January 2017

Panama’s

MEDICINE ON THE MOVE

piquant charm

Ottawa’s 150 candle

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JANUARY 2017

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GADGET PAGE 14

New year,

new bag Depression in men

Art that reveals disease Breakfast in a bowl Meet Dr Dulcamara, quack

FROM THE GSK COPD PORTFOLIO...

INCRUSE™ ELLIPTA® (umeclidinium) is indicated for the long-term once-daily maintenance bronchodilator .,! .(!). *" %,5 *1 * -.,/ .%*) %) + .%!).- 1%.$ $,*)% * -.,/ .%0! +/'(*) ,3 %-! -! %) '/ %)# chronic bronchitis and emphysema.

INCRUSEÂ&#x2122; ELLIPTA® is not %) % .! "*, .$! ,!'%!" *" /.! !.!,%*, .%*) *" Â&#x2122; ELLIPTA® should not be used in patients <18 years of age.

BREO® ELLIPTA® 5 /.% -*)! "/,* .! 0%' ).!,*' ( # %- %) % .! "*, .$! '*)# .!,( *) ! %'3 ( %).!) ) ! .,! .(!). *" %,5 *1 * -.,/ .%*) %) + .%!).- 1%.$ $,*)% * -.,/ .%0! +/'(*) ,3 %-! -! %) '/ %)# $,*)% ,*) $%.%- ) *, !(+$3-!( ) .* ,! / ! !2 !, .%*)- *" %) + .%!).- 1%.$ $%-.*,3 *" !2 !, .%*)- BREO® ELLIPTA® is not %) % .! "*, .$! ,!'%!" *" /.! ,*) $*-+ -( $! - "!.3 ) !"4 3 %) +! % .,% patients younger than 18 years have not been established.

BREO® ELLIPTA®

( # %- not %) % .! "*, + .%!).- 1%.$ $!,! %- )* %.%*) ' !)!4 . *" .$!

( # *-! *(+ ,! .* .$! ( # *-! ) .$!,! %- +*.!).% ' %) ,! -! ,%-& *" +)!/(*)% ) systemic corticosteroid-related adverse reactions.

Please consult the Product Monograph for INCRUSEÂ&#x2122; ELLIPTA® . #-& %) ,/-! !) ) ® ELLIPTA® . #-& ,!* !) "*, %(+*,. ). %)"*,( .%*) ,!' .%)# .* *) %.%*)- *" '%)% ' /-! *)., %) % .%*)- 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.

INCRUSE, BREO, and ELLIPTA, are trademarks of Glaxo Group Limited, used under license by GSK, Inc. BREO® ELLIPTA® was developed in collaboration with © 2016 GSK, Inc. All rights reserved.

01633 09/16

100/25 mcg for COPD

LAMA

“No ‘x’ in Nixon” and other curiosities Canada had a pretty good year in 2016, but given the state of uncertainty in the world, it’s probably best not to speculate about 2017. Instead, put your feet up for a bit and get silly.

There’s an excellent article in this issue on Panama, page 30. To read it is to daydream about what it would be like to retire there one day. But not quite yet. For me, Panama always makes me think of that most famous of palindromes, “A man, a plan, a canal: Panama.”

English being the quirky language that it is, it practically bleeds phrases that read the same way forward and backward. Here are a few favourites: The first conversation in Eden: “Madam, I’m Adam.”

Napoleon also had a way with words: “Able was I ere I saw Elba.”

Medical advice: “Straw? No, too stupid a fad; I put soot on warts.”

For lunch: “Tuna roll or a nut?”

The rude reply: “Go hang a salami, I’m a lasagna hog.”

Travel tip #1: “Let O’Hara gain an inn in a Niagara hotel.”

Travel tip #2, when in Rome: “Yawn a more Roman way.”

And wherever they are, girls like to share: “Marge lets Norah see Sharon’s telegram.”

Enough! Enough! Time to turn the page to other things, Doctors in Opera, page 42, for instance, or Ottawa’s year long party, page 36, or diagnosing Alzheimer’s in classic paintings, page 21.

May 2017 be an excellent year forwards and backwards.

David Elkins, publisher and editor delkins@parkpub.com

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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.

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

CA/EMP/00086 BI/EMP/00086

2

Doctor’s Review •

JANUARY 2017

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.

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contents JANUARY 2017

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features

24

24 36

Africa wide open A family physician takes his camera and his sense of humour back to Namibia to celebrate his 60th

by Dr Jonathan Hey

30

Paradise in Panama An adventure through a country that’s the best and safest travel destination in Central America

by Jane Finn

36

Ottawa 2017 The capital is spiffed up and ready to party all year in celebration of our 150th

by Lin Stranberg

30

42

The so-called love doctor A look at Donizetti’s comic opera L’elisir d’amore and the doctor who claimed he could cure everything — even heartache

by Dr J. Ian S. Robertson

44

Spoon feed Three nourishing breakfast bowls from avocado porridge to an overnight bircher that you can eat at your desk

by Annie Morris and Jonny Shimmin

44 JANUARY 2017 • Doctor’s

Review

5

contents JANUARY 2017

14

regulars

8

LETTERS Liquid matters

9

Award-winning warming huts in Winnipeg, Hamburg’s spectacular concert hall, Ottawa’s hotel shortage and more

by Camille Chin

14

GADGETS & GEAR A stylish leather and canvas rucksack

by David Elkins

9

PRACTICAL TRAVELLER

16

21

MEDICINE AND THE ARTS How brushstrokes reveal dementia in painters

by Theo Sands

48

PHOTO FINISH A tough spot

by Dr Jeff Allin

TOP 25 The best medical meetings scheduled for next spring

18

DEPRESSION KEYPOINTS Help for the affected men in your practice

by Eva Chanda

Coming in

21

February

Anguilla’s a piece of heaven Go for tranquility, food, talcum powder beaches — and, well, the food!

San Antonio for thinkers Listen for history’s murmur beneath the music and good times in a place where it’s impossible to forget the Alamo

Meet Pamela Wible, MD The author of Physician Suicide Letters Answered may just care more about your well-being than you do

6

Doctor’s Review • JANUARY 2017

R

Lolo A low-dose combined oral contraceptive with 10 mcg of ethinyl estradiol * ®

1

*Any benefits from the lower estrogen exposure provided by Lolo have not been evaluated. ®

Lolo offers the lowest ethinyl estradiol dose of any combined oral contraceptive in Canada * ®

2

Want to know more? Visit lolocanada.ca.

Indication and clinical use: Lolo® is indicated for the prevention of pregnancy.

The safety and efficacy of Lolo® have not been evaluated in women with a body mass index >35 kg/m2 or in women <18 years of age. Lolo® is not indicated for use before menarche or postmenopause. Any benefits from the lower estrogen exposure provided by Lolo® have not been evaluated.

Contraindications: Women with: • History of (or actual) thrombophlebitis or thromboembolic disorders • History of (or actual) cerebrovascular disorders • History of (or actual) myocardial infarction or coronary artery disease • Valvular heart disease with complications • History of (or actual) prodromi of a thrombosis • Active liver disease, or history of (or actual) benign or malignant liver tumours • Known or suspected carcinoma of the breast • Carcinoma of the endometrium or other known or suspected estrogen-dependent neoplasia • Undiagnosed abnormal vaginal bleeding • Steroid-dependent jaundice, cholestatic jaundice, history of jaundice of pregnancy • Any ocular lesion arising from ophthalmic vascular disease • Known or suspected pregnancy • Current (or history of) migraine with focal aura • History of (or actual) pancreatitis if associated with severe hypertriglyceridaemia • Presence of severe/multiple risk factor(s) for arterial or venous thrombosis

Most serious warnings and precautions: Smoking: Cigarette smoking increases the risk of serious cardiovascular events associated with the use of hormonal contraceptives. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked. For this reason, Lolo® should not be used by women over the age of 35 who smoke.

Sexually Transmitted Infections (STIs): Patients should be counselled that birth control pills DO NOT PROTECT against sexually transmitted infections (STIs) including HIV/AIDS. For protection against STIs, it is advisable to use latex or polyurethane condoms IN COMBINATION WITH birth control pills.

General: Patients should discontinue medication at the earliest manifestation of thromboembolic and cardiovascular disorders, conditions which predispose to venous stasis and vascular thrombosis, visual defects (partial or complete), papilledema or ophthalmic vascular lesions, severe headache of unknown etiology or worsening of pre-existing migraine headache, or increase in epileptic seizures.

Other relevant warnings and precautions: • Potential increased risk of breast cancer, cervical cancer, hepatocellular carcinoma • Predisposing factors for coronary artery disease • Hypertension • Diabetes • Adverse lipid changes • Crohn’s disease, ulcerative colitis • Vaginal bleeding • Fibroids • Increased risk of arterial and venous thrombotic and thromboembolic diseases • Jaundice, gallbladder disease, hepatic nodules

LOLO® and its design are registered trademarks of Allergan Pharmaceuticals International Limited, used under license by Allergan Pharma Co. Allergan® and its design are trademarks of Allergan Inc., used under license by Allergan Pharma Co. © 2017 Allergan. All rights reserved.

• Angioedema, fluid retention • Risk of thromboembolic complications after major surgery • History of emotional disturbances • Amenorrhea • Reduced efficacy (due to missed dose, gastrointestinal disturbances or concomitant medication) • Chloasma • Pregnant or nursing women • Physical examination and follow-up For more information: Consult the Product Monograph at www.lolocanada.ca/lolo/pm for important information regarding adverse reactions, drug interactions and dosing information (particularly in regards to dose intervals not exceeding 24 hours) not discussed in this piece. The Product Monograph is also available by calling 1-855-892-8766.

References: 1. Lolo® Product Monograph. Warner Chilcott Canada Co. December 10, 2013. 2. Data on file. 2012 Hormonal Contraception Available in Canada. The Society of Obstetricians and Gynaecologists of Canada.

R

ethinyl estradiol 10 mcg/ norethindrone acetate 1 mg and ethinyl estradiol 10 mcg

LETTERS

Liquid matters

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

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

MONTREAL HEAD OFFICE

Parkhurst Publishing Ltd. 3 Place Ville Marie, 4th floor Montreal, QC H3B 2E3 Tel: (514) 397-8833 Email: editors@doctorsreview.com www.doctorsreview.com

VICTORIA ON THE STEEP Really — $75 for a tea [The Empress’s new clothes, November/ December 2016, page 42]! On someone’s bucket list indeed!

Having lived in Victoria for many years, I can tell you that true natives shun the [Fairmont Empress] and did so even when the tea was originally overpriced at around $25 for a few poorly done scones and stale cucumber sandwiches. If you look in the teapot you’ll actually find a tea bag.

It’s too bad that the Empress seems to have gone the route of attracting the gaudy and those with more money than taste. If you want the real Victorian experience, head down to Oak Bay and the Oaks Restaurant and Tea Room.

On the other hand, if you want to end up with a bunch of guided tours or Condé Nast-Donald Trump type people, sounds like the new Empress is just the place for you.

Dr Malcolm Brigden Via DoctorsReview.com

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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.

A PORTRAIT OF EMILY CARR I enjoyed reading about Emily Carr [“10 things you need to know about Emily Carr,” Medicine and the Arts, November/December 2016, page 21].

I love her work and am always interested in learning more about her.

Another little-known fact is that she taught at the Vancouver Ladies Art Club for a few weeks, but students boycotted her classes because she cursed at them and smoked!

Angela Say Via email

CONTENT DEVELOPMENT There are no differences [in smoothies] after the use of a blender like this [“Smoothie search,” Gadgets, November/ December 2016, page 14]. All is in a

8

Doctor’s Review • JANUARY 2017

liquid form. Too bad life was not this simple in affecting segregation and respect for one another.

Dr Ilmar Kents Via DoctorsReview.com

HEAR THIS I have two pairs of Bluetooth headphones [“Headsets without wires,” Gadgets, October 2016, page 17]. I use the smaller in-ear ones for the gym, and the bigger over-ear ones on the bus to and from work. They are so convenient and I don’t have to untangle cables.

The sound is better in the bigger ones, but I paid $70 for them and $30 for the smaller ones. They were easy to pair with my Android phone and they are decent on phone calls. Great purchase and recommended!

R. Yang 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.

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

C a mi lle C hi n

Photographers gone wild

TOP: Entwined Lives by Tim Laman.

BOTTOM: The Moon and the Crow by 16-year-old Gideon Knight.

American photographer Tim Laman is 2016’s Wildlife Photo­ grapher of the Year. Laman spent three days rope-climbing a 30-metre-tall tree in the Indonesian rainforest to set GoPro cameras that he could trigger remotely. Entwined Lives captures a critically endangered Bornean orangutan and the forest below.

Agriculture and logging are threatening the habitat of wild orangutans that are also being poached for the illegal pet trade.

Laman’s winning photo was selected out of almost 50,000 entries from 95 countries; an exhibit of 100 of the best entries are on display now until March 19 at Toronto’s Royal Ontario Museum. Sixteen-year-old Gideon Knight from the UK is the Young Wildlife Photographer of the Year. He describes The Moon and the Crow, taken near his home in London, as “almost supernatural, like something out of a fairy-tale.” Adults $25; kids four to 14 $21. rom.on.ca.

JANUARY 2017 • Doctor’s

Review

9

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

Dates in the

UAE

The United Arab Emirates (UAE) has opened its first UNESCO World Heritage Site and it’s a green space that’s quite contrary to all of Dubai’s skyscrapers, city-sized shopping malls and palm-tree shaped islands — extraordinary sights that the Middle Eastern country has become synonymous with. The Al Ain Oasis, an hour south of Dubai in the country’s fourth largest city, is spread over 1200 hectares, and contains fruit trees and more than 147,000 date palms of up to 100 different varieties. Cool, shady walkways wind through the palm plantations, which are dependent on both wells and the remarkable 3000-year-old falaj (traditional irrigation channels). The purpose-built eco-centre highlights the efforts taken to preserve the Al Ain Oasis, part of a larger plan to invest in the country’s ancient sites. For more info on the oasis: visitabudhabi.ae.

Canada Day 2017 will be huge — and Ottawa is desperate for new hotel-like rental options. So many visitors are expected for Canada’s 150th anniversary celebrations that a motion was debated before city council in December to allow 10 commu­ nity and sports centres to become temporary shelters for visitors. Steve Ball, president of the Ottawa Gatineau Hotel Association, suggests that travellers call hotels directly to find out about availability, rather than rely on travel websites.

(Expect two- or three-night minimums). Of course, Airbnb is an alternative, but hoteliers are adding pressure on the City of Ottawa to impose the same fees and taxes on Airbnb rentals that are imposed on hotel rooms. Tip: book early or, like, now.

For more on happenings in Ottawa, turn to page 36.

10

Doctor’s Review • JANUARY 2017

DAVID P. LEWIS / SHUTTERSTOCK.COM

Ottawa or bust

2016 vacation review

UNGURYANU / SHUTTERSTOCK.COM

How many vacation days did you take last year? How many days went unused? If you took 14 and gave up one, your holiday habits were on par with most Canadian employees.

Expedia released its 2016 Vacation Deprivation Report last November and it charts the number of vacation days offered and used in 28 countries around the world. Data was collected from 9424 adults aged 18 and older. Employees in Spain, France and Finland got 30 paid vacation days last year — all were fully taken. Workers in Japan and South Korea took the fewest days: 10 and 8, respectively. The three days that were unused by each American adds up to about US$375 million paid vacation days being wasted. The full list follows.

Country

Days offered

Days taken

Unused days

Australia Austria Belgium Brazil Canada Denmark Finland France Germany Hong Kong Ireland India Italy Japan Malaysia Mexico Netherlands New Zealand Norway Singapore South Korea Spain Sweden Switzerland Thailand UAE United Kingdom USA

20 25 24 30 15 25 30 30 30 14 21 21 30 20 16 15 25 20 25 18 15 30 25 25 15 30 25 15

15 25 23 30 14 25 30 30 28 14 21 15 25 10 12 12 22 19 25 14 8 30 25 25 12 30 25 12

5 0 1 0 1 0 0 0 2 0 0 6 5 10 4 3 3 1 0 4 7 0 0 0 3 0 0 3

JANUARY 2017 • Doctor’s

Review

11

Hamburg’s new concert hall Elbphil­ harmonie sits on the banks of the river Elbe in the Sandtorhafen docks so it’s fitting that it has a wave-like top that rises 110 metres into the sky. Its brick warehouse foundation stored tea, tobacco and cocoa until the 1990s.

Designed by Herzog & de Meuron — also the minds behind the Tate Modern’s new Switch House — the spectacular glass structure opens in mid January.

It consists of three concert halls, a music education centre, a Westin hotel and an observation deck that’s nestled in between the lower brick building and the newer glass one. The Grand Concert Hall is the building’s heart, but is decoupled from the rest of the building for soundproofing reasons. It features 2100 seats arranged around a centrally located stage — no one in the audience will be seated more than 30 metres from the conductor. There’s also an extraordinary organ with 4765 pipes. elbphilharmonie.de.

12

Doctor’s Review • JANUARY 2017

© MICHAEL ZAPF

Beautiful music in Germany

© IWAN BAAN

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

Feeling hut, hut, hut

Open Border.

Winnipeg isn’t an obvious city for a world-class design competition, and winter isn’t the most hospitable season, but the winners of the Warming Huts: An Art + Architecture Competition on Ice have been setting up their installations along parts of the Assiniboine and Red Rivers every January since 2009. The competition receives entries from around the globe — the 100 this year came from as far away as China and Australia — which are evaluated by a blind jury. Three winning warming huts that best “push the envelope of design, craft and art” are then constructed along the Red River Mutual Trail in a weeklong building blitz for ice skaters to enjoy until the end of the skating season. The 2017 winners are: Ice Lantern designed by a four-person team from Nova Scotia; Open Border by a pair from Rotterdam, Netherlands and Greetings from Bubble Beach from Chicago, IL. This year’s invited submission comes from British-Indian artist Anish Kapoor best known for Cloud Gate in Chicago’s Millennium Park. warminghuts.com.

Bean me up

Ice Lantern.

You don’t choose an airline based on your coffee preferences, but a bad cup 30,000 feet in the air will no doubt affect your “guest experience.” In November, WestJet decided to fly McDonald’s McCafé brand on its aircraft — it outbid Tim Hortons and Starbucks. The Calgary-based airline serves 30,000 cups of coffee a day, and chose McDonald’s based on price and other factors, including previous partnering with WestJet in children’s charities. It’ll be served (for free) in a custom-made cup with a “special McCafé and WestJet design,” and will feature the fast food chain’s loyalty card and peelable sticker. Air Canada serves Second Cup coffee on its flights; Porter Airlines serves Starbucks coffee.

JANUARY 2017 • Doctor’s

Review

13

GAD GE TS AND G EAR by

Da vi d Elki ns

The doctor’s “got a brand new bag!”

I like bags and I know I’m not alone.

We all have stuff we have to carry around with us and we need something to put it all in. What we choose to do that in has a lot to say about the kind of person we are.

Case in point: I was at the mall in the week between Christmas and New Year’s along with millions of other Canadians.

I’d lost a glove and needed a new pair (though there may be a business in selling single lefts or rights). I know I’m not alone in this. Single gloves start showing up on our streets in surprising numbers as soon as the weather turns cold. Nothing is quite so lonely, or of so little use, as half a pair of gloves.

Though most of the winter was yet to come, store after store was already out of stock. To revive my spirits and warm my digits, I ducked into a coffee shop and ordered a hot soup to go.

While I waited for my order, I noticed two big guys enjoying an early lunch.

They were impeccably dressed and on the table beside each of them was the latest iPhone and a fine pair of leather gloves. Just as my order was ready, the guys got up to leave, carefully storing phones and gloves in beautifully crafted briefcases. I envied their elegance — not to mention their warm hands — and had a quick conversation with them at the door. Turned out they were pro-basketball players out of Texas.

Man, they had style.

Win a brand new bag to start the New Year in the Gadget of the Month contest at doctorsreview.com After the encounter, my search continued at a higher level. I ditched the idea of a pair of serviceable running gloves and, two stores later, allowed myself to be seduced by the only rack of men’s gloves in buttery leather at about twice what I’d planned to pay.

I bought a pair, of course, and driving home, my mind drifted back to those well-turned-out gents and their beautiful bags.

The large leather and canvas bag on offer as the January Gadget of the Month has several things going for it.

It’s handsome; roomy enough to use for an overnighter; has straps so you can wear it as a backpack and it’s uncomplicated with only a few pockets.

On the outside there are just two: one for gloves and one for a phone. Perfect.

It measures 40 x 12 x 32 centimetres.

US$79.99. rucksackbag.com.

CONGRATULATIONS! The winner of a wireless Bluetooth headset is Dr Beau Blois, an emergency physician from Old Barns, NS. 14

Doctor’s Review • JANUARY 2017

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Canada Mont Tremblant, QC June 7-10

June 2-3 18th Canadian Collaborative Mental Health Care Conference shared-care.ca

June 20-23 73rd Annual Clinical and Scientific Conference of the Society of Obstetricians and Gynaecologists of Canada sogc.org/conference/acsc/welcome.html

Toronto, ON May 10-13 Pri-Med CANADA pri-med.ca

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

June 16-18 North American Refugee Health Conference northamericanrefugeehealth.com

June 22-23

Mont Tremblant Village, QC.

Around the world

Lyon, France June 20-24

Basel, Switzerland June 7-9

12th Congress of the European Paediatric Neurology Society epns2017.com

2017 Joint Chest-SGP Congress chest-sgp-switzerland2017.org/congress.html

Boston, MA May 12-14 65th Annual Meeting of the Society for Pediatric Urology spuonline.org/annualmeeting.cgi

May 12-16

2017 Canadian Breast Cancer Symposium breastsymposium.ca

2017 Annual Meeting of the American Urological Association aua2017.org

Vancouver, BC May 17-20

Gothenburg, Sweden June 15-18

13th World Congress on Endometriosis endometriosis.ca/world-congress/wce2017

6th International Congress on Neuropathic Pain neupsig2017.kenes.com

Whistler, BC June 3-7

Lisbon, Portugal June 6-9

2017 Annual Conference of the Canadian Association of Emergency Physicians caep2016.ca/caep-2017

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28th Annual Meeting of the European Society of Paediatric and Neonatal Intensive Care espnic2017.kenes.com

Pittsburgh, PA.

SEAN PAVONE / SHUTTERSTOCK.COM

Ottawa, ON

HOWARD SANDLER / SHUTTERSTOCK.COM

2017 Annual Symposium of the Canadian Academy of Sport and Exercise Medicine casem-acmse.org/news/casem_annual_symposium/ tremblant-2017

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

Pittsburgh, PA May 17-20

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

Rome, Italy June 22-25 3rd World Summit on Pediatrics wsp-congress.com

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

San Diego, CA May 6-9 2017 Annual Clinical and Scientific Meeting of the American Congress of Obstetricians and Gynecologists acog.org

BYVALET / SHUTTERSTOCK.COM

36th Annual Scientific Meeting of the American Pain Society ampainsoc.org/annual-meeting/overview

Würzburg, Germany.

San Francisco, CA May 6-9

Washington, DC May 4-7

2017 Pediatric Academic Societies Meeting pas-meeting.org

19th Annual Conference of the International Society for Bipolar Disorders isbd2017.com

MEDICAL QUIPS Medical definitions – Part 1 Outpatient: a person who has fainted Post operative: letter carrier Recovery room: place to do upholstery

May 19-24 2017 International Conference of the American Thoracic Society conference.thoracic.org

Würzburg, Germany June 10-13 8th International Conference on Children’s Bone Health iccbh.org

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

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DE PRESSIO N K EY PO I NT S by

Eva Chanda, MSc

Depression in men Shining a light on a hidden problem

W

ith depression diagnosed twice as often in women as in men,1 it’s easy to think of it as a “women’s problem”—but for men with undiagnosed depression, that could be a lifethreatening mistake. Depression is a key risk factor for suicide, and men are three times more likely to commit suicide than women.2 For too many men, the problem isn’t recognized until it’s too late.

Practice tips11 • Work with men’s desire to be strong and self-reliant by positioning help-seeking as a positive, manly step toward self-management of mental health.

• Reframe depression as a disease, not an emotional/ character weakness.

• Use directed, open-ended questions, not just screening tools, to gain men’s trust and encourage them to open up.

• Monitor for emerging depression and suicide risk factors, such as relationship breakdowns and job insecurity.

• Seek men’s input and collaboration in treatment, to restore their vital sense of control.

Big boys don’t cry Sociocultural factors are thought to play a major role in gender disparities in depression diagnosis. From childhood, men learn to follow male-specific behaviour and ideals known as masculine gender norms. Emotional awareness and expression, and displays of sadness, such as crying, are implicitly and sometimes explicitly discouraged by parents and others.3 A systematic review of quantitative and qualitative studies on the effects of masculine gender norms on help-seeking in men with depression identified several recurring themes. Men may find it difficult to recognize and communicate symptoms of depression, and are more likely to attribute depressive symptoms such as fatigue, low mood, restlessness and irritability to physical illness. Masculine norms like control, stoicism, strength and success clash with feelings of shame and weakness in depression, increasing self-stigmatization and inhibiting help-seeking.

Rather than getting help, many men try to avoid their troubles through isolation, substance abuse, risk-taking, anger and working longer hours. Even men who seek help may not disclose all symptoms, or may downplay their seriousness to maintain the façade. Men prefer collaborative interventions using practical problem-solving, such as cognitive behavioural therapy and group therapy. Men may accept a more flexible masculinity to integrate depression with masculine ideals of strength and independence, viewing help-seeking as “fighting” depression.4 Even clinicians may harbour gender stereotypes that prevent recognition and diagnosis of depression in men.5

Table 1. Two-pronged clinical assessment approach for depression in men 1. Assess for traditional depression criteria10

2. Assess for male-type symptoms

• Depressed mood

• Anger

• Decreased interest or pleasure in activities

• Relational strain

• Fatigue

• Conflict between work/family

• Sleep or appetite disturbance

• Substance use

• Feelings of worthlessness

• Discrepancy between experience (loss, rejection) and expression of emotions

• Guilt

• Increased somatic complaints

• Difficulties concentrating

• Problems with motivation

• Thoughts of death and suicide

• Decrease in sexual interest but not activity • Increased strain between gender role expectations and performance

Adapted from: Fields AJ, Cochran SV. Men and depression: current perspectives for health care professionals. Am J Lifestyle Med 2011;5:92–100.

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Online resources Men’s Depression: Help Yourself (mensdepressionhelpyourself.ubc.ca) This website highlights research on men with depression, conducted by the Men’s Health Research Program at the School of Nursing, University of British Columbia. The site offers videos and podcasts of mental health professionals and patients sharing their perspectives on depression in men.

HeadsUpGuys (headsupguys.org) Developed by the University of British Columbia and the Movember Foundation, this website offers user-friendly information on depression symptoms, triggers, risk factors, an online Self Check, practical tips, how to take action and get help, and real stories of men with depression.

Rage against the machine In the past, the gender gap was thought to be due to women being at higher risk for depression, but there’s a growing awareness now that men with depression may present differently from women.6 In an analysis of data from a large US national mental health survey (nearly 6000 respondents), men reported significantly higher rates of anger attacks/aggression, substance abuse and risk-taking than women. When a depression rating scale incorporating these alternative symptoms with traditional depression symptoms was used, the sex difference in depression rates disappeared.6 A simple, robust rating scale for male depression is still needed.

The Gotland Male Depression Scale (GMDS; see “Online Resources” for link),7 the Masculine Depression Scale (MDS),8 and the Male Depression Risk Scale (MDRS-22)9 have been validated, but may be of limited use clinically. An alternative is to do a two-pronged clinical assessment, using both the traditional criteria from the Diagnostic and statistical manual of mental disorders, 5th ed.

(DSM-5),10 and alternative, male-specific symptoms (see Table 1).5

The road to recovery Once depression is properly diagnosed and treated, the prognosis is good for most men. The standard, evidence-based interventions involving psychotherapy and antidepressants are equally effective in men and women.5 It’s important, however, to consider sexual side effects in treatment selection and monitoring, as these can adversely affect men’s adherence to treatment and quality of life. Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs), are known to cause sexual side effects such as changes in libido, erectile dysfunction, anorgasmia and delayed ejaculation.

One approach may be to prescribe bupropion or mirtazapine, which have a lower incidence of sexual dysfunction. Keep in mind that sexual dysfunction could also be due to the depression itself, or medical or psychosocial factors. Also, since men rarely report sexual dysfunction on their own, be sure ask directly about such symptoms.3,5

Man Therapy (mantherapy.org) This website from the Colorado Office of Suicide Prevention blends tongue-in-cheek videos and advice from fictitious “Dr. Rich Mahogany, Man Therapist” with serious information on depression, anger and suicide, links to resources, and the “20-Point Head Inspection,” an online screening tool.

Gotland Male Depression Scale (sundhed.dk/content/ cms/67/83367_gotland-male-depression-scale-april2015.pdf) Printable form with scoring instructions.

References 1. Department of Mental Health and Substance Dependence. Gender Disparities in Mental Health. Vol 48.; 2001. http://www.who.int/mental_health/media/en/242.pdf.

2. Navaneelan T. Suicide rates: An overview. Health at a Glance. http://www.statcan. gc.ca/pub/82-624-x/2012001/article/11696-eng.htm. Published 2012. Accessed January 3, 2017.

3. Ogrodniczuk JS, Oliffe JL. Men and depression. Can Fam Physician. 2011;57(2): 153-155. http://www.ncbi.nlm.nih.gov/pubmed/21321163. Accessed November 23, 2016.

4. Seidler ZE, Dawes AJ, Rice SM, Oliffe JL, Dhillon HM. The role of masculinity in men’s help-seeking for depression: A systematic review. Clin Psychol Rev. 2016; 49:106-118. doi:10.1016/j.cpr.2016.09.002.

5. Fields AJ, Cochran S V. Men and Depression: Current Perspectives for Health Care Professionals. Am J Lifestyle Med. 2011;5(1):92-100. doi:10.1177/ 1559827610378347.

6. Martin LA, Neighbors HW, Griffith DM, et al. The Experience of Symptoms of Depression in Men vs Women. JAMA Psychiatry. 2013;70(10):1100. doi:10.1001/ jamapsychiatry.2013.1985.

7. Sigurdsson B, Palsson SP, Aevarsson O, Olafsdottir M, Johannsson M. Validity of Gotland Male Depression Scale for male depression in a community study: The Sudurnesjamenn study. J Affect Disord. 2015;173:81-89. doi:10.1016/j. jad.2014.10.065.

8. Magovcevic M, Addis ME. The Masculine Depression Scale: Development and psychometric evaluation. Psychol Men Masc. 2008;9(3):117-132. doi:10.1037/1524-9220.9.3.117.

9. Rice SM, Fallon BJ, Aucote HM, Möller-Leimkühler AM. Development and preliminary validation of the male depression risk scale: Furthering the assessment of depression in men. J Affect Disord. 2013;151(3):950-958. doi:10.1016/j. jad.2013.08.013.

10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: Author; 2013.

11. Gagnon M, Oliffe JL. Male depression and suicide. Nurse Pract. 2015;40(11):5055. doi:10.1097/01.NPR.0000472250.13456.80.

JANUARY 2017 • Doctor’s

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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.

PRISTIQ® Wyeth LLC, owner/Pfizer Canada Inc., Licensee © 2016 Pfizer Canada Inc., Kirkland, Quebec H9J 2M5

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 T S by

T he o S a n d s

Cognitive decline in famous painters Do fractals uncover disease?

Willem de Kooning’s work continues to find a ready market. Last September this painting, Untitled XXV, sold for over $66 million at a Christie’s auction in New York.

P

ainter Willem de Kooning was an undocumented immigrant when he arrived in New York as a stowaway on a British freighter in 1927. Born in

Rotterdam on April 24, 1904, he was to become the leader of American abstract expressionism in the 1950s. His series Woman epitomizes the form and his work continues to find wealthy buyers.

In September 2015, his painting Interchange was purchased, in a private sale, by hedge fund billionaire Ken Griffin for $300 million, the highest price yet paid for any painting.

JANUARY 2017 • Doctor’s

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ME D I C I N E A N D T H E A R T S This past September, Christie’s sold Untitled XXV at auction for more than $66 million, a record for the work of an abstract expressionist. It had previously been auctioned in 2006 and sold for $27.1 million.

His work is of special interest for another reason. Alex Forsythe, a psychologist at the University of Liverpool, has just published a paper based on the analysis of more than 2000 works by seven famous artists. She thinks she’s found a way of detecting changes in brushwork that indicate the beginnings of Alzheimer’s in painters in their 40s.

De Kooning, who died in 1997 at the age of 92, had been diagnosed with the disease.

A second painter, James Brooks, the last of the original American abstract expressionists which also included Jackson Pollock, died in 1992 at the age of 85. His wife told the New York Times he had suffered from Alzheimer’s for the last seven years of his life.

Forsythe says she’s found signs of dementia in the works of both painters.

Of the works she’s analyzed, those of Claude Monet, Pablo Picasso and Marc Chagall showed no signs of disease.

Those of Salvador Dali and Norval

Salvador Dali’s Parkinson’s disease was picked up by examining his artwork using fractal software.

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Doctor’s Review • JANUARY 2017

Willem de Kooning in his studio in the 1940s: fractal analysis of his work indicated he suffered from Alzheimer’s after age 85.

Morrisseau indicated both had developed Parkinson’s.

Fractal tales In her research, Forsythe used digital imaging software to calculate how fractal

density varied in the artists’ paintings over their careers. And what precisely are fractals? Fractals are infinitely complex patterns that are self-similar across different scales. They are created by repeating a simple process over and over.

Fractal patterns abound in nature and are found in the branching of trees and rivers, mountains, clouds, seashells and so on.

(To learn more go to fractalfoundation. org/resources/what-are-fractals).

In paintings, fractals appear when patterns made by the tiniest brush strokes are repeated on larger scales. The fractal dimension is a measure of fractal complexity where an artwork with a large fractal dimension has a high ratio of fine to coarse fractal patterns.

Forsythe found that paintings varied in their fractal dimensions over an artist’s career, but in the case of de Kooning and Brooks, the measure changed dramatically and fell sharply as the artists aged.

“The information seems to be like a footprint that artists leave in their art,” says Forsythe. “They paint within a normal range, but when something is happening to the brain, it starts to change quite radically.”

Her research suggests that the frac-

Forsythe thinks she’s found a way of detecting changes in brushwork that indicate the beginnings of Alzheimer’s in painters tal dimensions of paintings by Monet, Picasso and Chagall tended to rise as they aged. For Dali and Morrisseau’s work, the fractal dimension followed an upside down U-shape over time, at first rising and then falling. The starkest result was seen in the works of de Kooning and Brooks, where the fractal dimension started high and dropped rapidly from the age of 40.

Forsythe is not the first to look for early signs of dementia in writing and painting. In 2008, a team at the University of Toronto published a paper often referred to as “Three British Novelists,” which spotted early signs of dementia in the works of Agatha Christie and Iris Murdoch.

Researchers at Arizona State University used similar software to examine non-scripted news conferences of former presidents Ronald Reagan and George Herbert Walker Bush. President Reagan, they wrote, showed “a

significant reduction in the number of unique words over time and a significant increase in conversational fillers and non-specific nouns over time,” while there was no such pattern for Bush. The researchers concluded that during his presidency, Reagan was showing a reduction in linguistic complexity consistent with what others have found in patients with dementia.

Another study found similar results in autobiographical essays written by nuns in the ’20s.

Yeas and nays Richard Taylor, a physicist at the University of Oregon who pioneered the use of fractals, describes Forsythe’s work as a “magnificent demonstration of art and science coming together” and suggests it could be used more broadly to learn more about dementia. uu CONTINUED ON PAGE 47

Analysis of the 1984 presidential debate between Ronald Regan and George Herbert Walker Bush suggest Regan’s word use showed he was in the early states of dementia. BELOW: Over 2000 paintings by seven artists were examined using fractals. Four artists were found to suffer from disease; Claude Monet, Pablo Picasso and Marc Chagall (pictured below left) were disease free.

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I PRES CR I B E A TRIP TO...

NAMIBIA

Africa wide open An MD photographs dunes during the day and stares at the stars at night during a holiday to celebrate his 60th birthday text and photos by Dr Jonathan Hey

Dr Jonathan Hey is a family physician of South African origin who lives in Saskatoon. Despite having been here for 25 years — and married to a Canadian — he has yet to acclimatize to our winters. He intends on travelling until his money runs out.

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Doctor’s Review • JANUARY 2017

The luxurious Little Kulala desert retreat has 11 thatched accommodations and its own gate into Namib-Naukluft National Park.

he start to my trip was a bit of a downer. “Any metal in your knees or hips?” asked airport security. “What?” I thought. “In this temple?”

I considered doing a one-arm push-up as proof of my youth, but quickly remembered that I hadn’t done one for 20 years and even if I could, I might not be able to get up.

“Of course not,” I said, with what I thought was the right amount of disdain.

I had been honouring my 60th birthday for the entire year, with my family rolling their eyes every time

I suggested yet another celebration. This time I thought a trip to Namibia would be a suitable destination to let that country know of my birth — and to try to keep up with Angelina Jolie, who, for some strange reason, had decided to deliver her fourth child in that country.

Dune 45’s shape, colour and accessibility make it the most photographed dune in the world.

Namibia is on the southwest coast of Africa, home to the oldest desert in the world and the tallest sand dunes. “Namib” means “open space,” Namibia the “land of open spaces.” I had been there before in another lifetime, courtesy of the South African Army, and had always wanted to go there again in a more peaceful time.

We flew from Atlanta to Johannesburg and then on to Cape Town, and spent a few days recovering at the Cape Grace Hotel (capegrace.com; doubles from $697 a night). My wife went on a shopping frenzy (at last a country where the Canadian dollar translates well, with the South African rand doing poorly at the moment) and I tried to sample each and every Cape wine, an impossible task, but one that needed to be done.

The Cape Grace Hotel is situated on the waterfront, a reclaimed area around the working docks of Cape Town, resplendent with smart restaurants and expensive shops — shops so expensive that it’s worth looking around at others, as prices varied enormously.

The hotel has splendid rooms, excellent food and a whiskey bar with over 500 types of whiskey, in case, I suppose, one runs out of wine to drink. The personalized service could not have been better. The staff greeted me every morning, asked how I slept and the impressive concierges were more than willing to share their knowledge and make suggestions to an “elderly” visitor such as myself. There is a “Hop On, Hop Off” bus close to the hotel that’s very easy to use. It takes visitors all over the city and into

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the surrounding areas: Table Mountain, Kirstenbosch Botanical Gardens and Hout Bay.

PAINTINGS COME TRUE

My wife and I set off from Cape Town airport one morning and flew directly to Walvis Bay, two hours up the West Coast of Africa. It’s a desolate landscape with sand stretching as far as the eye can see.

(Keep the Atlantic Ocean on your left and you can’t go wrong). Our plan was to spend two nights in Swakopmund, a small town 30 minutes away, three nights in Sossusvlei, famous for its red sand dunes, which are among the tallest in the world, and then finish off in Namibia’s capital, Windhoek.

Namibia, or South West Africa as it was once called, was a German colony around the turn of the last century, mandated to South Africa after the First World War by the League of Nations, and given over to a trustee system after the Second World War by the United Nations. This was disputed by South Africa, which led to a long and protracted civil war until independence was achieved in 1994.

The German influence is strikingly obvious in Swakopmund, where most people speak German first and then English. Here, the streets are clean, the food European and there are lots of elderly people, the women in frilly bathing caps, swimming in an unusually warm Atlantic Ocean.

One of the reasons for the visit was that my late stepfather, a judge, had spent a week in Swakopmund

The greenery on this isolated tree near Sossusvlei means that there’s an underground water supply below the rocky terrain.

Swakopmund has a very German feel, and visitors love the town’s seaside promenade, sidewalk cafés and immaculate hotels.

I had been to Namibia before, courtesy of the South African Army, and had always wanted to go again in a more peaceful time while attending a law conference in the ’70s. He was, to me, a Renaissance man, with a formidable intellect and a multitude of interests. He was an artist as well. He spent his off time from the conference painting two landscapes of the town. I am at heart a romantic and had photographs of them, and we wandered around the town until, with the help of the hotel manager, we worked out where he had sat to create them. It was fun to do and, to me, quite emotional, thinking of him sitting quietly painting, those many years ago.

My wife and I wandered about the town, buying enough curios to tip us into the “heavy luggage” sticker at the airport on the way home. We stayed at the Hansa Hotel (hansahotel.com.na; singles from $145 per person a night; doubles from $100 per person) in a suite because we had been warned that the other rooms didn’t have air-conditioning. We needn’t have worried: the nights were cool and pleasant, even in the heat of summer. The hotel is situated a few blocks from the sea and is very comfortable. It’s also well worth having a meal there; the food was excellent.

A DAY AT THE DUNES The next stage of our journey was to Sossusvlei, south of Swakopmund, home to what is thought to be the highest sand dunes in the world, rising some 300 metres from the desert floor, and located in Namib-Naukluft Park.

Our Namibian trip was arranged by Wilderness Safaris (wilderness-safaris.com) and we stayed at Little Kulala (sossusvlei.org/accommodation/little-kulala; from $650 per person a night, all inclusive), a lodge of 11 cabins overlooking the bleak Namibian desert with the wind and sand constant companions. Each cabin has air-conditioning (a must in the Namibian summer heat), a plunge pool on its deck and a rooftop double bed for those wanting to sleep under the stars. The stars alone are worth the trip. Unhindered by smog and lights, they are simply magnificent.

We were awakened one morning at 4:30am by our guide and set off at 5:30am after a light breakfast of fruit, muffins and full cream yogurt. No point in attempting a diet here. We arrived at the Naukluft Park gates a half hour later, just as the sun was rising, and JANUARY 2017 • Doctor’s

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Namibia’s national animal is the gemsbok, a large antelope with straight horns and a thick muscular neck.

Desert larks have sand-coloured upper parts and grayish-pink under parts, which make them hard to spot.

If my photographs are ever discussed, they will say, “This was his ‘solitary-treein-front-of-a-sand-dune’ period.

It was unfortunately his only period.” set off for Dune 45, the sand dune featured in most National Geographic magazines.

The sun was just tipping the top of the dune, casting strong contrasting shadows with beautiful light playing on the edges. The orange colour of the sand is a sign of the age of the dune. The iron in the sand oxidizes over time creating a deep orange glow made spectacular by the morning sun.

I enjoy taking photographs of landscapes. Put me in front of a solitary tree on an open plain and I will take hundreds of them. If my photographs are ever discussed, they will say, “This was his ‘solitarytree-in-front-of-a-sand-dune’ period. It was unfortunately his only period.”

Little Kulala and her sister camp, Kulala Desert Lodge, both run by Wilderness Safaris, are the closest private camps to the gates of the park and, therefore, the dunes. Within half an hour of our arrival, the parking lot was filled with tourists staying at camps further away, climbing to the top of the dune.

We travelled from there down the road (fourwheel drive only) and then walked three kilometres into the desert to “Doodvlei” or “Deadpan,” a dried pan with dead trees, some more than 500 years old, scattered about. The area used to be a river, until the dunes encroached, cutting off its path to the sea. It was a spectacular morning, one that I will always remember.

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Apart from seeing the sand dunes, appreciating the bleakness of the landscape and contemplating one’s own insignificance in the face of such vastness, there’s a lot to do.

There are ATVs that one can use to roar about the desert accompanied by a guide and even hot-air ballooning at dawn.

I spent a lot of time looking for — and finding!

— the desert lark, a small, rather dull bird that is endemic to the sand dunes of Namibia. “A serious tick” as the ornithologists would say.

There is little wildlife compared to Namibia’s neighbours, Botswana and South Africa. Oryx or gemsbok, a large stately antelope with straight horns; springbok; cape and bat-eared foxes; brown hyenas and blackbacked jackals. As for the bird life, I saw 24 endemic species, all mostly brown that blended in with the desert scrub, except for the crimson-breasted bush shrike, with its flash of colour on a brown background.

For me, three nights in Sossusvlei was ideal.

Enough time to see the dunes, to experience the sunsets with a gin and tonic every evening, to spend an afternoon sitting on the deck of one’s cabin with the occasional dip in the plunge pool.

As I left Namibia for home, a friend shook me warmly by the hand and said “I hope to see you before one of us pops off.” I can’t wait for my 70th birthday celebration.

Picture yourself in Africa.

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ALL PHOTOS DAVE FINN UNLESS OTHERWISE NOTED

The luxury tree houses at the Lucero Golf and Country Club in Boquete feature views that stretch to the Pacific Ocean.

Paradise in Panama From the busy capital to beautiful Boquete, a road trip through the country that’s fast becoming the next affordable hot spot

by Jane Finn

t’s seven o’clock as the sun rises over the ridge. The stillness of the morning is broken only by the sounds of the Agua Blanca River babbling below or the occasional soft whinny of a horse grazing on a nearby hillside. Butterflies and birds of every colour flit through the rainforest, and the sky is so clear I can see the Pacific Ocean, about an hour and a half away. I’m so relaxed, but also so energized, I find myself

reflecting on how I came to be at the top of the world in a tree house in Panama’s Boquete Highlands.

Our adventure began soon after we arrived at Tocumen Airport in Panama City. I had read about

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the Panamanian Papers, understood the importance of the Canal and knew that Panama was rapidly emerging as the best value travel destination in Central America, but I was still unprepared for the scene that greeted me as we made our way towards the city. Slowly, suburban enclaves gave way to towering office buildings, luxury condos, shopping malls, casinos and five-star hotels. The skyline reminded me of Miami, and before I knew it, we were in the downtown core.

The streets were teeming with people and traffic.

There were runners and cyclists on the Amador Causeway, and shoppers laden with bags strolled along Avenida Balboa in search of more duty-free bargains.

Taxis loudly honked their horns, anxious to get passengers to their next meeting, and street vendors vied with cafes and restaurants for passersby’s patronage.

It was a lot to take in, but after dining on tapas and

and extravagant new apartments, art galleries and night clubs were taking up residence behind the walls, a testimony to how the historical and modern can coexist in harmony.

A

trip to Panama would not be complete without a visit to the Canal so before hopping on the Pan-American Highway, the world’s longest road, enroute to our tree house, we stopped at Miraflores Locks to see what many consider the eighth wonder of the world. It was amazing to watch a giant container ship glide through the massive locks and then sail past a rainforest.

While I would have been hard-pressed to get behind the wheel in Panama City, once we crossed the Bridge of the Americas it was a comfortable drive to the string of coastal towns that lie just an hour outside

The Casablanca restaurant is housed in one of the prettiest Spanish Colonial buildings in Casco Viejo.

You can buy souvenirs, and sample food and drink, in Plaza Francia, originally the main square in Old Panama.

ceviche, it occurred to me: the city is like Panamanian food — fresh, vibrant and a little bit spicy.

In contrast, when we toured Casco Viejo (cascoviejo.com) the next day, I felt like I’d taken a step back in time. Founded in the late 17th century, Old Panama is lined with buildings heavily influenced

by French, Spanish and American architecture. Its narrow cobblestone streets, or callejones, encourage exploration on foot and when you stroll along the Esteban Walkway, the views of Ancón Hill and the Bay of Panama are spectacular.

The UNESCO World Heritage Site is experiencing a period of renewal and when we visited crumbling facades were under repair, plazas and hidden courtyards were being restored to their former glory,

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the city. Punta Chame, Gorgona, El Palmar and San Carlos are all beautiful, but we decided to stop to check out Coronado, Panama’s first resort community, to see for ourselves why tourists are relocating here in increasing numbers.

The new Scarlett Martínez International Airport at Río Hato provides North Americans and Europeans easy access to Coronado’s spectacular white- and blacksand beaches, crystalline waters, five golf courses and large expat population, but that’s not the only reason so many want to call these Pacific Shores home. It appears that many foreigners are impressed with the country’s stable democracy, state-of-the-art medical facilities and affordable lifestyle based on US dollars.

The Lucero tree houses are nestled in the Boquete Highlands — amazingly they have Wi-Fi.

Also, retirees, or pensinados, are entitled to numerous benefits including discounts ranging from 30 to 50 percent on airfare, restaurant meals, movie tickets and hotel accommodation, and there is no tax on foreign income. With an income of greater than $1000 per month, Canadians and Americans can obtain a residential visa and start living the good life in less than three months.

T

he last leg of our trip was north to Boquete in the Chiriquí Province, which has a more temperate climate.

In David, the provincial capital, we met up with Daniel, Boquete’s unofficial ambassador who joined us as we made our way up into the mountains. The 45-minute drive passed all too quickly as he shared suggestions about what to see and do, and also insights about politics, real

LIFE IN TREES Panama City is one of the most cosmopolitan capitals in Central America where many worlds coexist.

estate investments and why Boquete has become a haven for backpackers, tourists and expats alike. His enthusiasm was infectious and set the tone for the rest of our trip. Although Dave was here to play Panama’s only mountain golf course, Daniel left us in no doubt that we’d chosen well when we decided to visit Boquete to explore life like a local.

One of our first stops was Sugar & Spice (sugarandspiceboquete.com), an artisan bakery and gathering place for expats. While sitting at an outdoor table, it was easy to strike up a conversation over a cup of coffee and gain their perspective on why they had left North America for the simpler life.

Later that afternoon, we hiked the Sendero Los Quetzales trail to Cerro Punta, Panama’s food basket,

You know that expression “Life isn’t measured by the number of breaths you take, but by the moments that take your breath away?” When we stepped onto the deck of our tree house at the Lucero Golf and Country Club (tel: 877-727-2476; lucerocountryclub.com; US$395 per night, double occupancy, during high season), I literally experienced the latter. Standing 40 metres above the floor of the Caldera Valley, protected by the rainforest canopy and the Jaramillo Mountains, I felt a profound sense of peace. It was at least an hour before I tore myself away from the views to explore our very private, very romantic getaway.

Luxuriously appointed, our tree house included a walk-in rain shower, cozy sitting area with kitchenette and deliciously comfy bed where we could see not only the stars, but the twinkling lights of David in the distance.

Nestled next to the tee off blocks at the third hole of Lucero’s mountain golf course, we were steps away from the clubhouse and Season’s, the community’s farm-to-table restaurant. Last year alone, the staff planted over 500 tropical fruit trees, 320,000 coffee plants and an extensive vegetable garden.

Adjacent to the restaurant is the pool, tennis courts, golf pro shop and, next year, a spa and fitness centre. In 20 minutes, you can also be in Boquete to shop, dine or dance the night away.

Be as active or relaxed as you like, but make sure you take time to savour the flavour of living life “at the top.” Whoever said the “world is your oyster” was surely staying in a tree house, not on a beach as I originally assumed!

Two tree houses are currently available. Two more are scheduled for completion this month.

Continental breakfast, use of a golf cart, the pool and hot tub are included.

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It was amazing to watch a giant container ship glide through the massive locks and then sail past a rainforest where we gorged on the plumpest, juiciest strawberries I’ve ever tasted, only to return by car the next day for a 10-kilogram sack of vegetables known as puercas for the princely sum of US$6.

There is a magical quality about the Chiriquí Highlands and over the next few days, we quickly adapted to a more relaxed way of life.

We visited the Caldera Hot Springs on horseback, travelled to the top of Volcán Barú to see the sunrise, took in a soccer game on a makeshift pitch below a coffee plantation and learned how the indigenous people of the Emberá tribe live. We also explored La Amistad International Park, part of a Biosphere Reserve maintained by both Panama and Costa Rica, zip-lined through the cloud forest above a canopy of trees, went whitewater rafting past spectacular gorges and discovered hidden waterfalls.

Did I mention that we were able to do all this despite the fact that we were here during the rainy season? Like clockwork, around mid-afternoon, the rain would come. Sometimes it was nothing more than a gentle mist, other times it was biblical, but it didn’t dampen our spirits. In fact, it was a welcome respite from the heat of the coastal areas.

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Sugar & Spice in Boquete is a popular artisan bakery and gathering place for expats.

One afternoon we got caught in a torrential downpour. Drenched and feeling a bit parched, we sought refuge in Boquete’s oldest bar, Fusion J&B, and quenched our thirst with a Balboa, one of the country’s local beers. It was then that we truly embraced the local culture and it embraced us.

We were the only non-Spanish speaking patrons in the restaurant — not that it mattered because English is widely spoken throughout Panama — and we had arrived during the final moments of the UEFA Championship game. Emotions were running high.

It was hard to keep up with the conversation, but then, suddenly, Ronaldo scored on a penalty shot and Real Madrid triumphed over their arch rivals, Atlético Madrid. Fans erupted and we were immediately swept up in the celebration, one of the crowd, rejoicing in the victory and the camaraderie of friends.

I’m not sure how it happened, but as I sit here on the evening before we depart, Daniel’s prediction rings true: “we don’t just like it, we love it.” After our time in Boquete, Panama has captured our hearts. This little slip of a country, the gateway between two continents, may have satisfied our wanderlust — not just for a few weeks, but potentially a lifetime.

JANE FINN

The formerly sleepy fishing village of Farallón is now one of Panama’s hottest beach destinations.

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Ottawa

2017 Five reasons the revamped capital is the best place to celebrate Canadaâ&#x20AC;&#x2122;s 150 years as a nation

ALL PHOTOS COURTESY CTC UNLESS OTHERWISE NOTED

by Lin Stranberg

Winterlude 2017 will run for three weekends in Ottawa-Gatineau from February 3 to 20.

T

used to think that visiting Ottawa was like a grown-up version of going to my grandparents’ place for Sunday dinner. It was lovely to be there in that old-school way: not of the moment, but solid and comforting.

Ottawa today? It’s like the grandparents took out a new lease on life. They’ve dumped the old place, moved into urban digs and are throwing a lot of parties.

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Canada’s quiet capital has morphed into a lively city that’s actually exciting to visit with hip new hotels, fabulous new restaurants and a new vitality in the air that simply wasn’t there before. Over and above the cultural benefits of a national government centre, it’s transformed itself into a city to visit for fun, not just to take a tour of the Parliament buildings — although you can, happily, still do that while you’re at it.

What’s more, Ottawa is positively buzzing with celebrations for the 150th anniversary of Confederation this year.

1

Like an aging beauty after good cosmetic surgery, Ottawa has been refreshed and rejuvenated. It’s the same city, but it feels more exuberant these days.

Landmarks like the monumental Beaux-Arts Wellington Building and the National War Memorial have gotten a facelift, there are new builds all over the city centre, and the new LRT will launch in 2018 as the largest infrastructure project in the history of the capital. The 12.5-kilometre route is aptly named the Confederation Line (ligneconfederationline.ca).

COURTESY OTTAWA CELEBRATIONS BUREAU

CANADA’S GRANDE DAME HAS HAD A MAKEOVER

2

PARTY ALL-YEAR LONG The sesquicentennial is a big birthday for Canada.

Ottawa 2017 (ottawa2017.ca), the official planning organization, is throwing some major A-list events under the leadership of Executive Director Guy Laflamme. “Epic is the target here,” he says. “We want to use this anniversary to open up new horizons... this is not just a Canada Day blowout.”

COURTESY OTTAWA CELEBRATIONS BUREAU

Giant mechanical creatures from France will roam the streets of downtown from July 26 to 30.

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Most Winterlude activities are free and the festival attracts close to 600,000 people every year.

In addition to sporting events like the Red Bull Crashed Ice Championships, in which Canada’s best ice cross downhill athletes will hurtle down a hair-raising ice track on the Rideau Canal near the Château Laurier, and iconic Canadiana like the Juno Awards and Grey Cup game, there are a number of special happenings that Laflamme promises will be “culturally audacious.”

He described some of the most avant-garde as “live experiences requiring audience participation.”

These blockbusters include Inspiration Village, music/ dance/theatre/cinema happenings presented in partnership with the Nelson Mandela Foundation; an underground multimedia event in a transit station, and La Machine, where visitors will encounter huge and fanciful mechanical creatures on the city streets.

3

OTTAWA LOVES A FESTIVAL Ignite 150 will bring 17 epic stunts to every corner of the capital throughout the year.

With its talent for inclusion, a welcoming attitude and easy accessibility, the city is always game to host new visitors and loads up its social calendar with annual events. Season by season, Ottawa loves a festival, making it easy to catch one just about any time of year. These are diverse celebrations like the spectacular Tulip Festival (tulipfestival.ca) in May, big-name jazz, blues and classical music fests in summer, Pride (ottawacapitalpride.ca) in August, the International Animation Festival (animationfestival.ca) in September and Winterlude (pch.gc.ca/winterlude) in February.

(As soon as the temperatures drop, the Rideau Canal (rcs.ncc-ccn.ca) turns into a deluxe skating rink. It’s an only-in-Ottawa experience beloved by both visitors and locals, some of whom even skate with briefcases and backpacks on their daily commute to work.)

4

STYLISH NEW SPACES

COURTESY ALT HOTEL

Last summer I checked into the new ALT Hotel (althotels.com; from $154) on Slater Street, just a few blocks down from Parliament Hill. As the baby of the chic Germain-hotel family, it’s got a no-frills price point, but rolls the same brand of comfort and style into a package with an additional perk: no checkout time on Sundays — ever. In my books, that more than makes up for the lack of room service. As of now, it’s my new go-to for any Ottawa stay.

Plus, if you’re a museum-restaurant-walk around kind of traveller like I am, the location is ideal. From The lobby of the new ALT Hotel features a mosaic with 7000 photos of landmarks across the country.

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There’s a reconstruction of the Rideau Street Convent Chapel inside the National Gallery of Canada.

The Heart & Crown Irish Pub is just one of many restaurants located in the Byward Market.

COURTESY OTTAWA CELEBRATIONS BUREAU

The Ice Cross Downhill World Championship will skate through the city on March 3 and 4.

CAPITAL EVENTS In addition to ongoing celebrations, these and other special events are scheduled for Ottawa 2017: January 16–22: Canadian Tire National Skating Championships March 3–4: Red Bull Crashed Ice World Championships March 15–18: Stanley Cup 125th anniversary tribute March 27–April 2: Juno Awards May 20–September 4: Exhibits and performances at Inspiration Village End of June–September: Underground Multimedia Experience July 1: Canada Day on and around Parliament Hill July 1 onward: Canada Scene, a cultural festival at the newly renovated National Arts Centre July 2: Interprovincial Picnic on the Bridge July 26–30: Giant mechanical creatures by La Machine roam free downtown Summer 2017: YOWttawa, a two-day ticketed outdoor music event November: Canadian Videogame Awards November 26: 105th Grey Cup December 2–10: Tim Hortons Roar of the Rings Olympic curling trial

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the hotel, it’s a pleasant 20-minute stroll over to Sussex Drive and the light-filled spaces of the National Gallery of Canada (gallery.ca). On the way back, you can look around the Byward Market (byward-market. com), which is older than Canada’s Confederation.

Take a ramble through historic streets crammed with fruit and vegetable stands, restaurants and quirky shops.

The market area is looking more stylish and contemporary these days with the arrival of the new Andaz Hotel (ottawa.andaz.hyatt.com; from $249), a progressive boutique-inspired Hyatt that opened last August. Andaz is global, but keeps it local in cuisine and décor. It features Canadian Council Art Bank-curated artwork on hotel floors saluting each Canadian province.

Nearby, the Ottawa Art Gallery (ottawaartgallery.ca) is expanding into a multi-use high-rise that includes a posh new Le Germain hotel, opening later this year.

5

GREAT EATS Ottawa’s new restaurant scene will surprise you.

A great new spot for lunch or dinner is Riviera (dineriviera.com) on Sparks Street, named not after a Mediterranean coast, but a classic Buick. I had the orecchiette carbonara with fresh pasta that was made in-house. Other dishes on the dinner menu include lobster pappardelle, black cod with carrot puree and braised beef short ribs with soft white polenta.

The latest from the chefs of Elgin Street’s El Camino (a tacos and tequila raw bar) and Datsun (Asian fusion) opened last summer. Set in a former bank building, Riviera’s soaring ceilings and urban ambiance are a stylish complement to its fabulous food and service. The restaurant serves up interesting cocktails too. Reservations are a must.

For more information on travel to the capital, visit Ottawa Tourism (ottawatourism.ca).

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The so-called love doctor Dr Dulcamara in Donizetti’s comic opera L’elisir d’amore and his concoctions that cure everything — even heartache

by Dr J. Ian S. Robertson

The excerpt which follows comes from Doctors in Opera: An Irreverent Look at Operatic Medicine by the Scottish doctor J. Ian S. Robertson. As he explains in the preface, the account of this, and the more than 40 operas considered in the book, is derived mainly from the author’s own “often very free” interpretation of the scores, libretti on the sources on which they are based and on other publications on the subject.

I

t is hardly surprising to find quack doctors appearing in opera. If indeed there is any surprise at all, it is that there are not more of them.

An early colourful example of this genre is Rubiccone (tenor) in

Fischietti’s Il mercato di Malmantile to a libretto by Goldoni. One of the most successful of operatic quacks is to be seen in Donizetti’s L’elisir d’amore (The Elixir of Love) of 1832. Donizetti composed this work to a libretto in Italian by Romani, who derived his text from what Scribe had earlier prepared in French for Auber’s opera Le philtre of 1831.

The action of Donizetti’s opera is set on a farm somewhere in Italy. Nemorino, tenor, a semi-literate farm worker, is in love with Adina, soprano, the as yet unmarried well-to-do farm owner, but she initially spurns Nemorino in favour of the dashing soldier, the baritone Sergeant Belcore. Nemorino has vaguely heard the story of Tristan and Isolde, and he understands from this that if he can somehow get hold of a love potion — and provided it is properly administered — he can induce Adina to fall for him.

J. Ian S. Robertson FRS, MD, FRCP is a retired Professor of Medicine with a BA in Opera Studies from the University of Manchester. He has written and lectured widely on the medical aspects of opera.

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And then there is for Nemorino a godsend. The village is visited by Dr Dulcamara, a quack doctor peddling fake medicines purporting to cure anything: hemorrhoids, headaches, baldness, impotence, infertility, hyperfertility or whatever.

Nemorino approaches the so-called “Dr” Dulcamara and requests to purchase from him a love potion. Dr Dulcamara is momentarily taken aback. He has never been asked for a love potion before. Nevertheless, despite external appearances (he is usually sung by a portly bass), Dulcamara is quick on his feet, and he promptly provides for Nemorino to purchase what purports to be a love potion, but is in fact a bottle of cheap Bordeaux wine. That is what Romani’s libretto says: “Bordeaux wine.”

There are several points of comment here. The date of the opera is 1832. The great classification of Bordeaux wines, centred on the Medoc, was introduced only later, in 1855. Since that classification, and probably largely because of it, Bordeaux wines have rarely looked back. Nowadays Bordeaux wines include some of the most exclusive and expensive in the world. It might then be thought odd, even in 1832, for a librettist to select a Bordeaux wine to

palm off as a cheap fake medicine. And I think it is even odder for a Bordeaux wine of any sort to turn up in a remote Italian village. But this is an Italian opera with an Italian librettist. By taking a Bordeaux wine as a quack doctor’s prop, the Italians are here, I believe, mocking French pretensions.

Indeed there is, in my opinion, evidence that this is the case. There was, as I mentioned, an earlier version of this opera, the French composer Auber’s Le philtre of 1831 to a libretto by the French writer Scribe. Although the two stories are very similar, there are some interesting differences.

The action of Le philtre takes place in a village, on the banks of the River Adour, in the Basque region of southwest France. The quack is described as “an Italian charlatan by the name of Dr Furbaroso.” In the only two scores of this opera that I have been able to find, there is no mention of wine of any sort; the nature of the elixir is not revealed. Hence I consider that in Donizetti’s later opera, the Italians are getting back at the French. If that is the case, the Italians have won this particular skirmish, because whereas Donizetti’s opera has survived prominently in the repertoire to this day, Auber’s Le philtre has disappeared almost without trace.

Nemorino buys the supposed love potion and then proceeds to drink it himself. This is not, I think, the recommended procedure. Although I cannot claim to have gone in for a great deal of this sort of thing myself, my understanding of the matter is that it is the girl who must somehow be induced to swallow the elixir. She then gazes on her would-be suitor, seducer or whatever, and is lost.

Nemorino, however, does not know that. He is just doing what he has been told to do by Dr Dulcamara, and Dulcamara does not know either, he is simply making things up as he goes along. So Nemorino drinks the stuff. He gets slightly drunk and makes rather a fool of himself, but not much else happens. Certainly Adina does not show the slightest sign of falling for him.

Nemorino returns to Dr Dulcamara and asks if perhaps matters can be speeded up. He is particularly anxious because the wedding of Adina with Sergeant Belcore is now impending. Dulcamara is now, of course, on familiar ground. He has been through this sort of thing many times before.

“Ah, that is straightforward. You simply need a further dose.”

This, however, raises a problem for Nemorino because he has no more money. Nothing daunted, he raises the necessary funds by enlisting in the army via the offices of the conveniently adjacent Sergeant Belcore, and for this he receives a small fee. Nemorino now purchases another bottle of Bordeaux, as before believing it to be an elixir of love and also, as before, he drinks it himself.

This time round, things are very different. Not

RICHARD CAMPBELL

L’elisir d’amore: Dr Dulcamara (Francesco Facini) proffers Nemorino (Edgaras Montvidas) a bottle of Elixir of Bordeaux. Scottish Opera, 2009.

L’elisir d’amore: Dr Dulcamara (Francesco Facini) proffers Nemorino (Edgaras Montvidas) a bottle of Elixir of Bordeaux. Scottish Opera, 2009.

only Adina, but virtually every other girl in the village is now chasing furiously after him. However, there is hereabouts another, possibly confounding factor. Nemorino’s rich uncle has died, leaving him a considerable fortune. Nemorino at first does not know this, but the village girls have got wind of it and it could well be that the legacy, rather than the second bottle of wine, has done the trick.

In the end, almost everyone in the opera goes away happy. Nemorino gets the girl whom he has pursued all along. Adina has acquired a now wealthy, if somewhat dim, husband and she buys him out of the army. Sergeant Belcore rationalizes matters by reflecting that Adina was probably not up to much anyway and there are plenty of other girls around. Finally, Dr Dulcamara is especially content. Not only is he in the business of selling worthless medicines for the supposed relief of hemorrhoids, headaches, impotence and so forth, he now also purveys love potions which, as can be seen by all, spectacularly work.

Extract reprinted with permission from Doctors in Opera: An Irreverent Look at Operatic Medicine (Scottish Opera, 2016).

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Toasted buckwheat with berries.

Spoon feed Unusual bowl-based breakfasts that you can enjoy at home or â&#x20AC;&#x153;al deskoâ&#x20AC;? recipes by

Annie Morris and Jonny Shimmin photos by Jacqui Melville

W

hen Annie Morris worked in advertising, her creative partner knew that she had to have her breakfast bowl and a strong cup of coffee before they could have a conversation in the morning. Annie’s fix of muesli, fruit and milk or yogurt

gave her energy and made her happy.

Annie’s idea for Spoon Cereals — high-quality granola made with pure maple syrup — was born from her love of healthy breakfast bowls and a wish to help other hungry and grumpy commuters. She quit her job and, together with her now brother-in-law, opened London’s first cereal pop-up bar in 2013.

Last fall, they released Spoon, published

by Hardie Grant Books.

The cookbook features 50 out-of-theordinary, bowl-based breakfasts, many that can be pulled together during a hectic workweek. Birchers, like the one featured here, for example, are “overnight oats” that, yes, require advance thought, but can be made in jars for grab-and-go portability in the morning.

More healthy starts for 2017 follow, including a savoury porridge starring an all-time favourite: avocado!

TOASTED BUCKWHEAT WITH BERRIES A breakfast bowl is just as much about the texture as it is about the flavour.

When you’re not after a smooth and creamy porridge on a winter’s morning, try this muesli for a bit of crunch. Here, the humble oat in a classic bowl of muesli is replaced with buckwheat, coconut chips and cashew nuts. These ingredients are toasted with a little coconut oil.

For the muesli 2 c. (500 ml) buckwheat groats 1 tbsp. (15 ml) coconut flakes 2 tbsp. (30 ml) flaked almonds 2 tbsp. (30 ml) chopped cashew nuts 2 tbsp. (30 ml) sunflower seeds 3 tbsp. (45 ml) coconut oil, melted ¼ c. (60 ml) dried cranberries For the toppings milk or yogurt freeze-dried berries blueberries pomegranate seeds

Avocado porridge with sweet chili.

Preheat the oven to 180°C (350°F/ Gas 4).

Mix all the dry ingredients, except for the dried cranberries, in a large mixing bowl.

Melt the coconut oil in a small pan over medium heat.

Pour the oil over the dry ingredients and stir to combine.

Spoon the mixture onto a baking tray lined with baking parchment,

spreading it out and patting it down with a wooden spoon. Use 2 trays if necessary.

Place on the tray on the middle shelf in the oven. Bake for 15 minutes, turning the mixture after 5 minutes.

Remove from the oven, add the dried cranberries and leave to cool.

Serve with your favourite milk or yogurt and the suggested fruit toppings.

Makes 8 to 10 bowls.

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AVOCADO PORRIDGE WITH SWEET CHILI Often confined to toast in the mornings, avocado on porridge may sound odd, but the squeeze of lemon lifts the taste and when topped with the sweet chili, provides a perfect harmony of flavours.

For the sweet chili jam ½ fresh red chilli 2 tbsp. (30 ml) honey For the porridge 1 c. (250 ml) oats 1 c. (250 ml) water 1 c. (250 ml) milk squeeze of lemon juice

For the topping 1 ripe avocado

To make the sweet chili jam, deseed the chili and slice it into thin strips.

Place the chili and honey in a pan over a medium heat and cook for 5 minutes until it forms an almost jam-like consistency.

To make the porridge, place all the ingredients in a pan and cook over a medium heat for 5 to 10 minutes.

Slice the avocado in half, and remove the skin and stone. Then slice each half into thin strips.

Divide the porridge into bowls, top with the avocado and a drizzle of the sweet chili jam. Makes 2 to 3 bowls.

SPICED CARROT BIRCHER Your body will thank you for incorporating vegetables into your breakfast bowl. Grated carrot is a great one to sneak in there, adding flavour, nutrients, texture and colour. Prepare this recipe before bed and you’ll have something to look forward to in the morning.

For the bircher ¾ c. (180 ml) oats ¹⁄³ c. (80 ml) milk ¹⁄³ c. (80 ml) natural yogurt ¼ c. (60 ml) water 1 carrot, peeled and grated ½ apple, peeled and grated 1 tsp. (5 ml) maple syrup ½ tsp. (2.5 ml) ground cinnamon ¼ tsp. (1.25 ml) ground nutmeg For the toppings dried dates walnuts maple syrup (for those with a sweet tooth)

Place all the ingredients for the bircher in a mixing bowl and stir to combine.

Cover and place in the fridge overnight.

The next morning, divide the mixture between two bowls. Serve with the suggested toppings. Makes 2 bowls.

Recipes and photos from Spoon: simple and nourishing breakfast bowls that can be enjoyed any time of day (Hardie Grant Books, 2016).

Spiced carrot bircher.

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Jardiance................................................... 2

“The most inspiring message to come out of this work is that beautiful artworks can result from pathological conditions…”

For Taylor “the most inspiring message to come out of this work is that beautiful artworks can result from pathological conditions… these more simple works conveyed a peacefulness that wasn’t present in his nurture-dominated earlier work. It all goes to show that sometimes you can think too much about art. Sometimes you just need to tune into your inner self, the ‘nature’ part.”

Critics had suggested that when de Kooning was diagnosed with Alzheimer’s he should stop painting. Clearly Taylor does not agree. That said, another American physicist, Kate Brown at New York’s Hamilton College, calls

Forsythe’s research “complete and utter nonsense.”

Forsythe concedes that the small number of artists involved in the study means the findings are highly tentative, but hopes that it will open up fresh avenues for investigating the disease. “I don’t believe this will be a tool for diagnosis, but I do think it will trigger people to consider new directions for research into dementia,” she says.

Forsythe’s paper, “What paint can tell us: A fractal analysis of neurological changes in seven artists,” appears in the journal Neuropsychology (psycnet. apa.org/?&fa=main.doiLanding&doi=10.1037/ neu0000303).

MEDICAL QUIPS Medical definitions – Part 2 Seizure: Roman Emperor Terminal illness: getting sick at the airport Urine: opposite of “you’re out”

JANUARY 2017 • Doctor’s

Review

47

PHOTO FINISH by

D r Je f f Alli n

A tough spot

Botswana exceeded our expectations. My wife and I learned many years ago that the rewards of staying within the boundaries of national parks or game reserves outweighed the cost: less travel time morning and night, and — as in this case — being first on the scene.

Our experienced Chobe Lodge game driver had located almost all the animals, both on land and during our late afternoon “sundowner cruises” on the Chobe River — but no leopards. Until our final game drive.

At 5:30am, still silence dominated as slivers of the morning sun peeked through overarching foliage, dappling the dust-bowl-beige sand. Suddenly our South African companion hissed: “Stop. Stop now. Back up. Slowly. Slowly.”

No one else, our guide included, saw anything other than a two-metre-round bush with thumbnail-sized emerald leaves identical to the dozens of other bushes dominating the landscape. But this veteran game hunter of the African wilds had spotted a distinctive fawn-and-ebony discolouration sheltered securely beneath the leaves.

As Chewpe glided our 4x4 backwards, an emerging leopard stretched, slouching gracefully with haunches elevated, then trotted toward the shoreline. Only one glance toward us betrayed her annoyance. Rustling her from her shelter, we had eliminated her breakfast of unsuspecting antelope, her anticipation now fading into tonight’s dream.

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48

Doctor’s Review • JANUARY 2017

For your adult patients with type 2 diabetes

Equipped for glycemic control.

~5 million patient-years of experience.1

Trajenta® is indicated in adult patients with type 2 diabetes mellitus (T2DM) to improve glycemic control.

• Monotherapy: In conjunction with diet and exercise in patients for whom metformin is inappropriate due to contraindications or intolerance.

• Combination therapy: with metformin when diet and exercise plus metformin alone do not provide adequate glycemic control; with a sulfonylurea when diet and exercise plus a sulfonylurea alone do not provide adequate glycemic control; with metformin and a sulfonylurea when diet and exercise plus metformin and a sulfonylurea do not provide adequate glycemic control.

Simple, once-daily dosing with one 5 mg dose.2* – Independent of ethnicity,† BMI,‡ mild or moderate hepatic impairment,§ and renal function.||

BMI = body mass index. * Please see the Product Monograph for complete dosing and administration information. † No dose adjustment is required based on race. Race had no obvious effect on the plasma concentrations of linagliptin based on a composite analysis of available pharmacokinetic data. ‡ No dose adjustment is required based on BMI. § Use of Trajenta® in patients with severe hepatic insufficiency is not recommended. || Use of Trajenta® in patients with ESRD (eGFR <15 mL/min/1.73 m2) and those on dialysis should be with caution.

Please refer to the product monograph at www.TrajentaPM.ca for important information about: • Contraindications in patients with type 1 diabetes or diabetic ketoacidosis.

• Relevant warnings and precautions regarding congestive heart failure, patients using insulin, hypoglycemia, glycemic control, use in patients with severe hepatic insufficiency, pancreatitis, hypersensitivity reactions, use in immunocompromised patients, use in patients with End Stage Renal Disease (ESRD) or on dialysis, skin monitoring, use in special populations (e.g., pregnant and nursing women), hepatic function (should be assessed before starting treatment and periodically thereafter), and interactions with strong inducers of P-gp or CYP3A4 (monitoring recommended).

• Conditions of clinical use, adverse reactions, drug interactions and dosing recommendations.

The product monograph is also available by calling 1-800-263-5103 ext. 84633.

References: 1. Boehringer Ingelheim (Canada) Ltd. Data on File. s00042091-01.

2. Boehringer Ingelheim (Canada) Ltd. Trajenta® Product Monograph. May 14, 2015.

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