices plummet and service staff are all smiles. The trick is to find that slot of time between the low season (usually plagued by bad weather) and high season (high demand and low supply, stratospheric prices). The bliss of shoulder season doesn’t fall at the same time everywhere — it takes a bit of research.

Doctor’s Review • OCTOBER 2015

We’ve got your back, with some planning suggestions and tips to go along with some popular locations.

CANADA SHOULDER SEASON: After Labour Day

is the perfect time to practice leaf peeping in the Maritimes, Ontario and Quebec. Daytimes are still warm (thank you, Indian Summer), the pesky bugs have disappeared and roads are clear for hops between farmers’ markets or along culinary trails. For winter travel, many ski resorts in British Columbia,

shoulder

Hotspots like London see less tourists in the shoulder season and as the leaves fall, so do prices.

New Mexico is scorching in summer so take in sites like the Gila Cliff Dwellings when temperatures are cooler.

JOSEPHINE MATYAS

The Yukon Quest is held annually in February and covers 1600 kilometres of wilderness between Whitehorse, YT and Fairbanks, AK.

Toss in Northern Lights watching, sightseeing flights over glaciers, soaking in hot springs and you’ve got an instant vacation Alberta, Ontario and Quebec open in November, but the crowds don’t clog the hills until the Christmas break. Check websites for early season specials on accommodation and ski passes. TIPS: Road trips, resort stays and camping

dominate Canada’s short warm weather window in the summer months. Late spring and early fall often bring good weather and great deals at campgrounds and resorts. Consider camping during the shoulder seasons when you may have large parts of the park to yourself. Ontario Parks (ontarioparks.ca) have developed a system of yurts — round, tent-like structures on an elevated wooden platform — outfitted with bunk beds (sleeps six), dining table, propane barbecue, picnic table and fire pit. Parks Canada (pc.gc.ca) has a similar system called oTENTiks — soft-sided platform tents with sleeping and dining for six, solar powered lights, charcoal barbecues and fire pits. Rent a kayak and paddle out to an island of Thousand Islands National Park and you may have it to yourself. The leaves change about two weeks later on the islands than on the mainland due to the water’s insulating properties. Local outfitter 1000 Islands Kayaking (tel: 613-329-6265; 1000islands kayaking.com) will even schlep your gear out for you.

Doctor’s Review • OCTOBER 2015

Finally, think outside the box. Wintertime in frosty destinations like the Yukon is magical, with guaranteed snow conditions for skiing, snowshoeing, snowmobiling and dogsledding. Toss in Northern Lights watching, sightseeing flights over glaciers, soaking in hot springs and you’ve got an instant vacation. Hotels and local outfitters rent heavy-duty cold weather wear especially popular during the territory’s many winter events like the Yukon Quest International Dog Sled Race (February 6, 2016, yukonquest.com) or Sourdough Rendezvous Festival (February 19-28, 2016, yukonrendezvous.com).

US SHOULDER SEASON: As a general rule,

right after the kids head back to school: from September through mid-December (avoiding US Thanksgiving) and in January immediately after the winter break has ended. The toasty Southwest states (Arizona and New Mexico) run deep discounts in the summer months, but temperatures in the Phoenix area can easily top 100 degrees. Fall and springtime have perfect weather and low crowds. CURRENCY: Given the loonie’s sharp

tumble, US travel this year requires close scrutiny of prices. Add 30 percent to get a figure closer to the ultimate cost in Canadian dollars.

STEPHEN B. GOODWIN / SHUTTERSTOCK.COM

North Carolina’s Roanoke Marshes Lighthouse closes in early fall, but visitors can still walk the boardwalk over Roanoke Sound.

WEATHER: The Atlantic hurricane season

runs from June through November, so popular tourist destinations like Florida’s Keys and Gulf Coast, and the Carolina and Texas coastlines are vulnerable. The good news is the chance of a major storm hit is small and weather disturbances are tracked days in advance through the National Hurricane Center (nhc.noaa.gov). Tornados are a more tempestuous danger, but the Storm Prediction Center (spc.noaa.gov) issues outlooks for the following eight days. The main season is late springtime and early summer across the Southeast, Midwest and Plains. The infamous Tornado Alley in the southern plains of the US (Texas, Oklahoma, Kansas, Nebraska) consistently receives supercell thunderstorms and violent tornados. Remember Dorothy and Toto? TIPS: Like Canada, the United States is a

travel buffet of vastly different climate zones and geography. A general rule of thumb is to stay away from school breaks and national holidays. Canadians tend to think of Florida and Walt Disney World in the same breath as a peak cold-weather destination. The truth is Disney’s high season happens whenever kids are out of school: Christmas,

Easter and the sweltering summer months. Avoid these times, and prices drop and lines for rides shrink. Orlando is inland and may see rain and wind in the fall, but not the same dangerous weather as along coastlines. Creative solutions abound with one-way drive programs like Toronto Drive-Away (tel: 800-5612658; torontodriveaway.com), a service for snowbirds that shuttles cars back and forth between the GTA and Florida in the spring and fall shoulder seasons. Once accepted as a driver with the service, you choose a date and location to pick up (or drop off) a car in Florida for the Toronto owners. Drivers are given several days to follow a direct route back to Toronto and are reimbursed for gas costs. In addition, the driver receives a bonus payment for performing the service (an amount that easily covers one-way airfares and baggage charges). The locals rave about the empty beaches and the fishing along the Carolinas coastline in the fall. Autumn is white shrimp season in South Carolina and the perfect time to buy right from the dock at shrimpers like Gay Fish Co. outside Beaufort (the docks may look familiar, they were a film shoot location for Forrest Gump). The Outer Banks of North Carolina are practically deserted, perfect for windsurfing, kite flying and beach walking. OCTOBER 2015 • Doctor’s

Review

JOSEPHINE MATYAS

Aruba sits outside the traditional “hurricane belt” making the Bucuti & Tara Beach Resort perfect for an autumn getaway.

CARIBBEAN SHOULDER SEASON: Fall brings the

promise of warm waters, clear snorkelling and diving and — if you choose your spots right — almost no risk of tropical storms. The closer you get to the equator, the less fluctuation in temperatures year-round. As a result, spring and fall are warm enough to fight off the memory of northern winter chill. WEATHER: Like the Southeast US, much

of the Caribbean is on tropical storm and hurricane watch from June through November. Weather disturbances can be tracked days in advance through the National Hurricane Center (nhc.noaa.gov). TIPS: The islands of the southern Caribbean

lie outside the traditional hurricane belt: the chance of a tropical storm barrelling through Trinidad or Grenada is low and almost nonexistent in the ABC islands of Aruba, Bonaire and Curaçao. Being tucked out of the way is a tourism blessing. The three small islands sit far west of the hurricane path and — with a low chance of rainfall

Doctor’s Review • OCTOBER 2015

and a high chance of sunshine — are considered a reliable bet for postcard-perfect weather year-round. For those who crave relaxation and downtime, Aruba’s Bucuti & Tara Beach Resort (tel: 297-583-1100; bucuti.com; from US$483 per room a night, December through March) is an adults-only boutique property perfect for anniversary celebrations, honeymoons, romantic getaways and adults looking to unwind without the buzz of scheduled activities. Curaçao’s (curacao.com) capital city of Willemstad, a UNESCO World Heritage Site, is filled with Dutch colonial architecture in a rainbow of pastel colours and gabled, red-tiled roofs. The three- and four-storey buildings are part of the original Dutch settlement where the merchants plied their trade in the main floor shops and warehouses, living on the floors above. Today they are filled with trendy shops, bars and restaurants. There are dozens of major music festivals in the islands through the low-season summer months. In Barbados, August’s lively Crop Over Festival (barbados. org/cropclnd.htm) marks the traditional end of the intensive sugarcane harvest. August is also the month when Grenadians let loose at Spice Mas (spicemas grenada.com), a carnival celebration of the island’s African, French, British and Caribbean heritage.

PLUSONE / SHUTTERSTOCK.COM

JOSEPHINE MATYAS

The tight canals and alleyways of Venice seem so much more spacious when the high-season throngs have gone.

Curaçao’s capital, Willemstad, features Dutch colonial architecture and is one of the Caribbean’s few UNESCO cities.

The ABC islands sit far west of the hurricane path and are a reliable bet for perfect weather year-round EUROPE

WEATHER: The weather across much of the

Avalon Waterways (tel: 800-268-3636; avalonwaterways. ca/river-cruise-deals) is March/April and late October/ November. Look for excellent value in Christmas Market cruises in November/early December, visiting charming outdoor markets in medieval settings. Avalon has numerous promotions and sales year-round, and many are offered in shoulder season, either through cash savings, waived single supplements or other goodies. Rail passes offer special deals and promotions in the quieter fall months. Eurail’s (eurail.com) 2015 fall promotions include deep discounts or free promo days on rail passes. The Swiss Rail Pass offers deals through the Rail Europe website (raileurope.ca, handled by Rail Europe in Canada), with info on promos like two-for-one offers, discounted prices or added values.

continent is fantastic in the fall and spring. This autumn the unseasonable warmth should continue across most of central and eastern Europe.

SHIFT INTO PLANNING GEAR

SHOULDER SEASON: As the leaves fall,

so do prices in cities like London, Paris and Rome. Fall also brings the harvest experience in many of the wine-growing regions of France, Italy and Germany. Airlines often hop on board with deals at much better rates than summertime prices. In short, fall is fantastic (followed closely by the magic of springtime in Europe, without the crowds). CURRENCY: The euro was trading around

$1.50 Canadian at the time of writing. Check exchange rates before you book.

TIPS: The tight quarters in historic cities —

think of the alleyways in Venice or Heidelberg, or the Colosseum in Rome or the flea markets of Paris — seem so much more spacious when the high-season throngs have evaporated. Shoulder season for European river cruises like

Arm yourself with maps, a calculator and a list of websites to help with research. Try: kayak.com or skyscanner.ca for flights, car rentals and hotels vrbo.com for vacation rentals through property owners theweathernetwork.com for current weather and seasonal trends OCTOBER 2015 • Doctor’s

Review

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

AndroGel

速

TESTOSTERONE REPLACEMENT THERAPY (TRT) FOR MEN WITH HYPOGONADISM 1

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

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

Pennsylva Amish farms, art museums and estate gardens for a charming day trip through Philadelphia’s countryside by Cherie DeLory

Dutch- and German-speaking immigrants settled in Delaware and Chester in the 17th and 18th centuries; today many Amish live in “Pennsylvania Dutch” country.

vania Dutch “I

t’s Pennsylvania Bluestone,” a local resident explains after I inquire. While out for a

scenic drive in the pretty Pennsylvania countryside, I’m charmed by the immaculate farmhouses adorned with stylish slabs of bluish-grey stone. The rock is predominately quarried in Pennsylvania so it’s part of the landscape. I’m in Delaware and Chester County, a region traditionally referred to as Pennsylvania Dutch because of Dutch- and German-speaking immigrants who settled in the area. The pastoral Amish farms and congenial small towns are less than an hour’s drive or train trip from Philadelphia. If the allure of gardens, galleries and culinary treasures makes your heart skip a beat, it’s time to explore the calm of the Philadelphia countryside. The vacation and residential town of Wayne evokes an old-world charm. There’s the Wayne Art Center (413 Maplewood Avenue; tel: 610-688-3553; wayneart.org), established in 1930 as the first art centre on the Main Line, and the Anthony Wayne Theatre (109 West Lancaster Avenue; tel: 610-225-2442; reelcinemaspa.com), a first-run art deco cinema circa 1928. There’s also the Wayne Hotel (139 East Lancaster Avenue; tel: 610-687-5000; waynehotel.com), an elegant Tudor Revival-style property that dates from around 1906, and plenty of vintage and contemporary boutiques for browsing along the main street. With more than 30 public gardens within 48 kilometres of Philadelphia, it’s no wonder the city’s moniker is America’s Garden Capital and no trip to Wayne is complete without a visit to the lush landscapes

OCTOBER 2015 • Doctor’s

Review

COURTESY CHESTER COUNTY CVB

The Love Temple gazebo at Longwood Gardens is a favourite spot for fall leaf peeping.

and ornate gardens of Chanticleer (786 Church Road; tel: 610-687-4163; chanticleergarden.org; ages 10 and up US$10; April through October). The 14-hectare garden sits on the grounds of the old estate once owned by the head of the pharmaceutical company Rosengarten and Sons. Guided tours are available (US$15). After smelling the roses at Chanticleer, why not house hunt for a property in Wayne with Hollywood connections? Director George Cukor’s Oscar-winning film The Philadelphia Story, starring Katharine Hepburn, Carey Grant and Jimmy Stewart, was inspired by socialite Helen Hope Montgomery, who lived in the Montgomery-Scott Ardrossan manor. Over the years, much of the 300-hectare cattle farm has been sold off, most recently to an upscale housing development.

ongwood Gardens (1001 Longwood Road; tel: 610-388-1000; longwoodgardens.org; adults US$20) in Kennett Square’s cherished Brandywine Valley is open year round with a hectare of plants from around the world inside the enchanting glass conservatory. The outdoor gardens occupy over 400 hectares of meadows, woodlands, cascading waterfalls, trails and ponds, and more fountains than any garden in the United States. The Italian Water Garden was inspired by

Doctor’s Review • OCTOBER 2015

At Penns Woods Winery, Gino Razzi and his daughter Carley Mack offer tastings year-round.

the Villa Gamberaia in Florence. The property was an arboretum when purchased by businessman Pierre S. du Pont (of the du Pont chemical company empire) in 1906. The open-air theatre hosts concerts and plays, and the conservatory is home to an Aeolian pipe organ, not to mention America’s best-loved bathrooms. Longwood recently won top prize for its restroom facilities (bestrestroom.com). The doors to

Thousands of Amish still live a “Plain” lifestyle and commute by horse and buggy.

MICHELLE D. MILLIMAN / SHUTTERSTOCK.COM

LEE SNIDER PHOTO IMAGES / SHUTTERSTOCK.COM

Many Amish women sell handmade quilts and pillows at roadside markets — but never on a Sunday.

Penns Woods Winery is a place where you can walk barefoot in the grass and simply enjoy the vineyard with a view the 17 private fern-draped lavatories morph seamlessly into the living wall landscape. The historic town of Kennett Square imbues a sophistication and foodie distinction that comes with being labeled the “Mushroom Capital of the World.” The local farms produce close to 60 percent of the country’s fungi. The Mushroom Cap shop and museum (114 West State Street; tel: 610-444-8484; themushroomcap.com), located on the main street, is a mushroom lover’s delight and boasts everything from porcini to portobello. Next door at Talula’s Table (102 West State Street; tel: 610-444-8255; talulastable.com), dinner guests lock in their reservation to dine at the farm table up to one year in advance. We’re talking fresh from the farmer’s garden to your mouth, serving up comfort food dishes like macaroni and cheese, baked chicken, grilled salmon, and tender tomatoes and asparagus prepared to perfection. No need to despair if you can’t dine at the table; takeout is an option. Lastly, a visit to the Kennett Underground Railroad Center (tel: 484-544-5070; undergroundrr.kennett.net) to learn the story of slavery and the road to freedom should make your to-see list. The Kennett Square area reportedly has the largest concentration of secret safe houses in the nation.

rom the second floor of the Brandywine River Museum of Art (1 Hoffman’s Mill Road; tel: 610-388-2700; brandywinemuseum. org; adults US$15), a restored 19th-century gristmill in Chadds Ford, one can watch passersby in kayaks and tubes happily floating along the Brandywine River. The museum’s galleries house a sizable collection of works by the acclaimed Wyeth family. Tours of N.C. Wyeth and Andrew Wyeth’s homes and spacious art studios offer a glimpse into their creative surroundings. Tours of the historic Kuerner Farm are available April through November 22. A short drive away, the award-winning fatherdaughter winemaking duo at Penns Woods Winery (124 Beaver Valley Road; tel: 610-459-0808; pennswood swinery.com) knows how to host a good party. Themed pairing events are held in the tasting room inside a darling century-old clapboard farmhouse. Outside, enjoy picnics, concerts, movie screenings on the barn, yoga in the vineyard, and special culinary events. This is a place where you can walk barefoot in the grass with a superb glass of Pinot Grigio and simply enjoy the vineyard with a view. The historic town of West Chester in the heart of the Brandywine Valley is home to West Chester OCTOBER 2015 • Doctor’s

Review

COURTESY BRANDYWINE CONSERVANCY AND MUSEUM OF ART

University, which hosts the Kennett Symphony (kennettsymphony.org) and the Brandywine Ballet (brandywineballet.org). Heritage enthusiasts should note there are a staggering 4200 West Chester structures listed in the National Register of Historic Places. Some date back as early as the 18th century. The Dower House estate began as a two-room stone house occupied by George Washington’s parents in 1712. And there’s Hotel Warner, a 1930s art deco theatre turned hotel. The original façade is intact as is the lobby and elegant staircase leading to the second-floor eating area. It’s easy to imagine the movie reels spinning. There’s even buttered popcorn in the lobby! For a taste of history and a few ghost stories, enjoy a candlelit dinner at The Dilworthtown Inn (1390 Old Wilmington Pike; dilworthtown.com), once a private home built in 1754. The Avalon Restaurant serves fresh Italian cuisine by fireside, and there are trendy vintage clothiers as well as chocolatiers and bakeries to peruse. There’s a cat hospital too. In Glen Mills, Terrain (914 Baltimore Pike; tel: 610-459-2400; shopterrain.com/glen-mills) is the botanical jackpot of gardening centres. It’s a nursery, lifestyle and home-décor boutique, and artisanal farm-to-table dishes are served in the antique greenhouse cafe. After brunch, you’ll find everything from fire pits to hydrangea petal earrings in the shop. Certainly after experiencing the inspiring ornamental gardens in

MORE ONLINE

The Kuerner Farm and its red barn was an inspiration to painter Andrew Wyeth for more than 70 years.

Chanticleer features 15 distinct gardens, including a gravel garden, Asian woods, and the house garden pictured here.

the Pennsylvania countryside, you won’t be able to resist the treasures at Terrain. For more info on travel to the region, visit the Delaware County website (delawarecountypa.com), Chester County website (chesco.org) or Pennsylvania Tourism (visitpa.com).

The best Philly art museums on the Benjamin Franklin Parkway. doctorsreview.com/features/creative-thinking

Doctor’s Review • OCTOBER 2015

COURTESY CHESTER COUNTY CVB

TOM CRANE

The 40-room Wayne Hotel, located 30 kilometres west of Philadelphia, underwent a million-dollar reno in 1985.

WIN an all-inclusive trip to Casa de Campo, one of the most luxurious resorts in the Caribbean

Doctor’s Review and Casa de Campo will send one lucky physician and a guest for a holiday at this renowned Dominican Republic venue.

EX CON NO TEN TE VE DE ST MB D ER TO 15

The winning MD receives airfare for two aboard Air Transat and four nights “Elite” accommodation. A $5800 value! Enjoy “The Sporting Life” set on 2833 hectares: • golf the Teeth of the Dog, 90 holes designed by Pete Dye • play tennis on championship courts • ride horseback • shoot skeet • swim, dive, sail, kayak and paddle board at Minitas Beach • spin, work on your abs and glutes at the fitness centre • please your palate — six restaurants in a variety of fascinating venues And so much more. Whet your appetite at casadecampo.com.do

Enter at doctorsreview.com. Click on the contest box in the top right. Use access code drcme to participate. The winner will be announced in the October issue, just in time for a glorious winter vacation. This prize is valid from October 1, 2015 to October 1, 2016, subject to availability. Not valid for the period of December 20, 2015 to January 4, 2016; other blackout dates may apply. Absolutely no date extension will be made to redeem prize after expiration. Prize is not redeemable for cash and estimated package value may not be applied as credit to an existing reservation.

Donate a week at your cottage to a cancer survivor Choose a time you won’t be using your cottage in Quebec or Ontario

and Cottage Dreams will take care of the details Guests will bring their own groceries and stay from 2pm Sunday to noon Friday. Guests are fully insured and tax receipts are available. Cottage Dreams has, since 2003, found a week at a cottage in Ontario or Quebec for thousands of those recovering from cancer.

If you know of someone who could benefit, send them along — you’ll be glad you did! For full details visit cottagedreams.ca or e-mail program.info@cottagedreams.org.

Make short getaways last longer 10 ways to get more out of those breaks away from your practice

ALL ILLUSTRATIONS EVELLEAN / SHUTTERSTOCK.COM

by David Elkins

hort getaways are wonderful things. They have the power to rest, refresh, restore and rejuvenate. Only trouble is, they’re often over before you know it. There are, though, a few tricks to making a

brief time away from the office seem longer without taking away from the benefits.

1. GET TO YOUR DESTINATION QUICKLY. Some people’s idea of a good time is to drive until you drop. A couple I know are like that. On their last

three-day, 72-hour outing, they drove from Toronto to New Orleans and back — over 4000 kilometres. Their greatest pleasure in the excursion? They did it in under 36 hours. Don’t do that. The less time spent getting there the better for most people. You want to arrive ready to enjoy yourself. OCTOBER 2015 • Doctor’s

Review

Set out to do what you’ve never done before like learning to fly a glider or, for example, make a pair of shoes 2. TAKE YOUR TIME ON THE ROAD. This is

3. UNPLUG. Unless it makes you nervous to be

the flip side of rushing to get there. You can make a trip seem longer by taking frequent stops at roadside attractions. Visit the home of an admired prime minister. For example, Diefenbaker’s house in Prince Albert, SK is now a museum. Stop at that place that advertises “foot-high pies.” Canada is loaded with quirky stops (roadsideattractions.ca/tch.htm) along the road. You’ll be amazed at what’s out there.

away from a wireless connection for longer than an hour or two, resolve not to check your messages, watch videos or even check the weather on your smartphone. It can be most restful for you — and that goes double for your travelling companions.

4. PLAN SPECIAL EVENTS. Certainly include a leisurely meal at a restaurant you know you’ll enjoy. Add a show, the theatre or even just a movie you’ve been hoping to see. Hike a beautiful trail, rent a kayak and go for a paddle. When did you last go bowling? Might be fun. Go mad — there are archery ranges out there and places you can play croquet — the possibilities are yours to explore.

5. TAKE ALONG SOMEONE YOU DON’T KNOW VERY WELL. For example, in his book A Walk in the Woods, author Bill Bryson hooks up with an old school pal he hasn’t seen for 40 years for a go at the 3000-plus kilometre Appalachian Trail. Both the book and the movie (staring Robert Redford and Nick Nolte) are as much about renewing friendships as they are about the hike — with often hilarious results. Consider going off with a friend from your own past or plan an adventure with one of your kids, just the two of you.

6. GO SOMEWHERE NEW. Take some time to plan the holiday. Talk to friends and go on the Net to ferret out spots you’ve never visited — if they’re nearby, all the better. Try a bike tour or a canoe trip. Hint for Ontarians and Quebecers: spend a few days in Prince Edward County (prince-edward-county.com).

Doctor’s Review • OCTOBER 2015

7. BOOK A HOTEL OR B&B IN YOUR HOMETOWN. Could be the place you grew up or where you’re living now. The great recession added the word “staycation” to the vocabulary. Go to a concert or plays three nights in a row. Sign up for a course in meditation — most places offer them for free — or take an intensive cooking course. The Dirty Apron (dirtyapron.com) in Vancouver offers terrific courses, but there are cooking classes all over the country. A Google search is all you need to do to find one nearby. Feeling less energetic? Load up on books and videos at the local library, take the phone off the hook, disconnect the Wi-Fi. Read. Watch. Sleep.

8. TRY SOMETHING NEW. Be creative. Set out to do what you’ve never done before like learning to fly a glider (see the article in this issue on page 30) or, for example, make a pair of shoes for yourself. There’s a workshop (shoeschool.com) in Port Townsend, Washington. Interested in Canadian art, making it, buying it or just appreciating it? There’s a world of possibilities at canadianart.ca. Finally, two surefire ways to stretch out holiday time:

9. TACK ON AN EXTRA DAY OR TWO. 10. GET UP EARLIER EVERY DAY AND GO TO BED LATER.

Plan special events like a fancy meal at a restaurant you know you’ll enjoy

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

07/16

OCTOBER 2015 • Doctor’s

Review

ÉPREUVE

ONCE DAILY Controlled release methylphenidate hydrochloride capsules

ONCE DAILY

Controlled release methylphenidate hydrochloride capsules

PRODUCT OF CANADIAN RESEARCH

10 mg 10 mg

1515 mg mg 20 mg2030mg mg

40 mg 30mg mg 50 40

60 mg 5080 mg mg mg

60 mg

80 mg

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

Doctor’s Review • OCTOBER 2015

Parchment-steamed sea bass Veracruz over cilantro quinoa.

Full steam ahead One-pot meals that you can make in a rice cooker recipes by

Diane Phillips

photos by

Jennifer Causey

iane Phillips wants you to realize your rice cooker’s potential. The cookbook author lived in Japan for three years where she learned to make soups, stews

and even stir-fries in her electric model. Back in California, she bought a similar rice cooker and used it to make onepot meals like the ones featured in her latest project, The Everyday Rice Cooker, published by Chronicle Books. A rice cooker uses steam, which can make fish and poultry bland, and veggies wimp. To obtain deep flavour,

Phillips suggests marinating proteins first. For crisp-tender veggies, she recommends tossing them with olive oil, a few herbs or spices, or just salt and pepper, and adding them to the steamer basket during the final minutes of cooking a pot of grains in a flavourful liquid. But the steamer approach — grain OCTOBER 2015 • Doctor’s

Review

on the bottom, proteins and veggies on top — is not the only one-pot method. Another approach is to sauté and then simmer, as when making a soup or stew, or steaming the entire dish in the rice cooker pot itself, as you would pilafs and risotto. Three easy examples from the crafty cookbook follow. (Note: All the recipes in the book have been tested in 5- to 6-cup/1.2- to 1.4-litre rice cookers).

For the fish 1½ lb. (680 g) sea bass fillets, cut into 4 portions 1½ c. (375 ml) cherry tomatoes, quartered 1 medium white onion, finely chopped 1 Anaheim chili, seeded, deribbed and finely chopped ½ tsp. (2.5 ml) ground cumin ¼ c. (60 ml) extra-virgin olive oil 2 tbsp. (30 ml) fresh lime juice

PARCHMENTSTEAMED SEA BASS VERACRUZ OVER CILANTRO QUINOA

For the quinoa 1½ c. (375 ml) pre-washed quinoa 2½ c. (625 ml) chicken or vegetable broth ½ tsp. (2.5 ml) salt ¼ tsp. (1.25 ml) freshly ground black pepper ½ c. (125 ml) finely chopped fresh cilantro or flat-leaf parsley 1 Hass avocado, pitted, peeled and thinly sliced

The Mexican port of Veracruz is famous for its seafood. This dish is enjoyed in many iterations, made with either snapper or cod. But since the protein structure of sea bass will allow you to cook it in a rice cooker for the entire cooking cycle of the quinoa, it is the fish of choice here. Wrapped up in a packet of parchment paper along with Anaheim chili, tomatoes and onions, the fish soaks up their flavours. It’s a perfect dish to serve with quinoa.

Cut four pieces of parchment paper into 10-by-12-inch (25-by-30.5-cm) rectangles. Lay a piece of sea bass in the centre of each piece of parchment. In a mixing bowl, stir together the tomatoes, onion, chili, cumin, olive oil and lime juice. Top each piece of fish

with some of the tomato-onion mixture. If you have extra, save it to garnish the quinoa. Fold the paper over the fish and seal the edges by folding them over a few times to make a trim package. Stack the fish packages in the steamer basket of the rice cooker and set aside. Put the quinoa in a medium rice cooker and stir in the chicken broth, salt and pepper. Arrange the steamer basket over the quinoa. Cover the rice cooker and set to the regular cycle. At the end of the cooking cycle, check the fish to make sure it is cooked through (it should register 145°F/63°C on a thermometer). Allow the fish and quinoa to continue steaming for an additional 5 minutes on the keep-warm setting or with the machine turned off. (Many rice cookers, including all fuzzylogic machines, do this automatically.) Fluff the quinoa and stir in ¼ c. (60 ml) of the cilantro. Transfer the quinoa to a serving bowl. Open each packet of fish, lay a few slices of avocado over the fish and sprinkle with the remaining cilantro. Plate the fish packets and serve. Serves 4. Cook’s note: Want to keep that leftover avocado from turning brown? Spritz it with water and then wrap it tightly in plastic wrap. Submerging the slices in water will also keep them green overnight.

BUTTERNUT SQUASH AND SAUSAGE RISOTTO Risotto made with winter squash is typically enjoyed in Italy in the fall. This variation incorporates sweet sausage and sage leaves. For the sage leaves ¼ c. (60 ml) extra-virgin olive oil 6 sage leaves For the risotto 1 c. (250 ml) medium-grain rice, such as Arborio or Carnaroli ½ lb. (225 g) sweet Italian sausage, removed from its casing 1 medium shallot, finely chopped 1½ c. (375 ml) finely chopped, peeled and seeded butternut squash Butternut squash and sausage risotto.

Tomato-parmesan soup with ricotta and spinach dumplings.

¼ c. (60 ml) white wine (Sauvignon Blanc or Pinot Grigio) 2½ c. (625 ml) chicken or vegetable broth 2 tbsp. (30 g) unsalted butter ¹⁄³ c. (90 ml) freshly grated Parmigiano-Reggiano cheese

Set a medium rice cooker to the regular cycle or to quick cook if it’s a fuzzylogic machine. Heat the olive oil, add the sage leaves and fry until they are crisp. Remove to paper towels and drain. Transfer the oil from the rice cooker to a measuring cup and set aside. Place the rice in a sieve and rinse under a steady stream of cool water, stirring the grains. When the water runs clear, stop rinsing and shake the sieve to drain off excess water. Sauté the sausage in the rice cooker until it loses its pink color, breaking up any larger pieces. Add the shallot and butternut squash, and cook for about 3 minutes or until the shallot begins to soften. Add the wine and chicken broth, and bring to a boil. Add the rice and stir to coat the grains. Cover the rice cooker and reset to the regular cycle. At the end of the cooking cycle, check the risotto; there should still be a bit of liquid in the pan and the rice should be al dente (still firm to the bite). Stir in the butter and half of the Parmigiano. Serve the risotto in shallow bowls, garnished with a drizzle of the sage oil and a leaf of sage. Pass the remaining Parmigiano on the side. Serves 4 to 6.

TOMATO-PARMESAN SOUP WITH RICOTTA AND SPINACH DUMPLINGS The combination of the robust tomato and Parmesan soup, and the delicate dumplings is comfort food to soothe the soul. You will need the rind from Parmigiano-Reggiano cheese to flavour this soup.

MORE ONLINE

For the soup 2 tbsp. (30 ml) extra-virgin olive oil 2 garlic cloves, minced 1 medium onion, finely chopped 2 medium carrots, peeled and finely chopped 1 14½-oz. (415-g) can crushed tomatoes, with their juices 2½ c. (625 ml) chicken or vegetable broth rind from Parmigiano-Reggiano cheese (about 1 inch/2.5 cm square), coarsely chopped For the dumplings 2 c. (500 ml) frozen chopped spinach, defrosted and thoroughly drained ¾ c. (180 ml) whole-milk ricotta cheese ½ c. (125 ml) freshly grated Parmigiano-Reggiano cheese 1 c. (250 ml) fresh bread crumbs 1 large egg, lightly beaten a pinch of freshly grated nutmeg 1 tsp. (5 ml) salt ½ tsp. (2.5 ml) freshly ground black pepper

Recipes from Slow Cooker: The Best Cookbook Ever. doctorsreview.com/food/book/slow-cooker

Garnish ½ c. (125 ml) freshly shredded Parmigiano-Reggiano cheese ¼ c. (60 ml) thinly sliced fresh basil

Set a medium rice cooker to the regular cycle or to quick cook if it’s a fuzzylogic machine. Heat the olive oil then add the garlic, onion, and carrots, and sauté until the onion is softened, 2 to 3 minutes. Add the tomatoes, chicken broth and Parmigiano rind. Cover the rice cooker and reset to the regular cycle. Set a timer for 30 minutes. In a large bowl, combine the spinach, ricotta, grated Parmigiano, bread crumbs, egg, nutmeg, salt and pepper, stirring until well blended. Using a portion scoop, shape the dough into balls about 1 inch (2.5 cm) in diameter. When the timer goes off, carefully add the dumplings to the soup. Cover and cook for an additional 10 minutes. Garnish each bowl of soup with some of the shredded Parmigiano-Reggiano and basil, and serve. Serves 4. Recipes and photos from The Everyday Rice Cooker: Soups, Sides, Grains, Mains and More (Chronicle Books, 2015).

OCTOBER 2015 • Doctor’s

Review

P H OT O FI NI S H by

Dr H a n s B e r k hou t

A small fortune advertisers index ASTRAZENECA CANADA INC. Forxiga.......................................IFC spread Komboglyze/Onglyza............................. 18 BOEHRINGER INGELHEIM (CANADA) LTD Corporate..................................................6 Inspiolto Respimat...............................OBC Jardiance...................................................8 Trajenta................................................... 10 GLAXOSMITHKLINE Anoro.................................................... 4, 5 LEO PHARMA INC. CANADA Picato................................................... IBC LUNDBECK CANADA Trintellix....................................................2 MERCK CANADA INC. Zenhale.................................................... 21 MYLAN AndroGel.......................................... 40, 41 PFIZER CANADA Pristiq...................................................... 28 PURDUE PHARMA CANADA Analgesic Portfolio.................................. 20 Biphentin............................................. 9, 24

We were invited to attend a wedding in San Miguel de Allende, Mexico. The religious ceremony took place in the famous 17th-century Parroquia church located in the centre of town. It was followed by a traditional walk along medieval streets to a hotel for the reception and dinner. Small ceramic cups hung around our necks with a ribbon, they were continuously refilled with tequila. A little girl collected these cups as they were lost by partying guests. This photo was taken with a Leica M6 with Summicron 5cm lens. I processed the Tri-X film in D23.

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

editors@doctorsreview.com

Doctor’s Review • OCTOBER 2015

SEA COURSES INC. Corporate................................................ 17 TAKEDA CANADA INC. Alvesco.................................................... 12 Nesina (Quebec only).............................. 33

FAIR BALANCE INFORMATION Biphentin................................................. 52 Komboglyze............................................ 51

COVERED ON MOST PRIVATE P L A N S

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

• Local Skin Responses (LSRs)* are transient

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

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

For more information

• • • • • • • • • •

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

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

www.leo-pharma.ca

PIC-006-15E

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

NEW once-daily combination COPD therapy

grounded in long-term maintenance

INSPIOLTO RESPIMAT 速 TM

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

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

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

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