September 2015 by Doctor's Review

MEDICINE ON THE MOVE

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SEPTEMBER 2015

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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.

What your holidays say about you

RDONAR / SHUTTERSTOCK.COM

Are you an introvert or extrovert? Apparently, your travel preferences know. Psychologists have long hypothesized that we select surroundings that fit our values and desires. Now researchers at the University of Virginia have taken it a step farther. A standard questionnaire was given to 921 students to rate their personalities and they were asked whether they preferred mountains or the ocean. The results showed conclusively that extroverts preferred the beach while introverts chose mountains as their most comfortable environment. In other tests, most respondents said they’d go to the beach if they wanted to spend time with family and friends, and head for the hills if they needed solitude. Other research has shown that people are happier when they’re planning a holiday than they are when they’re actually on it. It also turns out that the simplest, most relaxed trips are the only ones that can be counted on to boost your happy-level. If you’re hooked on technology, you’re probably in another category altogether. New York Times reporter, Nick Bilton, describes the affliction this way: “The second you land, you check your cellphone and are greeted by a flood of messages. After an hour sitting in your hotel room replying to work emails, you finally go to the beach. You pull out your iPad to read a book and, oh look: you have a message on Facebook, not to mention WhatsApp, Snapchat and Twitter. And because the beach is so beautiful, it’s probably a good idea to take an Instagram. After a hundred attempts to capture the best and most original photo of a beach ever taken, you spend another hour seeing how many “likes” your photo got.” There’s a little something for every taste in this issue. Extroverts will enjoy Casa de Campo reverie (page 45), the highly rated Caribbean resort that provides guests with as much beach-time as they like along with a host of other activities. And don’t forget our contest (page 50): you could win a holiday there. Introverts would be more likely to enjoy time in the forests of Croatia searching for truffles (page 34). For techies, there’s the new mobile app Doxy.com that allows you to have face time with patients 24/7 from anywhere in the world (page 20). Happy trails wherever you roam,

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David Elkins, Publisher and editor delkins@parkpub.com

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SEPTEMBER 2015 • Doctor’s

Review

Contraindications: • Patients with severe hypersensitivity to milk proteins. Most Serious Warnings and Precautions: 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 another long-acting beta2-adrenergic agonist (salmeterol) to placebo added to 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, the active ingredient in BREO® ELLIPTA®. • BREO® ELLIPTA® is only indicated for COPD. • The safety and efficacy of BREO® ELLIPTA® in patients with asthma have not been established. BREO® ELLIPTA® is not indicated for the treatment of asthma. Other Relevant Warnings and Precaution: Precaution • BREO® ELLIPTA® should not be used to treat acute symptoms of COPD (i.e., as rescue therapy for the treatment of acute episodes of bronchospasm) and should not be initiated in patients with acutely deteriorating COPD. • Patients who have been taking a rapid onset, short duration, inhaled bronchodilator on a regular basis (e.g., q.i.d) should be instructed to discontinue the regular use of these drugs and use them only for symptomatic relief if they develop acute symptoms while taking BREO® ELLIPTA®. • 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. • BREO® ELLIPTA® should not be used more often than recommended, at higher doses than recommended, or in conjunction with other medicines containing a LABA, as an overdose may result. • Caution in patients with cardiovascular disease: vilanterol can produce clinically significant cardiovascular effects in some patients as measured by an increase in pulse rate, systolic or diastolic blood pressure, or cardiac arrhythmias such as supraventricular tachycardia and extrasystoles. In healthy subjects receiving steady-state treatment of up to 4 times the recommended dose of vilanterol (representing a 12-fold higher systemic exposure than seen in patients with COPD) inhaled fluticasone furoate/vilanterol was associated with dosedependent increases in heart rate and QTcF prolongation. Use with caution in patients with severe cardiovascular disease, especially coronary insufficiency, cardiac arrhythmias, hypertension, a known history of QTc prolongation, risk factors for torsade de pointes (e.g., hypokalemia), or patients taking medications known to prolong the QTc interval. • Effects on Ear/Nose/Throat: Localized infections of the mouth and pharynx with Candida albicans. • Endocrine and Metabolic effects: possible systemic effects include Cushing’s syndrome; Cushingoid features; and HPA axis suppression. • Hypercorticism and adrenal suppression (including adrenal crisis) may appear in a small number of patients who are sensitive to these effects. Doses of the rapid onset, short duration, beta2 adrenoceptor agonist salbutamol, when administered intravenously, have been reported to aggravate pre-existing diabetes mellitus and ketoacidosis. • Adrenal insufficiency: particular care should be taken in patients transferred from systemically active corticosteroids because deaths due to adrenal insufficiency have occurred during and after transfer to less systemically available inhaled corticosteroids. • Bone Effects: An increase in the incidence of bone fracture has been observed in COPD patients. Decreases in BMD have been observed with long-term administration of products containing inhaled corticosteroids. • Monitoring recommendations: Serum potassium levels should be monitored in patients predisposed to low levels of serum potassium. Due to the hyperglycemic effect observed with other beta-agonists, additional blood glucose monitoring is recommended in diabetic patients. Patients with hepatic impairment should be monitored for corticosteroid effects due to potentially increased systemic exposure of fluticasone furoate. • Use with caution in patients with convulsive disorders or thyrotoxicosis and in those who are unusually responsive to sympathomimetic amines.

• Hematologic effects: may present with systemic eosinophilic conditions, with some patients presenting clinical features of vasculitis consistent with Churg-Strauss syndrome. Physicians should be alerted to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. • Hypersensitivity effects: immediate hypersensitivity reactions have occurred after administration, and patients should not be re-challenged with BREO® ELLIPTA® if it is identified as the cause of the hypersensitivity reaction. There have been reports of anaphylactic reactions in patients with severe milk protein allergy with other inhaled dry powder drug products containing lactose. • Immune effects: greater susceptibility to infections. Administer with caution and only if necessary in patients with active or quiescent tuberculosis infections of the respiratory tract; chronic or untreated infections such as systemic fungal, bacterial, viral, or parasitic; or ocular herpes simplex. Chickenpox and measles can have a more serious or even fatal course in susceptible patients using corticosteroids. In such patients who have not had these diseases or been properly immunized, particular care should be taken to avoid exposure. • Ophthalmologic effects: Glaucoma, increased intraocular pressure, and cataracts. Close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts. • Respiratory effects: paradoxical bronchospasm may occur with an immediate increase in wheezing after dosing. This should be treated immediately with a rapid onset, short duration inhaled bronchodilator. BREO® ELLIPTA® should also be discontinued immediately, the patient assessed, and alternative therapy instituted if necessary. An increase incidence of pneumonia, and pneumonias resulting in hospitalization, has been observed with inhaled fluticasone furoate/vilanterol in COPD patients. In some incidences these pneumonia events were fatal. Physicians should remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of such infections overlap with the symptoms of COPD exacerbations. COPD exacerbations may occur during treatment. Patients should be advised to continue treatment and seek medical advice if symptoms remain uncontrolled or worsen after initiation of therapy. Patients should not stop therapy without physician supervision since symptoms may recur after discontinuation. • Drug interactions: caution should be exercised when considering coadministration with inhibitors of cytochrome P450 3A4; inhibitors of P-glycoprotein (P-gp); sympathomimetic agents; beta-adrenergic receptor blocking agents; non potassium sparing diuretics (i.e. loop or thiazide diuretics); drugs that prolong the QTc interval (e.g. monoamine oxidase inhibitors and tricyclic antidepressants); xanthine derivatives; and acetylsalicylic acid. Adverse Events: Adverse reactions reported at a frequency of ≥1% 1% from two 6-month placebo-controlled clinical studies of BREO® ELLIPTA® 100/25 mcg included: nasopharyngitis (9%); upper respiratory tract infection (7%); oropharyngeal candidiasis (5%); sinusitis (2%); bronchitis (1%); pharyngitis (1%); headache (7%); back pain (2%); COPD (2%); cough (2%); nausea (1%); ventricular extrasystoles (1%); and pyrexia (1%). Dosage and Method of Administration: Administration The recommended dose of BREO® ELLIPTA® 100/25 mcg is one oral inhalation once daily, administered at the same time every day (morning or evening). After inhalation, patients should rinse their mouth with water (without swallowing). If a dose is missed, the patient should be instructed not to take an extra dose, and to take the next dose when it is due. Dosing Considerations • For optimum benefit, advise patients that BREO® ELLIPTA® must be used regularly, even when asymptomatic. • No dosage adjustment is required in patients over 65 years of age, or in patients with renal or hepatic impairment. For More Information: Please consult the Product Monograph at http://gsk.ca/breo/en for important information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374.

BREO and ELLIPTA are registered trademarks, used under license by GlaxoSmithKline Inc. BREO® ELLIPTA® was developed in collaboration with Theravance, Inc. © 2014 GlaxoSmithKline Inc. All rights reserved. ®

ONC e ve r

24 h y

BREO ELLIPTA ®

The first and only once-daily ICS/LABA combination for COPD.* BREO® ELLIPTA® (fluticasone furoate/ vilanterol) is indicated for the long-term oncedaily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema, and to reduce exacerbations of COPD in patients with a history of exacerbations. BREO® ELLIPTA® is not indicated for the relief of acute bronchospasm in COPD. BREO® ELLIPTA® is not indicated for the treatment of asthma. BREO® ELLIPTA® is not indicated for use in children and should not be used in patients <18 years of age. *Comparative clinical significance is unknown.

fluticasone furoate / vilanterol

Practical once-daily dosing.

00416 12/14

* 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

LURI / SHUTTERSTOCK.COM

SEPTEMBER 2015

features 34

Croatia underfoot Dig for truffles, dine on seafood and discover the Istrian peninsula’s delicious secrets by Anita Draycott

Two wheel it through Israel Choose from 25 one-day bike trips designed for maximum pleasure by Gary Crallé

contest! LAST CHANCE! Enter now to WIN a Caribbean holiday valued at $5800. Turn to page 50

Casa de Campo reverie Caribbean holidays don’t get much better than this by David Elkins

Go with the grain Nutrient-dense recipes that feature buckwheat, millet and quinoa by Chrissy Freer

Coming in

October • Take in the pleasure and value of shoulder-season travel • Go power gliding with one of your colleagues • Explore Pennsylvania’s delightful countryside • Master the art of the short getaway

SEPTEMBER 2015 • Doctor’s

Review

For the Treatment of IBS-C and CIC in Adults CONSTELLA ® (linaclotide) is indicated for the treatment of: • irritable bowel syndrome with constipation (IBS-C) in adults • chronic idiopathic constipation (CIC) in adults Pr

CONSTELLA showed significant improvement in abdominal discomfort vs. placebo (secondary endpoints, mean change from baseline at Week 12)

IBS-C

CIC

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

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

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

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

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

contents SEPTEMBER 2015

regulars 11 LETTERS A look at physician suicide

PRACTICAL TRAVELLER The first US cruise company to sail to Cuba, Butterfield and Robinson’s partnership with Saveur magazine, Greyhound buses go to Mexico and more! by Camille Chin

19 GADGETS An award-winning printer that fits in your pocket by Theo Sands

Strategies to help patients recovering from depression stay well by Mairi MacKinnon

BEST MD APPS A free telemedicine app for doctors and patients by Roger White

DEPRESSION KEYPOINTS

TOP 25 The biggest medical meetings to kick off 2016

HISTORY OF MEDICINE Facial expressions don’t lie by Rose Foster

PHOTO FINISH Greek revolution by Dr Vanessa H. Le

SEPTEMBER 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. ®

LETTERS

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

A look at physician suicide

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

s T s lis eting eTing .com/me + me 2500 rsreview cto

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

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

czech beer Fabulous cranes Poet’s tower Tasty fish Flight attendant secrets

canada raw wildlife 10 hangouts PlUs

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David Elkins

DIRECTOR, SALES & MARKETING

July / august 2015

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inTerview: mds in trouble and

depression in the elderly

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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.

Dr Dennis Freer Toronto, ON

includes fine meals and airfare Page 8

CANADA WILD Where are those people hiking on your [July/August 2015] cover? MONTREAL HEAD OFFICE

WHAT GOES UP…. My wife travels a good deal for work and she’s seen some real characters. People who clip their nails and trim their nose hairs onboard drive her nuts. When I learned that new flight attendants are at the beck-and-call of airlines 24/7 and that their incomes aren’t that lucrative, I was surprised [Flying secrets, July/August 2015, page 42]. The work is difficult and tests your patience. Flights are overbooked and badly under staffed. Benefits are diminishing. I admire how flight attendants hold it together.

Dr Noah Gale Montreal, QC

The photo by Paddy Pallin was taken at Quill Creek in Kluane National Park in the Yukon.

MD DEATHS Thank you for the article on physician suicide [“Physician wellness and suicide prevention,” History of Medicine, July/August 2015, page 21]. My husband is a doctor and it’s a very serious issue. My girlfriend’s partner is also a physician and they have a close doctor-friend who’s had some dark times recently. She has $100,000 of student debt and works long hours at a very competitive hospital. Add the pain and death she faces on daily basis — it’s extremely overwhelming.

HAPPY AS A CLAM I’m passionate about food and cooking so I always look forward to the recipes in your magazine. I did some reading on sustainable seafood on David Suzuki’s website recently so I was thrilled to see recipes from Ocean Wise in your latest issue [Fish for compliments, July/August 2015, page 52]. Your article didn’t mention Ocean Wise’s website though, which is another good resource for info on recommended seafood. They’ve even got an app that you can download on your cell phone and how-to videos to help with dinner prep. Dr Vena Lad Via email

Dr Derek Puddester specializes in physician wellness. Read an interview with him in the July/August issue.

Sandra P. Via email

SEPTEMBER 2015 • Doctor’s

Review

Your banking should be as personalized as your patient care.

Specialized banking advice for your practice. Your expert advice helps your patients stay healthy. TD Business Banking Specialists work with you to help keep your business just as healthy with product expertise and specialized banking advice. And because weâ&#x20AC;&#x2122;re open earlier, open later and even on Sundays,* you can get the advice you need, on your time. Because a healthy practice deserves specialized care.

Visit tdcanadatrust.com/doctors or call 1-888-679-4808 *Individual branch hours vary. 400 branches are open Sundays. ÂŽ The TD logo and other trade-marks are the property of The Toronto-Dominion Bank.

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

C a mi lle C hi n

Baring of soles

PHOTOS THIS PAGE © VICTORIA AND ALBERT MUSEUM, LONDON

Men’s shoes, gilded and marbled leather, Northamptonshire, England, 1925.

London’s Victoria and Albert Museum has a shoe collection that spans 2000 years. Curator Helen Persson chose 250 pairs from the V&A art and design museum as well as from other collections for Shoes: Pleasure and Pain, on now through January 31, 2016. Sandals decorated in gold leaf dating from ancient Egypt are on view as are lotus shoes made for bound feet, 16th-century chopines and silk mules with dizzying platforms designed to lift skirts above muddy streets. Contemporary shoes designed by Manolo Blahnik, Jimmy Choo, Christian Louboutin and Prada are on view too and there’s also futuristic-looking shoes created using 3D printing. The exhibit’s ground floor “boudoir” examines three themes: transformation, status and seduction. The first floor’s “laboratory” dissects the design and creation process, laying out the story from concept to final shoe. Tickets £12 ($24). vam.ac.uk/shoes.

SEPTEMBER 2015 • Doctor’s

Review

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

Carnival cruises takes Cuba

The Carnival Cruise Line Corporation launched a new brand called Fathom in June. Its first destination will be the Dominican Republic in April 2016. It’ll head to Cuba in May, which will make it the first American cruise company to visit the island since the 1960 trade embargo. Fathom’s focus is “social impact travel” — experiences working alongside locals to tackle community needs. Their inaugural trip to the Dominican Republic will begin with an orientation to the country, conversational Spanish lessons and “impact” activity training. After that, travellers can choose how they’d like to help. Options include: cultivating cacao plants then producing artisanal chocolate at a women’s coop; teaching English in classrooms and through adult-learning programs; building water filters using clay and delivering them to families. (At the time of writing, Cuba’s itinerary was awaiting approval from the Cuban government.) Seven days aboard a 710-passenger ship set to sail from Miami start at US$1540 per person to the DR; US$2990 to Cuba, including meals. tel: (206) 626-8300; fathom.org.

¡Hola Greyhound! Greyhound serves more than 3800 destinations across North America, but it only began bus service within Mexico this past July. It now connects the northeastern cities of Monterrey and Nuevo Laredo via 13 daily departures; 10 daily departures link Monterrey to cities in Texas. New terminals were built in Monterrey and Nuevo Laredo complete with free Wi-Fi, charging stations and parking lots. Buses on the routes are among the company’s newest with seat belts, power outlets and free Wi-Fi throughout. tel: (800) 231-2222; greyhound.com.

Doctor’s Review • SEPTEMBER 2015

El Celler de Can Roca, Girona, Spain.

The plane truth

QATAR AIRWAYS

TOP 10 AIRLINES OF 2015 1. Qatar Airways 2. Singapore Airlines 3. Cathay Pacific Airways 4. Turkish Airlines 5. Emirates 6. Etihad Airways 7. ANA All Nippon Airways 8. Garuda Indonesia 9. EVA Air 10. Qantas Airways

Claudia Masciotra

For

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BEST CABIN STAFF 1. Garuda Indonesia 2. Cathay Pacific 3. Singapore Airlines 4. Asiana Airlines 5. Malaysia Airlines 6. Qatar Airways 7. EVA Air 8. ANA All Nippon Airways 9. Thai Airways 10. Hainan Airlines CLEANEST AIRCRAFT CABINS 1. EVA Air 2. Singapore Airlines 3. ANA All Nippon Airways 4. Cathay Pacific 5. Asiana Airlines 6. Garuda Indonesia 7. Japan Airlines 8. Hainan Airlines 9. Korean Air 10. Hong Kong Airlines

SINGAPORE AIRLINES

Paris hosted the prestigious 2015 World Airline Awards — also known as the Passengers Choice Awards — in June. Launched in 1999, the “independent, impartial” survey, conducted by the UK-based Skytrax, was carried out online between September 2014 and May 2015. Almost 19 million travellers from 105 nationalities answered the questionnaire about 245 airlines. The winners of four of the 13 global categories are below. For more: worldairlineawards.com.

BEST INFLIGHT ENTERTAINMENT 1. Emirates 2. Qatar Airways 3. Singapore Airlines 4. Qantas 5. Etihad Airways 6. Turkish Airlines 7. Cathay Pacific 8. Virgin Atlantic 9. Thai Airways 10. Air France

September 2015 issue

CME CRUISES New Years 2015 

Dec 27/15 - Jan 3/16



Clinical Medicine Update

Spring Break 2016 

Mar 13 - 20, 2016



Caribbean



Primary Care Review

Aug 7 - 21, 2016



ASIA

Caribbean

Summer Escape 2016 Update in Patient Care

www.seacourses.com

Europe

BALTIC

DUBAI

ICELAND

GREECE/TURKY

TAHITI

NEW ZEALAND

SOUTH AMERICA

1-888-647-7327 SEPTEMBER 2015 • Doctor’s

Review

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

Food to travel for

B&R’s new culinary tours include trips to New Orleans and Napa (right).

Dubai’s Miracle Garden.

Butterfield and Robinson has partnered with food and wine magazine Saveur. The Toronto-based travel outfitter — which will be celebrating its 50th anniversary in 2016 — has launched three new fall trips to a few of the most “edible” destinations in the Americas. The sevennight Peru walking tour, October 19 to 26, begins and ends in Lima. Peru was named the World’s Leading Culinary Destination at the 2014 World Travel Awards. The three-night New Orleans tour, November 12 to 15, features visits to chef Donald Link’s award-winning Herbsaint and Peche restaurants, and Willy Mae’s Scotch House to make fried chicken. The three-night Napa and Sonoma tour, November 19 to 22, leaves from San Francisco. It includes visits to artisanal cheese producers, the Dry Creek Olive Oil company, the Conn Creek Winery and Gundlach Bundschu Caves. From $4700 to $13,415 per person. tel: (866) 551-9090; butterfield.com/saveur-culinary-trips.

The Sasquatch is a new two-kilometre (continuous) zip line in Whistler, and said to be the longest in Canada and the US. It launches from high on Blackcomb Mountain, whizzes over the Fitzsimmons Valley, and ends mid-mountain on Whistler. The zip line is 183 metres above ground at some points and participants reach speeds of 100 kilometres per hour. Until October 12. Ages 10 and up only. Adults $119; youth 10 to 14 $99. Package tours are available. tel: (866) 935-0001; ziptrek.com/en/whistlercanada/tours/ziptrek-sasquatch.

MIKE CRANE

Mountain do

Doctor’s Review • SEPTEMBER 2015

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

BUDGET TRAVELLER

C a mi lle C hi n

great deals to help you stretch summer

Maui, HI The Honua Kai Resort and Spa on North Kaanapali Beach is making the best of a bad situation by offering a Hard Hat package while a new Westin — slated to open in 2017 — is being built next door. The rates for one-, two- and threebedroom suites that overlook the construction site have been cut by as much as 40 percent through the rest of 2015. One-bedroom suites feature a king-size bed and a queen-size sofa bed, and can accommodate a family of four. They include a full kitchen and even a washer and dryer. Rates started at US$230 (plus US$29 daily resort fee) when we searched online in mid-July for a mid-Aug vacation dates — US$65 per person. tel: (855) 718-5789; honuakai.com.

Honua Kai Resort and Spa, Maui.

Los Angeles, CA

Dallas, TX

A Mama Shelter just opened in Hollywood and accommodations start at US$149. The 70-room hotel on Selma Avenue is a few minutes walk from Hollywood Boulevard and is the European hotel chain’s first North American property. (There are four Mamas in France; one in Turkey). Medium Mama rooms are 20 to 21 square metres and the most affordable; Medium, Large and XXL Mama rooms all feature an iMac (to double as a TV), a mini fridge and free Wi-Fi. There’s a restaurant, coffee shop and bar on-site. Breakfast is not included; 12-kilo pets are welcome for an additional US$79 per stay. tel: (323) 7856666; mamashelter.com.

Dallas just joined the CityPass family. The Big D’s CityPass booklet costs US$44 for adults and US$33 for kids aged three to 12, and covers the admission to four of the city’s most popular attractions — a savings of 30 percent. The booklet includes the Reunion Tower GeO-Deck for 360-degree views of Dallas and the Perot Museum of Nature and Science. Travellers then get the choice of either the Dallas Zoo or the Sixth Floor Museum, and the choice of the George W. Bush Presidential Library and Museum or the Dallas Arboretum and Botanical Garden. The booklet is valid for nine consecutive days. For details: citypass.com/dallas.

Honua Kai Resort and Spa, Maui.

Caribbean

BOOK NOW!

Hilton Curaçao.

Doctor’s Review • SEPTEMBER 2015

The Hilton Caribbean Summer Sale is on now through August 31. Accommodations at 18 of its properties — from Curaçao to Trinidad to Puerto Rico — start at US$96 a night with the fourth night free and a $100 resort credit per room per stay. When we searched online for rooms at the Dorado del Mar Beach Resort at the end of July, we found nightly rates of US$96 for stays between September 7 and 17. The Dorado del Mar is 32 kilometres west of San Juan in Puerto Rico. hiltoncaribbean.com/summer.

GA D GE T S by

Da vi d E l k i n s

Floodlights on security About a year ago there was a break-in at a neighbours down the street. I was tasked with putting up security lights. The plan was to put one over our garage, another near the front door and a couple on the rear corners of the house that would come on if anyone breeched the back garden. I found what I needed at the local hardware store. Conventional motion-detection lights sell for about $30, take two bulbs ($8) and are easily mounted except for one thing — wiring them up. I was able to run a line from the garage and another from the light at the front door, but the back lights were a challenge. I had to call an electrician who did the job in less than two hours for $166. How much easier it would have been had I known about Smart-Sensor Outdoor LED Lighting. The battery-operated units do not need wiring and — the best feature — they communicate with each other. If anything comes within nine metres of one, a radio transmitter turns on a bright 200-lumen floodlight in all of the others that are within a 46-metre range. You can add additional lights at any time up to a total of 50. A network of that many would illuminate an area of 697 square metres, says the manufacturer. It’s not clear to me why anyone would want to do this, but if you did, it would certainly alert anyone in the vicinity that something untoward was going on. Each unit runs for 3000 activations on three D batteries. To conserve power, they shut off if no motion is detected for 30 seconds. A sensor prevents them from coming on in daylight. The weatherproof fixtures stand about 17 centimetres tall. An easily screwed in mount allows the beam to be rotated to shine where it’s needed. The lights are sold in pairs and I’ve ordered a set to attach to the back fence as a kind of distant early-warning system. I’m hoping for better luck than my Australian father-in-law had when he installed outdoor lights and a burglar alarm at his townhouse outside Brisbane. The first night it was up, he and his wife were woken at 3am by a siren and a blaze of light only to find a kangaroo calmly grazing on the front lawn. Smart-Sensor LEDs, package of two, $89.50, batteries not included. leevalley.com. SEPTEMBER 2015 • Doctor’s

Review

BEST MD APPS by

R og e r W hi t e

Free telemedicine comes to your iPhone With Doxy.me an easy online doctor/ patient communication has arrived both on computer and now with an Apple app for mobile devices. An Android version on devices that use Chrome or Firefox is also available. Doxy.me, a free telemedicine site, launched an app in June that provides an easy and simple way to meet with your patients remotely. To use it, you simply share your URL with a patient (for example, doxy.me/DrSmith) and that’s all there is to it — no download or log in needed. The patient signs into a customizable waiting room to your practice and you join them there. The 2P2 encrypted app also has a queue and chat capabilities to allow you to handle several patients at once. All 13 users, both physicians and patients, who have ranked Doxy on the Apple site have given it five stars.

iMedicalApps.com ranks it as one of the best apps launched so far in 2015. Users are enthusiastic. A physician using the app for the first time comments: “Wow! Just did my first visit with a patient and it worked great. They were at home on their iPad and I was at my office on my iPhone.… This will change the way care is delivered globally.” Another reviewer concurs: “Doxy.me bridges the gab between medical providers and patients…. Time and location are no longer a blocker to getting advice or diagnosis from medical professionals.” Writes an ER administrator: “Been working with Doxy.me on our emergency room readmission reduction program and patients have adopted to it well as have ER staff.” The app was developed by Brandon Welch who invites healthcare providers to try it with this message on the website: “(Doxy.me)… is specifically designed to fit your clinical workflow. You’ll appreciate its simplicity and versatility, you also can’t beat the price!” Doxy.me by Brandon Welch Devices: iPhone, iPad that support iOS 6 or newer Cost: Free

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

Staving off depression rec Strategies to help your patients stay well

M .

ajor depressive disorder (MDD) is a common and highly recurrent condition. The recurrence rate rises with the number of episodes an individual experiences (50 percent after the first, 70 percent after the second, and 90 percent after the third episode). Diagnosing and treating symptoms early is essential, as failure to do so effectively can lower the chances of successful recovery.1-3 So what triggers the return of depressive symptoms? What factors can predict and contribute to recurrence? Who is most at risk and what are the early signs of relapse? Is it possible to improve the odds? Helping patients learn to recognize their vulnerability, and to monitor and manage their mental health, can lessen the impact of chronic depression on their lives.

Risk factors Many different variables determine which individuals are most liable to suffer relapse. Clinical risk factors include: older age, multiple (three or more) prior occurrences, chronic or severe episodes (e.g. numerous symptoms; intractable features; suicidal tendencies), significant psychiatric or medical comorbidity, residual symptoms, and pattern of recurrence when antidepressants are stopped.4

Goals of maintenance therapy The objective of acute therapy is full remission of depressive symptoms — as opposed to simple reduction of symptoms or treatment “response.”2 Long-term maintenance therapies that addresses individual patient factors can greatly decrease the chances of relapse. Goals during the maintenance phase (lasting 6–24 months or longer) include dealing with residual symptoms, treating comorbid conditions, restoring normal function and preventing symptoms from coming back. Approaches to diminish recurrence should centre on healthy lifestyle, understanding of one’s personal susceptibilities, self-management and continued pharmacologic and nonpharmacologic therapy. Patient education and a strong physician/patient relationship are key elements to reinforce adherence to the treatment plan and to promote successful recovery.2,5

Relapse prevention The following are some key strategies to help individuals achieve full remission of depressive symptoms and stay well in the long term.

Doctor’s Review • SEPTEMBER 2015

Build a close alliance with your patients from the outset, to establish ongoing trust and confidence and improve treatment adherence. Involve patients in their own management by educating them about the nature of MDD (i.e. explain it is characterized by changes in brain chemistry and physiologic imbalances). Work together to select the best treatment options, set realistic goals and monitor progress.2,5,6 Identify possible triggers and early warning signs of depression. Discuss your patients’ personal risk factors and vulnerabilities as well as possible triggers, for instance stressful life situations, negative thinking patterns, season-related disturbances. Alert them to possible indicators of recurrence, such as problems with sleep or appetite, physical signs like upset stomach or tension, changes in energy levels, emotional/ behavioural signs such as irritation, anxiety, negative/hopeless thinking, aggression, etc. Urge people to seek help and take action before these issues become overpowering. Being familiar with these depressive symptoms can also help patients who are undergoing treatment to assess their improvement.6,7 Encourage patients to develop healthy lifestyle coping skills. Attention to proper nutrition, regular exercise and good sleep routines are paramount. Persistent efforts to manage stress (techniques such as relaxation/breathing exercises, meditation, mindfulness practice can help), avoiding substance use and keeping up with pleasurable activities are also crucial.2,5,7 Manage comorbid conditions. Chronic illnesses such as cardiovascular disease, cancer, diabetes and other such conditions can be ongoing stressors that increase the likelihood of relapse; they are modifiable risk factors and should be treated.2,4 Recommend evidence-based psychologic therapies. Psychotherapy has an essential role in enhancing adherence to antidepressant treatment and reducing/preventing relapse in MDD. Recommended first- and second-line maintenance strategies include cognitive behavioural therapy, behaviour activation, interpersonal therapy and mindfulness-based cognitive therapy (MBCT). A combination of “talk” and drug therapies has been shown to surpass pharmacotherapy alone in averting relapse, especially for patients with chronic/ severe MDD, psychiatric comorbidity and/or poor response to medication.4,5,8 For people who are looking for alternatives to medication, a large UK study comparing MBCT (with support to taper/ discontinue antidepressants) to maintenance antidepressants over 24 months recently reported that both approaches conferred

currence

equally positive results in terms of preventing relapse, residual symptoms and quality of life.9 Educate patients about medication use. Current recommendations support continuing antidepressants for at least six months after symptom remission, at the same dose as during acute treatment. Individuals at high risk of relapse should keep taking their medication, with frequent monitoring for side effects and comorbidities, for two years or longer (sometimes even throughout their lifetime).4,5 It is important to emphasize the benefits of medication, but patients should also understand that symptom improvement can take time — up to eight weeks. Discuss common side effects that may occur; explain that they are usually mild, occur at the beginning of treatment and improve with time. Patients should also be aware of the possibility of more serious antidepressant side effects, including the risk of suicidal thoughts and sexual dysfunction, that require consultation with their doctor.5,6 Allay fears about the potential for addiction with antidepressants. Also, make sure patients take medications as prescribed and only stop them gradually, under medical supervision, to avoid discontinuation syndrome. If patients resist taking their medications, explore the reasons why (e.g. attitudes, dissatisfaction with results, side effects, cost, etc).5,6 Follow all patients carefully (whether on pharmacologic and/or nonpharmacologic therapies or engaging in selfmanagement programs) to watch for adverse reactions and to measure progress.5,6 Support the whole person. A personalized approach that considers individual needs and treatment preferences is the most useful. Show empathy for the patient’s experience of

their illness. Most important, reassure people that, with time and commitment to self-management, they are very likely to recover from depression and enjoy a full return to their normal everyday functioning and quality of life.4,6 References 1. CANMAT CME. Depression. Treating depressive disorder. Relapse and recurrence. www.canmat.org/cme-depression-relapse-and-recurrence.php. Accessed July 17, 2015. 2. 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. 3. Government of Canada. The human face of mental health and mental illness in Canada 2006. Ottawa: Minister of Public Works and Government Services Canada, 2006. 4. 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. 5. BCGuidelines.ca. Major depressive disorder in adults: Diagnosis & management. British Columbia Ministry of Health, 2013. 6. CANMAT CME. Depression. Treating depressive disorder.Tips to get depressed patients well. www.canmat.org/cme-depression-tips-to-get-depressed-patientswell.php. Accessed July 17, 2015. 7. Canadian Mental Health Association British Columbia. Tips for preventing relapse of depression. 2011. www.heretohelp.bc.ca. Accessed July 17, 2015. 8. Parikh SV, Segal ZV, Grigoriadis S et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Aff Disord 2009;117(Suppl 1): S15–S25. 9. Kuyken W, Hayes R, Barrett B et al. Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of relapse or recurrence (PREVENT): a randomised controlled trial. Lancet 2015;386:63-73.

SEPTEMBER 2015 • Doctor’s

Review

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

IN CHILDREN, ADOLESCENTS AND ADULTS 1*

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

Flexible dosing – available in 8 strengths for dose optimization2¶

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

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

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

54 See additional safety information on page XX

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada 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 Digestive Diseases Week cag-acg.org/cddw

Quebec City, QC January 21-22, 2016 24e Réunion Scientifique Annuelle de la Société Québécoise d’Hypertension Artérielle hypertension.qc.ca Edmonton’s Art Gallery of Alberta.

CTC

Vancouver, BC January 28-30, 2016 Early Years Conference 2016 interprofessional.ubc.ca/EarlyYears2016/default.asp

Around the world

Cannes, France January 14-17, 2016

Lake Tahoe, CA February 22-26, 2016

2016 World Congress on Recurrent Pregnancy Loss wcrpl.com

39th Annual Emergency Medicine Winter Conference ucdmc.ucdavis.edu/cme/conferences/index.html

Cape Town, South Africa December 2-6

Atlanta, GA February 1-6, 2016 36th Annual The Pregnancy Meeting smfm.org/the-pregnancy-meeting

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

46th Union World Conference on Lung Health capetown.worldlunghealth.org

Hyderabad, India March 2-5, 2016 17th International Congress on Infectious Diseases isid.org/icid

Las Vegas, NV February 17-21, 2016 22nd Annual Scientific Assembly of the American Academy of Emergency Medicine aaem.org/education/scientific-assembly

February 27-March 1, 2016 Fourth International Congress on Cardiac Problems in Pregnancy 2016.cppcongress.com

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

SEPTEMBER 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

Miami, FL January 20-22, 2016 18th International Conference on Dialysis: Advances in Kidney Disease renalresearch.com

February 18-21, 2016

Milan, Italy February 3-6, 2016 9th International Conference on Advanced Technologies and Treatments for Diabetes attd2016.com

New Orleans, LA February 23-27, 2016 2016 Winter Meeting of the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction sufuorg.com/Meetings.aspx St. Pete’s Loews Don CeSar Hotel aka The Pink Palace.

The Galleria Vittorio Emanuele II shopping mall in Milan.

Olympic Valley, CA February 25-28, 2016

Sleep Medicine Trends 2016 aasmnet.org/events.aspx

Orlando, FL February 10-14, 2016

Sacramento, CA February 5-6, 2016

2016 Annual Meeting and Courses of the American Clinical Neurophysiology Society acns.org/meetings/annual-meeting-andcourses/2016 45th Critical Care Congress sccm.org/Education-Center/Annual-Congress/ Pages/default.aspx

Palm Springs, CA February 18-21, 2016 32nd Annual Meeting of the American JEFF KINSEY / SHUTTERSTOCK.COM

Academy of Pain Medicine painmed.org/annualmeeting

Paris, France January 13-16, 2016 26es Journées Européennes de la Société Française de Cardiologie sfcardio.fr/JESFC-2016 Doctor’s Review • SEPTEMBER 2015

Phoenix, AZ February 12-14, 2016

Vascular Care Conference 2016 ucdmc.ucdavis.edu/cme/conferences/index.html

February 20-24, 2016

PCRUCIATTI / SHUTTERSTOCK.COM

14th Annual Cardiovascular Disease Prevention International Symposium cme.baptisthealth.net/cvdprevention/pages/ index.aspx

34th Annual Infectious Diseases Conference ucdmc.ucdavis.edu/cme/conferences/index.html

St. Petersburg, FL February 13-16, 2016 16th Annual International Symposium on Congenital Heart Disease allkids.org/health-professionals/conferencesclasses/cme/conferences

The Hague, Netherlands March 2-5, 2016 Eleventh World Congress on Brain Injury internationalbrain.org/news/save-dateeleventh-world-congress-2016

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

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

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

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

R os e F os t e r

The face of the deceiver Expressions reveal the true emotional intention behind words and actions

The face betrays true emotions.

“T

he face is like the penis!” once roared Princeton psychology professor Silvan Tompkins. That was back in the ’50s and his students were properly shocked. The outburst occurred during a

course on human emotions and the point Tompkins so memorably made was that the face betrays true emotions, regardless of how “zipped-up” a person may think himself to be. Another Tompkins trick was to watch politicians’ debate on television with the sound turned off to more accurately discern their motivations. His pedagogic fervour and his uncanny ability to accurately assess facial emotions inspired one bright young student to set out on a quest for the holy grail of emotion-reading: a system which could be used to correctly analyze the emotional content of faces just by observing people talk. Named one of the top 100 most influential people of 2009 by Time Magazine, Dr Paul Ekman has risen to near-celebrity status. His work on facial expressions informed the animation of sympathetic characters in Pixar’s Toy Story and he was the inspiration for a character in a 2006-2009 TV miniseries called Lie To Me.

He also works with the US Transportation Security Administration (TSA) on airport screening. His detractors take issue with that as yet another governmental invasion of privacy. They could have a point; he’s often been called “the best human lie detector in the world.”

MAD MAN? When he set out to crack the code of the face, his first visit was to renowned anthropologist Margaret Mead at her office in the American Museum of Natural History. He was excited about a discovery he had just made in a book published by Charles Darwin in 1872 called The Expression of the Emotions in Man and Animals which suggested that all mammals reliably show emotions in their faces. But Mead thought Darwin’s idea was wrong and that Ekman SEPTEMBER 2015 • Doctor’s

Review

Ekman recognizes the potential for Big Brother-style abuses and suggests that he may have “created a monster”

Dr Paul Ekman also developed a 60 Face Test for use by medical staff.

was crazy — a less than auspicious start. In the ’60s, the prevailing theory was that facial expressions were culturally determined. Undaunted, Ekman embarked on a global journey with a stack of black and white photographs of peoples’ faces, gathering evidence of an overwhelming agreement on how people interpreted expressions of fear, sadness, happiness, anger, surprise and disgust, what he thought might be the six major universally recognized emotions. Concerned that Western culture may have influenced his subjects, he travelled to the jungles of Papua, New Guinea and showed his stack of face photos to people in remote villages, with similar results. At the time, his results — which may seem a little obvious to us now — were a breakthrough. Confirming the cross-cultural correlation of the six major expressions felt like the tip of the iceberg to Ekman.

DETRACTORS Ekman has had many detractors (popsci.com/article/science/facialexpressions-arent-universal-wethought). The latest is Dr Lisa Feldman Barrett at Northeastern University in Boston who, based on her 2014 study, says: “By giving (only) six words and six faces, you’re pre-categorizing…. Left to their own devices people consistently separate negative and positive emotions, but the rest of the sorting is a “very noisy sort.”

Doctor’s Review • SEPTEMBER 2015

What he wanted was a complete taxonomy of facial expressions. Sit across from a friend and make faces at each other. How many distinct expressions can you count? He quickly realized that simply recording the faces he and his colleagues could produce was inadequate. He adopted a systematic, anatomical approach, digging through anatomy books and isolating each facial muscle. He and his team came up with 43 possible distinct muscular movements in the face, calling them “action units.” By layering the action units on top of each other, they came up with 300 combinations of muscles, capable of producing over 10,000 visible facial configurations. About 7000 of those were nonsensical funny-faces but the other 3000 could be catalogued as the essential vocabulary of human emotion.

SUICIDE FACE The coding took seven years and was completed in 1975. Ekman and colleagues called it the Facial Action Coding System. Once that hefty task was done, he could focus on his real passion: detecting hidden emotions. In the early days of his career he had stumbled on a fascinating detail while watching a slow-motion video of a suicidal patient at a mental hospital. While speaking casually about future plans, a look of total despair flashed across her face, perceptible only when the video was seen frame by frame. Ekman would later dub this brief flash of feeling a “micro-expression.” The patient confessed to having been planning to kill herself the following weekend.

EMOTION SPOTTING This insight served as the basis for what has become Ekman’s most popular concept: our faces betray our true emotions, even when we want to hide what we’re feeling, the observation pointed out

so unforgettably by his mentor. Ekman believed that the ability to read hidden emotions could be taught, and after considerable work, he developed a training program to do so, calling it the Micro Expressions Training Tool (METT). Ekman’s reach has been considerable. Highlights include: • As little as an hour of training in the perception of micro and subtle emotions has been shown to increase patient-rated empathy among medical and surgical trainees. • Using the Ekman 60 Faces Test, health professionals have been able to reach 97 percent diagnostic accuracy in patients with front temporal dementia. • Those suffering from schizophrenia can dramatically improve their ability to read emotions after going through the METT training. • Law enforcement officers, educators, therapists, entertainers, and the full range of health care professionals have benefited from METT training. One of Ekman’s weightiest and most controversial projects has been his involvement with the US Transportation Security Administration (TSA), as an advisor on a project known as Screening Passengers by Observation Technique (SPOT). In spite of the billions that have been spent on the program — which uses Ekman’s methods among a host of others to train security personnel to focus on facial and body cues that might indicate suspicious behavior — the scientific efficacy of the program has yet to be proven. Indeed, the US Government Accountability Office, the investigative arm of the US Congress, says that it is unsure whether the SPOT program has “ever resulted in the arrest of anyone who is a terrorist, or who was planning to engage in terrorist-related activity.”

GOING GLOBAL? Proven in the field or not, the SPOT program continues and may soon be

Othello’s Error points out that what our faces don’t reveal is what triggered the emotion.

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.

About 3000 expressions catalogue the vocabulary of human emotion augmented by computers to take the place of humans trained to detect worrisome emotions. One such piece of software, known as the Computer Expression Recognition Toolbox (CERT), has the same success rate as trained humans at detecting emotions, but it’s faster, which makes it an appealing option for airport security. A number of other emotion-detection software companies have sprung up, with names like Emotient, Affectiva, and Eyeris. Emotient has recorded the facial reactions of thousands of people with a variety of ethnic backgrounds, while Affectiva says it has culled seven billion emotional reactions from 2.4 million face videos in 80 countries. Ekman questions the development of such software. He recognizes the potential for Big Brother-style abuses and even suggests that he may have inadvertently “created a monster.” “I can’t control usage,” says Ekman. “I can only be certain that what I’m providing is at least an accurate depiction of when someone is concealing an emotion.” Emotions should not be recorded without a person’s permission, he is careful to assert.

OTHELLO’S ERROR In spite of Ekman’s claim to fame as a human lie-detector and his fondness for spotting lies on the faces of politicians — he is famous for pointing out the signs of distress on Clinton’s face during the former president’s famous assertion that he did “not have sexual relations with that woman” — he is the first to point out that micro expressions do not necessarily indicate the presence of a lie. The failure to recognize this is what he calls, “Othello’s error.” “Othello read Desdemona’s fear accurately. But he didn’t recognize that the fear of being disbelieved is just like the fear of being caught. Yes, our faces reveal what emotions we’re experiencing, if you can read the signs. What our faces don’t necessarily reveal is what triggered the emotion,” he explains. So your face may betray you, but that doesn’t make your true emotions any easier for others to fathom. For those who prefer to keep their feelings to themselves, this is a comforting reminder.

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

SEPTEMBER 2015 • Doctor’s

Review

Doctor’s Review - September

ÉP

速

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

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

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

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

Controlled release oxycodone/naloxone HCl tablets

TOMISLAV PINTER / SHUTTERSTOCK.COM

Croatia

Motovun is one of Istriaâ&#x20AC;&#x2122;s better-known interior towns because of its medieval streets, excellent restaurants and fine wines.

underfoot Dig for truffles in the Istrian peninsula and discover seaside towns that’ll have you coming back for more by Anita Draycott

t’s hard to believe this small, dirty nugget resembling a knobby potato dug out of the ground by a dog named Betty is worth a fortune. But then I take a whiff. How can I describe the heady aroma?

Is it earth, musk, garlic, honey, hay — sweaty sock? Whatever, it’s intoxicating. We’ve discovered the illusive “white gold” of Istria (istra.hr). And the hunt has just begun. Four foodie friends and I have rented a villa in the medieval hilltop town Motovun the first week of October to coincide with the truffle season and its festivities. Nowhere is truffle worship more fervent than in the northern Croatian region of Istria. Croatian truffles aren’t as well known as those from Piedmont, Italy and parts of France, but they are recognized as being just as good by international gourmands. Istria also produces some of Croatia’s finest wines, honey and award-winning olive oils. It’s been called the best-kept food secret in Europe. Giancarlo Zigante, a local caterer and truffle hunter, and his dog, Diana, dug up a “joker” — the term for humongous truffle — weighing 1.31 kilograms on November 2, 1999, not far from Motovun. Guinness World Records listed his find as the largest in the world and helped put Istria on the map as a truffle mecca. Seductive and mysterious, white truffles were thought to be an aphrodisiac by the ancient Greeks and Romans. Their exorbitant price — up to $6000 per kilogram based on availability and quality — is

due to their unpredictable growth habits and the fact that no one has been able to cultivate these rare and illusive fungi that grow in a symbiotic relationship with the roots of oak, hazelnut and poplar trees. In Istria, the fungus-hunting season is celebrated with a plethora of rural festivals. We literally followed our noses to the annual Tuberfest (October 24 and 25 this year) in the neighbouring hamlet of Livade as the unmistakable truffle aroma wafted out of the entrance of a large tent. Visitors pay a small admission fee for a wine glass and an afternoon going from stall to stall sampling Istrian wines, brandies and all sorts of products made with truffles from olive oil to pasta to chocolate to ice cream. As much as I adore truffles, I found the truffle ice cream a bit of a stretch. Local chefs put on cooking demonstrations and truffle hunters submit their entries in the white truffle contest. The winning tuber is the largest and most beautiful. In the normally sleepy town of Buzet, virtually everyone who is anyone in Istria gathers on a midSeptember weekend to celebrate the Festival of Subotina (September 12 and 13 this year). As evening approaches, thousands of locals queue for a slice of the world’s biggest truffle omelette, fried up in a mind-bogglingly large pan in the town’s main square. SEPTEMBER 2015 • Doctor’s

Review

Last year they cracked 2014 eggs; this year the egg count will be 2015 to which they’ll add about 10 kilos of truffles. The festivities end with folk dancing, fireworks, alfresco pop concerts and large quantities of biska, the local mistletoe-flavoured brandy.

ur group had pre-booked a truffle hunt with the Karlic family (karlictartufi.hr) in Paladini. First we gathered at an outdoor picnic table where Kristina explained about the illusive tubers. Her family has been in the truffle business since 1966. She offered samples of truffle-spiked cheeses and sausages washed down with homemade wine. In order to fortify us for our upcoming truffle hunt, Kristina whipped up an amazing omelette, albeit smaller than the one in Buzet, but absolutely oozing with black and white truffles both inside and shaved raw on top. After lunch we trekked into the nearby forest with Kristina’s brother, Ivan, and his two dogs, Betty and Candy. Just as the fungi and tree roots have a special relationship, so do Ivan and his adorable mutts. It takes about three months for winter white truffles to mature at which point their spores release that addictive aroma from beneath the earth. Often the truffle hunter and his dogs have their best luck early in the autumn evenings when the cold air keeps the perfume close to the ground. Ivan explained that he starts training his dogs when they’re about three months old. The breed is Lagotto Romagnolo from Italy, known for their faithful happy

IVICA DRUSANY / SHUTTERSTOCK.COM

You can buy truffle-infused honey, olive oil and even grappa at souvenir shops in Motovun.

temperament, keen sense of smell and work ethic. By giving a pup some truffle bits it acquires a taste for them and comes to associate that taste and smell with food. Ivan then teaches his dogs to fetch truffle pieces or bits of bread coated in truffle oil buried about three centimetres deep. At first the canine unearths whole truffles with its snout since it hasn’t yet learned how to dig with its paws. Every time the dog finds a truffle, it gets a treat. This is clearly an example of Pavlov’s dogs in action. Eventually, the truffles are buried deeper in the woods and dogs learn to use their paws. In the final training stage, a pup accompanies a more experienced truffle dog in the woods. When the older dog sniffs out a truffle, it is distanced from the hole and the pup is brought in to dig it up. Judging from their wagging tails, Betty and Candy seem to love their work. Every once in awhile when we were hunting the dogs got super rambunctious and started sniffing and pawing at the soil. It was Ivan’s job to grab the truffles before the dogs devoured them. After a couple of hours, we found two black beauties that we purchased and took back to our villa. To say that our group binged on truffles would be an understatement. Usually, we’d start the day with some truffles shaved on scrambled eggs. Then, after a bit of sightseeing or a dip in the pool, we’d hike almost 300 metres to the top of Motovun where the main cobbled street is lined with truffle shops offering free tastings of oils, sauces, cheeses, pasta, sausages and chocolate all spiked with the white or black gold nuggets.

ITALY

SLOVENIA

HUNGARY

CROATIA Venice Motovun Porec Rovinj

AD RI AT IC

BOSNIA AND HERZEGOVINA SE A

The village of Motovun is home to less than 600 people.

TRUFFLE TIDBITS OPIS ZAGREB / SHUTTERSTOCK.COM

The white truffle is considered to be superior in smell and taste to the black truffle. It should be eaten raw in thin shavings over bland foods such as pasta, rice and eggs. Store truffles unwashed, wrapped in a paper or cloth towel in a sealed glass jar in the refrigerator and use within 15 days. Truffle oil, a cheaper alternative, is wonderful drizzled over scrambled eggs, beef carpaccio and wild mushroom soup.

Lagotto Romagnolo dogs have a keen sense of smell and a good work ethic.

PHANT / SHUTTERSTOCK.COM

ANITA DRAYCOTT

The 6th-century Euphrasian Basilica in Porec is one of Europeâ&#x20AC;&#x2122;s finest intact examples of Byzantine art.

ALEKSANDAR TODOROVIC / SHUTTERSTOCK.COM

Rovinj was originally on an island separated from the mainland by a channel that was filled in 1763.

We discovered Konoba Mondo, a terrific Old World restaurant where you can have your white truffles liberally shaved on all sorts of dishes from soufflés to steak. They even infuse honey with truffles and use it in a panna cotta desert. Konoba Mondo was featured on Anthony Bourdain’s travel food show No Reservations.

ut one cannot live on truffles alone. Along with its hill hamlets and forests, Istria also has some appealing coastal towns and beaches. We took day excursions to the seaside towns of Rovinj and Porec in search of fresh seafood. The Italianate port of Rovinj is postcard-perfect. Boats bob in a harbour of pristine blue water and fishermen mend their nets. Shops and houses, painted in a palette of Italian watercolours that seem to have ripened in the sun, line the cobbled streets around the main port. From the Venetian-style campanile of Rovinj’s crowning glory, the Church of St. Euphemia, named for the town’s patron saint, the views are marvelous. At Monte restaurant, near St. Euphemia, we sampled shrimps in a buzara sauce of sautéed onions, garlic, parsley, tomatoes, white wine and olive oil. For dessert, I tried the fennel ice cream — much better than the truffle recipe. The ancient Roman town of Porec, though less of a beauty queen than Rovinj, is not without its charms. The 6th-century Euphrasian Basilica, a World

Doctor’s Review • SEPTEMBER 2015

Heritage Site and one of Europe’s finest intact examples of Byzantine art, is a must. In nearby Kukci, we discovered the outdoor terrace of Marina restaurant where it’s best to forget the menu and have your waiter bring on a parade of Piscean platters paired with chilled crisp Malvasia white wines from the region. All in all, the trip was a huge success. The prices for the villa rental, truffles and truffle meals in Istria were more reasonable than in Piedmont and the quality was fantastic. (Note that prices for truffles fluctuate with supply and demand, but a first-class white specimen weighing about 100 grams sells for about $200.) Most Croatians speak English and are very hospitable. But, alas, all good things must come to an end. When your burps start to taste like truffles, you’ve probably had enough.

CROATIAN CONNECTIONS We rented a six-bedroom villa with a large wellequipped kitchen and swimming pool called Villa Dolce Vita in Motovun through My Istria (myistria. com; from €1485 per week, visit the website for date specific rates). We flew into Venice’s Marco Polo Airport. The villa management sent a driver to transfer us to the villa (about 2½ hours). They also arranged for a car rental during our stay in Istria.

CONSIDER

COVERSYL®

DISPENSED ACEI IN INITIAL THERAPY*

COVERSYL® reduces blood pressure in patients with mild to moderate essential hypertension. COVERSYL® is indicated for the treatment of mild to moderate essential hypertension. It may be used alone or in association with other drugs, particularly thiazide diuretics. The safety and efficacy of COVERSYL® in renovascular hypertension have not been established and therefore, its use in this condition is not recommended. The safety and efficacy of concurrent use of COVERSYL® with antihypertensive agents other than thiazide diuretics have not been established. Use in children is not recommended.

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

Please consult the product monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for contraindications, warnings, precautions, adverse reactions, interactions, dosing and conditions of clinical use. The product monograph is also available by calling us at 1-800-363-6093. ACEI = Angiotensin converting enzyme inhibitor *Data on file, IMS Brogan, Servier Canada Inc., April 2014 to March 2015.

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

COVERSYL® is a registered trademark of Servier Canada Inc.

Israel on two wheels and a prayer A bike tour of the Holy Land text and photos by Gary CrallĂŠ

The landscape around Halukim Ridge in the Negev Desert inspired some cyclists to do impromptu gymnastics.

The Mitzpe Hayamim Hotel gets fruit and veggies for its breakfast buffet from its 60-hectare organic farm.

The paved path around Hula Lake is suitable for cyclists of all levels, but bikers have to look out for turtles.

Yechiel Luterman left his law practice in Montreal to join the Bazelet HaGolan kosher winery in 2012.

srael enthrals in a myriad of ways, but here’s one you may never have considered: the small nation has an astonishing 1000 kilometre network of cycling trails. They stretch from the Golan Heights in

the north to the Gulf of Eilat in the south and, given the country’s penchant for impeccable planning, the trails are divided into 25 neat one-day sections. That, of course, is just the beginning. The dramatic landscape and the sites it embraces are imbued with the long human struggles and spiritual seeking that has gone on here since Abraham. For Jews, Christians and Muslims, this is biking on an entirely different level. As you would hope given the lofty history, I found Israeli bike tour companies to be most professional. There’s an infrastructure for sightseeing and dining and lodging, guides are skilled, equipment is good, tour organization is coordinated and safety is looked after. Of course, you still might fall off your bike. I’m a leisure cyclist, someone who regards culinary and cultural breaks as essentials to a balanced itinerary. Throw in this exotic mix of times past and astonishing present scenery and I’m dancing on the handlebars. I took six short tours interspersed with tourist attractions and I highly recommend this approach to touring for anyone with a moderate level of fitness. Best time to cycle? You can do it any time that takes your fancy, of course, but in summer it’s very hot in the south and humid along the coast. The best times in the north and centre are April to October, in the south, November to April.

CAESAREA A Mediterranean breakfast at the old Roman port of Caesarea is an easy transition from West to Middle East. On leaving airport Tel Aviv Ben Gurion Airport, our guide, Ali Abu Rabia (deadseatourguide.com), makes a first stop here, just an hour’s drive north, to give us a chance to catch our breath and stretch our limbs. Augustus Caesar gifted the site to King Herod who developed it into a thriving harbour. It’s now part of Caesarea National Park, with an amphitheatre and stadium and is much more peaceful than it must have been in the days of the Roman capitol.

MITZPE HAYAMIM SPA HOTEL A 1½ hour drive northeast of Caesarea into the Golan Heights, the Mitzpe Hayamim Spa Hotel (mitzpehayamim.com) is an oasis onto itself. Plants adorn the roof and atrium of the building, defying separation of interior and exterior. Rooftop decks provide a panoramic view. My room is spacious. A swatch of herbs and a small card have been placed at the edge of the bed. On the card is written “Wellness: a balanced lifestyle that includes care for body, mind and soul.” The hotel restaurants support this very well with an array of fresh produce and an outstanding Israeli breakfast buffet. SEPTEMBER 2015 • Doctor’s

Review

Israelis love falafel: it’s cheap, filling and everywhere.

Boya overlooks the sea in Tel Aviv and on breezy nights ocean spray will dust you and your Mediterranean dinner.

HULA VALLEY Forty-five minutes north from Mitzpe is the Agamon Ha’Hula (agamon-hula.co.il), a station on the Great Rift Valley migratory route for birds from Europe and Asia to Africa. It’s an appropriate home to one of the world’s leading ornithology centres. Eleven kilometres of flat, paved circular pathway are easily navigated on foot, bike, golf cart or “bird train,” with stops for lookout points and slow moving turtle traffic. There are Canadian connections too with a Memorial of Understanding between Agamon Hula and Manitoba’s Oak Hammock Marsh regarding shared wetland research. More recently, Stephen Harper set the cornerstone for a new bird sanctuary.

GALILEE One hour north of Mitzpe, almost at the current border with Syria, the 62 kilometre route winds downhill from Mount Hermon to the Sea of Galilee. We met the Genesis Cycling crew (genesiscycling.com) in the village of Neve Ativ and were soon whizzing along a two-lane road that spiralled through the hills and Odem Forest, named for the colour of volcanic rock in the area. Along the route, Bazelet HaGolan kosher winery (bazelet-hagolan.com) in Kidmat Zvi offers tastings from a surprising range of wines by vintner/owner Yoav Levy. Montreal native Yechiel Luterman poured samples while describing the winery. Capernaum was our final destination for the day’s ride. There, on the shores of Galilee, we ended up soaking our feet to celebrate our feat.

Doctor’s Review • SEPTEMBER 2015

A two-day bike tour of Jerusalem with guide Yonni Simmons includes a visit to the Supreme Court.

TEL AVIV In marked contrast to the countryside, Tel Aviv is a swirl of activity. From the InterContinental David Hotel (ihg.com/intercontinental/hotels/gb/en/tel-aviv/ tlvha/hoteldetail) I sauntered over to the beach where I was blown a kiss by a young woman. “Yes,” I thought. “I like it here.” The city’s sand necklace is a featured jewel much appreciated by citizens who sunbathe by day and party by night. Old Jaffa gave birth to the now much larger Tel Aviv, Israel’s first modern city. The only way to explore Jaffa is on foot. Artists’ quarters maintain an Ottoman architectural charm and there are great views of Tel Aviv. Namaltours (namaltours.co.il) pulls Tel Aviv together with its urban bike tours. Setting off from a mobile location at the beach boardwalk near the repurposed port, we did a three-hour circle tour of the main sights within the city core. Tel Aviv is wonderfully bike friendly. Dedicated cycle paths blend seamlessly with sidewalks, streets and promenades for a delightful excursion through various neighbourhoods. In contrast to North American cities, traffic is minimal.

On a tour through the Judean Hills, cyclists will pass vineyards, caves and even the olive tree where David and Goliath fought.

JERUSALEM

DEAD SEA

Just one hour east, Jerusalem is noticeably more pious than its secular big brother Tel Aviv. Biblical sites from Christianity, Islam and Judaism are the nuclei around which daily life revolves for both residents and visitors alike. During the day, walking is the best way to tour within the Old City walls, take to a bike for a wider view of New Jerusalem. We pedalled for two days with guide Yonni Simmons, storing our machines at our hotel, the David Citadel (thedavidcitadel.com). Bikes are convenient and quick transport in the city. However, you’ll need leg muscles to handle some extended distances and minor hills. It can be a bit hairy navigating Jerusalem traffic, but Israelis seem to have a spirit of adventure. The pièce de résistance is a night tour when even the Old Town is navigable using mountain bikes — as long as you don’t mind the occasional steps. Before setting out, we fuelled up with an ample dinner at the Colony Restaurant (rol.co.il/sites/colony/)

Ninety minutes south of Jerusalem, Ein Bokek is a health and tourist resort on the Dead Sea in the Negev desert. A visit to Masada, site of the Jewish revolt against the Romans in 73 CE, precedes a spa treatment and leisurely float in the sea’s buoyant salt water. Capping off our tour is a moonlit bike ride led by expert cyclist and Botzbike (botzbike.co.il) founder Arnon Shadmi first to the summit of Mount Sodom (lowest mountain in the world!), then through gullies and plateaus in the dark before celebrating with hot dogs and beer around a campfire at midnight. Bed at 2am. What a rush!

JUDEAN HILLS The Judean Hills are a 45-minute drive south of Jerusalem. On a 17 kilometre tour organized by Gordon Active Bike Tours (bit.ly/1ILaPis) and Trailhead (bit.ly/1DbBC5i), Yanay Cohen guided us over isolated trails, past vineyards and through an underground cavern. We stopped beneath an olive tree to hear him tell the familiar story of David and Goliath who fought near that very spot. Stunning to contemplate.

MITZPE RAMON Our final stop, 75 minutes south of Ein Bokek, is Mitzpe Ramon, a village in the central Negev highlands. We check into iBike (ibike.co.il) a classy boutique hotel for cyclists. Owners Aviva and Menachem left Tel Aviv to create this unique lodging and to provide excellent meals over which cyclists share their stories. Ramon Crater is just a short walk from the front door. The Mitzpe Ramon-Han Be’erot segment of the desert bike trail is technical which means that some skill is required... or luck. I nearly fell off my machine several times, but never did, because I have “a good sense of balance,” according to expert cyclist Rammy Gold. I noticed that he didn’t say “skill” but “balance” will do. For more info on the region, visit the Tourism Israel website (goisrael.com). SEPTEMBER 2015 • Doctor’s

Review

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

“The sporting life” begins with elegant rooms in an outstanding setting.

Casa de Campo reverie A resort that sets the benchmark for Caribbean luxury by David Elkins

photos by Dave Finn

he sound of gentle lapping of water. A tall white bird. Palm trees. Exotic flowers. Soft scented air. I woke from the dream slowly. Across a misty pond, an egret stood in the shallows near a small

wooden bridge. Sunlight from below the horizon seeped into the sky as I stepped into the glass shower and torrents of hot water brought me fully back into the world, smiling. This was the start of a luxurious adventure in which I would learn that the Casa de Campo (CDC) was not so much a resort as a way of life. And it was time for breakfast. The open-walled Lago Grill, a pleasant 10-minute stroll away through meticulously tended gardens, overlooks a rolling green vista to the 18th hole of the famous

Teeth of the Dog (TOTD) golf course. The Caribbean Sea glistens in the distance. Lovely to contemplate, but there’s work to be done. One of the most sumptuous breakfast buffets I’ve ever seen awaits — a dozen kinds of tropical fruit, smoothies whipped up on the spot, eggs prepared as you like them, sauces and salsas, trays of freshly baked croissants and pastries, eight fruit jams, smoked salmon, seven kinds of French cheese, cold cuts, ham, sausages and bacon. Good-natured waiters drift by with tea and coffee. It was hard to pull myself away. SEPTEMBER 2015 • Doctor’s

Review

he beach was tempting, but it’s always there waiting. What about a horseback ride to start the morning and a visit to a few of the venues that give CDC its motto: “the sporting life.” From the stables, I rode down a shaded path out past the polo field. A rider from Texas trotted up beside me with a big grin on his face and said, “You know what I like about this place? Everything’s included. It’s wide open. You can do whatever you like without thinking about it.” Located near La Romana on the Dominican Republic’s southeast coast, Casa de Campo began as a sugar cane plantation and then, commencing over 30 years ago, was transformed into the stunning property it’s become. Right from the start, CDC attracted those at the top of their game. Frank Sinatra inaugurated the 5000-seat classic Greek amphitheatre in 1982. Andrea Bocelli performed there this past April, as have Julio Iglesias, Sting, Elton John and a host of other music royalty. Sports stars also

come. This past January, John McEnroe and Jim Courier put on an exhibition at the 13-court tennis centre. Today, the property houses three championship golf courses including the Caribbean’s #1 ranked TOTD, a polo field, shooting club, marina, luxury hotel, an art centre and private homes from townhouses to mansions. After a lunch of shrimp ceviche with lemon and coriander at La Caña by Il Circo, I paused for a refreshing nap in my commodious room by the pond. The rich mahogany decor, fine artwork and orchids, European linen and fluffy duvet almost persuaded me to dream the afternoon away, but I resisted and around 3pm, I headed off to the shooting club in my golf cart — guests are provided with carts to get around the sprawling 2832-hectare site. There, a companion, Dan Donovan, publisher of Ottawa Life, and I were suited up with vests and, gently aided by gracious loaders, shot clays for the first time. It was a heady experience helped immeasurably by the fact

Casa de Campo began as a sugar cane plantation and was transformed into the stunning property it’s become

Golf may pale after the adrenaline rush of racing a top polo pony.

A guest shoots traps at the 140-hectare shooting centre.

The amphitheatre was inaugurated by Frank Sinatra in 1982.

The Teeth of the Dog (pictured and below) was ranked the #1 course in the Caribbean in 2014.

GOLF AND SPA The Teeth of the Dog (TOTD), one of three courses at Casa de Campo, was ranked in 2014 as the #1 golf course in the Caribbean and #52 in the world by the Top 100 Golf Courses in the World website (top100golfcourses.co.uk). Designed by Pete Dye and his wife, the “First Lady” of golf architecture, Alice, the 44-year-old course was hacked out along the coral coastline by 300 workers using picks and shovels. The Dyes took credit for 11 holes, but said the other seven along the ocean were created by God. Renovated in 2005, TOTD now measures 7350 yards and attracts golfers from all over the world. There are two other Dye courses at CDC: Dye Fore ranked #5 in the Caribbean and Links ranked #7. Golf rates begin at US$90, depending on the time of year. For details: casadecampo.com.do/golf/golf-rates. The spa at CDC is tucked away in a grove of tropical trees near the pool and is a finalist in the 2015 Global Wellness Travel Awards (winners to be announced this fall). The staff seems to possess magic fingers — they certainly did on the day I put myself in their hands. Under the direction of naturopath Kyra Montagu, the spa offers both traditional treatments and holistic Ayurvedic massage which aims to detox, strengthen bones and muscle fibres, stimulate circulation, and reduce inflammation. Says Dr Montagu, “…(we do) more than pamper guests with a relaxing massage, we help them understand the advantages of holistic health care and start living healthier lifestyles.” For those interested in meditation and a vegetarian diet, Kyra and her partner, Simon Furlonger, offer retreats on a property adjacent to the resort. For more: ki-ra.com. Sand traps on the Dye Fore course.

SEPTEMBER 2015 • Doctor’s

Review

Home prices begin at US$300,000 and go up to US$45 million.

SU CASA, MI CASA Owning a home here is not an impossible dream; prices begin at US$300,000. As an owner, you enjoy all the facilities that make the “sporting life” so tempting as well as a host of special events from golf, tennis and polo matches to a New Year’s gala on the water that goes on for three days. For a look at what’s available at the low end (107 square metres, one bed, 1½ baths) to the US$11-million homes on offer (1610 square metres, six beds, eight baths), go to Casa de Campo Real Estate (casadecampore.com). Many owners of even the most luxurious homes rent their houses out. For example, during a polo tournament this past spring, a US$12-million property with eight bedrooms with bathrooms ensuite was leased out for US$8000 a week, a figure that included two maids, a cook and a chauffeured limousine.

A protected cove makes Minitas Beach a perfect place for both kids and adults.

A weekly Las Vegas style show at the amphitheatre ends with fireworks.

The offerings at the antipasto table at La Piazzetta are on a par with those in northern Italy.

that both of us managed to hit a good number. Shooting an orange clay disk out of the sky is a rush and we kept going until the box of shells was empty. The venue is run by shooting director Gary Salmon who began his career as a trainee at Sandringham, Queen Elizabeth’s 8000-hectare estate in Norfolk. He came to CDC last spring after 16 years as shoot manager on the Ashby St. Legers estate in Northamptonshire. He calls the 140-hectare shooting centre with its glades in the woods, hidden traps, striking tower and mowed areas for skeet and trap the most comprehensive he’s ever seen.

he shot guns safely stored away, it was time to take in a late afternoon polo match. I joined a small audience in the wooden bleachers and sat beside a woman whose 18-year-old son was competing and whom she very much wanted to win. At first she shot photos but soon got caught up in the action and abandoned the camera. In the end her son’s team lost by a point. He trotted his pony over after the match but was so downhearted at the loss he could hardly speak. Four or five other spectators hosted tailgate parties and toasted the winners with Moët & Chandon. Guests are encouraged to try polo, but Sporting Life manager Calixto García-Vélez warns golfers that “after the rush of adrenaline of racing a top polo

pony as you swing at a bouncing ball you may never go back to golf.” The sun was setting and I’d planned to meet some friends for dinner at the La Piazzetta over in the Altos de Chavón, a replica of a 16th-century Mediterranean village that’s located on a cliff overlooking the Chavón river. Remarkably, the collection of old buildings fits right into the Caribbean landscape. Built by Paramount pictures set designer Roberta Cappa and completed in 1982, the remarkably authentic looking town has a theatrical flair to it. A cobblestoned plaza links St. Stanislaus Church and an archeology museum that houses pre-Columbian and Taino artifacts (the island’s original inhabitants) and a gallery with good paintings on display. There’s also an art school and a full-time weaving workshop that fashions and sells highquality woven goods. A pleasure to wander through. La Piazzetta was a treat. The rustic Italian restaurant features a wonderful table of antipasto selections but, for me, the highlight was the homemade, melt-inyour-mouth ravioli that was stuffed with herbs and goat cheese. The good company, subtle flavours, Italian wine, candlelight, old stones and sweet evening breezes conspired to create a feeling of abundance and well-being so pervasive that I almost forgot the Vegas-style show at the amphitheatre. On a stage that looked as though it might have hosted Plato or Socrates, the long legs of the female dancers flashed from satin and feathers while the male performers snaked through elaborate choreography; the clownbuffoons were funny; and the fireworks spectacular. A fitting end to a perfect day. And so home to bed. I drifted off to sleep thinking about a dawn jog along the seafront, about fine food, the white sand at Minitas Beach, grilled seafood and vegetables with salsa chimichurri at The Beach Club and deep sea fishing out of La Marina or maybe a boat ride over to the long beach on Catalina Island. I thought I heard a bird call in the distance, an egret perhaps, but by then I was dreaming.

CARIBBEAN CONNECTIONS Given the many dining and activity options offered at Casa de Campo (tel: 800-877-3643; casadecampo.com.do), the complete package is the favoured choice. It includes breakfast, lunch and dinner; unlimited drinks and unlimited selected sports: tennis, horseback riding, non-motorized boating and others. Rates for two start at US$479 a day. The resort is serviced by La Ramana International Airport (LRM) about an hour’s drive away. A pickup service is provided. There are no daily flights to LRM so check with the airline before you plan your dates. Flights aboard Air Transat (tel: 877-872-6728; airtransat.ca) from Toronto, Montreal and Quebec City, December through April, start at $600; WestJet (tel: 888-937-8535; westjet.com) from Toronto, Fridays, start at $756. St. Stanislaus Church at the Altos de Chavón hosts dozens of weddings every year.

SEPTEMBER 2015 • Doctor’s

Review

CH LA A EN NC ST TE E T R! O

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.

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.

Roasted beet, buckwheat and goat cheese salad.

Go with the grain Nutrient-dense recipes for breakfast, lunch and dinner recipes by

Chrissy Freer

photos by

Julie Renouf

hrissy Freer’s cookbook Supergrains consists of over 100 recipes for barley and buckwheat, faro and freekeh, kamut, quinoa and more. Grains are

the seeds of certain plants that have had their hard inedible outer husks removed. Unrefined (whole) grains have their entire edible kernel intact: the bran, the germ and the endosperm. Refined grains on the other hand — white rice, white wheat flour — have had the bran and germ removed leaving just the endosperm, which has the fewest

vitamins and minerals. Supergrains are essentially unrefined grains. A nutritionist from Australia, Freer explores 12 supergrains in her cookbook and includes nutritional info for each. The book features a cooking chart — quantity of liquid required, cooking time, yield — and another chart that describes each grain’s flavour and how to best SEPTEMBER 2015 • Doctor’s

Review

use it. Grains of truth! Here are fun ways to use three of them: buckwheat, millet and quinoa.

ROASTED BEET, BUCKWHEAT AND GOAT CHEESE SALAD (GLUTEN-FREE) The earthy flavour of the buckwheat is delicious with roasted beets and goat cheese. Buckwheat is an ideal grain for vegetarian dishes as it is rich in protein, B vitamins, calcium and phosphorus. The cheese and hazelnuts also add extra protein. Prep time: 20 minutes (plus cooling) Cooking time: 45 minutes 10-12 baby beets, trimmed (about 1-1½ lb./455-680 g in total) 1 c. (250 ml) raw buckwheat groats

½ c. (125 ml) hazelnuts, lightly toasted and skinned 4 oz. (110 g) baby arugula leaves (about 3 c./750 ml) 3 tbsp. (45 ml) snipped chives 4 oz. (110 g) soft goat cheese (see tips), crumbled For the dressing 3 tbsp. (45 ml) olive oil 3 tbsp. (45 ml) fresh orange juice 1½ tbsp. (22.5 ml) balsamic vinegar

Preheat the oven to 400ºF (200ºC). Put the beets in a large roasting pan, cover the pan with foil and roast for 40 to 45 minutes or until they are tender when pierced with a skewer. Set aside to cool slightly, then peel (see tips) and cut into wedges. Meanwhile, heat a large, nonstick skillet over medium-high heat. Add the buckwheat and cook, stirring, for 3 to 4

Millet-stuffed roast chicken.

minutes or until fragrant. Put the toasted buckwheat and 2 cups (500 ml) water in a saucepan and bring to a boil. Cover, reduce the heat to low and simmer for 10 to 12 minutes or until just tender (be careful not to overcook). Rinse under cold running water then drain well. Coarsely chop the hazelnuts and place in a large bowl. Add the beets, cooked buckwheat, arugula and chives, and stir to combine. To make the dressing, whisk the olive oil, orange juice and balsamic in a small bowl until combined. Add to the salad and toss well. Sprinkle with the goat cheese and season with sea salt, and freshly ground black pepper, to taste. Serves 4. Tips: Wear gloves while peeling the beets to prevent your hands from becoming stained by the juices. You could substitute a creamy feta cheese or marinated feta for the goat cheese if you like.

MILLET-STUFFED ROAST CHICKEN Millet works wonderfully as a stuffing because it absorbs the flavours and juices from the chicken. It is also a gluten-free alternative to a traditional breadcrumb stuffing. Using millet in a stuffing is a great way to introduce it to people — they won’t know it’s in there, but will enjoy the flavour. Prep time: 20 minutes Cooking time: 1 hour 20 minutes 3 tbsp. (45 ml) olive oil 1 small yellow onion, finely chopped 5 oz. (140 g) sliced uncooked bacon (about 3 slices, see tips), rind removed, diced 2 garlic cloves, crushed 1 c. (250 ml) cooked millet (instructions follow) 3 tbsp. (45 ml) coarsely chopped parsley 1½ tbsp. (22.5 ml) finely chopped sage 1 tsp. (5 ml) finely grated lemon zest 3-4 lb. (1.35-1.8 kg) free-range chicken roast potatoes and steamed greens, to serve

Heat 1 tablespoon (15 ml) of the oil in a large skillet over medium-high heat. Add the onion and bacon and cook, stirring occasionally, for 5 minutes or until golden. Add the garlic and cook, stirring, for 1 minute more. Transfer

Banana, honey and walnut bread.

the mixture to a large bowl and add the millet, herbs and lemon zest. Season with sea salt and freshly ground black pepper, then set aside to cool. Preheat the oven to 425ºF (220ºC). Rinse the chicken and pat dry with kitchen paper. Spoon the stuffing into the cavity of the chicken. Tie the legs together with kitchen string. Place the chicken, breast side up, in a large roasting pan. Drizzle with the remaining olive oil, and season with salt and pepper. Roast for 20 minutes, then reduce the oven temperature to 400ºF (200ºC) and cook for a further 50 minutes or until the juices run clear when you prick the thickest part of the thigh. (Cover the chicken with foil if it is browning too quickly.) Remove the chicken from the oven and set aside for 10 minutes to rest before carving. Serve with roast potatoes and steamed greens. Serves 4. Tips: If you want this dish to be gluten-free, make sure you use glutenfree bacon. Millet works particularly well with poultry or pork, so you could also try this stuffing in spatchcock, quail, turkey or a rolled pork loin.

To cook millet Heat a large saucepan over medium-high heat, add 1 cup (250 ml) hulled millet and cook, stirring, for 3 minutes or until fragrant. Add 2 cups (500 ml) water and bring to a boil. Reduce the heat to low, cover and simmer for 20 minutes or until the water is absorbed. Remove from the heat and set aside, still covered, to steam for 10 minutes. Fluff the grains with a fork and transfer to a large bowl to cool completely. (Sometimes you may find you need to add an extra ½ cup/125 ml during cooking).

½ c. (375 ml) all-purpose flour 1 1 tsp. (5 ml) ground cinnamon 1 tbsp. (15 ml) baking powder ²⁄³ c. (160 ml) quinoa flakes ½ c. (125 ml) walnut halves, coarsely chopped ½ c. (125 ml) honey, plus extra, to serve 2 eggs ¹⁄³ c. (80 ml) sunflower oil ¼ c. (60 ml) sour cream 2 c. (500 ml) mashed banana (about 1 lb. / 450 g) fresh ricotta cheese, to serve

BANANA, HONEY AND WALNUT BREAD

Preheat the oven to 350ºF (180ºC). Lightly brush a 4- by 8-inch (10- by 20cm) loaf pan with oil and line the base with parchment paper. Sift the flour, cinnamon, baking powder and a pinch of salt into a large mixing bowl. Add the quinoa flakes and ¹∕³ cup (80 ml) of the walnuts and stir to combine. Combine the honey, eggs, oil, sour cream and banana in a separate bowl. Add to the dry ingredients and stir until just combined.

Quinoa flakes are ideal to use in baked goods where you would typically use rolled oats. This banana bread is great to freeze and can then be toasted straight from the freezer for a quick breakfast. Just cut into slices, wrap in plastic wrap and freeze for up to two months. Prep time: 20 minutes Cooking time: 45 to 50 minutes

Spoon the mixture into the prepared pan and smooth the surface with the back of the spoon. Sprinkle the remaining walnuts over the top. Bake for 45 to 50 minutes or until golden and a skewer inserted into the centre comes out clean. Cover the top with foil if the loaf is browning too quickly. Remove from the oven and set aside to cool for 10 minutes before turning out onto a wire rack. Serve warm or at room temperature with fresh ricotta and a drizzle of extra honey. Serves 8. Tips: To make banana and blueberry bread, omit the walnuts and stir through 1 cup (250 ml) fresh (or frozen) blueberries after combining the wet and dry ingredients. Excerpted from Supergrains by Chrissy Freer. Recipes copyright © 2015 Chrissy Freer. Photography copyright © 2015 by Julie Renouf. Published by Appetite by Random House, a division of Random House of Canada Ltd., a Penguin Random House Company. Reproduced by arrangement with the Publisher. All rights reserved. SEPTEMBER 2015 • Doctor’s

Review

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 • SEPTEMBER 2015

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

Review

P H OT O FI NI S H by

Dr Va n e s s a H . L e

Greek revolution advertisers index ACTAVIS SPECIALTY PHARMACEUTICALS Constella....................................................8 AMERICAN SEMINAR INSTITUTE Corporate ................................................ 27 ASTRAZENECA CANADA INC. Forxiga.......................................IFC spread Komboglyze/Onglyza............................. 18 BOEHRINGER INGELHEIM (CANADA) LTD Corporate..................................................6 Spiriva Respimat..................................OBC GLAXOSMITHKLINE BREO Ellipta......................................... 4, 5 LEO PHARMA INC. CANADA Dovobet Gel......................................... IBC Picato...................................................... 17

The impressive Mykonos windmills — pure white, circular, with a conical wooden roof — are symbols of this infamous Greek island. In Greek mythology, Mykonos was the site of the great battle between Zeus and the Gigantes. The island, made mostly of granite, was named in honour of Apollo’s grandson, Kykons. The “Island of the Winds,” as locals call it, is one of the Cyclades, a group of islands of the Aegean Sea. The windmills were once used to mill flour for local residents and for people living in areas off Mykonos. No matter where you are on the island, you can see their spectacular silhouettes. Today, the windmills are no longer used for grinding grain, but their value and importance remain. A few have been restored and now welcome visitors as museums; others have been renovated and function as dwellings. For dramatic effect, this photograph was taken at sunset, with an Olympus iZoom 2000 (non-digital) camera loaded with black and white film.

LUNDBECK CANADA Trintellix....................................................2 MERCK CANADA INC. Zenhale.................................................... 25 PFIZER CANADA Pristiq...................................................... 21 PURDUE PHARMA CANADA Analgesic Portfolio.................................. 28 Biphentin............................................. 9, 24 Targin................................................ 32, 33 SEA COURSES INC. Corporate................................................ 15 SEVIER CANADA Coversyl.................................................. 39 TAKEDA CANADA INC.

Alvesco........................................................10 Nesina (Quebec only)...................................44

TD BANK FINANCIAL

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Doctor’s Review • SEPTEMBER 2015

Corporate.....................................................12

FAIR BALANCE INFORMATION Biphentin................................................. 54 Komboglyze............................................ 31 Targin..................................................... 55

F O R B O DY * A N D S C A L P PS O R I A SI S , CO N SI D E R D OVO B E T ® G E L

A Corticosteroid plus Vitamin D Analogue in one formulation. Providing a dual mechanism of action†: anti-inflammatory properties and suppresses keratinocyte proliferation Dovobet® Gel (calcipotriol + betamethasone dipropionate) is indicated for the topical treatment of:1 • moderate to severe scalp psoriasis vulgaris in patients 18 years and older for up to 4 weeks • mild to moderate plaque psoriasis vulgaris on the body in patients 18 years and older for up to 8 weeks Contraindications • Disorders of calcium metabolism • Viral skin lesions; fungal, bacterial, parasitic skin infections; skin manifestations related to tuberculosis or syphilis • Perioral dermatitis • Skin atrophy or striae • Fragility of skin veins • Ichthyosis • Acne vulgaris, acne rosacea or rosacea • Ulcers and wounds • Perianal and genital pruritus • Guttate, erythrodermic, exfoliative and pustular psoriasis • Severe renal insufficiency • Severe hepatic disorders • Ophthalmic use

Relevant Warnings & Precautions • Should not be used on the face, axillae, flexures, groin or genitals • Skin AE risk: Application on large areas of damaged skin, in skin folds, or under occlusive dressings should be avoided • Prolonged use of corticosteroid containing preparations may produce striae or atrophy of the skin or subcutaneous tissues

• Post-treatment medical supervision recommended related to the risk of pustular psoriasis or rebound psoriasis when discontinuing corticosteroids after prolonged periods of use • Hypercalcaemia and hypercalciuria may occur if the maximum daily dose (15 g), maximum weekly dose (100 g), or maximum treated body surface area (30%) is exceeded • Monitoring recommendation: baseline and at other suitable intervals for serum calcium levels • Calcipotriol when used in combination with ultraviolet radiation (UVR) may enhance the known skin carcinogenic effect of UVR • Risk of enhanced skin carcinogenic effect with exposure to ultraviolet radiation. Excessive exposure to both natural and artificial sunlight should be avoided. • May cause eye irritation. Avoid contact with the eyes or conjunctiva • Avoid concomitant treatment with other corticosteroids • Monitoring recommendation for HPA axis suppression related to the systemic absorption of topical corticosteroids • AE risks with systemic absorption of topical corticosteroids: Manifestations of Cushing’s syndrome, effects on the metabolic control of diabetes mellitus and unmasking of latent diabetes mellitus • Dermatitis AE risk • Not recommended for use in pregnant and nursing women

*Should not be used on the face, axillae, flexures, groin or genitals. †Clinical significance unknown.

Adverse Reactions • Most common was pruritus (0.6% body and 2.3% scalp) • Others, occurring in ≥ 1% of patients Body: application site pain (0.4%) • Others, occurring in ≥ 1% of patients Scalp: headache (0.5%), skin irritation (0.5%), alopecia (0.4%), and erythema (0.4%)

For More Information Please consult the product monograph at www.leopharma.ca/dovobetgel_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.

®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 1. Dovobet® Gel product monograph. LEO Pharma Inc. July 3, 2013.

www.leo-pharma.ca

DOV-007-15E

NOW INDICATED IN

ASTHMA

NOW IN CANADA FOR COPD: MAINTENANCE TREATMENT + THE REDUCTION OF EXACERBATIONS1

IN COPD:

Indications and clinical use: SPIRIVA RESPIMAT (tiotropium bromide monohydrate) is indicated as a long-term, once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema, and for the reduction of exacerbations. SPIRIVA RESPIMAT is indicated as add-on maintenance bronchodilator treatment in adult patients with asthma who remain symptomatic on a combination of inhaled corticosteroid (equivalent to, but not limited to ≥500 mcg fluticasone/day or ≥800 mcg budesonide/day) and a long acting β2 agonist and who experienced one or more severe exacerbations in the previous year. SPIRIVA RESPIMAT is not indicated as rescue medication for the relief of acute bronchospasm in COPD or asthma. Safety and efficacy of SPIRIVA RESPIMAT in patients less than 18 years of age have not been established. Contraindications: - Patients with a history of hypersensitivity to atropine or its derivatives (e.g. ipratropium) Relevant warnings and precautions: - Should not be used for initial treatment of acute episodes of bronchospasm or for the relief of acute symptoms - Should not be used as a first-line treatment or monotherapy for asthma References: 1. O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2008 Update. Can Respir J 2008;15(Suppl A):1A-8A. 2. SPIRIVA® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., May 20 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. 4. Data on file. Boehringer Ingelheim (Canada) Ltd., 2015.

- Immediate hypersensitivity reactions may occur - Should not be used more frequently than two inhalations once daily - Patients with narrow-angle glaucoma, urinary retention (prostatic hyperplasia or bladder-neck obstruction) - Avoid getting mist into eyes - Should not be used with other medicine containing a long-acting muscarinic antagonist - Occurrence of dizziness or blurred vision may influence ability to drive and use machinery - Cardiovascular effects, such as cardiac arrhythmias (e.g. atrial fibrillation and tachycardia), may be seen after the administration of muscarinic receptor antagonists - Moderate to severe renal impairment - Inhalation-induced bronchospasm - Pregnant and nursing women For more information: Please consult the product monograph at www.boehringer-ingelheim.ca/ content/dam/internet/opu/ca_EN/documents/humanhealth/product_monograph/ SpirivaRespimatPMEN.pdf for important information relating to adverse reactions, interactions, and dosing information not discussed in this piece. The product monograph is also available by calling us at 1 (800) 263-5103 Ext. 84633.

NEW

* See Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease (2008) for complete recommendations. Spiriva® and Respimat® are registered trademarks used under license by Boehringer Ingelheim (Canada) Ltd.