February 2017 by Doctor's Review

FEBRUARY 2017

Treat refugee mental health Medical VR: a DR interview Virtual reality headsets Set up a soup swap

MEDICINE ON THE MOVE

Luxury in

WIN

THIS MONTH’S

Anguilla

PAGE 12

Renewal in

GADGET

San Antonio Aquitaine’s

72017 PLACES TO GO

joie de vivre

FROM THE GSK COPD PORTFOLIO...

INCRUSEÂ&#x2122; ELLIPTAÂ® (umeclidinium) is indicated for the long-term once-daily maintenance bronchodilator .,! .(!). *" %,5 *1 * -.,/ .%*) %) + .%!).- 1%.$ $,*)% * -.,/ .%0! +/'(*) ,3 %-! -! %) '/ %)# chronic bronchitis and emphysema. INCRUSEÂ&#x2122; ELLIPTAÂ® is not %) % .! "*, .$! ,!'%!" *" /.! !.!,%*, .%*) *" Â&#x2122; ELLIPTAÂ® should not be used in patients <18 years of age. BREOÂ® ELLIPTAÂ® 5 /.% -*)! "/,* .! 0%' ).!,*' ( # %- %) % .! "*, .$! '*)# .!,( *) ! %'3 ( %).!) ) ! .,! .(!). *" %,5 *1 * -.,/ .%*) %) + .%!).- 1%.$ $,*)% * -.,/ .%0! +/'(*) ,3 %-! -! %) '/ %)# $,*)% ,*) $%.%- ) *, !(+$3-!( ) .* ,! / ! !2 !, .%*)- *" %) + .%!).- 1%.$ $%-.*,3 *" !2 !, .%*)- BREOÂ® ELLIPTAÂ® is not %) % .! "*, .$! ,!'%!" *" /.! ,*) $*-+ -( $! - "!.3 ) !"4 3 %) +! % .,% patients younger than 18 years have not been established. BREOÂ® ELLIPTAÂ® ( # %- not %) % .! "*, + .%!).- 1%.$ $!,! %- )* %.%*) ' !)!4 . *" .$!

( # *-! *(+ ,! .* .$! ( # *-! ) .$!,! %- +*.!).% ' %) ,! -! ,%-& *" +)!/(*)% ) systemic corticosteroid-related adverse reactions. Please consult the Product Monograph for INCRUSEÂ&#x2122; ELLIPTAÂ® . #-& %) ,/-! !) ) Â® ELLIPTAÂ® . #-& ,!* !) "*, %(+*,. ). %)"*,( .%*) ,!' .%)# .* *) %.%*)- *" '%)% ' /-! *)., %) % .%*)- 1 ,)%)#- precautions, adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monographs are also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374. $,*)% * -.,/ .%0! +/'(*) ,3 %-! -! *)# .%)# (/- ,%)% ). #*)%-. '-* &)*1) - '*)# .%)# ).% $*'%)!,#% %)$ '! *,.% *-.!,*% '*)# .%)# !. 2-adrenergic agonist.

01633 09/16

100/25 mcg for COPD

LAMA

Winter dreams and pastimes One of my most lasting travel memories is a visit to the Lascaux Caves in the Dordogne River Valley in Southwest France. The stunning Paleolithic paintings, executed during the Ice Age, take your breath away and set the mind to wondering about all that we don’t know about human life on this planet. When Picasso first saw them, a few years after they were discovered by two schoolboys in 1940, he exclaimed, “We have learned nothing in 12,000 years!” When I first gazed on the miraculous things in the 1980s, the steady visitor traffic had begun to damage some of the work and a replica of the cave had been created. Since then it has been expanded and refined. Lascaux 4 opened recently. Do visit if you can, the recreation is so good, it gives the same spinetingling experience it did when Picasso first saw the work. You can read more about Lascaux and the ceaseless delights of the surrounding countryside in Lin Stranberg’s Aquitaine and the art of living (page 32). The gadget column this month offers readers a chance to win a Virtual Reality viewer, the gizmo that uses a smartphone to create 3D environments that surround you. I loaded up a Google Cardboard viewer last night with a demo VR video that featured a tour through Boston Dynamics, an outfit that builds robots. I highly recommend it. Four-hooved animal robots cavort about, knock each other over and get up again. A biped human-like character goes upstairs and down, and even takes a robot out for a walk in the woods. My takeaway: they seem so real you immediately attribute thoughts and emotions to them. Hmmmm… It’s enough to make you want to get far away to somewhere warm and sunny like Anguilla; we’ve got that too on page 21.

Indications and Clinical Use: Monotherapy: JARDIANCE® (empagliflozin) is indicated for use as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance. Add-on combination: JARDIANCE® is indicated in adult patients with type 2 diabetes mellitus to improve glycemic control, when metformin used alone does not provide adequate glycemic control, in combination with: • metformin, • pioglitazone (alone or with metformin), • metformin and a sulfonylurea, • basal or prandial insulin (alone or with metformin), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control. Add-on combination in patients with established cardiovascular disease: JARDIANCE® is indicated as an adjunct to diet, exercise and standard care therapy to reduce the incidence of cardiovascular death in patients with type 2 diabetes mellitus and established cardiovascular disease who have inadequate glycemic control. Important Limitation of Use: Use of JARDIANCE® with insulin mix (regular or analogue mix) has not been studied. Therefore, JARDIANCE® should not be used with insulin mix. Contraindications: • Patients with a history of hypersensitivity reaction to the active substance or to any of the excipients • Renally impaired patients with eGFR less than 45 mL/min/1.73m2, severe renal impairment, endstage renal disease and patients on dialysis Most Serious Warnings and Precautions: Diabetic Ketoacidosis: Clinical trial and post-market cases of diabetic ketoacidosis (DKA), a serious, life-threatening condition requiring urgent hospitalization, have been reported in patients on JARDIANCE® and other sodium-glucose co-transporter 2 (SGLT2) inhibitors. Some cases of DKA have been fatal. A number of these cases have been atypical with blood glucose values below 13.9 mmol/L (250 mg/dL) • Patients should be assessed for DKA immediately if non-specific symptoms of DKA occur (difficulty breathing, nausea, vomiting, abdominal pain, confusion, anorexia, excessive thirst, unusual fatigue, or sleepiness), regardless of blood glucose level, and JARDIANCE® should be discontinued immediately • JARDIANCE® should not be used for the treatment of DKA or in patients with a history of DKA • Not indicated, and should not be used, in patients with type 1 diabetes Other Relevant Warnings and Precautions: • Not recommended for use in patients who are volume depleted • Use with caution in patients for whom a drop in blood pressure could pose a risk or in case of intercurrent conditions that may lead to volume depletion. Careful monitoring of volume status and electrolytes is recommended. Temporary interruption of JARDIANCE® should be considered for patients who develop volume depletion until the depletion is corrected • Caution should be observed in patients at high risk for cerebrovascular accidents • In clinical situations known to predispose to ketoacidosis (e.g., major surgical procedures, serious infections and acute serious medical illness), consider temporarily discontinuing JARDIANCE® • Use caution in patients at higher risk of DKA • Use caution when reducing the insulin dose in patients requiring insulin • The use of JARDIANCE® in combination with a secretagogue or insulin was associated with a higher rate of hypoglycemia • Dose-related increases in LDL-C can occur with JARDIANCE®. LDL-C levels should be measured at baseline and monitored • JARDIANCE® increases the risk of genital mycotic infections, particularly for patients with a history of genital mycotic infections • JARDIANCE® increases the risk of urinary tract infections • Use with caution in patients with an elevated hematocrit • Not recommended in patients with severe hepatic impairment • Assessment of renal function is recommended prior to JARDIANCE® initiation and regularly during treatment. Do not initiate JARDIANCE® in patients with an eGFR <60 mL/min/1.73m2 • Monitoring of renal function is recommended prior to and following initiation of any concomitant drug which might have an impact on renal function, JARDIANCE® must be discontinued if eGFR falls below 45 mL/min/1.73m2 • JARDIANCE® must not be used during pregnancy or breastfeeding • Should not be used in patients <18 years of age • Use with caution in patients ≥65 years of age due to a greater increase in risk of adverse events, and because diminished efficacy is expected in this population as older patients are more likely to have impaired renal function • Patients ≥75 years of age are at a higher risk of volume depletion. Prescribe with caution • Initiation of therapy in patients ≥85 years of age is not recommended • Patients receiving JARDIANCE® will test positive for glucose in their urine For more information: Please refer to the product monograph at www.JardiancePM.ca for important information relating to adverse events, drug interactions, dosing, and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633. For important safety information on SGLT2 inhibitors and the risk of DKA, please refer to http:// www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2016/58404a-eng.php. References: 1. JARDIANCE Product Monograph. Boehringer Ingelheim, September 12, 2016. 2. Boehringer Ingelheim (Canada) Ltd. Data on File. Medical Letter. September 6, 2016.

David Elkins, publisher and editor delkins@parkpub.com

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FEBRUARY 2017

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JARDIANCE® is a registered trademark of Boehringer Ingelheim International GmbH, used under license.

CA/EMP/00086 BI/EMP/00086

NEW INDICATION

In type 2 diabetes patients with inadequate glycemic control and established CV disease…

CV DEATH HAS A NEW OPPONENT. JARDIANCE® is the only T2D agent indicated as an adjunct to diet, exercise and standard care therapy to reduce the incidence of cardiovascular death in patients with T2D and established CV disease who have inadequate glycemic control.1,2*

JARDIANCE® is not recommended for use in patients who are volume depleted. Due to its mechanism of action, JARDIANCE® causes diuresis that may be associated with decreases in blood pressure. Caution should be exercised in patients for whom an empagliflozin induced drop in blood pressure could pose a risk, such as patients with known cardiovascular disease, patients on antihypertensive therapy (particularly loop diuretics), elderly patients, patients with low systolic blood pressure, or in case of intercurrent conditions that may lead to volume depletion (such as gastrointestinal illness). Careful monitoring of volume status is recommended. Temporary interruption of JARDIANCE® should be considered for patients who develop volume depletion until the depletion is corrected. CV=cardiovascular; T2D=type 2 diabetes. *Comparative clinical significance is unknown.

contents FEBRUARY 2017

COVER: UBER IMAGES / SHUTTERSTOCK.COM

features 21 Anguilla’s place in the sun The Caribbean island’s deliberately low-key despite 33 beaches, 100 restaurants and more luxury than you could imagine by Robb Beattie

The Alamo and more

San Antonio’s revamped River Walk plus the Spanish missions, art museums, restaurants and neighbourhoods along the way by Josephine Matyas

Aquitaine and the art of living Southwest France is rich with art, history and culture, and now boasts a revitalized Bordeaux that’s simply buzzing by Lin Stranberg

7 places to go in 2017 The best cities in the US to catch a total solar eclipse, Canada’s big birthday party, Italy, Portugal and more by Theo Sands

21 32

DEPRESSION KEYPOINTS Mental health and multicultural issues by Dr Brit Cooper-Jones

MEDICINE AND THE ARTS Augmented and virtual reality: how it’s made and its future in your practice. An interview. by Tilke Elkins

PHOTO FINISH Monkey business by Dr Fredericka Abcarius

Stir it up An award-winning journalist and cookbook author tells you how to setup a soup swap plus three recipes to get you started by Kathy Gunst

regulars

LETTERS

Coming in

Worldly opinions

Finland is 100! Celebrate the Finns and their wonderful little-known country — we have so much in common

PRACTICAL TRAVELLER A bicycle helmet made of paper, the end of food and drinks on short-haul flights, San Francisco’s big love fest and more by Camille Chin

Holland’s Year of Art Enjoy major exhibits around the country celebrating painter Piet Mondriaan and modern Dutch style Vancouver’s new Chinese chefs Call it Chinese nouvelle, the classic rules are changing and old Saltwater City is in the vanguard

GADGETS Now’s the time to go VR by David Elkins

TOP 25 The best medical meetings scheduled for this summer

March

Pam Wible, a doctor who cares — a lot Meet this Eugene, Oregon family doctor in an interview that starts with her TED talk on MD suicide …and much more

FEBRUARY 2017 • Doctor’s

Review

LETTERS

Worldly opinions

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CAPITAL GAINS It’s true that I haven’t visited Ottawa in years and am always a little hesitant to do so [Ottawa 2017, January 2017, page 36]. Lin Stranberg’s article has piqued my curiosity about our capital though and I’m wondering if a road trip might be in the works sometime this spring. I do wish she would’ve made more restaurant suggestions. My impression is that Ottawa isn’t the easiest place to find a good, healthy, somewhat exciting meal. That too may have changed, but three or four suggestions are always helpful.

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

OFFICE MANAGER

Denise Bernier

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

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

ALL EYES ON AFRICA Dear Jonathan, Even if this is your only photography period please keep writing [I Prescribe a Trip to…, “Africa Wide Open,” January 2017, page 24]. You make travelling sound fun! Dr Michelle Hart Via DoctorsReview.com

Dr Amelia K. Via email

Editor’s note: Here are three Ottawa eating places that serve healthy vegetarian, vegan and gluten-free meals: the oldest is The Green Door (thegreendoor.ca) on Main, the newest is Pure Kitchen (purekitchenottawa. com) on Richmond, another is Café My House (cafemyhouse.com) on Wellington.

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

I know Jonathan well. I was in Namibia too in May 2016. We were a group of eight photographers and we flew by Cessnas into the desert. We stayed at fabulous places and got great shots. Dr Farook Oosman Via DoctorsReview.com

POPULAR PANAMA It was great to read the article on Panama [Paradise on Panama, January 2017, page 30]. My sister’s boyfriend is from Panama and she just bought a condo there. Construction will be finished sometime next year so after her kids finish school she’s planning on moving there permanently. I’ve never been and am hoping to go there soon after. I’ve been worried about her decision to uproot and move so far away, but the article gave me some insight. Dr Tanya Gyenes Via email

Doctor’s Review • FEBRUARY 2017

DEMENTIA BRUSH-OFF I’m a painter myself and I read with great interest Cognitive decline in famous painters [January 2017, page 21]. I’m in my mid-50s and I’ve noticed that my work has become looser with less attention to detail. I’m not suffering from any mental conditions that I know of, but I will watch my brushstrokes more carefully from now on. Name withheld by request Via email

We want to hear from you! Send your comments and questions to: Doctor’s Review, Parkhurst Publishing Ltd., 3 Place Ville Marie, 4th Floor, Montreal, QC H3B 2E3. Or email us at editors@doctorsreview.com.

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

C a mi lle C hi n

The ROM’s modern digs

ALL IMAGES © ROYAL ONTARIO MUSEUM, 2016

It’s hard to believe that the Royal Ontario Museum’s crystal-addition was completed nine years ago. Designed by Daniel Libeskind, the now well-known building consists of five glass-and-metal-clad sections reminiscent of crystals. The edgy extension was a huge departure in style for the 104-year-old institution and, now again, the Toronto museum is going contemporary. In December, the ROM opened the Gallery of Modern Design, which is dedicated to six design movements from 1910 to 1965; 20th-century furniture, glassware, ceramics, silver and other metalwork from Europe and North America are on view. Although the Barcelona Chair ROM is best known for ancient objects, the design gallery by Ludwig Mies has been planned for years. “I thought that we had a van der Rohe, 1929. moral obligation as an educational institution to continue the presentation that we’ve got from 1900 to at least 1965, so that these works are out on permanent view,” said Robert Little, the gallery’s curator. “There was no other place where people could go to see Mies van der Rohe or Frank Lloyd Wright or [Émile-Jacques] Ruhlmann or all of these other great artists. Seeing as we’ve got these pieces, we have to share them with people.” General admission: adults $20; kids four to 14 $14. rom.on.ca.

Stacking stools by Stacy Dukes, 1965.

FEBRUARY 2017 • Doctor’s

Review

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

San Fran love-in

Doctor’s Review • FEBRUARY 2017

CLOCKWISE FROM TOP: Dead on Haight, 1967. A poster from 1967: Yardbirds, The Doors, James Colton Blues Band, Richie Havens, July 25, 30, Fillmore Auditorium. Wool crocheted “hands” dress by Birgitta Bjerke.

Don’t forget to wear flowers in your hair when you visit San Francisco this year. Throughout 2017, the city will celebrate the 50th anniversary of the Summer of Love. As many as 100,000 young people converged in San Francisco’s Haight-Ashbury neighbourhood near Golden Gate Park in 1967 in antiestablishment and anti-government protests, and in opposition to the Vietnam War. The offshoot was a cultural revolution that created some of the era’s famed art, music, literature and fashion. Highlights of this year’s tribute will include the Haight-Ashbury Street Festival in June and the Fillmore Jazz Festival in July. Exhibits include Jim Marshall’s 1967 at San Francisco City Hall (80 photos of American music icons, including Janis Joplin, Jimi Hendrix, Jefferson Airplane and more); Summer of Love: Art, Fashion and Rock & Roll, April 8 to August 20 at the de Young Museum (300 photos, posters, costumes and textiles); Beyond beauty: FLOWER POWER, June 24 to October 1 at the Asian Art Museum (the power of flowers to inspire peace and love from the courts of China and the gardens of Persia, to the budding Buddhists of 1960s San Francisco). The San Francisco Love Tour is aboard an authentic VW hippie bus. For more happenings: sftravel.com/summer-love-2017.

Made from

A bike helmet designed by Isis Shiffer, a student at the Pratt Institute of Design in New York, recently won the prestigious James Dyson (design) Award — and the helmet is made out of paper. Shiffer’s EcoHelmet was created with bike-sharing programs in mind and also travellers who may want to rent a bike, but don’t have protective headwear. The helmet is made of waterproofed recycled paper in a radial honeycomb pattern; it absorbs blows from any direction as effectively as traditional polystyrene. The helmet fits most head sizes and folds flat for vending. It can be recycled at the end of the ride. Before the EcoHelmet hits the market it has to pass the tests necessary to be CPSC certified. It’s expected to launch in 2017 and will be available for around $5 at bike-share stations. ecohelmet.com.

ECOHELMET.COM

recycled paper

James Dyson (right) with student Isis Shiffer (left), recipient of the 2016 James Dyson (design) Award.

FEBRUARY 2017 • Doctor’s

Review

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

Chew on this

Canada’s

Pack your own pretzels the next time you take a British Airways flight. Passengers flying in economy class are no longer being offered free food or drink on any short-haul flights. Predictable? Maybe. The airline announced a partnership with Marks and Spencer last September. The M&S on board menu features sweet and savoury snacks as well as sandwiches: Whippy One marshmallow chocolate bars and bags of crisps for £1; nuts for £1.60; yogurt and granola for £1.95; mozzarella and tomato focaccia £4.95. Tea and coffee will cost £2.30, beer £4, a gin and tonic £6. Credit and debit cards only. britishairways.com/en-gb/ information/food-and-drink/short-haul-economy-dining.

red couch tour

Doctor’s Review • FEBRUARY 2017

If you see a red sofa embossed with white geometric maple leaves rolling through your hometown, you might want to take a seat. The handcrafted, made-in-Winnipeg couch will be visiting 10 provinces and the country’s three territories throughout 2017 as one of 38 signature projects selected by the Federal Government of Canada to celebrate Canada’s 150th anniversary. Testimonies will be collected from people while sitting on the sofa on what Canada means to them. A video will be produced and posted on YouTube; a photo exhibit of some of the participants will appear online. The tour kicks off in March. redcouchtour.ca.

G AD GE TS AND G EAR by

Da vi d Elki ns

Now’s the time to go VR

Virtual reality at its fullest requires sophisticated computers, advanced software, wrap-around stereo headsets and data gloves with built-in sensors. Fully decked out, you’re immersed in an environment that feels as authentic as the real world. You’re doubtless familiar with the medical applications of virtual reality particularly in surgery and telemedicine. (For more, read “Virtual reality comes to medicine,” page 19). On the other hand, it doesn’t have to be that complicated. In 2014, Google developed an inexpensive head-mounted viewer that uses a smartphone to create virtual reality. Two screens display slightly different, stereoscopic images to create a realistic 3D perspective of the virtual world. The cardboard viewer consists of a couple of lenses with a simple magnetic metal ring on the side that serves as a “click.” All the heavy lifting is done by the smartphone’s accelerometer and gyro. Once you’ve got the hardware, you need an app that will split the display

Win a VR KiX Virtual Reality Headset in the Gadget of the Month contest at doctorsreview.com image into two, one for each eye, and applies barrel distortion to each image to counter the pincushion distortion from the lenses. Hundreds of VR apps are available from the Apple apps store and Google Play including but not limited to games, travel, education, real estate and more. Even better, Netflix, YouTube and others offer VR movies. Download a VR app, fire it up, place your smartphone in the viewer, strap it on and you’re instantly immersed in wide-screen “reality.” Moving your head tracks a 360-degree view. Choosing the right model headset is a challenge. The device is new enough that despite thousands of independent reviews, reactions to any given model remain mixed.

A homegrown company offers the VR KiX Virtual Reality Headset which has a number of attractive features including a spring-loaded tray to hold your smartphone; compatibility with most iPhone and Samsung models (check the website for phone fit); adjustable lenses; comfortable head-straps, and front and side ventilation (it can get hot in there!). If this is your first VR experience consider starting with the inexpensive widely available Google Cardboard ($20) and moving up from there. The VR KiX Virtual Reality Headset is available at Canada Computers, Staples and other retailers. Alternatively, you can purchase it online at vrkix.ca. $69.99.

CONGRATULATIONS! The winner of the Ninja BL660 is Dr Loree Larratt, a hematologist from Edmonton, AB. 12

Doctor’s Review • FEBRUARY 2017

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Ottawa, ON June 2-3 18th Canadian Collaborative Mental Health Care Conference shared-care.ca 73rd Annual Clinical and Scientific Conference of the Society of Obstetricians and Gynaecologists of Canada sogc.org/conference/acsc/welcome.html

Toronto, ON June 16-17 20th International Toronto-Ottawa Heart Summit torontoottawaheartsummit.com

June 22-23 2017 Canadian Breast Cancer Symposium breastsymposium.ca

July 20-23 2017 Annual Meeting of the American Orthopaedic Society for Sports Medicine sportsmed.org/aossmimis

Vancouver, BC July 14-16 22nd World Congress on Heart Disease cardiologyonline.com/wchd2017

CHOOSE CHICAGO

June 20-23 The Frank Gehry-designed Pritzker Pavilion in Chicago.

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

Around the world Baltimore, MD June 2-6 28th Annual Scientific Sessions of the American Society of Echocardiography asescientificsessions.org

Barcelona, Spain June 28-July1 19th World Congress on Gastrointestinal Cancer worldgicancer.com/wcgi/index.asp

July 16-21 7th World Congress of Pediatric Cardiology and Cardiac Surgery wcpccs2017.org

Berlin, Germany July 8-13 26th Biennial Congress of the International Society on Thrombosis and Haemostasis isth2017.org

Boston, MA June 8-11 Vancouver’s bike-friendly Musette Caffé.

59th Annual Scientific Meeting of the American Headache Society americanheadachesociety.org/events/59thannual-scientific-meeting

Chicago, IL July 6-9 13th World Congress of Pediatric Dermatology wcpd2017.com

Kuala Lumpur, Malaysia July 6-9 11th International Symposium on Pediatric Pain ispp2017.org

Lake Tahoe, CA June 11-16 41st Annual UC Davis Fingers to the Toes: Primary Care Orthopaedics Conference ucdmc.ucdavis.edu/cme/conferences

London, England July 16-20 2017 International Conference of the Alzheimer’s Association alz.org/aaic

Lyon, France July 7-9 3rd International Neonatology Association Conference 2017.worldneonatology.com

Maui, HI July 1-7 Pediatric in the Islands... Clinical Pearls 2017 childrenshospitallamedicalgroup.org FEBRUARY 2017 • Doctor’s

Review

NEW

VIACORAM

EN ROUTE TOWARDS BP CONTROL The only combination antihypertensive medication with an ACEi (perindopril arginine) and a dihydropyridine CCB (amlodipine besylate)*

Contraindications Patients who are hypersensitive to the active ingredients of this drug, to any ingredient in the formulation or component of the container, to any other angiotensin converting enzyme inhibitor (ACE-inhibitor), or to any other dihydropyridine derivatives • Patients with renal impairment (creatinine clearance < 60 ml/min) • Patients with a history of hereditary/ idiopathic angioedema, or angioedema related to previous treatment with an ACE-inhibitor • Pregnant women or planning to become pregnant • Nursing women • Patients with mitral valve stenosis and left ventricular outflow tract obstruction (e.g. aortic stenosis, hypertrophic cardiomyopathy) • Patients with heart failure • Concomitant use of angiotensin converting enzyme (ACE) inhibitors, including VIACORAM®, with aliskiren-containing drugs in patients with diabetes mellitus (type 1 or 2) or moderate to severe renal impairment (GFR < 60 ml/min/1.73 m2) • Patients with hereditary problems of galactose intolerance, glucose-galactose malabsorption, or the Lapp lactase deficiency as VIACORAM® contains lactose • Patients with extracorporeal treatments leading to contact of blood with negatively charged surfaces • Patients with bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney •

Most serious warnings and precautions sulphate): May lead to life-threatening anaphylactoid reactions. Pregnancy: When used in pregnancy, angiotensin converting enzyme (ACE) Other relevant warnings and precautions inhibitors can cause injury or even death • Caution in driving a vehicle or performing of the developing fetus. When pregnancy other hazardous tasks is detected, VIACORAM® should be • Co-administration of ACE inhibitors, discontinued as soon as possible. including the perindopril component of Hyperkalemia (serum VIACORAM®, with other agents blocking the potassium > 5.5 mEq/L): Can cause serious, RAS, such as ARBs or aliskiren-containing sometimes fatal arrhythmias; serum potassium drugs, is generally not recommended in must be monitored periodically in patients patients other than patients with diabetes receiving VIACORAM®. Concomitant use with mellitus (type 1 or type 2) and/or potassium supplements, potassium-sparing moderate to severe renal impairment diuretics, or potassium-containing salt (GFR < 60 ml/min/1.73 m2) as it is substitutes is not recommended. contraindicated in these patients Collagen vascular disease, • Risk of hypotension; closely monitor immunosuppressant therapy, treatment patients at high risk of symptomatic with allopurinol or procainamide, or a hypotension. Similarly monitor patients combination of these complicating with ischaemic heart or cerebrovascular factors (especially if there is pre-existing disease; an excessive fall in blood pressure impaired renal function): May lead to could result in a myocardial infarction or serious infections, which may not respond to cerebrovascular accident ® intensive antibiotic therapy. If VIACORAM is • Risk of mild to moderate peripheral edema used in such patients, periodic monitoring of • Safety and efficacy of VIACORAM® in white blood cell counts is advised and patients hypertensive crisis have not been established should be instructed to report any sign of • Risk of angina worsening/acute myocardial infection to their physician. infarction after starting therapy or dose increases Angioedema: May be life-threatening and occur at any time during therapy. Where there • Risk of hyperkalemia; monitor serum potassium periodically is involvement of the tongue, glottis or larynx • Risk of neutropenia/agranulocytosis, likely to cause airway obstruction, it may be thrombocytopenia and anemia fatal. Emergency therapy should be • Increases in serum transaminase and/or administered promptly. bilirubin levels, cholestatic jaundice, Syndrome starting with cholestatic cases of hepatocellular injury with or jaundice with progress to fulminant without cholestasis hepatic necrosis: May lead to death. • Not recommended in patients with impaired Use during low-density lipoproteins liver function (LDL) apheresis (with dextran • Angioedema

•

• •

• • •

•

Risk of anaphylactoid reactions during desensitization or membrane exposure (hemodialysis patients) Risk of nitritoid reactions in patients on therapy with injectable gold Patients undergoing major surgery or during anesthesia with agents that produce hypotension Black patients vs. non-black patients Not recommended in patients with a recent kidney transplantation Risk of changes to renal function in susceptible patients; potassium and creatinine should be monitored in these patients Risk of cough Dermatological reactions Not indicated for the initiation of treatment in the elderly (> 65 years) patients; not recommended in pediatrics (children < 18 years of age) Patients with diabetes treated with oral antidiabetic agents or insulin, glycemic control should be closely monitored during the first month of treatment with VIACORAM® Patients with unilateral or bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney Sexual function/reproduction

For more information Please consult the Product Monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/indexeng.jsp for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-363-6093.

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VIACORAM® (perindopril arginine/amlodipine) is indicated for the treatment of mild to moderate essential hypertension in patients for whom combination therapy is appropriate. VIACORAM® 3.5 mg/2.5 mg is indicated for initial therapy in patients with mild to moderate essential hypertension. VIACORAM® is not indicated for switching therapy from the individual drugs currently on the market (perindopril as erbumine or arginine salt, amlodipine). VIACORAM® is not indicated for the initiation of treatment in elderly patients (> 65 years of age). There is not sufficient clinical experience to justify the use in these patients. VIACORAM® is not indicated in pediatric patients < 18 years of age. The efficacy and safety have not been studied in this population.

The Old Town in Prague as seen from Powder Tower.

Milan, Italy June 16-19 27th Scientific Meeting of the European Society of Hypertension esh2017.eu

Nashville, TN June 4-6

INDICATED IN INITIAL THERAPY

3.5 mg Perindopril arginine / 2.5 mg Amlodipine

*Comparative clinical significance unknown. Reference: VIACORAM® Product Monograph. Servier Canada Inc. February 17, 2016. VIACORAM® is a registered trademark of Servier Canada Inc.

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

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San Antonio, TX May 18-20 2017 Annual Meeting of the American Geriatrics Society americangeriatrics.org

San Diego, CA June 9-13

2017 Scientific Sessions of the American Delirium Society americandeliriumsociety.org/ads-2017

77th Scientific Sessions of the American Diabetes Association professional.diabetes.org/meeting/scientificsessions/77th-scientific-sessions

New Orleans, LA June 14-17

Warwick, England July 6-7

2017 Annual Scientific Sessions of the Society for Vascular Medicine vascularmed.org

Pittsburgh, PA May 17-20 36th Annual Scientific Meeting of the American Pain Society ampainsoc.org/annual-meeting/overview

Prague, Czech Republic June 8-10 2017 International Conference for Eating Disorders aedweb.org/index.php/

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A new option in the treatment of mild to moderate essential hypertension in initial therapy

THE TOP 25 MEDICAL MEETINGS

27th Annual Conference of the British Menopause Society thebms.org.uk/meeting/bms-27th-annual-conference

MEDICAL QUIPS A psychotic thinks that two and two are five. A neurotic knows two and two are four — but he hates it.

FEBRUARY 2017 • Doctor’s

Review

DE PRESSIO N K EY PO I NT S by

Dr Brit Cooper-Jones

Depression and mental health issues in immigrants and refugees Strategies to meet the needs of the recent influx of new arrivals, including nearly 40,000 Syrian refugees

ccording to former Canadian Immigration Minister John McCallum, over 300,000 immigrants have come to Canada over the past year.1,2 This includes the 39,671 Syrian refugees who arrived in the country between November 2015 and January 2017.3 In light of the increasing influx of immigrants and refugees in Canada, it is important for family doctors to provide appropriate care and resources. This is especially true when it comes to patients’ mental health. While studies show that, upon arrival in Canada, immigrants have lower rates of mental health issues than the general population, having undergone screening prior to being admitted into the country, the same is not true of refugees who are often at a heightened risk of mental illness.4,5 As outlined in a 2014 article in the FP Essentials Journal by Rew et al., “The prevalence of mental health conditions is high among refugees, who comprise a specific subgroup of immigrants who have been displaced forcibly and often have experienced severe trauma.”6 Primary care physicians are in a unique position to offer help by learning effective techniques to screen for and subsequently treat mental illness in these populations.4

What you need to know In 2012, the Citizenship and Immigration Department of the Government of Canada conducted a Longitudinal Survey of Immigrants to Canada (LCIS) evaluating the mental health and well being of recent immigrants to Canada.7 The study showed 5.95 percent of immigrants are diagnosed with mental health issues prior to their arrival in Canada, and this rate rises to 7.04 percent — the equivalent of Canadian residents — within a few years of their arrival in the country.4,7 This is attributed to a number of factors and social stressors, including the challenges of finding appropriate work, of navigating unemployment or underemployment, of overcoming language barriers, of being displaced from family and/or support networks, and of overcoming prejudice and discrimination. The LCIS notes, “The process of immigration and settlement is inherently stressful, and the well-being of recent immigrants is of particular concern, primarily when migration is combined with additional risk factors such as unemployment and language barriers.”7 An even higher number of refugees experience mental illnesses including depression, chronic pain and other psychosomatic symptoms, and up to ten times the rate of post-traumatic stress disorder (PTSD) as compared to the general population.4

Doctor’s Review • FEBRUARY 2017

As explained in a 2011 article in the CMAJ by Kirmayer et al., the heightened incidence of mental illness among refugees is largely correlated to their “exposure to war, violence, torture, forced migration and exile and uncertainty of their status in the countries where they seek asylum.”4 The documented association between refugees’ exposure to torture and other forms of violence or trauma and the subsequent development of PTSD is often misdiagnosed by physicians — or missed altogether — due to the somatization of symptoms.4 In other words, patients may present with ongoing physical complaints that are actually a manifestation of an underlying mental illness.4 Frequent physical complaints that may be indicative of PTSD or another underlying mental illness include unexplained fatigue, unexplained pain, and gastrointestinal and genitourinary symptoms.4 Reasons that somatization is more common among refugees include the stigmatization of mental illness within their culture as well as a perception that it is inappropriate to discuss personal struggles and mental health concerns with one’s family doctor.5 For these reasons effective communication becomes especially important in the primary care setting. It is also key

Evidence-based recommendations for depression and PTSD among immigrants and refugees Depression • Screen adults for depression using a systematic clinical inquiry or validated patient health questionnaire (PHQ-9 or equivalent). Individuals with major depression may present with somatic symptoms (pain, fatigue or other nonspecific symptoms). • Link suspected cases of depression with an integrated treatment program and case management or mental health care. Post-traumatic stress disorder • Do not conduct routine screening for exposure to traumatic events, because pushing for disclosure of traumatic events in well-functioning individuals may result in more harm than good. • Be alert for signs and symptoms of post-traumatic stress disorder (unexplained somatic symptoms, sleep disorders or mental health disorders such as depression or panic disorder). For more go to ncbi.nlm.nih.gov/pmc/articles/PMC3168666

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for physicians to understand the specific risk factors that accompany each phase of the transitional journey.4,5

Assessing risk factors: premigration, migration, and postmigration The transitional journey of an immigrant or a refugee consists of three phases: premigratory, migratory, and postmigratory.4 The specific issues encountered fall into three broad categories: social challenges such as reconstructing social networks and creating new personal connections, financial challenges such as finding employment and being able to support one’s family in the new country, and cultural challenges such as adapting to societal norms and a new way of life.4 The premigration period refers to an immigrant’s or refugee’s situation prior to leaving their country of origin.4 If an immigrant is educationally equipped to thrive in a new country, is fluent in the native language, and is leaving with a sense of control or choice in the matter, this is a very different picture than a refugee who is forcibly uprooted, underequipped to thrive in the new place of residence, and prone to the mental and emotional suffering that often goes hand-in-hand with traumatic displacement. The migration period refers to the transitional journey itself.4 It includes the route and duration of the move as well as the living conditions during the period of transition such as living in refugee camps, being kept in detention centres, and/or being exposed to torture or endemic violence.4 The postmigration or resettlement phase refers to an immigrant’s or refugee’s ability to successfully adapt to the new life and integrate into the new culture.4,8 This is arguably the most important phase, for an ability to successfully navigate the postmigration (or resettlement) stage can help to mitigate premigration and migration stressors.4,8 Immigrants and refugees often report a sense of social alienation, racism, and/or discrimination, in addition to language barriers, all of which can lead to a sense of hopelessness and isolation — particularly if they do not have proper resources and supports to help them cope.4,5

Strategies for primary care physicians What can family doctors do to help? It comes down to effective communication strategies and a compassionate understanding of the migratory journey and the stresses it presents, and an ability to interact with patients in a culturally sensitive way.6

There are key strategies that primary care physicians can employ to bridge language barriers and cultural differences. Whenever a patient is not proficient in the same language as his or her physician, and especially when mental health concerns are suspected, it is essential to have an interpreter present for the office visit.4,5 Ideally, the same interpreter should be used for the same patient over the course of multiple visits. The interpreter should be seated in between the patient and the healthcare provider in a triangle formation.4 The physician should speak directly to the patient using second person pronouns (i.e. “you,” rather than “he” or “she”).4 Culture brokers can also be used to bridge both the culture and communication gaps between the patient and the healthcare provider.4 This can help narrow in on specific resources, treatments, and coping strategies that will optimally serve the patient in light of his or her ethnocultural background.

Resources for physicians Primary care physicians are advised to have resources for language courses, food sources, housing options, and social support available in the office.4 For more information, visit: multiculturalmentalhealth.ca References 1. Government of Canada Website. Notice – Supplementary Information 2016 Immigration Levels Plan. Last modified: 2016-10-27. Available at: cic.gc.ca/english/department/media/notices/2016-03-08.asp 2. Canada on track to welcome more than 300,000 immigrants in 2016. The Globe and Mail. Published March 8, 2016. Available at: theglobeandmail.com/news/politics/ ottawa-seeks-to-bring-more-than-300000-newcomers-this-year/article29069851 3. Government of Canada Website. Welcome Refugees: Key figures. Last modified: 2017-01-10. Available at: cic.gc.ca/english/refugees/welcome/milestones.asp 4. Kirmayer, J et al. Common mental health problems in immigrants and refugee: general approach in primary care. CMAJ. 2011 Sep6;183(12):E959-E967. doi: 10. 1503/cmaj.090292. Available at: ncbi.nlm.nih.gov/pmc/articles/PMC3168672 5. Jensen, NK et al. How do general practitioners experience providing care to refugees with mental health problems? A qualitative study from Denmark. BMC Fam Pract. 2013 Jan 28;14-17. doi: 10.1186/1471-2296-14-17. Available at: ncbi.nlm.nih.gov/pubmed/23356401 6. Rew, KT et al. Immigrant and refugee health: mental health conditions. FP Essent. 2014 Aug;423:19-23. Available at: ncbi.nlm.nih.gov/pubmed/ 25127536 7. Robert, A and Gilkinson, T. Mental health and well being of recent immigrants in Canada: Evidence from the Longitudinal Survey of Immigrants to Canada (LCIS). Published November 2012 by Citizenship and Immigration Canada. Available at: cic.gc.ca/english/pdf/research-stats/mental-health.pdf 8. Guruge, S and Butt, H. A scoping review of mental health issues and concerns among immigrant and refugee youth in Canada: Looking back, moving forward. Can J Public Health. 2015 Feb 3;106(2):272-8. doi: 10.17269/cjph.106.4588. Available at: ncbi.nlm.nih.gov/pubmed/25955675 FEBRUARY 2017 • Doctor’s

Review

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

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

•

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

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

•

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

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

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

CA0116PRI017E

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

ME D I C I N E A N D T H E A R TS by

T i lk e Elk i n s

Virtual reality comes to medicine From $20 Google Cardboard to high tech $Millions

s 2017 the year of virtual reality (VR)? A plethora of techie commentators and journalists insist that it is. That goes double for the medical field,

where the many uses of VR — surgical training, trauma treatment, corpse dissection, patient education, and more — have been widely touted. But how much VR are doctors actually using? What most people imagine when they hear mention of the technology is a high-end version: a fully immersive experience involving headsets, haptic sensors that give the wearer a variety of touch sensations, and a fully computerprogrammed set of graphics that can be explored in three dimensions. Given its hefty price tag, this form of VR has yet to be used outside large institutions. But lower-tech versions of VR, like Google Cardboard, which attaches to a smartphone, are available for as little as $20. Simple devices like this have already made it possible to perform medical breakthroughs. In a recent case, a team of surgeons was able to save the

life of a baby with a serious heart defect by examining the organ with the Google device. To get a sense of how the technology is evolving from the inside, DR spoke with Meredith Osborn (meredithosborn. com), a professional medical illustrator who creates both 2D and 3D animation. DR: What’s your understanding of the difference between augmented reality (AR) and virtual reality (VR)? Are physicians using one more than the other? Ms. Osborn: In the case of augmented reality you’re interacting with the real world, but with some digital enhancements. Pokémon Go is a great example of augmented reality: looking at your phone screen you see what is really in front of you but augmented with a little digital Pokémon bouncing on the screen. Virtual reality is different.

Chicago-based Meredith Osborn, MS — Biomedical Visualization, is a medical illustrator and animator with a portfolio of international 2D and 3D clients.

It is a completely immersive alternate reality. You’re “in” the game, the simulator, the whatever (often by wearing a headset and holding controllers). Physicians are using both AR and VR. DR: How well-informed do you think most doctors are about the uses of AR and VR tools in medicine? Ms. Osborn: Like any new technology, it will take time for everyone to become fully informed. As for AR and VR, it appears to me we’re still in the very early stages of applying it to medicine. There is some truly fascinating work being done, but mostly in artists’ studios, engineers’ labs, and any medical school or program that has groups lucky enough to be in testing and early adoption. DR: Based on your personal experience in medical contexts, how do you see doctors actually using these technologies today? Ms. Osborn: In my experience, very few are actually using it. Those that do are mostly using it in medical education as opposed to patient practice. For example, having a teaching mannequin, but with the internal anatomy accurately projected onto the skin so that students learning a procedure FEBRUARY 2017 • Doctor’s

Review

M EDICINE AND T H E AR T S

can understand the relationship between what they’re doing and the underlying anatomy that’s being affected. Or virtual reality where you are performing a procedure and the controls give haptic responses appropriate to the textures of the different tissue types — if you hit bone, you feel it. Or you feel the slight give when you’ve broken through the virtual skin. And since it’s virtual reality, you can choose to display whatever underlying anatomy you want — or don’t want — depending on your level of mastery. DR: How much about AR/VR is just hype? In other words, do you think that the industry has made claims about the technologies that will not reach fruition? Ms. Osborn: AR/VR is very much the cool kid on the block right now. There is a lot of genuine enthusiasm about potential that will be realized in the next decade or so. A particular point where I feel it crosses into unsubstantiated hype is any claim to completely replace unaugmented boring reality. A great example is cadaver dissection. Digital cadavers exist and there are probably a few programs that have completely replaced physical cadavers with them — and saved huge amounts of money by doing so. Digital cadavers can be re-used again and again. And digital cadavers with haptic feedback can be programmed to “feel” like living tissue as opposed to the preserved texture of actual tissue, so they are useful. But I have played with digital cadavers, and I have spent hours (and hours and hours) in the anatomy lab elbow deep in actual cadavers… and there is

Doctor’s Review • FEBRUARY 2017

something about the real experience that is irreplaceable to me. To get a little philosophical about it, medical knowledge will always be tactile and physical. It’s not the sort of knowledge that just lives in your head. It’s also in your fingers and nose and eyes. Though AR and VR are sensory experiences, digital sensation and real sensation are not the same thing. Both can provide valuable learning opportunities, but I do not think any claims that AR/VR will completely replace reality are substantiated. DR: When it comes to benefits to doctors and patients, what technology do you think has the most potential to impact the practice of medicine? Ms. Osborn: Clearly the training tools available through AR and VR are powerful, but what I think has the most potential is a completely different approach — using VR to teach empathy. For example, Carrie Shaw with Embodied Labs created a VR experience that simulates the experiences of the elderly. Using the simulation, you become Alfred, with his poor eyesight

fects treatment decisions. The power of stepping into another’s shoes is impossible to hype, and VR can literally put you there. DR: Do you think that 2D illustration will continue to remain relevant in medicine, or do you see 3D imaging supplanting it entirely? Ms. Osborn: Great question, and the answer is no. 2D won’t ever go away. In addition to the fact that I don’t think print media will ever go away completely, 2D is simply much faster to produce. So if a 2D illustration will get the job done, why waste precious time and money on going 3D with it? DR: As an artist, do you think that there’s as much context for personal expression in 3D formats as there is in 2D? How exactly does that manifest? (i.e. choice of colours, shapes, movement, etc.). Do you have a preference, 2D or 3D? Ms. Osborn: I’m a commercial artist (as opposed to a fine artist) so I care less about personal expression in my work. My work is intended to commu-

Controls give haptic responses to the textures of the different tissue types and hearing, his occasional wandering into memory-land, and you see and feel what that is like (youtube.com/ watch?v=pOW7oG6bIFI). In one scene, you are sitting in your doctor’s office having been given a cognition test, but you couldn’t really hear the instructions and can’t read the paper. You fail the test. Now, perhaps Alfred really is experiencing cognitive decline but his physician doesn’t know because he didn’t realize that Alfred could not properly hear the questions or read the instructions. I appreciate that scene in the VR experience because it demonstrates how empathy is more than just better bedside manner; it can affect outcome of assessments which, in turn, af-

nicate a message or convey information that meets the needs of the audience. That said, I understand what you’re getting at, and I do think the answer is yes, 3D can hold just as much personal expression as 2D, the same way as working with clay can hold as much personal expression as working with paint. DR: Have you met with any creative challenges in learning to use advanced imaging technologies? Ms. Osborn: One of the beauties of art is that anyone can pick up a pencil and draw. But that is definitely not true for these advanced imaging technologies. uu CONTINUED ON PAGE 47

Zemi Beach House on Shoal Bay East opened in early 2016 with 63 accommodations and tiered infinity pools.

Anguilla’s place in the sun Escape to the Caribbean island that is deliberately low-key, despite beaches and hotels that are the height of luxury by Robb Beattie

ropical beaches give me vertigo. It’s not just unfamiliarity or a midwinter vitamin D deficiency or even the surrealness of holiday air travel, all parkas one instant, flip flops the next. Instead, I’m

ROBB BEATTIE

usually dizzy with nordic astonishment at life’s vividness nearer the equator: the dazzling laser sunshine, the sky’s technicolor depth and clarity, the iridescence of the jewel-like sea. And then there are the beaches. Whether tranquil coves or endless expanses of sand, stepping out of February onto a beach at this latitude makes anybody feel like an astronaut in a bathing suit.

My most recent experience of beach wooziness came courtesy of a splashdown in the British Caribbean territory of Anguilla, a slender, 24-kilometre-long island due east of Puerto Rico and the Virgins. It boasts 33 sprawling beaches reputed to be the best in the Caribbean, if not the world. That’s a tall order, but spectacular, immaculate and never crowded,

FEBRUARY 2017 • Doctor’s

Review

Anguilla’s gleaming white beaches are routinely compared to velvet, wax, powder snow or icing sugar, the last one perhaps the most apt given the incredible fineness of the sand. When I got to highly praised Shoal Bay East, a curving four-kilometre stretch of turquoise and ivory, I was as enthralled as a pastry chef by the beach’s silky, delicate texture, never mind the molecular way it clung to every surface, including me. Apart from a far-off kite surfer, the only other person around was a local guy walking a horse through the breakers. Grinning on noticing my dusting motions, he called out in a lilting voice, “Just like flour and sugar, right? All caked in sand!” On cue, his horse snorted at the joke and vigorously shook saltwater from its sun-bleached mane. As they splashed away, the owner shouted back, “Here we have our cake and eat it too, but leave the sweetness of the beach be!”

Doctor’s Review • FEBRUARY 2017

ROBB BEATTIE

f you’re unsure whether you’ve heard of Anguilla, relax; even the mail has to be occasionally redirected from neighbouring Antigua or the African nation of Angola. Deliberately low-key, the island also tends to be overlooked because of its flashy close cousins, the jet-set island of St. Barts (10 minutes south by small plane), and the joint Dutch-French possession of St. Maarten/St. Martin, a major Caribbean destination and travel hub with many regular flights from Canada. Easily reached from St. Maarten via an 11-kilometre ferry ride, Anguilla has been flying under the radar since the British first settled it with slaves in 1650. Flat, scrubby, dry and fairly featureless apart from its ravishing beaches (the north side has ocean bluffs and a pretty, hilly lookout), the limestone and coral island was long left to goats and the deliciously sweet giant crayfish that congregate on its offshore reefs. Now a self-governing UK dependency and tax haven, it still has only six traffic lights, no real urban area (the main centre, the Valley, is not much more than that), and an easygoing, gregarious population of 15,000 locals with far fewer surnames (everyone you meet seems to be a Richardson or a Gumbs). Most strikingly, Anguilla, unlike many vacation spots in the West Indies, has absolutely no chain hotels, high-rise condos, cruise ships, casinos, swanky nightclubs or shopping malls. Instead, along with day trippers from St. Maarten, the island attracts about 50,000 overnight visitors a year who raid their bank accounts to stay an average four days at the discrete boutique hotels and exclusive upscale resorts ($900 and up per night for a double room). The languid seashore on the breathtaking bays of the island’s western half is particularly popular, where Rendezvous Bay and Meads Bay are two favourite havens. A wide range of rental villas are also available: lavish ones patronized by celebrities like actor Robert de Niro can start at $50,000 per week. While mid-range

Cap Juluca in Maunday’s Bay is home a small crescent beach where visitors can go kayaking, waterskiing, windsurfing and more.

“Anguilla’s too small and slow a place for snobbery or pretension. Nobody would ever come here to show off”

We were loitering beside food shacks eating the island’s best corn soup, cooked with “sun, spices and the right amount of shade” hotels and even cheaper options under $200 per night exist, Anguilla’s emphasis is definitely on luxury with a laidback, unfussy twist.

“I

t’s about being chic, but casual; what people like to call ‘barefoot elegance,’ you know?” explains Chantelle Richardson, graciously spending the day escorting me around her island. “Anguilla’s too small and slow a place for snobbery or pretension. Nobody would ever come here to show off; they come to unwind and completely escape in the most relaxing way we can offer.” Chantelle and I had just come from seeing Cap Juluca (capjuluca.com; doubles from $1300), probably Anguilla’s premiere resort, a Moorish extravaganza of domed, whitewashed guest compounds featuring Moroccan rugs, multiple bedrooms, courtyard lap pools, plant-filled solariums and the hyper-real panorama of Maunday’s Bay Beach just outside the French windows. Now, though, we were loitering beside food shacks on the curb of a dusty thoroughfare in the Valley eating the island’s best corn soup, cooked in a big pot with “sun, spices and the right amount of shade” by 85-year-old Mabel Gumbs under the boughs of an overhanging tree. Looking around at the pecking chickens and sleepy dogs, the lack of commercialization and laconic pace of life, I could easily understand why Anguilla is often referred to as the way the Caribbean used to be. Although its resorts are jaw dropping — another one, Zemi Beach House (zemibeach.com; doubles from $800) sports tiered infinity pools like a Babylonian garden along with a spa in a transplanted 300-year-old Thai pagoda — what stays with visitors is the island’s unassuming charm and colourful houses, the children who dawdle with goats en route to school, and the affability of its inhabitants, always ready to chat with sunburned strangers. But the island also holds other treasures. Hidden in the tangle of scrub and palms are over 100 restaurants, more per acre than Manhattan, and the vibrant food scene is rated as the West Indies’ best. International accolades aside, the island’s culinary vibe is as relaxed and casual as everything else. When I went to well-known Blanchards (blanchardsrestaurant.com) for spiny lobster, geckos followed me in the door; on the terrace at Veya (veya-axa.com), a bird seemed to have read the rave reviews and filched at what might have been the last of the Moroccan spiced shrimp cigars (it’s on the menu, along with conch carpaccio with

Doctor’s Review • FEBRUARY 2017

chayote slaw). Complimented on the roasted-tomato charmoula (an Arabic marinade), owner Carrie Bogar said she had sourced the tomatoes from the taxi driver dozing behind his newspaper in front of the restaurant. Ultimately, though, every day in Anguilla is a beach day. You can snorkel the reefs, hunt down hidden coves, commune with dolphins (try Captain’s Beach) or listen to local reggae legend Bankie Banx serenade the waves at his bar, Dune Preserve, built from driftwood. (Moonsplash, the jubilant music festival he founded, takes place annually the second week of March). On my last afternoon, I went for a sea cruise to Prickly Pear, two deserted islands of blinding white sand 10 kilometres offshore. When we left to return to Anguilla, I stood at the launch’s prow watching a team of clearly visible barracuda prowling the shallows and shuddered at the thought of my immanent departure into frigid orbits. Elvis Raun, the boat’s captain, saw me twitch, and shouted concernedly, “Feeling lightheaded by the sun and sand, Mr. Canada?” “Always,” I replied, “always,” as, once again, I dusted sand like icing sugar from my shorts.

ENTERTAINMENT ETCETERA Sandy Ground is a small nightlife strip with live music venues. The Pumphouse (pumphouse-anguilla.com/ menu.php) and Johnno’s Beach Stop (facebook.com/ johnnosbeachstop) are local institutions, while Elvis’ Beach Bar (elvisbeachbar.org) has a 16-foot boat as the bar. The CuisinArt Resort (cuisinartresort. com) boasts a Greg Norman designed 18-hole golf course. Racquet sports are available at the Anguilla Tennis Academy (anguillatennis.com). For more laidback afternoons, Anguilla has 33 magnificent white sand beaches. Below are some of the best. Most heavenly beach: Shoal Bay East, excellent for snorkelling Most secluded: Captain’s Bay on the island’s northeast tip Most romantic: Cove Bay hidden near Maunday’s Bay Best wind and kite surfing: Rendezvous Bay Best for a sunset swim: Meads Bay with its beach cafés and bars Best outer island: Scilly Cay, great beach, cocktails and food

There are four dining options at Cap Juluca, including Spice, a Moroccan-style restaurant overlooking Maunday’s Bay.

Veya has received rave reviews from The New York Times, Bon Appétit, and Food & Wine — dinner costs about $175 for two.

ROBB BEATTIE

Elvis’ Beach Bar is a hotspot for nightlife and celebrity spotting.

Prickly Pear is one of two deserted islands a short 30-minute boat cruise from Anguilla.

Founded in 1718, The Alamo initially served as a way station between east Texas and Mexico, and was later the first mission in San Antonio.

The Alamo San Antonio has shed its sleepy stereotype with a revamped River Walk that stretches to the Spanish missions, art museums, new restaurants and more text and photos by Josephine Matyas

and more I

t’s hard to open a newspaper without reading about the comings and goings of

people, integration and cultural assimilation. I find myself asking: how long has this been going on? As it turns out, a very long time. In Texas, it’s a story woven into the missions of San Antonio, the most famous of which is downtown’s The Alamo (thealamo.org), the state’s top visitor attraction. A well-established crossroads, there’s more to San Antonio than history. The movement of people has fostered a community steeped in a vibrant mix of art, culture and tastes that has been influenced by the past, but generates a forward-looking energy. The story of San Antonio begins with the area’s Spanish missions built along the lush San Antonio River. “Think about someone living in this area in the early 19th century,” says Anna Martinez-Amos, a National Park Service Interpreter at Mission San José on the outskirts of San Antonio. “From 1821 to 1865 — the span of a lifetime — somebody living here starts out Spanish, then they’re Mexican, then they’re Texan, then American, then part of the Confederacy, and then they’re back to being American again. And it all happens without them moving.” Initially, the missions were built as way stations for travellers coming up from the interior of New Spain (what today is Mexico) on their way to east Texas. By building missions and growing communities, the Spanish felt they could solidify their toehold, decisively planting the flag for Spain. Large parts of Mission San José are a reconstruction of what would have been a very busy compound;

FEBRUARY 2017 • Doctor’s

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The long, low double-wall stone buildings around the perimeter of Mission San José are a reconstruction of its living quarters.

It took roughly 14 years to build the church at Mission San José, which is still an active parish with several masses held each week.

a self-contained city offering safety and prosperity. The long, low double-wall stone buildings were living quarters for the people residing at the mission, with outdoor communal stone ovens shared by several families. The large Spanish Colonial church, with its curved Roman arches, dominates the treedotted, walled compound and would have been the very pulse of daily life. “The Spanish wanted to bring the Native American Coahuiltecan into the mission and teach them the Spanish way of life for the purpose of becoming Spanish citizens who would then populate the Spanish colony,” says Martinez-Amos. Martin Vasquez, who leads interpretive tours at The Alamo agrees. “The initial goal of the mission program was to convert Native Americans and establish the area as Spanish territory. But, in 1793, when the missions program ended, The Alamo became a fort.” When the Texas Revolution erupted, it all came to a (very famous, but bloody) head in 1836. During the Battle of The Alamo, the Mexican army of 3000 well-armed troops stormed a mere 189 men barri-

Doctor’s Review • FEBRUARY 2017

caded inside the mission. The names Jim Bowie, William Travis and David Crockett are forever linked with the line Remember The Alamo — a reminder of bravery against overwhelming odds. All that remains of the original mission are the church and the long limestone walls of the barracks where the troops bunked down. Display cases are filled with artifacts like a locket of Crockett’s hair, a Bowie knife and a Spanish cannon used in the famous battle. Many were donated by celebrity musician Phil Collins, who, with a collection valued at US$15 million, is the world’s most enthusiastic packrat of Alamo artifacts.

t was the river that pulled people to this spot. Today, visitors flock to the 24-kilometre River Walk (thesanantonioriverwalk.com) in downtown San Antonio, much of it a tree-shaded walkway hugging the riverbank lined with shops, galleries, colourful Mexican food restaurants and upscale hotels. Weary walkers can take a break on narrated cruises aboard riverboats that travel up and down the canal.

The heart of the Pearl District is the old brew house, built in the late 1800s in the Second Empire style.

Lined with shops, galleries, colourful Mexican restaurants and hotels, the 24-kilometre-long River Walk winds through the city centre.

Somebody living here starts out Spanish, then they’re Mexican, then they’re Texan — and it all happens without them moving Just steps from the River Walk, the Briscoe Western Art Museum (briscoemuseum.org; adults US$10) fills several floors of the original public library, a building that was painstakingly restored to its former Art Deco, Neo-Classical glory. The Briscoe is one of San Antonio’s newer museums, ironically making its home in one of the city’s older buildings. Dedicated to the art of the American West, multi-media stations share floor space with a replica Wells Fargo stagecoach, a refurbished chuck wagon and artifacts like a saddle belonging to Pancho Villa, the Mexican Revolutionary general who was an advocate for the poor. This theme of creating something new and beautiful from something old and worn is found all across San Antonio. The eclectic, broad collection of the

CITY HIGHLIGHTS • In The Alamo chapel, look for the Crockett vest. David Crockett was only at the mission for two weeks prior to the siege of The Alamo. • According to legend, William Travis drew a line in the sand with his sword and asked the men to step across to join him in a fight for freedom that would mean certain death. All but one joined the cause. A plaque marks the spot at the front entrance to The Alamo. • The Irish silver collection at the San Antonio Museum of Art is one of the largest outside of the home country.

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PARK IT HERE There are many lovely properties along the San Antonio River Walk. The author stayed at the Westin Riverwalk (westinriverwalksanantonio.com; doubles from US$209). The hotel has 473 guestrooms with either city or river views. Five of the missions have been carefully preserved as UNESCO World Heritage Sites cared for under the umbrella of the National Park Service (nps.gov/saan). Admission to San Antonio Missions National Historical Park is free. For more info on travel to the region, visit the San Antonio tourism website (visitsanantonio.com).

Musician Phil Collins is the world’s most enthusiastic packrat of Alamo artifacts with a collection valued at US$15 million celebrated San Antonio Museum of Art (samuseum. org; adults US$10) is on display at the restored Lone Star Brewery building. The Persian Ceiling in the front foyer is an installation of dramatic and colourful glass art by sculptor Dale Chihuly. The museum is known for its Antiquities — especially Egyptian, Greek and Roman pottery and sculpture — as well as the collections of Asian and Latin American art. “San Antonio is good at being true to what these buildings were in the past,” explains Cathy Siegel, director of the annual San Antonio Cocktail Conference, as she sips a craft cocktail at Bohanan’s (bohanans.com), a jazzy Old World lounge in the

The menu at Southerleigh marries a heavy coastal influence with traditional south Texan comfort food.

Doctor’s Review • FEBRUARY 2017

up-and-coming Houston Street historic district of downtown. “Bars like this are places where the bartenders are knowledgeable and proud of their craft.” Perhaps nowhere in town struts its renovation cred quite like Pearl (atpearl.com), a restored and expanded brewery warehouse right on the banks of the San Antonio River. In addition to hip restaurants, shops and apartments, Pearl has morphed into the place for music in the outdoor amphitheatre, food festivals, a very authentic taco stand and a weekly farmers’ market. It also houses a campus of the Culinary Institute of America (ciachef.edu), where visitors can register for culinary boot camps, cooking classes and demonstrations. In the original brick brew house, Chef Jeff Balfour of Southerleigh Fine Food & Brewery (southerleigh. com) has created a menu of Texas’ cross-cultural cuisine, marrying a heavy coastal influence with traditional south Texan comfort food. In the complex’s renovated cooper’s house, The Granary 'Cue & Brew (thegranarysa.com) is known for a huge outdoor smoker that cranks out flavourful sausages, beef brisket and pulled pork. Priding themselves on a “from-scratch” philosophy, the restaurant also serves house-brewed root beer and their own craft beers are on tap. The pleasing mix of forward-looking entrepreneurship and respect for the city’s past have given Texas’s second largest city a distinct neighbourhood feel. People may come for The Alamo, but it doesn’t take much to convince them to stay awhile and tuck into a plate of ribs, a tangy margarita and a dose of San Antonio arts and culture.

Enjoy more good mornings.

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® ULTIMATE GLUCOSAMINE and ULTIMATE GLUCOSAMINE logo are registered trademarks. All are used under license.

The spouts in Bordeaux’s Le Miroir d’Eau shoot out both water and then fog, which create a pool that reflects the Place de la Bourse.

Aquitaine and the art of living It begins in Bordeaux and just keeps getting better

THOMAS SANSON

by Lin Stranberg

Doctor’s Review • FEBRUARY 2017

rt, wine and food — these sum up the Aquitaine lifestyle,” said Bordeaux guide Bruno Beurrier, pointing up to signs with those headings as he steered me through a door at Mollat (mollat.com), the vast warren of rooms that is France’s largest independent bookstore. Aquitaine, the region in southwest France that includes the Dordogne and now Limousin and Poitou-Charentes, teems with art, history, and stellar food and wine, starting with the revitalized city of Bordeaux itself.

BORDEAUX BUZZ

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After years of being under the radar, Bordeaux is buzzing and seems to be on everyone’s list. For all that, this small and beautiful cosmopolitan city on the Garonne River is surprisingly unpretentious — and a lot of fun.

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Remarkably, most of Bordeaux’s 1310 hectares are a UNESCO World Heritage Site. It’s an officially designated Town of Art and History with more than 350 official monuments, second only to Paris. The façades of its elegant 18th century buildings are fresh after a massive clean-up program spearheaded by dynamic mayor Alain Juppé, who was France’s Prime Minister under President Jacques Chirac. The city’s waterfront district along the Garonne has been transformed by the new Cité du Vin (bordeaux.fr/p47144/la-cite-du-vin), toasting Bordeaux’s reputation for joie de vivre and its celebrity status in the world of wine. Somewhere between an international viticulture museum and a hi-tech temple to the history of the grape, the Cité du Vin, with its distinctive architecture and many interactive experiences, is the new icon of 21st century Bordeaux.

LIN STRANBERG

Air France (airfrance.com) has convenient connections to Bordeaux from Paris, and a Paris stopover is free in either direction whatever your final destination. TGV train service between Paris and Bordeaux starts later this year.

Call in at the Cité du Vin’s front desk for great info on regional wine tours. Pause on the eight floor Belvedere for a glass of wine — included with your ticket — and take in the wraparound deck before heading to Le 7 Restaurant for the fine cuisine and panoramic view.

PLAYS AND STAYS

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You can catch sophisticated opera and ballet performances at Bordeaux’s 18th century Grand Théâtre (opera-bordeaux.com), one of the oldest in Europe. Nearby, the newer hotel zone includes The Intercontinental Grand (bordeaux.intercontinental.com) a Jacques Garcia-designed five-star with two Gordon Ramsay restaurants (from €285); Mama Shelter (mamashelter.com/en/Bordeaux), the trendy Philippe Starck-designed hipster hotel inside the Deco bones of the 1930s Gaz Building (from €69); and the Etche-Ona Bordeaux (bordeaux-hotel.com), a solid Best Western close to everything (from €138).

With more than a thousand restaurants and 13 Michelin stars, there are almost too many good

Doctor’s Review • FEBRUARY 2017

ANAKA / LA CITÉ DU VIN

Bordeaux’s sleek new tramway system is handily accessible and will take you almost everywhere you want to go. No need to bother with cabs.

Don’t give the region’s wines all your attention; make sure you visit Bordeaux’s superlative market for vegetables, cheese, meat, baked goods and even oysters.

You simply cannot come to Aquitaine without a truly awe inspiring call in at the newly opened caves at Lascaux-4, a visitor-friendly exact recreation of the original.

meals to be had in Bordeaux. For an authentic, oldschool southwest bistro experience, do what French heads of state have done and dine at La Tupina (latupina.com). Be sure to save your appetite: this is hearty fare.

BORDEAUX’S OUTBACK

FRANÇOIS POINCET

There’s a party every night at the cafés and restaurants in Bordeaux’s Place du Parlement.

Bordeaux is an ideal bookend for a jaunt through Aquitaine. There’s way too much to see in just a few days. One suggestion: focus on exploring some of Périgord-Dordogne and the big-name wine country closest to Bordeaux. Even if you normally prefer independent, selfdirected travel, good food and drink are so much a part of the Aquitaine you might want to leave the getting around to a tour company. Ophorus (ophorus.com), is one of several that offer tailored excursions. They’ll take you from the high energy of Bordeaux through quiet medieval villages, with fabulous food, and historic hotels. Here are some of the things you’ll see. Cave art at Lascaux 4 in Black Périgord: People have been making art in the caves and cliffs of the Vézère Valley since humanity began. Lascaux, near Montignac, has the finest found to date. The original cave, Lascaux 1, was discovered by local kids in 1940, remained hidden from the German army during World War II, and opened to the public from 1946 until 1963, when it was permanently closed to the public for preservation’s sake. Lascaux 2, which replicates about 40 percent of the art, opened to the public in 1983. Lascaux 3, a globe-trotting exhibition, is currently in Japan. The brand-new International Centre for Parietal Art (projet-lascaux.com), or Lascaux 4, opened in December 2016. It fully recreates the environment and art of the original cave, duplicating its undulating contours and prehistoric painting techniques to evoke the same haunting qualities of life and movement. “They’ve invented everything,” Picasso reportedly said to his guide when he visited the original Lascaux back in the day. Lascaux 4 is designed for all age groups with interactive exhibits, games and content to stimulate thought and fire the imagination — an absolute must see.

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Lascaux 4 has the power to change your mind about history and art. Go. And take the kids.

La Cité du Vin with its stunning bulbous silver exterior offers fine wine and sweeping city views from the eighth floor Belvedère.

Périgueux, Neuvic and more in DordognePérigord: White Périgord got its name from the colour of the stone. Périgueux, the area’s principal town and food capital, is architecturally engaging and yet another Town of Art and History, with well-preserved Gallo-Roman, Medieval-Renaissance, 18th and 19th FEBRUARY 2017 • Doctor’s

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century buildings. Gastronomy here is steeped in tradition. For a quick take on the food of the terroir, take in the open-air Wednesday market outside the SaintFront cathedral, then head out to lunch on housemade foie gras, out-of-this-world French fries, cèpes, truffles, and other regional specialties at the excellent La Ferme St-Louis (facebook.com/La-FermeSaint-Louis-199131863449913)

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In the afternoon consider a taste of caviar at the innovative Neuvic caviar farm (caviardeneuvic.com) and/or go on to sample the traditional walnut and hazelnut oils at Le Moulin de la Veyssière (moulin delaveyssiere.fr), produced with the same equipment and techniques the Elias family has used for seven generations. Feudal castles, Sarlat and more in Black Périgord: The fairytale scenery in the Dordogne valley is studded with castles. Beynac (chateau-beynac.com), which belonged to Richard the Lionheart when Aquitaine was ruled by England, is the oldest. It sits high above Beynac-et-Cazenac, one of the prettiest villages in France. The chateau is open daily and just 10 minutes from Sarlat, an appealing Gallo-Romanmedieval town visited by more than two million visitors a year.

LIN STRANBERG

Périgord is the place to say, “I’ll have fries with that.” They’re a local staple and usually cooked in duck fat, that superstar of cooking oils.

Sarlat’s Sainte-Marie’s is no longer a place to pray but somewhere to shop for vegetables thanks to architect Jean Nouvel’s remarkable conversion.

In Sarlat, don’t miss the conversion — by Pritzker-winning local architect Jean Nouvel — of 14th century Sainte-Marie church into a covered market, with giant steel doors and a glass elevator in the bell tower.

The goose is golden in Sarlat, a town that boasts some of the most highly rated foie gras in France which may help to explain why American writer and 1930s expatriate Henry Miller called Sarlat “the closest thing to heaven.” The grand medieval, Romanesque and 18th century architecture may be another. Or perhaps it was his stay at Le Vieux Logis (vieux-logis.com) in nearby Trémolat, the hotel he booked for a week and stayed on in for a month. I too could have happily stayed on a while in this lovely former tobacco estate, a jewel passed down through the Giraudel family for hundreds of years. (from €165) “I am not a merchant of soup, I am a merchant of happiness,” says Bernard Giraudel, the soulful nonagenarian proprietor. His immense charm and character raise the bar on Relais & Chateaux members’ hospitality, set high to start with. And the food

Book well in advance for lunch or dinner in the airy, highceilinged dining room, formerly the tobacco-drying barn.

Doctor’s Review • FEBRUARY 2017

MATHIEU ANGLADA

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You could make a case that France is the first and ultimate home of the B&B with Château Troplong in Saint-Emilion being exhibit #1.

— oh, the food! — from Michelin Chef Vincent Arnould, a Maître Ouvrier de France, is a standout even for the star-studded cuisine of the region.

SAINT-EMILION – ONLY 50 KM FROM BORDEAUX Saint-Emilion, a UNESCO World Heritage Site, is better known as one of the wine world’s greatest appellations. The first vineyards were planted by the Romans long before Emilion, a confessor monk from Brittany, retreated to a rockbound hermitage and the village built up around him. At only 250 inhabitants, it’s still small, yet more than a million tourists navigate its cobbled streets every year.

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To visit Saint-Emilion’s hermitage and other historic sites, you need to book with the tourist office: www.saint-emilion-tourism.com

The tourist office can hook you up with your choice of vineyard tours. The Chateau Troplong Mondot (chateau-troplong-mondot.com) is one choice among many that you wouldn’t regret and might even be worth saving up for. A Premier Grand Cru Classé estate on a hill with a picture-perfect vista over the vineyards to Saint-Emilion offers lunch at the Chateau’s Michelin-starred restaurant, Les Belles Perdrix (bellesperdrix.com).

Le Moulin de la Veyssièyre in Périgord offers caviar from their innovative caviar “farm” as well as the walnut oil being prepared here.

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Chateau Troplong-Mondot has a small and elegant onsite B&B (from €195).

LIN STRANBERG

Wine estates, historic chateaux, inns and B&Bs: Aquitaine has thousands of wine estates, and almost as many chateaux, manors and country houses are hotels, inns and B&Bs.

Saint-Emilion is famous for food and drink like the now ubiquitous macarons that have been taken up the world over.

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Unless you buy a data package in advance, you could be in for a little digital detox along the way. Most hotels and restaurants offer WiFi, but 300-year-old walls are often built to be impenetrable. If you can’t bear to unplug, arrange to rent My Web Spot (my-webspot.com) before you go.

LIN STRANBERG

Art, wine and food: a trip to Aquitaine can do wonders for developing one’s art de vivre. In addition to all the glorious food you can also cycle, kayak, canoe, surf, cook, golf, fish and more. The sites below will help you get started. Aquitaine: tourisme-aquitaine.fr Dordogne-Perigord: dordogne-perigord-tourisme.fr Bordeaux: bordeaux-tourism.co.uk Atout France: ca.france.fr FEBRUARY 2017 • Doctor’s

Review

places to go in by Theo Sands

For a good time — stay home. Canada is big travel news this year for visitors from all over the world. The 150th anniversary of Confederation celebrations are on from coast to coast to coast. Certainly plan to take in at least one national park or historic site; admission is free all year. Ottawa, featured in our January issue (page 36), will be in full party mode all year as will Montreal, which is celebrating its 375th along with the country’s birthday. This is a great year to visit PEI where it all began in 1867. You’re invited to Vancouver’s $7.5-million extravaganza in July and Calgary will be stomping for Canada at the Stampede as towns across the country get out to flag wave, parade, barbecue and light up the night with fireworks. Stage your own celebrations up at the lake or in the backyard, and invite friends to join you, especially American friends who can see what became of all those United Empire Loyalists who went north — and they can do it on $0.75 per dollar.

Duba Plains Camp opening in March offers small groups their own private guide — and a chef and butler.

SEHENSWERK / SHUTTERSTOCK.COM

CANADA’S BIG PARTY

The Montreal skyline lights up to celebrate the city’s 375th and the country’s 150th.

SAFARI PERFECTION IN BOTSWANA Been hoping and planning to go on safari for an elephant’s age? This is the year to do it. In March, Dereck and Beverly Joubert, filmmakers and National Geographic explorers, will open Duba Plains Camp (greatplainsconservation.com/duba-plains-camp) in conjunction with Great Plains Conservation. The 32,000hectare private reserve in the Okavango Delta is home

to lions, leopards, elephants, buffalo and “everything in-between.” Five luxury tents on raised platforms offer splendid wildlife views, there’s a chef and butler and a private guide to explore the surroundings via Land Rover. At the end of the day, exchange adventure stories around the fire pit over a glass of wine produced in a vineyard by friends of the Jouberts. FEBRUARY 2017 • Doctor’s

Review

LISSANDRA MELO / SHUTTERSTOCK.COM

Sedona’s classic Slide Rock joins dozens of new offerings that have put a sophisticated gloss on the high desert town.

SEDONA’S NEW GLITTER Sedona, AZ sits in the centre of a 20-kilometre circle of stupendous red rock cliffs, buttes and mesas so compelling that they inspired Walt Disney’s Fantasia. Once a sleepy desert town known for New Age psychics, UFO visitations and energy vortexes, there’s a new sophisticated gloss on the place. Today, it’s a haven for seekers of good food, healthy spas and fine accommodation as much as for those in search of spiritual renewal. Hiker alert: over 160 kilometres of trails snake through some of the most astonishing vistas outside the Grand Canyon. After the trek

there’s good coffee at Java Love and VOC’s Desert Flower Bakery. For a remarkable icy treat, sample an açai frozen fruit bowl at Berry Divine on Hwy 89A. Take in movies and plays and Live at the Met at the intimate Mary D. Fisher Theatre, which also shows indie films and hosts the annual Sedona Film Festival. Old favourites include Pink Jeep tours of the backcountry, fly-overs in the Red Baron’s biplane and daily early morning hot air balloon rides followed by a champagne breakfast. Or simply stroll the uptown shops and have your aura read.

For a Sedona icy treat try an açai frozen fruit bowl at Berry Divine 40

Doctor’s Review • FEBRUARY 2017

BEACH IT IN COMPORTA, PORTUGAL

On August 21 a total eclipse of the sun will sweep across the US from west to east beginning in Oregon.

MURATART / SHUTTERSTOCK.COM

OK, you want a beach vacation this year, but where? PEI could work but there are crowds in July and August, and the weather can be iffy. There are nude beaches at the University of British Columbia and Whistler if that’s your fancy. The Atlantic coast of the US has some terrific sand, but this might be the year you’d prefer to take a “Pasadena” on America. Here’s one that could work. Comporta, Portugal is only about an hour from Lisbon, but it’s emphatically not the Algarve. It’s been compared to Ibiza or Corfu’s Paleokastritsa or the 1960s French Riviera, but it’s none of these. Think creative-laidback-chic. Europeans with an artistic bent love it. There’s but one major hotel and a bunch of smaller ones all with a rustic feel. The beach fronts rice paddies ribboned with canals. The breeze off the Atlantic is cool as are the vibes.

This beach is one of the favourite swimming holes for artsy Europeans.

MRFOTOS / SHUTTERSTOCK.COM

CATCH A TOTAL SOLAR ECLIPSE Mark August 21, 2017 on your calendar. That’s the day a total eclipse of the sun will speed across the US beginning on the Oregon coast and racing southeast until it leaves the continent on the shores of South Carolina. There will be lots of places to view it, including Idaho, Montana and Wyoming in the west, and Kentucky, Tennessee, Georgia and the Carolinas in the east, but if you want to be first, make it Lincoln Beach, OR. It’s a small town of just over 2000 right on the ocean and as you’d expect, hotel rooms are going fast. At that spot on earth, the eclipse begins at just after 9 in the morning with totality at 10:15am. Make sure you’re on time; totality lasts just one minute and 58 seconds. And don’t forget to get the proper glasses. For full instructions, including timing, the path with full and shade areas, and precautions to take to protect your eyes go to eclipse2017.org. FEBRUARY 2017 • Doctor’s

Review

SANTA FE FOR ENHANCED ENCHANTMENT

Meow Wolf, backed by Game of Thrones George Martin, is just one of a host of new attractions in The City Different.

now opening one in Manhattan. Not all the action is downtown. Meow Wolf (meowwolf.com), supported by local George Martin, creator of Game of Thrones, offers an immense multimedia experience with a wander through a large, old, multi-story house with secret passages, a spaceship and a mystery to solve. Kids and adults are equally enthralled. African homestyle dishes at Jambo Café, located in a mall on Cerrillos Road, have become a local favourite as has food from the Midtown Bistro on San Mateo Road. Santa Café and Coyote Café continue with their outstanding offering and ambiance. They’re joined by scrumptious pies at Roof Top Pizza tucked upstairs near the Lensic Theatre on San Francisco. The City Different in the Land of Enchantment has more going on in 2017 than ever.

THE KILENS / FLICKR

Santa Fe, New Mexico is the third largest art market in the US and for that reason alone it has always attracted artists and art buyers. A spate of new galleries offering contemporary work has blossomed around the extensively revamped Rail Yards a couple of blocks south of the Plaza. Also there for your pleasure is the year-round indoor/outdoor farmers’ market in spiffed up new quarters. A huge permanent flea market is housed just across the tracks and around the corner is the innovative Victoria Crown cinema. The VC transforms movie going with beer on tap and a healthy snack pizza bar. Leather sofas invite you to come early, enjoy the food and drink or have it delivered to your armchair in one of eight cinemas upstairs. The concept has been so popular, they’re

GIANNI TRIGGIANI / SHUTTERSTOCK.COM

Start your stay in Bari with a wander along the ancient harbour where fishers offer seafood direct from their boats.

FIND THE “REAL” ITALY IN BARI Yes, there’s Florence and Venice and Milan and Naples, but for a taste of the “real” Italy unclouded by hype, Bari’s the place. Located on the Adriatic near the ankle of Italy’s boot, it’s a student town with a youthful sensibility, interesting history — St. Nicholas is buried here — lively waterfront and freshly restored opera house. Teatro Petruzzelli is the fourth largest in the country and one of the most beautiful. It’s also perhaps the least expensive of Italian cities. Many hotels are less than $75 a night. Make a point of taking the street-food tour and plan at least one meal at the Paglionico Vini e

Cucina, run by the same family for over a century. The food is classic Italian, the waiters are “brusque but brilliant.” Do have a glass of local primitivo — zinfandel to you — for its depth of flavour. When it comes to communications, bring along a smartphone with a good language app; this is your chance to delve deeply into the culture one word at a time. When your seafood cravings are sated, you’ve filled up on opera and are happy with the improvement in your Italian, grab a ferry from Bari’s ancient harbour to the Balkans, Greece or Turkey.

Amsterdam, Brasilia, Florence, Hamburg, Honolulu, Istanbul, Madrid, Milan, Paris, Quebec City, San Diego, Seoul, Shanghai, Sydney, Toronto

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Review

Sopa de lima.

Stir it up Around the world with three soups that are perfect for sharing — or not recipes by

Kathy Gunst

photos by

Yvonne Duivenvoorden

athy Gunst’s Soup Swap story started six winters ago when her neighbour, Hope Murphy, suggested that they meet once a month to share homemade

soup. Gunst, an award-winning journalist and author of 14 cookbooks, loved the idea, and they invited six food-loving couples that lived within 30 minutes of each other to participate. One couple hosted, and provided salad and crusty bread; the others brought big pots of chili, chowders and more. At the end of the night, the leftovers were packed in to-go containers

Doctor’s Review • FEBRUARY 2017

for lunches etc. The dinners made long New England winters bearable — and led to a more healthful diet for some. Here are three of the best recipes from Gunst’s Soup Swap cookbook, published by Chronicle Books. Embracing flavours from around the world, they’ll warm up your winter kitchen and they’re perfect for sharing — or, of course, keeping all to yourself.

SOPA DE LIMA GLUTEN-FREE

This lime, chicken and tortilla soup is inspired by a bowl Kathy Gunst first sampled on the Yucatán Peninsula of Mexico many years ago. You can cut corners and use canned chicken stock, a rotisserie-roasted chicken from your favourite market, and a bag of tortilla chips, but it won’t be the same. For the tortilla strips canola oil for frying 6 corn tortillas, about 5½ in. (14 cm) in diameter, cut into ½-in.- (12-mm-) thick strips sea salt For the soup 2 tbsp. (30 ml) olive oil 1 large onion, chopped 3 garlic cloves, finely chopped sea salt freshly ground black pepper 1 jalapeño chili, cored, seeded and finely chopped, plus more as needed 1 c. (250 ml) diced tomatoes, fresh or canned 1 tbsp. (15 ml) chopped fresh oregano 4 c. (1 L) your favourite homemade roasted chicken stock or canned low-sodium broth 1 c. (250 ml) cooked shredded chicken ¼ c. (60 ml) fresh lime juice, plus more as needed

In a large stockpot over low heat, warm the olive oil. Add the onion and garlic, and cook for 10 minutes. Season with salt and pepper, stir in the jalapeño, and cook for another 2 minutes. Stir in the tomatoes and oregano, and cook for 5 minutes more. Turn the heat to high, add the chicken stock, and bring to a boil. Turn the heat to low, cover, and cook for 30 minutes. Add the chicken and cook for another 5 minutes. Just before serving, add the lime juice to the soup. Taste and adjust the seasoning, adding more salt, pepper, jalapeño or lime juice if needed. Ladle the soup into mugs or bowls, top each with two or three tortilla strips and serve. Have all the garnishes arranged decoratively on a large serving plate and let guests add their own. Makes 8 to 10 tasting portions or 6 full servings. To go: Pack the tortilla strips and garnishes separately.

MAYA’S HOT-ANDSOUR BROTH WITH WONTONS DAIRY-FREE

This thin, spicy chicken broth gets its special sour flavour from Chinese black vinegar, which is available in any Asian market. Serve any extra dumplings on the side with a dipping sauce of soy sauce, a drop of sesame oil, chili paste, chopped scallions, and fresh cilantro. For the beef-and-pork wontons 1 garlic clove, minced 1 scallion, finely chopped one 1-in. (2.5-cm) piece fresh ginger, peeled and minced ½ tsp. (2.5 ml) sesame oil 8 oz. (230 g) ground beef 8 oz. (230 g) ground pork ½ tsp. (2.5 ml) Chinese chili paste with garlic

For the garnishes 1 poblano chili, seeded and chopped 1 ripe, but not overly ripe or mushy, avocado, cut into ½-in. (12-mm) cubes ¼ c. (60 ml) finely chopped fresh cilantro 1 c. (250 ml) cotija Mexican cheese or feta, grated or finely chopped 1 lime, cut into wedges

In a medium skillet over medium-high heat, add enough canola oil to reach a depth of ½ inch (12 mm) and heat until a small piece of tortilla or a speck of salt immediately sizzles on contact. Cook the tortillas, one at a time, for 1 to 2 minutes on each side, or until golden brown and slightly puffed. Using tongs, transfer the tortillas to paper towels to drain; sprinkle with salt.

Maya’s hot-and-sour broth with wontons.

FEBRUARY 2017 • Doctor’s

Review

1 tsp. (5 ml) Chinese black vinegar pinch of sea salt 48 wonton wrappers For the soup 1½ tbsp. (22.5 ml) canola oil 3 garlic cloves; 2 thinly sliced, 1 quartered 1 tbsp. (15 ml) finely minced fresh ginger 2 scallions, chopped 1½ tsp. (7.5 ml) sesame oil ¹⁄³ c. (80 ml) Chinese black vinegar 1 tsp. (5 ml) Lao Gan Ma (spicy chili crisp sauce) or Chinese chili paste (optional) 8 c. (2 L) your favourite homemade chicken stock or canned lowsodium broth ¼ to 1 tsp. (1.25 to 5 ml) Sriracha or other hot-pepper sauce ½ c. (125 ml) packed finely chopped fresh cilantro

In a large bowl, combine the garlic, scallion, ginger, sesame oil, ground beef, ground pork, chili paste, black vinegar and salt. Using your hands or a rubber spatula, mix thoroughly to make sure all the ingredients are evenly incorporated. Have a small bowl of water at hand. Fill the centre of a wonton wrapper with a heaping 1 teaspoon (5 ml) of the filling. Dab your finger in the water and moisten the edge of the wrapper. Fold the wonton wrapper over to form a triangle and press the edges together with your fingers to seal it well. Repeat with the remaining wrappers and filling. You should have enough filling for 48 wontons, give or take a few not-sopretty ones. Arrange the wontons about 1 inch (2.5 cm) apart on a parchment paper–lined baking sheet; the wontons can be covered and refrigerated for up to 3 hours.

In a large stockpot over low heat, warm the canola oil. Add all the garlic, ginger and scallions, and cook, stirring, for 3 minutes. Stir in the sesame oil, vinegar and Lao Gan Ma (if using) and cook for 1 minute. Turn the heat to high, add the chicken stock and bring to a boil. Turn the heat to low and add a ¼ teaspoon (1.25 ml) of the Sriracha and ¼ cup (60 ml) of the cilantro. Taste and adjust the seasoning, adding more Sriracha if you like a spicy broth. Cover and simmer for about 20 minutes. Meanwhile, fill a large pot a little over halfway with water and bring to a boil over high heat. Add half the wontons to the water and return to a boil. Add 1 cup (250 ml) cold water and return to a boil. Add another 1 cup (250 ml) cold water and bring to a boil. Using a slotted spoon, transfer the wontons to a clean parchment paper-lined baking sheet. Repeat with the remaining wontons. Ladle the soup into mugs or small bowls. Add three or four dumplings to each tasting-size portion, or six dumplings to each full-size portion. Sprinkle with the remaining ¼ cup (60 ml) cilantro and serve. Makes 12 to 14 tasting portions or 8 full servings. To go: Place the cooked, cooled wontons in a glass or plastic container with about 1 cup (250 ml) of the cooled broth. Cover and refrigerate. Pack the remaining ¼ cup (60 ml) cilantro in a separate container. At the soup swap, reheat the soup. Add the wontons and cook for about 5 minutes or until hot.

CHORIZO AND CLAM STEW DAIRY- AND GLUTEN-FREE

This simple stew takes about 20 minutes from start to finish, and makes a thoroughly satisfying meal.

Chorizo and clam stew with tomatoes and arugula.

Doctor’s Review • FEBRUARY 2017

3 tbsp. (45 ml) olive oil 1 large onion, finely chopped 2 shallots, finely chopped sea salt freshly ground black pepper 10 oz. (280 g) fresh chorizo, casing removed, or dried chorizo, thinly sliced or coarsely chopped

¼ c. (60 ml) packed finely chopped fresh parsley ¼ c. (60 ml) packed thinly sliced fresh basil 3 large ripe tomatoes (red, yellow or heirloom variety), chopped 1½ c. (375 ml) dry white wine 6 c. (1.5 L) fish stock (recipe follows) or bottled clam juice dash of hot-pepper sauce 3 lb. (1.4 kg) littleneck or Manila clams, scrubbed clean 4 c. (150 g) packed coarsely chopped baby arugula or arugula

In a large stockpot over low heat, warm the olive oil. Add the onion and shallots, a pinch each of salt and pepper, and cook, stirring occasionally, for 8 minutes. Add the chorizo and cook, stirring and breaking up the sausage, for 5 minutes. Add the parsley, basil and tomatoes, and cook, stirring, for another 3 minutes. Turn the heat to high, add the wine, and bring to a boil for 1 minute. Add the fish stock and hot-pepper sauce, and bring to a boil. Turn the heat to medium, cover, and cook for about 5 minutes. Add the clams and cook for 5 to 7 minutes, until they just begin to open. Discard any clams that don’t open. Add arugula. Makes 10 to 12 tasting portions or 8 full servings. To go: Make the soup without adding the clams or arugula. Pack them both separately. At the party, reheat the soup and then add the clams. Once they open, add the arugula and serve.

FISH STOCK

4 lb. (1.8 kg) fish frames (bones), with or without heads, gills removed (you may need to coarsely chop the bones to fit in your stockpot) ¾ c. (180 ml) dry white wine 1 large onion, quartered 2 medium carrots, peeled and chopped 2 celery stalks, chopped 1 bay leaf 8 peppercorns ½ c. (125 ml) packed chopped fresh parsley 6 sprigs fresh thyme or 1 tsp. (5 ml) dried sea salt freshly ground black pepper

In a large stockpot, combine the fish bones and wine. Add enough cold water to just barely cover and bring to a boil over high heat. Skim off the white foam that forms on the surface and turn the heat to low. Add the onion, carrots, celery, bay leaf, peppercorns, parsley and thyme, and season with salt (go easy; you can always add more at the end). Partially cover and simmer gently (try not to let it boil or simmer too vigorously) for 20 to 45 minutes. Taste the stock (it should have a mild briny flavour) and adjust the seasoning, adding ground pepper and more salt if needed. (Remember that a lot of seafood, particularly crustaceans, is salty, so you want to avoid over salting the stock.) Strain the stock and let cool. Store in airtight containers in the refrigerator for up to 5 days or in the freezer for up to 4 months. Makes about 8 cups (2 L).

DAIRY- AND GLUTEN-FREE

Fish stock, or what the French call fumet, is quick and easy to make. Ask your local fish store to save you “frames,” the bones that are left after filleting a fish. Look for mild-tasting white fish like flounder, cod, halibut or haddock. Stronger fish like salmon, bluefish or mackerel are too oily to make a clean-tasting fish stock. You can also add lobster shells to the stockpot. This stock is the base of many fish soups. If you don’t want to make your own, ask the folks at your fish store if they make/sell it. It will be more flavourful than what you find in the supermarket.

Recipes and photos from Soup Swap: Comforting Recipes to Make and Share (Chronicle Books, 2016).

MEDICINE AND THE ARTS uu CONTINUED FROM PAGE 20

The learning curve is steep and you really should pay someone to teach you — whether that’s a traditional for-credit academic environment or less traditional online experience. Like any art form, you have to learn the tools before you have an opportunity to be creative in your use of them. That’s the biggest challenge for 3D, just learning the tools. DR: What would you like to see in the future in how AR/VR are used? Ms. Osborn: I’m most excited about what will happen once patients get their hands on this tech. Imagine a clinician holding up an iPad and looking through the camera at the patients arm, but with the underlying anatomy showing so the patient can see as s/he explains their condition and treatment. Or — though we all love to imagine a world where clinicians have that kind of time — handing the patient the iPad with a self-guiding educational app including that AR experience. Or imagine a geriatric office having VR headsets for people in the waiting room. Caregivers could go through Carrie’s Alfred simulation just for fun and find themselves with re-invigorated empathy.

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PHOTO FINISH by

D r F r e d e r i c k a Ab c a r i us

Monkey business

Last winter I was lucky enough to vacation in Panama and stayed at the wonderful Gamboa Rainforest Resort. The trip provided ample opportunity to photograph wildlife. It was difficult to photograph Geoffroy’s tamarin monkeys, however, because they were almost constantly in motion. I managed this picture using my iPhone 6s. I was surprised by the quality of this simple camera. We had our moment.

MDs, submit a photo! Please send a high-resolution photo along with a 150- to 300-word article to:

editors@doctorsreview.com

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