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The plumage of Ploceidae males is typically brightly coloured, usually red or yellow and black. Some species show colour variation only during the mating season.
Find out more from your Boehringer Ingelheim/Eli Lilly Alliance representative. TRAJENTA is a trademark of Boehringer Ingelheim International GmbH. Jentaduetoâ„˘ is a trademark used under license by Boehringer Ingelheim (Canada) Ltd.
To sleep, perchance to dream
FXQUADRO / SHUTTERSTOCK.COM
You’re sleep deprived. You probably don’t need me to tell you that, but I’m talking science here. A survey conducted by this magazine suggests that 68 percent of Doctor’s Review readers get less than eight hours of sleep a night. On the other hand, I could be wrong. Who says eight hours a night is an appropriate amount? A better number might be seven. Two surveys of more than one million adults conducted by the American Cancer Society (ACS) found that those who slept seven hours had less mortality risk after six years than those sleeping both more and less. It also showed that those who slept less than seven hours and those who slept longer than eight hours had an average mortality risk that was greater but — and here’s a surprise — the risk was higher for longer sleepers. So, it turns out that between seven and eight hours is the optimum amount of sleep. Here some readers of this magazine do better: 28.7 percent of you reported that you were in the sweet spot. That’s all to the good. According the ACS study, to sleep outside the “zone” is to put oneself at risk of a higher BMI, diabetes, heart problems, depression and substance abuse. Not getting enough sleep has another downside. It’s now believed that 20 percent of car crashes are caused by drivers falling asleep at the wheel, a greater number than from accidents caused by DUIs. I’m a pretty good sleeper except when I’m away from home, then I resort to that most Canadian of soporifics: the CBC. This is not a criticism of our national station, it’s a kudo. They’re on the air 24 hours a day, and if I find myself tossing and turning after the midnight hour, CBC Radio 1 or 2 is there coast-to-coast to soothe me back into the Land of Nod. Airlines and hotels have been focusing on sleep. Most business class flights now offer seats that fold down flat on longer routes. The article on sleep (page 43) describes the substantial efforts classier hotels are using to put you to bed. One not mentioned is Holiday Inn Express, which offer pillow-top beds, pillows of varying softness and duvets. Most also take dogs; a real bonus this past winter when we endured so many “three-dog nights.” Sweet dreams,
doctorsreview.com David Elkins, Publisher firstname.lastname@example.org
@doctorsreview APRIL 2014 • Doctor’s
Covered on RAMQ and most private plans
heartburn associated with GERD With the demonstrated power of DEXILANT™ Visit www.DEXILANT.ca 24 hours a day to learn more
In patients maintaining healed erosive esophagitis (EE) with DEXILANT ™ 30 mg:
99% of nights were heartburn-free vs 72% with placebo (median; p<0.00001)1* 96% of 24-hour periods were heartburn-free vs 29% with placebo (median; p<0.00001)1*
Indications and clinical use: In adults 18 years and older, DEXILANT™ is indicated for: • Healing of all grades of erosive esophagitis for up to 8 weeks • Maintenance of healed erosive esophagitis for up to 6 months • Treatment of heartburn associated with symptomatic non-erosive gastroesophageal reflux disease (GERD) for 4 weeks Contraindication: • Should not be concomitantly administered with atazanavir Other relevant warnings and precautions: • Symptomatic response does not preclude the presence of gastric malignancy • May slightly increase the risk of gastrointestinal infections such as Salmonella and Campylobacter and possibly Clostridium difficile • Concomitant methotrexate use may elevate and prolong serum levels of methotrexate and/or its metabolites
• May increase risk of osteoporosis-related fractures of the hip, wrist, or spine. Use lowest dose and shortest duration appropriate • Patients >71 years of age may already be at high risk for osteoporosisrelated fractures and should be managed carefully according to established treatment guidelines • Chronic use may lead to hypomagnesemia. For patients expected to be on prolonged treatment or concurrent treatment with digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), initial and periodic monitoring of magnesium levels may be considered • May interfere with absorption of drugs for which gastric pH is important for bioavailability For more information: For important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions and dosing, please consult the product monograph at www.dexilant.ca/PM. The product monograph is also available by calling us at 1.866.295.4636.
*Results of a 6-month, multicenter, double-blind, placebo-controlled, randomized study of patients who dosed DEXILANT™ 30 mg (n=140) or placebo (n=147) once daily and had successfully completed an EE study and showed endoscopically confirmed healed EE.1 Reference: 1. DEXILANT (dexlansoprazole) Product Monograph, Takeda Canada Inc. ™DEXILANT is a trademark of Takeda Pharmaceuticals U.S.A., Inc. and used under license by Takeda Canada Inc. ©2013 Takeda Canada Inc.
contents APRIL 2014
EKATERINA POKROVSKY / SHUTTERSTOCK.COM
I prescribe a safari in…
A Saskatoon doc and his sons go to Botswana and Zimbabwe, and almost get eaten for dinner by Dr Jonathan Hey
Pillars of strength Ancient monuments that’ll stun you in Spain’s Castile and León by Robb Beattie
Eggs to infinity An everyday ingredient that’ll save supper by Andrea Slonecker
The inside story Apartments and other holiday rentals for a summer trip to France by Jeremy Ferguson
The business of sleep The best hotels and airlines for tired travellers trying to catch some z’s by Stephanie Rosenbloom
a new contest! WIN two romantic nights in an Executive Suite at Hôtel Le Crystal Montréal! Turn to page 27 for details.
APRIL 2014 • Doctor’s
Omnaris : Powerful allergic rhinitis relief with an excellent tolerability profile. ®
Common adverse reactions (1%–10%) in 2 to 6 week clinical trials with SAR or PAR patients (≥12 years) for Omnaris and placebo include epistaxis (2.7% vs. 2.1%), nasal passage irritation (2.4% vs. 2.2%) and headache (1.3% vs. 0.7%). Most common adverse reactions reported in a 52-week clinical trial of PAR in patients ≥12 years, OMNARIS vs. placebo, were epistaxis (8.4% vs. 6.3%), nasal passage irritation (4.3% vs. 3.6%) and headache (1.6% vs. 0.5%).
Indications and clinical use: OMNARIS (ciclesonide nasal spray) is indicated for the treatment of seasonal allergic rhinitis, including hay fever, and perennial allergic rhinitis in adults and adolescents 12 years of age and older. ®
Contraindications: • Patients with tuberculosis Relevant warnings and precautions: • Patients who are on drugs that suppress the immune system are more susceptible to infections than healthy individuals • Patients should be examined periodically for changes or signs of adverse effects on the nasal mucosa (e.g. Candida albicans)
• Do not use in patients with recent nasal ulcers, nasal surgery, or nasal trauma until healing has occurred • Monitor for growth suppression in children and adolescents • Signs of adrenal insufficiency and withdrawal can accompany the replacement of a systemic corticosteroid with a topical corticosteroid; patients should be carefully monitored. Rapid decreases in systemic corticosteroid dosages following long-term treatment may cause a severe exacerbation of symptoms • Monitor for hypoadrenalism in infants born to mothers taking corticosteroids • Use with caution, if at all, in patients with untreated local or systemic fungal or bacterial infections, viral or parasitic infections, or ocular herpes simplex
• Rare instances of wheezing, nasal septum perforation, cataracts, glaucoma, increased intraocular pressure have been reported with intranasal corticosteroid use For more information: For important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions and dosing information, please consult the product monograph at http://www. takedacanada.com /ca /omnarispm. The product monograph is also available by calling us at 1-866-295-4636.
REFERENCE: 1. OMNARIS (ciclesonide nasal spray) Product Monograph. Takeda Canada Inc., January 2, 2013. ®
COVERED BY MOST PRIVATE INSURANCE PLANS. ® Registered trademark of Takeda GmbH. Used under licence.
Powerful AR relief. Excellent tolerability profile.
contents APRIL 2014
regulars 7 LETTERS All eyes on Africa
PRACTICAL TRAVELLER A brand new Sea-to-Summit Trail in BC, the Orient-Express is renamed, banning naked tourists in Machu Picchu, plus more! by Tyson Lowrie
BUDGET TRAVELLER Cheap sleeps in Hong Kong, Rome and Tokyo by Annarosa Sabbadini
PHOTO FINISH The sands of time by Dr Dominika Jegen
coming in May
A running shoe that’s cool, compact and so, so comfy by David Elkins
ONE BOTTLE Sake to me by James Nevison
HISTORY OF MEDICINE The Maine-born MD who invented calorie counting by Jackie Rosenhek
Ace across the country: a Winnipeg doc takes on Canada’s greens
BEST MD APPS
10 of the world’s weirdest works of art
A drug formulary app by UBC med students that you’ll become addicted to by David Elkins
Is rice the finest grain of them all?
Was the man with two faces a fictional circus freak or a real medical marvel?
The best med meetings, hot MD apps, the yummiest recipes and much more
The biggest medical meetings through September, plus what conferencing cardiologists should do in Vegas
19 APRIL 2014 • Doctor’s
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OFF THE MARK? I was delighted to see the Maasai Mara, Kenya [On the prowl, page 34] featured in the February 2014 edition, having just returned from there myself. I have visited each year as a part of a project to help local girls stay safely in school. It is indeed one of the best places to go on safari, especially to see the big cats. We saw lions, cheetahs and leopards with young on our last visit, but other wildlife abound, too. I was concerned at the statement that “When you’re looking for wildlife, off road is best.” Being off road is actually illegal, and your driver and guide will suffer stiff penalties if caught. There is a good system of tracks throughout the park and they are maintained and moved to minimize the effect on the local ecosystem, which supports the animals that we go to see. When vehicles frequently go off road they compact and destroy the land, reducing the places animals can escape to for some peace and quiet, thus forcing them deeper into the park where they are harder to find. Most of the animals are well habituated to the tourists in vans and you can watch natural behaviours. Lions have even been known to lie down in the shade of a van right below us or to pass so close to the window that the foolhardy could have reached out. Cheetah will even get up and sit on a van for a better view. Go! It will be the experience of a lifetime and the presence of visitors helps to maintain the local people who otherwise only have their cattle and poaching to sustain them. But visit responsibly. Preserve this wonderful savannah for the people there and for future generations, so your grandchildren can also stand speechless at the beauty of it.
The winner of a $100 Atmosphere gift card is Dr Ihsaan Peer, an FP from Abbotsford, BC.
BODY POLITICS Sure, I’d like to shed my tons of clothe layers for Asian spring [“Asia’s springtime celebrations,” Practical Traveller, January 2014, page 14]. Just curious: what happens to the goat carcass in the game of kupkari in Uzbekistan? Don’t tell me lean goat meat is left to rot! Dr Muri B Abdurrahman Via email
Correction: In February’s Best MD Apps column, Skyscape’s newest was misspelled. Their latest app is called Omnio and not Omino. It contains drug info, medical calculators, a symptom checker, a reference checker and medical alerts. Read more about it at doctorsreview.com/ gadgets/aggregators.
Dr Pippa Moss Tatamagouche, Nova Scotia
StiStill sufferi ll sufferingnfrom g fromGERD? GERD? Roll over to page xx. Roll over to page xx. APRIL 2014 • Doctor’s CHANGE #
TAK TEC 13435 Doctor Review_1.25x3.5.indd 1
2013-10-23 4:06 PM
Open up to a new
LAAC option in COPD
IMPROVED PATIENTS’ QUALITY OF LIFE (LS mean change in SGRQ total score vs. placebo, -3.32; p<0.001)1,2†
Now co by the vered and RAODB MQ
DEMONSTRATED 5-MINUTE ONSET AND 24-HOUR BRONCHODILATION FEV1 improvement shown 5 minutes after first dose (0.093 L vs. placebo, p<0.001, serial spirometry)1,3‡
Significantly greater LS mean FEV1 vs. placebo demonstrated at all time points over 24 hours (LS mean FEV1 [L] vs. placebo after first dose, p<0.001; time points were 5 min, 15 min, 30 min, 1 hr, 2 hrs, 3 hrs, 4 hrs, 6 hrs, 8 hrs, 10 hrs, 12 hrs, 23 hrs 15 min, 23 hrs 45 min)4§ Indication & clinical use: SEEBRI* BREEZHALER* (glycopyrronium bromide) is indicated as a long-term once-daily maintenance bronchodilator treatment in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema. Not indicated for the relief of an acute deterioration of COPD Can be used at the recommended dose in elderly patients 65 years of age and older Should not be used in patients under 18 years of age Contraindications: Hypersensitivity to glycopyrronium or to any other component of SEEBRI* BREEZHALER* Relevant warnings and precautions: Not indicated for treatment of acute episodes of bronchospasm Not indicated for treatment of acutely deteriorating COPD Caution in patients with narrow-angle glaucoma Caution in patients with urinary retention In severe renal impairment (estimated GFR <30 mL/min/1.73m2), use only if the expected benefit outweighs the potential risk Risk of paradoxical bronchospasm: discontinue immediately
* SEEBRI and BREEZHALER are registered trademarks. Product Monograph available on request. 13SEE029E © Novartis Pharmaceuticals Canada Inc. 2013
For more information: Please consult the Product Monograph at www.novartis.ca/SeebriMonograph for important information relating to adverse events, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling the Medical Information department at 1-800-363-8883. LAAC: long-acting anticholinergic; COPD: chronic obstructive pulmonary disease; LS: least square; SGRQ: St. George’s Respiratory Questionnaire; measures health-related quality of life in symptoms, activities and impact on daily life;5 FEV1: forced expiratory volume in 1 second. † GLOW2: A 52-week, randomized, double-blind, placebo-controlled parallel-group study of 1,060 patients with COPD. Patients received either SEEBRI* BREEZHALER* (glycopyrronium 50 mcg o.d.; n=525), placebo (n=268), or open-label tiotropium (18 mcg o.d.; n=267) as an active control. Primary endpoint was 24-hour post-dose (trough) FEV1 following 12 weeks of treatment. ‡ GLOW1: A 26-week, randomized, double-blind, placebo-controlled parallel-group study to assess the efficacy, safety and tolerability of once-daily SEEBRI* BREEZHALER* (50 mcg) in patients with COPD (n=550); placebo (n=267). § LS mean FEV1 (L) after first dose; SEEBRI* BREEZHALER* (n=169) vs. placebo (n=83), respectively: 5 min: 1.39 vs. 1.30; 15 min: 1.43 vs. 1.28; 30 min: 1.44 vs. 1.28; 1 hr: 1.47 vs. 1.28; 2 hrs: 1.53 vs. 1.34; 3 hrs: 1.53 vs. 1.35; 4 hrs: 1.52 vs. 1.35; 6 hrs: 1.48 vs. 1.33; 8 hrs: 1.47 vs. 1.33; 10 hrs: 1.47 vs. 1.32; 12 hrs: 1.45 vs. 1.31; 23 hrs 15 min: 1.37 vs. 1.27; 23 hrs 45 min: 1.39 vs. 1.31; p<0.001 for all time points. References: 1. SEEBRI* BREEZHALER* Product Monograph. Novartis Pharmaceuticals Canada Inc., October 12, 2012. 2. Kerwin E, Hébert J, Gallagher N et al. Efficacy and safety of NVA237 versus placebo and tiotropium in patients with COPD: the GLOW2 study. Eur Respir J 2012;40:1106-14. 3. D’Urzo A, Ferguson GT, van Noord JA et al. Efficacy and safety of once-daily NVA237 in patients with moderate-to-severe COPD: the GLOW1 trial. Respir Res 2011;12:156(1-13). 4. Data on file. Novartis Pharmaceuticals Canada Inc. 5. Jones P. St. George’s Respiratory Questionnaire Manual. Available from: www.healthstatus.sgul.ac.uk/SGRQ_download/SGRQ%20 Manual%20June%202009.pdf. Accessed December 5, 2011. 6. Ontario Drug Benefit Formulary, August 29, 2013. 7. RAMQ, June 1, 2013.
P R AC T I C AL T R A V E L L E R by
T y s on L ow r i e
The Chief Overlook viewing platform.
Hikers have yet another reason to visit BC. The Sea-to-Sky Gondola, just outside Squamish, is opening on May 16 and will shuttle visitors 885 metres up a mountain adjacent to the famed granite monolith Stawamus Chief. At the top, there are several hiking trails, viewing platforms overlooking Howe Sound, a rope suspension bridge and several food and interpretive centres. The ride to the top will take about 10 minutes, but anybody who wants a challenge can tackle the Sea-to-Summit trail instead, which climbs 916 metres and takes about three to four hours. The $22-million attraction expects 300,000 visitors per year. Tickets: adults $35, ages 13 to 18 $23, ages 6 to 12 $14. Download only $10. tel: (855) 732-8675. seatoskygondola.com.
Soaring over Squamish
The Sea-to-Sky Gondola.
APRIL 2014 â€˘ Doctorâ€™s
PR A CTICA L T RAVEL L ER
The best beach in the world
DANIEL WIEDEMANN / SHUTTERSTOCK.COM
Sancho Bay in Fernando de Noronha, Brazil.
The best beach in the world is officially — at least according to TripAdvisor — Baia do Sancho, on the island of Fernando de Noronha, Brazil. The beach is just one of many highly-rated spots on the island, and is particularly prized for its combination of warm water, dolphins and turtles, and scenic rocky outcroppings. TripAdvisor used 12 months of user reviews to come up with their top beach destinations. The Caribbean and South America put in a strong showing in the top 10. There were a couple surprises though, such as Rhossili Bay in Swansea, Wales, hardly the best place to get some sun, coming in at number nine. To see the full list, go to tripadvisor.com/ TravelersChoice-Beaches-cTop-g1.
The good news: if you’re a solo climber of Mount Everest, you can now do it for less money. The bad news: you might have some more company up there. Under the old system, you’d pay about US$10,000 if you were part of a large group, and US$25,000 solo. Now Nepal is making the fee a flat US$11,000 for everyone (except Nepalese citizens), which will hopefully reduce the amount of large group expeditions. Overcrowding on the mountain has also become a problem in recent years, with higher base camps becoming increasingly polluted with trash and human waste. Higher traffic also causes dangerous climbing delays, particularly at the narrow Hillary Step, where climbers sometimes have to wait for hours. Canadian Shriya Shah-Klorfine’s 2012 Everest death was partly due to having to wait several hours in the freezing cold and low oxygen at the Step.
Doctor’s Review • APRIL 2014
ILKERENDER / FLICKR.COM
The Himalayas, made cheaper
D-STANLEY / FLICKR.COM KELSEY GREEN / SHUTTERSTOCK.COM
Keeping Machu Picchu pristine The Peruvian government has drafted a new set of regulations that will make visiting Machu Picchu a much stricter affair. For one, you’ll have to hire a guide and follow one of three planned routes into the abandoned 15th-century mountaintop Inca city. As part of the new rules, stops at many key sites are limited to three to five minutes. Oh, and you’ll have to keep your clothes on at all times. (Several tourists have recently been detained for getting naked and posing for photos at Machu Picchu.) The Peruvian government says the current set of rules puts the UNESCO World Heritage site, which sees over 1.2 million visitors every year, at risk. UNESCO has been pressing Peru since 2009 to enact tougher regulations, even threatening in July 2013 to consider Machu Picchu for its “World Heritage in Danger” list in 2015 if no action was taken. The new rules are set to be adopted in the coming months.
What’s in a name? MARK HIND
“The impossible cannot have happened, therefore the impossible must be possible in spite of appearances,” wrote Agatha Christie in Murder on the Orient Express. The impossible has indeed happened; the Orient-Express travel empire has ditched the famous name, associated with the London-Paris-Constantinople/ Istanbul train route, for the new name of Belmond. The change happened March 10, with the 45 hotel, rail and cruise divisions of the company banking on it to boost sales. The Venice SimplonOrient-Express luxury train line will keep running under the old name; the original Orient-Express train ceased operations in 2009. The company is hoping that a stronger brand name, which they chose from a list of 650 options, will help link their diverse properties together. belmond.com. APRIL 2014 • Doctor’s
P R A CTICA L TR AVEL L ER
London’s Shangri-La Let’s say you want to really see lots of London. You could either hoof about endlessly on foot, or you could splurge a large amount of money to get absurdly good sightlines over the city thanks to the new Shangri-La Hotel in the Shard. The posh hotel chain has installed itself in floors 34 to 52 of Europe’s tallest building, with a two-floor lobby, 202 rooms and plenty of opportunities to bathe in front of (hopefully one-sided) floor-to-ceiling windows and peer out over the city. The Asian chain’s third European hotel, after Paris and Istanbul, will offer rooms from £450 to £3250 per night and opens May 6. The 306-metre-tall Shard was opened in 2013. shangri-la. com/london/shangrila.
How many Lego bricks does it take to create a tourist attraction? Three million, according to the folks behind the new Legoland Discovery Center Boston. Actually located just outside the city, in Somerville, the 4000-metre attraction is set to open May 23 and will feature a 4D cinema (a 3D cinema with weather effects), building workshops, a train-ride with laser guns and a miniature version of Boston, made with Lego bricks. Master Model Builder Ian Coffey, a former desk clerk who got the job by virtue of winning a well-publicized January contest, will be tasked with maintaining and installing the various displays of the attraction. The Boston location will be the sixth Discovery Centre in the US and the 11th worldwide. The lone Canadian version is in Toronto. Admission: US$22.50, kids 3 to 12 US$18. tel: (866) 228-6439. legolanddiscoverycenter.com/boston.
Doctor’s Review • APRIL 2014
Boston goes blocky
BUDGET TRAVELLER by
An n a r os a S a b b a d i n i
budget sleeps in 5 costly cities HongPortugal. Kong at sunset. Porto,
Hong Kong If you want to pay budget rates, but still be within walking distance of Central, then the Bishop Lei International House, run by the Catholic Diocese of Hong Kong, is perfect. Some of its rooms are small, but all are spotless and a many feature views of Victoria Harbour. The outdoor swimming pool is a major plus in summer. Book early; rooms fill fast. $85-290. bishopleihtl.com.hk. Tensing Pen in Negril, Jamaica.
Melbourne Alto Hotel is worth paying a little more for. Located in the heart of Melbourne, its sound-proofed, nicely appointed rooms come with the latest in mattress comfort, high-def TVs, free Wi-Fi and complimentary espresso in the lounge. If that’s not enough, consider that this hotel is full to capacity in credible green credentials. While you’re there, try one of the complimentary electric cars. $150-240. altohotel.com.au.
Tokyo Ryokan Katsutaro is in the friendly Yanaka neighbourhood, not the GinzaMasciotra shopping area. The Japanese-style Tofar fromClaudia rooms (tatami flooring with futon bedding that rolls out) are spacious can sleep up to four. In keeping Japan’s For and Doctor’s Review April with 2014 mix of traditional and modern, Wi-Fi and other mod-cons are available throughout. The ryokan has bicycles for rent — Fax for exploring 1-855-861-0790 great neighbourhood galleries or visiting the nearby Ueno Park. $53-195. katsutaro.com.
London The area of Bloomsbury is full of quality B&B-style places to stay. A great example is Jesmond Hotel. There are elegant furnishings throughout and 15 rooms, varying in rate from $118 to $291. Some feature original Georgian marble fireplaces. A small, English garden only adds to the charm. jesmondhotel.org.uk.
Rome You can’t do better than scoring a room close to Rome’s historic Piazza Navona. Relais Palazzo Taverna has 11 rooms very cleverly decorated — think just a touch of the ’60s sprinkled onto the Papal State — with AC, satellite TV and Internet access. From here, you can stroll to cafés, restaurants or the Gelateria del Teatro, considered one of the best ice cream places in Rome. €80-240. relaispalazzotaverna.com.
SUN & FUN
Jun 2 - 14 Baltic & Russia
Aug 3 - 11 Bermuda
Update in Medicine
Jul 19 - 26 Greece & Italy Mental Health 2014
Oct 2 - 11 Canary Islands Musculoskeletal Navigator
Sep 8 - 19 France & Spain
Dec 28-Jan 4 Caribbean
Endocrinology & Geriatrics
Jul 4 - 11 Aug 16 - 23
New Year’s CME cruise
call for promotions and pricing 1-888-647-7327
ALASKA Endocrinology & Gastro. ER, Geriatrics, Psychiatry
Nov 26-Dec 9 India & Sri Lanka Feb 3 - 24
Antarctic & S. America
view more destinations www.seacourses.com APRIL 2014 • Doctor’s
Act NOW Purdue Pharma has replaced OxyContin® with OxyNEO®.
OxyNEO® (oxycodone hydrochloride controlled release tablets) is indicated for the relief of moderate to severe pain requiring the continuous use of an opioid analgesic preparation for several days or more. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reﬂecting the greater frequency of decreased hepatic, renal, or cardiac function, concomitant disease or other drug therapy. The use of OxyNEO® is not recommended in patients under 18 years of age. Dosing requirements vary considerably between patients and limitations may be imposed by adverse effects. If they occur, refer to the prescribing information. The adverse effects associated with OxyNEO® are similar to those seen with other opioid analgesics. The most frequently observed are asthenia, constipation, dizziness, dry mouth, headache, nausea, pruritus, somnolence, sweating and vomiting. OxyNEO® is contraindicated in: patients hypersensitive to oxycodone or other opioid analgesics or to any ingredient in the formulation; patients with mechanical gastrointestinal obstruction or diseases/conditions that affect bowel transit; patients with suspected surgical abdomen; patients with mild, intermittent, short or acute pain; patients with acute asthma or other obstructive airway, status asthmaticus; patients with acute respiratory depression, elevated carbon dioxide levels in blood, cor pulmonale; patients with acute alcoholism, delirium tremens, convulsive disorders; patients with severe CNS depression, increased cerebrospinal or intracranial pressure, head injury; patients taking MAO inhibitors (or within 14 days of such therapy); women who are breastfeeding, pregnant, or during labour and delivery. Warning: Opioid analgesics should be prescribed and handled with a degree of caution appropriate to the use of a drug with abuse potential. Patients should be cautioned not to consume alcohol while taking OxyNEO®, as it may increase the chances of experiencing dangerous side effects. There have been post-marketing reports of difﬁculty swallowing OxyNEO®. If patients experience swallowing difﬁculties or pain after taking OxyNEO® tablets, they are advised to seek immediate medical attention. To avoid difﬁculty swallowing, OxyNEO® tablets should not be pre-soaked, licked or otherwise wetted prior to placing in the mouth and should be taken one tablet at a time with enough water to ensure complete swallowing immediately after placing it in the mouth. A single dose greater than 40 mg of oxycodone, or total daily doses greater than 80 mg of oxycodone, may cause fatal respiratory depression when administered to patients who are not tolerant to the respiratory depressant effects of opioids. OxyNEO® tablets must be swallowed whole as taking cut, broken, chewed, dissolved or crushed OxyNEO® tablets could lead to the rapid release and absorption of a potentially fatal dose of oxycodone. The tablets have been hardened, by a unique process, to reduce the risk of being broken, crushed or chewed, and consist of a matrix with hydrogelling properties. Patients should be instructed not to give OxyNEO® to anyone other than the patient for whom it was prescribed as such inappropriate use may have severe medical consequences, including death. Product monograph available on request.
To contact Purdue Pharma, please call 1-800-387-4501. www.OxyNEO.ca OxyNEO® is a registered trademark of Purdue Pharma. © 2013 Purdue Pharma. All rights reserved.
See prescribing summary on page 50 xxx
h i s t o r y o f m e di ci n e by
Ja c k i e R os e n he k
The queen of calories
Dr Lulu Hunt Peters penned the first best-selling diet book ever when much of the world was slim on good sense
When corsets suddenly fell out of fashion, the only way to achieve thinness was through diet.
Peters infused her text with fictional dieters sporting names like Mrs. Tiny Weyaton and Mrs. Ima Gobbler
he North American weight-loss industry is booming, to put it mildly. Dieters spent well over
$60 billion last year trying to shed extra pounds, and that may just be the tip of the iceberg. People are getting bigger, and their appetite for a quick fix seems as insatiable as their craving for fats and sugar. South of the border, more than one third of Americans are considered clinically obese, but Canadians are far from immune to the problem of packing on the pounds. Close to one quarter of Canucks are significantly overweight (as well as over 30 percent of our kids) and the numbers are still rising. Obesity — and the long list of serious health risks that accompany it — is poised to overtake smoking as the leading cause of preventable death in North America. No wonder patients are shelling out the big bucks to win the battle of the bulge. But long before there were paleo plans and master cleanses, treadmill desks and thighmasters, gastric bypasses and gluten-bashing, there was Dr Lulu Hunt Peters: a woman on a weight-loss mission, and the only voice of reason in a world of desperate dieters. Lulu Hunt Peters didn’t start out as a passionate publichealth advocate, but she did go on to pen the first best-selling diet book ever, as well as introduce the concept of counting calories to the world. Stunning accomplishments, to be sure, but even more amazing if you think she did it in 1918, a time when women were scarcely allowed to study medicine, let alone influence the waistlines of the world. But wait! Were Americans already overweight a century ago? The short answer is yes, though certainly not to the extent they are today. As far back as colonial times, Americans grew taller than their European counterparts, due to healthier and more abundant crops. By the mid-19th century, there was an eight-centimetre height discrepancy between Americans and Europeans. Robustness was praised in body and mind. It was an attitude that applied to women too; on this side of the pond, less restrictive corsetry and fewer fainting couches april 2014 • Doctor’s
meant a heartier female ideal. Healthy mothers could till fields and give birth to strong babies who were more likely to survive diseases. That’s not to say everyone valued a plump woman in 19th-century America, which led to several early attempts to encourage slimness. Notably, one of the first fat-shamers on these shores was an austere Presbyterian minister by the name of Sylvester Graham (1794-1851). His followers were active through the 1880s, promoting an extremely restrictive diet and lifestyle. During the 1830s, Graham admonished what he saw as the new American gluttony, singing the praises of a vegetarian diet instead and renouncing alcohol as a way to reduce rampant lustiness. Most expressions of sexuality would result in disease of body and mind, he claimed. He also promoted his very own superfood: the Graham cracker. This tasteless treat was the reverend’s bland replacement for virtually everything he despised, from spices to masturbation. He was a big fan of cold showers, and claimed that ketchup and mustard caused insanity. But he also preached a high-fibre diet of fresh vegetables and unrefined grain products, plenty of fresh air and exercise, and abstinence from tobacco. Though he was a bit of a fringe figure, Graham and his many believers did spark in the American public the first inklings of the dangers of excess. Slowly, public mores began to shift. The West had been won, and the Industrial Revolution was changing the face of America. The frontier life was waning as cities were growing. And, yes, being overweight became increasingly shameful over the course of the 19th century. Where once bombastic, cigar-chewing businessmen men enjoyed memberships in “Fat Clubs” and sad, skinny girls of marrying age gobbled up weight-gain tonics in the hopes of snaring husbands, a different ideal was beginning to emerge. Unflattering words appeared in the language to describe the overweight, and plenty of “fat salts” and tonics hit the market promising to melt away the flesh. To make matters worse, it turned out that being heavy was actually bad for one’s life expectancy, as the burgeoning field of actuarial science began to prove. Armed with statistics, physicians started advising their patients to keep their weight under control — with apothecaries and snake-oil salesmen taking full advantage of the demand created by the new prohibition against pudge. Fashion followed suit for women in the early 20th century as corsets were replaced with a desire for natural slimness. When America entered WWI in 1917, the newly established US War Industries Board asked women to do their patriotic duty by giving up their corsets so that the metal might be used for the war effort. Sales plummeted instantly; the iron redirected from corsetry production alone was said to have been enough to construct two entire battleships. Relieved women everywhere stopped lacing up and turned to diet instead to achieve the look they wanted. Before too long, the waifish, flat-chested form of flappers was in and the stage was set for a “reducing” revolution.
Doctor’s review • april 2014
FROM TOP: Graham crackers were invented in 1839 as a cure for obesity and masturbation. Tapeworms in pills were one of the first and all-time silliest fad diets. Diet and Health sold as many as two million copies during the 1920s. The illustrations in the book were done by the author’s nine-year-old nephew.
Amazingly, Peters’ nearly 100-year-old advice is not too far off today’s weight-loss methodology FOR THE LOVE OF LULU Lulu Hunt Peters (1873-1930) was born in Maine but moved to California in her youth. She was always heavy, and when she didn’t outgrow her baby fat as she had hoped, she set about researching the problem that was so personal to her. After earning her medical degree at the University of California at Berkeley in 1909, she began devising a solution to the problem of being overweight. Through a sensible regimen of calorie-counting and self-control, Peters lost 32 kilograms and began a public-health campaign to educate women about healthy diet, exercise and weight loss. Peters compiled the latest dietary research from a wide variety of sources and set about putting it all into layman’s terms. Diet and Health: With Key to the Calories was released in 1918. Amazingly, her nearly 100-year-old advice is not too far off today’s best weight-loss methodology. Simply put, her plan was successful because it was based on the tried-and-true wisdom that in order to lose weight or maintain it, calories taken in must never exceed calories burned. She devised a fairly accurate way to determine the amount of calories in food, as well as a method for calculating one’s ideal weight very similar to today’s body-mass index standards. Interestingly, Diet and Health was geared almost exclusively towards women in the way it was conceived and written. Part of the reason Peters’ voice appealed to so many was that she took a subject that had until then been considered dull and relatively clinical, and somehow turned it into a great read filled with wit, humour and general wisdom. Peters infused her text with fictional dieters sporting names like Mrs. Tiny Weyaton, Mrs. Natty B. Slymm and Mrs. Ima Gobbler. She also had her nine-year-old nephew do all the illustrations. Women found they could relate well to Peters, who’d struggled with her own size, admitted to frequent chocolate binges, and truly knew the pitfalls of dieting and understood the self-control required to lose weight. The book also discussed many previously unspoken-of psychological aspects of weight loss, such as jealous husbands and passive-aggressive friends rooting for the dieter to fail. The good doctor had an innate understanding of what made dieters tick. Though much of her advice was practical — she included lists of 100-calorie portion sizes of common foods, and put forth a carefully thought-out regime of physical activity — Peters also seemed to embody a somewhat prescient weight-loss philosophy: “How anyone can want to
be anything but thin is beyond my intelligence... if there is anything comparable to the joy taking in your clothes I have not experienced it.” Now, nearly a century later, hopeful dieters still repeat the mantra that nothing tastes as good as being thin feels.
BEST-SELLING BOOK Thanks to its chatty style — and the effectiveness of the diet — Peters’ unassuming little book slowly began to garner a following. Diet and Health climbed non-fiction best-seller lists across North America and there it stayed for more than four years. It all came as a huge shock to the author, who’d moved to Bosnia to work for the Red Cross immediately after she finished writing it. When Peters returned to the States from the Balkans two years later, she was shocked to find her book a best-seller and herself somewhat of a celebrity. Peters’ success spread rapidly along with Diet and Health. Her newspaper advice column of the same name became nationally syndicated. The so-called Queen of Calorie Counting was arguably the most well-known female physician in America during the 1920s. She used her fame to promote healthy dieting practices, and also railed against dangerous ways to lose weight, like over-exercising and purging. She was particularly hard on what she called “freak reducing diets.” If you thought the grapefruit or cabbage-soup diets were bad, the tapeworm-pill craze of the early 20th century was even worse. It’s doubtful any of the hungry little critters were actually present in the capsules being hawked in magazine ads, but the mere fact that so many women were willing to try them was seriously concerning. Parasites aside, Peters wisely warned that even more innocent-sounding diet pills contained dangerous ingredients like arsenic and mercury. With no federal oversight demanding safety in food and drugs, it was up to the consumer to make wise choices — no easy matter when all manner of ridiculous options with outlandish claims were available at every turn. Various accounts list total sales of Diet and Health somewhere between 800,000 and two million copies sold — an amazing feat, even by today’s standards. Even more impressive is the fact that the book is still in print, still racking up positive reviews. One can only hope that, 96 years after her book’s initial release, the wise words of Dr Lulu Hunt Peters might one day sink in and spare some of the many millions weighed down by the scourge of obesity.
Is hospital food making patients sick? Five tips to make overnight stays easier to stomach. doctorsreview.com/nutrition/hospital-food. april 2014 • Doctor’s
Where can you turn for help in preventing
* MENB? Serogroup B has become the most common invasive meningococcal disease (IMD) serogroup to affect Canadians (2007).1 Percentage of reported IMD cases by age and serogroup, Canada (2007)1,† AMONG INFANTS <1 year of age Other serogroups 20%
AMONG CHILDREN 1-4 years of age
AMONG ADOLESCENTS 15-19 years of age‡
Other serogroups 33%
Other serogroups 38%
B 62% ‡BEXSERO® is used in individuals 2 months through 17 years of age.
BEXSERO® is indicated for active immunization of individuals from 2 months through 17 years old against invasive disease caused by N. meningitidis serogroup B strains. Refer to the page in the bottom right icon for additional safety information and for a web link to the Product Monograph discussing t$POUSBJOEJDBUJPOTJOJOEJWJEVBMTXIPBSFIZQFSTFOTJUJWF to the BEXSERO® vaccine or to any ingredient in the formulation or components of the container closure.
The ﬁrst and only vaccine indicated for active immunization against invasive meningococcal disease caused by serogroup B strains.1,2,§
t3FMFWBOU XBSOJOHT BOE QSFDBVUJPOT SFHBSEJOH temperature elevation following vaccination of infants and children (less than 2 years of age), postponement of the administration of BEXSERO ® in subjects suffering from an acute severe febrile illness, thrombocytopenia, hemophilia or any coagulation disorder that would contraindicate intramuscular injection, impaired immune responsiveness, not administering by intravascular, intravenous, subcutaneous or intradermal injection, not mixing with other vaccines in the same syringe, availability of appropriate medical treatment and supervision in
case of an anaphylactic event following administration of the vaccine, risk of apnoea in premature infants and need for respiratory monitoring, known history of hypersensitivity to latex, hypersensitivity to kanamycin, that protection against invasive meningococcal disease caused by serogroups other than serogroup B should not be assumed and that as with any vaccine, BEXSERO® may not fully protect all of those who are vaccinated. t$POEJUJPOTPGDMJOJDBMVTF BEWFSTFSFBDUJPOT ESVH interactions and dosing instructions.
*MenB: meningococcal disease caused by serogroup B. †In 2007, in infants <1 year old, 20 out of 25 reported IMD cases were caused by serogroup B, in children 1-4 years old, 18 out of 27 reported IMD cases were caused by serogroup B and in 15-19-year-olds, 18 out of 29 reported IMD cases were caused by serogroup B. §Comparative clinical signiﬁcance is unknown.
References: 1. National Advisory Committee on Immunization. Update on the use of quadrivalent conjugate meningococcal vaccines. Can Commun Dis Rep. 2013; 39(ACS-1):1-40. 2. BEXSERO ® Product Monograph. Novartis Pharmaceuticals Canada Inc. December 6, 2013. Novartis Pharmaceuticals Canada Inc. Dorval, Québec H9S 1A9 www.novartis.ca T: 514.631.6775 F: 514.631.1867
BEXSERO is a registered trademark. Product Monograph available on request. Printed in Canada ©Novartis Pharmaceuticals Canada Inc. 2014 13BEX017E
Be informed. Be immunized.
See additional safety information on page xxxx 55
GE A R by
D a v i d Elk i n s
I run. I fly. I take carry-on More airlines are operating smaller planes on longer routes. Regional aircraft like Bombardier’s CRJ series and the even smaller Brazilian Embraer E-Jet family often show up on longer hops. The aircraft are well appointed and comfortable but the overhead racks only seem to get smaller. My carry-on is a 56-centimetre, hard-sided four-wheeler. It no longer fits in some overheads. I now either leave it at the aircraft door to be retrieved at the other end or, even worse, check it in. On a recent flight I had to wait 45 minutes for my “carry-on” to appear on the Montreal carousel. So I’m in the market for a small bag. The dilemma: will everything fit? My running shoes take a lot of room. In warmer months I pack my FiveFingers (vibramfivefingers.com), shoes that fit over each toe and are akin to running barefoot. They take little space; they’re not, however, appropriate for colder climates so, for much of the year, I tote a pair of standard New Balance, which are big and bulky. Now there’s a compromise. The Nike Free 5.0 (nike.com) combines the feel of a barefoot runner with the support and padding of a traditional shoe. They’re light and crushable — perfect for cramming into a tight space. But this shoe has a lot more going for it than just compactness. The first thing you notice when you try the shoe on is how light it is; the second is how closely it moves with your foot. The ribbed sole literally cleaves to the bottom of your foot. People who run marathons credit them with faster times and are surprised at their support and durability. You may experience some calf-strain after your first few outings but this quickly disappears. The only caveat users cite is that the shoes are built small so it’s best to try them on at a store rather than ordering online. Many people find they need a half size bigger than what they usually wear. Available for both men and women in a terrific range of colours. The Running Room (runningroom.com) is a good place to see the variety.
Is injury-free running even possible? According to some, a reclusive Mexican tribe has the answer. doctorsreview.com/fitness/running-free APRIL 2014 • Doctor’s
Actavis, a new name in Women’s Health. • We’re passionate about improving the lives of women • We’re committed to leadership in R&D, Quality and Customer Service • We have an exciting pipeline of new products
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BEST MD APPS by
D a v i d Elk i n s
A formulary that finds it fast Looking for a smart, easy-to-use drug formulary app? The UBC Med Formulary has become a hit as quickly as it can be downloaded — and that takes less than two minutes. Developed by students at the University of British Columbia medical school and launched this past February, it’s winning users among residents and practicing doctors as well, not just in BC but across the country, the US and abroad. It’s a Canadian app — a big plus for home-based users, but its charms clearly go well beyond that. An effort has been made to present only that information that’s most germane. No more slogging through reams of material that’s less than pertinent, ample proof that brevity is a virtue. Screenshots on the iTunes apps store illustrate how the app works using
Doxycycline as an example. But why bother. Better to simply download it for free and take a few minutes to play with it. Don’t be put off by the “Student Drug Formulary” heading: you’ll quickly discover that the database is highly useful to busy practitioners. Users can browse by drug class or category, check for updates and even take a quiz. For example, checking in drug categories for antifungals shows three products: Fluconazole, Nystatin and Terbinafine. Tap on your selection and be shown the mechanism of action, side effects, dosages, indications, contraindications and pharmacokinetics, all contained in a concise three-screen scroll down. Want to test your knowledge of a given category? Take the quiz. Select a drug and what you wish to be questioned on, for example “What are the contraindications for Amiloride?” Touch “Answer” and it appears. Pros: simplicity of use and a careful edit of the material. It’s concise yet complete enough to cover most eventualities. It’s obviously portable and easily readable on the smallest mobile phone screen. Kudos to the developers: project lead Matthew Toom, supervisor Stan Bardal with pharmacy consultations from John Lee, Jimmy Tsai and Sufei Wei. Dr Bardal is a senior instructor at UBC, the rest of the team are all UBC med students.
UBC Med Formulary by Matthew Toom Devices: Android, iPhone, iPad Cost: free
APRIL 2014 • Doctor’s
NEW TO DOCTORSREVIEW.COM BEST OF THE WEB Links to articles, deals and special opportunities of interest to Doctor’s Review readers selected by the editors
Updated on our website three times a week!
Includes selections from: Guardian Travel, The Travel Magazine, National Geographic Travel, NYT Travel, Globe & Mail Travel, Spas in Canada, Budget Travel, LA Times Travel, The Frugal Traveller, Smartertravel.com, Petergreenberg.com, The Travel Guys, Travelzoo.com, Triponadeal.com, Adventurouskate.com, Dave and Deb Travel, The World Wanderer, Boston Globe Travel, Chicago Tribune Travel, Savvy Traveller, The Gypsy Nester, WSJ Health & Travel, Wanderlust, Independent Traveler, Outpost Magazine, Travel+Leisure, Outside Magazine, Go Green Travel, Washington Post Travel, National Post Travel, Vancouver Sun Travel, Backpacker, Islands, Condé Nast Traveler, Coastal Living, Caribbean Living, Camping Life… and many, many more
doctorsreview.com/meetings access code: drcme
the top 20 medical meetings compiled by Camille Chin
Canada Montreal, QC September 9-12 20th International Congress on Palliative Care
Ottawa, ON August 17-20 147th Annual Meeting of the Canadian Medical Association
Toronto, ON September 3-6
Winnipeg’s Esplanade Riel bridge is north of the junction of the historic Red and Assiniboine Rivers. LEFT: The Fairmont Château Laurier is as much an Ottawa landmark as the Parliament Buildings.
40th Annual Conference of the International Society for Pediatric and Adolescent Diabetes
September 11-13 64th Annual Conference of the Canadian Psychiatric Association
September 19-20 15th Annual Interventional Neuroradiology Symposium
For contact info on these and 2500+ more conferences, visit doctorsreview.com/meetings
Quebec City, QC September 11-14 60th Annual Meeting of the Canadian Fertility and Andrology Society
Vancouver, BC September 22-24 14th World Conference of the International Society for Diseases of the Esophagus
For meetings around the world, turn to page 26. Winnipeg, MB September 24-26 5th Conference on Recent Advances in the Prevention and Management of Childhood and Adolescent Obesity
Amsterdam, Brasilia, Florence, Hamburg, Honolulu, Istanbul, Madrid, Milan, Paris, Quebec City, San Diego, Seoul, Shanghai, Sydney, Toronto
Go to doctorsreview.com/meetings for a reason to visit these cities... and many more! APRIL 2014 • Doctor’s
TOURISM WINNIPEG/GRAJEWSKI FOTOGRAPH
2014 Annual Meeting of the Canadian Heart Rhythm Society
Why Las Vegas?
by Tyson Lowrie
Eater magazine readers just voted Pizza Rock the best pie place in town. It might have something to do with the downtown joint’s four different pizza ovens and the myriad styles of pie you can choose from, including gluten-free options.
Spring Mountain Road is home to the best of Las Vegas’s many Asian restaurants. The Raku Grill is a classic, where you choose pieces of meat à la carte to be cooked over charcoal. Or order Japanese dishes like cold green-tea soba noodles with poached egg (pictured left). Firefly on Paradise Street is a few minutes off the Strip, a four-minute cab drive or 25-minute walk from Caesars Palace. The perfect-for-sharing tapas menu is full of the Spanish classics (patatas bravas, anyone?), but Italian, Mexican and American influences find their way into the kitchen too.
The granddaddy of Vegas eateries is Joël Robuchon Restaurant, often named the best in Vegas and sometimes all of the US. The prix-fixe menu starts at US$120, with prices climbing up to the 16-course tasting menu at US$485. For a cheaper (not cheap) version of the experience, try the Atelier de Joël Robuchon next door.
BRADLEY TINNEY / FLICKR.COM
Cut, by Wolfgang Puck, is always a contender for the best steakhouse in town: not an easy feat given that Vegas is rife with ‘em. You can get real Japanese Wagyu beef, and among the many signature dishes is a bone marrow flan. You’ll pay for the privilege though. At the Cosmopolitan, the Wicked Spoon takes the concept of the Vegas buffet and elevates it to absurd heights. Watch the butchers slice prime rib and leg of lamb, and dole out unlimited roasted marrow bones. Then saunter over to their famous dessert counter and grab macarons or try the homemade ice cream.
A Las Vegas meeting: September 14-17 18th Annual Scientific Meeting of the Heart Failure Society of America
For contact info on this and 2500+ more conferences, visit doctorsreview.com/meetings
Doctor’s Review • APRIL 2014
Mrs. Duffee seated on a striped sofa, reading, by Mary Stevenson Cassatt.
There are plenty of attractions for those in Sin City looking to see human bodies up close, but none like the MD-friendly Bodies exhibit at the Luxor Hotel and Casino. You’ll find 13 entire cadavers, and over 250 organs and body parts, all artfully and informatively displayed. The Bellagio Gallery of Fine Art is the city’s best fine arts gallery. The Painting Women exhibit, on loan from the Boston Museum of Fine Arts, runs until October 26. Make sure to catch the casino’s famous fountains on the way in and stroll through the free conservatory. The Mob Museum opened in 2012 and has become one of the city’s top attractions. Fittingly located in a former federal courthouse, it takes you through the history of organized crime and names like Capone, Hoover and Gotti.
You can’t throw a stone without hitting a least one Cirque du Soleil productions in Vegas. Now eight years old, Love!, featuring the Beatles’ music, is still considered by many to be the city’s best show. The more edgy Absinthe (for ages 18 up) has been running at Caesar’s Palace since 2011 and combines elements of circus, carnival, vaudeville and burlesque. It’s the top-rated show in Vegas on Yelp. If you have the kids with you, the Mac King Comedy Magic Show is good for all ages and gets great reviews. The Kentucky-born magician uses quirky tricks, a plaid suit and offbeat charisma to win over audiences. Ticket prices are on the cheaper side for Vegas, so it’s good if you’re bringing a gang.
DIRECTORY Absinthe 3570 South Las Vegas Boulevard tel: 800-745-3000 (box office) absinthevegas.com tickets from US$99 Atelier de Joël Robuchon 3799 South Las Vegas Boulevard tel: 702-891-7358 mgmgrand.com/restaurants Bellagio Gallery of Fine Art 3600 South Las Vegas Boulevard tel: 888-987-6667 bellagio.com/attractions Big Apple Roller Coaster 3790 South Las Vegas Boulevard nynyhotelcasino.com/attractions US$14 Bodies 3900 South Las Vegas Boulevard tel: 800-557-7428 luxor.com/entertainment adults US$32, kids 4 to 12 US$24 Cut 3325 South Las Vegas Boulevard tel: 702-607-6300 wolfgangpuck.com/restaurants Firefly 3824 Paradise Road tel: 702-369-3971 fireflylv.com Joël Robuchon Restaurant 3799 South Las Vegas Boulevard tel: 702-891-7925 mgmgrand.com/restaurants Love! 3400 South Las Vegas Boulevard cirquedusoleil.com/en/shows/love tickets from US$98.50
Mac King Comedy Magic Show 3475 South Las Vegas Boulevard harrahslasvegas.com tickets from US$30 Mob Museum 300 East Stewart Avenue tel: 702-229-2734 themobmuseum.org adults US$20, kids 11 to 17 US$14 The TripAdvisor award-winning SkyJump (for ages 14 and up) lets you leap off the Stratosphere Hotel and plunge 260 metres down a vertical zip line. Dubbed a “controlled freefall” that hits speeds up to 65 kilometres per hour, it offers a unique perspective on the Strip. If you prefer your thrills (mostly) on the ground, the Sun Buggy dune-buggy company has a variety of packages. More leisurely packages are available, but the classic Baja Chase is for anyone who wants to mash down the gas pedal and dare the gods to roll them over. A cheaper and shorter experience (for anyone at least 1.37 metres tall) is the Big Apple Roller Coaster. It zips at speeds of up to 107 kilometres per hour on a circuit that twists around the New York New York Hotel and Casino’s faux-Big Apple skyline. If you’re there around 11am, you might spot people getting married on it (Vegas….)
Pizza Rock 201 North Third Street tel: 702-385-0838 pizzarocklasvegas.com Raku Grill 5030 Spring Mountain Road tel: 702-367-3511 raku-grill.com SkyJump 2000 South Las Vegas Boulevard tel: 702-380-7777 skyjumplasvegas.com US$110 Sun Buggy 6925 Speedway Boulevard tel: 866-728-4443 sunbuggy.com Baja Chase from US$149 Wicked Spoon 3708 South Las Vegas Boulevard tel: 877-551-7772 cosmopolitanlasvegas.com/taste APRIL 2014 • Doctor’s
doctorsreview.com/meetings access code: drcme
Shops, restaurants and pubs await in Dublin’s Temple Bar Cultural Quarter.
MILOSZ M. / SHUTTERSTOCK.COM
the top 20 medical meetings
Around the world Barcelona, Spain September 14-17 24th World Congress on Ultrasound in Obstetrics and Gynecology
Copenhagen, Denmark September 18-21 4th European Headache and Migraine Trust International Congress
Dublin, Ireland September 18-20 L.BURKA STUDIO / SHUTTERSTOCK.COM
53rd Annual Meeting of the European Society for Paediatric Endocrinology
September 19-20 Perspectives in Melanoma XVIII
Geneva, Switzerland September 6-9 36th Annual Congress of the European Society for Clinical Nutrition and Metabolism
The façade of the Church of Santo Ildefonso in Porto is covered with 11,000 azulejo tiles.
For meetings in Canada, turn to page 23.
Singapore, Singapore September 4-7
Porto, Portugal September 18-20
Vienna, Austria September 15-19
16th World Congress of Psychiatry
47th Annual Scientific Meeting of the European Society for Pediatric Nephrology
50th Annual Meeting of the European Association for the Study of Diabetes
Munich, Germany September 6-10
Santiago de Compostela, Spain September 6-10
2014 Annual Congress of the European Respiratory Society
38th Annual Meeting of the European Thyroid Association
Madrid, Spain September 7-10 15th Congress of the International Society for Peritoneal Dialysis
Doctor’s Review • APRIL 2014
XXII International Pigment Cell Conference
For contact info on these and 2500+ more conferences, visit doctorsreview.com/meetings
CO NE NT W ES T!
Win two romantic nights in an Executive Suite at Hôtel Le Crystal Montréal
A lucky physician and a guest will receive: • Two nights in an Executive Suite (part of the Diamond Collection) • Continental breakfast at Restaurant La Coupole • Valet parking for two nights This prize is valued at $1192
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I P R E S C R I B E A S A F A R I I N ... BOTSWANA AND ZIMBABWE Viewing natural-born killers like these lionesses is safe from an unprotected Land Rover.
A Saskatoon doc and his sons have near-death adventures on an African safari text and photos by Dr Jonathan Hey
t started with my oldest son, Spencer, making cinnamon buns for Mother’s Day. At any other time that would have been a wonderful gesture, but not at midnight with the taxi to the airport arriving at 3am. He wanted to make them from scratch, using a recipe from the Internet. At 2am, he asked me what a dough hook was; at 2:30am, still not packed, he gave up, leaving a bubbling morass on the stove and utensils strewn around the kitchen for my wife to clean up. He did though leave a Mother’s Day card.
Dr Jonathan Hey is a family physician of South African origin who lives in Saskatoon. Despite having been in this country for 25 years — and married to a Canadian — he has yet to acclimatise to our winters. He intends on travelling until his money runs out. His next adventure will take him to Scotland in May.
Doctor’s Review • APRIL 2014
I had planned this trip a year ago, down to the last detail, and nothing was going to get in the way. Certainly not the main reason for going: Spencer. Ever since he was old enough, I had been reading him stories about my home country, South Africa, and the continent I grew up in. “When you turn 21, I’ll take you on a safari,” I used to say. And so it had come to pass. The safari was to take my two sons and I from Saskatoon, via Minneapolis and Atlanta, to Johannesburg, a 36-hour journey that left us gasping. There we spent the night in the luxurious InterContinental Hotel at O.R. Tambo International Airport, not far from the arrival gate. It was our reward and, after a supper of lamb wontons and beef curry, washed
A busy night: besides a stalking leopard and a lion that nearly ate my son, the baboons outside my tent were not happy down with a bottle of Pinotage, I felt I deserved it. The three of us met my sister and brother the next morning at the departure gate to Maun, Botswana. Once in Maun, we took a small plane into the Okavango Delta to Machaba Camp (machabacamp.com). The Okavango River doesn’t end in the sea, but dissipates into the land, creating a vast area of crystal-clear water a metre deep. The camp sits on the Khwai River and looks onto the famous Moremi Game Reserve. Machaba is new, built in a Hemingway 1950sstyle with eight luxury safari tents and two family tents. The tents have living areas, ensuite bathrooms, and indoor and outdoor showers. Since the camp is built on a private concession area and controlled by locals, earnings stay in the community. The view from my tent overlooked the Khwai River. From my large bed I could see elephants grazing and hippos splashing. One morning while eating my cereal I saw a pack of wild dogs and a leopard come down to the river to drink. I have never seen that while eating my cereal in Saskatoon, despite the large river. The first night I found it difficult to sleep, not only due to jet lag, but because hippos were making a cacophony of grunts and groans that kept me up. Hippos, being large and really not interested in making a good impression, have an annoying habit of farting underwater and then thrashing the water with their tails — I suppose to dissipate the smell. Not unlike humans. I’d hear loud gurgling, a pause and then thrashing water. Then, I imagined, a look around to say “No, it wasn’t me.” Each day was the same: a 6am wake-up from our guide, tea or coffee and rusks, and into the open Land Rover by 7am to explore. We would stop a few hours later for more tea and rusks, then continue for a while, returning to camp at around 11am for brunch. Then it was siesta time until 3:30pm (sleeping for some, swimming for others). After tea, coffee or juice with very good cakes, it was back into the Land Rover with our guide, who ironically was called Leopard. At sunset, we’d stop for drinks in some idyllic spot, and then take a night drive with an infrared light to not hurt the animals’ vision. Supper and then to bed. There were several unforgettable moments at Machaba. On the second morning, Leopard stopped
From left to right: Dr Hey with his two sons, Nigel and Spencer.
the vehicle and gazed intently at the dirt track we were on. “Leopard,” he said, leading to some confusion. “Behind us.” We turned the vehicle around. A few minutes later he stopped. “The tracks are on top of our tire marks. He can’t be far.” We slowly inched forward, Leopard gazing intently at the ground as he drove, veering off into the undergrowth, until at last he pointed under a bush: “There she is.” I couldn’t see anything, but kept firing off my camera in the general direction, hoping to at least get one good shot. And if not, there was always Photoshop. Suddenly a blade of grass twitched, and into focus came the head of a large leopard, gazing equally intently at me. We followed her for a long time, watched as she tried to stalk an impala, crouching low to the ground, tail twitching. Another “unforgettable” was coming across a pride of seven lions lying in the shade, playing with the horns of some poor antelope that had been a late night snack. I sat in the Land Rover not more than six metres from them, thinking of the insignificance APRIL 2014 • Doctor’s
An armed guard walks with you to and from your tent at night. Presumably during the day you see the lion stalking you Dr Hey’s son Spencer watches elephants at the Machaba Camp in Botswana.
of Man. Or, if not Man, then of me. Another time, we turned a corner and came across three waterbuck sunning themselves. The light was perfect and I asked Leopard to stop while I took pictures. My younger son, Nigel, was sitting in the trackers chair that juts out from the hood of the vehicle. As I clicked away, Leopard quietly said, “Nigel, I don’t want you to move. The rest of you, turn slowly and look down. A leopard.” And there it was, at our feet, seriously upset with us for coming between it and its breakfast. I believe now in levitation. I swear Nigel floated, without moving a limb, to the safety of the Land Rover. The leopard snarled at us, flicked its tail, and sauntered off.
e left Machaba after five nights and flew in a small Cessna, following the Chobe River to Kasane, a small town in Botswana, where we were driven to the Chobe Game Lodge (chobesafarilodge.com), in the most northeasterly corner of Chobe National Park. The view from the lodge’s verandah is of the vast Caprivi Flood Plains, and not far away the four corners of Botswana, Zambia, Zimbabwe and Namibia. There are a reported 45,000 elephants here, all the game Machaba has and then some. We had decided to spend two nights in relative civilization, so that my sons could get onto Facebook. And speak to their mother.
Doctor’s Review • APRIL 2014
Mod cons have a trade off. The grounds were manicured, the staff efficient and the wine list extensive. But the lodge catered to large groups and reduced the safari knowledge to the lowest common denominator. Travelling from the airport to the hotel, we pointed to a tree and asked our driver what it was. “Just a bush,” she said, proving that we had been spoiled at Machaba. Rather than join a group of tourists on the game drive the next day, we paid $250 extra for a guide and our own Land Rover — well worth it. Ishmael was a wonderful guide who grew up in the area and knew the game and birds — not to mention the name of the undefined “bush.” We spent a spectacular day with him driving out in the morning and floating down the Chobe River in the afternoon on a motorized boat. We encountered hippos on their turf and saw game come down to drink, watchful and nervous. We set off again the next day, this time into Zimbabwe. Our destination was the Hwange Game Reserve, and in particular Davison’s Camp (wildernesssafaris.com/camps/davisons-camp), where we met Brian, our game ranger for the next five days. Davison’s is an open camp, with game moving freely through it. An armed guard has to walk with you to and from your tent at night. Presumably during the day you can see the lion stalking you and take evasive action. The area has no natural water so man-made pans are usually constructed for the animals. There seemed nothing more civilized than sipping a glass of chilled white wine watching elephants, sable, antelopes, baboons or lions come down to drink right in front of the camp. The first full morning set the tone. We came across a lion and lioness sunning themselves against a termite mound; we spent time watching them and they, it seemed, watched us. We drove, as we did at Machaba, in an open Land Rover, with no protection. I was told that the animals look at it as a large, smelly animal, and don’t see the edible tourists inside. The lioness was in estrus and mated often and without shame. The act was over in 20 seconds, with much roaring and snarling and absolutely no foreplay, and then both went to sleep. Although they repeated the act several times, the lioness was always the initiator. There was the option to explore on foot, which we did one morning. Our guide was Themba, a lo-
The group always stopped for drinks and to watch the sunset in an idyllic spot — like this one around Machaba Camp.
cal ranger who had grown up in the area and, as an added bonus, had taken courses in tracking game and carrying a firearm, though he had yet to use it. It was a lovely, informative morning. Themba knew the plants and their uses, and he knew the spoor of the game. We passed within 200 metres of a lion kill, hearing the lion grunting and tearing. Themba made us pass upwind to let them know we were there. Despite reassurances, I couldn’t help but glance behind me and walk quickly with my buttocks clenched. I’m not sure why, but it made me feel safer. Another party of three decided to walk the following morning. We waved them goodbye, set off on our drive, and within three kilometres came across two lionesses struting resolutely down the dirt road. Less than 100 metres behind came the male, looking magnificent in the morning sun. They walked straight passed the Land Rover; they were so close that I could have reached over and patted them. They disappeared around a bend in the road, heading for the group on foot, about two kilometres behind us. I was later told that Themba spotted the male some distance away. The lion looked intently at them, crouched down and disappeared out of sight. Themba radioed the camp, two kilometres away, telling them to hurry with a truck. They then saw the two lionesses, who did the same: they stopped in their tracks and then veered off into the bush. Themba got the group to huddle together in the middle of
the road while he radioed again. The truck roared up, they clambered aboard, and as they pulled away, the lion stepped onto the road where they had been standing. Twenty metres away the lionesses were crouched down, waiting to pounce. There weren’t any more walks that week. On our final night, we had planned to stop for sundowners on the other side of a man-made basin called a pan, looking across at the campsite. Unfortunately, a lion got there first. He sat gazing across at the camp, perhaps smelling the dinner that Nicholas, the cook, had prepared. After a long time, he let out a low guttural roar, got up, stretched and started towards the camp. Straight for Nigel’s tent. Nigel had decided to skip the evening drive and catch up on sleep. I turned to Brian, and in as nonchalant a voice as possible, informed him that I would rather face the lion barehanded than face my wife when I had to tell her that one of her son’s had been eaten. He radioed the armed guard who ran into Nigel’s tent and brought him safely to the dining area. The lion sauntered around the camp well into the night. Then, to cap things off, we heard the call of sidestriped jackals. “They’re not happy,” said Brian as he shone his flashlight towards them and then towards the pan. There we saw why: a leopard. It was a busy last night: besides a stalking leopard and a lion that nearly ate my son, the baboons in the trees outside my tent were not at all happy. We had to be at the airport early the next morning so APRIL 2014 • Doctor’s
Dr Hey took this photo during a helicopter tour over Victoria Falls.
I saw a leopard come to the river. I’ve never seen that while eating cereal in Saskatoon, despite the large river there would be enough time to clear any animals from the runway. It was off to Victoria Falls the next day for two nights at the Victoria Falls Hotel (victoriafallshotel.co), the grand dame of the Falls, resplendent in portraits of Queen Victoria, King George and Livingstone. I had to have a Pimm’s Cocktail sitting on the verandah, with the spray from the falls and the bridge over the Zambezi River as a backdrop. I gazed about, picturing myself as Livingstone meeting Stanley. Then I shook my head, coming to my senses and ordered another drink: far too strenuous, that exploration stuff. The next day was full of tourist things to do. We started by taking a helicopter ride above the Falls, something well worth doing for the spectacular views. Later my dear son Spencer decided that what he would really like to do would be to bungee jump from the bridge 111 metres to the raging Zambezi, which incidentally was at its highest since 1963. Even whitewater rafting had been cancelled. But he
wanted to do it and so the five of us walked across the bridge into Zambia, paid $130 and then returned to the centre of the bridge, where Spencer was strapped up and pretty well pushed over, arms flailing, howling into the abyss, while I gripped the railing and prayed. He said he would do it again in a heartbeat, but he came back up puffy-eyed and red in the face. I didn’t tell Spencer that the platform from where he jumped was strapped together with duct tape and I certainly haven’t told his mother. But I have a picture of it. And so ended the trip of a lifetime. The next day we flew to Johannesburg and on to my hometown of Pietermaritzburg. The trip had taught me plenty of things: never go anywhere without your camera, you never know when you’ll see majestic sable antelope from the view of a toilet. Believe in levitation, especially when an angry leopard is looking at you. Drink a Pimm’s cocktail on the verandah of the Victoria Falls Hotel. And try hard not to let a lion eat your offspring.
Trying to decide which African country to safari in? Consider Kenya’s Maasai Mara, which has the most savannah species in the world. doctorsreview.com/features/kenya-prowl
Doctor’s Review • APRIL 2014
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oing out for lunch on a Saturday is a big deal in Spain. In the region of
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Castile and León, north of Madrid, sleepy towns suddenly come alive with crowds of socializing locals. Wine barrels put to use as outdoor tables fill narrow streets lined with eateries; inside the busy restaurants, bow-tied waiters dart through throngs of patrons with carafes of vino blanco and tinto, or balance platters of lamb and suckling pig, hooves and snouts bobbing above the hubbub. Families congregate, old friends meet and lovers twine their glasses through the early afternoon — often in settings that come with exotic extras, as I learned on a weekend stopover in Aranda de Duero, the main town in Castile’s Ribera del Duero wine region. Navigating a bustling lagar (a restaurant with its own winery) after a little too much house red, I located discrete stairs that I thought would lead to my destination. I headed down the steps and, a
Pillars of stre
Segovia’s Roman aqueduct dates to the 1st century CE and, at 29 metres tall, it dwarfs everything around it.
Tour Spain’s Castile and León and take in an ancient history that’s still very much part of everyday life by
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Built during the 12th century, Ávila’s 2.5-kilometre-long wall consists of 90 turrets and nine gates.
minute later, was standing amidst a series of dimly lit chambers and tunnels. A poster on a sloping cavern wall told me that I was 12 metres below the El Lagar de Isillia restaurant (Calle Isilla 18, Aranda de Duero; lagarisilla.es) in a sizeable cave-complex carved from bedrock 800 years ago to make and store wine. (The “wine cave” is now a tourist attraction.) As I stood there, absorbing it all, an elderly Spaniard appeared from one of the subterranean corridors. “The servicios are upstairs,” he said in slow Spanish sensing my confusion. “No restaurants with caves in your country?”
s you might expect, there are umpteen reasons why Castile and León will never be mistaken for Canada. For one, there’s the Spanish habit of dining late — lunch at two; dinner at 10 — and enjoying life earlier. Wine bars open well before convenience stores. The scenery is also arrestingly alien: an arid landscape of big skies and bare hills dotted with vineyards and groves of strange pines and firs that are bushy and round. On my recent visit, I often glimpsed old monasteries and castles off the sides of
Doctor’s Review • APRIL 2014
quiet highways, ancient reminders of Castile and León’s biggest asset: the centuries of history and tradition that still make up daily life there. Castile, and the smaller state of León it absorbed in 1301, was originally the richest and greatest of the medieval kingdoms that combined to form Spain. It was the Castilian queen, Isabella I, who sent Columbus to America; the language we call Spanish is the Castilian dialect gone global. Filled with monuments of its past, Castile’s realm remains a big region even in a rental car, taking up a large inland chunk of northwest Spain that runs to Portugal’s border, most of it enjoying a sunny year-round Mediterranean climate. Spring and fall are the best times to visit. Today, Castile and León’s attractions include hundreds of castles, scores of historic churches, palaces and plazas, and many towns and cities celebrated for their Roman, Gothic, Renaissance and Baroque architecture. Three are UNESCO recognized: the ancient centres of Ávila, Segovia, and Burgos. Recreational opportunities abound ranging from hiking trails made by medieval pilgrims to excellent golfing. When you factor in the region’s gustatory charms (international expos regularly call Castilian ham the world’s best) and celebrated wine-makers (prized reds from vintners like Emilio Moro and
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The Alcázar in Segovia was built on top Built over 500 years, the Gothic Burgos of a rock and passageways connect it Cathedral features a beautiful rose window to some of the city’s other palaces. and eight statues of Castilian monarchs.
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Dine on roasted suckling pig at Mesón de Cándido where the waiters use the edges of heavy dinnerware to cut the meat.
The structure talked endlessly at night when the wind echoed through its 166 arches like “teeth chattering with history” Vega Sicilia fetch over $200 per bottle), it’s easy to see why locals here relish life.
began my own visit at Castile’s southern border, driving an hour north of Madrid to see the walled medieval town of Ávila, supposedly founded by Hercules, the ancient hero. A hilltop town that’s still circled by a 12-metre-high stone wall with 90 towers topped by round turrets, Ávila remains as spectacular now as it must have been in the Middle Ages. Its wall is one of the few that’s still intact in Europe and it turns vivid flame-colours at dawn and dusk, offering endless possibilities for photographers. You can walk on large sections and climb the towers, too. Within the ring of walls, Ávila’s original centre spreads across 31 hectares, a compact area filled with beautiful Romanesque and Gothic architecture. Even my hotel, the four-star Parador de Ávila (2 Marqués Canales de Chozas; parador.es/es/parador-de-avila; doubles from €80 per night), was historic. A parador is a kind of luxury hotel located in a castle or palace. Many, including my own lodging, now belong to Spain’s best hotel chain, Paradores de Turismo de España, founded by King Alfonso XIII in 1928. The Parador de Ávila looked out from a 16th-
century palace at formal gardens of hedges and roses; from its stone terrace, I could see downhill to an enormous gate in Ávila’s ramparts, opening like an eye on the landscape below. Sixty-one kilometres northeast of Ávila, Segovia rises up between an arid plain and a mountain backdrop like a mythical city in the TV series, Game of Thrones. Perched on a rocky crag beside the town, the Alcázar (Plaza de la Reina Victoria Eugenia; alcazardesegovia. com; admission €5) is undoubtedly one of the world’s grandest castles, its spires towering above battlements that thrust out like the bow of a ship over rugged cliffs. The royal seat of Castile’s kings in the age of chivalry, it’s open to the public from 10am to 7pm daily, April through September (10am to 6pm in winter). uu CONTINUED ON PAGE 54
APRIL 2014 • Doctor’s
Half-timbered, 15th-century row houses — with windows that actually open! — are aplenty in Saint-Jean-de-Côle, Dordogne.
All the details on how to ditch hotels and find a holiday rental in France Jeremy Ferguson
n Paris, on Rue Saint-Honoré, it’s possible to rent the historic quarters of Maximilien Robespierre, the fiery revolutionary whose gift to French history was the Reign of Terror. Robespierre’s
ghost, which could still be searching for its head, would hardly recognize the place. Today it’s a pretty, airy space with exposed beams, a rain shower, big-screen TV, kitchen with Nespresso maker and Wi-Fi. It sleeps up to four and it’s yours (via homeaway.com) for €195 a night. If you think this might be a tad creepy, alternatives abound by the thousand. The City of Light — the
Doctor’s Review • APRIL 2014
most popular city in the world with 27 million visitors annually — has spaces aplenty for visitors anxious to avoid ultra-expensive hotels, settle into their own cozy digs and live for a while as Parisians do. If Paris is the urban jewel of the planet, it’s also true that France is the most popular destination. In 2012, 83 million tourists arrived to wonder at and delight in its incomparably beautiful countryside,
COURTESY KAREN FROST
This house in Saint-Jean-de-Côle featured three storeys, a living room with fireplace and a modern kitchen.
medieval villages, seaside resorts, 38 UNESCO World Heritage Sites, castles, cathedrals and, of course, legendary pleasures of the table. The countryside offers a still vaster range of rental accommodations from gîtes de France — holiday rentals targeting the family market — to elaborate châteaux and fortified castles. So what will it be? A barge on the Seine? A villa on the Côte d’Azur? A farmhouse in Brittany? A house in the Dordogne? A renovated pigeon house in Languedoc? Simply Châteaux (simplychateau.com) is an agency catering to aspiring aristocrats. It represents 270 châteaux that can accommodate up to 50 guests apiece. Another outfit, A Castle for Rent (a-castlefor-rent.com), has 50 châteaux in the Loire Valley. Bring your own powdered wig. My wife and I have rented for years. Rentals, even with often-hefty agency fees, are much less expensive than hotels. We save fortunes by cooking at home, taking advantage of marvellous French produce and wine at prices to make a Canadian drool. And we have a neighbourhood to call our own. Last fall, we blueprinted a seven-week stay encompassing two Paris apartments, a townhouse in a Dordogne village and a gîte on the outskirts of Toulouse. What follows are on-site notes to give you a more comprehensive notion of what to expect.
PARIS APARTMENT #1
Because we were travelling with two doctors in the family, we sought out a generous living space (we once rented an apartment only 32 square metres in size and spent the week bumping into each other). Next was the issue of an elevator (we have friends once forced to climb six floors to their garret accommodation; it nearly killed them). Diligence bought us a two-bedroom apartment on the second floor of a classical 19th-century Baron
With most Paris apartments, the price of a two-and-a-half-week stay is the same as a month, so the longer term is a bargain Haussmann building. The neighbourhood was the upper Marais, just off the Place de la République. Our landlord was a vivacious and charming Parisienne, Véronique Azoulay (firstname.lastname@example.org), whose hands-on approach became a running delight. It cost €950 a week. (Note: with most Paris apartments, the price of a two-and-a-half-week stay is the same as a month, so the longer term is something of a bargain.) The fully furnished apartment had belonged to Véronique’s grandmother and it retained elegant 19th-century touches such as a trio of French doors leading to a balcony, high ceilings with original plaster moldings, and comfortable furniture and beds. Many of her grandmother’s personal possessions remained, imparting the warmth and character of a family home. The galley kitchen, which was merely functional, seemed an afterthought.
COUNTRY HOME #1
Our first rental in the French countryside was a 15thcentury row house in Saint-Jean-de-Côle in the upper Dordogne, Périgord Vert of yore. Officially one of Les Plus Beaux Villages de France (les-plus-beauxvillages-de-france.org) — always a superlative credenAPRIL 2014 • Doctor’s
tial — it exudes a Brigadoon-like atmosphere that can exist only where people have been going about their lives on the old stones of centuries. Its survivor credentials run from the Black Death and Wars of Religion to the French Revolution and WWII. It has a teeming population of 350, a few blocks of stone and half-timbered houses, a Gothic bridge, a castle, a cathedral and one grocery store with excellent croissants. The owner of the three-storey “French House” is Karen Frost (email@example.com), a South African who manages to visit once a year. It had two extremely comfortable bedrooms, a living room with fireplace and an excellently outfitted modern kitchen. Its shabby chic decor of wood plank floors, overstuffed couches with white cotton slipcovers, antique shutters laying about as accents and soft neutral colours contributed to a comfy lived-in atmosphere. It cost €426 a week. It was a perfect base for exploring a Dordogne landscape greener than Ireland, villages of honeycoloured stone and castles including the multi-turreted Château de Jumilhac. This realm could not be further from the universe of strip malls, condo developments, corporate men and Starbucks. Not far away is the tragic Limousin village of Oradour-sur-Glane, just as it was on that dreadful day in 1944 when a German Waffen-SS company massacred all 642 inhabitants and razed it to the ground. DeGaulle ordered it preserved as a reminder, a kind of 20th-century horror archeology. Our evenings were rightly reserved for the table and the specialties de la région, namely foie gras seared in the pan with peaches or apples; duck confit roasted in crinolines of its own fat paired with magret, duck breast; and truffled potatoes. And Rhône wines at six bucks a bottle.
COUNTRY HOUSE #2 Autumn was driving summer southwards and we went with it. A chill in the Dordogne gave way to the toasty climate of the Lauragais farm country outside Toulouse. Our base was a gîte, a holiday home for rent by independent owners registered with Gîtes de France (gites-de-france.com). Commonly, gîtes are cottages or outbuildings on a larger tract of land, the owners within easy reach. In Lauragais, farmers Denis and Liliane Loubet (firstname.lastname@example.org; facebook. com/les.gites.de.mervilla) live next door. At a gîte, such owners quickly become friends. Our home was a traditional Lauragais-style, redbrick barn that was renovated to include an open-plan main floor with a dream kitchen, and handsomely appointed living and dining areas. Two-storey-high picture windows open onto a patio and panoramic view of the Pyrénées. A winding staircase leads to a second floor with two comfy bedrooms and a spacious bathroom with walk-in shower. The cost was an offseason €470 per week. Toulouse was our nearest city, with a fine selection of monuments and markets to visit. The countryside allowed for easy day trips to picturesque towns including Auch — birthplace of d’Artagnan, the Musketeer turned to legend by French writer Alexandre Dumas — the medieval city of Albi, the hill villages of Puycelsi and Cordes, and the great fortress of Carcassonne. A special pleasure, minutes from the gîte, was a stretch of the Canal du Midi, the 241-kilometre engineering marvel built in the 17th century. Its purpose was to allow goods to travel from the Mediterranean to the Atlantic without having to confront pirates on
Built in the 17th century to avoid pirates enroute from the Mediterranean to the Atlantic, the Canal du Midi is now a waterway for pleasure boats.
the coast of Spain. Today a UNESCO World Heritage Site, it still functions as a waterway for canal and pleasure boats. Our stretch of the canal made for beautiful photographs. Our walks frequently finished with lunch at L’Écluse de Castanet (Chemin d’Augustin; 31320 Castanet-Tolosan; l-ecluse-de-castanet.fr), a small, charming canal restaurant that serves considerable pleasures like fresh foie gras and ris de veau.
PARIS APARTMENT #2 As our sojourn came to an end, we decided to spend a final week in Paris. A spur-of-the-moment decision isn’t especially smart. It left us little time to find accommodation: even in early November, Paris is a sellout. We were compelled to fall back on an agency, Paris Attitude (parisattitude.com), which we’d used before. The agency represents 6000 lofts, apartments, private homes and even riverboats on the Seine. Its website illustrates each property amply (although a wide-angle lens can make a palace of a closet) with a slew of reviews from previous tenants. (Spokesperson Priscilla Huste says the company advocates for the client if the property has been misrepresented.) An agency costs a chunk more, but is generally a reliable source for rentals (friends, who booked from an independent owner, found themselves above a nightclub that blared until 5am and left them sleepless for a week). Our apartment was a one-bedroom off an interior courtyard in the 6th Arrondissement. The space could have used a spruce-up throughout, but the
COURTESY VÉRONIQUE AZOULAY
One apartment in this 19th-century Baron Haussman building in Paris’ upper Marais featured a trio of French doors leading to a balcony.
This Paris apartment belonged to the owner’s grandmother and her personal possessions make it feel like home.
beds were comfortable and the kitchen was just fine. It cost almost twice what we would have normally paid for 40 square metres: €879 a week. But the 6th was a new section of town for us, and there was much to love: a fine bakery did a booming business across the street. It was a pleasant walk (all Paris walks are pleasant) to Napoleon’s tomb at Les Invalides, the Rodin Museum, the Musée d’Orsay and the Latin Quarter. One afternoon, we walked the Seine from the Eiffel Tower to the Pont Neuf. By this time, winter was gathering and Paris skies were filled with powerfully sculpted, charcoalbellied cumulus. Sudden storms broke into brittle winter sunlight and vice-versa. At such moments, Paris was a woman, tempestuous and disheveled, flaunting the last of her summer abandon. She never looked more ravishing.
Discover the quiet, medieval city in France’s Southwest that the colourful painter Henri de ToulouseLautrec called home. doctorsreview.com/features/lautrec-legacy APRIL 2014 • Doctor’s
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The business of sleep UNGTAMAN / SHUTTERSTOCK.COM
The new way hotels and airlines are trying to help tired travellers catch some z’s by
t Four Seasons Hotels and Resorts, new beds allow guests to play Goldilocks and choose one of three mattress toppers, from soft to firm, that feels just right.
In the air, Etihad Airways — after almost two years of research with the American Center for Psychiatry and Neurology in Abu Dhabi — just introduced a sleep program that includes all-natural mattresses, mood lighting, noise-canceling headphones, pillow mist and calming pulse-point oil. And at sea, Celebrity Cruises has outfitted some suites with mattresses that can be adjusted at the whim of a passenger. Perhaps you’ve been too bleary-eyed to notice, but sleep is a trendy topic. And no wonder. We’re hardly getting any. “Everyone in our country is sleeping an hour and a half less than they did last generation,” said Russell A. Sanna, the executive director of Harvard Medical School’s division of sleep medicine. “Sleep is the enemy of capitalism,” he added, noting that you can’t produce or consume when you’re asleep.
APRIL 2014 • Doctor’s
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“Sleep is the enemy of capitalism,” Russell A. Sanna of Harvard’s division of sleep medicine added. You can’t produce or consume when you’re asleep
Add to that dictum a growing dependency on technology, including laptops, tablets and smart phones — tools Dr Sanna calls “sleep stealers” because we cozy up with them at night and blue wavelengths from their screens suppress the secretion of melatonin (a hormone that influences circadian rhythm) more powerfully than other types of light. Mobile devices that enable us to be anywhere and respond to anything at all hours, he said, erase “boundaries and cycles between work, home, sleep, wake.”
t’s hardly surprising, then, that the travel industry is dreaming up ways to woo weary consumers. Sleep was once the specialty of a handful of hotels — most notably Westin and its Heavenly Bed, which was rolled out 15 years ago. Today, cruise lines and airlines are also in the business of selling sleep with high-tech mattresses, slumber-inducing scents and relaxation techniques. Not to be outdone, hotels are hiring sleep consultants and devising sleep-related services. The Benjamin hotel in New York, for instance, offers reminder calls to guests to shut off their electronic devices in preparation for bedtime. In other words, sleep — a naturally recurring human state for hundreds of thousands of years — is now being treated as if it’s a luxury amenity like an iPod dock or spa shower. Of course, offering a good night’s rest has always been important to hoteliers. “It’s the holy grail for hospitality,” said Dana Kalczak, the vice president
Doctor’s Review • APRIL 2014
of design for Four Seasons Hotels and Resorts. But brands today can’t be competitive with one-size-fitsall solutions. “No matter how good a brand you are or what legendary service you provide,” Ms. Kalczak said, “guests have their preferences, and the best we can do is give them what they want.” When Four Seasons researched what guests desire, it found that people considered mattresses to be too soft or too hard. So how to please everyone? Four Seasons partnered with Simmons to create three types of proprietary mattress toppers — Signature, Signature Firm, Signature Plush — that can be zipped on or off. If guests don’t like the default firmness, hotel staff members will change it. So far the beds (which have their own social media hashtag #inbedwithFS) are at the brand’s Santa Barbara and Jackson Hole hotels, but all properties will offer them in some capacity by 2016. The beds can also be purchased at a Four Seasons.
eluxe mattresses found in some suites on certain Celebrity ships and made by Reverie, a high-tech bedding company, are also sold online. While it may seem as if travel brands are seeking additional income from bed sales, that’s not necessarily what they’re after. “It’s more of a PR thing,” said Steven A. Carvell, the associate dean for academic affairs at Cornell University’s School of Hotel Administration. “It’s not going to be a huge profit percent driver for the brand.” The real value, he said, is getting a traveller
to associate a brand with a fantastic night’s sleep and a productive day. “That’s worth them almost giving you the bed.” Airplanes are among the most difficult places to sleep, though on some it’s getting a little easier — even in coach. “How do we extend that five-star hotel experience in the sky?” said Anna Brownell, the head of product development and innovation for Abu Dhabi-based Etihad Airways. The company had given a lot of thought to things like in-flight entertainment, and food and beverage service, yet when it came to sleep, she said, “we hadn’t focused enough attention on one of the things our guests are most interested in.” As part of its new sleep program, Etihad just began providing free noise-cancellation headphones to all three cabin classes to help minimize ambient sound. The first-class suites have mattresses made from natural materials, along with down duvets and pillows that are sprayed with a scented mist as a kind of “sweet dreams” gesture. Last year, Delta Air Lines (despite being among the laggards in installing flatbed seats) began offering Westin Heavenly bedding in all of its Business Elite international and some domestic flights — a result of customer surveys that said that sleep was the most important part of the in-flight experience. The company also added a white-noise channel on Delta Radio. And, to keep cabins quieter, flight attendants are trying to be more mindful of announcements. Last year, the airline promoted its new sleepfriendly amenities at the TED (Technology, Entertainment, Design) conference in California.
“Everyone in the end is taking you from one place to another in a metal tube,” Dr Carvell said. “How do you impress upon a consumer that Delta is the way to go?” He expects to see more of these airline-hotel partnerships in the future. “Don’t be surprised if you wind up seeing first-class cabins pairing with Four Seasons,” he said. “Or that Cathay Pacific will pair with Peninsula or Mandarin Oriental.”
ndeed, all kinds of travel-sleep pairings are taking off. Last fall, WestHouse Hotel New York partnered with Sleep Studio, the sleep accessories store, to create suites with mattresses that adjust to different zones of your body, sleep masks and aromatherapy oils. And last summer JW Marriott, a luxury Marriott brand, introduced “nightly refresh,” a turndown service that includes Revive Oil, a blend of essential oils from Aromatherapy Associates. Sleep amenities are a step in the right direction, according to Dr Sanna of Harvard. Yet rather than sell sleep as a commodity, he is advocating a shift in cultural norms. He wants people to stop thinking about sleep as a lifestyle choice and rather as the third pillar of health along with diet and exercise. “Ask people if they can name three mammals on the planet that voluntarily sleep-deprive themselves,” he said. “There’s only one.” From The New York Times, March 26, 2014 © 2014, The New York Times. All rights reserved. Used by permission and protected by the Copyright Laws of the United States. The printing, copying, redistribution, or retransmission of this Content without express written permission is prohibited.
BOBAA22 / SHUTTERSTOCK.COM
Perhaps you’ve been too blearyeyed to notice, but sleep is a trendy topic, and no wonder. We’re hardly getting any APRIL 2014 • Doctor’s
ONE BOTTL E by
Sake: pure and subtle All sake (pronounced “sah-keh”) is not created equal. This may be obvious, but is nonetheless worth stating upfront. If to date your sake experience amounts to a steaming beverage served from a ceramic carafe alongside sushi, it’s time to expand your horizons. For sake is just as complex as wine, yet it too often remains shrouded in misconception. For starters, the notion it’s “rice wine” (as commonly transliterated in English) is misleading. Sake is actually brewed rather like beer, with special sake-specific rice gently cooked so its starch can be converted to sugar to facilitate the fermentation process. Perhaps the wine comparison arrives from a similar alcohol content, as finished sake normally checks in at 12 to 15 percent alcohol-by-volume. There is also myriad types of sake, with strict regulations outlining quality levels and designations. Craft-brewed sake, oak aging, and so on, the variety is downright exciting. For example, the amount of rice polish and the allowance of (or lack thereof) distilled alcohol are two significant factors that affect sake’s quality. The more the rice is polished or milled, the more rice that is required for brewing, and typically the better the final sake. The bottom line is that the hot sake on draft at most Japanese restaurants is the sake equivalent of white zinfandel. Certainly not unpleasant, but not altogether memorable either. Quality sake deserves to be served cold, or at least cool. It also demands to be sipped rather than slurped. If you are interested in determining the difference between bulk-boxed and special-designation sake, a good starting point is Hakutsuru’s Junmai Ginjo¯. The Junmai Ginjo¯ designation ensures that the sake is produced completely from rice with no addition of distilled alcohol, and also that the rice in this sake has been milled to a minimum 60 percent level — removing almost half of each grain! The Hakutsuru Junmai Ginjo¯ is widely available and accessibly-priced, yet offers great fruit and a silky, smooth flavour profile complemented by a light, balanced finish. There is no burn with this sake, and therefore no need to quaff. Serve chilled in a white wine glass alongside take-out sushi, or even try sipping with roast chicken or steamed fish.
Where to find it Hakutsuru Junmai Ginjo¯ is available across Canada, priced from $8.55–9.95 for a 300ml bottle
Doctor’s Review • APRIL 2014
James is an award-winning wine writer and educator based in Vancouver. The 2014 edition of his bestselling wine guide, Had a Glass: The Top 100 Wines Under $20, is currently available through all major booksellers. Visit hadaglass.com to learn more.
Chinese tea eggs.
Eggs to infinity
An everyday ingredient you can add to any meal recipes by
David L. Reamer
pparently, the 100 pleats in a chef’s tall white hat represent the number of egg dishes in his/her repertoire. That’s what Oregonbased food writer Andrea Slonecker imparts in Eggs on Top, a new
cookbook published by Chronicle Books. Eggs always make it onto grocery lists and everyone knows that they can be boiled, fried and even preserved, but most overlook the fact that they can be added to almost any recipe. A sunny-side-up egg on steamed rice or sautéed veggies, for example, turns a simple side into a main — with a sauce built right in — that’s ideal for busy weeknights. Or, if you have more time, take a “crack” at the fancier recipes that follow. We think they’re eggcellent!
CHINESE TEA EGGS These Chinese delicacies are boiled in a sultry brew of tea, spices, soy and sugar for at least a half hour (some recipes say 3 hours!) to stain the eggs with colour and flavour. They’re stunning piled in a pretty bowl like antique ornaments in a museum.
6 eggs boiled for 8 minutes*, cold but unpeeled ¼ c. (60 ml) loose-leaf black tea like Lapsang Souchong (smoky) or Earl Grey (citrusy) ¼ c. (60 ml) soy sauce 2 tbsp. (30 ml) light or dark brown sugar 1 star anise pod 1 cinnamon stick 1 tsp. (5 ml) peppercorns 1½ c. (375 ml) water
One by one, cradle the boiled eggs in your palm and use the back of a spoon to tap fine cracks in the shells like a mosaic. Crack firmly enough to penetrate the membrane between the shell and egg white, but not *8-minute eggs: Yolks are set, but moist, creamy and golden with just the edges turned light yellow. Whites are firm, but tender and easy to peel. APRIL 2014 • Doctor’s
so hard that the shell flakes away. If a piece falls off here and there, the contrast will be lovely. Put the eggs in a 1½-quart (1.5-L) saucepan with all of the ingredients, and bring to a boil. Reduce the heat to low, cover the pot and cook for 30 minutes. Gently stir the eggs a few times to be sure they are cooking and dyeing evenly. Adjust the heat as needed to maintain a low simmer. It may be necessary to set the pan slightly off the burner to keep the heat low enough. Remove the pot from the heat, uncover and let the eggs cool in the tea until they reach room temperature. Transfer the eggs and tea to a storage container, and refrigerate to cool completely, or peel and eat right away. For darker marbling and deeper flavour, leave the eggs in the tea overnight. Unpeeled eggs will keep for a few days, out of the tea, refrigerated in a covered container. Makes 6 eggs.
EGG-DROPPED MISO SOUP
4 c. (1 L) dashi 4 oz. (115 g) shimeji, enoki or shiitake mushrooms, cleaned and trimmed
6 oz. (170 g) baby bok choy, ends trimmed and leaves separated 4 tbsp. (60 ml) miso paste (red, white or a combination), or to taste 4 oz. (115 g) silken tofu, cubed 4 coddled eggs (recipe follows) 2 green onions, white and green parts, thinly sliced on a diagonal for garnish
Bring the dashi to a boil, covered in a medium pot. Add the mushrooms. When the dashi returns to a simmer, reduce the heat to medium and cook the mushrooms until just tender, 1 minute. Use a slotted spoon to transfer to a bowl and cover with foil to keep warm. Add the bok choy to the broth and simmer until just tender, but still a little firm, 2 minutes. Strain and transfer to a separate bowl and cover to keep warm. Reduce the heat so the broth is just below a simmer. Put 4 tablespoons (60 ml) miso paste into a fine-mesh strainer and lower it into the broth. Use the back of a spoon to push the miso through the strainer and dissolve it in the liquid. Remove the strainer and discard any chunks inside. (If your miso paste is finely ground, then just stir it directly into the broth.) Taste and add more as needed. Add the tofu and heat through, 1 Egg-dropped miso soup with mushrooms and bok choy.
minute. Never allow the broth to come to a boil after the miso has been added, or it may become gritty. Arrange the mushrooms and bok choy along the edges of four warmed soup bowls. Use a slotted spoon to divide the tofu evenly, heaping it in the centre. Make sure the broth is piping hot, then ladle it into the bowls. One at a time, peel the thick end of the eggs and slip them from the shells directly into the bowls. Garnish with green onions and serve. Serves 4.
TIPS: • Buy packets of instant dashi granules at Asian markets. Kombu/kelp dashi is best for miso soup. Dissolve in boiling water like bouillon cubes. • For a filling meal, add cooked soba noodles to each bowl before the broth. • Plan for the coddled eggs to cook so they are done when the soup is ready. If they’re finished before, run cold water over them to stop the cooking. They will warm up from the broth.
CODDLED EGGS These eggs are barely cooked in their shells by submerging them in near-boiling water so that the whites hardly set and the yolks remain liquid. They are ideal to drop into a brothy soup. They melt away, thickening and enriching the hot broth. Put as many room-temperature eggs as you’d like to cook in a tall heat-proof vessel like a measuring cup or a narrow pitcher. Pour in at least 1 cup (250 ml) of boiling water per egg, so that the eggs are completely submerged. Set a timer for 8 minutes. When the timer goes off, drain the eggs and quickly plunge into a bowl of ice water. If serving later, cool completely. If serving immediately, leave in the ice water for only 1 or 2 minutes, just until cool enough to touch. To peel, lightly tap the wide end of the egg on the countertop to crack around the air pocket. Holding the egg with the wide end pointing up, start peeling around the air pocket, being sure to get under the shell membrane, to create an opening that’s just wide enough for the egg to slip through. Pour the egg from the shell into the dish, probably a hot bowl of soup. Be sure the broth is piping hot, reheating the egg on contact.
Stir-fried Brussels sprouts and wok-fried eggs.
BRUSSELS SPROUTS AND WOK-FRIED EGGS 12 oz. (340 g) Brussels sprouts salt 2 tbsp. (30 ml) Thai or Vietnamese fish sauce 1½ tsp. (7.5 ml) fresh lime juice 1 tsp. (5 ml) soy sauce 1 tsp. (5 ml) sugar 2 tbsp. (30 ml) peanut or vegetable oil 2 garlic cloves, thinly sliced 1 1-in. (2.5-cm) piece fresh ginger, peeled, thinly sliced and cut into matchsticks 2 green onions, white and green parts, halved lengthwise and cut into 1½-in. (4-cm) segments 1 or 2 red Thai chilies, thinly sliced 2 wok-fried eggs (recipe follows)
Trim the Brussels sprouts and discard any wilted leaves. Halve the smaller ones and quarter the larger ones. Keep any fresh leaves that detach. Fill a medium pot two-thirds full with water, add a few big pinches of salt and bring to a boil. Add the sprouts and leaves, and cook until bright green and just beginning to tenderize, 45 seconds. Drain in a colander and cool under cold water. Spread out on a kitchen towel to dry and continue cooling. Stir together the fish sauce, lime juice, soy sauce and sugar in a small bowl, and set near the stove. Before you get to stir-frying, know that this is a super-quick cooking process, so it is important to have everything prepped and ready to go. Line the ingredients up next to the stove in the order that they will be added. Also, this is a high-heat process, but if the stir-fry begins to burn, reduce the heat briefly, add the next ingredient(s) to bring the temperature down, and then continue over medium-high or high heat. Heat a flat-bottomed wok over high heat. (You can also use a 10-inch/25-cm sauté pan over medium-high heat, but the timing will be a little different, so rely on the visual cues.) Add the oil and
swirl to coat the bottom and edges of the pan. When you begin to see wisps of smoke, add the garlic and ginger, and stir-fry until just brown at the edges, 15 seconds. Quickly add the green onions and chilies, and continue stir-frying until wilted, 15 seconds more. Add the Brussels sprouts and stir-fry until lightly browned in some spots, 2 to 3 minutes. Pour in the fish sauce mixture and continue to stir-fry until the sauce is slightly thickened, 1 minute more. Transfer the stir-fry to a warm platter. Top with the eggs and serve familystyle. Serves 2.
TIP: • After plating the stir-fry, quickly wipe the wok with paper towels and fry the eggs. The sprouts will stay hot in the short time it takes the eggs to cook.
3 tbsp. (45 ml) peanut or vegetable oil 2 room-temperature eggs pinch of salt
Heat a seasoned, carbon-steel or nonstick flat-bottomed wok over high heat. Add the oil, and swirl to coat the bottom and edges of the pan. When you begin to see wisps of smoke, add the eggs; they will spit and splatter. After 45 seconds, they will be crispy and browned on the bottom. Flip the eggs away from you to avoid splatter, and cook until crisp and browned on the other side, 30 to 45 seconds more. Transfer to a plate lined with a paper towel, or directly onto the dish. Sprinkle with salt.
WOK-FRIED EGGS When eggs are fried over high heat in a well-seasoned wok, the edges turn crunchy, and the tops and bottoms crisp and turn a deep golden brown. The best part is that the yolks stay saucy to moisten fried rice, stir-fried noodles or vegetables. To get the best results, be sure that the oil is smoking hot before adding the eggs, and don’t fry more than two at a time.
Recipes and photos from Eggs on Top (Chronicle Books, 2014).
Hungry for an easy weeknight dinner? Try a zesty egg recipe that’s a staple in the Middle East and North Africa. doctorsreview.com/recipes/shakshuka APRIL 2014 • Doctor’s
Oxycodone hydrochloride controlled release tablets 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, and 80 mg
Prescribing Summary IMPORTANT: Before making prescribing decisions, please refer to the complete Product Monograph at www.Purdue.ca or request a hard copy from Pharmacovigilance and Product Information Service of Purdue Pharma at 1-800-387-4501.
Patient Selection Criteria THERAPEUTIC CLASSIFICATION: Opioid Analgesic INDICATIONS AND CLINICAL USE Adults: OxyNEO (oxycodone hydrochloride controlled release tablets) is indicated for the relief of moderate to severe pain requiring the continuous use of an opioid analgesic preparation for several days or more. ®
Geriatrics (> 65 years of age): In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, concomitant disease or other drug therapy (see DOSAGE AND ADMINISTRATION). Pediatrics (< 18 years of age): The safety and efficacy of OxyNEO® has not been studied in the pediatric population. Therefore the use of OxyNEO® is not recommended in patients under 18 years of age. CONTRAINDICATIONS OxyNEO (oxycodone hydrochloride controlled release tablets) is contraindicated in: • Patients who are hypersensitive to the active substance (oxycodone) or other opioid analgesics or to any ingredient in the formulation. For a complete listing, see the DOSAGE FORMS, COMPOSITION AND PACKAGING section of the Product Monograph • In patients with known or suspected mechanical gastrointestinal obstruction (e.g, bowel obstruction, strictures) or any diseases/conditions that affect bowel transit (e.g., ileus of any type) • Patients with suspected surgical abdomen (e.g., acute appendicitis or pancreatitis) • Patients with mild, intermittent or short duration pain that can be managed with other pain medications • The management of acute pain ®
Doctor’s Review • APRIL 2014
• Patients with acute asthma or other obstructive airway, and status asthmaticus • Patients with acute respiratory depression, elevated carbon dioxide levels in the blood, and cor pulmonale • Patients with acute alcoholism, delirium tremens, and convulsive disorders • Patients with severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury • Patients taking monoamine oxidase (MAO) inhibitors (or within 14 days of such therapy) • Women who are breast-feeding, pregnant, or during labour and delivery
Safety Information WARNINGS AND PRECAUTIONS General: OxyNEO® (oxycodone hydrochloride controlled release tablets) must be swallowed whole. Taking cut, broken, chewed, dissolved or crushed OxyNEO® tablets could lead to the rapid release and absorption of a potentially fatal dose of oxycodone. The tablets have been hardened, by a unique process, to reduce the risk of being broken, crushed or chewed. There have been post-marketing reports of difficulty swallowing OxyNEO® tablets. These reports include choking, gagging, regurgitation and tablets stuck in the throat. If patients experience such swallowing difficulties or pain after taking OxyNEO® tablets, they are advised to seek immediate medical attention. To avoid difficulty swallowing, OxyNEO® tablets should not be pre-soaked, licked or otherwise wetted prior to placing in the mouth and should be taken one tablet at a time with enough water to ensure complete swallowing immediately after placing it in the mouth. OxyNEO® should not be taken by patients with difficulty in swallowing or who have been diagnosed with narrowing of the esophagus. Do not administer OxyNEO® via nasogastric, gastric or other feeding tubes as it may cause obstruction of feeding tubes. OxyNEO® 60 mg and 80 mg tablets, or a single dose greater than 40 mg are for use in opioid tolerant patients only (see also DOSAGE AND ADMINISTRATION). A single dose greater than 40 mg of oxycodone, or total daily doses greater than 80 mg of oxycodone, may cause fatal respiratory depression when administered to patients who are not tolerant to the respiratory depressant effects of opioids (see WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS). Patients should be instructed not to give OxyNEO® to anyone other than the patient for whom it was prescribed as such inappropriate use may have severe medical consequences, including death. Patients should be cautioned not to consume alcohol while taking OxyNEO®, as it may increase the chance of experiencing dangerous side effects.
Abuse of Opioid Formulations: OxyNEO® is intended for oral use only. Abuse of OxyNEO® can lead to overdose and death. This risk is increased when the tablets are cut, crushed, dissolved, broken or chewed, and with concurrent consumption of alcohol or other CNS depressants. With parenteral abuse, the tablet excipients, can be expected to result in local tissue necrosis, infection, pulmonary granulomas, and increased risk of endocarditis and valvular heart injury. Cardiovascular: Oxycodone administration may result in severe hypotension in patients whose ability to maintain adequate blood pressure is compromised by reduced blood volume, or concurrent administration of such drugs as phenothiazines or certain anesthetics. Dependence/Tolerance: As with other opioids, tolerance and physical dependence may develop upon repeated administration of oxycodone and there is a potential for development of psychological dependence. OxyNEO® tablets should therefore be prescribed and handled with the degree of caution appropriate to the use of a drug with abuse potential. Abuse and addiction are separate and distinct from physical dependence and tolerance. In addition, abuse of opioids can occur in the absence of true addiction and is characterized by misuse for non-medical purposes, often in combination with other psychoactive substances. Tolerance, as well as physical dependence, may develop upon repeated administration of opioids, and are not by themselves evidence of an addictive disorder or abuse. Concerns about abuse, addiction, and diversion should not prevent the proper management of pain. The development of addiction to opioid analgesics in properly managed patients with pain has been reported to be rare. However, data are not available to establish the true incidence of addiction in chronic pain patients. Opioids, such as oxycodone, should be used with particular care in patients with a history of alcohol and drug abuse. Withdrawal symptoms may occur following abrupt discontinuation of therapy or upon administration of an opioid antagonist. Patients on prolonged therapy should be withdrawn gradually from the drug if it is no longer required for pain control. Use in Drug and Alcohol Addiction: OxyNEO® is an opioid with no approved use in the management of addictive disorders. Its proper usage in individuals with drug or alcohol dependence, either active or in remission, is for the management of pain requiring opioid analgesia. Gastrointestinal Effects: There have been rare post-marketing cases of intestinal obstruction, and exacerbation of diverticulitis, some of which have required medical intervention to remove the tablet. Patients with underlying GI disorders such as esophageal cancer or colon cancer with a small gastrointestinal lumen are at greater risk of developing these complications.
Use caution when prescribing OxyNEO® for patients who have any underlying GI disorders that may predispose them to obstruction. Oxycodone and other morphine-like opioids have been shown to decrease bowel motility. Oxycodone may obscure the diagnosis or clinical course of patients with acute abdominal conditions. Neurologic: CNS Depression: Oxycodone should be used with caution and in a reduced dosage during concomitant administration of other opioid analgesics, general anesthetics, phenothiazines and other tranquilizers, sedative-hypnotics, tricyclic antidepressants, antipsychotics, antihistamines, benzodiazepines, centrally-active anti-emetics and other CNS depressants including alcohol. Respiratory depression, hypotension and profound sedation, coma or death may result. When such combination therapy is contemplated, a substantial reduction in the dose of one or both agents should be considered and patients should be carefully monitored (see DRUG INTERACTIONS). Severe pain antagonizes the subjective and respiratory depressant actions of opioid analgesics. Should pain suddenly subside, these effects may rapidly become manifest. Head Injury: The respiratory depressant effects of oxycodone and the capacity to elevate cerebrospinal fluid pressure, may be greatly increased in the presence of an already elevated intracranial pressure produced by trauma. Also, oxycodone may produce confusion, miosis, vomiting and other side effects which obscure the clinical course of patients with head injury. In such patients, oxycodone must be used with extreme caution and only if it is judged essential. Peri-Operative Considerations: OxyNEO® is not indicated for pre-emptive analgesia (administration pre-operatively for the management of post-operative pain). In the case of planned chordotomy or other pain-relieving operations, patients should not be treated with OxyNEO® for at least 24 hours before the operation and OxyNEO® should not be used in the immediate post-operative period. Physicians should individualize treatment, moving from parenteral to oral analgesics as appropriate. Thereafter, if OxyNEO® is to be continued after the patient recovers from the post-operative period, a new dosage should be administered in accordance with the changed need for pain relief. The risk of withdrawal in opioid-tolerant patients should be addressed as clinically indicated. The administration of analgesics in the perioperative period should be managed by healthcare providers with adequate training and experience (e.g., by an anesthesiologist). Oxycodone and other morphine-like opioids have been shown to decrease bowel motility. Ileus is a common post-operative complication, especially after intra-abdominal surgery with opioid analgesia. Caution should be taken to monitor for decreased bowel motility in post-
operative patients receiving opioids. Standard supportive therapy should be implemented. OxyNEO® should not be used in the early post-operative period (12 to 24 hours postsurgery) unless the patient is ambulatory and gastrointestinal function is normal. Psychomotor Impairment: Oxycodone may impair the mental and/or physical abilities needed for certain potentially hazardous activities such as driving a car or operating machinery. Patients should be cautioned accordingly. Patients should also be cautioned about the combined effects of oxycodone with other CNS depressants, including other opioids, phenothiazine, sedative/hypnotics and alcohol. Respiratory: Respiratory Depression: Oxycodone should be used with extreme caution in patients with substantially decreased respiratory reserve, pre-existing respiratory depression, hypoxia or hypercapnia. Such patients are often less sensitive to the stimulatory effects of carbon dioxide (CO2) on the respiratory centre and the respiratory depressant effects of oxycodone may reduce respiratory drive to the point of apnea. Patient Counselling Information: A patient information sheet should be provided when OxyNEO® tablets are dispensed to the patient. Patients receiving OxyNEO® should be given the following instructions by the physician: 1. Patients should be informed that accidental ingestion or use by individuals (including children) other than the patient for whom it was originally prescribed, may lead to severe, even fatal consequences. 2. Patients should be advised that OxyNEO® contains oxycodone, an opioid pain medicine. 3. Patients should be advised that OxyNEO® should only be taken as directed. The dose of OxyNEO® should not be adjusted without consulting with a physician. 4. OxyNEO® must be swallowed whole (not cut, broken, chewed, dissolved or crushed) due to the risk of fatal oxycodone overdose. 5. To avoid difficulty swallowing, patients should be advised to take OxyNEO® tablets one at a time. Tablets should not be pre-soaked, licked or otherwise wetted prior to placing in the mouth. Each tablet should be taken with enough water to ensure complete swallowing immediately after placing in the mouth. If patients experience difficulty in swallowing or pain after taking OxyNEO®, they should seek immediate medical attention. 6. Patients should be advised to report episodes of pain and adverse experiences occurring during therapy. Individualization of dosage is essential to make optimal use of this medication. 7. Patients should not combine OxyNEO® with alcohol or other central nervous system depressants (sleep aids, tranquilizers) because dangerous additive effects may occur, resulting in serious injury or death. 8. Patients should be advised to consult their physician or pharmacist if other medications are being used or will be used with OxyNEO®.
9. Patients should be advised that if they have been receiving treatment with OxyNEO® and cessation of therapy is indicated, it may be appropriate to taper OxyNEO® dose, rather than abruptly discontinue it, due to the risk of precipitating withdrawal symptoms. 10. Patients should be advised that the most common adverse reactions that may occur while taking OxyNEO® are asthenic conditions, constipation, dizziness, dry mouth, headache, nausea, pruritus, somnolence, sweating and vomiting. 11. Patients should be advised that OxyNEO® may cause drowsiness, dizziness or lightheadedness and may impair mental and/ or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating machinery). Patients started on OxyNEO® or patients whose dose has been adjusted should be advised not to drive a car or operate machinery unless they are tolerant to the effects of OxyNEO®. 12. Patients should be advised that OxyNEO® is a potential drug of abuse. They should protect it from theft or misuse. 13. Patients should be advised that OxyNEO® should never be given to anyone other than the individual for whom it was prescribed. 14. Patients should be advised that OxyNEO® 60 mg and 80 mg tablets or a single dose greater than 40 mg are for use only in individuals tolerant to the effect of opioids. 15. Women of childbearing potential who become or are planning to become pregnant should be advised to consult a physician prior to initiating or continuing therapy with OxyNEO®. Women who are breast-feeding or pregnant should not use OxyNEO®. Special Populations: Special Risk Groups: Oxycodone should be administered with caution and in a reduced dosage to debilitated patients, to patients with severely reduced hepatic or renal function or severely impaired pulmonary function, and in patients with Addison’s disease, hypothyroidism, toxic psychosis, pancreatitis, prostatic hypertrophy or urethral stricture. Pregnant Women: Animal reproduction studies have revealed no evidence of harm to the fetus due to oxycodone, however, as studies in humans have not been conducted, OxyNEO® is contraindicated in patients who are pregnant. Labour, Delivery and Nursing Women: In view of the potential for opioids to cross the placental barrier and to be excreted in breast milk, oxycodone is contraindicated during labour or in nursing mothers. Physical dependence or respiratory depression may occur in the infant if opioids are administered during labour. Pediatrics (< 18 years of age): The safety and efficacy of OxyNEO® have not been studied in the pediatric population. Therefore, use of OxyNEO® is not recommended in patients under 18 years of age. Geriatrics (> 65 years of age): In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency
APRIL 2014 • Doctor’s
of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy (see DOSAGE AND ADMINISTRATION). “In Vitro” Dissolution Studies of Interaction with Alcohol: Among readily available drugs with the established potential to pharmacologically augment the CNS depressant effect of opioids, ethanol also has the potential to chemically interact with the pharmaceutical formulation to accelerate the release of opioids from the dosage form. Given the larger doses of opioids in controlled release opioid formulations on average, the occurrence of such a formulation effect can further augment the risk of serious and unintended respiratory depression. A method to assess the potential for ethanol to accelerate the release of opioids from a pharmaceutical formulation requires the use of in vitro dissolution studies using simulated gastric fluid and 40% ethanol. With OxyNEO®, increasing concentrations of alcohol in the dissolution medium (from 0% to 40% v/v), resulted in a slight decrease in the rate of release of oxycodone from intact tablets. Additional in vitro dissolution testing in ethanol (40% v/v), conducted with OxyNEO® tablet fragments over a range of particles sizes, showed that dose dumping did not occur with the particle sizes tested. Other “In Vitro” Testing: The physical properties of the tablet were examined following an extensive battery of physical manipulations. Beyond demonstrating that OxyNEO® was harder to crush than another controlled release oxycodone formulation, testing over the range of OxyNEO® tablet fragment sizes showed that some of the controlled release properties were still retained. Hydrogelling properties continued to be demonstrated and dose dumping was not associated with OxyNEO®. ADVERSE REACTIONS Adverse Drug Reaction Overview: Adverse effects of OxyNEO® (oxycodone hydrochloride controlled release tablets) are similar to those of other opioid analgesics, and represent an extension of pharmacological effects of the drug class. The major hazards of opioids include respiratory and central nervous system depression and to a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest. The most frequently observed adverse effects of OxyNEO® are asthenia, constipation, dizziness, dry mouth, headache, nausea, pruritus, somnolence, sweating and vomiting. Sedation: Sedation is a common side effect of opioid analgesics, especially in opioid naïve individuals. Sedation may also occur partly because patients often recuperate from prolonged fatigue after the relief of persistent pain. Most patients develop tolerance to the sedative effects of opioids within three to five days and, if the sedation is not severe, will not require any treatment except reassurance. If excessive sedation persists beyond a few days, the dose of the opioid should be reduced and alternate causes investigated. Some of these are: concurrent CNS depressant medication, hepatic
Doctor’s Review • APRIL 2014
or renal dysfunction, brain metastases, hypercalcemia and respiratory failure. If it is necessary to reduce the dose, it can be carefully increased again after three or four days if it is obvious that the pain is not being well controlled. Dizziness and unsteadiness may be caused by postural hypotension, particularly in elderly or debilitated patients, and may be alleviated if the patient lies down. Nausea and Vomiting: Nausea is a common side effect on initiation of therapy with opioid analgesics and is thought to occur by activation of the chemoreceptor trigger zone, stimulation of the vestibular apparatus and through delayed gastric emptying. The prevalence of nausea declines following continued treatment with opioid analgesics. When instituting therapy with an opioid for chronic pain, the routine prescription of an antiemetic should be considered. In the cancer patient, investigation of nausea should include such causes as constipation, bowel obstruction, uremia, hypercalcemia, hepatomegaly, tumour invasion of celiac plexus and concurrent use of drugs with emetogenic properties. Persistent nausea which does not respond to dosage reduction may be caused by opioidinduced gastric stasis and may be accompanied by other symptoms including anorexia, early satiety, vomiting and abdominal fullness. These symptoms respond to chronic treatment with gastrointestinal prokinetic agents. Constipation: Practically all patients become constipated while taking opioids on a persistent basis. In some patients, particularly the elderly or bedridden, fecal impaction may result. It is essential to caution the patients in this regard and to institute an appropriate regimen of bowel management at the start of prolonged opioid therapy. Stimulant laxatives, stool softeners, and other appropriate measures should be used as required. The following adverse effects occur less frequently with opioid analgesics and include those reported in OxyNEO® clinical trials, whether related or not to oxycodone. General and CNS: abnormal dreams, abnormal gait, agitation, amnesia, anaphylactic reaction, anaphylactoid reaction, anxiety, confusional state, convulsion, delirium, depersonalization, depression, disorientation, drug dependence, drug tolerance, drug withdrawal syndrome, dysphoria, emotional lability, euphoria, hallucinations,headache, hypertonia, hypoaesthesia, hypotonia, insomnia, miosis, muscle contractions involuntary, nervousness, paresthesia, speech disorder, thought abnormalities, tinnitus, tremor, twitching, vertigo and vision abnormalities Cardiovascular: chest pain, faintness, hypotension, migraine, palpitation, ST depression, syncope, tachycardia and vasodilation Respiratory: bronchitis, bronchospasm, cough, dyspnea, pharyngitis, pneumonia, respiratory depression, sinusitis and yawning Gastrointestinal: abdominal pain, anorexia, biliary spasm, dental caries, diarrhea, dyspepsia, dysphagia, eructation, flatulence, gastritis,
gastrointestinal disorder, hiccups, ileus, increased appetite, stomatitis and taste perversion Genitourinary: amenorrhea, antidiuretic effects, libido decreased, dysuria, hematuria, impotence, polyuria, urinary retention or hesitancy Dermatologic: dry skin, exfoliative dermatitis, edema, other skin rashes and urticaria Other: allergic reaction, asthenia, chills, dehydration, fever, hypoglycemia, increased hepatic enzymes, lymphadenopathy, malaise, thirst and weight loss Post-marketing Experience: The following have been reported during post-marketing experience with OxyNEO®, potentially due to the swelling and hydrogelling property of the tablet: choking, gagging, regurgitation, tablets stuck in the throat and difficulty swallowing the tablet. To report any suspected adverse event associated with this drug, you may notify: • The Canada Vigilance Program at 1-866-234-2345 or • Purdue Pharma at 1-800-387-4501 or email@example.com For complete information on options when Reporting Suspected Side Effects, please see “Part III: Consumer Information” of the Product Monograph. DRUG INTERACTIONS Overview: Interaction with Central Nervous System (CNS) Depressants: OxyNEO® (oxycodone hydrochloride controlled release tablets) should be dosed with caution and started in a reduced dosage (1/3 to 1/2 of the usual dosage) in patients who are currently taking other central nervous system depressants (e.g., alcohol, other opioids, sedatives, hypnotics, anti-depressants, sleeping aids, phenothiazines, neuroleptics, anti-histamines and anti-emetics), pyrazolidone and beta-blockers, as they may enhance the CNS-depressant effect (e.g., respiratory depression) of OxyNEO®. Drug-Drug Interactions: Drugs Metabolized by Cytochrome P450 Isozymes: Oxycodone is metabolized in part by cytochrome P450 2D6 and cytochrome P450 3A4 pathways. The activities of these metabolic pathways may be inhibited or induced by various co-administered drugs, which may alter plasma oxycodone concentrations. Oxycodone doses may need to be adjusted accordingly. Inhibitors of CYP3A4: Since the CYP3A4 isoenzyme plays a major role in the metabolism of OxyNEO®, drugs that inhibit CYP3A4 activity, such as macrolide antibiotics (e.g., erythromycin), azole-antifungal agents (e.g., ketoconazole), and protease inhibitors (e.g., ritonavir), may cause decreased clearance of oxycodone which could lead to an increase in oxycodone plasma concentrations. A published study showed that the co-administration of the antifungal drug, voriconazole, increased oxycodone AUC and Cmax by 3.6- and 1.7-fold, respectively. Although clinical studies have not been conducted with other CYP3A4 inhibitors, the expected clinical results would be increased or prolonged
opioid effects. If co-administration with OxyNEO® is necessary, caution is advised when initiating therapy with, currently taking, or discontinuing CYP450 inhibitors. Evaluate these patients at frequent intervals and consider dose adjustments until stable drug effects are achieved. Inducers of CYP3A4: CYP450 inducers, such as rifampin, carbamazepine and phenytoin, may induce the metabolism of oxycodone and, therefore, may cause increased clearance of the drug which could lead to a decrease in oxycodone plasma concentrations, lack of efficacy or possibly the development of an abstinence syndrome in a patient who had developed physical dependence to oxycodone. A published study showed that the co-administration of rifampin, a drug metabolizing enzyme inducer, decreased oxycodone (oral) AUC and Cmax by 86% and 63% respectively. If co-administration with OxyNEO® is necessary, caution is advised when initiating therapy with, currently taking or discontinuing CYP3A4 inducers. Evaluate these patients at frequent intervals and consider dose adjustments until stable drug effects are achieved. Inhibitors of CYP2D6: Oxycodone is metabolized in part to oxymorphone via cytochrome CYP2D6. While this pathway may be blocked by a variety of drugs (e.g., certain cardiovascular drugs including amiodarone and quinidine as well as polycyclic antidepressants), such blockade has not been shown to be of clinical significance during oxycodone treatment. Administration with Mixed Activity Agonist/ Antagonist Opioids: Mixed agonist/antagonist opioid analgesics (i.e., pentazocine, nalbuphine, butorphanol, and buprenorphine) should be administered with caution to a patient who has received or is receiving a course of therapy with a pure opioid agonist analgesic such as oxycodone. In this situation, mixed agonist/ antagonist analgesics may reduce the analgesic effect of oxycodone and/or may precipitate withdrawal symptoms in these patients. MAO Inhibitors: MAO Inhibitors intensify the effects of opioid drugs which can cause anxiety, confusion and decreased respiration. OxyNEO® is contraindicated in patients receiving MAO Inhibitors or who have used them within the previous 14 days (see CONTRAINDICATIONS). Warfarin and Other Coumarin Anticoagulants: Clinically relevant changes in International Normalized Ratio (INR or Quick-value) in both directions have been observed in individuals when oxycodone and coumarin anticoagulants are co-administered. Drug-Food Interactions: Administration of OxyNEO® with food results in an increase in peak plasma oxycodone concentration of up to 1.5-fold but has no significant effect on the extent of absorption of oxycodone. Drug-Herb Interactions: Interactions with herbal products have not been established. Drug-Laboratory Interactions: Interactions with laboratory tests have not been established.
Administration DOSAGE AND ADMINISTRATION Dosing Considerations: OxyNEO® tablets must be swallowed whole and should not be cut, broken, chewed, dissolved or crushed since this can lead to rapid release and absorption of a potentially fatal dose of oxycodone. The tablets have been hardened by a unique process to reduce the risk of being broken, chewed or crushed. There have been post-marketing reports of difficulty swallowing OxyNEO® tablets. These reports include choking, gagging, regurgitation and tablets stuck in the throat. If patients experience such swallowing difficulties or pain after taking OxyNEO® tablets, they are advised to seek immediate medical attention. To avoid difficulty swallowing, OxyNEO® tablets should not be pre-soaked, licked or otherwise wetted prior to placing in the mouth and should be taken one tablet at a time with enough water to ensure complete swallowing immediately after placing it in the mouth (see Patient Counselling Information). OxyNEO® should not be taken by patients with difficulty in swallowing or who have been diagnosed with narrowing of the esophagus. Do not administer OxyNEO® via nasogastric, gastric or other feeding tubes as it may cause obstruction of feeding tubes. OxyNEO® 60 mg and 80 mg tablets, or a single dose greater than 40 mg, are for use in opioid tolerant patients only. A single dose greater than 40 mg, or total daily doses greater than 80 mg, may cause fatal respiratory depression when administered to patients who are not tolerant to the respiratory depressant effects of opioids. OxyNEO® should not be used in the early post-operative period (12 to 24 hours postsurgery) unless the patient is ambulatory and gastrointestinal function is normal. OxyNEO® is not indicated for rectal administration. The controlled release tablets may be taken with or without food, with a glass of water. Recommended Dose and Dosage Adjustment: Adults: Individual dosing requirements vary considerably based on each patient’s age, weight, severity and cause of pain, and medical and analgesic history. Patients Not Receiving Opioids at the Time of Initiation of Oxycodone Treatment: The usual initial adult dose of OxyNEO® for patients who have not previously received opioid analgesics is 10 mg or 20 mg every 12 hours. Patients Currently Receiving Opioids: Patients currently receiving other oral oxycodone formulations may be transferred to OxyNEO® tablets at the same total daily oxycodone dosage, equally divided into two 12 hourly OxyNEO® doses. For patients who are receiving an alternate
opioid, the “oral oxycodone equivalent” of the analgesic presently being used should be determined. Having determined the total daily dosage of the present analgesic, TABLE 1 in the product monograph can be used to calculate the approximate daily oral oxycodone dosage that should provide equivalent analgesia. This total daily oral oxycodone dose should then be equally divided into two 12 hourly OxyNEO® doses. It is usually appropriate to treat a patient with only one opioid at a time. Patients who are receiving 1 to 5 tablets/capsules per day of a fixed-dose combination opioid/ non-opioid containing 5 mg of oxycodone or 30 mg codeine should be started on 10 mg to 20 mg OxyNEO® q12h. For patients receiving 6 to 9 tablets/capsules per day of a fixed-dose combination opioid/non-opioid containing 5 mg of oxycodone or 30 mg codeine, a starting dose of 20 mg to 30 mg q12h should be used and for patients receiving 10 to 12 tablets/capsules per day of a fixed-dose combination opioid/nonopioid containing 5 mg of oxycodone or 30 mg codeine, a starting dose of 30 mg to 40 mg q12h is suggested. For those receiving > 12 tablets/ capsules per day of a fixed-dose combination opioid/non-opioid containing 5 mg of oxycodone or 30 mg codeine, conversions should be based on the total daily opioid dose. Use with Non-Opioid Medications: If a non-opioid analgesic is being provided, it may be continued. If the non-opioid is discontinued, consideration should be given to increasing the opioid dose to compensate for the non-opioid analgesic. OxyNEO® can be safely used concomitantly with usual doses of other non-opioid analgesics. Dose Titration: Dose titration is the key to success with opioid analgesic therapy. Proper optimization of doses scaled to the relief of the individual’s pain should aim at regular administration of the lowest dose of controlled release oxycodone (OxyNEO®) which will achieve the overall treatment goal of satisfactory pain relief with acceptable side effects. Dosage adjustments should be based on the patient’s clinical response. In patients receiving OxyNEO®, the dose may be titrated at intervals of 24 to 36 hours to that which provides satisfactory pain relief without unmanageable side effects. OxyNEO® is designed to allow 12 hourly dosing. If pain repeatedly occurs at the end of the dosing interval it is generally an indication for a dosage increase rather than more frequent administration of controlled release oxycodone (OxyNEO®). Adjustment or Reduction of Dosage: Following successful relief of pain, periodic attempts to re-assess the opioid analgesic requirements should be made. If treatment discontinuation is required, the dose of opioid may be decreased as follows: one-half of the previous daily dose given q12h (OxyNEO®) for the first two days, followed thereafter by a 25% reduction every two days. Withdrawal symptoms may occur following abrupt discontinuation of therapy. These symptoms may include body aches, diarrhea, gooseflesh, loss of appetite, nausea, nervousness
APRIL 2014 • Doctor’s
or restlessness, runny nose, sneezing, tremors or shivering, stomach cramps, tachycardia, trouble with sleeping, unusual increase in sweating, palpitations, unexplained fever, weakness and yawning. Patients on prolonged therapy should be withdrawn gradually from the drug if it is no longer required for pain control. In patients who are appropriately treated with opioid analgesics and who undergo gradual withdrawal for the drug, these symptoms are usually mild. Opioid analgesics may only be partially effective in relieving dysesthetic pain, stabbing pains, activity-related pain and some forms of headache. That is not to say that patients with these types of pain should not be given an adequate trial of opioid analgesics, but it may be necessary to refer such patients at an early time to other forms of pain therapy. Missed Dose: If the patient forgets to take a dose, it should be taken as soon as possible, however, if it is almost time for the next scheduled dose, they should skip the missed dose and take their next dose at the scheduled time and in the normal amount. OVERDOSAGE For management of a suspected drug overdose, contact your Regional Poison Control Centre. Symptoms: Serious overdosage with oxycodone may be characterized by respiratory depression (a decrease in respiratory rate and/or tidal volume, Cheyne-Stokes respiration, cyanosis), extreme somnolence progressing to stupor or coma, miotic pupils, skeletal muscle flaccidity, cold and clammy skin, and sometimes bradycardia and hypotension. Severe overdosage may result in apnea, circulatory collapse, cardiac arrest and death. Treatment: Primary attention should be given to the establishment of adequate respiratory exchange through the provision of a patent airway and controlled or assisted ventilation. The opioid antagonist naloxone hydrochloride is a specific antidote against respiratory depression due to overdosage or as a result of unusual sensitivity to oxycodone. An appropriate dose of an opioid antagonist should therefore be administered, preferably by the intravenous route. The usual initial i.v. adult dose of naloxone is 0.4 mg or higher. Concomitant efforts at respiratory resuscitation should be carried out. Since the duration of action of oxycodone, particularly sustained release formulations, may exceed that of the antagonist, the patient should be under continued surveillance and doses of the antagonist should be repeated as needed to maintain adequate respiration. An antagonist should not be administered in the absence of clinically significant respiratory or cardiovascular depression. Oxygen, intravenous fluids, vasopressors and other supportive measures should be used as indicated. In individuals physically dependent on opioids, the administration of the usual dose of narcotic antagonist will precipitate an acute withdrawal syndrome. The severity of this syndrome will depend on the degree of physical dependence and the dose of antagonist administered. The use of narcotic antagonists in such individuals should be avoided if possible. If a narcotic antagonist must be used to treat serious respiratory depression in the physically dependent patient, the antagonist should be administered with extreme care by using dosage titration, commencing with 10% to 20% of the usual recommended initial dose. Evacuation of gastric contents may be useful in removing unabsorbed drug, particularly when a sustained release formulation has been taken. Product Monograph available on request. Purdue Pharma Canada, 575 Granite Court, Pickering, Ontario, L1W 3W8, 1-800-387-4501, http://www.purdue.ca
To contact Purdue Pharma please call 1-800-387-4501. www.OxyNEO.ca OxyNEO® is a registered trademark of Purdue Pharma. © 2012 Purdue Pharma. All rights reserved.
Pillars of strength uu CONTINUED FROM PAGE 37
Segovia itself long predates the days of knights in armour, as I found out in its historic centre, which is dominated by an enormous 2000-year-old Roman aqueduct that cuts the town in two and marches 16 kilometres into the countryside. As tall as an eight-storey building, the aqueduct starts at springs by the Alcázar castle and stretches through Segovia’s main plaza. Its scale dwarfs the Mesón de Cándido (5 Plaza de Azoguejo; mesondecandido.es), a restaurant where I ate asparagus and suckling pig, a Roman favourite. Like the aqueduct, my meal was a spectacle: the waiters used the edges of heavy dinnerware to cleave apart tender carcasses, then smashed the plates on the floor, a longstanding tradition. Recovering in the shadow of the aqueduct outside, I eavesdropped on an Irish visitor poetically describing how the stone-block structure talked endlessly at night when the wind echoed through its 166 arches like “teeth chattering with history.” More prosaically, a local Segovian reminded me that the aqueduct, though non-functional now, remains “future back-up.”
orth of Segovia is the Ribera del Duero, the area of my lunchtime “cave encounter” and 2012’s Wine Region of the Year according to oenophile bible, Wine Enthusiast Magazine. (Consult the Wine Tourism Guide at riberate.com for more). From there, a short detour west took me through The Golden Mile, a who’s who of well-known wineries that offer tours and tastings. Out in the hillside vineyards, I thought the tempranillo grapes looked like plump blueberries as I listened to Maria Escudero of the Abadía Retuerta winery (47340 Sardón de Duero, Valladolid; abadia-retuerta.com) explain the effects of soils and microclimates on vintages and varietals. “The finished wine might have very different qualities,” Maria said. “That’s something you can experience right here, the variations in the wines from this slope to the valley down below.” A few glasses later, the subtleties might have escaped my unrefined palate, but a dinner party back at L’Domaine (ledomaine.es; doubles from €230 per night), the winery’s five-star hotel in a renovated 12th-century abbey, certainly caught my attention. The staff were laying out a table in the stone expanse of the old chapel, an imposing setting of soaring columns and stained glass flickering with candlelight. My final destination in Castile and León was the historic royal capital of Burgos, 244 kilometres from Madrid. Known for its savoury cuisine (the local blood pudding, morcilla, changes bad attitudes in a hurry), the city of 200,000 is home to a cathedral often considered the third grandest in Christendom after the Vatican and the Chartres in France. Built over centuries in opulent Gothic style, Burgos Cathedral is a stopping point on the famous Camino de Santiago pilgrimage route. In 2012, over 270,000 hikers, religious and secular, passed through the city to complete the last 480 kilometres of their trek to a shrine of the Apostle St. James on Spain’s Atlantic coast. Sitting by the Cathedral, I watched the sunburnt pilgrims come and go. Behind us stood El 24 de la Paloma (Calle Paloma 24; restauranteel24delapaloma. com), a contemporary restaurant in a 16th-century dining hall, a place where the great Spanish writer, Cervantes, once penned parts of Don Quixote — presumably between goblets of wine and heaping courses of Castile’s weekend meals. Listening to the restaurant’s clinking glasses and friendly clamour, I opened my notebook, and disappeared happily inside for lunch. For more info on the region, visit Castile and León Tourism (turismocastilla yleon.com).
Doctor’s Review • APRIL 2014
Explore architecture that’s over-the-top cool on Barcelona’s Gaudí Trail. doctorsreview.com/features/gaudi-barcelona
Indications and clinical use: BEXSERO ® is indicated for active immunization of individuals from 2 months through 17 years old against invasive disease caused by N. meningitidis serogroup B strains. As the expression of antigens included in the vaccine is epidemiologically variable in circulating group B strains, meningococci that express them at sufficient levels are predicted to be susceptible to killing by vaccine-elicited antibodies. Contraindications: • Hypersensitivity to the BEXSERO ® vaccine or to any ingredient in the formulation or components of the container closure. Relevant warnings and precautions: • Temperature elevation following vaccination of infants and children (less than 2 years of age) • Administration of BEXSERO® should be postponed in subjects suffering from an acute severe febrile illness • Individuals with thrombocytopenia, hemophilia or any coagulation disorder that would contraindicate intramuscular injection • Subjects with impaired immune responsiveness • Do not inject intravascularly, intravenously, subcutaneously or intradermally
• Do not mix with other vaccines in the same syringe • Availability of appropriate medical treatment and supervision in case of an anaphylactic event following administration of the vaccine • Risk of apnoea in premature infants; need for 48-72 hours respiratory monitoring • Caution in subjects with known history of hypersensitivity to latex • Hypersensitivity to kanamycin • Protection against invasive meningococcal disease caused by serogroups other than serogroup B should not be assumed • As with any vaccine, BEXSERO® may not fully protect all of those who are vaccinated For more information: Please consult the Product Monograph at www.novar tis.ca / BexseroMonograph for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling Medical Information at 1-800-363-8883.
BEXSERO is a registered trademark. Product Monograph available on request. Printed in Canada ©Novartis Pharmaceuticals Canada Inc. 2014 13BEX017E Novartis Pharmaceuticals Canada Inc. Dorval, Québec H9S 1A9 www.novartis.ca T: 514.631.6775 F: 514.631.1867
Be informed. Be immunized.
BEX_7386_PI_DoctorsReview E01.indd 1
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advertisers index ACTAVIS SPECIALTY PHARMACEUTICALS Corporate......................................................................................... 20 ASTRAZENECA CANADA INC. Vimovo.........................................................................................OBC BOEHRINGER INGELHEIM CANADA LTD. Trajenta..........................................................................................IFC CANADIAN ASSOCIATION OF EMERGENCY PHYSICIANS Corporate........................................................................................... 6 LEO PHARMA INC. Picato.............................................................................................IBC NOVARTIS PHARMACEUTICALS CANADA INC. Corporate......................................................................................... 18 Seebri.........................................................................Front cover, 8, 37 PURDUE PHARMA CANADA OxyNeo.........................................................................................5, 14 SEA COURSES INC. Corporate......................................................................................... 13 TAKEDA CANADA INC. Dexilant.............................................................................................. 2 Omnaris.............................................................................................. 4
PRESCRIBING INFORMATION Corporate...................................................................................... 55 OxyNeo................................................................... 50, 51, 52, 53, 54
APRIL 2014 • Doctor’s
PHOTO FINISH by
D r D omi n i k a Je g e n
The sands of time
I dreamed of visiting Morocco ever since I can remember. The thought of ocherstained villages streaming down mountainsides, souks bustling with activity and camels plodding through the desert were embedded in my mind while growing up. Now, having graduated from residency and in active practice, I ventured on my dream journey with my husband, supportive of my travels as ever. We drove through the country for two weeks and came upon the south; this is where the Sahara desert begins. Just 40 kilometres from the Algerian border, we spotted the orange-hued mountains of sand from the paved highway. It indeed looked just like in the movies. One day, we hired a caravan of dromedaries to take us deep into the desert. My husband and I played like children — not the adult professionals that we are — in this giant sandbox. We ran, climbed, sandboarded, made pizzas baked on the sand and, of course, petted camels. At the end of the day, our dutiful dromedaries and guide were captured in this timeless photograph. It encapsulates the realization of a decades-long dream: the Morocco of my dreams really does exist and is more spectacular than I imagined. This photograph was taken with my Samsung WB800F Smart Camera, and 23-mm wide-angle, 21x optical-zoom lens. Not coincidentally it is now being professionally refurbished for sand-related damage.
MDs, submit a photo! Please send photos along with a 150- to 300-word article to: Doctor’s Review, Photo Finish, 400 McGill Street, 4th Floor, Montreal, QC H2Y 2G1.
Doctor’s Review • APRIL 2014
The speed of 2 or 3 day dosing
in Actinic Keratosis is here
Picato® Gel (ingenol mebutate) is indicated for topical treatment of non-hyperkeratotic, non-hypertrophic actinic keratosis (AK) in adults. Relevant Warnings & Precautions • Severe Local Skin Responses (LSRs) including erythema, flaking/scaling, crusting, swelling, vesiculation/pustulation, and erosion/ulceration can occur after topical application • Severe eye disorders, including periorbital edema, eyelid edema, eye edema, eye pain, and eyelid ptosis, occurred more frequently in patients treated with Picato® Gel than vehicle, and may result from spreading of application site edema • Administration of Picato® Gel is not recommended until the skin is healed from treatment with any previous medicinal product or surgical treatment • Contact with skin outside the treatment area should be avoided • Picato® Gel is for topical use only but should not be used near the eyes, on the inside of the nostrils, on the inside of the ears, or on the lips • Picato® Gel must not be ingested • Avoid the use of Picato® Gel during pregnancy • Nursing mothers should avoid physical contact between her newborn/infant and the treated area for 6 hours after application • The efficacy of Picato® Gel in the prevention of squamous cell carcinoma (SCC) associated with actinic keratosis (AK) has not been studied • Clinical data on re-treatment and treatment of more than one area is not available • Clinical data on treatment in immunocompromised patients is not available
Demonstrated efficacy Median % reduction in lesion count at day 57:1 for face and scalp - 87% (study 1) and 83% (study 2)* for trunk and extremities - 75% (study 3) and 69% (study 4)†
Complete clearance at day 57:1 for face and scalp; 47% for Picato® Gel vs. 5% for placebo gel (study 1) and 37% for Picato® Gel vs. 2% for placebo gel (study 2) (p<0.001)* for trunk and extremities; 42% for Picato® Gel vs. 5% for placebo gel (study 3) and 28% for Picato® Gel vs. 5% for placebo gel (study 4) (p<0.001)†
Once daily dosing: 3 days - face & scalp, 2 days - trunk & extremities 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. 1. Picato® product monograph, January 30 2013. *Two multi-centre, double-blind, randomized, parallel-group, vehicle-controlled, clinical studies of AK patients evaluating the efficacy and safety of Picato® Gel 0.015% applied once daily on the face or scalp to a 25cm2 area of skin for 3 consecutive days in adult patients. Efficacy measurements included
®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
complete clearance rate and median percent reduction compared to vehicle control assessed at day 57 in Study 1 (PEP005-025) (Picato® Gel N=142, Placebo Gel N=136) and Study 2 (PEP005-016) (Picato® Gel N=135, Placebo Gel N=134) (8 weeks). †Two multi-centre, double-blind, randomized, parallel-group, vehiclecontrolled, clinical studies of AK patients evaluating the efficacy and safety of Picato® Gel 0.05% applied once daily on trunk and extremities to a 25cm2 area of skin for 2 consecutive days in adult patients. Efficacy measurements included complete clearance rate and median percent reduction compared to vehicle control assessed at day 57 in Study 3 (PEP005-028) (Picato® Gel N=100, Placebo Gel N=103) and Study 4 (PEP005-014) (Picato® Gel N=126, Placebo Gel N=129) (8 weeks).
A MATCH MADE FOR OA VIMOVO unites powerful OA efficacy with the reduction of NSAID-associated gastric ulcer risk VIMOVO (naproxen/esomeprazole) is indicated for the treatment of the signs and symptoms of osteoarthritis (OA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and to decrease the risk of developing gastric ulcers in patients at risk for developing NSAID-associated gastric ulcers.
Clinical use: VIMOVO is not recommended for initial treatment of acute pain because the absorption of naproxen is delayed (as with other modified release formulations of naproxen). VIMOVO, as an NSAID, does NOT treat clinical disease or prevent its progression. VIMOVO, as an NSAID, only relieves symptoms and decreases inflammation for as long as the patient continues to take it. Evidence from naproxen clinical studies and postmarket experience suggest that use in the geriatric population is associated with differences in safety. For patients with an increased risk of developing cardiovascular (CV) and/or gastrointestinal (GI) adverse events, other management strategies that do NOT include the use of NSAIDs should be considered first. Use of VIMOVO should be limited to the lowest effective dose for the shortest possible duration of treatment in order to minimize the potential risk for cardiovascular or gastrointestinal adverse events. Contraindications: • The peri-operative setting of coronary artery bypass graft surgery (CABG) • Women in the third trimester of pregnancy or who are breastfeeding
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• Patients with severe uncontrolled heart failure • Patients with known hypersensitivity to substituted benzimidazoles • Patients with history of asthma, urticaria, or allergic-type reactions after taking ASA or other NSAIDs • Patients with active gastric/duodenal/peptic ulcer or active gastrointestinal bleeding • Patients with cerebrovascular bleeding or other bleeding disorders • Patients with inﬂammatory bowel disease • Patients with severe liver impairment or active liver disease • Patients with severe renal impairment or deteriorating renal disease • Patients with known hyperkalemia • Children and adolescents less than 18 years of age Most serious warnings and precautions: Risk of cardiovascular (CV) adverse events: Naproxen, which is a component of VIMOVO, is a non-steroidal anti-inﬂammatory drug (NSAID). Use of some NSAIDs is associated with an increased incidence of CV adverse events (such as myocardial infarction, stroke or thrombotic events), which
can be fatal. This risk may increase with duration of use. Patients with CV disease or risk factors for CV disease may be at greater risk. Caution should be exercised in prescribing NSAIDs such as naproxen to any patient with ischemic heart disease, cerebrovascular disease, congestive heart failure (NYHA II-IV) and/or renal disease. Use of NSAIDs such as naproxen can result in increased blood pressure and/or exacerbation of congestive heart failure. Randomized clinical trials with VIMOVO have not been designed to detect differences in CV events in a chronic setting. Therefore, caution should be exercised when prescribing VIMOVO. Risk of gastrointestinal (GI) adverse events: Use of NSAIDs such as naproxen is associated with an increased incidence of GI adverse events (such as ulceration, bleeding, perforation and obstruction of the upper and lower gastrointestinal tract). Special Populations: Caution should be exercised in prescribing VIMOVO during the first and second trimesters of pregnancy.
Other relevant warnings and precautions: • Patients with haemophilia, platelet disorders, ASA-intolerance, or who are frail or debilitated • Women attempting to conceive • Concomitant use with: other non-ASA NSAIDs; NSAIDs containing naproxen; clopidogrel; anticoagulants; methotrexate; atazanavir; nelfinavir • Hypomagnesaemia, hypokalemia, hypocalcemia, blood dyscrasias and antiplatelet effects • Hepatic, renal and genitourinary impairment • Neurologic adverse events, including blurred or diminished vision, decreased alertness or depression • Infection, risk of masking signs and symptoms of infection and skin reactions For more information: Consult the Product Monograph at www.azinfo.ca/ vimovo/pm846 for important information relating to adverse reactions, drug interactions and dosing information. The Product Monograph is also available by calling AstraZeneca Canada Inc. at 1-800-668-6000.