November 2018; 60:9 Pages 421–472

Diabetes in : Starvation in the midst of plenty

Challenges to managing type 2 diabetes in BC: Discordant guidelines and limited treatment options Diabetes care in First Nations populations in BC From beta cells to bedsides: A 2018 update on diabetes research in BC

www.bcmj.org 422 bc medical journal vol. 60 no. 9, november 2018 bcmj.org November 2018 Volume 60 • Number 9 Pages 421–472 contents

425 Editorials Rhinos, take 2, David R. Richardson, MD (425) Knock, knock, it’s the doc, Jeevyn Chahal, MD (426)

427 President’s Comment Come together, right now: Why diversity matters, Eric Cadesky, MD

428 Letters to the Editor Photo radar, and stories from those close to people killed by a fast-moving vehicle, Robert Shepherd, MD

On the cover 430 WorkSafeBC British Columbia has Canada’s Engaging with research at WorkSafeBC, Susan Dixon most restrictive formulary when it comes to diabetes treatment. Our theme issue highlights both 432 General Practice Services Committee the highs and the lows of caring for people with diabetes in BC. New GPSC incentive supports family doctors to implement panel Articles begin on page 436. management, Brenda Hefford, MD, Alana Godin

434 News Eric Zhau receives Canadian Medical Hall of Fame award (434) Screening tool to identify deceptive online ads (434) New device for post-prostatectomy urinary incontinence (435) The ultrasound scanner of the future? (435) Revamped mental health and substance use website for young people The BCMJ is published by (464) Doctors of BC. The journal provides peer-reviewed clinical and review articles written primarily by BC physicians, Clinical Articles for BC physicians, along with debate on medicine and medical politics in editorials, letters, and THEME ISSUE: DIABETES CARE essays; BC medical news; career and CME listings; physician AND MANAGEMENT profiles; and regular columns. Print: The BCMJ is distributed monthly, other than in January 436 Guest editorial: Diabetes in British Columbia: and August. Starvation in the midst of plenty Web: Each issue is available at Ehud Ur, MBBS www.bcmj.org. Subscribe to print: Email [email protected]. 439 Challenges to managing type 2 diabetes Single issue: $8.00 Canada per year: $60.00 in British Columbia: Discordant guidelines Foreign (surface mail): $75.00 and limited treatment options Subscribe to the TOC: Maureen Clement, MD, Breay Paty, MD, G.B. John Mancini, MD, David Miller, MD, To receive the table of contents Adi Mudaliar, MD, Dave Shu, MD, David Thompson, MD, Adam White, MD, by email, visit www.bcmj.org and click on free e-subscription. Ehud Ur, MBBS Prospective authors: Consult the “Guidelines for Authors” at www.bcmj.org for submission requirements.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 423 contents

BC Medical Journal , Canada 604 638-2815 451 Diabetes care in First Nations [email protected] populations in British Columbia www.bcmj.org Keith G. Dawson, MD

455 From beta cells to bedsides: A 2018 update Editor David R. Richardson, MD on diabetes research in British Columbia C. Bruce Verchere, PhD Editorial Board Jeevyn Chahal, MD David B. Chapman, MBChB Brian Day, MB David Esler, MD 460 Obituaries Timothy C. Rowe, MB Dr Richard Wadge, Alex Wadge (460) Yvonne Sin, MD Benedict M. Garry, MD (460) Cynthia Verchere, MD Dr John Daniel Garry, Dr Fred Ceresney, Alister F. Frayne, MD (461) Managing Editor Jay Draper Senior Editorial and 462 BC Centre for Disease Control Production Coordinator Kashmira Suraliwalla Raccoon latrines and risk of Baylisascaris transmission Associate Editor Erin Fraser, DVM, Eleni Galanis, MD, Muhammad Morshed, PhD, Joanne Jablkowski Copy Editor 463 Barbara Tomlin Council on Health Promotion

Proofreader Climate change and infectious disease in Canada and BC Ruth Wilson David McVea, MD, Ray Copes, MD, Eleni Galanis, MD

Design and Production Scout Creative 465 CME Calendar Cover Concept & Art Direction Jerry Wong Peaceful Warrior Arts 466 College Library Printing DynaMed available through College Library, Robert Melrose Mitchell Press

Advertising Kashmira Suraliwalla 467 Guidelines for Authors 604 638-2815 [email protected] 468 ISSN: 0007-0556 Classifieds Established 1959 470 Back Page Opting out (Nanaimo 1992), Paul Mitenko, MD

471 Club MD

Postage paid at Vancouver, BC. Advertisements and enclosures carry no endorsement of Doctors of BC or BCMJ. Canadian Publications Mail, Product Sales Agreement #40841036. © British Columbia Medical Journal, 2018. All rights reserved. No part of this journal may be reproduced, stored in a retrieval Return undeliverable copies to BC Medical Journal, system, or transmitted in any form or by any other means—electronic, mechanical, photocopying, recording, or otherwise—without 115–1665 West Broadway, Vancouver, BC V6J 5A4; prior permission in writing from the British Columbia Medical Journal. To seek permission to use BCMJ material in any form for tel: 604 638-2815; email: [email protected]. any purpose, send an email to [email protected] or call 604 638-2815. Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not necessarily those of Doctors of BC or the institutions they may be associated with. Doctors of BC does not assume responsibility or liability for damages arising from errors or omissions, or from the use of information or advice contained in the BCMJ. The BCMJ reserves the right to refuse advertising.

424 bc medical journal vol. 60 no. 9, november 2018 bcmj.org editorials

Rhinos, take 2

“ his year, as another flu sea- “Sure, but they are rare. Where’s “But you’re a physician.” son begins, I’m going to try your sense of adventure?” “Yeah, but not a very good one— T a different approach with my “I’m feeling a little uncom- just ask my wife. She tells everyone. patients to conserve all the energy I fortable.” I’m just in it for the fame and fortune.” expend trying to educate them (see “But you don’t have a car and you my editorial in the Jan/Feb 2017 is- I’m sure that, aren’t famous.” sue, “Of rhinos and flu”). “Regardless, that flu shot causes like all of you, I will “Hey Doc, do you think I should all sorts of problems. Lots of my pa- get the flu shot?” soldier on instead and tients get colds after receiving the “Nope.” present logical vaccine and last year one of my pa- “Why not?” scientific arguments tients got into a car accident after re- “Haven’t you heard? That shot until I am once again ceiving the shot.” gives you the flu!” blue in the face. “Isn’t that a coincidence?” “What?” “That’s what they would like you “Well, it contains parts of the flu to think.” virus, which are injected into you.” “But wait, that’s not all.” “Who are they?” “That doesn’t sound good.” “There’s more?” “Everybody knows who they are, “I know. It’s horrible. Your “The flu shot takes time to pro- but I can’t talk about it here in case body’s immune system responds and duce so scientists have to decide they have my office bugged again.” you might even feel unwell for a few months ahead of time which strains “Are you sure you’re not one of hours. Can you imagine? Way better to include, and the last few years those impaired physicians?” to fight it off bedridden for a week they haven’t been very accurate. Of “Define impaired.” or 2.” course, there is some cross-protection So, okay, maybe not, but it’s still “Really?” to other strains, but whatever.” fun to think about going to the dark “Oh yeah, always better to get the “Isn’t protection a good thing?” side. However, I’m sure that, like all disease. What would I do if no one got “My advice is to hang out with of you, I will soldier on instead and sick?” people who get the flu shot and stay present logical scientific arguments “Aren’t there serious complica- away from the sickies. That’s what I until I am once again blue in the face. tions from getting the flu?” do.” —DRR

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 425 editorials

Knock knock, it’s the doc

“ nock knock.” tucked in with lots of blankets and ing a patient’s health over the phone. “Who’s there?” facing an amazing view. He is pale Telehealth and virtual house calls K “Your doc.” and unresponsive and remains that are becoming the new fad. Telemedi- “Your doc who?” way throughout the visit. cine limits the doctor’s ability to actu- “Your family doctor.” Mrs and Mr S. are both my pa- ally see the patient and to assess the “What?! No way!” tients. His health declined rapidly patient’s real environment. We also The door swings open and there over the past few years to a point forget that many patients do not have she stands, Mrs S., with a genuine where his Parkinson disease and de- the technological savvy or the appro- smile on her beautifully wrinkled mentia made it difficult for Mrs S. to priate device required to conduct a face. Her smile widens even more virtual house call. when she sees that I have my 3-year- A house call is an There have been a few survey old daughter in tow. She opens her eye-opener. It usually takes studies done to assess physicians’ arms for a hug and welcomes us into thoughts about house calls. A study about 30 minutes and it her home. It is a very tidy and orga- cited in the Canadian Family Phy- nized space full of knickknacks and is not structured. sician, January 2013, had a 29.2% pictures of her loved ones. survey return (unacceptable by Dr We walk through the living room, bring him into the office. She hired a Richardson’s standards) and conclud- which looks untouched, and then to private caregiver to help her as she ed that physicians lacked time and re- the kitchen, which has nothing on the didn’t want a different home care muneration for doing house calls. counters. It is immaculate. Then we worker looking after her husband ev- has a house-calls pro- enter the family room, where we see ery day. He was a very private person, gram in which four physicians each Mr S. He is lying on a hospital bed and she wanted him to maintain his see eight patients per day. The pro- dignity. For the past few years I have gram provides an at-home care ser- been visiting him at home to ease the vice for seniors in Toronto who are Dragon® Medical burden on Mrs S. unable to get a doctor. Financial con- Mrs S. offers us a fruity drink and I straints limit this program. Practice Edition 4 see that her fridge is well stocked with Uber for doctor house calls is be- (it’s the version you have been food. During the visit, my daughter coming popular in the US. The patient waiting for) has to use the bathroom and I see that downloads an app on their smartphone the raised toilet seat and bath bars are and enters their symptoms, address, in place and there are no dangers of and other personal information and, tripping on any risky rugs. poof, there is a bona fide doctor at the A house call is an eye-opener. It patient’s front door in 20 to 60 minutes. usually takes about 30 minutes and it Amazing, right?! What’s the catch? It is not structured. We talk about every- costs money—privately $50 to $200 thing and anything, not just medicine. per visit, depending on the company Usually it ends up being more about used and the reason for the visit. assessing the health of the caregiver, Despite all this new technology, and it lets me see and understand so I still think that a hands-on approach much more than I ever would if the should apply to most patient care. patients came to the clinic. When and if possible, see your patient Dragon Software MSP pays a family physician in the flesh. Listen to their concerns Installation & Support $114.29 per house call between 8 while looking them in the eye. I re- EMR Integration & Training a.m. and 11 p.m. and $71.06 between alize that this is not always possible 11 p.m. and 8 a.m. It usually takes me with the current lack of family physi- CONTACT US TODAY! an hour to do one house call, includ- cians and the growing patient popula- speakeasysolutions.com ing drive time. Many doctors don’t tion. But for those patients who can’t 1-888-964-9109 do house calls because the financial make it into our offices—like our se- speech technology specialists incentive is poor. They will rely on niors and those who are physically or for 18 years home care nursing or caregiver histo- mentally challenged—the house call ry to make medical decisions regard- is priceless. —JC

426 bc medical journal vol. 60 no. 9, november 2018 bcmj.org president’s comment

Come together, right now: Why diversity matters

We don’t have including committees, the Represen- References an aging health tative Assembly, and the Board. 1. Higgs M, Plewnia U, Ploch J. Influence of care system as How do we make this happen? We team composition and task complexity on much as we can’t find solutions unless we under- team performance. Team Performance have an out- stand the problems. Our consultation Management 2005;11:227-250. dated collec- will focus on understanding the bar- 2. Ka-yee Leung A, Maddux WW, Galinsky tion of silos riers that are keeping us from being AD, Chiu C. Multicultural experience en- where excel- diverse and inclusive within our lead- hances creativity: The when and how. Am lent work is ership structures. Psychol 2008:63:169-181. done, but rare- 3. Miller T, del Carmen Triana M. Demo- ly connected or scaled. graphic diversity in the boardroom: Me- In my previous President’s Com- diators of the board diversity–firm perfor- ment [BCMJ 2018;60:389], I reviewed We have many mance relationship. J Management the challenges we face in improving challenges ahead and Studies 2009;46:755-786. health care. We need solutions that are 4. Dezsö CL, Gaddis Ross D. Does female to meet them we need innovative, fair, and inclusive. That is representation in top management im- why we need diversity—now. every voice, every prove firm performance? A panel data in- Aside from the intrinsic benefits idea, and every vestigation. Strategic Management J derived from including others, there person. 2012;9:1072-1089. is evidence that diversity is our best 5. Zalis S. The truth about diversity—and chance of achieving needed health why it matters. Accessed 3 September care reform. Studies have shown that 2018. www.Zalis.com/sites/shelleyza diverse teams are more creative,1-4 Improving diversity will only be lis/2017/11/30/the-truth-about-diversity achieve better results,5-7 act more successful if everyone feels a sense of -and-why-it-matters/amp/. ethically,8 and promote more social belonging and is part of the process. 6. Avery DR, McKay PF, Tonidandel SD, et al. responsibility.9-10 Watch for information about these Is there method to the madness? Examin- Slowly, through medical school consultations in newsletters, on the ing how racioethnic matching influences admissions and licensing processes, Doctors of BC website, and through retail store productivity. Personnel Psy- we as a profession are better reflect- social media. chol 2012;65:167-199. ing society. Working toward diversity This will be neither easy nor com- 7. Woolley AW, Chabris CF, Pentland A, et al. intentionally ensures that our leader- fortable, but it is worthy. We must Evidence for a collective intelligence fac- ship will as well. This is about more look at ourselves and each other with- tor in the performance of human groups. than gender, ethnicity, demographics, out judgment, united in our common Science 2010;330:686-688. abilities, health, family situation, and vision of a medical association where 8. Cumming DJ, Yan Leung T, Rui OM. Gen- sexual orientation—this is about ex- all members feel safe to be them- der diversity and securities fraud. Soc Sci periences and attitudes. This is about selves, choose to participate how they Res Network. Working Paper Series respecting those who think differently want, and know they belong. 2012;58:1572-1593. because they have lived through dif- We have many challenges ahead 9. Soares R, Marquis C, Lee M. Gender and ferent times, places, and experiences. and to meet them we need every corporate social responsibility: It’s a mat- This is about trying to move barri- voice, every idea, and every person. ter of sustainability. Accessed 5 October ers so that we include everyone who If “diversity is an action, inclusivity is 2018. Catalyst 2011. www.catalyst.org/ wants to participate. a culture, and belonging is a feeling,”5 system/files/gender_and_corporate Like health care itself, diversity is then Doctors of BC is committed to _social_responsibility.pdf. complex and evolving. Learning from model our motto and show that we are 10. Bear S, Rahman N, Post C. The impact of the initiatives of other organizations, Better. Together. board diversity and gender composition Doctors of BC will soon embark on —Eric Cadesky, MDCM, CCFP, on corporate social responsibility and firm consultation to support greater di- FCFP reputation. J Business Ethics 2010;97: versity in our governance structures, Doctors of BC President 207-221.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 427 letters to the editor

We welcome original letters of less than 300 words; they may be edited for clarity and length. Letters may be emailed to [email protected], submitted online at bcmj.org/submit-letter, or sent through the post and must include your mailing address, telephone number, and email address. All letter writers will be required to disclose any competing interests.

Photo radar, and stories from In the years 2008 through 2017, www.who.int/violence_injury_preven those close to people killed 3268 people died in motor vehicle in- tion/publications/road_traffic/world by a fast-moving vehicle cidents in British Columbia. Among _report/speed_en.pdf. In the September issue of the BCMJ, the 298 people killed in motor ve- 5. BC Coroners Service. Motor vehicle inci- Ms Fahra Rajabali and colleagues hicle incidents in BC in 2017, 163 dent deaths 2008–2017. Accessed 10 wrote that the gross cost for the lead- were younger than age 50.5 BC used September 2018. www2.gov.bc.ca/ ing causes of injury (including trans- to have speed enforcement by photo assets/gov/birth-adoption-death-mar port incidents) in 2013 ranged from radar. Gordon Campbell promised to riage-and-divorce/deaths/coroners $547 to $922 million.1 Dr Richard- discontinue photo radar in the elec- -service/statistical/mvi-incident.pdf. son’s editorial in the same issue asked tion campaign of 2001. He won the 6. Lunman K. BC scraps photo radar as cab- for good studies,2 and Dr Cadesky election, and scrapped photo radar.6 inet debuts on TV. The Globe and Mail. 28 asked us to use science and stories to Some people might argue that it June 2001. www.theglobeandmail.com/ appeal to people.3 is ghoulish for doctors to engage with news/national/bc-scraps-photo-radar Here is some science: kinetic en- the family and friends of people who -as-cabinet-debuts-on-tv/article4150046. ergy equals one half mass times ve- have died because of a speeding ve- locity squared. In real-life terms, a hicle. It is not. If the family consents Doctors of BC declined to comment motor vehicle causes more damage to sharing their story about a loved because it does not have a policy or or- if it is moving fast. In a fact sheet on one killed by a fast-moving vehicle, ganizational position on photo radar. road safety,4 the World Health Orga- the doctor and the family could ask nization states the following: a writer to draft a story for publica- • “An increase in average speed of tion. Speed kills. Photo radar reduces 1 km/h typically results in a 3% speeding. I suggest that Doctors of 60 volumes strong higher risk of a crash involving BC recommend that the BC govern- injury, with a 4–5% increase for ment bring back photo radar. crashes that result in fatalities.” —Robert Shepherd, MD • “For car occupants in a crash with Victoria an impact speed of 80 km/h, the likelihood of death is 20 times what References it would have been at an impact 1. Rajabali F, Beaulieu E, Smith J, Pike I. The speed of 30 km/h.” economic burden of injuries in British Co- • “Pedestrians have been shown to lumbia: Applying evidence to practice. have a 90% chance of survival BCMJ 2018;60:358-364. when struck by a car travelling at 30 2. Richardson D. Spot-on studies. BCMJ The BCMJ is publishing its km/h or below, but . . . almost no 2018:60:341. 60th volume this year! chance of surviving an impact at 80 3. Cadesky E. Pseudoscience, anti-science, km/h.” and woo: This time it’s personal. BCMJ • “Speed cameras are a highly cost- 2018;60:343. effective means of reducing road 4. World Health Organization. Road safety – crashes.” speed. Accessed 10 September 2018.

428 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Audi Downtown Vancouver Wowing you from Start to Park!

Audi Vorsprung durch Technik

EXCLUSIVE OFFERS FOR CLUB MD MEMBERS. SHOW YOUR MEMBERSHIP CARD AND SAVE UP TO $6,000

Proud Club MD Partner Sales: 1788 West 2nd at Burrard Service: 1675 West 3rd Ave at Pine. Tel: 604.733.5887 | audidowntown.ca Tel: 604.733.9820 | audidowntown.ca

DocOfBC_Audi_1118_Final.indd 1 2018-10-18 1:47 PM KEY CONTACTS: Directory of senior staff

Mr Allan Seckel Ms Margaret English Ms Afsaneh Moradi Chief Executive Officer Director, Shared Care Committee Director, Community Partnership & 604 638-2888; [email protected] 604 638-2947 Integration; 604 638-5845 [email protected] [email protected] Ms Marisa Adair Executive Director of Communications and Ms Alana Godin Ms Cindy Myles Public Affairs; 604 638-2809 Director, Community Practice and Quality Director, Facility Physician Engagement [email protected] 250 218-3924 604 638-2834; [email protected] [email protected] Mr Jim Aikman Ms Carol Rimmer Executive Director of Economics Dr Brenda Hefford Director, Technology and Operations, and Policy Analysis; 604 638-2893 Executive Director, Community Practice, Doctors Technology Office [email protected] Quality, and Integration 604 638-5775; [email protected] 604 638-7855; [email protected] Dr Sam Bugis Mr Paul Straszak Executive Director of Physician Mr Rob Hulyk Executive Director of Negotiations and and External Affairs; 604 638-8750 Director of Physician Advocacy Chief Negotiator; 604 638-2869 [email protected] 604 638-2883; [email protected] [email protected]

Dr Andrew Clarke Mr Adrian Leung Ms Sarah Vergis Executive Director, Physician Health Director, Specialist Services Committee Chief Financial Officer Program; 604 398-4301 604 638-2884; [email protected] 604 638-2862; [email protected] [email protected] Ms Sinden Luciuk Ms Deborah Viccars Ms Amanda Corcoran Executive Director of Members’ Products Director of Policy Chief People & Technology Officer and Services; 604 638-2886 604 638-7865; [email protected] 604 638-2812; [email protected] [email protected]

Ms Cathy Cordell Mr Tod MacPherson General Counsel Director of Negotiations; 604 638-2885 604 638-2822; [email protected] [email protected]

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 429 worksafebc

Engaging with research at WorkSafeBC

orkSafeBC’s Research • Research training awards. Each The partnership works with routinely Services department sup- spring, Research Services invites collected data from multiple sources, W ports the development of applications from master’s and doc- pulled together through Population high-quality scientific evidence in oc- toral students pursuing training in Data BC, allowing researchers to de- cupational health and safety. Focus- occupational health and safety and velop a unique and comprehensive ing on emerging issues and applied workers’ compensation research in picture of the health and well-being research, Research Services provides BC. of workers in our province. The part- funding for academic scientific study nership team is made up of a diverse and practical, innovative projects Research Services group of faculty members, students, aimed at finding solutions for press- and staff working at UBC. Advis- funds independent, ing workplace safety needs. ors from WorkSafeBC meet regu- For physicians, this research may scientifically valid larly with researchers to identify new be relevant to the treatment and care research. topics and receive updates on ongoing of those who are injured or become ill projects. on the job. Medical experts and prac- • Systematic reviews. These studies Additionally, Research Services titioners are encouraged to connect ask researchers to find and analyze fosters and maintains partnerships with Research Services by explor- the best evidence addressing critical with workers’ compensation orga- ing the active and completed research issues in policy and practice. Open nizations and government groups projects detailed on www.worksafebc to researchers worldwide, these across Canada to support research .com, and to participate in research by competitions are held as needed that benefits all Canadian workers. submitting funding proposals or part- and help WorkSafeBC stakehold- These collaborations enable Work- nering with other researchers. ers better understand the state of SafeBC to reach a wider sphere of knowledge on priority issues, pro- researchers and encourage interpro- Funding opportunities vide critical assessment of current vincial initiatives. Through rigorous peer-reviewed science, and identify gaps in areas competitions, WorkSafeBC provides of relevance to workers’ compensa- About Research Services funding for research through the fol- tion policy and practice. Research Services funds independent, lowing four specialized streams: • Specific priorities research. This scientifically valid research that can • Innovation at work. Open to Cana- stream was launched in 2014 to an- provide insight into real issues faced dian residents, this stream has been swer occupational health and safety by workplaces and workers’ com- designed to support nimble, small- questions that have immediate rel- pensation organizations. The central scale projects that promote col- evance to WorkSafeBC with find- objectives are improving health and laboration between workplace par- ings that have clear application in safety in BC workplaces, fostering ties and researchers. Recent topics policy and practice. Current areas successful rehabilitation and return- include health-promotion programs of focus include the relationship be- to-work of injured workers, and en- for long-haul truck drivers, barri- tween sex and gender and occupa- suring fair compensation for people ers for psychiatric workers seeking tional health and safety, the impact suffering injury or illness on the job. help for PTSD, eye exposures to of emerging technologies and artifi- Outlines, summaries, and full re- radiation among veterinary clini- cial intelligence, return to work fol- ports of active and completed projects cians, and new tools for detecting lowing mild traumatic brain injury, are available on our website. To learn pathogens in emergency-services and key indicators for evaluation of more about the department, ongoing environments. The next request for violence prevention in health care. research, and upcoming funding op- proposals will be announced this portunities, visit www.worksafebc fall. Partnerships .com/en/about-us/research-services The Partnership for Work, Health, and or email [email protected]. This article is the opinion of WorkSafeBC Safety was established in 2005 be- —Susan Dixon and has not been peer reviewed by the tween WorkSafeBC and researchers Knowledge Transfer, BCMJ Editorial Board. at the University of British Columbia. WorkSafeBC Research Services

430 bc medical journal vol. 60 no. 9, november 2018 bcmj.org DOCTORS OF BC VIP SALES EVENT For all ClubMD Members only NOVEMBER 17TH - 18TH all 18 dilawri franchised dealerships

RSVP ONLINE bc.dilawri.ca/clubmd

RSVP and attend the private sale to be entered in for a chance to win a luxury vehicle loan and a weekend in Whistler.

From out of town? Dilawri and JW Marriott Hotel are offering an exclusive room rate to all ClubMD members. Contact: [email protected] | Tel 778.370.8179

Visit any of the Dilawri dealerships to access your exclusive offers during our Doctors of BC VIP Sales Event. RSVP online.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 431

Print_BCMJ_MagazineAd_1018 Final.indd 1 2018-10-17 1:53 PM gpsc

New GPSC incentive supports family doctors to implement panel management anel management is a pro- provide planned, proactive care. Compensation: The Panel cess of proactively managing Completing the phases will en- Development Incentive P a defined population of pa- able better care for individual patients The Panel Development Incentive1 tients using EMR data to identify and and help GPs understand their patient (made available in September 2018) respond to the patients’ chronic and population as a whole. This deeper compensates eligible family phys- preventive care needs. Better patient icians for committing to and com- data lead to better patient care, which pleting the three phases of panel is why the GPSC has developed a management—empanelment, panel new incentive and supports to en- The Panel cleanup, and panel optimization. courage doctors to implement panel Development Incentive To be eligible for the incentive, management. family doctors must be using an EMR (made available in system to manage patient information A new phased approach September 2018) and have completed the GPSC PMH to panel management compensates eligible Assessment in the 12 months before In addition to enabling planned pro- family physicians for applying for the incentive. active care for patients, accurate and committing to and Valued at $6000, the Panel De- optimized patient data are foundation- completing the three velopment Incentive consists of three al to the transition to the patient med- payments: phases of panel ical home—particularly in supporting • Payment 1 ($2000) may be claimed work between groups of family doc- management— after eligible family doctors com- tors and multidisciplinary teams. To empanelment, panel mit to completing the three phases help doctors ensure they have the best cleanup, and panel of panel management within 12 possible patient data, the Practice Sup- optimization. months after claiming the incentive. port Program (PSP) is implementing a • Payment 2 ($1000) may be claimed newly developed phased approach to after eligible family doctors indi- panel management. This approach is cate that they have completed phas- based on what’s been learned from a es one and two of panel manage- PSP pilot project and the experiences understanding of their patient popula- ment by submitting a copy of their of other jurisdictions (e.g., Alberta). tion empowers physicians to advocate GPSC Panel Management Manual It guides physicians and their teams for community resources, make the and Workbook. toward data-informed, proactive care. most of their time with patients, im- • Payment 3 ($3000) may be claimed The three phases of panel man- prove preventive and proactive care, after eligible family doctors in- agement are: and organize team members to best dicate that they have completed 1. Empanelment: Develop an accurate serve patients. phase three of panel management list of active patients by confirming the patient-provider relationship and most responsible provider. 2. Panel cleanup: Develop accurate, up- Self-learning Mainpro+ credits to-date clinical registries for three to five chosen disease indicators. Use EMR data to inform and plan proactive patient care. 3. Panel optimization: Develop accu- GPs can earn three credits per hour (up to 75 credits) for rate, up-to-date clinical registries updating and managing their patient panels as guided by the for 10 to 15 disease indicators to GPSC Panel Management Manual and Workbook.

This article is the opinion of the GPSC and For details, contact [email protected]. has not been peer reviewed by the BCMJ Editorial Board.

432 bc medical journal vol. 60 no. 9, november 2018 bcmj.org gpsc Save the date! Specialist Symposium by submitting a copy of their GPSC the PSP Regional Support Teams to 18 January 2019 Panel Management Manual and learn more (www.gpscbc.ca/what Workbook. -we-do/professional-development/ On 18 January 2019 the Specialist Doctors may claim the Panel De- psp/rst-contacts). Services Committee (SSC) in partnership velopment Incentive only once. Doc- For more information about panel with Specialists of BC will host a tors who have completed some or all management and supports, contact symposium designed to actively engage of the phases with PSP support are eli- [email protected]. and gather input from front-line specialist physicians and champions gible to receive the incentive, less any —Brenda Hefford, MD across BC in collaboration with BC sessional payments already claimed Executive Director, health authorities and the Ministry of for this work through the PSP and Community Practice, Health. This input will help define the provided that the incentive require- Quality and Integration future direction of health care planning ments have been met. Department, Doctors of BC for all stakeholders, including SSC’s next —Alana Godin strategic plan (2020 to 2023). Other resources Director, and supports Community Practice and Quality, Interested to join? Check out our • The Panel Management Manual and Community Practice, webpage for more details: sscbc.ca/ Workbook guides GPs and practice Quality and Integration specialist-symposium-shaping-future teams through the phases of panel Department, Doctors of BC -specialist-care-bc management step-by-step.1 Questions? Email Joanna Pannekoek at • EMR-based Panel Management Reference [email protected] Tools help update patient informa- 1. GPSC. What we do. Patient medical tion and develop disease registries.1 homes. Panel management. Accessed 19 • In-practice coaching provides as- September 2018. www.gpscbc.ca/what- sistance directly in practices by PSP we-do/patient-medical-homes/panel- Regional Support Teams. Contact management.

Exclusive deals from brands you trust You work hard. Your downtime is important and we want to help you make the most of it to do the things you love. Club MD provides exclusive deals from trusted brands so you can spend your time on what’s important. Go ahead, put yourself in the picture.

doctorsofbc.ca/clubmd

hotels • travel • entertainment • car purchase & lease • fitness & wellness • food & beverage • ski • spa • sporting events

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 433 news

Eric Zhau receives Canadian medication care plans for patients it gets another point. More points are Medical Hall of Fame award with complex health needs. Nation- added if the ad uses mystical language Mr Eric Zhao ally, he advises on the CIHR Strategic or claims that the product is very rare has received Working Group on Health Research or in short supply. The higher the over- the 2018 Can- Training and served as VP Internal all score, the greater the probability adian Medical of the Clinician-Investigator Trainee that the ad is a scam. Hall of Fame Association of Canada. The system was devised by a team award, which of two nurses, two doctors, two phys- recognizes Screening tool to identify iotherapists, a pharmacist, and a so- second-year deceptive online ads cial worker, all from UBC.

Photo: UBC medical stu- Researchers at the University of Brit- Researchers analyzed advertise- dents with an established track ish Columbia have devised a simple ments targeting 112 different health record of community leadership, su- screening tool ( Figure ) to evaluate if concerns. They found that the most perior communication skills, and a health product that appears on the In- common deceptive ads were those demonstrated interest in advancing ternet is likely to be a scam. The Risk promoting bodybuilding and weight knowledge. of Deception Tool (https://news.ubc loss, followed by medicinal products, Mr Zhau is a data scientist and .ca/wp-content/uploads/2018/09/2018 which claim to treat pain, asthma, or health innovator committed to em- -Health-Scams-Assessment-Tool.jpg) other conditions, and lifestyle prod- powering patients and personalizing assigns points based on the type and ucts, which include antiaging or sex- medicine. As an MD/PhD student number of persuasion techniques used ual enhancement remedies. at the University of British Colum- in an ad. If the ad includes a celeb- The developers also found a high bia, he coauthored over 15 original rity endorsement, it gets one point; number of advertisements from al- research articles, reviews, and book if it uses pseudo-technical language, ternative health practitioners that chapters, and has delivered presenta- tions at leading conferences, includ- ing Advances in Genome Biology and Celebrity endorsement Technology and the American Society or appeal to Claims of scarcity or of Clinical Oncology. He recently de- Is it a scam? personal status short supply Pseudo- Add up the 1 point fended his PhD, developing computa- 2 points technical points to language: tional methods to personalize cancer find out. Made-up words, therapy using whole-genome DNA jargon, stability analysis. For his accomplish- repetition ments he received the Lloyd Skars- 1 point gard Research Excellence Award Popular association “Free” gift or sample and the Vanier Canada Scholarship. Extraordinary techniques, e.g., for something in return: Mr Zhau served as vice chair of the claims, before & sociocultural memes: phone call, subscription, after photos, “People like you use this” meeting UBC Vancouver Senate and president testimonials “Docs don’t want you to know this” 2 points 1 point of the UBC Medical Undergraduate 2 points Society (MUS). In this latter role, he oversaw passage of a position paper Pseudoscience: on national Pharmacare, revamped overreliance on student representation on Faculty of unverified studies, mystical Medicine committees, overhauled theories, vague Evidence of efficacy: member communication, and sup- language Very low: no evidence, alternative explanations 4 points Total points = risk of deception Low: some evidence, quasi-scientific work cited 3 points 0–5 = low risk 2 points Moderate: empirical evidence, but no consensus 2 points ported the launch of the inaugural Good: readily accessible empirical evidence 1 point 6–9 = moderate risk MUS strategic plan. He now co-leads Excellent: large volumes of empirical evidence 0 points 10 or above = high risk a Faculty of Medicine working group on disruptive innovation in medical education. In 2015, he co-founded Figure. Screening tool to evaluate the risk of deception of Internet health ads. a start-up tailoring evidence-based Image source: UBC Internet Health Scams Study, 2018.

434 bc medical journal vol. 60 no. 9, november 2018 bcmj.org news made claims that were well outside consistent and effective blood flow to terial that can be wrapped around the what their therapies could reasonably the penis. The device is designed for body for easier scanning and more de- achieve. Most of the scams identi- compression of the urethra to mini- tailed views. fied originated in the United States. mize leakage and also to protect the Conventional ultrasound scanners Misleading health ads on the Inter- blood circulation in the topside of the use piezoelectric crystals to create net are concerning because consum- penis, eliminating possible blood sup- images of the inside of the body and ers may end up self-medicating, say ply restriction pain. The cuff was cre- send them to a computer to create so- researchers. ated to be light, soft, and comfortable nograms. UBC researchers replaced The study, “Internet health to ensure men can discretely wear it the piezoelectric crystals with tiny vi- scams—developing a taxonomy and all day, continue to live a normal life, brating drums made of polymer resin, risk‐of‐deception assessment tool,” and engage in regular activities. called polyCMUTs (polymer capaci- was published in Health and Social The device was created by BC tive micro-machined ultrasound Care in the Community. The lead re- vascular and general surgeon Dr Jack transducers), which are cheaper to searcher is Bernie Garrett, an associ- Pacey. More information is available manufacture. Sonograms produced ate professor in the UBC School of at www.paceycuff.com. by the UBC device were as sharp as Nursing. or even more detailed than traditional The ultrasound scanner sonograms. New device for post- of the future? Researchers will next be develop- prostatectomy urinary Engineers at the University of British ing prototypes and eventually testing incontinence Columbia have developed an ultra- the device in clinical applications. Vancouver-based Pacey MedTech sound transducer that could dramat- The study’s lead author is Carlos Ge- has created a urethral control device ically lower the cost of ultrasound rardo, a PhD candidate in electrical that is a reliable solution to urinary scanners to as little as $100. The pat- and computer engineering at UBC. incontinence in men—specifically ent-pending innovation is portable, The research, “Fabrication and testing those who have undergone prostate wearable, and can be powered by a of polymer-based capacitive micro- cancer treatment. Urinary incontin- smartphone (it needs just 10 volts to machined ultrasound transducers for ence is one of the greatest challenges operate). The transducer also has the medical imaging,” was published in for men post-prostatectomy. Trad- potential to be built into a flexible ma- Continued on page 464 itionally, men with incontinence de- pend on adult diapers/pads, external catheters, leg bags, medication, and penile clamps. These options may be costly, leak, have odor, and produce extreme discomfort. Artificial sphinc- ter surgery is also an option; however, additional surgery is not always pos- sible or wanted by patients with urin- ary incontinence. Prostate cancer is the most com- mon cancer in Canadian men, with one in seven facing a diagnosis dur- ing his lifetime. The problem of leakage post–radical prostatectomy is widespread. The Prostate Cancer Foundation reports that about 24% of men experience frequent leakage or no bladder control at 6 months after prostatectomy. The Pacey Cuff stops urinary leakage and reduces the dependency on absorption pads by up to 100%. They are more comfortable than tradi- Study lead author Carlos Gerardo holding the new tional penile clamps as they maintain ultrasound transducer that could revolutionize ultrasounds.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 435 Guest editorial

Diabetes in British Columbia: Starvation in the midst of plenty

ritish Columbia is one of Can- self-care responsibilities for people ada’s wealth­iest provinces. So living with diabetes, health care pro- B why do people­ with diabetes viders, and governments. The charter fare so poorly here? states that governments have the re- A stark picture was painted recent- sponsibility to: ly by Diabetes Canada (DC), formerly • Form comprehensive policies and known as the Canadian Diabetes As- plans for the prevention, diagnosis, sociation, in a report estimating that and treatment of diabetes and its 29% of British Columbians (1.4 mil- complications. lion people) are living with diabetes • Collect data on diabetes burden such or prediabetes.1 Moreover, another as costs and complications, and to DC report describes an “estimated regularly evaluate whether progress increase of diabetes prevalent cases is being made. Ehud Ur, MBBS from 2016 to 2026” of 46%.2 This is • Guarantee fair access to diabetes a profoundly worrying prospect for care, education, prescribed medi- a disease that shortens lifespan by cations, devices, and supplies to all 5 to 15 years; contributes to 30% of Canadians, no matter what their in- strokes, 40% of heart attacks, 50% come or where they live. of renal failures requiring dialysis, • Address the unique needs and dis- 70% of nontraumatic limb amputa- parities in care and outcomes of vul- tions; and is a leading cause of vision nerable populations that experience loss.3-5 BC’s highly diverse population higher rates of diabetes and compli- includes many at-risk ethnic groups, cations and significant barriers to including South Asian, Chinese, and diabetes care and support. Indigenous peoples.1,6 In addition, al- • Implement policies and regulations most 15% of British Columbians are to support schools and workplaces smokers, and almost 40% percent of in providing reasonable accommo- the population is not physically active dation to people with diabetes in enough, with 50% of adults and al- their self-management. most 20% of youth being overweight While other provinces (notably or obese.1 DC estimates that the cost to ,8 ,9 and the BC health care system of diabetes- Ontario10) have long recognized the related hospitalizations, physician vis- need for a guiding and cohesive strat- its, and inpatient medications alone is egy to achieve these goals, BC has $418 million per year.1 So what is the not. province doing about the present dan- Although BC has taken some ger and anticipated tsunami of health positive steps in the past number of care costs? years,2 the initiatives resulting from The Diabetes Charter for Canada7 these steps exist in isolation and are This article has been peer reviewed. has established agreed-upon rights and not part of an integrated approach.

436 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Guest editorial

For example: the Ike Barber lab is comparing And every day these dedicated pro- • In 2013 the province’s public health the progression of microvascular fessionals are faced with the reality plan11 set a target to reduce the an- complications in patients with islet of being unable to provide optimal, nual incidence rate for diabetes from transplantation and those receiving evidence-based care to many of their 6.3 (2009/10 baseline) to 6.0 per current medical therapy. patients. Why? Because we live in 1000 by 2023. However, no explicit • The Diabetes Delivery Education British Columbia. plan was proposed for achieving Research program is translating This theme issue was born out of this, and the prevalence of diabetes evidence-based interventions in the concern and frustration produced is now expected to increase from high-risk and medically under- by practising in a province with Can- 8.3% in 2013 to 10.3% in 2020.12 served communities, evaluating ada’s most restrictive drug formulary • In 2018, the provincial insulin pump program, first introduced in 2008 for children and youth age 18 and younger, was expanded to insure pa- BC is a have province, yet patients who do tients of all ages.13 not have private insurance coverage are Other examples of initiatives that operate in isolation include the forced to use outdated, higher-risk, and following: less-effective therapies, while patients with • The Food Skills for Families pro- gram, which is funded by the pro- private insurance have access to the best vincial government and delivered evidence-based therapies available. by DC. • The Primary Health Care Charter, which identifies diabetes manage- ment as a priority medical condition peer support models for long-term and where successive governments and establishes outcome measures. self-management, and designing have been reluctant to show leadership • Medical Services Plan fee codes culturally innovative approaches in attempting to address the epidemic for family physicians providing to lifestyle change in ethnic minor- of diabetes. BC is a have province, care for chronic illnesses, including ity communities. yet patients who do not have private diabetes, and fee codes for diabetes • The Diabetes Clinical Trial Unit at insurance coverage are forced to use remote consults and remote glucose Vancouver General Hospital is being outdated, higher-risk, and less-effec- monitoring. supported by an electronic medical tive therapies, while patients with Despite the lack of a coordinated record system for 22 000 patients, private insurance have access to the provincial approach to diabetes care, the largest and most comprehensive best evidence-based therapies avail- BC has a very strong diabetes re- longitudinal diabetes database of its able. And to complicate matters, the search and clinical community that kind. government funds the Therapeutics is engaged in many initiatives. For • The Endocrine Research Society Initiative (TI), which provides physi- example: at St. Paul’s Hospital is conducting cians with its own unique interpreta- • Scientists at the University of Brit- groundbreaking research into novel tion of the diabetes literature through ish Columbia are undertaking fun- diabetes technologies, including bimonthly Therapeutics Letters that damental research into islet cell insulin pumps, continuous glucose often cast doubt on the findings of ro- biology. sensors, and Internet-based care de- bust trials and guideline recommen- • Participants are being monitored at livery and blood glucose reporting dations issued by highly respected Vancouver General Hospital in the systems. international organizations. first in-human cellular implant trial Every day in British Columbia, The first article in this theme issue to treat type 1 diabetes. primary care physicians, allied health reports on findings from a working • First Nations populations are the professionals such as dietitians and group of primary care physicians and focus of diabetes care and cultural social workers, endocrinologists, and specialists from across BC formed to outreach programs. other medical and surgical specialists identify both the negatives and posi- • The Islet Transplant Program at are caring for people with diabetes. tives of diabetes care in BC. This

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 437 Guest editorial

article by Dr Maureen Clement and nate research opportunities, align Diabetes 2016;40:484-486. colleagues considers the conflicting with population needs, and ensure 6. Statistics Canada. 2011 national house- recommendations for diabetes man- the implementation of best practices. hold survey: Data tables. Accessed 2 April agement and notes that Therapeutics This theme issue is particularly 2018. www12.statcan.gc.ca/nhs-enm/ Initiative messages disseminated to timely with the recent release of the 2011/dp-pd/dt-td/index-eng.cfm. BC physicians differ significantly Diabetes Canada 2018 clinical prac- 7. Diabetes Canada. Diabetes charter for from recommendations provided by tice guidelines, which provide the Canada. Accessed 18 August 2018. national and international bodies that most up-to-date evidence-based rec- www.diabetes.ca/getmedia/aed8565b follow rigorous guideline develop- ommendations for preventing and -0967-4092-ab0b-87fa84ab2f47/Dia ment processes. The authors also managing diabetes.14 We hope that betesCharter_English_2017.pdf.aspx. describe the way restrictive drug cov- these new guidelines and the articles 8. Diabetes Care Program of Nova Scotia. erage policies in BC limit options for in this issue will generate discussion Accessed 2 April 2018. http://diabetes diabetes management. among BC health care professionals care.nshealth.ca/. The second article is by Dr Keith that lead to changing the status quo. 9. New Brunswick Health. A comprehen- Dawson, who describes the preva- British Columbians deserve better. sive diabetes strategy for New Bruns- lence of diabetes in Indigenous —Ehud Ur, MBBS, FRCPC wickers 2011-2015. Accessed 18 August populations. He reviews innovative Professor, Division of 2018. www.gnb.ca/0053/phc/pdf/2011/ programs that are addressing the ep- Endocrinology 8023-e.pdf. idemic of diabetes affecting Indig- University of British Columbia 10. Ministry of Health and Long-Term enous British Columbians, but also Care. Preventing and managing chronic expresses concern about the lack of References disease: Diabetes program. Accessed 2 coverage for guideline-recommended 1. Diabetes Canada. 2017 report on diabetes April 2018. www.health.gov.on.ca/en/ therapies under Pharmacare Plan W. in British Columbia. Accessed 2 April pro/programs/cdpm/diabetes.aspx. The third and final theme issue 2018. www.diabetes.ca/getmedia/8e 11. Ministry of Health. Promote, protect, pre- article is by Dr C. Bruce Verchere, 38f0cd-a2c4-4c17-a7df-9a2b385df961/ vent: Our health begins here: BC’s guiding who summarizes the extraordinary sv-2017-Diabetes-in-BC_final_HQ.aspx. framework for public health. 2013. Ac- research initiatives underway in our 2. Canadian Diabetes Association. Diabetes cessed 18 August 2018. www.health province. These include projects at in British Columbia. Updated June 2016. .gov.bc.ca/library/publications/year/2013/ the UBC Point Grey Campus, Van- Accessed 2 April 2018. www.diabetes BC-guiding-framework-for-public-health couver General Hospital, BC Chil- .ca/getmedia/ea061d58-065c-4add-84d6 .pdf. dren’s Hospital, and sites outside -0e3537de0600/diabetes-charter-back 12. Diabetes Canada. At the tipping point: Vancouver. grounder-bc-2016-06.pdf.aspx. Diabetes in British Columbia. Accessed It is time for the BC government 3. Public Health Agency of Canada. Diabetes 2 April 2018. www.diabetes.ca/CDA/ to take the lead in diabetes care and in Canada: Facts and figures from a public media/documents/publications-and develop an overarching approach in health perspective. , ON: PHAC; -newsletters/advocacy-reports/canada partnership with health care experts. 2011. Accessed 2 April 2018. www.phac -at-the-tipping-point-british-columbia-en A good start would be to implement -aspc.gc.ca/cd-mc/publications/diabetes glish.pdf. a provincial taskforce. Strategies con- -diabete/facts-figures-faits-chiffres-2011/ 13. British Columbia Health. Insulin pump & sidered must include: index-eng.php. insulin pump supplies. Accessed 17 Sep- • Defining achievable prevention and 4. Hux JE, Booth GL, Slaughter PM, Laupa- tember 2018. www2.gov.bc.ca/gov/con treatment goals. cis A (eds). Diabetes in Ontario: An ICES tent/health/health-drug-coverage/phar • Identifying standards for care and practice atlas. Toronto, ON: Institute for macare-for-bc-residents/what-we-cover/ barriers to their implementation. Clinical Evaluative Sciences; 2003. Ac- medical-supplies-coverage/diabetes • Collecting and analyzing popula- cessed 2 April 2018. www.ices.on.ca/ -supplies/insulin-pumps-insulin-pump tion-level data (e.g., outcomes, hos- Publications/Atlases-and-Reports/2003/ -supplies. pital admissions) through a provin- Diabetes-in-Ontario.aspx. 14. 2018 Clinical Practice Guidelines Commit- cial registry. 5. Canadian Diabetes Association Clinical tees. Diabetes Canada 2018 clinical prac- • Establishing a holistic diabetes re- Practice Guidelines Expert Committee. tice guidelines for the prevention and search institute within a provincial Pharmacologic management of type 2 management of diabetes in Canada. Can diabetes program to better coordi- diabetes: 2016 interim update. Can J J Diabetes 2018;42(suppl 1):S1-S325.

438 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Maureen Clement, MD, CCFP, Breay Paty, MD, FRCPC, G.B. John Mancini, MD, FRCPC, David Miller, MD, FRCPC, Adi Mudaliar, MD, CCFP, Dave Shu, MD, FRCPC, David Thompson, MD, FRCPC, Adam White, MD, FRCPC, Ehud Ur, MBBS, FRCPC

Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

Contradictory recommendations and formulary restrictions make it difficult for BC physicians to manage their patients with diabetes using the most robust and up-to-date evidence.

ABSTRACT: Type 2 diabetes is a three bodies differ in composition and publishes the findings in bul- common metabolic condition that and the methodology that they use letin form. Receiving conflicting in- requires a multifaceted approach to to prepare recommendations. Dia- formation is difficult for physicians reduce associated complications. betes Canada is a national organi- and can result in a wide variability Management is challenging be- zation supporting a large number of in quality of care, as well as clinical cause of the progressive nature of volunteers from many health pro- inertia, such as failure to implement the condition and the growing avail- fessions as they develop clinical or intensify a beneficial therapy. Fur- ability of different classes of antihy- practice guidelines. The Guidelines thermore, despite growing evidence perglycemic agents. Unfortunately, and Protocols Advisory Committee of significant clinical benefits for general practitioners and specialists consists of representatives from many diabetes drugs, most require looking for guidance in the complex the Ministry of Health and Doctors special authority approval or, in the pharmacological management of of BC who oversee working groups case of newer agents, are not cov- type 2 diabetes in BC can find them- that develop BC-specific guidelines ered at all by BC Pharmacare, which selves frustrated by contradictory on important clinical topics, includ- makes it difficult for physicians to recommendations from these three ing diabetes care. The Therapeutics manage their patients with diabetes bodies: Diabetes Canada, the Brit- Initiative is an organization funded using the most up-to-date and ro- ish Columbia Guidelines and Pro- by the Ministry of Health and the Uni- bust evidence. tocols Advisory Committee, and versity of British Columbia that com- the Therapeutics Initiative. These pletes assessments of drug therapy

Dr Clement is a family physician in the In- endocrinology. Dr Mancini is professor of Vancouver family physician. Dr Shu is an terior of British Columbia with a consulting medicine in the UBC Division of Cardiol- endocrinologist at Royal Columbian Hospi- practice in diabetes. She has been actively ogy, director of the CardioRisk Clinic at tal, currently serving as the regional head of involved with Diabetes Canada and was a Vancouver Hospital, staff physician in the endocrinology for the Fraser Health Author- member of the expert committee, steering Healthy Heart Program Prevention Clinic at ity. Dr Thompson is medical director of the committee, and executive committee dur- St. Paul’s Hospital, and a member of the VGH Diabetes Centre and principal investi- ing development of the 2003, 2008, 2013, writing group for the 2018 Diabetes Canada gator for the cell implant trial. Dr White is an and 2018 Diabetes Canada clinical practice clinical practice guidelines. Dr Miller is an endocrinologist and UBC clinical assistant guidelines. Dr Paty is an endocrinologist endocrinologist in Victoria and a clinical as- professor with a practice in Vancouver. Dr and UBC clinical associate professor who sociate professor, UBC and UVic. He was Ur is a professor in the Division of Endocri- specializes in diabetes and post-transplant actively involved with the Diabetes Canada nology at UBC. guidelines (2003–2018) and with the BC This article has been peer reviewed. guidelines (2003–2018). Dr Mudaliar is a

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 439 Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

iabetes is a chronic metabolic course of the disease, reduces long- • The Guidelines and Protocols Ad- disease that is becoming more term CV risk. visory Committee (GPAC), which Dcommon in British Columbia, Worldwide, clinical practice publishes clinical practice guide- with predicted prevalence rates rising guidelines based on the best available lines for use in BC on many topics, from 8.3% in 2013 to 10.3% in 2020.1 evidence support the use of antihy- including diabetes care.30 The complications of diabetes con- perglycemic agents to reduce the risk • The Therapeutics Initiative (TI), tribute significantly to morbidity and of long-term complications of diabe- which publishes recommendations mortality, and increase the cost bur- tes.2,23-25 In large, randomized con- regarding drug therapy for manag- den to patients, our medical system, trolled CV safety studies, agents such ing diabetes in their regular Thera- and society as a whole.2,3 Primary care as empagliflozin,26 liraglutide,27 sema- peutics Letters.31 physicians manage the majority of glutide,28 and canagliflozin29 have Table 1 summarizes the compo- people living with diabetes, and more sition and methodology of the bod- than 20% of a typical physician’s ies and shows how they vary in their caseload will likely involve caring for guideline development and publish- people with either diabetes or predia- ing processes. The recommenda- betes.4 Not only is the prevalence of tions produced by all three are widely diabetes increasing,5 but the manage- Recommendations disseminated. ment of patients with diabetes is be- issued by the TI coming more complicated as patients Diabetes Canada live longer and require additional care are notable for not In 1998 the Canadian Diabetes As- for frailty and comorbid conditions. aligning with those sociation published one of the first There are now nine classes of antihy- evidence-based guidelines for the perglycemic agents, which often need of other bodies. management of diabetes in Canada.32 to be used in combination owing to In this and subsequent publications the progressive nature of diabetes,6,7 a an independent expert committee de- situation that increases the complex- veloped and graded recommendations ity of therapeutic decision making. based on the quality of evidence from Diabetes requires a multifaceted demonstrated CV benefits. Conflict- key studies. Updates were published approach to reduce both microvascu- ing information regarding appropriate in 2003, 2008, 2013, and 2018.3 These lar and macrovascular complications.8 use of these and other antihypergly- guidelines are ranked among the best Glycemic control is an important risk cemic agents can confuse physicians in the world with respect to qual- factor for microvascular disease, in- and may result in widely variable ity, rigor, and process33 as assessed cluding retinopathy, nephropathy, quality of care as well as clinical in- using the AGREE II instrument (Ap- and peripheral neuropathy.9-13 Early ertia, which can mean physicians fail praisal of Guidelines for Research and improved glucose control slows pro- to implement or intensify a beneficial Evaluation).34 Each recommendation gression to these endpoints.9,14-17 An therapy. addresses a clinically important ques- association between macrovascular tion related to the management of dia- disease and aggressive glycemic con- Sources of betes and its sequelae. Health benefits trol is less clear.16,18,19 Cardiovascular recommendations of interventions as well as risks and (CV) benefit, most likely from bet- British Columbia physicians’ man- side effects are considered in formu- ter glucose control, has been seen in agement of diabetes is guided by rec- lating the recommendations. Patient long-term (10- to 20-year) observa- ommendations from three principle preferences and values are considered tional studies such as EDIC,20 long- sources: by consulting people with diabetes term follow-up of the UKPDS,21 and • Diabetes Canada (DC), formerly and reviewing the literature. Each a subset of VADT (although no over- known as the Canadian Diabetes recommendation is justified using the all survival benefit was seen in this Association, which publishes clini- strongest clinically relevant, empirical group with established cardiovascu- cal practice guidelines for the pre- evidence that can be identified. Sources lar disease),22 suggesting that good vention and management of diabe- of evidence are cited and the strength glycemic control achieved with less tes in Canada2,3 and updates these as of this evidence is indicated based hypoglycemia, if initiated early in the necessary.23 on criteria from the epidemiological

440 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

Guidelines and Protocols Advisory Diabetes Canada (DC) Therapeutics Initiative (TI) Committee (GPAC) Composition of • The 2013 clinical practice guidelines • The 2015 diabetes care guideline was • Since 1994 Therapeutics Letters have body were developed with the active developed by a working group led by been published regularly to identify participation of 120 volunteers. a physician chair and supported by a “problematic” issues and provide • Authors and reviewers of DC guidelines Ministry of Health research officer. “brief, simple, practical messages.”31 include health professionals from • GPAC working groups include general • Working groups have authored these family medicine, endocrinology, internal practitioners, specialists, and other letters under the guidance of the medicine, and other specialties, subject matter experts, as well as a TI executive, which includes five nursing, dietetics, pharmacy, and government-employed pharmacist. physicians and five nonphysicians, exercise physiology, as well as people including academics specializing in with diabetes. pharmacology. Scope of • Prevention and management of type 1 • Epidemiology and prevention. • Prescription drug therapies. recommend­ diabetes, type 2 diabetes, gestational • Management of type 1 and type • Laboratory testing considered on ations diabetes mellitus. 2 diabetes in adults, including occasion. • Macrovascular and microvascular complications. complications. • BC-specific topics (e.g., Pharmacare • Organization of care and self- coverage, Pharmacare special management education. authority process). • Diabetes in special populations. Authors • Yes. • No. • No. identified • In future, “lists of contributors may be published on the website.”36 Disclosures • Yes. • Conflict of interest must be disclosed, • Yes for TI members in general. published but is not published. • No for authors of Therapeutics Letters. • In future, disclosures will be published (personal conversation between Dr Clement and Ministry of Health). Committee • No, except for the hourly stipend paid to • Committee and working group members • Employed TI members receive a salary members members of the Independent Methods receive payment through the Ministry of from the University of British Columbia remunerated Review Committee, who are physicians Health and Doctors of BC for the hours supported by a Ministry of Health grant. with expertise in appraising evidence they spend performing GPAC business. and have no conflicts of interest. Literature • Yes. • No. • Yes. review • Full systematic literature review • Although a full systematic literature • The TI publication process “involves a conducted conducted based on clinically relevant review is not conducted, guideline literature review,”31 but no details are questions. authors quote extensively from DC provided. recommendations, which are based on • Previous Therapeutics Letters and a literature review. review articles are often cited. Recommend­ • Yes. • No statement is provided about • No process for assessing evidence and ations graded • Each recommendation is assigned a levels of evidence or grading of grading recommendations is identified grade based on the available evidence, recommendations. or declared. its methodological strength, and its • References are provided. • References are provided for some applicability to the Canadian population. statements. • Each recommendation is approved by the Steering Committee and Executive Committee, with 100% consensus required. Frequency of • A major rewrite is scheduled every • Each guideline is reviewed every • Therapeutics Letters tend to be publication and 5 years. 3 to 5 years. published in response to a topic of methodology for • Interim updates with independent discussion or controversy and when updates medical review are completed when there is a potential for cost to the important new trial evidence is medical system. published. • No schedule of topics is published. Independent • Yes. • No. • No. methodological review conducted Peer review • Clinical practice guidelines are sent to • Guidelines are sent for review, but not • Therapeutics Letters are sent for conducted national and international reviewers as part of a true peer-review process. review, but not as part of a true peer- by the publisher, Elsevier, as part of a review process since the authors are standard peer-review process. the editor and the reviewers do not have the ability to request rewrites.

Table 1. Comparison of three bodies issuing diabetes management recommendations.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 441 Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

literature and other guidelines pro- of Pharmacology and Therapeutics specialties from across Canada. The cesses. Recommendations based on in cooperation with the Department GPAC working groups responsible for biological or mechanistic reasoning, of Family Practice at the Univer- developing guidelines are smaller than expert opinion, or consensus are ex- sity of British Columbia “to provide the DC committees, but also include plicitly identified and graded as such. physicians, pharmacists, allied health medical experts and a Pharmacare Finally, harmonization is sought with professionals and the public with up- pharmacist. The members of TI work- guidelines issued by other bodies, in- to-date, evidence-based, practical ing groups include salaried employees cluding the Canadian Cardiovascular information on prescription drug and other health care professionals Society, the Canadian Hypertension therapy.”31 Funding is provided by and academics who are identified on Education Program, the Canadian the BC Ministry of Health through the organization’s website. While the Cardiovascular Harmonization of Na- a grant to UBC. Four TI working authors of DC guidelines are named, tional Guidelines Endeavour, and the groups are engaged in the develop- authors of GPAC guidelines and Ther- Society of Obstetricians and Gyne- ment of recommendations that are apeutics Letters are not. cologists of Canada. published bimonthly in Therapeutics Recommendations issued by the Letters and distributed as unsolicited TI are notable for not aligning with Guidelines and Protocols mail to physicians and pharmacists in those of other bodies, while recom- Advisory Committee BC. Each letter commonly focuses on mendations issued by DC and GPAC The Guidelines and Protocols Ad- adverse outcomes found in trials as align closely with American and Eu- visory Committee consists of repre- opposed to the primary or secondary ropean guidelines for diabetes man- sentatives from the BC Ministry of objectives of the trials reviewed. Au- agement24,25 and those of the United Health and Doctors of BC. The com- thors of the letters are not named and Kingdom’s National Institute for mittee advises the Medical Services there is no stated methodology for lit- Health and Care Excellence (NICE), Commission regarding both the ef- erature selection or review or grading which produces the only guidelines fective utilization of medical services of recommendations, nor a predefined to receive a higher rating than the DC and high-quality, appropriate patient schedule for discussion of specific diabetes guidelines33 and is cited in care,35,36 and oversees a number of therapeutic areas. Since 2010, 18 one Therapeutics Letter as a source of working groups responsible for de- drugs or classes of drugs have been “independent information.”38 veloping guidelines and protocols on reviewed in detail in 27 Therapeutics DC, GPAC, and these internation- almost 100 topics (see www.bcguide Letters and only one drug has been al bodies recommend monitoring pa- lines.ca). The diabetes care guideline given a full recommendation (intra- tients with diabetes using a glycated does not include an independent lit- venous iron in appropriately select- hemoglobin (HbA1c) level, and that erature review but instead relies heav- ed people with chronic severe iron the target A1c should be individual- ily on existing documents, including deficiency).37 ized, with a reasonable level for most the Diabetes Canada clinical practice adults being less than 7.0% and a tar- guidelines. The diabetes care guide- Recommendations get for those who are younger being line also addresses circumstances in compared 6.5% so they may benefit from more BC and includes BC-specific infor- Both Diabetes Canada and the Guide- years of excellent glycemic control mation such as Medical Service Plan lines and Protocols Advisory Com- to avoid microvascular complica- billing rules and incentive fees, lab mittee identify a process, structure, tions. Algorithms in DC, GPAC, and test availability, Pharmacare cover- and timeline for their work in advance. other international guidelines provide age, referral pathways, and local re- The recommendations produced diabetes care teams with direction sources. A handbook outlining the by both are more comprehensive in for management. No such direction process for guideline development scope than those of the Therapeutics is provided by the TI other than a indicates that “For guidelines pub- Initiative, which focuses mainly on preference for lifestyle intervention: lished after 2014, lists of contributors drug therapies and aims to “improve “While we await the trial evidence, may be published on the website.”36 prescription habits.” it is rational to emphasize lifestyle The composition of DC guidelines measures in these patients: weight Therapeutics Initiative committees is broad-based and inter- loss, low carbohydrate diets and ex- The Therapeutics Initiative was es- professional, including people with ercise.”39 This recommendation is tablished in 1994 by the Department diabetes as well as experts in various made despite the statement in another

442 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

Therapeutics Letter that “weight loss Perry, MD, FRCPC, Chair, TI Educa- older and less-expensive agents such is difficult to maintain”40 and a lack of tion Working Group, 21 March 2017, as glyburide, metformin, and human any references to support emphasiz- 9:05 p.m.). insulins) are fully covered under the ing “low carbohydrate diets,” which a provincial formulary.41 This makes it literature review by Diabetes Canada BC Pharmacare coverage much more difficult for physicians to found no evidence to support.3 In the The most recent Diabetes Canada use up-to-date evidence when manag- comments section of the TI website, clinical practice guidelines recom- ing their patients with diabetes. a request for clarification regarding mend that antihyperglycemic agents Table 2 and Table 3 illustrate the exactly what kind of carbohydrates should be chosen based on both pa- extent to which BC restricts Pharma- such a diet would include is answered tient and agent characteristics.2,3 care coverage compared with three as follows: “We [the TI] are not ex- While all agents named by DC have other provinces: Alberta and Ontario perts on evidence about diet” (reply been evaluated and approved for use (each historically considered a have to Dr Virendra Sharma by Thomas L. in Canada, in BC only a few (generally province) and Nova Scotia (considered

Table 2. Therapy recommended by Clinical priority British Columbia Alberta Ontario Nova Scotia Diabetes Canada At diagnosis A1c < 8.5% Lifestyle intervention n/a n/a n/a n/a First-line agents to consider based on clinical priority and patient characteristics Metformin (Glucophage, A1c 8.5% L L L L ≥ Glumetza) A1c ≥ 8.5% Metformin + another agent See second-line options below Symptomatic hyperglycemia with metabolic Insulin ± metformin See listings for insulin in Table 3 decompensation Second-line options to consider based on clinical priority and patient characteristics when glycemic target is not reached after 2–3 months Clinical cardiovascular Empagliflozin (Jardiance) NL R L R disease Liraglutide (Victoza) NL NL NL NL DPP-4 inhibitors Alogliptin (Nesina) NL NL NL NL Linagliptin (Trajenta) R R L R Sitagliptin (Januvia) DL R L R Saxagliptin (Onglyza) R R L R GLP-1 receptor agonists Albiglutide (Eperzan) NL NL NL NL Exenatide (Byetta) NL NL NL NL Liraglutide (Victoza) NL NL NL NL Hypoglycemia risk Dulaglutide (Trulicity) NL NL NL NL Semaglutide (Ozempic) NL NL NL NL SGLT2 inhibitors Canagliflozin (Invokana) NL R L R Dapagliflozin (Forxiga) NL R L R Empagliflozin (Jardiance) NL R L R TZDs Pioglitazone (Actos) R R L R Rosiglitazone (Avandia) DL R NL NL

Table 2. Formulary listings in BC and selected provinces for therapy recommended by Diabetes Canada. (Table continued on next page.) See next page for legend.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 443 Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

(Table continued from previous page.)

Therapy recommended by Clinical priority British Columbia Alberta Ontario Nova Scotia Diabetes Canada Second-line options to consider based on clinical priority and patient characteristics when glycemic target is not reached after 2–3 months (Continued) GLP-1 receptor agonists Albiglutide (Eperzan) NL NL NL NL Exenatide (Byetta) NL NL NL NL Liraglutide (Victoza) NL NL NL NL Semaglutide (Ozempic) NL NL NL NL Weight gain risk SGLT2 inhibitors Canagliflozin (Invokana) NL R L R Dapagliflozin (Forxiga) NL R L R Empagliflozin (Jardiance) NL R L R Alpha-glucosidase inhibitor Acarbose (Glucobay) DL L R L DPP-4 inhibitors Alogliptin (Nesina) NL NL NL NL Linagliptin (Trajenta) R R L R Sitagliptin (Januvia) DL R L R Saxagliptin (Onglyza) R R L R GLP-1 receptor agonists Albiglutide (Eperzan) NL NL NL NL Exenatide (Byetta) NL NL NL NL Liraglutide (Victoza) NL NL NL NL Dulaglutide (Trulicity) NL NL NL NL Semaglutide (Ozempic) NL NL NL NL Insulin (see Table 3) Insulin secretagogues Relative A1c lowering Gliclazide R L L L (Diamicron, Diamicron MR) Glimperide (Amaryl) NL NL L NL Glyburide (Diabeta, Euglucon) L L L L Repaglinide (GlucoNorm) NL L L NL SGLT2 inhibitors Canagliflozin (Invokana) NL R L R Dapagliflozin (Forxiga) NL R L R Empagliflozin (Jardiance) NL R L R TZDs Pioglitazone (Actos) R R L R Rosiglitazone (Avandia) DL R NL NL

Table 2 (Continued). Formulary listings in BC and selected provinces for therapy recommended by Diabetes Canada.

Adapted from Diabetes Canada. Formulary listings for diabetes medications in Canada. April 2018.41

L = listed. Can be prescribed by any doctor. Cost will be fully or partially covered according to the terms of the public drug plan. R = restricted. Only available to those who meet eligibility criteria and received prior approval from the drug benefit plan. Cost will be fully or partially covered according to the terms of the public drug plan. NL = not listed. Not available through the public drug plan. DL = delisted. Product has been removed from the formulary and is no longer available.

444 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

Insulin (Brand name) British Columbia Alberta Ontario Nova Scotia Bolus (prandial) insulins Aspart (NovoRapid/Novolog) L* L R L

Glulisine (Apidra) L* L L L Lispro (Humalog) L* L L R† Short-acting insulins Regular (Humulin-R, Novolin ge Toronto) L L L L Pork regular insulin (Hyperpurin Regular) R NL NL NL Basal insulins: Intermediate-acting regular NPH (Humulin-N, Novolin ge NPH) L L L L Basal insulins: Long-acting analogues Detemir (Levemir) R L L R Glargine (Lantus) R‡ L L R Glargine 300 (Toujeo) NL NL NL NL Glargine SEB (Basaglar) R‡ L L L Degludec (Tresiba) NL NL NL NL Pork isophane insulin (Hypurin NPH) R NL NL NL Premixed insulins Premixed regular-NPH L L L L (Humulin 30/70, Novolin 30/70, 40/60, 50/50) Biphasic insulin aspart (NovoMix 30) L* NL L NL Insulin lispro/lispro protamine suspension L* L L NL (Humalog Mix25, Mix 50)

Table 3. Formulary listings in BC and selected provinces for insulin.

Adapted from Diabetes Canada. Formulary listings for diabetes medications *Partial reimbursement provided for rapid-acting insulins; patients must pay in Canada. April 2018.41 the difference. †Full benefit provided for children 18 years and younger. L = listed. Can be prescribed by any doctor. Cost will be fully or partially ‡As of 21 August 2018, Pharmacare offers restricted coverage for Basaglar covered according to the terms of the public drug plan. brand of insulin glargine only. Patients starting insulin glargine will no R = restricted. Only available to those who meet eligibility criteria and longer be provided coverage for Lantus (www2.gov.bc.ca/assets/gov/ received prior approval from the drug benefit plan. Cost will be fully or health/health-drug-coverage/pharmacare/newsletters/news18-011.pdf). partially covered according to the terms of the public drug plan. NL = not listed. Not available through the public drug plan. SEB = subsequent-entry biologic.

a have-not province). Although drug glycemia with glyburide),41,42 and is the type 2 diabetes and clinical cardiovas- evaluation is now performed nation- only province to not list empagliflozin. cular disease. ally by the Common Drug Review and The rejection of empagliflozin appears As a result of TI conclusions, BC the Canadian Agency for Drugs and to be influenced largely by cost and residents with diabetes are at a disad- Technologies in Health (CADTH), it supported by the TI’s criticisms of the vantage when compared with Canadi- appears that recommendations from EMPA-REG OUTCOME trial.43 These ans in other jurisdictions. Essentially, the TI rather than those from the much criticisms, however, do not accord with BC has become a have-not province more robust DC guidelines are deter- most interpretations of the trial and oth- for people with diabetes, a problem mining BC Pharmacare policy. BC is er recent CV safety trials26-29 such as the likely to worsen as the rates of diabe- the only province to require special au- LEADER trial of liraglutide,27 which tes in BC continue to rise.44 thority for gliclazide (for use after hypo- demonstrated benefit for people with

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 445 Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

Key recommendations regarding cardiovascular outcomes dapagliflozin as “drugs to avoid”55 but considered and the use of empagliflozin, the does not name empagliflozin. Clear, high-quality, evidence-based Therapeutics Letter of July/August Contradictory recommendations recommendations are the cornerstone 2017 disputes the conclusions of the serve to confuse medical care provid- of medical training and subsequent EMPA-REG OUTCOME trial.43 The ers, and restrictive Pharmacare cov- decision making for health care pro- TI authors question the design of the erage only adds to this confusion and viders. Physicians and patients expect trial, which is one mandated by the promotes clinical inertia. A recent and deserve the best care possible FDA, and the “aggressive” use of evidence-based review of formulary based on transparent processes and insulin, sulfonylureas, and DPP4s in coverage for diabetes and cardiovas- unbiased sources. the control group, which are the very cular disease concluded that glucose- In BC, comparing key recommen- medications BC Pharmacare covers. lowering agents that reduce mortality dations on important clinical issues The TI authors also focus on genital in patients at very high cardiovascu- such as A1c targets and pharmaco- infections experienced by some study lar risk are now available, and that logical therapy45-55 reveals signifi- subjects, and emphasize these harms empagliflozin has been shown to be cant discord. The TI is at odds with in a table. Despite these concerns, the highly cost-effective. The authors DC and GPAC on a number of topics, Therapeutics Letter of September/Oc- urge all provincial formularies to “re- as shown in Table 4 . In an example tober 2017 names canagliflozin and examine their access requirements

Guidelines and Protocols Diabetes Canada (DC) Therapeutics Initiative (TI) Advisory Committee (GPAC)

A1c targets • Target levels for A1c should be • Recommendations for • No upper or suggested A1c level for treatment individualized. A1c align with DC. recommended: “The optimal glycemic target in patients 49 • A1c ≤ 7.0% recommended for most with type 2 diabetes is unknown.” individuals. • “A glycemic target of < 6.0% compared to a target • A1c ≤ 6.5 in some patients with type of 7.0% to 7.9% caused increased mortality in type 2 diabetes may further lower the risk 2 diabetics who were at high risk of cardiovascular of nephropathy16 (Grade A, Level 1 events.”49 recommendation) and retinopathy17 • “Most commonly used surrogate markers have not (Grade A, Level 1), but this must been proven to be consistently predictive of morbidity be balanced against the risk of or mortality risk thus their use in risk calculators is hypoglycemia16 (Grade A, Level 1). questionable.”50 • Less-stringent A1c targets of • “Relying on surrogate markers to assess effectiveness 7.1%–8.5% may be appropriate in of drug therapy has not been proven to yield clinically patients with limited life expectancy; meaningful benefits and there are important examples high level of functional dependency; where that strategy was harmful.”50 extensive coronary artery disease at • “Additional RCTs that test specific glycemic targets high risk of ischemic events; multiple are needed for the full spectrum of patients with type 2 comorbidities; history of recurrent diabetes.”49 severe hypoglycemia; hypoglycemia • “The current regulatory framework for glucose unawareness; longstanding diabetes for lowering drugs that bases benefit on lowering whom it is difficult to achieve an HbA1c and bases harms on not increasing specific A1c 7.0% despite effective doses of ≤ cardiovascular outcomes requires rethinking.”54 multiple antihyperglycemic agents, including intensified basal-bolus insulin therapy (Grade D, Consensus for all).

Lifestyle • Recommends starting lifestyle • Recommendations for • Recommends lifestyle intervention as opposed to intervention intervention at the time of diagnosis and lifestyle intervention align pharmacological management: “Type 2 diabetes continuing alongside pharmacological with DC. management should focus on weight management, management. appropriate nutrition, regular physical activity and • Guidelines include 5 physical activity blood pressure control, rather than intensive glucose recommendations and 13 nutrition lowering treatment.”51 recommendations. • “Exercise and weight loss are effective in treating type 2 diabetes.”40

Table 4. Key recommendations issued by three bodies for the management of type 2 diabetes. (Table continued on next page.)

446 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

(Table continued from previous page.)

Guidelines and Protocols Diabetes Canada (DC) Therapeutics Initiative (TI) Advisory Committee (GPAC)

Pharma­ • Treatment algorithm provided. • Treatment algorithm • No treatment algorithm provided. cological • Individualized therapy recommended. provided. • No recommendations regarding which medications therapy • Recommends adding second- and third- • Recommendations for to use, when to use them, and in which patient line agents to metformin according to treatment align with DC populations. agent and patient characteristics and 2013 guidelines published • Therapeutics Letter of March 2017 states that continuing until A1c target reached.23 prior to the November “glucocentric” approach to type 2 diabetes “may be 2016 update.23 misguided” and quotes from a study questioning “the • Lists each class of medication with effect on A1c lowering, hypoglycemia, likelihood that an individual will benefit from treatment of DM2 over an expected life span”39 and concluding weight, cardiovascular outcome, and cost. that “there is a potential epidemic of overtreatment with antihyperglycemic therapies.”39

Sulfonylureas Sulfonylureas Sulfonylureas • Gliclazide reported to cause less • Risk of hypoglycemia • Despite citing study findings that the incidence of hypoglycemia than glyburide, especially depends on agent (more hypoglycemic reactions was significantly greater with 45 in the elderly. In general, initial doses of risk with glyburide). glibenclamide than with gliclazide, the TI states “There is insufficient evidence from double-blind randomized sulfonylureas in the elderly should be • “Controversies in Care” trials that gliclazide provides a therapeutic advantage half of those used for younger people, section mentions data over other sulfonylurea drugs.”53 and doses should be increased more linking sulfonylureas • “Sulfonylureas, metformin, and insulin are equally slowly (Grade D, Consensus). with cardiovascular efficacious in improving glucose control in type 2 • Gliclazide45 and gliclazide46 MR (Grade B, harm, but concludes diabetes” and “are better than diet alone.”40 Level 2) and glimepiride47 (Grade C, Level that “At present, there 3) should be used instead of glyburide, is a lack of evidence Intensive insulin as they are associated with a reduced clearly demonstrating • “The effectiveness of intensive insulin treatment in frequency of hypoglycemic events. cardiovascular harm.”30 delaying the onset of complications of diabetes has been established for type 1 and, to a lesser extent, for • No specific preferred second-line type 2 diabetes.”40 agents are recommended except in cases of clinical cardiovascular disease, Acarbose where the preferred second-line agent is • “Acarbose can be used as an adjunct to diet and other empagliflozin or liraglutide.23 oral agents to achieve glucose control in patients with NIDDM. Its main disadvantages are cost and the high incidence of gastrointestinal side effects.”52 Antihyperglycemics • “Widely prescribed glucose lowering drugs for people with type 2 diabetes have been approved in Canada without evidence that they reduce mortality or major morbidity.”54

Cardio­ • Based on publications from the EMPA- • Latest guideline was • “Phase 4 trials have been published for saxagliptin, vascular REG OUTCOME26 and LEADER27 trials, issued before publication alogliptin, sitagliptin, empagliflozin, and liraglutide... outcomes the November 2016 DC update to the of EMPA-REG OUTCOME These trials must be interpreted cautiously considering 2013 guidelines23 recommends using and LEADER trials and DC the current uncertainty regarding the effects of an antihyperglycemic agent with update. standard of care on cardiovascular outcomes.”54 demonstrated cardiovascular outcome • Guideline links to • Question design and benefit of EMPA-REG trial benefit (empagliflozin,26 liraglutide27) in Canadian Agency for (see text). patients with clinical cardiovascular Drugs and Technology disease not meeting glycemic targets in Health and Common after lifestyle intervention and metformin. Drug Review statement Based on the CANVAS29 program, the that empagliflozin “was 2018 DC guidelines added canagliflozin superior to placebo to this recommendation. for improving glycemic control, reducing body weight, and lowering systolic blood pressure,” supporting use in patients with type 2 diabetes at high risk for cardiovascular disease.48

Table 4 (Continued). Key recommendations issued by three bodies for the management of type 2 diabetes.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 447 Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

for SGLT-2 inhibitors and to consider Canada Inc., Boehringer Ingelheim Canada 5. Gregg EW, Li Y, Wang, J, et al. Changes adding GLP-1 agonists to reflect cur- Ltd., and Janssen Inc., a Division of Johnson in diabetes-related complications in the rent evidence and clinical guideline & Johnson. The authors were volunteers and United States, 1990-2010. N Engl J Med recommendations.”56 received no remuneration for their time or ef- 2014;370:1514-1523. Patients in BC living with type 2 forts. With the exception of Dr Ur, all authors 6. Thrasher J. Pharmacologic management diabetes deserve care that meets na- were unaware of the sponsors’ identities of type 2 diabetes mellitus: Available ther- tionally vetted standards and provin- until after this article was submitted to the apies. Am J Cardiol 2017;120:S4-S16. cial support for the most up-to-date BCMJ. Funds were used exclusively for trav- 7. DeFronzo RA, Eldor R, Abdul-Ghani M. evidence-based approach to diabetes el and logistical support. Sponsors were not Pathophysiologic approach to therapy in management. involved in any aspect of the decision to de- patients with newly diagnosed type 2 dia- velop this article, in the content of the article, betes. Diabetes Care 2013;36(suppl 2): Summary in the selection of authors, or in any aspect of S127-S138. Type 2 diabetes is a common dis- the editorial process. In the past, all authors 8. Gaede P, Vedel P, Larsen N, et al. Multi- ease and its management is becoming of this article (except for Dr Mudaliar) have factorial intervention and cardiovascular increasingly complex. Management received fees and honoraria from pharma- disease in patients with type 2 diabetes. recommendations used in BC come ceutical companies for a variety of activities, N Engl J Med 2003;348:383-393. primarily from Diabetes Canada, the including speaking, attending meetings, and 9. Diabetes Control and Complications Trial Guidelines and Protocols Advisory organizing education. Details are available Research Group. The relationship of gly- Committee, and the Therapeutics upon request. cemic exposure (HbA1c) to the risk of de- Initiative. velopment and progression of retinopathy The use of antihyperglycemic References in the Diabetes Control and Complications therapy has been shown to reduce 1. Canadian Diabetes Association. At the tip- Trial. Diabetes 1995;44:968-983. complications and save lives. Phy- ping point: Diabetes in British Columbia. 10. Stratton IM, Adler AI, Neil HA, et al. sicians in BC are receiving con- Accessed 23 August 2018. www.dia Association of glycaemia with macrovas- tradictory information and facing betes.ca/CDA/media/documents/pub cular and microvascular complications of formulary restrictions not seen in oth- lications-and-newsletters/advocacy type 2 diabetes (UKPDS 35): Prospective er provinces. Better alignment of ev- -reports/canada-at-the-tipping-point observational study. BMJ 2000;321: idence-based recommendations and -british-columbia-english.pdf. 405-412. appropriate drug coverage is needed 2. 2013 Clinical Practice Guidelines Commit- 11. Cohen RA, Hennekens CH, Christen WG, to improve clinical outcomes and the tees. Canadian Diabetes Association et al. Determinants of retinopathy pro- lives of people in BC living with dia- 2013 clinical practice guidelines for the gression in type 1 diabetes. Am J Med betes, and to make the management prevention and management of diabetes 1999;107:45-51. of diabetes less challenging for physi- in Canada. Can J Diabetes 2013;37(suppl 12. Zoungas S, Arima H, Gerstein HC, et al; cians and patients alike. 1):S1-S212. Accessed 23 August 2018. Collaborators on Trials of Lowering Glu- http://guidelines.diabetes.ca/app cose (CONTROL) group. Effects of inten- Acknowledgments _themes/cdacpg/resources/cpg_2013 sive glucose control on microvascular out- The authors wish to acknowledge the _full_en.pdf. comes in patients with type 2 diabetes: A editorial assistance of Cynthia N. Lank 3. 2018 Clinical Practice Guidelines Commit- meta-analysis of individual participant data (Halifax, NS) and the logistical support of tees. Diabetes Canada 2018 clinical prac- from randomised controlled trials. Lancet Aleta Allen (Division of Endocrinology, tice guidelines for the prevention and Diabetes Endocrinol 2017;5:431-437. UBC) for their part in supporting the publi- management of diabetes in Canada. Can 13. Ismail-Beigi F, Craven T, Banerji MA, et al.; cation of this theme issue. J Diabetes 2018;42(suppl 1):S1-S325. Ac- ACCORD trial group. Effect of intensive cessed 19 April 2018. http://guidelines treatment of hyperglycaemia on micro- Competing interests .diabetes.ca/docs/CPG-2018-full-EN.pdf. vascular outcomes in type 2 diabetes: An This and the other articles in the theme 4. Leiter LA, Barr A, Bélanger A, et al. Diabe- analysis of the ACCORD randomised trial. issue were developed under the aus- tes screening in Canada (DIASCAN) Lancet 2010;376(9739):419-430. pices of the Division of Endocrinology at the study: Prevalence of undiagnosed diabe- 14. UK Prospective Diabetes Study (UKPDS) University of British Columbia and supported tes and glucose intolerance in family phy- Group. Intensive blood-glucose control by an educational grant from AstraZeneca sician offices. Diabetes Care 2001;24: with sulphonylureas or insulin compared Canada Inc., Merck & Co. Inc., Novo Nordisk 1038-1043. with conventional treatment and risk of

448 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

complications in patients with type 2 betes.com/article/S1499-2671(16)30592 Canagliflozin and cardiovascular and renal diabetes (UKPDS 33). Lancet 1998;352 -5/pdf. events in type 2 diabetes. N Engl J Med (9131):837-853. 24. American Diabetes Association. Stan- 2017;377:644-657. 15. UK Prospective Diabetes Study (UKPDS) dards of medical care in diabetes—2018. 30. Guidelines and Protocols Advisory Com- Group. Effect of intensive blood glucose Diabetes Care 2018;41(suppl 1):S1-S159. mittee. Diabetes care. Accessed 2 April control with metformin on complications Accessed 23 August 2018. https://pro 2018. www2.gov.bc.ca/assets/gov/ in overweight patients with type 2 diabe- fessional.diabetes.org/content/clinical health/practitioner-pro/bc-guidelines/ tes (UKPDS 34). Lancet 1998;352(9131): -practice-recommendations. diabetes_care_full_guideline.pdf. 854-865. 25. Inzucchi SE, Bergenstal RM, Buse JB, et 31. Therapeutics Initiative. Accessed 2 April 16. ADVANCE Collaborative Group, Patel A, al. Management of hyperglycaemia in 2018. www.ti.ubc.ca. McMahon S, Chalmers J, et al. Intensive blood glucose control and vascular out- comes in patients with type 2 diabetes N Engl J Med 2008;358:2560-2572. 17. ACCORD Study Group; ACCORD Eye Study Group, Chew EY, Ambrosius WT, Davis MD, et al. Effects of medical thera- BC residents are at a disadvantage pies on retinopathy progression in type 2 diabetes. N Engl J Med 2010;363: when compared with Canadians 233-244. in other jurisdictions. 18. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Mill- er ME, Byington RP, et al. Effects of inten- sive glucose lowering in type 2 diabetes. N Engl J Med 2008;358:2545-2559. 19. Duckworth W, Abraira C, Moritz T, et al.; VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes, 2015: A patient-centred 32. Meltzer S, Leiter L, Daneham D, et al. type 2 diabetes. N Engl J Med 2009; approach. Update to a position statement 1998 clinical practice guidelines for man- 360:129-139. of the American Diabetes Association and aging diabetes. Canadian Diabetes Asso- 20. Nathan D; DCCT/EDIC Research Group. the European Association for the Study of ciation. CMAJ 1998;159(suppl 8):S1-29. The Diabetes Control and Complications Diabetes. Diabetologia 2015;58:429-442. 33. Bennett WL, Odelola OA, Wilson LM. Trial/Epidemiology of Diabetes Interven- 26. Zinman B, Wanner C, Lachin JM, et al.; Evaluation of guideline recommendations tions and Complications study at 30 years: EMPA-REG OUTCOME Investigators. on oral medications for type 2 diabetes Overview. Diabetes Care 2014;37:9-16. Empagliflozin, cardiovascular outcomes, mellitus. Ann Intern Med 2012;156:27-36. 21. Holman RR, Paul SK, Bethel MA, et al. 10- and mortality in type 2 diabetes. N Engl J 34. Brouwers M, Kho ME, Browman GP, et year follow-up of intensive glucose control Med 2015;373:2117-2128. al., on behalf of the AGREE Next Steps in type 2 diabetes. N Engl J Med 2008; 27. Marso SP, Daniels GH, Brown-Frandsen Consortium. AGREE II: Advancing guide- 359:1577-1589. K, et al.; LEADER Steering Committee; line development, reporting and evalua- 22. Hayward RA, Reaven PD, Wiitala WL, et LEADER Trial Investigators. Liraglutide tion in healthcare. CMAJ 2010;182: al.; VADT Investigators. Follow-up of gly- and cardiovascular outcomes in type 2 E839-842. cemic control and cardiovascular out- diabetes. N Engl J Med 2016;375: 35. Guidelines and Protocols Advisory Com- comes in type 2 diabetes. N Engl J Med 311-322. mittee. External review of guidelines. Ac- 2015;372:2197-2206. 28. Marso SP, Bain SC, Consoli A, et al.; SUS- cessed 2 April 2018. www2.gov.bc.ca/ 23. Canadian Diabetes Association Clinical TAIN-6 Investigators. Semaglutide and gov/content/health/practitioner-profes Practice Guidelines Expert Committee. cardiovascular outcomes in patients with sional-resources/bc-guidelines/external Pharmacologic management of type 2 type 2 diabetes. N Engl J Med 2016; -review. diabetes: 2016 interim update. Can J Dia- 375:1834-1844. 36. Guidelines and Protocols Advisory Com- betes 2016;40:484-486. Accessed 23 Au- 29. Neal B, Perkovic V, Mahaffey KW, et al.; mittee. Guidelines and Protocols Advisory gust 2018. www.canadianjournalofdia CANVAS Program Collaborative Group. Committee handbook: How our “made in

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 449 Challenges to managing type 2 diabetes in British Columbia: Discordant guidelines and limited treatment options

BC” clinical practice guidelines and proto- peutics Letter July/August 2017. Acces­ wordpress/wp-content/uploads/ cols are developed. Revised March 2017. sed 2 April 2018. www.ti.ubc.ca/word 2010/08/20.pdf. Accessed 2 April 2018. www2.gov.bc.ca/ press/wp-content/uploads/2017/11/107 53. Therapeutics Initiative. Gliclazide for type assets/gov/health/practitioner-pro/bc .pdf. 2 diabetes mellitus. Therapeutics Letter -guidelines/gpac-handbook/gpachand 44. Diabetes Canada. 2017 report on diabetes October 2007. Accessed 2 April 2018. book2017.pdf. in British Columbia. Accessed 2 April www.ti.ubc.ca/2007/10/10/gliclazide 37. Therapeutics Initiative. Intravenous (IV) 2018. www.diabetes.ca/getmedia/8e38 -type-2-diabetes-mellitus. iron for severe iron deficiency. Therapeu- f0cd-a2c4-4c17-a7df-9a2b385df961/sv 54. Therapeutics Initiative. Questioning the tics Letter November/December 2015. -2017-Diabetes-in-BC_final_HQ.aspx. basis of approval for non-insulin glucose Accessed 2 April 2018. www.ti.ubc.ca/ 45. Tessier D, Dawson K, Tétrault JP, et al. lowering drugs. Therapeutics Letter May/ 2016/02/24/97-intravenous-iv-iron-for Glibenclamide vs gliclazide in type 2 dia- June 2016. Accessed 2 April 2018. www -severe-iron-deficiency. betes of the elderly. Diabet Med 1994; .ti.ubc.ca/wordpress/wp-content/ 38. Therapeutics Initiative. Is prescribing in- 11:974-980. uploads/2016/09/100.pdf. formation from sales representatives bal- 46. Drouin P. Diamicron MR once daily is ef- 55. Therapeutics Initiative. Drugs to avoid. anced? Therapeutics Letter August/Sep- fective and well tolerated in type 2 diabe- Therapeutics Letter September/October tember 2014. Accessed 2 April 2018. tes a double-blind, randomized, multina- 2017. Accessed 2 April 2018. www.ti www.ti.ubc.ca/2014/10/23/is-prescribing tional study. J Diabetes Complications .ubc.ca/wordpress/wp-content/ -information-from-sales-representatives 2000;14:185-191. uploads/2018/01/108.pdf. -balanced. 47. Holstein A, Plaschke A, Egberts EH. Low- 56. Riar SS, Fitchett D, FitzGerald J, Dehghani 39. Therapeutics Initiative. Is the current “glu- er incidence of severe hypoglycaemia in P. Diabetes mellitus and cardiovascular cocentric” approach to management of patients with type 2 diabetes treated with disease: An evidence based review of pro- type 2 diabetes misguided? Therapeutics glimepiride versus glibenclamide. Diabe- vincial formulary coverage. Can J Cardiol Letter November/December 2016. Ac- tes Metab Res Rev 2001;17:467-473. In Press, Accepted Manuscript, Available cessed 2 April 2018. www.ti.ubc.ca/ 48. Canadian Agency for Drugs and Technolo- online 19 July 2018. Accessed 23 August 2017/03/15/103-current-glucocentric gies in Health. Common Drug Review. 2018. https://doi.org/10.1016/j.cjca -approach-management-type-2-diabetes CADTH Canadian Drug Expert Commit- .2018.07.011. -misguided. tee final recommendation. Empagliflozin. 40. Therapeutics Initiative. Management of 26 October 2016. Accessed 2 April 2018. type 2 diabetes. Therapeutics Letter Janu- www.cadth.ca/sites/default/files/cdr/ ary/February/March 1998. Accessed 2 complete/SR0488_complete_Jardiance April 2018. www.ti.ubc.ca/wordpress/ -Oct-28-16.pdf. wp-content/uploads/2010/08/23.pdf. 49. Therapeutics Initiative. Glycemic targets 41. Diabetes Canada. Formulary listings for in type 2 diabetes. Therapeutics Letter diabetes medications in Canada (April January/February 2008. Accessed 2 April 2018). Accessed 23 August 2018. 2018. www.ti.ubc.ca/2008/02/28/glyce 1-Diabetes-Guest-ed-Ur-Nov-18-BT-AU mic-targets-in-type-2-diabetes. -clean to LR (ID 225340).docx www.dia 50. Therapeutics Initiative. The limitations and betes.ca/getmedia/d9dff34c-0c0b-43a9 potential hazards of using surrogate mark- -b5e0-7372358a470c/PT_formulary_list ers. Therapeutics Letter October/Decem- ing_April_2018.pdf.aspx. ber 2014. Accessed 2 April 2018. www 42. Province of British Columbia. Drug cover- .ti.ubc.ca/wordpress/wp-content/up age. Accessed 2 April 2018. www2.gov loads/2015/02/92.pdf. .bc.ca/gov/content/health/health-drug 51. Therapeutics Initiative. Self-monitoring of -coverage/pharmacare-for-bc-residents/ blood glucose in type 2 diabetes. Thera- what-we-cover/drug-coverage. www2 peutics Letter April/June 2011. Accessed .gov.bc.ca/gov/content/health/health 2 April 2018. www.ti.ubc.ca/wordpress/ -drug-coverage/pharmacare-for-bc-resi wp-content/uploads/2011/09/81.pdf. dents/what-we-cover/drug-coverage. 52. Therapeutics Initiative. New drugs III. 43. Therapeutics Initiative. EMPA-REG OUT- Therapeutics Letter July/August 1997. COME Trial – what does it mean? Thera- Accessed 2 April 2018. www.ti.ubc.ca/

450 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Keith G. Dawson, MD, PhD, FRCPC

Diabetes care in First Nations populations in British Columbia

More, not less, should be done to mitigate the negative impact of diabetes on Indigenous people, especially when it comes to Pharmacare coverage for guideline-recommended therapies.

ABSTRACT: Indigenous populations he estimated global prevalence Indigenous health are disproportionally affected by dia- rate of type 2 diabetes is 8.8%,1 care in BC betes, as seen in predictions that one with Indigenous people being First Nations populations in BC may T 2 in two Indigenous people in their 20s disproportionally affected. In Cana- receive different health care servi- will develop diabetes at some point da, the prevalence rate in Indigenous ces based on whether they live on or in life. The health care services that adults younger than age 35 is over off reserve. Both on-reserve and off- Indigenous people receive will vary 50.0%, and the lifetime risk of dia- reserve health care may be supported greatly and will depend on whether betes at age 20 is estimated at 75.6% by clinics, but there are major differ- they live on or off reserve. In 2013 in men and 87.3% in women.3 It is ences in the services provided de- the First Nations Health Authority as- predicted that one in two Indigenous pending on the particular clinic and on sumed the programs, services, and people in their 20s will develop diabe- the size and location of the commun- responsibilities formerly handled for tes at some point in life.3 ity (urban, semi-urban, or remote). Indigenous people in British Colum- The social determinants of health Larger clinics may have physicians in bia by Health Canada. Two innovative play a major role in the development attendance, while smaller clinics tend programs that have been successful of chronic diseases such as diabetes. to be staffed by nurses or commun- in addressing the epidemic of dia- Colonization is recognized world- ity health care workers. There is high betes in First Nations populations wide as the most significant social physician turnover in clinics serving in BC are the Diabetes and My Na- determinant of health.3,4 Other social First Nations communities and a lack tion program and the mobile diabe- determinants affecting diabetes in of Indigenous caregivers with whom tes telemedicine clinic program. A First Nations include poverty, iso- community members can identify and significant challenge to care deliv- lation, poor access to care, food in- from whom they will accept advice. It ery has arisen since October 2017, security, obesity, and lack of health is uncommon to find Indigenous phys- when the First Nations Health Au- education. Risk is compounded by icians or nurses staffing most of these thority joined BC Pharmacare and lifestyle habits such as smoking, low clinics, and Indigenous patients are the new Plan W formulary was intro- levels of physical activity, and un- often seen by non-Indigenous phys- duced. Plan W severely limits or de- healthy eating habits that contribute icians in nearby non–First Nations nies access to diabetes medications to high rates of obesity.5-7 Further, ur- communities. This is of consequence, that were previously covered, in- banization means that food is no lon- since many Indigenous people have cluding gliclazide, repaglinide, some ger obtained by traditional hunting had adverse experiences with author- DPP-4s, all SGLT2s, insulin glargine, and gathering methods but is bought ities who are less able to provide cul- insulin detemir, and rapid insulins. from a local commissary stocked with turally appropriate assistance. This means Indigenous British Co- high-carbohydrate, energy-dense pre- In 2013 the First Nations Health lumbians do not have ready access pared foods promoted by ubiquitous Authority (FNHA) assumed the pro- to many guideline-recommended advertising. grams, services, and responsibilities therapies that can mitigate the nega- tive impact of diabetes. Dr Dawson is a professor emeritus in the Division of Endocrinology at the University This article has been peer reviewed. of British Columbia.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 451 Diabetes care in First Nations populations in British Columbia

formerly handled for Indigenous Brit- Two other successful initiatives in The patient’s ability to take charge ish Columbians by Health Canada’s BC are the Diabetes and My Nation of his or her own diabetes self-care is First Nation and Inuit Health Branch program and the mobile diabetes tele- assessed and a full laboratory evalu- (FNIHB) and the Non-Insured Health medicine clinic program. ation is performed by point-of-care Benefits (NIHB) program. Since then, tests that include fasting or random FNHA has administered programs Diabetes and My Nation blood glucose, hemoglobin A1c, a for all status Indigenous people in the The Diabetes and My Nation pro- full lipid profile, and urinary micro­ province to ensure they have access to gram (www.diabetesandmynation albumin/creatinine ratio, liver func- the health and wellness programs pro- .com) addresses the complex problem tion tests, and full visual field retinal vided for other citizens. An Indigenous of diabetes through education in local photographs. All laboratory tests are person residing either on or off reserve community schools, physical activ- rigidly quality controlled (supported has access to care providers through- ity programs proposed by local com- by CEQAL Inc. laboratories). Re- out the province, as well as access to munity members, “circles of diabetes ports, including recommendations, a different list of medications and ser- care” that emphasize the importance are generated by the nurses and vi- vices than non-Indigenous people. of glucose monitoring to take owner- sion technician and are then up- In October 2017 FNHA joined BC ship of the disease, and long-term loaded to a secure Internet site15 and Pharmacare and the new plan Plan follow-up. When the effectiveness accessed by endocrinology and oph- W formulary was introduced.8 While of this program was compared with thalmology consultants. A complete FNHA has promoted this transition to the effectiveness of diabetes care in report containing recommendations a 100% paid plan for Indigenous peo- a non-Indigenous local community for improved care is generated and ple as a positive step, Plan W in fact provided by the same family phys- transmitted to family physicians and severely limits or denies access to dia- icians, the outcomes in the First Na- community health units. Wherever betes medications that were covered tions community were superior.14 possible, follow-up contact is made previously,9 including gliclazide, re- with the patients themselves, as well paglinide, some DPP-4s, all SGLT2s, Mobile diabetes telemedicine as their family physicians and other insulin glargine, insulin detemir, and clinic consultants. Efforts are made to see rapid insulins. This is unfortunate, as The mobile diabetes telemedicine the same patients a second time with- Indigenous people have a significant clinic program has provided consul- in the subsequent 6 months to 2 years, problem with obesity and prediabe- tative care in the past 5 years to over depending on resources, and episodi- tes as well as diabetes, and GLP-1s 4000 First Nations patients, many liv- cally thereafter. The most significant (which are not listed by either BC ing in remote locations. Established aspect of these assessments is that Pharmacare or NIHB) and SGLT2s in 2003 and expanded in 2009 to cov- they include extensive patient educa- are the only medications that assist in er almost all First Nations commun- tion in healthy eating, the importance weight reduction as well as glycemic ities in northern and southern BC, this of physical activity, glycemic targets, control while providing proven car- program is delivered by a team con- and advice regarding the risks of com- diovascular protection.10-13 Moreover, sisting of one or two nurses who are plications and methods of avoiding combination therapies that enhance certified diabetes educators, a clerk, such complications. Aspects of self- adherence and often provide reduced and a vision technician. Currently two care are emphasized, and a website16 costs also have restricted coverage. teams provide these mobile diabetes provides educational support for both telemedicine clinics: Carrier Sekani patients and community health care Initiatives in diabetes Family Services and Seabird Island workers. care delivery Band. The team visits requesting com- These annual assessments in- Support for diabetes care delivery to munities to see those people known dicate that while obesity is a major First Nations populations in BC has to have diabetes who wish to receive baseline problem, many other indica- come from various programs, includ- an in-depth health status evaluation, tors improve over subsequent clinic ing the Aboriginal Diabetes Initiative which includes a full history, physical visits, including blood pressure lev- (ADI), introduced by Health Canada examination, and medication review els, A1c levels, lipid levels, and use and now administered by FNHA. using the Virtual Diabetes Program of antihypertensive ACE inhibitors or This program provides funding to 196 EMR, which is oriented specifically ARBs and statins. The patient educa- of 203 on-reserve communities. to First Nations clients.15 tion aspect is particularly appreciated

452 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Diabetes care in First Nations populations in British Columbia

and it is clear that this improves pa- to take two less-reliable insulin injec- betes in First Nations populations tient participation in care. tions per day, and to use less-reliable in BC are the Diabetes and My Na- The success of the mobile clinic short (rapid-acting) insulins before tion program and the mobile diabetes program may be seen by comparing meals. FNHA’s decision to restrict telemedicine clinic program. Un- diabetes care results in BC with those drug coverage means that First Na- fortunately, the adoption of Pharma- found in the rest of Canada. For ex- tions people will lose access to many care Plan W by FNHA in 2017 now ample, in the Diabetes Mellitus Status guideline-recommended therapies. severely limits or denies access to survey,17 49.6% of diabetes patients in While lifestyle changes are clearly diabetes medications that were previ- Canada had an A1c level lower than 7.0% compared with 54.0% of First Nations diabetes patients in north- ern BC and 54.9% in southern BC.18 According to this metric, Indigenous people served by the clinic program in multiple BC communities with many Indigenous people are disproportionally challenges had glycemic outcomes affected by diabetes, and the care superior to those in the rest of Canada. The BC mobile telemedicine clin- they receive will depend on whether ic approach has proven to be effective they live on or off reserve. and appreciated in rural and urban set- tings, and could be equally effective in non–First Nations communities, particularly as it is an efficient use of resources.

Challenge to diabetes care delivery important, we need to help people ad- ously covered, which means Indigen- A significant challenge to diabetes care here to recommended care, and pla- ous British Columbians do not have delivery in BC is the limitations on cing any obstacles in their way will access to many guideline-recom- access to medications. After lifestyle have deleterious consequences. mended therapies. changes are introduced to patients Diabetes places an enormous newly diagnosed with type 2 diabetes, burden on First Nations in BC by Acknowledgments optimal first-line therapy with met- decreasing quality of life and pro- Dr Dawson wishes to acknowledge the formin begins. This is then followed ductivity, and increasing morbidity, editorial assistance of Cynthia N. Lank by or combined with additional oral premature mortality, and health care (Halifax, NS) and the logistical support of agents that promote glycemic control, costs. In a wealthy province such as Aleta Allen (Division of Endocrinology, weight loss, and reduction of adverse BC more, not less, should be done to UBC) for their part in supporting the publi- outcomes. Three different classes of mitigate the negative impact of this cation of this theme issue. these second-line agents provide this disease on Indigenous people. and are recommended by clinical Competing interests practice guidelines: DPP-4s, SGLT2s, Summary This and the other articles in the theme and GLP-1s.19,20 BC has one of the Indigenous people are disproportion- issue were developed under the aus- most limited formularies in Canada, ally affected by diabetes, and the care pices of the Division of Endocrinology at offering only restricted coverage for they receive will depend on whether the University of British Columbia and two DPP-4 agents, and no coverage they live on or off reserve. In BC the supported by an educational grant from for GLP-1s. BC is also the only prov- First Nations Health Authority is re- AstraZeneca Canada Inc., Merck & Co. ince in Canada to provide no coverage sponsible for programs and services Inc., Novo Nordisk Canada Inc., Boehringer for any SGLT2 agents. In addition, formerly handled by Health Canada. Ingelheim Canada Ltd., and Janssen Inc., BC’s restriction on insulin choice Two innovative initiatives that have a Division of Johnson & Johnson. Like the causes those who need basal insulin helped address the epidemic of dia- other theme issue authors, Dr Dawson

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 453 Diabetes care in First Nations populations in British Columbia

was a volunteer and received no remu- the CIRCLE study. Diabetes Res Clin Canada: Is it improving? Can J Diabetes neration for his time or efforts and was un- Pract 2011;92:272-279. 2013;37:213. aware of the sponsors’ identities until after 7. Bruce SG, Reidiger ND, Zacharias JM, 18. Jin A. Aboriginal Diabetes Initiative (ADI) this article was submitted to the BCMJ. Young TK. Obesity and obesity-related co- funded mobile screening and manage- Funds were used exclusively for travel morbidities in a Canadian First Nation ment projects—synthesis report. First Na- and logistical support. Sponsors were not population. Prev Chronic Dis 2011;8:A03. tions and Inuit Health Branch, Health Can- involved in any aspect of the decision to 8. First Nations Health Authority. Pharma- ada. February 2014. Accessed 23 August develop this article, in the content of the Care Transition. Accessed 2 April 2018. 2018. www.researchgate.net/profile/ article, in the selection of authors, or in any www.fnha.ca/benefits/pharmacare Andrew_Jin3/publication/320386708 aspect of the editorial process. In the past, -transition. _Aboriginal_Diabetes_Initiative_ADI Dr Dawson has received honoraria and 9. Diabetes Canada. Formulary listings for _funded_Mobile_Screening_and_Man fees from Boehringer Ingelheim, Merck, diabetes medications in Canada. April agement_Projects_-_Synthesis_Report/ Janssen, Sanofi, Lifescan, and GSK 2018. Accessed 23 August 2018. www links/59e122b5a6fdcc7154d36913/ for speaking and taking part in advisory .diabetes.ca/getmedia/d9dff34c-0c0b Aboriginal-Diabetes-Initiative-ADI-fund board activities. -43a9-b5e0-7372358a470c/PT_formu ed-Mobile-Screening-and-Management lary_listing_April_2018.pdf.aspx. -Projects-Synthesis-Report.pdf. References 10. Zinman B, Wanner C, Lachin JM, et al.; 19. Kosiborod M, Cavender MA, Fu AZ, et al.; 1. Guariguata L, Whiting DR, Hambleton I, et EMPA-REG OUTCOME Investigators. CVD-REAL Investigators and Study al. Global estimates of diabetes preva- Empagliflozin, cardiovascular outcomes, Group. Lower risk of heart failure and lence for 2013 and projections for 2035. and mortality in type 2 diabetes. N Engl J death in patients initiated on SGLT-2 in- Diabetes Res Clin Pract 2014;103:137- Med 2015;373:2117-2228. hibitors versus other glucose-lowering 149. 11. Marso SP, Bain SC, Consoli A, et al.; SUS- drugs: The CVD-REAL Study (Compara- 2. Yu CH, Zinman B. Type 2 diabetes and TAIN-6 Investigators. Semaglutide and tive Effectiveness of Cardiovascular Out- impaired glucose tolerance in aboriginal cardiovascular outcomes in patients with comes in New Users of Sodium-Glucose populations: A global perspective. Diabe- type 2 diabetes. N Engl J Med 2016; Cotransporter-2 Inhibitors). Circulation tes Res Clin Pract 2007;78:159-170. 375:1834-1844. 2017;136:249-259. 3. Turin TC, Saad N, Jun M, et al. Lifetime 12. Marso SP, Daniels GH, Brown-Frandsen 20. Canadian Diabetes Association Clinical risk of diabetes among First Nations and K, et al.; LEADER Steering Committee; Practice Guidelines Expert Committee. non–First Nations people CMAJ 2016; LEADER Trial Investigators. Liraglutide Pharmacologic management of type 2 188:1147-1153. and cardiovascular outcomes in type 2 diabetes: 2016 interim update. Can J Dia- 4. Social determinants and Indigenous diabetes. N Engl J Med 2016;375:311- betes 2016;40:484-486. Accessed 2 April health: The international experience and 322. 2018. www.canadianjournalofdiabetes its policy implications. Presented at the 13. Neal B, Perkovic V, Mahaffey KW, et al.; .com/article/S1499-2671(16)30592-5/pdf. International Symposium on the Social CANVAS Program Collaborative Group. Determinants of Indigenous Health, Ad- Canagliflozin and cardiovascular and renal elaide, Australia, 29-30 April 2007. Ac- events in type 2 diabetes. N Engl J Med cessed 2 April 2018. www.who.int/ 2017;377:644-657. social_determinants/resources/indige 14. Dawson K, Nabih H, de Goeij L, Joseph R. nous_health_adelaide_report_07.pdf. Diabetes and my nation: A model program 5. Public Health Agency of Canada. Diabetes for diabetes teaching and treatment in ab- in Canada: Facts and figures from a public original communities. Can J Diabetes health perspective. Ottawa, ON: PHAC; 2009;33:279-280. 2011. Accessed 2 April 2018. www.can 15. Virtual Diabetes Center website. Ac- ada.ca/en/public-health/services/chronic cessed 2 April 2018. www.virtualdiabetes -diseases/reports-publications/diabetes/ center.com. diabetes-canada-facts-figures-a-public 16. Live Well with Diabetes website. Ac- -health-perspective.html. cessed 2 April 2018. www.livewellwith 6. Harris SB, Naqshbandi M, Bhattacharyya diabetes.com. O, et al. Major gaps in diabetes clinical care 17. Leiter LA, Berard L, Bowering CK, et al. among Canada’s First Nations: Results of Type 2 diabetes mellitus management in

454 bc medical journal vol. 60 no. 9, november 2018 bcmj.org C. Bruce Verchere, PhD

From beta cells to bedsides: A 2018 update on diabetes research in British Columbia

Laboratory and clinical investigators in BC are making notable discoveries as they collaborate to reach a better understanding of diabetes, especially regarding pancreatic beta cell biology, obesity, and autoimmunity.

ABSTRACT: With more than 1.4 mil- orldwide prevalence of This group of investigators also lion British Columbians impacted by both type 1 and type 2 played a significant part in training prediabetes or diabetes, the need W diabetes is on the rise, many current diabetes researchers in has never been greater for research yet we remain without a cure for this BC and around the world. into the causes of the disease and metabolic disease and have limited new approaches to predict, prevent, therapeutic options. With 1.4 million Research sites and reverse this devastating con- people impacted by prediabetes or Diabetes research in BC today takes dition. Fortunately, BC has a rich diabetes in British Columbia alone,1 place primarily at three sites: Van- history of diabetes research dating the need has never been greater for couver General Hospital (VGH), back to the 1960s and has become research into the causes of the dis- the UBC Point Grey Campus, and a world leader in the area, with re- ease and new approaches to predict, BC Children’s Hospital (BCCH). As search projects underway at three prevent, and reverse this devastating well, research efforts are underway Vancouver sites and more research condition. elsewhere in BC. Close collabora- capacity developing outside Vancou- BC has a rich history of diabetes tion among the Vancouver research ver. Current research strengths lie research, discovery, and training that groups is facilitated by complement- in pancreatic beta cell biology and dates back to the 1960s, when experi- ary expertise, sharing of core infra- replacement, obesity, autoimmuni- mental studies led to the discovery structure, and outstanding trainees. In ty, and community health. Notable of the first incretin hormone, gastric recent years, increasing collaboration discoveries and plans for future re- inhibitory polypeptide—also called among wet laboratory scientists and search have resulted from progress glucose-dependent insulinotropic diabetologist clinicians has benefited made by wet laboratory scientists polypeptide (GIP)—by Drs John the diabetes research community as a and diabetologist clinicians based Brown and Raymond Pederson in the whole and enabled innovative clinic- at Vancouver General Hospital, the Department of Physiology at the Uni- al trials and translational research that University of British Columbia, and versity of British Columbia (UBC).2 BC Children’s Hospital. The future is Subsequent work by this group, in- Dr Verchere is a professor in the Depart- bright for the province’s strong and cluding Dr Chris McIntosh, using ment of Surgery and in the Department of collegial community of researchers, preclinical models of type 2 diabetes, Pathology and Laboratory Medicine at the especially with the establishment of played a key role in the eventual thera- University of British Columbia and holds the BC Diabetes Research Network. peutic application of dipeptidyl pep- the Irving K. Barber Chair in Diabetes Re- tidase-4 (DPP-4) inhibitors,3 today a search. He is also head of the Canucks widely used class of type 2 diabetes for Kids Fund Childhood Diabetes Labo- drugs that prolong the biological ac- ratories at the BC Children’s Hospital Re- tivity of the incretin hormones GIP search Institute. This article has been peer reviewed. and glucagon-like peptide-1 (GLP-1).

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 455 From beta cells to bedsides: A 2018 update on diabetes research in British Columbia

has provided cells and blood samples type 2 diabetes,8 including the part from diet-induced obesity13 and pro- from patients for study at the labora- played by amyloid formation.9 longs lifespan.14 tory bench. VGH is also the site of multiple Dr Kieffer’s pioneering work in trials in type 2 diabetes and clinical stem cell derivation of insulin-pro- Vancouver General Hospital research into the regulation of glucose ducing cells15 has moved us closer to At VGH, the world-leading Ike Barber metabolism in older adults with type having a source of unlimited, func- Human Islet Transplant Laboratory 2 diabetes. Given the risk of hypo- tional beta cells for transplantation was initiated by a donation from Dr glycemia in this understudied popu- in patients with type 1 diabetes. Beta Irving K. Barber that enabled the re- lation, such research has significant cell replacement—currently by trans- cruitment of Dr Garth Warnock, a pi- implications for clinical practice.10 plantation of pancreatic islets isolated oneer in human islet transplantation in In the area of translational re- from cadaveric organ donors—has type 1 diabetes. Since 2003, the clinic- search in diabetes prevention and the potential to be a functional cure al program at the lab has transplanted control, Dr Tricia Tang is leading a for persons with type 1 diabetes, but islets into 54 individuals with type 1 program that focuses on high-risk is limited by tissue supply and graft diabetes. Follow-up of these patients and medically underserved patient failure. Dr Kieffer’s group has also shows that islet transplantation and populations.11,12 She is conducting developed protocols for generating the resulting improvement in glucose community-based trials investigating human insulin-producing cells from regulation has slowed progression of the impact of low-cost, sustainable embryonic stem cells completely in microvascular complications.4 Clin- behavioral interventions on glycemic the laboratory dish.15,16 Insulin-produ- ical studies of islet transplant recipi- control, diabetes distress, and other cing cells derived from stem cells are ents in Vancouver have also identified health-related outcomes in South now entering clinical trials, including beta cell prohormones as biomarkers Asian Canadians and members of one in Vancouver. This exciting area of islet graft function that may have other ethnic communities. of research has led to a number of value in predicting islet transplant collaborative studies with UBC and failure.5 UBC Point Grey campus BCCH researchers aiming to further Importantly, the availability of In the regulatory peptide group of improve these protocols and to engin- human islets for research has stimu- the UBC Department of Cellular and eer better beta cells that can evade im- lated collaborative research projects Physiological Sciences (formerly the mune attack, last longer, and function in human islet biology among many Department of Physiology) the retire- better following transplantation. BC-based diabetes researchers. For ment of investigators once threatened Other laboratories in the UBC example, using human islets from to leave a void in diabetes research Life Sciences Institute are studying the Ike Barber lab, local researchers in BC. Fortunately, this was avoid- the genetics of obesity, insulin ac- reported that immune-suppressive ed with the recruitment of Dr Tim tion, and lipid metabolism, as well drugs such as tacrolimus, typically Kieffer in 2002 and Dr Jim Johnson as viral pathogenesis of type 1 dia- used in islet transplant recipients to in 2004. These capable investiga- betes. Long-standing research activ- prevent allograft rejection, have dele- tors have now developed large and ity at UBC is continuing in the areas terious effects on human beta cell diverse diabetes research programs of insulin action and diabetes compli- function and thus may contribute to with strengths in islet biology, and cations, pharmacological modulation graft failure.6 This widely cited find- have made significant contributions of insulin sensitivity, and changes ing has led to greater consideration of to our understanding of incretin, lep- in cardiac metabolism that occur in the impact immunosuppressive proto- tin, and stem cell biology, as well as diabetes. One example is Dr Brian cols have on transplanted islets. Oth- hyper­insulinemia and obesity. Rodrigues’s work, which has led to a er human islet studies have provided Dr Johnson has used novel mouse better understanding of the metabolic new insight into why toxic islet amy- models of altered insulin production machinery that drives energy metab- loid plaques form in type 2 diabetes to gain insight into the biology and ac- olism in the cardiomyocyte and endo- and how they induce inflammation tions of insulin, pointing to unappre- thelial cell and its breakdown in the and beta cell loss.7 Related studies ciated roles for hyperinsulinemia in diabetic state.17 This information is have suggested that the beta cell death obesity and lifespan. He has shown now being used to devise novel thera- and dysfunction in islet transplants re- that genetically decreasing insulin peutic strategies to prevent or delay sembles the beta cell failure seen in production in mice confers protection diabetes-related heart disease.

456 bc medical journal vol. 60 no. 9, november 2018 bcmj.org From beta cells to bedsides: A 2018 update on diabetes research in British Columbia

BC Children’s Hospital loss in type 1 diabetes. These stud- Indigenous people and youth with Laboratory-based diabetes research at ies have also shown the tremendous mental illness. These studies have BCCH and its associated research in- power of the chimeric antigen receptor shown that youth prescribed cer- stitute began in the early 1990s under (CAR) to generate CAR T regulatory tain antipsychotic medications have the leadership of Dr Aubrey Tingle, cells with the potential to attenuate a twofold to threefold increased risk who partnered with UBC departments allograft responses to islet transplants of being overweight or developing to recruit new clinician scientists and and enhance graft survival. prediabetes,28 a discovery that has led wet laboratory investigators to build The BCCH diabetes research to changes in clinical practice guide- childhood diabetes research capacity group in the CFKF Childhood Dia- lines regarding the use of such medi- and programs focused on autoimmun- betes Laboratories has made a cations in these youth. Other studies ity in type 1 diabetes, viral pathology, number of impactful discoveries. have sought a better understanding antigen presentation, and causes of Pediatric endocrinologists at BCCH of cardiovascular complications in beta cell death and dysfunction in teamed with laboratory investiga- obese youth.29 BCCH is also home to diabetes. In the 2000s, childhood tors to demonstrate that children with studies aimed at reducing the preva- diabetes research in BC received a recent-onset type 1 diabetes have lence of obesity in youth through life- boost with investments from multiple higher circulating levels of a T cell style modification approaches such partners, including the BCCH Foun- subtype (Th17) that secretes a pro- as SCOPE, a program for preventing dation, Diabetes Canada (formerly inflammatory cytokine (IL-17).25 This childhood obesity through commun- known as the Canadian Diabetes As- work provided the rationale for test- ity engagement.30 Finally, BCCH sociation), UBC, and the Canucks for ing ustekinumab (a drug used in the clinicians have played a key role in Kids Fund (CFKF). With the help of treatment of psoriasis) in patients with enabling childhood diabetes transla- these partners, infrastructure fund- type 1 diabetes in a clinical trial now tional research to occur, spearheading ing from the Canada Foundation for underway in Vancouver (clinicaltrials multiple collaborative clinical studies Innovation and BC Knowledge De- .gov: NCT02117765). with laboratory-based investigators. velopment Fund, and the construction Other translational studies at of the Translational Research Build- BCCH have led to the recent discov- Research sites outside ing at BCCH, I was fortunate to be ery of circulating biomarkers of po- Vancouver able to recruit four laboratory-based tential value in predicting progression Outside Vancouver, diabetes research diabetes investigators. These indi- to diabetes and prognosis, including a is gaining in strength. At UBC Oka- viduals established strong research unique gene signature expressed in T nagan, discoveries have been made programs in beta cell development regulatory cells in patients with type 1 in the areas of nutrition and exer- and biology funded by the Canadian diabetes23 and peptides derived from cise. Links have been uncovered be- Institutes of Health Research.18-20 Our beta cell prohormones.5 Wet labora- tween intake of polyunsaturated fats growing diabetes research group was tory studies have provided new insight and the risk of developing diabetes,31 soon joined by other experienced into genes involved in the regula- and clinical studies have shown how BCCH investigators looking at the tion of pancreatic beta cell develop- exercise, in particular high-intensity genetics of metabolic disease, the epi- ment and function,18-20 and elucidated interval training (HIIT), impacts in- genetics of diabetes complications,21 how beta cell dysfunction occurs in flammation and metabolism in hu- and the role of nutrition.22 type 2 diabetes, pointing to roles for mans, providing evidence that HIIT Diabetes and transplant immunol- cholesterol accumulation26 and islet may reduce cardiovascular complica- ogy research was greatly strengthened macrophages.27 tions in type 2 diabetes.32 by the move from VGH to BCCH of BCCH also has strengths in clin- At the University of Northern Dr Megan Levings, who has estab- ical pediatric diabetes research. In BC, research has been aimed at de- lished a leading research program in addition to participating in type 1 veloping medications to manipulate human T regulatory cell biology.23,24 diabetes clinical trials through Trial- metabolic signalling pathways in adi- Recent studies in diabetes auto- Net, BCCH has strong community- pose tissue.33 immunity at BCCH by Levings and based clinical and population health Finally, at Simon Fraser Univer- colleagues have generated a better research programs. Clinical stud- sity, Dr Scott Lear is investigating understanding of the mechanisms that ies have investigated diabetes risk obesity and diabetes, and the role of lead to T cell activation and beta cell in vulnerable populations, including environment, ethnicity, and lifestyle

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 457 From beta cells to bedsides: A 2018 update on diabetes research in British Columbia

in chronic disease. This builds on an to create new opportunities through Competing interests important international study led by the sharing of data and ideas and the This and the other articles in the theme Dr Lear that showed physical activ- spawning of new partnerships and issue were developed under the aus- ity of any kind can reduce the risk of collaborations. Given the prevalence pices of the Division of Endocrinology at diabetes and heart disease.34 and burden of diabetes in our prov- the University of British Columbia and ince, country, and world, it is timely supported by an educational grant from The future and exciting that BC is now home to AstraZeneca Canada Inc., Merck & Co. The future is bright for diabetes re- this network and is increasingly tak- Inc., Novo Nordisk Canada Inc., Boehringer search in BC. A strong and collegial ing a leadership role in diabetes re- Ingelheim Canada Ltd., and Janssen Inc., environment is fostering collabora- search on the international stage. a Division of Johnson & Johnson. Like the tive studies across the various dia- other theme issue authors, Dr Verchere betes research sites in BC, and wet Summary was a volunteer and received no remu- laboratory researchers are increasing- The need has never been greater for neration for his time or efforts and was un- ly working closely with diabetes clin- research into diabetes and new ap- aware of the sponsors’ identities until after icians to move research from bench to proaches to predict, prevent, and this article was submitted to the BCMJ. bedside and back again. Current and reverse this devastating condition. Funds were used exclusively for travel and future clinical trials show promise Fortunately, the rich history of dia- logistical support. Sponsors were not in- in applying laboratory-based discov- betes research in BC that began in volved in any aspect of the decision to de- eries to improving the lives of people the 1960s continues today at Vancou- velop this article, in the content of the arti- with diabetes. ver General Hospital, the UBC Point cle, in the selection of authors, or in any as- Islet biology is clearly a recog- Grey campus, BC Children’s Hospi- pect of the editorial process. Dr Verchere nized strength of BC’s diabetes re- tal, and other sites in the province, has no competing interests to disclose. searchers, with local investigators including UBC Okanagan, the Uni- making discoveries in how healthy versity of Northern British Columbia, References insulin-producing beta cells develop and Simon Fraser University. Many 1. Diabetes Canada. 2017 report on diabetes and function, what goes wrong with notable discoveries have been made in British Columbia. Accessed 2 April beta cells in diabetes, and how to cre- by investigators and islet biology has 2017. www.diabetes.ca/getmedia/8e38 ate insulin-producing cells in culture proven to be a particular research f0cd-a2c4-4c17-a7df-9a2b385df961/ and how to regenerate and replace strength. With the establishment of sv-2017-Diabetes-in-BC_final_HQ.aspx. beta cells. Tremendous opportunities the BC Diabetes Research Network, 2. Pederson RA, McIntosh CH. Discovery of exist for training in diabetes research more discoveries and more collabora- gastric inhibitory polypeptide and its sub- across multiple disciplines, from tion can be expected. sequent fate: Personal reflections. J Dia- genetics to cell biology to physiol- betes Investig 2016;7(suppl 1):4-7. ogy, allowing BC to attract outstand- Acknowledgments 3. Pederson RA, White HA, Schlenzig D, et ing diabetes research talent to train Research described in this article is sup- al. Improved glucose tolerance in Zucker here. Fantastic new technologies are ported by a number of funders, including fatty rats by oral administration of the di- available as well. For example, we the Canadian Institutes of Health Research, peptidyl peptidase IV inhibitor isoleucine now have mouse models of disease, JDRF, Diabetes Canada, and Stem Cell thiazolidide. Diabetes 1998;47:1253-1258. and tools that enable deep interroga- Network. The BC Diabetes Research 4. Thompson DM, Meloche M, Ao Z, et al. tion of single cells from subjects with Network is funded through the Research Reduced progression of diabetic micro- diabetes. Excellence Clusters Initiative at UBC. vascular complications with islet cell The newly formed UBC-funded Dr Verchere is supported by an investiga- transplantation compared with intensive BC Diabetes Research Network torship from BC Children’s Hospital and the medical therapy. Transplantation 2011;91: (https://diabetesbc.ca) promises to Irving K. Barber Chair in Diabetes Research. 373-378. bring researchers together from dif- In addition, Dr Verchere wishes to acknowl- 5. Courtade JA, Klimek-Abercrombie AM, ferent disciplines at regular meetings, edge the editorial assistance of Cynthia N. Chen YC, et al. Measurement of pro-islet including the annual Vancouver Dia- Lank (Halifax, NS) and the logistical support amyloid polypeptide (1-48) in diabetes and betes Research Day held each fall, and of Aleta Allen (Division of Endocrinology, islet transplants. J Clin Endocrinol Metab UBC Okanagan Diabetes Research UBC) for their part in supporting the publi- 2017;102:2595-2603. Day. These meetings can be expected cation of this theme issue. 6. Johnson JD, Ao Z, Ao P, et al. Different

458 bc medical journal vol. 60 no. 9, november 2018 bcmj.org From beta cells to bedsides: A 2018 update on diabetes research in British Columbia

effects of FK506, rapamycin, and myco- 16. Bruin JE, Rezania A, Kieffer TJ. Replacing 26. Brunham LR, Kruit JK, Verchere CB, phenolate mofetil on glucose-stimulated and safeguarding pancreatic β cells for Hayden MR. Cholesterol in islet dysfunc- insulin release and apoptosis in human diabetes. Sci Transl Med 2015;7:23. tion and type 2 diabetes. J Clin Invest islets. Cell Transplant 2009;18:833-845. 17. Wan A, Rodrigues B. Endothelial cell-car- 2008;118:403-408. 7. Park YJ, Warnock GL, Ao Z, et al. Dual role diomyocyte crosstalk in diabetic cardio- 27. Westwell-Roper CY, Ehses JA, Verchere of interleukin-1β in islet amyloid formation myopathy. Cardiovasc Res 2016;111:172- CB. Resident macrophages mediate islet and its β-cell toxicity: Implications for type 183. amyloid polypeptide-induced islet IL-1β 2 diabetes and islet transplantation. Dia- 18. Krentz NA, van Hoof D, Li Z, et al. Phos- production and β-cell dysfunction. Diabe- betes Obes Metab 2017;19:682-694. phorylation of NEUROG3 links endocrine tes 2014;63:1698-1711. 8. Potter KJ, Westwell-Roper CY, Klimek- differentiation to the cell cycle in pancre- 28. Panagiotopoulos C, Ronsley R, Davidson Abercrombie AM, et al. Death and dys- atic progenitors. Dev Cell 2017;41:129- J. Increased prevalence of obesity and function of transplanted β-cells: Lessons 142. glucose intolerance in youth treated with learned from type 2 diabetes? Diabetes 19. Campbell SA, Hoffman BG. Chromatin second-generation antipsychotic medica- 2014;63:12-19. regulators in pancreas development and tions. Can J Psychiatry 2009;54:743-749. 9. Potter KJ, Abedini A, Marek P, et al. Islet diabetes. Trends Endocrinol Metab 2016; 29. Cote AT, Phillips AA, Harris KC, et al. Obe- amyloid deposition limits the viability of 27:142-152. sity and arterial stiffness in children: Sys- human islet grafts but not porcine islet 20. Aharoni-Simon M, Shumiatcher R, Yeung tematic review and meta-analysis. Arte- grafts. Proc Natl Acad Sci U S A 2010; A, et al. Bcl-2 regulates reactive oxygen rioscler Thromb Vasc Biol 2015;35: 107:4305-4310. species signaling and a redox-sensitive 1038-1044. 10. Sherifali D, Meneilly G. Diabetes manage- mitochondrial proton leak in mouse pan- 30. Amed S, Naylor PJ, Pinkney S, et al. Creat- ment and education in older adults: The creatic β-cells. Endocrinology 2016;157: ing a collective impact on childhood obe- development of a national consensus of 2270-2281. sity: Lessons from the SCOPE initiative. key research priorities. Can J Diabetes 21. Harel S, Cohen AS, Hussain K, et al. Alter- Can J Public Health 2015;106:e426-e433. 2016;40:31-34. nating hypoglycemia and hyperglycemia 31. Pither J, Botta A, Maity C, Ghosh S. Anal- 11. Tang TS, Funnell M, Sinco B, et al. Com- in a toddler with a homozygous p.R1419H ysis using national databases reveals a parative effectiveness of peer leaders and ABCC8 mutation: An unusual clinical pic- positive association between dietary poly- community health workers in diabetes ture. J Pediatr Endocrinol Metab 2015;28: unsaturated fatty acids with TV watching self-management support: results of a 345-351. and diabetes in European females. PLoS randomized controlled trial. Diabetes Care 22. Aleliunas RE, Aljaadi AM, Laher I, et al. One 2017;12:e0173084. 2014;37:1525-1534. Folic acid supplementation of female 32. Francois ME, Little JP. The impact of 12. Tang TS, Funnell MM, Sinco B, et al. Peer- mice, with or without vitamin B-12, before acute high-intensity interval exercise on led, empowerment-based approach to and during pregnancy and lactation pro- biomarkers of cardiovascular health in self-management efforts in diabetes grams adiposity and vascular health in type 2 diabetes. Eur J Appl Physiol 2017; (PLEASED): A randomized controlled trial adult male offspring. J Nutr 2016;146: 117:1607-1616. in an African American community. Ann 688-696. 33. Hogh KN, Craig MN, Uy CE, et al. Overex- Fam Med 2015;13(suppl 1):S27-35. 23. Pesenacker AM, Wang AY, Singh A, et al. pression of PPARγ specifically in pancre- 13. Mehran AE, Templeman NM, Brigidi GS, A regulatory T-cell gene signature is a spe- atic β-cells exacerbates obesity-induced et al. Hyperinsulinemia drives diet-in- cific and sensitive biomarker to identify glucose intolerance, reduces β-cell mass, duced obesity independently of brain in- children with new-onset type 1 diabetes. and alters islet lipid metabolism in male sulin production. Cell Metab 2012;16:723- Diabetes 2016;65:1031-1039. mice. Endocrinology 2014;155:3843-3852. 737. 24. Patterson SJ, Pesenacker AM, Wang AY, 34. Lear SA, Hu W, Rangarajan S, et al. The 14. Templeman NM, Flibotte S, Chik JH, et al. et al. T regulatory cell chemokine produc- effect of physical activity on mortality and Reduced circulating insulin enhances in- tion mediates pathogenic T cell attraction cardiovascular disease in 130 000 people sulin sensitivity in old mice and extends and suppression. J Clin Invest 2016; from 17 high-income, middle-income, and lifespan. Cell Rep 2017;20:451-463. 126:1039-1051. low-income countries: The PURE study. 15. Rezania A, Bruin JE, Arora P, et al. Rever- 25. Marwaha AK, Crome SQ, Panagiotopou- Lancet 2017;390(10113):2643-2654. sal of diabetes with insulin-producing cells los C, et al. Cutting edge: Increased IL- derived in vitro from human pluripotent 17-secreting T cells in children with new- stem cells. Nat Biotechnol 2014;32:1121- onset type 1 diabetes. J Immunol 2010; 1133. 185:3814-3818.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 459 obituaries

Dr Richard Wadge Rick was happily married to his married at Westminster Cathedral, 1946–2018 wife Mavourneen for 50 years and London, UK, in 1964. He was then together they were blessed with four posted to the divided city of Berlin, children: Jeff (Sara), Patrick (Zan), deep inside East Germany. In Berlin, Joy (Remo), and Chantal (Avassa). Dad welcomed the birth of a baby girl His eight grandchildren loved him and boy. The experience of living in dearly and he was an amazing “Bom- Berlin for those years initiated Dad’s pa” to them all. love of Germany, its history, people, Rick faced his ALS diagnosis and culture. with unflinching courage, and when In 1968, John and his family came the time came he exercised his right to Canada, where he would serve as to die on his own terms, in his own a public health physician starting in home, with his wife by his side and Prince George, next in Vancouver, surrounded by his family. where he obtained his FRCPC at —Alex Wadge UBC, and then to Kamloops. Harvard Sechelt, BC University and the United States then beckoned, and he completed a grad- Dr Richard (Rick) Wadge (UBC class Dr John Daniel Garry uate degree in epidemiology at the of 1970) practised family medicine 1936–2018 Harvard School of Public Health. in the Surrey/Delta region for 37 John’s public health career con- years. During his lengthy tenure as tinued in Vancouver and Richmond. a family doctor, Rick was devoted to He had a strong sense of public duty his patients, providing care in nursing and continued his military interest as homes, making house calls, and de- a physician in the Canadian Army livering over 1000 babies. His com- Reserve Force, becoming the com- passion, sense of humor, and ability manding officer of the 12th Vancou- to focus on an individual gave him ver Medical Company. a personal touch that endeared him John’s life was very blessed and as an exemplary doctor to his many he enjoyed many adventures and pur- patients. Rick clearly enjoyed his ca- suits. He was an avid golfer his en- reer, which saw him help thousands tire life. He and Julie traveled often to of people, and often spoke about how Germany, elsewhere in Europe, and to fortunate it was to be a physician. Australia to visit family and friends. After retiring from office practice, Dr John Daniel Garry had an exciting Dad declined over the last year Rick, a clinical associate professor, and rewarding life and career that of his life. However, he welcomed increased his involvement with the spanned the world. Dad was born in his granddaughter, Elise, in January UBC School of Medicine, accepting Kildysart, County Clare, Ireland, on 7 2017. Elise and Dad formed a unique a teaching position with the university June 1936. He was influenced by the bond and enjoyed each other’s com- where he taught students how to com- many physicians in his family to pany immensely. municate and how to properly conduct study medicine, and he completed his Our adventures with Dad have physical and sensitive examinations. medical studies in 1961 in Dublin at ended; however, this is just tempo- Rick enjoyed teaching as much as he the Royal College of Surgeons in rary. Mom, Alice, and I can’t wait to loved practising medicine, and many Ireland. continue the journey with him and of the qualities that made him such a Not being afraid of challenges, he join him in the future in everlasting great doctor made him an equally ex- joined the British Army at the height life together. ceptional teacher. Rick loved working of the Cold War as a physician. He —Benedict M. Garry, MD, CCFP with the patient simulation actors and was initially posted to Australia and Vancouver always spoke of them with the highest the Maralinga Nuclear Testing Fa- praise. He was also the chief exam- cility in South Australia. He met his iner for the LMCC. wife, Julie, in Sydney and they were

460 bc medical journal vol. 60 no. 9, november 2018 bcmj.org obituaries

was the nature of practice in those and acceptance. He was indefatig- days. Fred relished in it, working late ably cheerful, always polite, always into his life, always on top of things, considerate. on time, and enthusiastic. Every encounter ended with the Fred was also a patient of mine, gentle incantation: “Thank you, and and of our group practice in Fort Lang- God bless.” His demeanor reminded ley, for many years. Providing care to me of the saying, “The true measure a fellow physician is a great privilege, of a man is not to be found when the but can also be a great challenge as going is easy. Real character emerges they may prefer to direct their own when adversity strikes.” care. They may bristle at the reversal Fred Ceresney was such a man— of roles. They may be demanding. Or honorable in his personal life, com- noncompliant. But Fred was none of passionate and humane in his dealings these things—in fact, it was a remark- with people from all walks of life, able and mutually shared journey. ethical in his profession, and finally, Yes, Fred was the patient (technic- courageous and graceful in the face ally), and I was the physician (tech- of terminal failure and death. His life, Dr Fred Ceresney nically). But, somehow, together, in a and his living of it, is an inspiration 1927–2018 spirit of cooperation and teamwork, to us all, as physicians and as human Dr Fred Ceresney was born during the we navigated the treacherous waters beings. Roaring Twenties, graduated from the of his declining health in late mid- —Alister F. Frayne, MD University of Toronto, and served in dle life, and the rapids of his failing Fort Langley the Canadian armed forces as a med- health in old age. And, as the list of Adapted from remarks given at the ical officer before setting up family ailments and diagnoses grew, as was Langley Division of Family Practice practice in Langley. inevitable, so did Fred’s equanimity AGM, 26 September 2018. He was attracted to the area by his military compatriot Dr George Neil- son, who was the founder of the ori- ginal Fort Langley practice, where I now work. Fred served his patients in this same area for over 50 years. He saw Langley grow from a small rural agricultural community to the bust- ling suburban community it is today. Medical practice in those days was varied, interesting, and fulfilling—the very definition of a patient-centred service. Fred and his colleagues per- fected this model years ago, provid- ing availability and services around the clock to their patients. “Full service” doesn’t begin to describe it. According to Ina, Fred’s wife of 61 years—who answered the phone 24/7 in addition to caring for 10 children—the average day would end with 10 to 15 house calls. This was often followed by an overnight on-call for the hospital. More often than not she would wake to find the space be- side her in the bed empty and cold— Fred would be up at emergency, or in the OR, or in the maternity ward. This

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 461 bc centre for disease control

Raccoon latrines and risk of Baylisascaris transmission

ike it or not, raccoons are part Table. Clinical presentations of Baylisascaris larval migrans. of our urban landscapes. They Lcan be found eating, sleeping, Neural Ocular Visceral and defecating in parks, backyards, • Loss of coordination and • Visual impairment or • Macular rash and other areas where British Co- muscle control blindness (often one-sided) • Abdominal pain • Lethargy • Photophobia • Hepatomegaly lumbians live, work, and play. While • Seizures • Pneumonitis some may find them cute and others • Coma may find them a nuisance, what is certain is that raccoons commonly especially in cases of neural larval they can shed in their feces, racoon la- carry a serious zoonotic pathogen, migrans. The clinical effects of Bay- trines represent a health risk to people Baylisascaris procyonis or raccoon lisascaris are more severe than with and their pets. Baylisascaris eggs take roundworm. A large percentage (60% other parasites that cause larval mi- from 2 to 4 weeks to become infec- to 80%) of BC raccoons harbor this grans (e.g., Toxocara spp.) because tious and can remain viable in the en- parasite.1 Although human Baylisas- the larva continues to grow in the vironment for years.3 caris infections are extremely rare, intermediate host, causing extensive Prevention strategies include the clinical repercussions of this tissue damage and reaction.3 promptly removing latrines from larva migrans infection can be very Diagnosis of Baylisascaris is dif- affected properties and deterring severe or even fatal. This disease is ficult; consultation with medical mi- raccoons from revisiting, keeping not reportable in BC and the BCCDC crobiology and infectious disease children away from raccoon sites is aware of only two cases: one in a specialists is recommended. Diag- and deterring them from putting their 17-month-old boy and another in an nostic results from hematology (e.g., hands in their mouths when playing elderly woman with Alzheimer dis- eosinophilia), serology (Baylisasca- outside, keeping pets dewormed, and ease who was asymptomatic.2 ris antibodies), ocular examination, practising effective hand and house- Infection with Baylisascaris oc- and imaging contribute to a final di- hold hygiene when latrines and rac- curs when humans ingest infectious agnosis of Baylisascaris infection. In coons are present.4 eggs from raccoon feces or from addition, microscopy of suspect soil —Erin Fraser, DVM, MSc food, water, objects, or soil contami- or raccoon feces can be examined Public Health Veterinarian, nated with racoon feces that contain for infectious eggs. Early treatment BCCDC infectious eggs. Globally, cases are with albendazole has been shown to —Eleni Galanis MD, MPH, most commonly reported in children be effective if given within 3 days of FRCPC as they are more likely to have contact ingestion of the contaminated sub- Physician epidemiologist, BCCDC with infected raccoon feces, particu- stance (e.g., raccoon feces, infected —Muhammad Morshed PhD, larly in children with pica or geopha- soil). Once clinical signs develop, SCCM gia. Generalized clinical signs and treatment entails a combination of al- Program Head, Zoonotic Diseases symptoms, which often appear 1 to 4 bendazole, corticosteroids, and other & Emerging Pathogens, BCCDC weeks after infection, can include fa- supportive therapies depending on the Public Health Laboratory tigue, nausea, and fever. Other clini- organs that are affected.3 Program Head, Parasitology, cal presentations can take months to Raccoons habitually defecate in BCCDC Public Health Laboratory years to develop and depend on the the same location as other raccoons migratory pathway of the larva, cat- residing in the vicinity. Often these References egorized as neural, ocular, or visceral latrines, which can be shared by one 1. Ching HL, Leighton BJ, Stephan C. Intes- larva migrans ( Table ). to six raccoons, are near areas of hu- tinal parasites of raccoons (Procyon lotor) The prognosis of Baylisasca- man activity, such as in backyard from southwest British Columbia. Can J ris infection is often not favorable, woodpiles, around trees or shrubs, Vet Res 2000;64:107-111. or in open structures such as garages, 2. Hung T, Neafie RC, Mackenzie IRA. Bayl- This article is the opinion of the BC Centre decks, or attics. With the high preva- isascaris procyonis infection in elderly per- for Disease Control and has not been peer lence of Baylisascaris procyonis in son, British Columbia, Canada. Emerg In- reviewed by the BCMJ Editorial Board. racoons and the millions of eggs that Continued on page 464

462 bc medical journal vol. 60 no. 9, november 2018 bcmj.org council on health promotion

Climate change and infectious disease in Canada and BC

limate change in BC is pre- dengue, and Zika in travelers. Though of V. parahaemolyticus are expected dicted to bring warmer, rain- these diseases may not expand their in coming decades. ier winters; drier summers; range to BC, they will increase their C 1 and more extreme weather events. range into areas that Canadian trav- Other diseases As a result, interactions between peo- elers visit, including the Caribbean, Other diseases, such as Legionellosis, ple, the environment, and pathogens Latin America, and Asia.2 also peak in warmer months. A warm- will change. Here we review changes ing climate may increase the inci- to infectious diseases that clinicians dence of Legionella-related diseases. In Canada, outbreaks of may see as a result of climate change. E. coli, Campylobacter, Recommendations Vector-borne diseases and Cryptosporidium for clinicians Climate is a key factor in vector dis- have been linked to Clinicians should be vigilant for tribution and to a lesser extent the summer weather, and changing patterns of infectious dis- occurrence of vector-borne diseases. outbreaks may become eases that may be related to extreme The incidence of Lyme disease is in- weather and climate change. In par- more frequent in creasing in Eastern Canada as Ixodes ticular, extreme weather events such scapularis, the tick vector of this dis- the future. as heavy rainfall have been associated ease, expands its range northward into with an increased risk of outbreaks of populated regions.2 In BC, the tick Enteric diseases waterborne disease, and other dis- I. pacificus is the main carrier of Lyme Many enteric diseases are more com- eases such as Legionellosis peak dur- disease. It is already present in popu- mon in summer, partially due to pre- ing warm months and may increase lated regions and is likely to expand cipitation. Heavy rainfall, particularly as the climate warms. Warmer waters into less-populated regions.3 after a drought, can flush a pulse of may also increase the risk of infec- Incidence of West Nile virus, the contaminated material into water tious diseases from locally harvested most common mosquito-borne dis- supplies. This can be exacerbated by shellfish. ease in Canada, also may increase precipitation-related turbidity, which Clinicians should be aware of re- in BC with climate change. Levels may reduce the effectiveness of water portable infectious diseases in BC and of mosquitos from the genus Culex, treatment.6 This may be relevant in notify their local medical health offi- which transmit the virus to humans, BC with climate change predicted to cer of any outbreaks or unusual occur- have been linked to warm winters and bring heavier fall precipitation fol- rences of disease. Surveillance will be warm, wet springs that promote mos- lowing hotter and drier summers. key to understanding the interaction quito breeding and feeding.4 Though Activities associated with warm between climate change and infec- incidence of West Nile virus has been weather (e.g., swimming, boating, tious diseases. low in BC, more frequent weather and communal outdoor eating) also —David McVea, MD extremes on the back of a warm- contribute to this seasonal pattern of —Ray Copes, MD er climate may contribute to future waterborne illness. In Canada, out- —Eleni Galanis, MD outbreaks.5 breaks of E. coli, Campylobacter, and Clinicians are also likely to en- Cryptosporidium have been linked to References counter greater numbers of vector- summer weather, and outbreaks may 1. Pacific Climate Impacts Consortium. Plan- borne diseases such as Chikungunya, become more frequent in the future. 2Adapt. Accessed 19 September 2018. Enteric pathogens may also grow www.pacificclimate.org/analysis-tools/ This article is the opinion of the Environ- more widely and rapidly in warmer plan2adapt. mental Health Committee, a subcommit- weather. For example, outbreaks of 2. Greer A, Ng V, Fisman D. Climate change tee of Doctors of BC’s Council on Health Vibrio parahaemolyticus in BC have and infectious diseases in : Promotion, and is not necessarily the opin- been associated with above-aver- The road ahead. CMAJ 2008;178:715- ion of Doctors of BC. This article has not age ocean temperatures, which pro- 722. been peer reviewed by the BCMJ Editorial mote growth and proliferation of this 3. Henry B, Morshed M. Lyme disease in 7 Board. pathogen. More frequent outbreaks Continued on page 464

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 463 cohp news

Continued from page 463 Continued from page 435 ment information already provided British Columbia: Are we really missing Microsystems & Nanoengineering. through Facebook (www.facebook an epidemic? BCMJ 2011;53:224-229. .com/keltymentalhealth) and Twitter 4. Paz S. Climate change impacts on West Revamped mental health (https://twitter.com/KeltyCentre), Nile virus transmission in a global con- and substance use connecting followers to the latest text. Philos Trans R Soc Lond B Biol Sci website for young people resources and information on mental 2015;370:20130561. The BC Children’s Kelty Men- health and substance use via social 5. Kulkarni MA, Berrang-Ford L, Buck PA, tal Health Resource Centre has media. et al. Major emerging vector-borne zoo- launched a new website so families In addition to the website, the notic diseases of public health impor- and health professionals can more Kelty Centre offers a variety of ser- tance in Canada. Emerg Microbes Infect easily find mental health and sub- vices so that children, youth, and 2015;4:e33. stance use information and resour- families can find the help they need, 6. Yusa A, Berry P, Cheng JJ, et al. Climate ces to support children and youth. when they need it, as close to their change, drought and human health in The website, keltymentalhealth home communities as possible. This Canada. Int J Environ Res Public Health .ca, contains information, tools, and includes peer support services from 2015;12:8359-8412. services, including evidence-based trained young adults and parents 7. Taylor M, Cheng J, Sharma D, et al. Out- supports, created by trusted health with experience in child and youth break of Vibrio parahaemolyticus associ- experts at BC Children’s Hospital. mental health, through a collabora- ated with consumption of raw oysters in Kelty also launched a new Instagram tion with FamilySmart. Canada, 2015. Foodborne Pathog Dis account (@keltycentre) to comple- 2018;15:554-559.

bccdc Continued from page 462 fect Dis 2012;18:341-342. 3. Gavin PJ, Kazacos KR, Shulman ST. Bay- lisascariasis. Clin Microbiol Rev 2005;18:703-718. 4. BC Centre for Disease Control. Raccoon roundworm (Baylisascaris procyonis in- fection). Accessed 21 September 2018. nov-files-combined.docwww.bccdc.ca/ health-info/diseases-conditions/rac- coon-roundworm.

CIBC WOOD GUNDY

Peter Leacock has provided thoughtful investment advice to doctors and their families for the past 20 years. Client discretionary portfolio returns over the past 10 years have ranked ahead of 99% of peer group mutual funds1. Contact Peter for a complimentary consultation. Clients qualify for a complimentary financial plan. Minimum account size $250,000. Peter Leacock, BSc, MBA, CFA, Senior Portfolio Manager 604 806-5529 | [email protected] | www.cibcwg.com/web/peter-leacock 1 Ranked 10th out of 1,204 balanced mutual funds in Canada. Source: Morning Star Advisor Workstation, April 30, 2018.

CIBC Private Wealth Management consists of services provided by CIBC and certain of its subsidiaries, including CIBC Wood Gundy, a division of CIBC World Markets Inc. “CIBC Private Wealth Management” is a registered trademark of CIBC, used under license. “Wood Gundy” is a registered trademark of CIBC World Markets Inc. Past performance is not a guarantee of future performance. If you are currently a CIBC Wood Gundy client, please contact your Investment Advisor.

464 bc medical journal vol. 60 no. 9, november 2018 bcmj.org cme calendar

GP IN ONCOLOGY CASE guidelines in cancer care. Both offer includes great speakers and learning STUDY DAY & FP ONCOLOGY opportunity to build helpful cancer materials. Topics and dates: 30 Nov CME DAY care connections, and are accredited (diagnostics and radiology). Topics Vancouver, 23–24 Nov (Fri–Sat) by the College of Family Physicians include: Cardiac imaging: When and BC Cancer’s Family Practice Oncol- of Canada for up to 5.75 Mainpro+ what to order; Imaging modalities in ogy Network is presenting two prac- credits each. Register today at bccan- hip pain; Cardiovascular risk screen- tice-ready CME events for family cersummit.ca. Full details at fpon.ca ing: What’s new; Office assessment of physicians at BC Cancer’s 80th Anni- or via [email protected] dementia: A practical approach; Inter- versary Summit, at the Sheraton Van- preting a DEXA scan: What’s in the couver Wall Centre—November 23: MINDFULNESS IN MEDICINE numbers; PSA screening: A debate; GPO (General Practitioner in Oncol- Brentwood Bay, 23–26 Nov Interpreting sex hormone lab val- ogy) Case Study Day, and November (Fri–Mon) ues; Choosing wisely: Primary care’s 24: Family Practice Oncology CME This foundations experiential work- most overused lab tests. The next ses- Day. GPO Case Study Day provides shop introduces the theory and prac- sions are: 25 Jan (therapeutics); 1 Mar in-depth exploration of prevalent tice of mindfulness and meditation for (geriatrics); 12 Apr (gynecology and and emerging challenges in cancer physicians, nurses, and other allied urology); 10 May (internal medicine). care through case-based discussion, health professionals. Bringing mind- To register and for more information, while Family Practice Oncology fulness into our lives allows us to build visit ubccpd.ca, call 604 675-3777; or CME Day provides insight into new resilience and to find joy and meaning email [email protected]. developments and practice changing in the work that we do. During this 4-day workshop we will explore the GP IN ONCOLOGY TRAINING unique challenges of health care; re- Vancouver, 4–15 Feb 2019 view the clinical and neuroscientific (Mon–Fri) CME listings basis of mindfulness; learn formal The BC Cancer Agency’s Family rates and details and informal skills of stress man- Practice Oncology Network offers an agement, self-care, and meditation; 8-week General Practitioner in Onc- Rates: $75 for up to 1000 char- and find ways to bring these into our ology training program beginning acters (maximum),­ plus GST per personal and professional lives. This with a 2-week introductory session month; there is no partial rate. If popular 16-hour workshop will take every spring and fall at the Vancouver the course or event is over be- place over 4 half days in Brentwood Centre. This program provides an op- fore an issue of the BCMJ Bay, leaving lots of opportunity to ex- portunity for rural family physicians, comes out, there is no discount. plore the beauty and recreation of the with the support of their community, Visa and Master­Card accepted. area. Each workshop is accredited for to strengthen their oncology skills so Deadlines: 16 Mainpro+ group learning credits that they may provide enhanced care Online: Every Thursday (list­ings and has a 30-person limit, so register for local cancer patients and their are posted every Friday). today! For more information, contact families. Following the introductory Print: The first of the month 1 us at [email protected], or session, participants complete a fur- month prior to the issue in check out https://livingthismoment ther 30 days of customized clinic ex- which you want your notice to .ca/event/mindfulness-in-health-care perience at the cancer centre where appear, e.g., 1 February for the -foundations-of-theory-and-practice. their patients are referred. These can March issue. The BCMJ is dis- be scheduled flexibly over 6 months. tributed by second-class mail in CME ON THE RUN Participants who complete the pro- the second week of each month except Jan­uary and August. VGH and various videoconference gram are eligible for credits from the locations, 30 Nov–10 May (Fri) College of Family Physicians of Can- Place your ad at www.bcmj CME on the Run sessions are held at ada. Those who are REAP-eligible .org/cme-advertising. You will the Paetzold Lecture Theatre, Van- receive a stipend and expense cover- be invoiced upon publication. couver General Hospital, and there age through UBC’s Enhanced Skills Payment is accepted by Visa or are opportunities to participate via Program. For more information or to Mastercard on our secure on- videoconference from various hospi- apply, visit www.fpon.ca, or contact line payment site. tal sites. Each program runs on Friday Jennifer Wolfe at 604 219-9579. afternoons from 1 p.m. to 5 p.m. and

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 465 college library guidelines for authors (short form)

DynaMed available through College Library The British Columbia Medical Journal wel- provide it to the BCMJ. This helps reviewers Permissions come letters, articles, and scientific papers. determine whether the paper will be accepted It is the author’s responsibility to obtain written Manuscripts should not have been submitted for publication, and may be used for a note to permission from both author and publisher for he College Library provides cific disease, condition, or drug top- decision trees that allow you to enter to any other publication. Articles are subject to accompany the text. material, including figures and tables, taken or College registrants access to ic is easy. On the main page enter a values in commonly used formulas to copyediting and editorial revisions, but authors 4. Consent. If the article is a case report or if an adapted from other sources. Permissions should DynaMed, a point-of-care search term into the search box or se- obtain numerical data, such as urinary remain responsible for statements in the work, individual patient is described, written consent accompany the article when submitted. T including editorial changes; for accuracy of ref- from the patient (or his or her legal guardian or information tool available online and lect from the A-to-Z browse option to protein excretion estimation. erences; and for obtaining permissions. Material substitute decision maker) is required. Tables and figures as a mobile app. DynaMed has clini- Registrants may access DynaMed may be submitted for publication consideration Papers will not be reviewed without this docu- Tables and figures should supplement the text, not duplicate it. Keep length and number of tables cally organized summaries for more DynaMed has clinically from the College Library’s Point by either email or post, though upon acceptance ment, which is available at www.bcmj.org. an electronic file must be provided for all sub- and figures to a minimum. Include a descriptive than 3200 topics, including more than organized summaries for of Care and Drug Tools web page References to published material missions except short letters. Send submissions title and units of measure for each table and Try to keep references to fewer than 30. Authors 1000 drug summaries from AHFS more than 3200 topics, (www.cpsbc.ca/library/search-mate to: The Editor, BC Medical Journal, journal@ figure. Obtain permission and acknowledge are responsible for reference accuracy. Refer- Drug Information, a source of com- including more than rials/point-of-care-drug-tools). The doctorsofbc.ca; 115–1665 West Broadway, the source fully if you use data or figures from ences must be numbered consecutively in the another published or unpublished source. parative, unbiased, and evaluative 1000 drug summaries from DynaMed mobile app is available for Vancouver, BC V6J 5A4; 604 638-2815; www order in which they appear in the text. Avoid .bcmj.org. Tables. Please adhere to the following guidelines: drug information. Drug topics can be AHFS Drug Information download for iOS and Android de- using auto-numbering as this can cause prob- lems during production. • Submit tables electronically so that they may FOR ALL SUBMISSIONS be formatted for style. searched by generic or brand names. vices, and downloading instructions Include all relevant details regarding publica- • Avoid unnecessary formatting. • Number tables consecutively in the order of DynaMed’s content is updated daily display topics. The browse option dis- are provided on the apps and audio- tion, including correct abbreviation of journal • Double-space all parts of all submissions. their first citation in the text and supply a brief titles, as in Index Medicus; year, volume num- and presented in an easy-to-read bul- plays a list of subject specialties (e.g., visual page (www.cpsbc.ca/library/ • Include your name, relevant degrees, e-mail title for each. leted format. allergic disorders, geriatrics) with re- search-materials/audiovisual). address, and phone number. ber, and inclusive page numbers; full names and • Place explanatory matter in footnotes, not in • Number all pages consecutively. locations of book publishers; inclusive page the heading. Navigating DynaMed for a spe- lated topics subsumed under the spe- For further information about numbers of relevant source material; full web • Explain all nonstandard abbreviations in foot- cialty heading. The recent-updates DynaMed or any other e-resource, CLINICAL ARTICLES/CASE address of the document, not just to host page, notes. and date the page was accessed. Examples: This article is the opinion of the Library of tab displays the daily updates made to please contact the Library at medlib@ REpORTS • Ensure each table is cited in the text. 1. Gilsanz V, Gibbons DT, Roe TF, et al. Vertebral Manuscripts of scientific/clinical articles and case Figures (illustrations). Please adhere to the fol- the College of Physicians and Surgeons of DynaMed. cpsbc.ca or call 604 733-6671. bone density in children: Effect of puberty. reports should be 2000 to 4000 words in length, lowing guidelines: BC and has not been peer reviewed by the DynaMed includes more than 500 —Robert Melrose including tables and references. Email to journal Radiology 2007;166:847-850. • Have figures drawn and photographed pro- BCMJ Editorial Board. interactive calculators, equations, and Librarian @doctorsofbc.ca. The first page of the manu- (NB: For more than three authors, list first three, fessionally; freehand or typewritten letter- script should carry the following: followed by “et al.”) ing will not be accepted. Instead of original • Title, and subtitle, if any. 2. Mollison PL. Blood Transfusion in Clinical drawings, X-ray films, or other material, send • Preferred given name or initials and last name Medicine. Oxford, UK: Blackwell Scientific scans of these at 300 dpi or higher (or good- for each author, with relevant academic de- Publications; 2004:178-180. quality black-and-white photographic prints, 3. O’Reilly RA. Vitamin K antagonists. In: “Does this mean grees. usually 5" x 7" but no larger than 8" x 10"). Online cannabis-related • All authors’ professional/institutional affili- Colman RW, Hirsh J, Marder VJ, et al. (eds). • Number figures consecutively in the order of MORE REASONS more car rides?” resources for physicians ations, sufficient to provide the basis for an Hemostasis and Thrombosis. Philadelphia, their first citation in the text and supply a brief author note such as: “Dr Smith is an associate PA: JB Lippincott Co; 2005:1367-1372. title for each. TO TRAVEL. professor in the Department of Obstetrics and 4. Health Canada. Canadian STD Guidelines, • Place titles and explanations in legends, not Gynecology at the University of British Col- 2007. www.hc-sc.gc.ca/hpb/lcdc/publicat/ on the illustrations themselves. With the legalization of umbia and a staff gynecologist at Vancouver std98/index.html (accessed 15 July 2018). • Provide internal scale markers for photo- cannabis use, Doctors of Hospital.” (NB: The access date is the date the author con- micrographs. • A structured or unstructured abstract of no sulted the source.) • Ensure each figure is cited in the text. Johnson is pleased to offer Doctors of BC members access BC has assembled a list of more than 150 words. If structured, the pre- References to unpublished material • Color is not normally available, but if it is to special rates on MEDOC® Travel Insurance. ferred headings are “Background,” “Methods,” necessary, an exception may be considered. relevant online resources for These may include articles that have been read “Results,” and “Conclusions.” You’ll also receive: physicians (www.doctorsofbc • Three key words or short phrases to assist in at a meeting or symposium but have not been Units .ca/resource-centre/cannabis indexing. published, or material accepted for publication Report measurements of length, height, weight, An unlimited number of 17 or 35 day (or less) trips outside of Canada but not yet published (in press). Examples: -resources-physicians). • Name, address, telephone number, and e-mail and volume in metric units. Give temperatures An unlimited number of trips within Canada of any duration 1. Maurice WL, Sheps SB, Schechter MT. in degrees Celsius and blood pressures in mil- address of corresponding author. 1 The list will be updated as Sexual activity with patients: A survey limetres of mercury. Report hematologic and Up to $8,000 trip cancellation , interruption, and delay benefits Authorship, copyright, disclosure, additional items are gathered. of BC physicians. Presented at the 52nd clinical chemistry measurements in the metric Up to $5 million in emergency medical coverage and consent form Annual Meeting of the Canadian Psychiatric If you have suggestions for system according to the International System of Up to $1,500 ($3,000 for family coverage) for lost, stolen or damaged bags When submitting a clinical/scientific/review Association, , MB, 5 October 2008. Units (SI). articles or clinical studies to paper, all authors must complete the BCMJ’s 2. Kim-Sing C, Kutynec C, Harris S, et al. Breast cancer and risk reduction: Diet, Abbreviations 1-855-473-8029 add to this list, please email four-part “Authorship, copyright, disclosure, and consent form.” physical activity, and chemoprevention. Except for units of measure, we discourage www.johnson.ca/doctorsofbc them to communications@ 1. Authorship. All authors must certify in writ- CMAJ. In press. abbreviations. However, if a small number are Group code: 685 doctorsofbc.ca. ing that they qualify as an author of the paper. Personal communications are not included in necessary, use standard abbreviations only, pre- Order of authorship is decided by the co-authors. the reference list, but may be cited in the text, ceded by the full name at first mention, e.g., in Johnson Inc. (“Johnson”) is a licensed insurance intermediary. MEDOC® is a Registered Trademark of Johnson. MEDOC® 2. Copyright. All authors must sign and return with type of communication (oral or written) vitro fertilization (IVF). Avoid abbreviations in is underwritten by Royal & Sun Alliance Insurance Company of Canada (“RSA”) and administered by Johnson. Valid communicant’s full name, affiliation, and date provincial or territorial health plan coverage required. The eligibility requirements, terms, conditions limitations and an “Assignment of copyright” prior to publica- the title and abstract. exclusions, which apply to the described coverage are as set out in the policy. Policy wordings prevail. *17 or 35 day tion. Published manuscripts become the prop- (e.g., oral communication with H.E. Marmon, maximum duration applicable to each trip outside of Canada. 1For a trip to be covered for Trip Cancellation, MEDOC® erty of the BC Medical Association and may not director, BC Centre for Disease Control, 12 Drug names coverage must be in effect on the day of booking your trip. If you book your trip prior to your insurance being in effect, your coverage for Trip Cancellation Insurance benefits will begin on the date the insurance premium is paid and the be published elsewhere without permission. November 2017). Use generic drug names. Use lowercase for policy is issued. Johnson and RSA share common ownership. Eligibility requirements, limitations, exclusions or 3. Disclosure. All authors must sign a “Dis- Material submitted for publication but not generic names, uppercase for brand names, e.g., additional costs may apply and/or may vary by province or territory. Call 1-855-473-8029 for details. closure of financial interests” statement and accepted should not be included. venlafaxine hydrochloride (Effexor).

466 bc medical journal vol. 60 no. 9, november 2018 bcmj.org guidelines for authorsguidelines for authors (short form) www.bcmj.org/submit-article (short form)

The British Columbia Medical Journal wel- provide it to the BCMJ. This helps reviewers Permissions come letters, articles, and scientific papers. determine whether the paper will be accepted It is the author’s responsibility to obtain written Manuscripts should not have been submitted for publication, and may be used for a note to permission from both author and publisher for to any other publication. Articles are subject to accompany the text. material, including figures and tables, taken or copyediting and editorial revisions, but authors 4. Consent. If the article is a case report or if an adapted from other sources. Permissions should remain responsible for statements in the work, individual patient is described, written consent accompany the article when submitted. including editorial changes; for accuracy of ref- from the patient (or his or her legal guardian or erences; and for obtaining permissions. Material substitute decision maker) is required. Tables and figures may be submitted for publication consideration Papers will not be reviewed without this docu- Tables and figures should supplement the text, by either email or post, though upon acceptance ment, which is available at www.bcmj.org. not duplicate it. Keep length and number of tables and figures to a minimum. Include a descriptive an electronic file must be provided for all sub- References to published material missions except short letters. Send submissions title and units of measure for each table and Try to keep references to fewer than 30. Authors to: The Editor, BC Medical Journal, journal@ figure. Obtain permission and acknowledge are responsible for reference accuracy. Refer- doctorsofbc.ca; 115–1665 West Broadway, the source fully if you use data or figures from ences must be numbered consecutively in the another published or unpublished source. Vancouver, BC V6J 5A4; 604 638-2815; www order in which they appear in the text. Avoid .bcmj.org. using auto-numbering as this can cause prob- Tables. Please adhere to the following guidelines: lems during production. • Submit tables electronically so that they may FOR ALL SUBMISSIONS be formatted for style. Include all relevant details regarding publica- • Avoid unnecessary formatting. • Number tables consecutively in the order of tion, including correct abbreviation of journal • Double-space all parts of all submissions. their first citation in the text and supply a brief titles, as in Index Medicus; year, volume num- • Include your name, relevant degrees, e-mail title for each. address, and phone number. ber, and inclusive page numbers; full names and • Place explanatory matter in footnotes, not in • Number all pages consecutively. locations of book publishers; inclusive page the heading. numbers of relevant source material; full web • Explain all nonstandard abbreviations in foot- CLINICAL ARTICLES/CASE address of the document, not just to host page, notes. REpORTS and date the page was accessed. Examples: • Ensure each table is cited in the text. 1. Gilsanz V, Gibbons DT, Roe TF, et al. Vertebral Manuscripts of scientific/clinical articles and case Figures (illustrations). Please adhere to the fol- bone density in children: Effect of puberty. reports should be 2000 to 4000 words in length, lowing guidelines: including tables and references. Email to journal Radiology 2007;166:847-850. • Have figures drawn and photographed pro- @doctorsofbc.ca. The first page of the manu- (NB: For more than three authors, list first three, fessionally; freehand or typewritten letter- script should carry the following: followed by “et al.”) ing will not be accepted. Instead of original • Title, and subtitle, if any. 2. Mollison PL. Blood Transfusion in Clinical drawings, X-ray films, or other material, send • Preferred given name or initials and last name Medicine. Oxford, UK: Blackwell Scientific scans of these at 300 dpi or higher (or good- for each author, with relevant academic de- Publications; 2004:178-180. quality black-and-white photographic prints, grees. 3. O’Reilly RA. Vitamin K antagonists. In: usually 5" x 7" but no larger than 8" x 10"). • All authors’ professional/institutional affili- Colman RW, Hirsh J, Marder VJ, et al. (eds). • Number figures consecutively in the order of ations, sufficient to provide the basis for an Hemostasis and Thrombosis. Philadelphia, their first citation in the text and supply a brief author note such as: “Dr Smith is an associate PA: JB Lippincott Co; 2005:1367-1372. title for each. professor in the Department of Obstetrics and 4. Health Canada. Canadian STD Guidelines, • Place titles and explanations in legends, not Gynecology at the University of British Col- 2007. www.hc-sc.gc.ca/hpb/lcdc/publicat/ on the illustrations themselves. umbia and a staff gynecologist at Vancouver std98/index.html (accessed 15 July 2018). • Provide internal scale markers for photo- Hospital.” (NB: The access date is the date the author con- micrographs. • A structured or unstructured abstract of no sulted the source.) • Ensure each figure is cited in the text. more than 150 words. If structured, the pre- References to unpublished material • Color is not normally available, but if it is ferred headings are “Background,” “Methods,” necessary, an exception may be considered. These may include articles that have been read “Results,” and “Conclusions.” • Three key words or short phrases to assist in at a meeting or symposium but have not been Units indexing. published, or material accepted for publication Report measurements of length, height, weight, • Name, address, telephone number, and e-mail but not yet published (in press). Examples: and volume in metric units. Give temperatures address of corresponding author. 1. Maurice WL, Sheps SB, Schechter MT. in degrees Celsius and blood pressures in mil- Sexual activity with patients: A survey limetres of mercury. Report hematologic and Authorship, copyright, disclosure, of BC physicians. Presented at the 52nd clinical chemistry measurements in the metric and consent form Annual Meeting of the Canadian Psychiatric system according to the International System of When submitting a clinical/scientific/review Association, Winnipeg, MB, 5 October 2008. Units (SI). paper, all authors must complete the BCMJ’s 2. Kim-Sing C, Kutynec C, Harris S, et al. four-part “Authorship, copyright, disclosure, Breast cancer and risk reduction: Diet, Abbreviations and consent form.” physical activity, and chemoprevention. Except for units of measure, we discourage 1. Authorship. All authors must certify in writ- CMAJ. In press. abbreviations. However, if a small number are ing that they qualify as an author of the paper. Personal communications are not included in necessary, use standard abbreviations only, pre- Order of authorship is decided by the co-authors. the reference list, but may be cited in the text, ceded by the full name at first mention, e.g., in 2. Copyright. All authors must sign and return with type of communication (oral or written) vitro fertilization (IVF). Avoid abbreviations in an “Assignment of copyright” prior to publica- communicant’s full name, affiliation, and date the title and abstract. tion. Published manuscripts become the prop- (e.g., oral communication with H.E. Marmon, erty of the BC Medical Association and may not director, BC Centre for Disease Control, 12 Drug names be published elsewhere without permission. November 2017). Use generic drug names. Use lowercase for 3. Disclosure. All authors must sign a “Dis- Material submitted for publication but not generic names, uppercase for brand names, e.g., closure of financial interests” statement and accepted should not be included. venlafaxine hydrochloride (Effexor).

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 467 classifieds

Classified advertising (limited to 700 characters) Rates: Payment is required at the time that you Doctors of BC members: $50 + GST per place the ad. month for each insertion of up to 350 charac- Deadlines: Ads must be submitted or can- ters. $75 + GST for insertions of 351 to 700 celled by the first of the month preceding the characters. Payment is required at the time month of publication, e.g., by 1 November that you place the ad. for December publication. Non-members: $60 + GST per month for Visit www.bcmj.org/classified-advertising for each insertion of up to 350 characters. $90 + more information. Place your classified ad on­ GST for insertions of 351 to 700 characters. line at www.bcmj.org/classified-advertising.

For more information contact Dr Jagtar Rai at practices available BURNABY—PT/FT FP LOCUM/ [email protected]. SPECIALIST SMITHERS—TWO PRACTICES FOR Freshly renovated Burnaby office with beauti- NORTH DELTA—TWO FPs, LOCUM/FT SALE ful views looking for physicians. We feature Two family practices for sale. Acquire well- Looking for two family physicians for our a 75/25 split, a convenient location 7 minutes clinic at the Scottsdale Medical Centre to start established, 17-year-old, busy rural practices from the Patterson SkyTrain station, flexible in downtown Smithers, with services includ- ASAP as locums, full-time, or as associates, working hours, OSCAR EMR, a printer in with the intention of being partners in the long ing obstetrics and MOT medicals, using MOIS each room, group practice, friendly MOAs, EMR. Hospital is located nearby with potential run. Clinic is located in North Delta (open and free secure underground parking. Please since 1983). Fully equipped with EMR and pa- for ER shifts. Embrace the rural lifestyle with contact us at [email protected]. activities such as golfing, boating, kayaking, per charts. We have a full-time family practice lake and pool swimming, fishing, hunting, and a walk-in clinic. Billing split negotiable. NANAIMO—FT/PT FAMILY Contact [email protected] or call snowmobiling, cross country and downhill PHYSICIAN 604 597-1606 as soon as possible. skiing. If interested please email iss24@yahoo Drs Jenny, Margo, Stefan, Seamus, Alva, and .com or [email protected]. Jennifer are looking for a physician to join NORTH VAN—FP LOCUM their brand-new, state-of-the-art clinic. Great Physician required for the busiest clinic/fam- VANCOUVER (W BROADWAY)—FP support staff, Accuro-based EMR, online ily practice on the North Shore! Our MOAs Well-equipped, well-established, busy, turn- booking, kiosk check-in, and our friendly at- are known to be the best, helping your day run key, family practice for sale. OSCAR EMR, mosphere set our clinic apart from the rest. smoothly. Lucrative 6-hour shifts and no head- fibre-optic Internet. Lovely patients, lovely Walk-ins available and flexible hours; no buy- aches! For more information, or to book shifts view, lovely setting. Email broadwayfamily in, no overhead during vacation, competitive online, please contact Kim Graffi at kimgraffi [email protected]. splits. Please call Jenny or Shanda at 250 591- @hotmail.com or by phone at 604 987-0918. 9622 (ext. 6) for details or to book a tour of VANCOUVER—GENERAL PRACTICE our clinic. POWELL RIVER—LOCUM FOR SALE The Medical Clinic Associates is looking for Busy family practice/walk-in clinic in prime NANAIMO—GP short- and long-term locums. The medical Vancouver location for sale. Congenial col- General practitioner required for locum or community offers excellent specialist backup leagues and excellent staff are available in this permanent positions. The Caledonian Clinic and has a well-equipped 33-bed hospital. This well-established 22-year-old practice. Email is located in Nanaimo on beautiful Vancou- beautiful community offers outstanding outdoor [email protected] or call 778 233-7449. ver Island. Well-established, very busy clinic recreation. For more information contact Lau- with 26 general practitioners and 2 specialists. rie Fuller: 604 485-3927, email: clinic@tmca Two locations in Nanaimo; after-hours walk-in -pr.ca, website: powellrivermedicalclinic.ca. employment clinic in the evening and on weekends. Com- puterized medical records, lab, and pharmacy S SURREY/WHITE ROCK—FP ARMSTRONG—FT FAMILY on site. Contact Ammy Pitt at 250 390-5228 Busy family/walk-in practice in South Surrey PHYSICIAN or email [email protected]. Visit requires GP to build family practice. The com- Haugen Medical Group, located in the heart of our website at www.caledonianclinic.ca. munity is growing rapidly and there is great the North Okanagan, is in need of a full-time need for family physicians. Close to beaches family physician to join a busy family practice NORTH DELTA—GP and recreational areas of Metro Vancouver. group. Flexible hours, congenial peers, and Very busy, established family practice located OSCAR EMR, nurses/MOAs on all shifts. competent nursing and MOA staff will pro- on Scott Road. The practice consists mainly of CDM support available. Competitive split. vide exceptional support with very competitive Punjabi-speaking patients. Two spacious exam Please contact Carol at Peninsulamedical@ overhead rates. Obstetrics, nursing home, and rooms plus a private office available for the live.com or 604 916-2050. inpatient hospital care are not required, but re- physician. Underground parking. No set-up main optional. Payment schedule: fee for ser- fees or equipment required. Everything is in- SURREY/DELTA/ABBOTSFORD—GPs/ vice. If you are looking for a fulfilling career cluded in the billing split (80/20). Potential to SPECIALISTS balanced with everything the Okanagan life- earn $400K to $500K per year. Physician may Considering a change of practice style or loca- style has to offer, please contact Maria Varga decide their own schedule. Each exam room tion? Or selling your practice? Group of seven for more information at mariavarga86@gmail is fully equipped with everything required. locations has opportunities for family, walk-in, .com. EMR: Med Access. Very friendly office staff. or specialists. Full-time, part-time, or locum

468 bc medical journal vol. 60 no. 9, november 2018 bcmj.org classifieds doctors guaranteed to be busy. We provide administrative support. Paul Foster, 604 572- VANCOUVER—PHYSICIANS & VANCOUVER—TAX & ACCOUNTING 4558 or [email protected]. THERAPISTS SERVICES Fully furnished modern medical office located Rod McNeil, CPA, CGA: Tax, accounting, and business solutions for medical and health VANCOUVER/RICHMOND— in Fairmont Medical Building near VGH has professionals (corporate and personal). Spe- FP/SPECIALIST medical examination rooms available for phy- sicians/health professionals and consultation cializing in health professionals for the past 11 We welcome all physicians, from new gradu- years, and the tax and financial issues facing ates to semiretired, either part-time or full- rooms for therapists. Office is open 7 days a week 7a.m.–7 p.m. Terms are flexible to ac- them at various career and professional stages. time. Walk-in or full-service family medicine The tax area is complex, and practitioners are and all specialties. Excellent split at the busy commodate casual, part-time, and full-time hours. Offering both basic and fee-split leas- often not aware of solutions available to them South Vancouver and Richmond Superstore and which avenues to take. My goal is to help medical clinics. Efficient and customizable ing options. Able to accommodate both paper and EMR (Accuro) practices (EMR training you navigate and keep more of what you earn OSCAR EMR. Well-organized clinics. Please by minimizing overall tax burdens where pos- contact Winnie at medicalclinicbc@gmail available). Additional services provided in- clude medical billing, transcription, medical sible, while at the same time providing you .com. with personalized service. Website: www. supplies, marketing/advertising, and support rwmcga.com, e-mail: [email protected], staff. For more information please email raz@ phone: 778 552-0229. VICTORIA—GP/WALK-IN elitemedicalassociates.com. Shifts available at three beautiful, busy clinics: Burnside (www.burnsideclinic.ca), Tillicum (www.tillicummedicalclinic.ca), and Uptown (www.uptownmedicalclinic.ca). Regular and vacation properties occasional walk-in shifts available. FT/PT GP WHISTLER—CHALET, CHRISTMAS/ back page post also available. Contact drianbridger@ NEW YEAR’S 2018/19 gmail.com. Our lovely Whistler home is available 24 Continued from page 470 Dec to 6 Jan. It is a very short walking dis- VICTORIA—PERMANENT/P-T FP tance to all the attractions of the main village. The BCMA was very supportive Experienced family physician wishing to ex- It accommodates 10 people: 2 bunkrooms, 1 of our efforts, arranging meetings and pand medical team at Mattick’s Farm in beau- queen private, 1 king private. There is a huge mail-outs to encourage growth of the tiful Cordova Bay. Fully equipped office, OS- deck and indoor hot tub to add to the home- Opt-Out Movement as well as helping CAR EMR, congenial staff, close to schools. away-from-home feeling. Pics available upon Contact [email protected], phone request. $1800/night. Contact bobcheyne99@ physicians who had taken the plunge 250 658-5228. hotmail.com. by paying for their disability insur- ance, CMPA fees, and CME funding. medical office space The number of opted-out physi- miscellaneous cians was never large; it involved BURNABY (CENTRAL PARK)— CANADA-WIDE—MED about 50 doctors in Nanaimo and an- GENERAL PRACTITIONER/ TRANSCRIPTION SPECIALIST Medical transcription specialists since 2002, other 50 across the province out of Well-established, busy group practice has im- Canada wide. Excellent quality and turn- 8000 province wide. We may have mediate position available for family physician around. All specialties, family practice, and been small in number, but we pre- or specialist. Large office with Wolf EMR in IME reports. Telephone or digital recorder. vailed in the end because our cause a three-story health care building. Splendid Fully confidential, PIPEDA compliant. Dicta- opportunity for successful career and asso- tion tips at www.2ascribe.com/tips. Contact us was just. An agreement was reached ciateship in this friendly work environment. at www.2ascribe.com, [email protected], or in August 1993, essentially restoring Contact Dr Marcel Genest at 604 434-8024 or toll free at 1 866 503-4003. the original contracts, and was ap- email [email protected]. proved by the BCMA membership. FREE MEDICAL RECORD STORAGE BURNABY—INTERESTED IN JOINING Retiring, moving, or closing your family prac- We were proud that the doctors A PEDIATRIC PRACTICE? tice? RSRS is Canada’s #1 and only physician- of Nanaimo were at the forefront We are looking for pediatricians and pediatric managed paper and EMR medical records stor- of a difficult struggle against a gov- specialists to join Kensington Medical Clinic, age company. Since 1997. No hidden costs. a large multidiscipline practice located in Call for your free practice closure package: ernment that seemingly had all the . Burnaby. We have six pediatricians, a pediatric everything you need to plan your practice clo- weapons but didn’t have a principled cardiologist, and 12 GPs on staff. Collabora- sure. Phone 1 866 348-8308 (ext. 2), e-mail defence! I remember the united feel- tive atmosphere and competitive remuneration. [email protected], or visit www.RSRS.com. ing we had about leading the physi- Contact Jeremy at 604 299-9765 or jmickolwin @kensingtonmedicalclinic.com. PATIENT RECORD STORAGE—FREE cians of BC, and I continue to thank Retiring, moving, or closing your family or my colleagues here for their enthusi- NORTH VAN (DELBROOK PLAZA)— general practice, physician’s estate? DOCU- asm and support. I won’t attempt to MED OFFICE SPACE, 800 SQ. FT. davit Medical Solutions provides free storage mention them all, but will salute my Medical office building (800 sq. ft.) available at for your active paper or electronic patient re- 3759 Delbrook Ave., North Vancouver. Can be cords with no hidden costs, including a patient fellow internists and members of the rented as it is or after renovations. A convenient mailing and doctor’s web page. Contact Sid “Nanaimo Seven,” namely Drs Kam location for access by public transport or car Soil at DOCUdavit Solutions today at 1 888 Bandali, Kevin Lai, Bennett Horner, with free parking. Close to highway and phar- 781-9083, ext. 105, or e-mail ssoil@docudavit macies. Text 604 961-8432, email arminder .com. We also provide great rates for closing Marc Trajan, Lawrence Winkler, and [email protected]. specialists. Herb Welch.

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 469 back page

Opting out (Nanaimo 1992)

How a small group of Nanaimo doctors were able to exert an outsized influence on the provincial stage.

Paul Mitenko, MD

hysicians in Nanaimo have re- that established government contribu- Nanaimo on 11 September 1992. cently completed a prolonged tions to retirement savings plans for Various dire predictions were made P struggle with a difficult bu- physicians), seized control of fund- by the then Minister of Health, Ms reaucracy about a poorly designed ing arrangements (establishing reim- Elizabeth Cull, and other officials and hospital computer system. Our persis- bursement caps and underfunding the bureaucrats, but the arrangements we tent and perceptive leaders have per- health care system), and refused me- had made in our offices held up well, suaded the government to remove the diation and binding arbitration. The specifically those that made sure no most dangerous aspects of this sys- legislation was passed in July 1992 patient was denied care in the office tem, those which created real hazards despite concerns and protests by the or at the hospital, and certainly that for hospitalized patients. While we profession and the then BCMA. patients would not be turned down on worked toward solving this problem, the basis of their ability to pay. I was reminded of a previous fight These plans were put together by against bureaucracy in Nanaimo, and physicians and their devoted office offer this brief history. The amount of staff, and worked incredibly well for The NDP, under Mr Mike Har- publicity and coverage the duration of the dispute. Still, the court, was elected to provincial gov- by the media made amount of publicity and coverage by ernment in late 1991, and initially was opening day a trial. the media made opening day a trial, welcomed by the BC medical profes- even to the clerk in my office (my sion because of the new approaches wife, Donna) asking a bright young that they seemed to offer to medical TV reporter, “Will that be cash or care. That enthusiasm was replaced Any trust or understanding from Chargex?” by alarm within the next few months the profession was destroyed by the Thus began our great adventure. with the introduction of legisla- breaking of those legal contracts. Our patients proved to be very un- tion that canceled legal agreements Meetings and rallies were held, and derstanding, and on being acquaint- with the medical profession, “extin- in Nanaimo the result was the Opt- ed with the fee schedule (we did not guished” binding contracts (specifi- Out Movement. With a letter to the charge more than what was listed cally the previous year’s agreement provincial government, individual in the MSP schedule) were amazed physicians could withdraw from the at how little their services cost. We Dr Mitenko is a retired internist, and after Medical Services Plan. Since the gov- became closer to our patients even having had a satisfying career, he spends ernment had proven to be so intransi- though we made less money. his time visiting with friends and family, gent, it was proposed that physicians Opting out certainly created con- reading books, experimenting in the kitch- opt out, bill their patients directly, and fusion for the bureaucracy at MSP. I en, and catching up on family and personal ask patients to collect billed fees from recall one patient who traveled to Vic- history. MSP. After all, the government was toria to collect on a disputed charge not our master in our practices, but and refused to leave the wicket until For more Doctors of BC history, see The was actually the insurance company she got paid the full amount. Phy- BCMA, Then and Now: A selected history for our patients, and responsible to sicians suffered forever with dis- from 1965 to Doctors of BC by Dr Brad them for compensation via MSP. puted billings, but she got paid that Fritz, available at www.doctorsofbc.ca/ Plans were developed, and the afternoon. who-we-are/our-history. first opted-out doctors appeared in Continued on page 469

470 bc medical journal vol. 60 no. 9, november 2018 bcmj.org Club MD provides high value lifestyle offerings and services — exclusively for Doctors of BC members.

doctorsofbc.ca/club-md

CAR PURCHASE & LEASE • ENTERTAINMENT • FITNESS & WELLNESS • FOOD & BEVERAGE • HOTELS & TRAVEL

PARK’N FLY

$16.95 DAILY RATES There’s no better way to start $66.95 WEEKLY RATES and end your trip.

Call 604 270 9476 or visit the YVR location and mention code #09058. doctorsofbc.ca/parknfly

DELTA GRAND OKANAGAN RESORT

RATES FROM $166 Experience Okanagan Valley magic at this gorgeous lakefront Kelowna Resort.

Book online or call 1 888 236 2427 and use code JZN. doctorsofbc.ca/delta

COLLETTE GUIDED TOURS

SAVE UP TO $600 Choose from 177 tours across 7 continents and experience the Collette difference.

Call 1 844 310 4938 and mention code: CLUBMDSAVE. doctorsofbc.ca/collette

P 604 638 7921 TF 1 800 665 2262 ext 7921 E [email protected]

bc medical journal vol. 60 no. 9, november 2018 bcmj.org 471 PrescribeIT-Ad_BCMedJournal_Oct17_print.pdf 1 11/10/2018 1:37:23 PM

C

M

Y

CM

MY

CY

CMY

K What happens when this happens?

Lost or damaged prescriptions can delay or prevent your patients from taking the medications they need. Fortunately, now there’s PrescribeIT™, Canada’s only not-for-profit e-prescribing service. No more paper, no more fax. And no new technology — PrescribeIT™ integrates seamlessly with your EMR.

Visit PrescribeIT.ca to learn more.

472 bc medical journal vol. 60 no. 9, november 2018 bcmj.org