October 2017 by Doctor's Review

Get thee to a monastery!

MEDICINE ON THE MOVE

Cape Town charms

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

OCTOBER 2017

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HONKY TONK HEAVEN

Hildegardâ&#x20AC;&#x2122;s good medicine Fun Turkish food Switching depression medications

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Indications and clinical use: BREO® ELLIPTA® (fluticasone furoate/vilanterol) 100/25 mcg and BREO® ELLIPTA® 200/25 mcg are indicated for the once-daily maintenance treatment of asthma in patients aged 18 years and older with reversible obstructive airways disease. BREO® ELLIPTA® is not indicated for patients whose asthma can be managed by occasional use of a rapid onset, short duration, inhaled beta2-agonist or for patients whose asthma can be successfully managed by inhaled corticosteroids along with occasional use of a rapid onset, short duration, inhaled beta2-agonist. BREO® ELLIPTA® is not indicated for the relief of acute bronchospasm. Contraindications: • Patients with severe hypersensitivity to milk proteins. • In the primary treatment of status asthmaticus or other acute episodes of asthma. Most Serious Warnings and Precautions: ASTHMA-RELATED DEATH: Long-acting beta2adrenergic agonists (LABA), such as vilanterol, increase the risk of asthma-related death. Physicians should only prescribe BREO® ELLIPTA® for patients not adequately controlled on a long-term asthma control medication, such as an inhaled corticosteroid, or whose disease severity clearly warrants initiation of treatment with both an inhaled corticosteroid and a LABA. Once asthma control is achieved and maintained, assess the patient at regular intervals and do not use BREO® ELLIPTA® for patients whose asthma can be adequately controlled on low- or medium-dose inhaled corticosteroids. Other Relevant Warnings and Precautions: • BREO® ELLIPTA® should not be used for the relief of acute symptoms of asthma (i.e., as rescue therapy for the treatment of acute episodes of bronchospasm). • Patients who have been taking a rapid onset, short duration, inhaled bronchodilator on a regular basis (e.g., q.i.d) should be instructed to discontinue the regular use of these drugs and use them only for symptomatic relief if they develop acute symptoms while taking BREO® ELLIPTA®.

• BREO® ELLIPTA® should not be initiated in patients with acutely deteriorating asthma, which may be a life-threatening condition. • Exacerbations may occur during treatment. Patients should be advised to continue treatment and seek medical advice if symptoms remain uncontrolled or worsen after initiation of therapy. • BREO® ELLIPTA® should not be used more often than recommended, at higher doses than recommended, or in conjunction with other medicines containing a LABA, as an overdose may result. • Caution in patients with cardiovascular disease: vilanterol can produce clinically significant cardiovascular effects in some patients as measured by an increase in pulse rate, systolic or diastolic blood pressure, or cardiac arrhythmias such as supraventricular tachycardia and extrasystoles. In healthy subjects receiving steady-state treatment of up to 4 times the recommended dose of vilanterol (representing a 10-fold higher systemic exposure than seen in patients with asthma) inhaled fluticasone furoate/vilanterol was associated with dose-dependent increases in heart rate and QTcF prolongation. Use with caution in patients with severe cardiovascular disease, especially coronary insufficiency, cardiac arrhythmias (including tachyarrhythmias), hypertension, a known history of QTc prolongation, risk factors for torsade de pointes (e.g., hypokalemia), or patients taking medications known to prolong the QTc interval. • Effects on Ear/Nose/Throat: localized infections of the mouth and pharynx with Candida albicans have occurred. • Endocrine and Metabolic effects: possible systemic effects include Cushing’s syndrome; Cushingoid features; HPA axis suppression; growth retardation in children and adolescents; decrease in bone mineral density. • Hypercorticism and adrenal suppression (including adrenal crisis) may appear in a small number of patients who are sensitive to these effects. • Adrenal insufﬁciency: particular care should be taken in patients transferred from systemically

active corticosteroids because deaths due to adrenal insufficiency have occurred during and after transfer to less systemically available inhaled corticosteroids. • Bone effects: decreases in BMD have been observed with long-term administration of products containing inhaled corticosteroids. • Effect on growth: orally inhaled corticosteroids may cause a reduction in growth velocity when administered to children and adolescents. • Monitoring recommendations: serum potassium levels should be monitored in patients predisposed to low levels of serum potassium. Due to the hyperglycemic effect observed with other betaagonists, additional blood glucose monitoring is recommended in diabetic patients. Monitoring of bone and ocular effects (cataract and glaucoma) should be considered in patients receiving maintenance therapy. Patients with hepatic impairment should be monitored for corticosteroid effects due to potentially increased systemic exposure of ﬂuticasone furoate. • Use with caution in patients with convulsive disorders or thyrotoxicosis and in those who are unusually responsive to sympathomimetic amines. • Hematologic effects: may present with systemic eosinophilic conditions, with some patients presenting clinical features of vasculitis consistent with Churg-Strauss syndrome. Physicians should be alerted to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. • Hypersensitivity effects: immediate hypersensitivity reactions have occurred after administration, and patients should not be re-challenged with BREO® ELLIPTA® if it is identified as the cause of the reaction. There have been reports of anaphylactic reactions in patients with severe milk protein allergy with other inhaled dry powder drug products containing lactose. • Immune effects: greater susceptibility to infections. Administer with caution and only if necessary in patients with active or quiescent tuberculosis infections of the respiratory tract; chronic or

Find out if it’s a fit for your asthma patients.

Covered by all provincial formularies (special authorization)*

untreated infections such as systemic fungal, bacterial, viral, or parasitic; or ocular herpes simplex. Chickenpox and measles can have a more serious or even fatal course in susceptible patients using corticosteroids. In such patients who have not had these diseases or been properly immunized, particular care should be taken to avoid exposure. • Ophthalmologic effects: glaucoma, increased intraocular pressure, and cataracts. Close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts. • Respiratory effects: paradoxical bronchospasm may occur with an immediate increase in wheezing after dosing. This should be treated immediately with a rapid onset, short duration inhaled bronchodilator. BREO® ELLIPTA® should also be discontinued immediately, the patient assessed, and alternative therapy instituted if necessary. The incidence of pneumonia in patients with asthma was uncommon. Patients with asthma taking BREO® ELLIPTA® 200/25 mcg may be at an increased risk of pneumonia compared with those receiving BREO® ELLIPTA® 100/25 mcg or placebo. • Drug interactions: caution should be exercised when considering coadministration with inhibitors of cytochrome P450 3A4; inhibitors of P-glycoprotein (P-gp); sympathomimetic agents; beta-adrenergic receptor blocking agents; non-potassium sparing diuretics (i.e., loop or thiazide diuretics); drugs that prolong the QTc interval (e.g., monoamine oxidase inhibitors and tricyclic antidepressants); xanthine derivatives; and acetylsalicylic acid. Adverse Events: Adverse reactions reported at a frequency of ≥1% and more common than placebo in one clinical study of BREO® ELLIPTA® 100/25 mcg included: nasopharyngitis, oral candidiasis, upper respiratory tract infection,

headache, dysphonia, oropharyngeal pain, epistaxis. Adverse reactions reported at a frequency of ≥1% in another clinical study of BREO® ELLIPTA® 200/25 mcg and BREO® ELLIPTA® 100/25 mcg also included the following additional adverse reactions: inﬂuenza, bronchitis, sinusitis, respiratory tract infection, pharyngitis, cough, rhinitis allergic, abdominal pain upper, diarrhea, toothache, back pain, pyrexia, muscle strain. Dosage and Method of Administration: The recommended dose of BREO® ELLIPTA® 100/25 mcg or 200/25 mcg is one oral inhalation once daily, administered at the same time every day (morning or evening). Do not use more than once every 24 hours. The starting dose is based on patients’ asthma severity. For patients previously treated with low- to mid-dose corticosteroid-containing treatment, BREO® ELLIPTA® 100/25 mcg should be considered. For patients previously treated with mid- to high-dose corticosteroid-containing treatment, BREO® ELLIPTA® 200/25 mcg should be considered. After inhalation, patients should rinse their mouth with water (without swallowing). If a dose is missed, the patient should be instructed not to take an extra dose, and to take the next dose when it is due. Dosing Considerations: • For optimum beneﬁt, advise patients that BREO® ELLIPTA® must be used regularly, even when asymptomatic. • Once asthma control is achieved and maintained, assess the patient at regular intervals and do not use BREO® ELLIPTA® for patients whose asthma can be adequately controlled on low- or medium-dose inhaled corticosteroids.

• No dosage adjustment is required in patients over 65 years of age, or in patients with renal or mild hepatic impairment. • Caution should be exercised when dosing patients with hepatic impairment as they may be more at risk of systemic adverse reactions associated with corticosteroids. Patients should be monitored for corticosteroid-related side effect. For patients with moderate to severe hepatic impairment, the maximum daily dose is 100/25 mcg. For More Information: Please consult the Product Monograph at gsk.ca/breo/en for important information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374. *Quebec Code RE41: For treatment of asthma and other reversible obstructive diseases of the respiratory tract, in persons whose control of the disease is insufficient despite the use of an inhaled corticosteroid (ramq.gouv.qc.ca/en/regie/ legal-publications/Pages/list-medications.aspx)

02012 02/17

“It clicked when my doctor and I discussed Trulicity .” ®

• • •

Once-weekly dosing Ready-to-use pen† Preattached, hidden needle†

*Fictitious patient. May not be representative of all patients.

Trulicity 1.5 mg demonstrated A1c reduction comparable to liraglutide in a non-inferiority, open-label study. ‡§

Change from baseline in A1c at 26 weeks: Trulicity 1.5 mg + metformin, -1.4, liraglutide + metformin, -1.4; p<0.001 for non-inferiority. Trulicity is indicated for the once-weekly treatment of adult patients with type 2 diabetes mellitus to improve glycemic control, in combination with: • diet and exercise in patients for whom metformin is inappropriate due to contraindication or intolerance. • metformin, when diet and exercise plus maximal tolerated dose of metformin do not achieve adequate glycemic control. • metformin and a sulfonylurea, when diet and exercise plus dual therapy with metformin and a sulfonylurea do not achieve adequate glycemic control. • prandial insulin with metformin, when diet and exercise plus basal or basal-bolus insulin therapy (up to two injections of basal or basal plus prandial insulin per day) with or without oral antihyperglycemic medications, do not achieve adequate glycemic control.

Clinical use:

Contraindications: • Patients with a personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) • Pregnant and nursing women Most serious warnings and precautions:

Risk of thyroid C-cell tumours: In male and female rats, dulaglutide causes dose-dependent and treatment duration-dependent thyroid C-cell tumors after lifetime exposure. Patients should be counseled regarding the risk and symptoms of thyroid tumors. Other relevant warnings and precautions: • Heart rate increase • Prolongation of PR interval • Hypoglycemia (in combination with a secretagogue or prandial insulin) • Systemic hypersensitivity, including postmarketing reports of serious reactions (e.g., anaphylactic reactions and angioedema) • Pancreatitis • Systematic hypersensitivity • Not studied in pediatric patients • No dose adjustment required in patients over 65 years of age • Hepatic or renal impairment • Recent myocardial infarction, unstable angina and congestive heart failure For more information:

Please consult the product monograph at www.lilly.ca/TrulicityPM/en for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling us at 1-888-545-5972. Reference: 1. Trulicity Product Monograph. Eli Lilly Canada Inc., June 15, 2017. †

Clinical significance has not been established.

‡

The recommended starting dose for Trulicity is 0.75 mg once-weekly.

26-week, randomized, open-label, parallel group, multicentre, active-controlled, phase III non-inferiority study. Patients received either 1.5 mg Trulicity once weekly (n=299; baseline A1c 8.1%) or 1.8 mg liraglutide once daily (n=300; baseline A1c 8.1%). Treatment was added to background therapy with metformin (≥1500 mg/day). All n-values refer to intent-to-treat population. Primary endpoint was change in A1c from baseline to week 26 between once-weekly Trulicity and once-daily liraglutide.

Travel heartbreak Dr Michael Roberts writes about his visit to Cape Town and environs in this issue. It’s well worth a read for any doctor planning a trip to South Africa. The setting is spectacular, the surrounding country is beautiful, the flora and fauna quite wonderful. A nice place to visit but, as the saying goes, I wouldn’t want to live there. South Africa wasn’t a happy place when I last visited 10 years ago and it’s not happy now. Consider this: last month three councillors from the ruling African National Congress (ANC) were gunned down as they sat in a car in KwaZulu-Natal. Since 2016, there have been at least 40 politically motivated killings in the province. The party, which is riddled with corruption top to bottom, is led, for the time being, by Jacob Zuma who hails from there. There will be an election for new national leaders in December. The fighting and killing inside the party is largely about who gets government work —unemployment is stuck around 50 percent. In the 1980s, fighting between the ANC and the Inkatha Freedom Party left an estimated 20,000 dead. In the Glebelands hostel complex near Durban as many as 20,000 are crammed into horrific housing built during apartheid that the ANC has done nothing to improve. A commission has been appointed to look into killing in the province, but little is expected to come of it. Observers suggest that there will be no changes unless and until the ANC is out of power. On a different note, another physician, Mel Borins, a longtime DR contributor, visits Nashville and, somewhat to his surprise, finds a thriving arts culture there away from the honky tonk strip. That’s not to say he doesn’t take in the twangy side of Music City only to find his toe tapping. I get that; I’ve long been a fan of country and western music, and have survived more than one attack of the lovesick-blues to prove it. As a kid, I listened to the stuff at night under the covers and it stuck. I still get a kick out of a sad George Jones lyric sung in appropriately mournful tones as in “He stopped lovin’ her today...” (the day of his funeral, that is). In the C&W world, the titles often succinctly tell the whole story as in one of my faves: “She got the goldmine and I got the shaft!” Have an excellent fall and don’t take your guns to town, ya hear. ALEXKICH / SHUTTERSTOCK.COM

Trulicity has not been studied in combination with basal insulin. Trulicity is not a substitute for insulin. Trulicity should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis.

PP-DG-CA-0016

David Elkins, publisher and editor delkins@parkpub.com

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@doctorsreview OCTOBER 2017 • Doctor’s

Review

New LIXIANA®:

Helping patients along the journey of stroke prevention in AF LIXIANA® (edoxaban) is indicated for: › Prevention of stroke and systemic embolic events in patients with atrial fibrillation (AF), in whom anticoagulation is appropriate. › Treatment of venous thromboembolism (VTE) (deep vein thrombosis [DVT], pulmonary embolism [PE]) and the prevention of recurrent DVT and PE.

In the prevention of stroke and systemic embolic events in AF (primary composite endpoint), LIXIANA® 60 mg (30 mg dose-reduced):* • Demonstrated NON-INFERIORITY vs. warfarin

› Event rate of 1.18% vs. 1.50% per year seen with LIXIANA® 60 mg (30 mg dose-reduced*) vs. warfarin (mITT – on-treatment†)‡,1,2 HR (97.5% CI): 0.79 (0.632, 0.985); p<0.0001 for non-inferiority§

• Component scores (% per year) seen with LIXIANA® 60 mg (30 mg dose-reduced*) vs. warfarin‡ › First ischemic stroke: 0.87 vs. 0.93 HR (95% CI): 0.94 (0.75, 1.19)

› First hemorrhagic stroke: 0.26 vs. 0.49 HR (95% CI): 0.53 (0.36, 0.78)

› First systemic embolic events: 0.05 vs. 0.08 HR (95% CI): 0.62 (0.26,1.50)

• Significantly LOWER rates of MAJOR BLEEDING events demonstrated vs. warfarin

› Adjudicated event rate of 2.75% vs. 3.43% per year seen with LIXIANA® 60 mg (30 mg dose-reduced*) vs. warfarin (mITT – on-treatment†)‡,¶,1,2 HR (95% CI): 0.80 (0.71, 0.91); p=0.0009

Bleeding: LIXIANA® increases the risk of bleeding and can cause serious, potentially fatal bleeding. LIXIANA®, like other anticoagulants, must be used with caution in patients with increased risk of bleeding. Patients at high risk of bleeding should not be prescribed LIXIANA®. Should severe bleeding occur, treatment with LIXIANA® must be discontinued and the source of bleeding investigated promptly. Close clinical surveillance is recommended throughout the treatment period, especially in the presence of multiple risk factors for bleeding. ASA: acetylsalicylic acid; CI: confidence interval; CrCL: creatinine clearance; HR: hazard ratio; mITT: modified intent-to-treat; NSAID: nonsteroidal anti-inflammatory *In the study, patients receiving verapamil, quinidine, or dronedarone concomitantly with LIXIANA® had their dosing regimens halved. The recommended dose of LIXIANA® is 30 mg once daily in patients with concomitant use of P-gp inhibitors other than amiodarone and verapamil. †mITT population included only subjects who received at least one dose of study drug; the on-treatment period was the period during which the subject took study drug unless the patient had early drug discontinuation(s), in which case the on-treatment period included the 3 days following drug discontinuation(s). ‡Event rate (%/yr) is calculated as number of events/subject-year exposure. §The two-sided p-value is based on the non-inferiority margin of 1.38. ¶A major bleeding event (the primary safety endpoint), as defined by ISTH (International Society of Thrombosis and Haemostasis), was a clinically overt bleeding event that met one of the following criteria: fatal bleeding; symptomatic bleeding in a critical site such as retroperitoneal, intracranial, intraocular, intraspinal, intra-articular, pericardial, or intramuscular with compartment syndrome; a clinically overt bleeding event that caused a fall in hemoglobin of at least 2.0 g/dL (or a fall in hematocrit of at least 6.0% in the absence of hemoglobin data), when adjusted for transfusions (1 unit of transfusion = 1.0 g/dL drop in hemoglobin). **Please see Product Monograph for complete dosing and administration information.

® Registered trademark of Daiichi Sankyo Co., Ltd. Used under license.

DAILY

Convenient one pill, once-daily dosing, taken with or without food**

Clinical use Not recommended for use in children < 18 years. Contraindications › Clinically significant active bleeding, including gastrointestinal bleeding › Lesions or conditions at increased risk of clinically significant bleeding, e.g., recent cerebral infarction (hemorrhagic or ischemic), active peptic ulcer disease with recent bleeding, patients with spontaneous or acquired impairment of hemostasis › Hepatic disease associated with coagulopathy and clinically relevant bleeding risk › Concomitant treatment with any other anticoagulant, including: » unfractionated heparin (UFH), except at doses used to maintain a patent central venous or arterial catheter; » low molecular weight heparins (LMWH), such as enoxaparin and dalteparin; » heparin derivatives, such as fondaparinux; and » oral anticoagulants, such as warfarin, dabigatran, apixaban, rivaroxaban except under circumstances of switching therapy to or from LIXIANA® › Pregnancy › Nursing women Most serious warnings and precautions Premature discontinuation: PREMATURE DISCONTINUATION OF ANY ORAL ANTICOAGULANT, INCLUDING LIXIANA®, INCREASES THE RISK OF THROMBOTIC EVENTS. To reduce this risk, consider coverage with another anticoagulant if LIXIANA® is discontinued for a reason other than pathological bleeding or completion of a course of therapy. INR: Although LIXIANA® therapy will lead to an elevated INR, INR is not a valid measure to assess anticoagulant activity of LIXIANA®. INR is only calibrated and validated for vitamin K antagonists (VKA) and should not be used for any other anticoagulant, including LIXIANA®. Peri-operative spinal/epidural anesthesia, lumbar puncture: Risk of epidural or spinal hematoma is increased by use of indwelling catheters or concomitant use of drugs affecting hemostasis. Indwelling epidural or intrathecal catheters must be removed ≥ 5 hours prior to the first dose of LIXIANA®. Risk may also be increased by traumatic or repeated epidural or spinal puncture. If traumatic puncture occurs, administration of LIXIANA® should be delayed for 24 hours.

Other relevant warnings and precautions › Concomitant use of drugs affecting hemostasis may increase the risk of bleeding, such as aspirin, P2Y12 platelet inhibitors (i.e. clopidogrel, prasugrel, and ticagrelor), other antithrombotic agents, fibrinolytic therapy and chronic NSAIDs; long-term concomitant use is not recommended › Concomitant use with UFH is not recommended except at doses used to maintain a patent central venous or arterial catheter › Concomitant use of low dose (≤ 100 mg/day) ASA or thienopyridines (clopidogrel) and NSAIDs increased rates of clinically relevant bleeding › Not recommended in patients with prosthetic (mechanical or biological) heart valves or those with hemodynamically significant rheumatic heart disease, especially mitral stenosis › Not recommended in patients with severe hepatic impairment; caution in patients with mild to moderate hepatic impairment › A specific anticoagulant reversal agent for LIXIANA® is not commercially available › Not recommended in patients with severe renal impairment (CrCL ≤ 30 mL/min). Patients who develop acute renal failure while on LIXIANA® should discontinue treatment. › Peri-operative/procedural considerations › Following an invasive procedure or surgical intervention, restart LIXIANA® as soon as adequate hemostasis has been established and the clinical situation allows › Not recommended for prevention of VTE in patients who have undergone elective total knee or hip surgery › Not recommended as an alternative to UFH in patients with PE who are hemodynamically unstable or may receive thrombolysis or pulmonary embolectomy › Not recommended for treatment and/or prevention of VTE in patients with active cancer For more information Please consult the Product Monograph at https:// health-products.canada.ca/dpd-bdpp/index-eng. jsp for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-363-6093. Please visit www.servier.ca/references/ LIXIANA_EN.pdf to access the study parameters and reference list.

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

Servier Canada Inc. 235, boulevard Armand-Frappier, Laval, QC H7V 4A7

LIPR0117E

edoxaban tosylate monohydrate tablets

contents OCTOBER 2017

30 COVER: F11PHOTO / SHUTTERSTOCK.COM

features 26 Cape Town charms An MD and his wife experience the Western Cape’s highs and lows, from its beaches and mountains and more by Dr Michael Roberts

Nashville strikes a chord

The best art and culture in Music City, plus heartbreak lyrics and honky tonk to get your toes tapping by Dr Mel Borins

Sesame rings plus more famous street food from Turkey that you can replicate in your kitchen by Sevtap Yüce

A haven in Old Quebec Recharge at a wellness retreat in the historic wings of a monastery where simplicity is the ultimate luxury by Cherie DeLory

Ancient ways Five of the world’s most remarkable Indigenous tribes with traditions you may have never heard of by Camille Chin

14 6

Doctor’s Review • OCTOBER 2017

The Turkish table

36 44

HISTORY OF MEDICINE Hildegard von Bingen’s 12th-century healing ways by Tilke Elkins

PHOTO FINISH A whale of a time by Dr Dominic Dallaire

regulars

LETTERS Lyme disease: past, present, future

PRACTICAL TRAVELLER Ai Weiwei’s biggest exhibit ever opens in NYC and why Utrecht might be the most bike friendly city in the world by Camille Chin

GADGETS Does Google Home’s voice-activated speaker and assistant have a place in your home? by David Elkins

TOP 25 The best conferences scheduled for this winter

20 DEPRESSION KEYPOINTS Switching medications: a strategy for optimum outcomes by Alison Palkhivala

Coming in

November / December Budapest forward and back Hungarian culture finds a new footing Puerto Vallarta’s back After weathering the drug wars, the sun shines as always There’s more to Madeira than port Winter on the Portuguese island can be intoxicating

OCTOBER 2017 • Doctor’s

Review

LETTERS

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

Lyme disease: past, present, future

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

OFFICE MANAGER

Denise Bernier

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

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

MONTREAL HEAD OFFICE

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None of the contents of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means, without prior permission of the publishers. ISSN 0821-5758 Canadian Publications Mail Sales Product Agreement No. 40063504 Post-paid at St. Laurent, QC. Return undeliverable Canadian addresses to: Circulation Department, Parkhurst Publishing Ltd., 3 Place Ville Marie, 4th floor, Montreal, QC H3B 2E3. Subscription rates: One year (12 issues) – $17.95 Two years (24 issues) – $27.95* One year U.S. residents – $48.00 *Quebec residents add PST. All prescription drug advertisements appearing in this publication have been precleared by the Pharmaceutical Advertising Advisory Board.

Doctor’s Review • OCTOBER 2017

THE ROAD TO WELLNESS Borrelia bacteria are stealth pathogens that can dampen our immune response and hide intracellularly in immune protected locations [“Lyme disease: past, present and future,” History of Medicine, June 2017, page 21]. They have several different forms and have a very slow 21 to 23 hour reproduction rate. Success in treatment, if started late, depends on the length of treatment with several antimicrobials (for the different forms) used concomitantly and not on the dosage of a single bacteriostatic antibiotic used for brief periods of three months or less. The Dutch study used a single antibiotic that is useful only in the early stages of the disease and ended at three months. A simple case of late Lyme disease usually takes 1.5 to 2 years to treat. They were just looking for another headline to say that long-term antibiotics don’t work. Antibiotic resistance is a hospital phenomenon associated with high-dose short-term I.V. antibiotics and not long-term oral treatment used for Lyme disease. We can’t even kill this bug in a test tube with a single antimicrobial. It is like pretending to kill dandelions with the lawnmower. Evidenced based means you have to evaluate all the evidence not just the things you agree with while rejecting everything else. All decisions about Lyme disease are made behind closed doors and constitute dogma. The Canadian Lyme Disease Foundation (canlyme.com) has up-to-date sections on prevention, symptoms, di-

agnosis, treatment and news for physicians. Other sources of information are the peer-reviewed and published 2014 International Lyme and Associated Diseases guidelines (tandfonline.com/doi/ full/10.1586/14787210.2014.940900). There is an excellent free online CMEaccredited course [CFPC] on Lyme disease at lymecme.info. Rob Murray, Canadian Lyme Disease Foundation Via DoctorsReview.com

CONGRATULATIONS! The winner of an all-inclusive trip for two to Sandals Barbados is Janina Milanska, a pediatrician from Ottawa, ON. AN INSTANT SMILE Here are some of the online comments we received about the Fujifilm Instax Mini 8 camera [“A camera for instant gratification,” Gadgets, July/August 2017, page 16]: If I was lucky enough to win this, it will be very useful in the school in Kenya where I volunteer. Fingers crossed! Dr Pippa Moss

No more Kodak moments. It’s going to be Fuji fun times. Dr Amar Singh

Just what I need to give to my wife. She will absolutely love it! I love my wife and this Instax Mini 8 camera will make her love me even more! Dr Kirollos Mikail

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

C a mi lle C hi n

The bike stops here THIS PHOTO AND ABOVE COURTESY ECTOR HOOGSTAD ARCHITECTS

JJFARQ / SHUTTERSTOCK.COM

The city of Utrecht, 50 kilometres south of Amsterdam, wants to be the most bike-friendly place in the world. To become just that, the city recently opened Phase 1 of its new bike-parking facility and it’s now the largest of its kind in the world. Six thousand parking spaces are currently available over three levels; there’ll be room for 12,500 bikes when completed in 2018. Designed by Ector Hoogstad Architects, the enormous cyclepark is located below the city’s main train station (Station Square) and features a “bike trough” so cyclists can ride straight to their parking space. The cycle-park is colour-coded with electronic signals that tell users where the empty spaces are. There’ll be a repair shop and a bike-rental shop too. The facility is open 24/7; parking is free for the first 24 hours. Amazingly, many critics have said the cycle-park doesn’t go far enough to accommodate the country’s ever-increasing volume of cyclists. utrecht.nl/city-of-utrecht/living/mobility/cycling/bicycle-parking/

OCTOBER 2017 • Doctor’s

Review

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

Denmark’s house of bricks The ultimate LEGO playground opened in September. Located in Billund, Denmark, the birthplace of the beloved building brick, the new 12,000-square-metre LEGO House is made of 21 huge interlocking blocks with a large keystone at the top in the exact proportions and style of a 2x4 LEGO brick. Admission — adults and kids 3-12 $38 — gets you access to four colour-coded Experience Zones. The red zone is for creativity and free-building; the green zone for roleplaying with your own characters; blue puts cognitive skills to the test; yellow is about emotions. Ticket holders can also enter the Masterpiece Gallery to see amazing LEGO creations built by fans from around the world. The History Museum features hundreds of the most iconic LEGO sets. Visitors without tickets can play on nine rooftop playgrounds and also check out the LEGO Square lobby where the 15-metre-tall Tree of Creativity stands. It consists of 6,316,611 standard LEGO bricks and took 24,350 hours to assemble. legohouse.com.

BOWIE VERSCHUUREN

A theatre in

Doctor’s Review • OCTOBER 2017

PUBLIC ART FUND

Ai Weiwei in NYC Chinese artist Ai Weiwei has just installed numerous security fences throughout NYC and they’re likely the most beautiful fences the city has ever seen. Good Fences Make Good Neighbors, October 12 to February 11, 2018, is Weiwei’s largest exhibit to date. It consists of huge site-specific sculptural works in over 300 different locations — rooftops, in between buildings, bus shelters — including the Doris C. Freedman Plaza at Central Park, the Washington Square Arch and the Unisphere at Flushing MeadowsCorona Park in Queens. Created in collaboration with Public Art Fund to mark the 40th anniversary of the non-profit organisation, the project aims to spotlight the role of fences as psychic and physical barriers that divide us, which is at the heart of human rights issues, and debates about immigration and refugees today. In addition to the sculptures, Weiwei has also created 200 two-dimensional works that will appear on lampposts and banners in all of NYC’s five boroughs. publicartfund.org.

the Alps C

A new theatre has recently opened in Switzerland and we’re certain you’ve never seen anything like it. Julier Tower on the Julier Pass, a mountain road in the Albula Range, 2300 metres above sea level, was built in 1220 pieces using over 24,000 screws. The striking red structure can withstand winds of up to 240 kilometres per hour and can even resist dry snow avalanches — particularly impressive when you consider that the building was erected in two-and-a-half months. Huge arched windows look out onto the stunning Alpine backdrop, mountains and turquoise-coloured lakes. Natural light has been incorporated into all of the dance and opera productions, so that the end of the shows coincide with the passing of daylight, as it did in Shakespeare’s days. The theater will be dismantled in 2020. origen.ch.

CMY

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

Alone underground

DAN HUDSON

If the thought of wandering alone in a dark underground cave is your idea of an adventure, you’ll want to know more about the new six-hour Solitude excursion offered by Canmore Cave Tours in Alberta. With the company of just one guide, the tour begins with a 40-minute uphill hike on a mountain trail. Once you reach Rat’s Nest Cave, you can spend four hours exploring, photographing, meditating, or doing whatever else you want in the cave, which is named after, yes, the nests of Bushy-tailed woodrats located in the entrance. A moderate level of fitness is recommended because you’ll be climbing, crawling, sliding and wiggling your way through. Cost: $499 for two cavers. Regular group tours start at $130 per person. canmorecavetours.com/experiences/solitude.

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Doctor’s Review • OCTOBER 2017

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Google comes Home The latest electronic gadget for those who like to be in the vanguard is the voice-activated personal assistant. The device sits on a kitchen counter or convenient table in another room and is ever-ready to act on your voice commands. For these purposes I’m looking at Google Home. You may also be familiar with Echo offered by Amazon, but it’s not currently available in Canada. In any case, Home works in a similar way to voice commands on your computer or smartphone, and is compatible with both IOS and Android operating systems. Perhaps the most popular use of this device is to call up music from a streaming service. Google Home can access a variety of services, including Google Play, YouTube and Spotify. It does not stream Apple Music which is, after all, a direct competitor with Google Play. The sound quality is fine, if not exactly stunning. It’s not up to high-end systems like the ones offered by Pickering’s NAD BluOS and the Sonos but, at the price, it’s acceptable. Google is working with the CBC, Global, Sportsnet and The Weather Network to bring them to Home. But that’s only the start, using the command “Okay Google,” you can ask any question you like and it will go scurrying to the net to find the answer. Unlike Amazon’s device which confines its search to Wikipedia, Home searches

far and wide. This can be especially useful when looking for podcasts, for example. It will also allow you to use voice commands to operate the Internet of Things (IoT). It’s great, for instance, at operating the Philips Hue Smart Lights featured in an earlier Gadgets column. Google’s Nest products are a natural, naturally, as are SmartThings devices from Samsung, LIFX’s lightbulbs and Toronto-based Nanoleaf’s products. Overall, Google Home gets better reviews than the Amazon series of similar products so Canadians shouldn’t feel too bad about being ignored for the time being. A couple of cons: Home, with its two microphones (Amazon’s

Win a Google Home by entering the Gadget of the Month contest at doctorsreview.com. Echo has five), can sometimes have trouble hearing commands if you’re too far from the device and at present they can be programmed only to work with a single specific voice. Multiple voice machines are coming, but for the moment, only one person in a household can call the shots — that may be a good thing. Available from Walmart.ca or BestBuy.ca for just under $150.

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Doctor’s Review • OCTOBER 2017

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Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada 18th Annual Scientific Conference of the Canadian Spine Society spinecanada.ca

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Around the world Athens, Greece March 22-24, 2018 9th Annual Congress on Controversies in Ophthalmology: Europe comtecmed.com/cophy/2018/

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THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Mexico City, Mexico March 7-10, 2018

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2018 Annual Meeting of the International Society for the Study of Women’s Sexual Health isswshmeeting.org

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Doctor’s Review • OCTOBER 2017

Count on

for powerful symptom relief

PRISTIQ is indicated for the symptomatic relief of major depressive disorder.1

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

Demonstrated improvements in functional outcomes: work, family life and social life (secondary endpoints)2*

PRISTIQ 50 mg demonstrated signiﬁcant improvements in functional outcomes from baseline vs. placebo, as measured by the Sheehan Disability Scale (SDS).2† Work score: PRISTIQ -2.9 (n=156), placebo -2.2 (n=148), p=0.01 Family life score: PRISTIQ -3.0 (n=163), placebo -2.2 (n=160), p=0.002 Social life score: PRISTIQ -3.2 (n=163), placebo -2.3 (n=160), p=0.003 Clinical use: • PRISTIQ is not indicated for use in children under the age of 18 • The short-term efficacy of PRISTIQ has been demonstrated in placebo-controlled trials of up to 8 weeks • The efficacy of PRISTIQ in maintaining an antidepressant response for up to 26 weeks, following response during 20 weeks of acute, open-label treatment, was demonstrated in a placebo-controlled trial Contraindications: • Concomitant use with monoamine oxidase inhibitors (MAOIs) or within the preceding 14 days • Hypersensitivity to venlafaxine hydrochloride Most serious warnings and precautions: Behavioural and emotional changes, including self-harm: SSRIs and other newer antidepressants may be associated with:

•

− Behavioural and emotional changes including an increased risk of suicidal ideation and behaviour − Severe agitation-type adverse events coupled with self-harm or harm to others − Suicidal ideation and behavior; rigorous monitoring • Discontinuation symptoms: should not be discontinued abruptly. Gradual dose reduction is recommended Other relevant warnings and precautions: Concomitant use with venlafaxine not recommended Allergic reactions such as rash, hives or a related allergic phenomenon • Bone fracture risk with SSRI/SNRI • Increases in blood pressure and heart rate (measurement prior to and regularly during treatment) • Increases cholesterol and triglycerides (consider measurement during treatment) • Hyponatremia or Syndrome of Inappropriate Antidiuretic Hormone (SIADH) with SSRI/SNRI • •

Potential for GI obstruction Abnormal bleeding SSRI/SNRI • Interstitial lung disease and eosinophilic pneumonia with venlafaxine • Seizures • Angle-Closure Glaucoma • Mania/hypomania • Bipolar Disorder • Serotonin syndrome or neuroleptic malignant syndrome-like reactions • •

For more information: Please consult the Product Monograph at http://pfizer.ca/ pm/en/Pristiq.pdf for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-463-6001.

* A randomized, double-blind, parallel-group, placebo-controlled, multicentre trial involving 485 patients with MDD and a 17-item Hamilton Rating Scale for Depression (HAM-D17 ) total score ≥20, a HAM-D17 item 1 score ≥2, and a Clinical Global Impression-Severity (CGI-S) scale score ≥4. Patients were randomized to receive fixed-dose PRISTIQ 50 mg/day, PRISTIQ 100 mg/day, or placebo for 8 weeks. Primary endpoint was change from baseline to last observation carried forward (LOCF) in HAM-D17 total score. Secondary endpoints included change from baseline to LOCF in SDS individual domain scores.2

References: 1. PRISTIQ Product Monograph, Pfizer Canada Inc., October 26, 2016. 2. Boyer P, et al. Efficacy, safety, and tolerability of fixed-dose desvenlafaxine 50 and 100 mg/day for major depressive disorder in a placebo-controlled trial. Int Clin Psychopharmacol 2008;23:243-253. 3. Sheehan DV. Sheehan Disability Scale in: Rush AJ, Pincus HA, First MB, et al. eds. Handbook of psychiatric measures. Washington, DC: American Psychiatric Association; 2000:113-115.

CA0116PRI017E

† The SDS measures the functional impairment that depressive symptoms have on a patient’s work, family life and social life.2 A decrease in SDS score represents improved functional outcomes.3

DE PRESSIO N K EY PO I NT S by

A li son Pa lkhi va la

Switching antidepressants safely: a strategy for optimizing outcomes A rational, evidence-based approach

he Canadian Network for Mood and Anxiety Treatments (CANMAT) emphasizes the importance of achieving full remission whenever possible in patients with depression.1 In order to achieve that outcome successfully, a trial of more than one antidepressant is often necessary. For many clinicians, it can be difficult to determine at what point to consider switching antidepressant medication, when a response is not as desired or when tolerability is an issue. Fortunately, CANMAT offers clear guidelines on when to switch antidepressant therapy. They point out that early response to antidepressants, defined as a 20 to 30% improvement from baseline in a depression rating scale, has been shown to correlate with response and remission at 6 to 12 weeks.2 CANMAT recommends that if an antidepressant is not well-tolerated at 2 to 4 weeks, especially if the maximum dose has not yet been reached, switching antidepressants can be considered at this point. If the drug is well-tolerated but efficacy is suboptimal at 2 to 4 weeks, treatment should be optimized. This usually involves increasing the antidepressant dose as well as considering the addition of psychotherapy and/or neurostimulation strategies, if they have not already been initiated. It can also be helpful to revisit the initial diagnosis to ensure nothing was overlooked.1

Identifying the need to switch Patients with an inadequate response to optimized, maximum dose antidepressant therapy at 6 to 12 weeks can be managed either by switching antidepressants or by adding an adjunctive therapy. The decision to switch or add a medication should be individualized. Consider switching over the addition of an adjunctive medication when: • It is the first antidepressant trial. • There are poorly tolerated side effects to the initial antidepressant. • There is no response (< 25% improvement) to the initial antidepressant. • There is time to wait for a response (i.e., less severe symptomatology, less functional impairment). • The patient prefers to switch to another antidepressant.1 When switching is deemed to be the best option, taking a rational, evidence-based approach to selecting a new antidepressant can help optimize outcomes. While conclusive data are lacking, some evidence is available to guide clinical decisionmaking. Evidence for the benefits of switching patients to an antidepressant within the same class versus a different class is equivocal. Thus, CANMAT recommends switching patients to an antidepressant with evidence of better efficacy, regardless of class, as summarized in Table 1.1

Table 1. Antidepressants with evidence for superior efficacy based on meta-analyses.1 Antidepressant

Level of evidence

Comparator medications

Escitalopram

Level 1

Citalopram, duloxetine, fluoxetine, fluvoxamine, paroxetine

Mirtazapine

Level 1

Duloxetine, fluoxetine, fluvoxamine, paroxetine, sertraline, venlafaxine

Sertraline

Level 1

Duloxetine, fluoxetine, fluvoxamine, paroxetine

Venlafaxine

Level 1

Duloxetine, fluoxetine, fluvoxamine, paroxetine

Agomelatine

Level 2

Fluoxetine, sertraline

Citalopram

Level 2

Paroxetine

Doctor’s Review • OCTOBER 2017

ANDREJS PRILEPSKIS / SHUTTERSTOCK.COM

Switching strategies The four recommended strategies for switching antidepressants are: 1. Direct switch: The current antidepressant is stopped abruptly and the new antidepressant is started the next day. 2. Taper and immediate switch: The current antidepressant is tapered down gradually, and the new antidepressant is initiated as soon as the current antidepressant is discontinued completely. 3. Taper and switch after washout: The current antidepressant is tapered down gradually, and the new antidepressant is initiated after a washout period of 1 to 6 weeks (depending on the half-life of the drug being discontinued), during which time the patient takes no antidepressant medication. 4. Cross tapering: The dose of the current antidepressant is gradually tapered down while the dose of the new antidepressant is gradually tapered up.3 Selecting a switching strategy depends on multiple factors. Notably, when switching from one antidepressant to another that has potentially dangerous drug-drug interactions (e.g., when switching to or from a non-selective, irreversible monoamine oxidase inhibitor such as phenelzine or tranylcypromine), the taper and switch after washout strategy should always be employed.3 Cross tapering is a useful strategy when there is concern about drug-drug interactions, but it is not deemed advisable to have patients unmedicated for any period of time. It should be noted, however, that co-administration of certain antidepressants is absolutely contraindicated. This includes the combination of clomipramine with selective serotonin reuptake inhibitors (SSRIs), venlafaxine, or duloxetine as well as the combination of agomelatine and fluvoxamine. Cross tapering of SSRIs and tricyclic antidepressants should also be done with extreme caution.3

Cross tapering can additionally be used to minimize discontinuation symptoms from the initial antidepressant as well as short-term tolerability problems with the new antidepressant. For this reason, patients known to be sensitive to drug side effects may benefit from this approach. When switching between two antidepressants with a similar mode of action, a direct switch can often be safely employed. The one exception to this rule is switching from fluoxetine to another SSRI antidepressant. Because of the long half-life of fluoxetine, a gap of 4 to 7 days between antidepressants is recommended.3 If there is concern about discontinuation symptoms, particularly in patients who have been taking the current antidepressant for a long period of time, the taper and immediate switch can be used as an alternative to the direct switch. The taper and immediate switch approach can also be used when switching from one SSRI antidepressant to another, in order to avoid any risk of serotonin syndrome, or when switching from duloxetine to an SSRI or venlafaxine.3 There is considerable information to help guide clinicians when switching between two specific antidepressants. Clinicians can access this information through resources available online, including SwitchRx.ca and an antidepressant switch table compiled by BC Guidelines as part of their 2013 Guidelines entitled Major Depressive Disorders in Adults (Appendix D), available at http://www2.gov.bc.ca/assets/gov/health/ practitioner-pro/bc-guidelines/depress_appd.pdf. References 1. CANMAT Depression Work Group. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 3. Pharmacological treatments. Can J Psychiatry. 2016 Sep;61(9):540-60. 2. Kudlow PA, McIntyre RS, Lam RW. Early switching strategies in antidepressant non-responders: Current evidence and future research directions. CNS Drugs. 2014;28:601-609. 3. Luft B. Antidepressant switching strategies. Graylands Hospital Drug Bulletin North Metropolitan Health Services - Mental Health. 2013;20(1). OCTOBER 2017 â&#x20AC;˘ Doctorâ&#x20AC;&#x2122;s

Review

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

T i lk e Elk i n s

Feminist doctor of the Middle Ages Hildegard von Bingen was ahead of her time — and ours too

welfth century German mystic, composer, theologian and natural scientist, Hildegard von Bingen was, by some accounts, also the first female physician to practice in Europe. She is credited with authoring

Though there is some doubt about Hildegard’s reading skills, she hardly needed them because she said God spoke to her directly.

Doctor’s Review • OCTOBER 2017

volumes of detailed treatments for various illnesses, drawn from a vast body of knowledge about herbalism and disease. How did she pull this off eight centuries before modern feminists began to use her as an argument that women should be admitted to medical school? To the modern eye, her spiritual purity seems to have been matched by a keenly strategic approach to the maledominated universe she inhabited. A recipient of visions of God’s eternal light throughout her often bed-ridden childhood, Hildegard kept her mouth shut about her dialogue with the Divine until she was 42, likely aware of the dangers that might befall her if she were to be disbelieved. Given by her wealthy parents as a gift to the church at age eight, she was placed in the care of a nun named Jutta who ran a Benedictine monastery which focused on the virtues of prayer and silent meditation. Then, a few years after Jutta’s death, Hildegard received divine instructions that it was time to break the silence about her secret affair with the Holy Spirit and, “Write down that which you see and hear.” What followed was years of radical words and deeds that no other woman dared broach until many centuries later. She wrote about the anatomical details of the female orgasm. She claimed

Von Bingen’s interpretation of the universal man bears a surprising resemblance to Leonardo da Vinci’s version some five centuries later.

She kept her mouth shut about chats with the Divine until she was 42 that men and women were of equal and inseparable importance to each other, and that Eve was not to be blamed for succumbing to the Serpent’s guile. She shook her finger at the corruption of the church and went on preaching tours even though it was illegal for women to do so. A hundred years before the church admitted that housing nuns and monks together might not serve the best interests of the vul-

nerable nuns who couldn’t hide the effects of unwilling trysts, von Bingen insisted on moving her nuns to their own monastery in Ruperstberg, Her excuse for all this misbehavin’? The “Voice of the Living Light” made her do it. Once she “came out” as an instrument of God’s visions — a delicate and lengthy process that involved the approval of Pope Eugenius — she gained a widespread following of devotees

and much more heft when it came to getting her (ahem, God’s) way. But just to make sure no one got the wrong idea about her rise to eminence, she often repeated what a feeble, unlearned woman she was, “completely incapable of Biblical exegesis,” and referred to herself as a member of the “weaker sex” — wise woman that she was. Technically speaking, she was, in fact, unlearned — she never learned to write though she probably could read. This wasn’t much of an impediment, however, as with the help of scribemonks, she produced three volumes of visionary theology, dozens of musical compositions for use in liturgy, the musical morality play Ordo Virtutum, which is credited by some as the first opera ever written, two volumes of material on natural medicine and cures, and nearly 400 letters addressed to popes, emperors, abbots and abbesses which make up one of the largest surviving body of letters from the Middle Ages. In 2012, after 833 years of fencesiting, the Roman Catholic Church finally saw fit to name her a Doctor of the Church, making her one of only four women to receive the honour, ever. Pope Benedict XVI called Hildegarde “perennially relevant,” and it is this relevance that continues, remarkably, to keep her diverse and wide-ranging ideas popular to this day — particularly her ideas about healing. The monastery’s herb garden and infirmary were the basis of Hildegard’s medicinal writings, which she did not OCTOBER 2017 • Doctor’s

Review

NEW

THE FIRST AND ONLY TISSUE-SELECTIVE ESTROGEN COMPLEX (TSEC) * 1

FOR THE TREATMENT OF MODERATE TO SEVERE VASOMOTOR SYMPTOMS

A New Option in hormone therapy for women with a uterus

A purposeful pairing of conjugated estrogens (CE) with the selective estrogen receptor modulator (SERM) bazedoxifene (BZA)1*

DUAVIVE demonstrated: Significant reduction in the number and severity of average daily moderate to severe hot flushes (from baseline to week 12, n=122) vs. placebo (n=63)1† Mean change for number was -7.63 vs. -4.92 and -0.87 vs. -0.26 for severity, p<0.001 for both Incidence of breast pain and change in breast density shown not to be significantly different from placebo Incidence of breast pain at Weeks 9-12: 9% vs. 6%, respectively1‡ Mean percentage change in breast density from baseline after 1 year of treatment: -0.49 vs. -0.51, respectively1

Indications and clinical use: DUAVIVE is indicated in women with a uterus for the treatment of moderate to severe vasomotor symptoms associated with menopause. DUAVIVE should not be taken with a progestin, additional estrogens or selective estrogen receptor modulators (SERMs). Not recommended for women >75 years of age. Not indicated for pediatric use. Contraindications: • Active or past history of confirmed venous thromboembolism (VTE) or active thrombophlebitis • Active or past history of arterial thromboembolic disease • Hypersensitivity to estrogens

Low incidence of endometrial hyperplasia1§ In clinical studies up to 2 years’ duration, <1% incidence of endometrial hyperplasia or malignancies observed (0% and 0.30% at year 1, 0.68% at year 2) Cumulative amenorrhea rates similar to placebo1‡§ In SMART 1, cumulative amenorrhea at Year 1 was 83% in women treated with DUAVIVE, similar to placebo (85%). In SMART 5, cumulative amenorrhea at Year 1 (Cycle 1 to 13th), was 88% with DUAVIVE, similar to placebo (84%).

• Undiagnosed abnormal genital bleeding • Known, suspected, or past history of breast cancer • Known or suspected estrogen-dependent malignant neoplasia • Liver dysfunction or disease as long as liver functions tests have failed to return to normal • Endometrial hyperplasia • Known protein C, protein S, or antithrombin deficiency or other known thrombophilic disorders • Known or suspected pregnancy, women who may become pregnant, and nursing mothers • Partial or complete loss of vision due to ophthalmic vascular disease CA0117DUA010E

Most serious warnings and precautions: Risk of stroke and deep vein thrombosis: estrogen-alone therapy (mean age 63.6 years). Therefore, estrogens with or without progestins: • Should not be prescribed for primary or secondary prevention of cardiovascular diseases • Should be prescribed at the lowest effective dose and for the shortest period possible for the approved indication Other relevant warnings and precautions: • Possible risk of ovarian cancer • Monitor blood pressure with hormone replacement therapy use • Caution in patients with otosclerosis • Caution in women with pre-existing endocrine and metabolic disorders • Caution in patients with rare hereditary galactose intolerance • Abnormal vaginal bleeding • May increase pre-existing uterine leiomyomata • May exacerbate previous diagnosis of endometriosis • May increase the risk of VTE • Risk of gallbladder disease • Caution in patients with history or liver and/or biliary disorders • Caution in women with hepatic hemangiomas • Angioedema • Caution in women with systemic lupus erythematosus • Cerebrovascular insufficiency • May exacerbate epilepsy • Fluid retention • Not recommended in renal impairment • Not recommended in premenopausal women • Women with higher BMIs (≥30 kg/m2) may exhibit decreased bazedoxifene which may be associated with an increased risk of endometrial hyperplasia For more information: Please consult the Product Monograph at http://pfizer.ca/pm/en/duavive.pdf for important information relating to adverse reactions, drug interactions and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-463-6001. * Clinical significance has not been established. † SMART 2: 12-week, double-blind, placebo-controlled trial in 318 women who had 7 moderate to severe hot flushes/day or ≥50/week at baseline who were randomized to DUAVIVE (n=127), CE 0.625 mg/BZA 20 mg (n=128), or placebo (n= 63). Primary endpoint assessed efficacy of vasomotor symptom relief. ‡ SMART 1: 24-month, double-blind, placebo- and active-controlled dose-ranging trial of 3397 women who were randomized to DUAVIVE (n=433), raloxifene 60 mg or placebo. Women took calcium and vitamin D (Caltrate 600 + D™) daily. Primary endpoint was the incidence of endometrial hyperplasia; secondary endpoint was the treatment of vasomotor symptoms. § SMART-5: 12-month, double-blind, placebo- and active-controlled trial of 1843 women who were randomized to DUAVIVE (n=445), CE 0.625 mg/BZA 20 mg (n=474), BZA 20 mg (n=230), conjugated estrogens 0.45 mg / medroxyprogesterone acetate (MPA) 1.5 mg (n=220) or placebo (n=474). Women also took calcium, 600 mg and vitamin D, 400 IU daily. Reference: 1. DUAVIVE Product Monograph. Pfizer Canada Inc., October 20, 2014.

Ad #:

DUA-2017-08-E

She thought emotional trauma might be the root of chronic illness A grotto in a garden shows von Bingen in her element surrounded by flowers, herbs and medicinal plants.

ascribe to divine dictation. She had a wealth of practical skills in diagnosis, prognosis and treatment, and is thought to have gained much of her medicinal knowledge from the monastery’s extensive medical library. Her first medical text, Physica, describes the medicinal properties of a variety of plants, stones, animals, fish and reptiles, while the second volume, Causae et Curae, explores the human body and how its various conditions can be healed through empathy with the natural world. An impassioned belief in the connections between humans and all life sets the works of Hildegard apart from the usual medieval compendium of odd-sounding herbs and animal parts. She writes, “Everything that is in the heavens, on earth and under the earth is penetrated with relatedness.” Then, sounding positively 21st century, she declares: “The earth which sustains humanity must not be injured. It must not be destroyed!” Statements like these have made her something of a darling of the New Age movement, the field of naturopathy in particular. Sadly, though, many things done in her name have been accompanied by overpriced products for

under-proven treatments. There are aspects of medieval medicine that just don’t translate to the modern age — injunctions to avoid socalled poisonous foods like strawberries and plums while embracing a diet of spelt, chestnuts and fennel seed tea, not to mention the fondness for bloodletting. But there is one focus in Hildegard’s writing that is taken increasingly seriously today: the idea that emotional trauma may be the root of chronic illness. Working within the medieval fourhumours system — blood, yellow bile, black bile and phlegm — Hildegard categorizes emotional disturbance as melanche, or black bile. Rather than uu CONTINUED ON PAGE 47

MEDICAL QUIPS Get off the meds One of the first duties of the physician is to educate the masses not to take medicine. —Sir William Osler

OCTOBER 2017 • Doctor’s

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I P RE S C R I B E A TRIP TO... SOUTH AFRICA

Cape Town charms An MD and his wife explore the Western Cape’s beaches, mountains, deserts and so much more by Dr Michael Roberts

he Western Cape is a marvellous wonderland that lets the imagination run wild with windswept oceanscapes, arid deserts, nearby wine lands, hints of African safari and traces of Europe in Cape Town. San Bushmen, the Khoikhoi, Dutch and British have all inhabited the province. She has born witness to immense happiness and hardship. There are countless people involved in her history: Diaz, Da Gama, Van Riebeeck its Dutch colonial founder, Rhodes the British Victorian villain or visionary, and more recently Nelson Mandela and the African National Congress (ANC). During our recent visit, we were awed by the magnificent topographic setting of Table Mountain in Cape Town, which is bounded on three sides by the Southern Atlantic and Indian Ocean. We ventured to the mythical tip of Africa at Cape Point and the Cape of Good Hope. It’s no surprise that humans have found this a space for rest and renewal for millennia. Cape Town is a city swallowed up by its topography, from the green and verdant British colonial structures hugging mountain slopes to the California-like, glass-and-steel low rises edging into rocky watery outcrops to the colourful, but sadly infamous Cape Flats township shacks. It’s hard not to feel transformed by this great city, a magical and unusual land filled with contrasts between mountain and sea, African bush and desert, extreme social class divides and race. ALL PHOTOS COURTESY CARRIE CLARK

Lion’s Head is one of Cape Town’s most popular mountains to climb.

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Dr Michael Roberts is a family physician in Toronto. This was his first trip to Africa. He and his wife Carrie have travelled to and written about Europe, the Caribbean, South East Asia, South Pacific and New Zealand. Future travel plans include the Galapágos and Machu Picchu.

Photographer Carrie Clark strikes a pose at Hout Bay near Cape Town.

There are plenty of surprises at Richard Branson’s Vineyard in Franchshoek.

Cape Town’s geography and architecture seems to be a microcosm of the history of South Africa itself. Visiting the City Bowl, one is awed by the majesty of the Old Dutch and colonial British European style of the grand structures: City Hall, the Slave Lodge Museum, the Great Synagogue. The centre of town is lined with bucolic pedestrian walkways and the lovely Company’s Garden has been replenishing ocean seafarers since the 17th century. Everyone’s voices were hushed walking amongst the gracious cycads, palms and ancient pine trees. Sir Cecil Rhodes bequeathed Kirstenbosch Gardens (sanbi.org/gardens/kirstenbosch) on the southern slopes of Table Mountain, the largest and most diverse botanical gardens of the Southern Hemisphere. Here one finds Van Riebeeck’s infamous thorn fence

intended to prevent the migratory black Khoikhoi from venturing into the fledgling white Dutch colony of 1620. The gardens were created after all the native timber was cut down for shipmen’s fuel and mast poles. The leafy and Provençal vineyard of Constantia (constantiavalley.com) seems stuck in time with Cape Dutch châteaux on facing mountain slopes. Then there’s the suburb of Clifton with its glass condos for the rich and famous meandering down mountain sides to the South Atlantic’s sheltered beaches and the suburb of Camps Bay (campsbaytourism.com), a cross between South Beach and Malibu with highend bars and bistros serving gastronomic delights while impoverished teenaged Zulu dancers perform on the roadside for Yuppie delight. The soaring Cable Mountain is only a cable car ride away. Its presence never disappoints and only becomes more wondrous as its tablecloth of mist envelops the mountain’s crest in the late afternoon, adorning the entire city with a playful mystery. There is Bo Kaap, the colourful Malay district, the haunting desolation of District Six, the once thriving intercultural part of town now only acknowledged by a museum, and the Caribbean Haute Bay, a former fishing village that has been swallowed by Cape Town’s sprawl.

BEYOND CAPE TOWN During my visit, I found myself pondering the Western Cape’s present-day chapter: how has she fared since Nelson Mandela’s tear-filled revolutionary proclamation OCTOBER 2017 • Doctor’s

Review

You can lunch or dine al fresco at the Groot Constantia Wine Estate.

for the end of apartheid at Cape Town’s City Hall over 20 years ago? While apartheid is over, Cape Town still feels like a divided city based on social class. There are warnings galore about danger and crime, and many urban myths about venturing into the Cape Flats during the day or night. Visitors have to be mindful all the time, applying logic and commonsense as you would travelling in any developing country. Sadly, you only have to experience the Western Cape’s self-imposed sunset curfew to realize that not all is safe and peaceful. When we finally left Cape Town, we headed to the remarkable wine country, which is as authentic as France or Italy. Beautiful glistening vineyards amidst towering mountains… On the edge of the city and every town are the Townships with an unimaginable landscape of shacks with a sad, but vibrant life of their own. We were told life is better in this other world than during the days of apartheid. In Franschhoek (franschhoek.org.za), a gracious and prosperous former Huguenot colony, there is a small town filled with large atmospheric country inns. We hiked amidst the cypress and lavender to Richard Branson’s vineyard where we met Derrick, a young black waiter with fine British manners wearing a torn pair of shoes. He didn’t know where Toronto was except when we told him it is where Drake lives. Derrick was delighted and insisted we give Drake his SA regards. We then travelled on Highway 62 — a kind of South African Route 66 — through the Little Karoo at the edge of a great desert and visited frontier

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Many of the Cape Flats communities remain poverty stricken.

towns like Montagu with its thermal pools and Barrydale with its hippie eateries. We even stopped at Ronnie’s Sex Shop, a cowboy bar in the middle of nowhere. The temperature was in the mid 30s when we arrived in Oudtshoorn (oudtshoorn.com), an isolated Victorian town in the desert. It’s also the ostrich capital of the world. The grand old agricultural town is a trip back in time with wide boulevards and the aging British manors of turn-of-the-century ostrich barons. North of Outdshoorn is the Swartberg pass. It’s the highest pass in SA and runs into badlands on the way to Prince Albert, an oasis of a Cape Dutch town. We travelled southward to the Garden Route, encountering a baboon family scurrying across the road and eventually the wild Indian Ocean breaking along the coast filled with windswept beaches.

The steep cliffs of the Cape of Good Hope help shield Diaz Beach.

On the edge of the city are the Townships with an unimaginable landscape of shacks with a sad, but vibrant life of their own There were hints of dolphins and ancient jungle forests where wild elephants previously roamed. The Garden Route takes one through lovely towns like Wilderness with its freshwater lagoon and 12-kilometre-long beach, Knysna with its estuary, oysters and old-growth forests, and Plettenberg where South African affluence meets surfing culture. It culminates in Tsitsikamma National Park (tsitsikamma.info). Here the proportions of nature’s bounty and fury intensify with the crashing waves amidst isolated mountainscapes at Nature’s Valley and Storms River mouth. One is transformed by this magical and unusual land filled with contrasts between mountain and sea, jungle and desert, extreme social class divides and race. If you are looking for an adventure filled with history and lessons for humankind, make your way to the Western Cape, South Africa. For more info on travel to the region, visit Cape Town Tourism (capetown.travel) and South Africa Tourism (southafrica.net/za/en/articles/overview/ western- cape).

The kitschy sites along Highway 62 will keep you entertained.

Cape Town’s Bo-Kaap neighborhood was formerly known as the Malay Quarter.

OCTOBER 2017 • Doctor’s

Review

Nashville strikes a chord An MD visits Music City and finds art and culture beyond all the honky tonk — but he likes that too

F11PHOTO / SHUTTERSTOCK.COM; PATSY CLINE IMAGE COURTESY PATSY CLINE MUSEUM

by Dr Mel Borins

Doctor’s Review • OCTOBER 2017

PHOTO COURTESY GRAND OLE OPRY

Carrie Underwood hit the big time in 2005 with her album Some Hearts and now she’s a regular at the Grand Ole Opry.

here are lots of surprises in Nashville. Music City is a destination for those who just love music of almost any kind — as long as it has a country twang. Whether you enjoy hearing live music or

want to immerse yourself in country music history, Nashville is the place to go. Begin with a stroll down Lower Broadway, better known as Honky Tonk Highway. Live music spills out from a multitude of pubs and joints with names like Tootsie’s Orchid Lounge, Rippy’s Bar and Grill, Legends Corner and Nudie’s Honky Tonk. It’s all music, all the time from 10am ’till closing time at 3am. Even if country and western music is not your shot of bourbon, you can’t help but be caught up in the love fest of performers, and just being there where so much American music history has been made. The heartbreak lyrics, fiddles and banjos, and the sheer exuberance of the place had even me tapping my toes by the end of my four-day visit. Don’t leave Nashville without taking in a show at Nashville’s Grand Ole Opry (opry.com), the world’s longest running radio show. At the Opry, you get to enjoy some of country music’s rising stars. Since starting as a radio show in 1925, it has seen performances of all the great country stars. If you can swing it, go backstage, see the dressing

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rooms and perhaps even meet some of the movers and shakers of this Nashville tradition. For guitar addicts, The Gallery of Iconic Guitars (thegigatbelmont.com) at Belmont University is a must. Here you’ll learn about the history of guitar making, and get to see some famous instruments including Martins and Fenders and Gibsons, and even play a few old models known for their beautiful sounds. The Country Music Hall of Fame and Museum (countrymusichalloffame.org) located in downtown Nashville is another must see. One exhibit features my favourite songwriter, Bob Dylan, and his relationship with Johnny Cash, and the Nashville Cats. It also houses the Johnny Cash Museum (johnnycashmuseum. com) and the recently opened Patsy Cline Museum (patsymuseum.com). The music is the big draw, but there’s more to Music City than, well, music. In the late 1800s, Nashville’s Vanderbilt University was a centre for philosophy and learning. It gave the city its other enduring nickname, the Athens of the South. A full-scale replica of the Parthenon in Athens

PHOTO COURTESY PATSY CLINE MUSEUM

Recall all those old heartbreaks when you visit a recreation of Patsy Cline’s room at her eponymous museum.

Six-string reveries abound at The Gallery of Iconic Guitars.

was built in 1897 as part of Tennessee’s Centennial Exposition. Located in Centennial Park just west of downtown, today it’s The Parthenon art museum (nashville.gov/parks-and-recreation/parthenon.aspx). The collection of 19th- and 20th-century American paintings are worth a peek, but what you don’t want

F11PHOTO / SHUTTERSTOCK.COM

PHOTO COURTESY THE GALLERY OF ICONIC GUITARS

Alan LeQuire’s nearly full-sized replica of gilded Athena Parthenos stands nearly 13 metres tall.

to miss is local artist Alan LeQuire’s meticulous recreation of the Athena Parthenos, which first graced the original Parthenon in 447 BCE and remained there until it was dismantled by the Romans in the 5th century. At almost 13 metres tall, it’s the tallest indoor statue in the Western Hemisphere and was OCTOBER 2017 • Doctor’s

Review

At The Gallery of Iconic Guitars you can learn about guitar making and play a few old instruments with beautiful sounds Arts Crawl with an opportunity to meet local artists. For garden lovers and fanciers of turn-of-thecentury architecture, there’s Cheekwood (cheekwood. org). Once the private estate of the Cheek family of Maxwell House coffee fame, it’s now home to 22 hectares of botanical gardens, a sculpture garden and a museum of contemporary and decorative art, paintings and sculptures. The mansion is very well preserved and shows what it was like to be wealthy in Nashville in the 1930s. If you’re a foodie, then Nashville has some special restaurants. Le Sel (leselnashville.com) offers fine French-style food as well as more modern creations. Grab a pint of local beer at The Filling Station (brewstogo.com), which features 24 craft beers on tap, with rotating seasonal selections. Enjoy a coal fire dinner at Nicky’s Coal Fired Grill (nickysnashville.com) where dishes are cooked in a four-ton oven. Coal-fired pizzas are the focal point of Nicky’s menu along with great tasting house-made pastas and antipasto selections. Another highlight of my visit was the Bluebird Café (bluebirdcafe.com). Enjoy a meal while watching songwriters performing original material in an intimate “in the round setting.” Feast on a true Tennessean BBQ treat at Martin’s Bar-B-Que (martinsbbqjoint.com), and enjoy classic Lebanese dishes and friendly service at Epice (epicenashville. com). You won’t go hungry in Nashville.

The author visited sculptor LeQuire in his studio, which includes a small mockup of his controversial Musica with its naked dancers.

Doctor’s Review • OCTOBER 2017

MEL BORINS

crafted by LeQuire in 1990 and covered in 24-carat gold leaf in 2002. The sculpture bears a striking resemblance to the original and gives visitors the impression that they are truly inside an ancient place of worship. I had the good fortune to visit the sculptor at his gallery and preview his new work titled Monument to Women’s Suffrage. LeQuire works are well known in the southeast for his public commissions and sensitive portraiture. One of his better-known creations is Musica, a 12-metre-tall bronze that features nine naked male and female figures dancing in a circular composition. It was unveiled in 2003 and sits on a grassy knoll in a traffic circle in the Music Row area. The undressed nature of the dancers caused immediate controversy with Christian fundamentalists on one side and defenders of art on the other. In the end, the privately funded $1.1 million monument was allowed to remain. In recent years, pranksters have clothed the statues as part of St. Patrick’s Day celebrations. Meeting the remarkable artist and seeing his work was one of the highlights of my visit. If you’re interested in art, other venues worth a look are The Arts Company, Tinney Contemporary and The Rymer Gallery on 5th Avenue (nashvilledowntown.com/ go/fifth-avenue-district). There’s also the Frist Center for the Visual Arts (fristcenter.org) located in the former US Post Office building downtown. On the last Saturday of every month, the art community has an

There are many reasons to take in the Farmer’s Market, but they don’t get any better than the fresh-baked sourdough bread.

Indulge in a plate of enormous ribs at Martin’s Bar-B-Que.

JOSIAH TRUE / SHUTTERSTOCK.COM

Honky tonk the night away on Lower Broadway at one of a great many joints like this one.

All the national chains have hotels in Nashville and there’s an active AirBnB community. For something a little different, try the Urban Cowboy B&B (urbancowboybnb.com; from US$195 a night). Opened three years ago in a refurbished mansion by a couple from Brooklyn, it’s already a go-to spot for artists and musicians. For more info on travel to the city, visit the Nashville Convention and Visitors Corporation (visitmusiccity.com).

Book into an out-of-the-ordinary room at the Urban Cowboy B&B (pictured) and then take yourself to the party downstairs (right).

PHOTOS COURTESY URBAN COWBOY

PHOTO.UA / SHUTTERSTOCK.COM

WHERE TO STAY

The wellness retreat offers massage treatments and relaxation classes.

Authentic rooms in former “cells” are filled with antique furniture.

his is not your average wellness retreat. For starters, it’s a former nunnery in a

meticulously maintained heritage building dating back to 1639 with a chapel and the opportunity to sleep in the same cozy cells where the nuns slept. It consists of the same dormer window seats, the same antique furniture, the same weathered ceiling beams, and the same miniature doors leading to the rooms. There are no televisions or telephones. Oh, and nuns live here, too. I’ve watched the box office success A Nun’s Story, starring Audrey Hepburn as a conflicted nun experiencing life in a convent. Now, I’m getting a tiny glimpse into what it was like to live behind the cloistered walls of a monastery. Once you set foot inside the modern glass addition to the centuries-old Le Monastère des Augustines (monastere.ca/en; from $84 per person) in the heart of Old Quebec City, a splendid magic happens. First, I noticed a luminosity, then a lingering woodsy smell with a hint of je ne sais quoi. I was later told it’s a blend of botanicals curated from the apothecary garden and available in the gift shop. The blend of essential oils was inspired by a blend the Augustinian sisters made in the early 17th century to “soothe the atmosphere around the monastery and the HôtelDieu.” It was called Parfum de Sanctuaire. While making my way to the front desk, I noticed oversized lock keys artistically displayed on the wall. As it turns out, they’re the actual keys once used in the monastery to open cabinets, chests, cell doors and the like. When I’m handed my modern keycard, I’m intrigued that I’d soon be exploring a space that was for centuries closed off to the world, and is now not only a wellness retreat, but a living

PHOTOS COURTESY LE MONASTÈRE DES AUGUSTINES UNLESS OTHERWISE NOTED

The monastery’s modern glass addition showcases the building’s ancient wings.

A haven in

Old Quebec Recharge at a wellness retreat in the historic wings of a monastery where simplicity is the ultimate luxury by Cherie DeLory

One of the building’s old turrets now serves as the reception desk.

When I’m handed my modern keycard, I’m intrigued that I’d soon be exploring a space that was for centuries closed off to the world museum and window to the past. Rest assured, if you’re looking for peace, you’ll find it here. There’s an enduring history of caring at Le Monastère des Augustines. The Augustinian Order is the pioneer of healthcare in Canada. In 1639, France’s King Louis XIII sent three Augustinian sisters on a mission to start the first of 12 convent hospitals in Canada, the first in North America, north of Mexico. Hôtel-Dieu de Québec is the first hospital they opened, located adjacent to the monastery, with a private entrance connecting the buildings.

Central to the ambiance of the monastery is the museum, showcasing the history of all 12 monasteries and hospitals in Quebec, and the evolution of medicine. In the 17th century, if a young girl dreamed of becoming a nurse, she had to become a nun. My renovated room on the fourth floor faced the stone hospital with the apothecary garden courtyard below. Herbs and plants were an important aspect of holistic medicine, a practice that prevails today. A public archive office is located inside the monastery, available by appointment for specific research needs. OCTOBER 2017 • Doctor’s

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The new glassed-in reception hall was designed to reflect the monastery’s openness.

You can speak to the nuns if you wish, but do so en français with a simple “Bonjour” and a smile There you’ll find patient records and daily journals scribed by the nuns. Take time to explore the corridors. History is everywhere. There’s the sloping staircase next to the once omnipresent bell that would ring for wake up and meals. What used to be the main doors to the convent are now cocooned by the new addition. Nuns were cloistered, meaning they could not go outside and leave the convent. Ever. They couldn’t show their face to the outside world either. The main doors have a mail slot and voice box, and a

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turning shelf (tour), which visitors used to give and receive items. It was not uncommon to find babies on the tour left in the care of nuns. On the third floor there’s a recreation of a furnished cell. On my way to interpretive dance class in the basement vault, I noticed a display of cannons that were found on the property after the British conquest on the Plains of Abraham in 1759. This is a secular retreat, but its Catholic roots cannot be ignored. In its infancy, there were around 350 Augustinian sisters living here. Today, there are

CHERIE DELORY

fewer than 12, with an average age of 84 —plus Sister Sarah MacDonald, a 35-year-old from Sudbury, ON. It’s not uncommon to spot a sister browsing in the gift shop, walking in the garden or making her way in or out of the private living quarters through a stained glass entrance next to the dining area. You can speak to the nuns if you wish, but do so en français with a simple “Bonjour” and a smile. You may also attend morning mass or the Vespers, an evening choir service at 5pm daily in the chapel. In the tradition of caring for mankind, the Augustinian sisters are sharing their once-private haven with the secular world. Now there’s the spa I mentioned (reflexology recommended), wellness seminars, nutrition experts, yoga, meditation, dance, Pilates and tai chi. If all this isn’t enough, you can enjoy the private walled gardens or explore the intimate winding streets of Old Quebec City, a UNESCO World Heritage Site and the only North American city whose walls still exist. The Marché du Vieux-Port and Château Frontenac are within easy walking distance, and restaurants and boutiques are a two-minute walk in what some refer to as the Latin Quarter. I began my mornings with a 7:00 am group awakening exercise: gentle stretches and meditation. The classes are bilingual, so it was fun to practice my French. At breakfast, the monastic tradition of eating in silence is recognized. I looked forward to my peaceful breakfasts. I don’t like to talk much in the morning anyway, so it was energizing to sit with my own thoughts and gaze out the window towards the St. Lawrence River, while enjoying the buffet breakfast which included berries, nuts, homemade breads, and delicious raspberry-and-chocolate cashew yogurt. (Don’t leave without trying the yogurt!) There’s so much to like about the monastery. The calming ambiance, exemplary cuisine and holistic philosophy are comforting. Also satisfying is that guests are ultimately stewards of this not-forprofit’s social and cultural mission to preserve the heritage of the Augustinian sisters, and to promote its services and foster wellbeing to as many people as possible. At the adjoining hospital, rooms are reserved for members of the medical community and family members visiting patients — the Hôtel-Dieu de Québec is a teaching hospital that specializes in cancer treatments. There’s even a program that allows caregivers to stay at the monastery. “If we look at the name of the hospital,” says Sister Sarah, “Hôtel-Dieu, literally God’s Hotel, we believe that we are welcoming God in the presence of each person that we care for.”

The boutique is open to the public from 7am to 9pm.

Everything from the ancient vaults to the attic has been completely restored.

There are 40,000 artifacts drawn from 12 monastery hospitals in the museum.

Ancient ways Five of the world’s most remarkable Indigenous tribes with traditions you’ve probably never heard of

CHANWIT WHANSET / SHUTTERSTOCK.COM

by Camille Chin

KAZAKHS, MONGOLIA The Kazakhs of Mongolia’s Bayan-Ölgii, the country’s westernmost province on the border of both Russia and China, are avid hunters in winter, but they don’t use anything close to firearms. Wild golden eagles are their weapons of choice, which they capture as babies from nests or as adolescents using a net. Berkutchi, or Kazakh eagle hunters, prefer female eagles; they’re larger and more aggressive than males, and more loyal. Together the pair, saddled on a short stocky Mongolian horse, hunt foxes, rabbits and hares with thick, soft winter fur. Golden eagles have wingspans of two metres and descend on prey at 250 kilometres per hour. They kill quickly by applying up to 700 pounds of pressure with their razor-sharp claws. Each hunter keeps his eagle for 10 years before releasing her back into the wild. There are roughly 100,000 Kazakhs in Mongolia.

Doctor’s Review • OCTOBER 2017

HULI,

PAPUA NEW GUINEA

In the Tari region of Papua New Guinea, the eastern half of the world’s second largest island, it’s the young men that primp their hair all day. The tradition of growing tall wigs to be dyed and decorated with parrot feathers is an important stage in becoming a Huli man. It takes 18 months to grow a wig using your own hair; some are for every day, others for ceremonial use. Holy water is sprinkled three times daily to keep the hair soft; a neck rest with an adjustable wooden bar prevents the horrors of bed head in the morning. All of a man’s headdresses must be created before he’s married. The Huli, with a population of 90,000, consider themselves descendants of one common ancestor Huli, son of Hela, and have lived in their current location, north of Australia, for 1000 years. They fight over land, pigs and women.

AMY NICHOLE HARRIS / SHUTTERSTOCK.COM

Kazakh eagle hunters keep each bird for 10 years before releasing her into the wild for her remaining 20 years of life.

The Huli are culturally a warring people so they favour bright face paint to intimidate their opponents. OCTOBER 2017 • Doctor’s

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When rounding up a herd of 10,000, every person in the Nenets camp, even children, can recognize their reindeer’s faces.

NENETS, RUSSIA

VLADIMIR KOVALCHUK / SHUTTERSTOCK.COM

The Nenets of Siberia’s Arctic, population about 40,000, can confirm that reindeer are real — and not just figments of Santa’s imagination. The nomadic people are reindeer herders complete with handmade sleighs. They live in the Yamalo-Nenets Autonomous Okrug where temperatures can drop to 50˚C below. They migrate northwards in summer, back south in winter, covering more than 1500 kilometres over frozen lakes and treeless tundra each year. Their coats and tents are made from reindeer hide, threaded together with reindeer sinew. Lassos are crafted from reindeer tendons, tools and sleigh parts from bone. Reindeer meat is eaten raw, frozen or boiled, the fresh blood is rich in vitamins. Rising temperatures and melting permafrost are threatening the Nenets’ way of life. Herders have been forced to change centuries-old migration routes to ensure that reindeer have snow to walk on. The animals have also been starving because of changes in vegetation.

HIMBA, NAMIBIA Remote Kaokoland, in northwestern Namibia, is one of the last remaining wilderness areas in South Africa. Beginning from puberty, Himba girls paint their skin, and braid and coat their hair with a paste of red ochre and butter. Likened to the red of the earth and to blood, the “body butter” has been said to protect their skin from the sun and to repel insects. But the Himba themselves, population 30,000 to 50,000, have reportedly admitted it’s for aesthetics, a traditional makeup that women apply each morning. What’s more, Himba women don’t ever wash with water. A custom that developed during the area’s many droughts when only the men would wash, Himba women use aromatic plants and resins to take daily smoke baths. For a full body cleanse, they cover themselves with a blanket so that they sweat even more.

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The beaded anklets that Himba men and women wear serve a practical purpose: they protect wearers from getting snakebites.

RAFAL CICHAWA / SHUTTERSTOCK.COM

The reeds that the Uros use to construct their islands are partially edible, tasting like non-sweet sugarcane.

UROS, PERU

FRANCESCO DE MARCO / SHUTTERSTOCK.COM

The Uros of southeastern Peru walk on water every day. Descendants of the first settlers of the Altiplano, an inhospitable high-altitude land of fire and ice that stretches from Peru to Bolivia, the small tribe live on floating islands in Lake Titicaca that they made themselves using buoyant totora reeds. The ground is soft and squishy, and the wet reeds rot at the bottom and have to be constantly replenished from the top, but that hasn’t deterred about 1500 Uros from making a life on the lake near Puno, Peru. The islands that are closer to the shore have become slightly theatrical since tourists began visiting in the 1990s, but what isn’t exaggerated is that these people fled to the water centuries ago. They were discriminated against by the Incas and Spaniards, and with no claims to land, they made their own, and built homes and boats to match.

OCTOBER 2017 • Doctor’s

Review

Sesame rings.

The Turkish table Three traditional dishes that you can replicate in your own kitchen Recipes by Sevtap Yüce

Photos by Alicia Taylor

hef and restaurant owner Sevtap Yüce was born in Ankara, the capital of Turkey. In her latest cookbook Turkish Fire, she reminisces about

childhood road trips to freshwater springs. Her mother, father, sisters and brothers would load their big blackand-red Chevrolet with a gas burner, barbecue, plastic bottles for collecting water, blankets, plates, cutlery, meat, salads, tea and raki, and hit the road. On arrival, her father, who was from the small village of Çorum, would cook the meat while everyone else chopped tomatoes, green peppers, cu-

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cumbers and parsley into bite-sized pieces, and made tea with the fresh spring water. So began Yüce’s relationship with food — food that she says never tasted as good again. Today, married and living in Australia, Sevtap wants to show readers how to eat their way through slightly busier modern days, with traditional street-style dishes for your own family, big or small. These are some favourites.

RED LENTIL SOUP WITH MILK (Sütlü mercimek çorbası) There are loads of different Turkish red lentil recipes and this is just one of them. If you’re driving through the night and you stop at a roadhouse, you’ll see many people eating this soup before the main course. Sometimes they eat it for breakfast as a cure for hangovers. ¹⁄³ c. (80 ml) olive oil 1 large onion, diced 1 tbsp. (15 ml) plain all-purpose flour 1 tbsp. (15 ml) tomato paste (concentrated puree) ½ c. (125 ml) red lentils 1 tbsp. (15 ml) pul biber (see note below), plus extra for sprinkling 1 c. (250 ml) milk

1 free-range egg yolk, lightly beaten, for brushing ¹⁄³ c. (80 ml) sesame seeds, for sprinkling 9 oz. (250 g) unsalted butter, at room temperature ¼ c. (60 ml) milk ¼ c. (60 ml) olive oil 1 tbsp. (15 ml) mahlab (see note below) 2 tbsp. (30 ml) caster (superfine) sugar pinch of sea salt 2 c. (500 ml) plain all-purpose flour

Preheat the oven to 350°F (180°C). Set aside the egg yolk and sesame seeds. Put all the other ingredients in a large bowl and mix together to make a dough (using your hands is easiest). Allow to rest for about 10–15 minutes.

Heat the olive oil in quite a large saucepan. Fry the onion over a medium heat for 5–6 minutes, or until soft. Add the flour and tomato paste. Cook, stirring, for 5 minutes. Now add the lentils, pul biber and 2 cups (500 ml) water. Season with sea salt and freshly ground black pepper, and bring to the boil, then reduce the heat and simmer for 20 minutes, or until the lentils are tender. Stir in the milk and cook for a further 5 minutes, until heated through. Serve as is, sprinkled with a little extra pul biber or, if you wish, you can blend it to a smooth soup before serving. Serves 4. Note: Pul biber is a crushed red powder made from dried Aleppo peppers. It’s mild to medium in heat, and the Turkish love sprinkling it over just about anything. If you can’t find it in spice shops or Middle Eastern grocery stores, you can use chili flakes instead.

SESAME RINGS (Kandil simit)

Five holy nights each year, the mosques throughout Turkey are all lit up brightly and special prayers are made. Each of these holy evenings are known as Kandil (meaning “candle”). For these special religious celebrations, you buy or make these little babies to share with your loved ones. Red lentil soup with milk.

Divide the dough into 12 equal pieces, then roll each piece into a cigar, about 4 inches (10 cm) long, and 1 inch (2.5 cm) in diameter. Form each cigar into a circle by joining the two ends and pinching them together, making a bagel shape. Brush each circle with the egg yolk and sprinkle with the sesame seeds. Place on a baking tray and bake for 30 minutes, or until golden brown. Enjoy warm, fresh from the oven. Makes 12. Note: Mahlab (also labelled mahaleb, mahlep, mahleb or St. Lucie kernels) is a fragrant spice powder ground from the small seeds inside the pits of the wild, sour mahaleb cherry. You’ll find it in spice emporiums and Middle Eastern grocery stores.

BEEF DUMPLINGS WITH GARLIC YOGURT AND PAPRIKA BUTTER (Mantı) This dish is a labour of love, but amazingly delicious. Invite some friends over when you make these, and perhaps drink some wine — but not too much, or it will take twice as long! Because this makes a large quantity, it’s possible to freeze the dumplings before baking. Pull them out of the freezer before you leave for work and leave them to thaw; you can then come home after a hard day’s work, pop them into the oven and bake as directed. For the dumplings 2½ c. (625 ml) plain all-purpose flour 1 tsp. (5 ml) sea salt 1 free-range egg, lightly whisked ¹⁄³ c. (80 ml) cold water

¼ c. (60 ml) olive oil, plus extra for greasing garlic yogurt to serve (recipe follows) For the filling 7 oz. (200 g) ground beef 1 brown onion, peeled and grated 2 tbsp. (30 ml) finely chopped, flat-leaf (Italian) parsley For the paprika butter 2 oz. (60 g) butter 1 tbsp. (15 ml) sweet paprika

Sift the flour and salt into a bowl. Make a well in the centre, then add the egg, cold water and olive oil. Using your hands, mix together to make a dough. Turn out onto a floured surface and knead well for about 15 minutes, until the dough is elastic and soft, and feels like your earlobe. Oil the bowl and return the dough to it. Cover with a damp cloth and allow to rest for 1 hour at room temperature.

Preheat the oven to 340°F (170°C). Put all the filling ingredients in a bowl, season with sea salt and freshly ground black pepper, and mix together. Turn the dough out onto a wellfloured surface. Knead for 5 minutes, then divide into halves. Cover one half with a damp cloth while you work with the other half. Roll out the dough using a thin rolling pin. You want the dough to be as thin as possible — maybe as thick as two sheets of paper. Now cut into squares about 2 inches (5 cm) across. Spoon a tiny teaspoon of filling onto each square. Lift each corner and pinch together to create a little bow at the peak of the dumpling. Place each dumpling on a floured surface as you finish making the first batch, then use the second dough portion and the remaining filling to make as many of these delicious morsels as you can. Place the dumplings in a well-oiled baking dish and bake for 20 minutes, or until the edges turn slightly brown. Remove from the oven, then pour 4 cups (1 L) boiling water over the dumplings. Cover with foil and bake for another 15–20 minutes, or until the water is absorbed and the dumplings are soft. Meanwhile, make the paprika butter by gently melting the butter in a small saucepan and stirring the paprika through. Leave to infuse until needed. Transfer the dumplings to serving plates and generously dollop with garlic yogurt. Drizzle with the paprika butter and serve. Serves 10 generously.

Garlic yogurt 2 garlic cloves, peeled 1 tbsp. (15 ml) sea salt 2 c. (500 ml) plain (Greek-style) yogurt

Crush the garlic cloves to a smooth paste using a mortar and pestle. Gently fold the garlic and salt through the yogurt; don’t stir too vigorously as you don’t want the yogurt to liquefy. Cover and refrigerate until required; the garlic yogurt is best served cold, as it tends to get a little runny at room temperature. Makes 2 cups (500 ml). Recipes and photos from Turkish Fire: Street Food and Barbecue from the Wild Heart of Turkey (Hardie Grant Books, 2015). Beef dumplings with garlic yogurt and paprika butter.

A 12th-century depiction of a von Bingen vision of the hierarchy of the angelic choir.

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HISTORY OF MEDICINE uu CONTINUED FROM PAGE 25

regarding the body as a broken machine and asking the question — “What’s wrong and how do I fix it?” — Hildegard likens the body to a plant, filled with an electric life force she calls “veriditas” or “the greening,” and asks, “What’s in the way of veriditas, and what can I do to strengthen it? Dr Victoria Sweet, a California physician and scholar who has been inspired by the works of Hildegard, has written several books on the subject. She sees this acknowledgement of the psychological history of one’s patients as an intriguing component of Hildegard ’s viewpoint, drawing an analogy of a doctor as a gardener instead of a mechanic. “Slow Medicine” is the term Dr Sweet has coined for this approach, which she says is a much-needed companion for the “Fast Medicine” that is the focus of medicine today. Fast Medicine, she says, is essential for responding to emergencies, such as heart attacks and road accidents. Chronic illnesses, however, may respond better to a more drawn-out treatment where doctors take the time to make personal connections with patients and tend to them as though they were plants. She

Her Ordo Virtutum is credited by some as the first opera ever written calls this the “Efficiency of Inefficiency,” pointing to studies which show that spending extra time with patients saves significant costs in the long run and often leads to improved outcomes. Hildegard von Bingen was so far ahead of her time that the current catalog of her influences continues to grow. Think of her next time you read about the benefits of chlorophyll, the healing power of music, the urgent need for a healthy planet, or cancer treatment centres with herb gardens. While some proponents of retrospective medicine claim that her visions were merely the product of severe hallucinatory migraines, she seems to have gleaned crucial and unlikely wisdom from her monastic existence, be that wisdom divinely inspired or just plain genius.

MEDICAL QUIPS Ba-Da-Boom! I told the doctor I broke my leg in two places. He told me to quit going to those places. —Henny Youngman

OCTOBER 2017 • Doctor’s

Review

PHOTO FINISH by

D r D omi n i c D a lla i r e

A whale of a time

I started underwater photography about five years ago. It’s been extremely challenging and I improve every time I get in the water. My main focus for the last three years has been whales and big underwater animals. This is a picture of one of my most treasured moments: a sperm whale nursing her calf in the Indian Ocean. These encounters are rare and I was very lucky to be there. If you’d like to see more of my photography, have a look at my Facebook page: Dominic Dallaire UW Photography.

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Doctor’s Review • OCTOBER 2017

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