July August 2017 by Doctor's Review

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MEDICINE ON THE MOVE

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JULY / AUGUST 2017

PAGE 34

Halcyon days

Winding down in Charlevoix Floating on the Ganges

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

Glendorn’s

luxurious nostalgia

reimagined hotels

Mexican

comfort food Agnes Martin’s

happy grids SAD in all seasons

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

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

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

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

Covered by all provincial formularies (special authorization)*

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

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

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

02012 02/17

There’s only one EpiPen® Blue to the sky

Orange to the thigh

Visit EpiPen.ca for comprehensive patient education and support. EpiPen® and EpiPen Jr® Auto-Injectors are indicated for the emergency treatment of anaphylactic reactions in patients who are determined to be at increased risk for anaphylaxis, including individuals with a history of anaphylactic reactions. Please consult the prescribing information at www.pfizer.ca/pm/en/EPIPEN.pdf for important information on: • Warnings and precautions relating to: use in patients with thick subcutaneous fat, cardiogenic, traumatic or hemorrhagic shock, cardiac dilation, cerebral arteriosclerosis, organic brain damage, narrow-angle glaucoma, cardiac arrhythmias, coronary artery or organic heart disease, hypertension, hyperthyroidism; sulfite sensitivity; diabetes; Parkinson’s disease; seeking immediate medical care; use of multiple doses; biphasic anaphylaxis; proper injection technique; injection site infections. • Conditions of clinical use, adverse reactions, drug interactions, and dosing information which have not been discussed in this advertisement. The prescribing information is also available by calling 1-800-463-6001. © 2017 Pfizer Canada Inc., Kirkland, Quebec H9J 2M5 • Toll free: 1-877-EPIPEN1 (1-877-374-7361) • EpiPen®, EpiPen Jr® are registered trademarks of Mylan, Inc. licensed exclusively to its wholly-owned affiliate, Mylan Specialty, L.P.; sub-licensee, Pfizer Canada Inc., Kirkland, Quebec H9J 2M5 CA0117EPI009E

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Go stuff a pepper There’s a selection of Mexican recipes beginning on page 44, very much worth trying in the dog days of summer. Mexican food, as served in the Southwest US, tops my list of favourites and at the head of that list are chili rellenos. Over the years I’ve been lucky enough to enjoy the tasty dish across New Mexico and Arizona in elegant restaurants, Tex-Mex take-out joints, diners and greasy spoons. The basic recipe calls for a fresh poblano pepper — the long dark green ones — Chili rellenos at stuffed with Mexican asadero cheese, dusted Doc Martin’s in with flour and fried. I like them served in the Taos, NM. traditional way with beans and rice and lashings of green chili, red chili or, as is the custom in New Mexico, Christmas chili, a combination of the two. Here’s my four top picks. 1) Doc Martin’s at the Taos Inn, Taos, NM. This is so far out ahead of the pack it’s almost in a category of its own. Here the poblanos are stuffed with creamy goat cheese, coated in crushed pumpkin seeds and deep fried. The result is a crisp, dark, honey-coloured exterior that preserves the full shape of the pepper. Cut into the crust and the rich, melted cheese flows out to mingle with the chili and the beans: heaven, el paraiso! 2) La Choza and La Sena in Santa Fe. These spots have the same owner and, though the kitchens turn out slightly different fare, they both stand up to repeated visits. La Sena is downtown, just off the Plaza, and is full every night from 5:30 onwards, packed with locals and visitors alike. The funky décor enhances the authenticity of the place. Service is quick, plates come to the table hot and the flavour, both for the rellenos and the other dishes, is classic. La Choza, tucked away on Alarid Street, a five-minute drive from the Plaza, offers the same delicious food plus additional vegetarian offerings in a sprawling series of rooms. One plus for each: moderate prices in the $10-$12 range. 3) Rosita’s Place, 2310 East McDowell Road in Phoenix. Think of a Mexican roadhouse, their succulent rellenos queues the Mariachi band in my head. 4) Pepe’s Taco Villa, 2108 West Camelback. This unprepossessing spot, popular with locals, makes a great introduction to Mexican food in the valley, particularly their rellenos. Plan a stop if you’re heading north to Sedona and the Grand Canyon. In Sedona, get your poblanos at El Rincon in lovely Tlaquepaque Plaza. Elsewhere in the issue, take yourself on a road trip to Quebec’s Charlevoix region for some equally authentic cooking much closer to home. Something more exotic in mind? Be one of the first to cruise down the Ganges on a new line of ships. What ever you choose to do, may the remainder of the warm weather bring you smooth sailing.

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JULY / AUGUST 2017 • Doctor’s

Review

FOR THE TREATMENT OF MOD

A new option in hormone therapy for women with a uterus DUAVIVE demonstrated: Significant reduction in the number and severity of average daily moderate to severe hot flushes (from baseline to week 12, n=122) vs. placebo (n=63)1† Mean change for number was -7.63 vs. -4.92 and -0.87 vs. -0.26 for severity, p<0.001 for both Incidence of breast pain and change in breast density shown not to be significantly different from placebo Incidence of breast pain at Weeks 9-12: 9% vs. 6%, respectively1† Mean percentage change in breast density from baseline after 1 year of treatment: -0.49 vs. -0.51, respectively1‡ Low incidence of endometrial hyperplasia1§ In clinical studies up to 2 years’ duration, <1% incidence of endometrial hyperplasia or malignancies observed (0% and 0.30% at year 1, 0.68% at year 2)

Indications and Clinical use: DUAVIVE is indicated in women with a uterus for the treatment of moderate to severe vasomotor symptoms associated with menopause. Should not be taken with a progestin, additional estrogens or selective estrogen receptor modulators (SERMs). Not recommended for women >75 years of age. Not indicated for pediatric use. Contraindications: • Active or past history of confirmed venous thromboembolism (VTE) or active thrombophlebitis • Active or past history of arterial thromboembolic disease • Hypersensitivity to estrogens • Undiagnosed abnormal genital bleeding • Known, suspected, or past history of breast cancer • Known or suspected estrogen-dependent malignant neoplasia • Liver dysfunction or disease as long as liver functions tests have failed to return to normal • Endometrial hyperplasia • Known protein C, protein S, or antithrombin deficiency or other known thrombophilic disorders • Known or suspected pregnancy, women who may become pregnant, and nursing mothers

• Partial or complete loss of vision due to ophthalmic vascular disease Most serious warnings and precautions: Risk of stroke and deep vein thrombosis: estrogen-alone therapy (mean age 63.6 years). Therefore, estrogens with or without progestins: • Should not be prescribed for primary or secondary prevention of cardiovascular diseases • Should be prescribed at the lowest effective dose and for the shortest period possible for the approved indication Other relevant warnings and precautions: • Possible risk of ovarian cancer • Monitor blood pressure with hormone replacement therapy use • Caution in patients with otosclerosis • Caution in women with pre-existing endocrine and metabolic disorders • Caution in patients with rare hereditary galactose intolerance • Abnormal vaginal bleeding • May increase pre-existing uterine leiomyomata • May exacerbate previous diagnosis of endometriosis • May increase the risk of VTE • Risk of gallbladder disease • Caution in patients with history or liver and/or biliary disorders

NEW

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

ERATE TO SEVERE VASOMOTOR SYMPTOMS

Cummulative amenorrhea rates similar to placebo1‡§ In SMART 1, cumulative amenorrhea at Year 1 was 83% in women treated with DUAVIVE, similar to placebo (85%). In SMART 5, cumulative amenorrhea at Year 1 (Cycle 1 to 13th), was 88% with DUAVIVE, similar to placebo (84%). Improved sleep adequacy and menopause-specific quality of life total score vs. placebo (secondary endpoints)2† Adjusted mean change from baseline in sleep adequacy score 16.53 vs. 1.07, respectively, p<0.001 The parameters of sleep quantity, somnolence, snoring and shortness of breath were not significantly different from placebo2 Mean change from baseline in MENQOL total score at Week 12: -1.6 vs. -1.0, respectively, DUAVIVE demonstrated p <0.001

• Caution in women with hepatic hemangiomas • Angioedema • Caution in women with systemic lupus erythematosus • Cerebrovascular insufficiency • May exacerbate epilepsy • Fluid retention • Not recommended in renal impairment • Not recommended in premenopausal women • Women with higher BMIs (≥30 kg/m2) may exhibit decreased bazedoxifene which may be associated with an increased risk of endometrial hyperplasia For more information: Please consult the product monograph at http://pfizer.ca/pm/en/duavive.pdf for important information relating to adverse reactions, drug interactions and dosing information, which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001.

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

* Clinical significance has not been established. † SMART 2: 12-week, double-blind, placebo-controlled trial in 318 women who had 7 moderate to severe hot flushes/day or ≥50/week at baseline who were randomized to DUAVIVE (n=127), CE 0.625 mg/BZA 20 mg (n=128), or placebo (n= 63). Primary endpoint assessed efficacy of vasomotor symptom relief. Secondary endpoints included: number of mild, moderate, and severe hot flushes, sleep parameters [Medical Outcomes Study (MOS) scale], and overall Menopause Specific Quality of Life (MENQOL). Baseline MENQOL total scores: DUAVIVE 4.46, placebo 4.42. The domain of the MOS sleep scale designed to measure sleep adequacy included: getting enough sleep to feel rested upon waking in the morning and getting amount of sleep needed. Responders were defined as >75% reduction from baseline in daily number of hot flushes. ‡ SMART 1: 24-month, double-blind, placebo- and active-controlled dose-ranging trial of 3397 women who were randomized to DUAVIVE (n=433), raloxifene 60 mg or placebo. Women took calcium and vitamin D (Caltrate 600 + D™) daily. Primary endpoint was the incidence of endometrial hyperplasia; secondary endpoint was the treatment of vasomotor symptoms. § SMART-5: 12-month, double-blind, placebo- and active-controlled trial of 1843 women who were randomized to DUAVIVE (n=445), CE 0.625 mg/BZA 20 mg (n=474), BZA 20 mg (n=230), conjugated estrogens 0.45 mg /medroxyprogesterone acetate (MPA) 1.5 mg (n=220) or placebo (n=474). Women also took calcium, 600 mg and vitamin D, 400 IU daily.

References: 1. DUAVIVE Product Monograph. Pfizer Canada Inc., October 20, 2014. 2. Utian WH et al. Bazedoxifene/conjugated estrogens and quality of life in postmenopausal women. Maturitas. 2009;63:329-35. DUAVIVETM Wyeth LLC, Pfizer Canada Inc. Licensee ® Pfizer Inc., used under license © 2017 Pfizer Canada Inc., Kirkland, Quebec H9J 2M5

CA0117DUA001E

Enjoy more good mornings.

One daily spoonful of ULTIMATE GLUCOSAMINE helps relieve the pain of osteoarthritis.

A recent study published in the Annals of the Rheumatic Diseases demonstrated that glucosamine type molecules have comparable efficacy to celecoxib in reducing pain and stiffness after 6 months of treatment.† • ULTIMATE GLUCOSAMINE powder can be added to any beverage as a mild sweetener, sprinkled over cereal or added to a yoghurt smoothie. • It consists of 100% pure N-Acetylglucosamine, a natural substance, extracted from the shell of crustaceans. It is also found in healthy human cartilage. N-Acetylglucosamine has no known interactions with prescription medications. • The ULTIMATE GLUCOSAMINE formulation contains no additives, salts, preservatives, colouring agents, gluten, lactose or yeast. For more information on Ultimate Glucosamine see the 2016 CPS monograph.

Wellesley Therapeutics Inc. UltimateGlucosamine.com 1.800.449.1130

† Hochberg, M. C., J. Martel-Pelletier, et al. (2016). “Combined chondroitin sulfate and glucosamine for painful knee osteoarthritis: a multicentre, randomised, double-blind, non-inferiority trial versus celecoxib.” Ann Rheum Dis 75:37

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

contents JULY / AUGUST 2017

COVER: ONDREJSUSTIK / SHUTTERSTOCK.COM

features 26 On the road in old Quebec

It doesn’t get any better than the Charlevoix region on the north shore of the Gulf of St. Lawrence by Lin Stranberg

The art of hotel reinvention From fire stations to silos, five old buildings that have been repurposed into the world’s best new hotels by Camille Chin

35 Indulge in Glendorn’s understated luxury America’s No. 1 resort hotel whispers “wealth” softly by Dr Jean Marmoreo

A float down the Ganges New fascinations stud the path of the ancient river by Jeremy Ferguson

A Mexican fiesta Streetcorn, Baja–Med salmon tacos, and more creative and colourful recipes ideal for warmweather eating by Paul Wilson

JULY / AUGUST 2017 • Doctor’s

Review

PATIENTS CAN

DO IT WITHOUT LANCETS*

// Introducing the FREESTYLE LIBRE FLASH GLUCOSE MONITORING SYSTEM – a new way to monitor glucose without routine finger pricks†

Actual size

The FreeStyle Libre SENSOR

The FreeStyle Libre READER

A painless way to check glucose by scanning the FreeStyle Libre reader over the sensor

Scans through clothing‡

Eliminates the need for routine finger pricks†

Shows current glucose reading, 8-hour history and a trend arrow to indicate where glucose is heading with every scan

14-day sensor automatically measures glucose day and night

No finger pricks required for calibration

Recommend the FreeStyle Libre system to your patients

DISCOVER MORE BY CALLING OUR HCP SUPPORT LINE AT 1-844-610-1001 OR VISIT FREESTYLELIBRE.CA For In Vitro Diagnostic Use Only. Refer to package insert/label accompanied with your product for detailed instructions and indication of use. * Scanning the sensor does not require lancets. A finger prick test using a blood glucose meter is required during times of rapidly changing glucose levels when interstitial fluid glucose † levels may not accurately reflect blood glucose levels or if hypoglycemia or impending hypoglycemia is reported by the system or when symptoms do not match the system readings. ‡ The reader can capture data from the sensor when it is within 1-4 cm of the sensor. © 2017 Abbott FreeStyle, Libre and related brand marks are trademarks of Abbott Diabetes Care Inc. in various jurisdictions. Product images are for illustrative purposes only. ADC-02888

contents JULY / AUGUST 2017

regulars

PRACTICAL TRAVELLER Ottawa’s gallery for Canadian and Indigenous art, the darkest island in the world for seeing stars, a new wilderness trail in Sooke, BC, and more by Camille Chin

GADGETS The joys of instant print cameras by David Elkins

18 20

PHOTO FINISH Another Rocky Mountain high by Dr Dubravka Rakic

contest! Win a seven-day “CME Away” holiday at Sandals Barbados!

TOP 25 The best conferences scheduled for this winter

DEPRESSION KEYPOINTS

Turn to page 34 for details.

Seasonal affective disorder for all seasons by Alison Palkhivala

MEDICINE AND THE ARTS Agnes Martin, painter of happiness by Tilke Elkins

Coming in

September

New Zealand by station wagon A drive through both North and South islands Cape Town: the beauty and the challenge A doctor visits 20 years after the end of apartheid Nine inns in New York and Vermont Wonderful getaways just south of the border

JULY / AUGUST 2017 • Doctor’s

Review

RA EXP TI AN O D N E O D F US E DU

FIBRISTAL® FOR THE MEDICAL MANAGEMENT OF UTERINE FIBROIDS Indication: FIBRISTAL is indicated for the intermittent treatment of moderate to severe signs and symptoms of uterine fibroids in adult women of reproductive age. The duration of each treatment course is three months. ®

Contraindications: • Use during pregnancy and in women who are breastfeeding • Women with genital bleeding of unknown etiology or for reasons other than uterine fibroids • Women with uterine, cervical, ovarian or breast cancer Relevant warnings and precautions: • Concomitant use of hormonal contraceptives not recommended • Use in patients with severe hepatic impairment unless the patient is closely monitored • Use in patients with moderate or severe renal impairment • Use in severe asthmatics insufficiently controlled by oral glucocorticoids • Changes in the histology of the endometrium may be observed in patients. These changes are denoted as “Progesterone Receptor Modulator Associated Endometrial Changes” (PAEC) and are reversible after treatment cessation. Investigate persistent endometrial thickening beyond 3 months following end of treatment. Studied in up to 4 intermittent treatment courses.

• Concomitant use with moderate or potent CYP3A4 inhibitors, CYP3A4

inducers, and potent enzyme inducers

• Should excessive bleeding persist beyond the first 10 days of treatment,

patient should notify physician

• If altered, persistent or unexpected bleeding pattern occurs during treatment,

investigation of the endometrium including endometrial biopsy should be performed to exclude other underlying conditions

For more information: For additional information relating to adverse reactions, drug interactions, and dosing information, please consult the product monograph at http://fibristal. ca/docs/Fibristal_Product_Monograph_E.pdf. The product monograph is also available by calling us at 1-800-668-6424. REFERENCES: 1. FIBRISTAL Product Monograph, Allergan Pharma Co., November 2016. 2. Data on File, Allergan Inc., November 2016. ®

FIBRISTAL and its design are registered trademarks of Allergan Sales, LLC, used under license by Allergan Pharma Co. ALLERGAN and its design are trademarks of Allergan Inc. © 2017 Allergan. All rights reserved. ®

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

C a mi lle C hi n

Canadian and Indigenous art come together

Canadian and Indigenous Art: From Time Immemorial to 1967 at the National Gallery of Canada runs until June 2018.

JULY / AUGUST 2017 • Doctor’s

PHOTOS NGC

In its largest undertaking since 1988, The National Gallery of Canada (NGC) has re-envisioned the space to include an integrated Canadian and Indigenous gallery. The new exhibition area, which opened on June 15, presents close to 800 works from the NGC’s own collection alongside loans of historical Indigenous sculptures and objects by Inuit, Métis, and First Nation artists. Algonquin elders were consulted on how to properly welcome new objects; two Indigenous Advisory Committees were established to provide expertise on interpretation, display protocols and community engagement. More than 50 gallery texts were produced or translated in 17 Indigenous languages. Canadian and Indigenous Art: From Time Immemorial to 1967 will run through June 15, 2018. Among the highlights is a mid-19th-century Ceremonial Coat by a Naskapi artist. Adults $15; youth aged 24 and under and full-time students $7. gallery.ca.

Review

While picturesque, the trail to get to this area near the Waugh Creek Falls viewing platform is narrow with steep grades.

CAPITAL REGIONAL DISTRICT

BC’s new

Dr Seuss stories come to life There’s a new Dr Seuss museum in Springfield, MA and, as expected, it’s a huge hit with kids. The Amazing World of Dr. Seuss Museum opened in June as part of the Springfield Museum complex. The first floor is dedicated to Theodor Geisel’s Springfield roots; the second floor includes a recreation of his studio and living room complete with his actual drawing table. The Young Ted gallery features a replica of the writer’s childhood home; inside there’s a touchscreen where kids can “draw” on the bedroom walls as Ted famously did. Other spaces include the Seuss Bakery, similar to the one that Ted’s grandparents ran on Howard Street, and Forest Park Zoo, which was run by Ted’s father. Then there’s the ABC Wall, Green Eggs and Ham WordPlay, and zany characters from Wump of Gump to Cat in the Hat who has arms, legs and a tail that move. Timed tickets for the five museums in the complex: adults US$25, kids 3 to 17 US$13. springfieldmuseums.org.

Doctor’s Review • JULY / AUGUST 2017

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

nature trail Now open: the 13-kilometre Sooke Hills Wilderness Trail connecting Greater Victoria with the Cowichan Valley and closing the gap in The Great Trail. (Nine kilometres were also added to the Cowichan Valley Trail to make the connection.) While the Great Trail, formerly the Trans Canada Trail, has been criticized because much of the 24,000-kilometre route requires walking or cycling on roads and highways, most of the Sooke Trail cuts across rivers, through forests and over hilltop in the Sooke Hills Wilderness Regional Park Reserve. It offers safer opportunities for hiking, cycling and horseback riding, but it’s unpaved and challenging so not for all ages and novices. Key features include a 41-metre suspension bridge across the Goldstream River at the south end and hilltop vistas at the north end. The trail’s opening required cooperation from a number of communities, including the Malahat Nation. crd.bc.ca/ project/capital-projects/sooke-hills-wilderness-trail.

The best island for

seeing stars Great Barrier Island or Aotea, its Maori name, is the first island in the world to be designated an International Dark Sky Sanctuary. Sanctuaries are different from Dark Sky Parks or Reserves in that they are far more remote and there are fewer threats to the darkness of the night sky. It’s a fine distinction, for example Jasper National Park is a Dark Sky Preserve; Mont-Mégantic in Quebec is a Dark Sky Reserve. Designations are based on scientific measurements, strict outdoor lighting guidelines and innovative community outreach. Located 90 kilometres from Auckland in New Zealand, Great Barrier Island is only the third such Sanctuary in the world. The other two are the Cosmic Campground in the Gila National Forest in western New Mexico and the Gabriela Mistral Dark Sky Sanctuary in Chile. The latter is managed by a group of universities dedicated to astronomical research. darksky.org.

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

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There’s a new Frank Lloyd Wright Trail in Wisconsin, the state where the American architect was born in 150 years ago this year. As a kid, Wright spent summers working on his uncle’s farm in Spring Green, and eventually built his own home and studio a couple of kilometres away. The self-drive trail takes about two days by car and crosses through nine counties. Nine stops along the 300-plus kilometres include homes and mansions, churches, schools, workspaces and more. They were all designed by Wright between 1915 and the 1950s. The Great Workroom at the Johnson Wax Headquarters features massive tree-inspired columns; the First Unitarian Society Meeting House has a pitched copper roof, deep-red concrete floor and prow of interlacing wood and glass; Monona Terrace is a huge curvilinear gathering place on Lake Monana. travelwisconsin.com/frank-lloyd-wright.

MONONA TERRACE

ABOVE: The dendriform columns in the SC Johnson Administration Building are sometimes referred to as lily pads. RIGHT: The Grand Terrace at Monona Terrace has views of Lake Monona.

Sea Courses now offers RESORT CME programs!

Hawaii May 5 - 12, 2018 Featuring speakers: Dr. Jeff Habert, Dr. Sanjay Pandeya, Dr. Eileen Rakovitch & Ms. Tracey Tremayne-Lloyd

Doctor’s Review • JULY / AUGUST 2017

CME Topics:

Internal Medicine & Medical-Legal Updates

VYVANSE®*

The 1 & only medication in Canada indicated for the treatment of moderate to severe Binge Eating Disorder in adults1,2† Limitation of Use for Binge Eating Disorder (BED): Serious cardiovascular (CV) events have been reported with this class of sympathomimetic medications. The BED clinical trials were not designed to assess CV safety. Given the higher CV risk associated with obesity, the BED population may be at a higher risk. The safety and effectiveness of VYVANSE for the treatment of obesity have not been established. VYVANSE is not indicated or recommended for weight loss.

Consider a conversation with your patients who you believe may be suffering with Binge Eating Disorder. In addition to your clinical assessment, ask: • • • • •

Have you eaten an abnormally large amount of food in a short period of time? Did you have a sense of lack of control over eating during the episode? Are you distressed about the binge eating? Do you feel disgusted or guilty? Do you eat alone because you are embarrassed?

VYVANSE (lisdexamfetamine dimesylate capsules) is indicated for the treatment of Moderate to Severe Binge Eating Disorder (BED) in adults.3 Recurrent episodes of binge-eating are characterised by: • consuming an abnormally large amount of food in a short period of time and sense of lack of control over eating during the episode • marked distress about the behavior • feeling disgusted or guilty, or eating alone because of embarrassment.

Limitation of Use for BED: Prescribers should consider that serious cardiovascular (CV) events have been reported with this class of sympathomimetic medications. The BED clinical trials were not designed to assess CV safety. While there is an accumulation of safety data with VYVANSE use in the Attention Deficit Hyperactivity Disorder (ADHD) population, this is of limited relevance regarding CV risk in the BED population. Given the higher CV risk associated with obesity, the BED population may be at a higher risk.

The safety and effectiveness of VYVANSE for the treatment of obesity have not been established. VYVANSE is not indicated or recommended for weight loss. Use of other sympathomimetic drugs for weight loss has been associated with serious cardiovascular adverse events. Consult the product monograph at www.shirecanada.com/vyvpm/en for important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions, and dosing. The product monograph is also available by calling Shire Pharma Canada ULC at 1-800-268-2772.

References: 1. Shire Pharma Canada ULC. Data on file. 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. 3. VYVANSE Product Monograph. Shire Pharma Canada ULC, September 30, 2016. † Moderate BED is defined as 4-7 binge-eating episodes per week. Severe BED is defined as 8-13 binge-eating episodes per week.

G AD G E T S A N D GE A R by

D a v i d Elk i n s

A camera for instant gratification It’s fine to use your smartphone to take photos but, seriously, how many shots is enough? This year about 1.2 trillion pictures will be snapped with cell phones. The majority of these will be selfies, friends, family and pets as well as meals about to be consumed. Only a tiny percentage will ever be looked at again. Why? Because, as Bob Dylan might put it, “they’re blowin’ in the wind,” as quickly passing as a falling leaf, no sooner here than gone. Unless, that is, these images are liberated from their electronic coffins and printed on paper that can be passed around, admired, handed back and forth, shared in the absence of an electronic device and perhaps even left in some old drawer to be rediscovered to the delight of a future sock-sorter. Those are a few reasons why instant prints have never entirely disappeared. They have, though, morphed into other guises, the most popular being those offered by Fujifilm Instax cameras which use film that produces creditcard sized photos (10.2 x 6.25 cm) in either colour or monochrome for about a buck a print. The top seller is their Mini 8, a fixed focus point-and-shoot camera with the

Win a Fujifilm Instax camera and 60 shots of film by entering the Gadget of the Month contest at DoctorsReview.com. equivalent of a moderate wide-angle 35-mm lens. It focuses on everything from 0.6 metres to infinity. The 12-cm x 11.6-cm x 6.9-cm body weighs 590 grams, and comes in a variety of colours including black, blue, yellow, pink and white. It uses two AA batteries, is easy to use and gets good consumer reviews. Lomography and Polaroid offer more sophisticated cameras with a range of lens and features — and more professional-looking cases. The con-

sensus is to begin with the Instax Mini 8 and then go on to something fancier if you find you’re using it for more than birthdays and the occasional graduation or wedding snap. Available online at bestbuy.ca, walmart.ca and amazon.ca, and retail camera shops everywhere. Prices range from $80 to $100 so it’s worth shopping around. A three-pack of Fujifilm Instax Mini Film (60 shots) sells for around $55.

CONGRATULATIONS to Doug Maskall, a psychiatrist from White Rock, BC, winner of a Caduceus pen and a pair of Asclepius cuff links. 16

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THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Canada Edmonton, AB November 1-4 20th Professional Conference and Annual Meetings of Diabetes Canada diabetes.ca/clinical-practice-education/ professional-conference-annual-meetings

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Around the world

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26th Annual Scientific Conference of the Canadian Academy of Geriatric Psychiatry cagp.ca/Annual-Scientific-Meeting-2017

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of Tropical Medicine and Hygiene astmh.org/annual-meeting/future-meetings

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2017 Scientific Sessions of the American Heart Association professional.heart.org/professional/index.jsp

33rd Annual Meeting of the International Society for Traumatic Stress Studies istss.org/am17/home.aspx

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

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30th Annual Selected Topics in Internal Medicine https://ce.mayo.edu

Orlando, FL November 9-10

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St. Gallen, Switzerland December 4-7

8th Edition HIV Persistence During Therapy hiv-persistence.com

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National Harbour, MD November 12-16

Phoenix, AZ January 20-21, 2018

Vienna, Austria November 30-December 2

46th Global Congress of the American Association of Gynecologic Laparoscopists aagl.org/calendar

3rd Annual Update on Infectious Diseases for Primary Care https://ce.mayo.edu

25th World Congress on Controversies in Obstetrics, Gynecology and Infertility cogi-congress.org

Rome, Italy November 15-17

9th Excellence in Pediatrics Conference eip-pediatrics-conference.ineip.org

27th Congress of the European Childhood Obesity Group ecog-obesity.eu

San Diego, CA November 16-17 11th International Congress on Early Onset Scoliosis growingspine.org/iceos/2017

December 7-10 2017 Annual Meeting and Scientific Symposium of the American Academy of Addiction Psychiatry aaap.org/annual-meeting

Shenzhen, China December 2-5 LA’s Union Station.

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MEDICAL QUIPS Spiritual cure? Did you hear about the Buddhist who refused his dentist’s Novocaine? He wanted to transcend dental medication.

JULY / AUGUST 2017 • Doctor’s

Review

DE PRESSIO N K EY PO I NT S by

A li son Pa lkhi va la

Summer and winter seasonal affective disorder (SAD) An important diagnosis for northern climates

irst coined in the mid-1980s, the term seasonal affective disorder, or SAD, refers to a seasonal pattern of depression that usually comes on in the fall or winter and subsides in the spring or summer.1 The condition was incorporated into the Diagnostic and Statistical Manual of Mental Disorders III-R (DSM III-R) in 1987 when “seasonal pattern” was included as a specifier for both major depression and bipolar disorder. The current DSM-V addresses it in a similar manner (see Table 1). Most often, SAD is triggered by the onset of winter, with typical symptoms including sadness, hypersomnia, hyperphagia, and weight gain. Prevalence is highest in northern climates. In Canada, the prevalence of SAD is estimated to be between 2% and 6%, and it occurs four times as often in women as men.2 In an estimated 0.1% to 3% of patients, however, SAD is triggered by the onset of summer, with typical symptoms including agitation, poor appetite and weight loss.3

Diagnosis of SAD SAD can be diagnosed through careful questioning of patients regarding seasonal patterns and types of depressive symptoms. A helpful diagnostic tool is the Seasonal Pattern Assessment Questionnaire (SPAQ), but the SPAQ cannot consistently

Table 1. DSM-5 diagnostic criteria for major depressive disorder/bipolar disorder with seasonal pattern Recurrent episodes of major depression for at least two consecutive years in which: 1. The onset of symptoms follows a specific seasonal pattern and is not associated with seasonally-related psychosocial stressors (i.e., the start of the school year). 2. Full remission, or a switch from depression to mania or hypomania in the case of bipolar disorder, also follows a seasonal pattern. 3. Seasonally-related depressive episodes substantially outweigh nonseasonal episodes over a patient’s lifetime.

distinguish true SAD from the less severe “winter blues.”4 Substantial effects on functioning, such as interference with school, work or social activities, as well as signs of suicidality are indicators that a patient is suffering from true SAD and requires prompt treatment.2

Table 2. Winter-onset vs. summer-onset symptoms of SAD Winter-onset

Summer-onset

Hypersomnia

Insomnia

Lethargy/fatigue

Agitation/restlessness

Hyperphagia (especially carbohydrate craving)

Appetite loss

Weight gain

Weight loss

Suicidality

Irritability

Sadness (often with crying jags)

Anxiety

Social withdrawal

Violent outbursts (rare)

Difficulty concentrating Adapted from: Melrose S. Seasonal affective disorder: An overview of assessment and treatment approaches. Depress Res Treat. 2015;2015:178564.

Doctor’s Review • JULY / AUGUST 2017

PHOTOGRAPHEE.EU / SHUTTERSTOCK.COM

Treatment of SAD

Fortunately, such conditions are reasonably well understood, and several treatment options are available.

SAD is hypothesized to be triggered by changes in exposure to natural sunlight, which in turn can disrupt circadian rhythms and production or regulation of hormones, vitamin D and serotonin. Treatments for SAD attempt to address this disruption. First-line treatment is use of a light box that emits a minimum of 10,000 lux of cool, white light. Typically, 20 to 60 minutes of daily exposure is recommended.5 Adverse events can include eyestrain, increases in age-related macular degeneration, headaches, irritability and insomnia. It should not be combined with photosensitizing medication.6 Antidepressants are another treatment option. Selective serotonin reuptake inhibitors (SSRIs)7 and bupropion8 have the best evidence for efficacy. Many people with SAD have been shown to be deficient in vitamin D, and vitamin D deficiency was linked with symptoms of depression in a recent systematic review.9 Taking vitamin D supplements before the winter months set in may help reduce the risk of developing symptoms of depression.10 Counselling has also been found to be beneficial for the treatment of SAD. One recent randomized, controlled trial revealed that two weekly 90-minute sessions of cognitive behaviour therapy (CBT) in a group setting for six weeks was as effective as 30 minutes of daily exposure to 10,000 lux of cool white light for the treatment of SAD.11 Living in a northern climate means that patients are likely to present with mood symptoms related to long, hard winters.

References 1. Rosenthal NE, Sack DA, Gillin JC, et al. Seasonal affective disorder. A description of the syndrome and preliminary findings with light therapy. Arch Gen Psychiatry. 1984 Jan;41(1):72-80. 2. Melrose S. Seasonal affective disorder: An overview of assessment and treatment approaches. Depress Res Treat. 2015;2015:178564. 3. Mersch PP, Middendorp HM, Bouhuys AL, et al. The prevalence of seasonal affective disorder in The Netherlands: a prospective and retrospective study of seasonal mood variation in the general population. Biol Psychiatry. 1999 Apr 15; 45(8):1013-22. 4. Murray G. The Seasonal Pattern Assessment Questionnaire as a measure of mood seasonality: a prospective validation study. Psychiatry Res. 2003;120(1):53-9. 5. Campbell PD, Miller AM, Woesner ME. Bright Light Therapy: Seasonal Affective Disorder and Beyond. EJBM. 2017; 32:E13–25. 6. Gallin PF1, Terman M, Remé CE, et al. Ophthalmologic examination of patients with seasonal affective disorder, before and after bright light therapy. Am J Ophthalmol. 1995 Feb;119(2):202-10. 7. Cheung A, Dewa C, Michalak EE, et al. Direct health care costs of treating seasonal affective disorder: a comparison of light therapy and fluoxetine. Depress Res Treat. 2012;2012:628434. 8. Dilsaver SC1, Qamar AB, Del Medico VJ. The efficacy of bupropion in winter depression: results of an open trial. J Clin Psychiatry. 1992 Jul;53(7):252-5. 9. Anglin RE, Samaan Z, Walter SD, et al. Vitamin D deficiency and depression in adults: systematic review and meta-analysis. Br J Psychiatry. 2013 Feb;202:100-7. 10. Kerr DC, Zava DT, Piper WT, et al. Associations between vitamin D levels and depressive symptoms in healthy young adult women. Psychiatry Res. 2015 May 30; 227(1):46-51. 11. Rohan KJ, Mahon JN, Evans M, et al. Randomized trial of cognitive-behavioral therapy versus light therapy for seasonal affective disorder: acute outcomes. Am J Psychiatry. 2015 Sep 1;172(9):862-9. JULY / AUGUST 2017 • Doctor’s

Review

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

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

•

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

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

•

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

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

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

CA0116PRI017E

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

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

T i lk e Elk i n s

Agnes Martin, painter of happiness Lines of beauty that began in the Prairies

anadian-born Agnes Martin (1912–2004) is considered one of the preeminent abstract painters of the 20th century. Her work has inspired a

nearly cultish following, perhaps because it is both extremely accessible and potent with meaning. She provided very clear instructions for how to view her paintings, most of which are on large two metre-by-two metre canvases, meant to surround a close viewer with delicately inscribed grids of horizontal pencil lines and subtle, nearly invisible, color washes: “They’re not about horizontal lines, you know,” she explained at age 86, eight years before she completed her final painting. “They’re about meaning. Lots of painters paint about painting but my painting is about meaning.” She died at age 92.

How long should one gaze at an Agnes Martin painting? “A long time,” says the artist, “about a minute, a minute is a long time.”

Her paintings are intended to convey what she refers to as “the subtle emotions that we feel without cause in this world.” Emotions, she explains, such as happiness, joy, love and gratitude. Though these emotions often result in conjunction with encounters with the natural world, Martin repeatedly emphasized the lack of connection to any natural forms in her paintings. She painted inner emotion, she said, and hoped that peoples’ reactions to her subtle grids and washes would help them to realize that their days are replete with experiences that cannot be put into words or formed into pictures. She wanted, she said, to remind people that they regularly “make responses that are completely abstract, and that their lives are broader than they think.” When asked how long one should spend before each of her paintings, she said, “A long time.” When pressed for a more exact time, she said, “About a minute,” adding, “A minute is a long time!” A minute, though scant, is long in the context of the current selfie-snapping, art-viewing attention span. A minute with a Martin is enough to take in the variations in the grid, the minutely shifting pressures of the hand that held the pencil and the brush, the brush that caught the paint drips and distributed colour evenly, but with emotion. Her job was to blow them up without losing the rhythms of the grid’s JULY / AUGUST 2017 • Doctor’s

Review

proportions. She accomplished this using math, inscribing sheets of pale blue paper with masses of hand-written calculations, and mapping the grids on the canvas using a short ruler and a system of dots. Anyone who has ever tried to make evenly-spaced lines on a piece of paper will realize the almost preternatural discipline and self-control that her perfectly-formed grids required. Knowing this adds an element of awe to the viewer’s experience. Fittingly, her paintings must be seen first-hand and full-sized to be understood. In photographs, they appear inconsequential, even boring. Since subtle emotion was what propelled Martin’s austere-seeming works, she aligned herself not with the Minimalists (though she continues to be mistakenly identified as such) but with the Abstract Expressionists. She explains the root of the error best herself: “I made the mistake of showing with the minimalists [in 1966]. They had a very definite philosophy. They were non-subjective. That means no emotions were registered in the work of art. They tried to be, like, not there and have the inspiration be completely pure without any influence from them. Ever since people have called me a minimalist but I’m not a minimalist. I believe in having my emotions recorded in the painting. I sign my name on the back. I guess I’m the last abstract expressionist.”

A 1997 interview with Agnes Martin at her home in Taos, New Mexico.

Doctor’s Review • JULY / AUGUST 2017

To appreciate Martin’s large 1.83-metre-square canvases they should be seen full-size and close-up.

LET THE WORK SPEAK Martin’s distaste for references to biography with regard to her work is legendary. She balked when asked to put together bios for the catalogues that accompanied her gallery shows, and destroyed nearly all of her paintings in yearly bonfires until she began, in her late 40s, to at last make work that pleased her (the few surviving paintings from her early years demonstrate an eye adept at rendering and a sensitivity to colour). Before she died, Martin exacted promises from those who knew her never to share her personal matters with biographers or the press — and they complied, for the most part. Ignoring her denouncements of the representation of nature in her work, fans and critics of Martin have sought meaningful parallels between her shimmering grids and the Saskatchewan wheat fields where she was born, as well as with the expansive horizontals of the vast plains of the New Mexican desert where she lived out the latter half of her life. The curious have also pried insistently at the obscurities in her timeline, hoping for facts to add substance to the subtle beauty of her paintings. A favourite focus is Martin’s mental health. Though she referred throughout her recorded lectures and writing to her psychological conflicts, her diagnosis — of paranoid schizophrenia — was never publicly disclosed in her lifetime. Atypical in so many aspects of her life

Her paintings must be seen full-sized; in photographs, they appear inconsequential, even boring — a champion of solitude, an intrepid house-builder, a defier of gender stereotypes — Martin was extraordinary in that she thrived as an artist in spite of her mental condition. Her most recent biographer, senior editor of Art in America Nancy Princenthal, who spent 10 years hunting down the scant remaining details about Martin’s life, casts aspersions on those who point to Martin’s obsessively-crafted grids as essential therapy for her mental condition, calling such speculation “hazardous.” It would be “a gross error,” she says, to regard Martin’s work as a symptom of her illness and even more of a mistake to see it as a cure. Though she suffered from bouts of catatonia and was plagued by voices at various times in her life which abated as she grew older, she told those close to her that the voices did not meddle with her creative process. She suffered from multiple mental breakdowns in times of stress, spent brief stints

She hoped people would realize that their days are replete with experiences that cannot be put into words in mental health institutes, and was treated with medications and talk therapy.

ON GENDER AND SEXUALITY Martin’s sexual orientation is another topic that she strove to keep private. Though many critics confusedly dub her a “closeted lesbian,” she would not have concurred. She did form romantic attachments with women, but she refused the term lesbian, as she did the term feminist when it was applied to her. A friend who once told her she might have a bigger reputation if she was not a woman reported that Martin, “shot back, I’m not a woman and I don’t care about reputations.” She adamantly rejected gender identification and scorned all suggestions that her paintings were feminist. Her distaste for the confines of gender identity roles found sanctuary in the artist’s community at Coenties Slip in Lower Manhattan where she spent important years between 1957 and 1967 forming friendships with artists like abstract painter Ad Reinhardt, hard-edger Ellsworth Kelly, and Chryssa known for her neon and metal work. By the time she left New York, Martin sensed that she would be alone for the rest of her life, a fact she found “very odd,” but ultimately pleasing. A rebel in an age dominated by science, Martin reportedly didn’t read a newspaper for 50 years believing that inspiration and inner experience were more accurate barometers of reality than facts. She claimed, after many years of struggle, to have given up facts. Evolution and atomic theory were hard to let go of, she said, but she managed to do it. Unlike many of her peers and most artists today, she was distinctly apolitical, adhering strictly to the belief that the artist “is irresponsible because his life goes in a different direction.” The mind of the artist, she said, was involved not with facts, but with beauty and happiness.

Examination of the apparent “uniform field” in Winter Stone (1961) reveals an intricate lattice of grids and pencil work that lend a painstaking poignancy.

Hailed as a mystic and a sage by many, Martin was quick to distinguish herself as normal, saying that “you know you’re not a mystic when you respond to beauty.” She did meditate regularly, spend long periods of time in solitude, and maintain a simple lifestyle that veered towards asceticism. But to Martin, these were everyday experiences available to everyone. She ascribed suffering to choosing the negative and the maintenance of happiness to making positive choices. Though fond of humility, she embraced the good fortune and the considerable wealth that her paintings eventually brought her. She lived in small adobe houses she built herself, but drove nice cars and made large anonymous philanthropic donations to her New Mexican community in Taos. In 1998, she travelled from Taos to Washington to accept a National Medal

of Arts from the National Endowment of the Arts, presented by Hillary and Bill Clinton. In 2015, her painting Untitled #7 (1984) sold for $4.2 million at Phillips in New York. Last year, the Solomon R. Guggenheim Museum in New York presented a retrospective of her work.

MEDICAL QUIPS Pet signs Sign in a veterinarian’s waiting room: “Be back in 5 minutes. Sit! Stay!”

JULY / AUGUST 2017 • Doctor’s

Review

ANNE GARDON

Scooped out by a meteor 400 million years ago, the region is now a UNESCO World Biosphere Reserve.

It doesn’t get any better than Charlevoix region on the north shore of the gulf of St. Lawrence by Lin Stranberg

ne of the most beautiful places in the country for an easy road trip is Charlevoix, the smallest tourist region in Quebec. Hard to get to except over rough roads until the 1970s, it is now just a comfortable one-hour drive from Quebec City. June to October, you can catch the Train de Charlevoix from Quebec City to La Malbaie.

ALAIN BLANCHETTE

The beautiful and now highly civilized Charlevoix region began life in fire and brimstone — 400 million years ago, a meteorite carved out a 58-kilometre wide crater. Today, from the village of Petite-Rivière-SaintFrançois to the mouth of the Saguenay Fjord, the rolling farmlands of the Laurentian foothills are dotted with picturesque towns and villages overlooking the vast 24-kilometre-wide St. Lawrence River. In 1989, UNESCO declared the entire area a World Biosphere Reserve. Between June and October, you can book a tourist train from Quebec City to La Malbaie aboard the Train de Charlevoix (traindecharlevoix.com), a 125-kilometre scenic ride along the north shore of the St. Lawrence River, with some of the oldest towns and grandest landscapes anywhere. Here’s a sampling of what to see and do.

JULY / AUGUST 2017 • Doctor’s

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Baie St-Paul is known as a hub for artists and artisans. It was painted by members of the Group of Seven and was the birthplace of the Cirque du Soleil. Stroll down rue St-Jean-Baptiste, stop in at some of the many small boutiques and art galleries, and catch an exhibition at the Museum of Contemporary Art (macbsp.com). If you have a taste for vintage games and nostalgia, browse the remarkable collection at Le Joker, at 116 rue St-Jean-Baptiste. For beautiful items made from pure local wools and felts, visit Charlevoix Pure Laine (charlevoixpurelaine.ca) at 69 rue St-Jean-Baptiste — you may even get to see the charming Solange Bessette work her knitting machine.

Solange Bessette knits wonderful woolens at Charlevoix Pure Laine in Baie St-Paul.

ON THE ROAD TO ST-URBAIN From Baie St-Paul, take Route 138 north to 1167 Blvd. Mgr. de Laval. If you like cheese — or appreciate old memorabilia — Laiterie Charlevoix (fromagescharlevoix.com) is a must. Their cheese is sold throughout Canada, so you may already know these three superstars: L’Origine, a mixed-rind, Reblochon-like soft cheese from old-breed La Canadienne cows’ milk; L’Hercule, a firm, cooked and aged washed-rind cheese somewhat between a Comté and a Gruyère; and Le 1608, a semi-firm, smoothtextured washed rind cheese also from La Canadienne cows. After sitting down for a tasting, walk over to the on-site milk museum to view a fabulous collection celebrating the glory days of the white stuff. Back on 138 north, bear left at the gas station onto Route 381 and stop for a little agritourism at the Emu Farm (emeucharlevoix.com), 706 rue SaintÉdouard. With its flock of 400, this is the biggest emu farm in Canada. Raymonde Tremblay raises these big, kind of goofy-looking Australian birds to produce oil and meat products that you can sample at the small on-site boutique. Emu oil is recommended for sensitive skin. It’s moisturizing, anti-inflammatory, non-comedogenic and hypo-allergenic.

L’ISLE-AUX-COUDRES When Jacques Cartier discovered this small island in 1535, he named it for the many hazel trees called coudres that still grow there today. It’s known for great kite surfing and the spectacular sunsets from its western tip. With a population of only 1200, the island remains relatively untouched and quiet enough that you can drive or bike the 23-kilometre road around it in peace. Rent a bicycle, tandem, quadricycle or electric bike (velocoudres.com), tour the historic wind-cum-watermill (lesmoulinsdelisleauxcoudres.com),

Doctor’s Review • JULY / AUGUST 2017

Whale watchers get an eyeful during a Croisière aux baleines expedition at the mouth of the Saguenay.

The 200-year-old wind and water mill on L’Isle-aux-Coudres was extensively restored in 2012.

LIN STRANBERG

BAIE ST-PAUL

Peaceful off-shore sanctuary L’Isle-aux-Coudres is a place for bike rides, kite surfing and sunsets.

taste fine fruit ciders at Pednault (vergerpedneault.com) and stop in for a down-home island lunch at the Boulangerie Bouchard, a local favourite since 1945. The free car ferry (traversiers.com) takes 20 minutes or so, leaving from Saint-Joseph-de-la-Rive every half-hour and returning on the hour.

ANNIE BOLDUC

WHALE WATCHING ON THE ST. LAWRENCE

LA MALBAIE

LIN STRANBERG

CROISIÈRES AML

Miller Nicolas Harvey grinds grain in the iconic mill on L’Isle-aux-Coudres.

Head east on 138 and enjoy gorgeous river views all the way up to Baie St-Catherine at the mouth of the Saguenay River, then board a relaxing cruise boat or adventurous Zodiac boat (croisieresaml.com) to see the lively population of minke, beluga, blue whales and seals in the waters of the Saguenay-St. Lawrence Marine Park.

Samuel de Champlain named this lovely spot “the bad bay” in 1608 because of the low tides that prevented his ships from mooring there. Once known as Murray Bay, it was an international resort frequented by rich English Canadians and Americans who steamed upriver on the old “white boats” during the 19th and early 20th century. William Taft, US President from 1909 to 1913, had a summer home here until his death in 1930; his descendants still come up every year. Beginning in 1928, Canada Bay and its sister hotel, The Tadoussac at the mouth of the Saguenay, were serviced, during the summer months, by three large, 350-foot passenger ships out of Montreal and Quebec City. The service continued until 1965. Now the Fairmont Le Manoir Richelieu (fairmont.com/richelieu), the hotel continues to be a landmark on the cliffs of Pointe-au-Pic as it has been since it opened in 1898, offering a grand view of the ships that ply the river today.

WHERE TO STAY Le Germain Charlevoix (legermainhotels.com/en/ Charlevoix): contemporary country chic with a stylish urban feel, a Nordic spa, a heated outdoor pool and two good restaurants. The Baie St-Paul Charlevoix train stop is on the property. Auberge des Falaises (aubergedesfalaises.com): a charmingly traditional family-owned inn and a separate two-storey pavilion with comfortable condos and rooms with views. Reliable cuisine, Nordic spa and a heated outdoor pool with a spectacular river vista.

At Laiterie Charlevoix, stock up on the region’s famous cheeses made from the milk of La Canadienne cows.

For more information on travel to the region, visit Tourisme Charlevoix (tourisme-charlevoix.com/en). JULY / AUGUST 2017 • Doctor’s

Review

The art of reinvention From fire stations to silos, five old buildings that have been repurposed into stunning new hotels by Camille Chin

Doctorâ&#x20AC;&#x2122;s Review â&#x20AC;˘ JULY / AUGUST 2017

THE WAREHOUSE HOTEL, SINGAPORE If only the Warehouse Hotel had walls that could talk. The trio of gabled buildings on the bank of the Singapore River once sheltered aromatic spices on a street where palm and rice wines were being illegally distilled in alleyways and dark corners. The neighbourhood was run by Chinese and Fujianese secret societies: gambling and prostitution and opium were rampant. The three peaked-roof buildings were privy to it all; today, 100-plus years later, they guard the secrets of travellers as a chic 37-room hotel in Robertson Quay. Its industrial design boasts exposed brick walls, sleek black metal and custom lights modelled after pulleys. Rooms are done in taupe and grey accented with copper and green forest marble. There’s a rooftop infinity pool; the on-site restaurant called Pó features nine original, spice-infused cocktails inspired by the area’s naughty past. From about $235 a night*, double occupancy. thewarehousehotel.com.

THE DETROIT FOUNDATION HOTEL

*Note: all prices throughout are based on web searches.

JOE VAUGHN / FOUNDATION HOTEL

The fire engines are gone — and, sadly, so are the firemen — but some of the architectural details of Motor City’s former Fire Department Headquarters remain in what’s now the “industrial-chic” Foundation Hotel. Located in downtown Detroit across from the Cobo (Convention) Center, the five-storey Neoclassical goliath still boasts its iconic red firehouse doors. The storey-and-a half space that used to house fire trucks and equipment, and now the lobby and The Apparatus Room restaurant, features the original white-glazed brick walls. The building’s former life is celebrated in new ways too. A smokeinspired chandelier by artist Kim Harty hangs over a banquette table where fire hoses once hung to dry. The hotel’s 100 rooms are decorated in deep browns with pastel metallics, a nod to the colours of 1960-era automobiles. There are even cushy channel-tufted velvet sofas so guests can pretend they’re cruising in an old luxury Caddy. From US$219 a night, double occupancy. detroitfoundationhotel.com.

THE SILO, CAPE TOWN When Cape Town’s historic silo complex was built in 1924, it was the tallest structure in Sub-Saharan Africa. The 54-metre grain elevator still towers over the city’s waterfront, but, in March, it opened as the striking Silo Hotel. Its remarkable domed windows consist of hand-cut, multi-faceted glass that lets guests see what’s up, down and on each side. At night, the hotel resembles a modern-day lighthouse in the Table Bay harbour. The 28 rooms are eclectic with colourful furniture: hot pink bedroom rugs, huge teal headboards, yellow and green sofas and armchairs. The Granary Café is open to the public as are the spa and rooftop pool. You’ll also want to visit the Zeitz Museum of Contemporary Art Africa. It opens directly below the hotel in September. Admission is $20, which is way, way less than a hotel stay: about $1160 a night, double occupancy, including breakfast and museum entrance. theroyalportfolio. com/the-silo/overview.

THE NED, LONDON

COURTESY OF THE NED

If The Ned gives off an air of all business from the outside, it’s because the colossal, 252-room hotel and members’ club used to be the headquarters of London’s Midland Bank. Located across the street from the Bank of England in the city’s financial heartland, the building’s nine floors of high finance are now charming Edwardian-feeling rooms that feature brass bed frames, oak dressers, velvet club chairs, and textures and patterns inspired by the 1920s. There are seven public restaurants, a woman’s hair salon, a barbershop that serves beer, and a nail bar called Cheeky. Private spaces for members and/or overnight guests include a rooftop pool with views to the Gherkin and St. Paul’s Cathedral, and the very lavish Vault bar. The Vault’s original metre-thick metal door opens up to walls lined with 3600 safety deposit boxes, a chic new walnut bar and jewel-toned velvet furniture. From about $300 a night, double occupancy. thened.com.

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LE MONASTÈRE DES AUGUSTINES, QUEBEC CITY The airy rooms at Le Monastère des Augustines are all white and glass and steel, which makes sense because the wellness hotel is housed in a wing of what was once the Hôtel-Dieu de Québec. Established in 1639 by three sisters from the Augustinian Order, it was the continent’s first hospital north of Mexico. But that’s not to say that the hotel is sterile and uninspiring.

Rooms also feature aged wooden beams and pretty windows with shutters, centuries-old furniture and lovely quilts. TVs and telephones are missing; wi-fi is available. The 33 “authentic” rooms (from $84 per person, a night) each have a sink and share six bathrooms; the 32 “contemporary” rooms (from $104 per person) have new ensuites. There’s an onsite museum (admission $10) with 40,000 artifacts drawn from the 12 former monastery hospitals in Quebec. Breakfast is included and served in silence to honour the tradition of the nuns. monastere.ca/en.

JULY / AUGUST 2017 • Doctor’s

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co ne nt w es t!

Win a fabulous seven-day November 2018 all-inclusive “CME Away” holiday at a

new Sandals resort in Barbados!

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A lucky physician and a guest will receive: • Return airfare from Toronto on Air Canada • Luxurious accommodation • Concierge service • All meals and complimentary Mondavi wines at dinner (choose from 11 unique restaurants, including a new Indian restaurant, a Sandals first) • Complimentary snacks and bar service • Unlimited land and water sports and much more (the resort features seven pools, swim-up bars and the longest river pool in the Caribbean) Also included: 12 hours of CME Updates in Family Medicine, with Dr Sol Stern and other speakers, offered by CME Away Sea Courses.

EntEr and win at doctorsreview.com For info on the resort, go to sandals.com/main/barbados/bd-home

Glendorn’s Main Lodge has four rooms and suites; there are more than a dozen standalone cabins around the estate.

Indulge in Glendorn’s understated luxury

America’s No. 1 resort hotel whispers “wealth” softly by Dr Jean Marmoreo

he Lodge at Glendorn is a Relais & Château mountain property in Bradford, Pennsylvania that’s best known for fly-fishing and trapshooting. It opened in 1995 and was last year named the

#1 Resort Hotel in the Continental US by Travel & Leisure. I am neither a fly-fisher nor trapshooter, but last year, for our yearly getaway weekend, my two sisters and I drove 3½ hours south of Toronto, not unlike the pilgrimage skiers from southern Ontario make

to Ellicottville. Glendorn is down the road. It’s 607 hectares nestled deep in a valley abutting Allegheny State Park. While Glendorn is remote, it glows with the rustic elegance you’d expect from a five-star lodge. This is all because of its history. It started as the family retreat JULY / AUGUST 2017 • Doctor’s

Review

The Roost Cabin is ringed by ancient hemlock and maple trees, and sleeps up to nine.

Skeet shooting was a novelty, but our guide turned us from nervous beginners into eager ones of a 19th-century Pennsylvania oil baron, Clayton Grenville Dorn, and grew, topsy-turvy, springing up a total of eight cabins as the children enlarged their families. But when each cabin can sleep nine to 10 people, you have the makings of a commercial lodge. That happened in 1995, but the fourth generation of Dorns managed it for four more years, which explains its deeply homegrown roots. It has the feel of a stage set when you enter the cabins. We were housed in the Roost, named after a granddaughter called Bird. Constructed in the 1950s around a stone fireplace (there are 41 working fireplaces on the property), two later additions were added, each also with its own fireplace. It is an enchanting warren of rooms with handcrafted built-in everything. We opened doors, chattering about details, getting lost in the maze of rooms, laughing as we rounded corners. Yet, as always, it’s the small details that captivated us. Still-warm chocolate chip cookies awaited us. Two different coffee machines turned us into discriminating baristas. The ice bucket was chilled and an ancient metal-lined ice-drawer provided endless

Doctor’s Review • JULY / AUGUST 2017

Guests can go fly fishing on-site on three trout ponds or explore seven kilometres of mountain streams.

restocking for our whole visit. The fridge was full of sodas, the bar amply stocked. We knew, sitting in front of the crackling fire, we would happily never move. But we had adventures planned.

SLIPPERY FISH Skeet shooting was a novelty, but our guide, Damon Newpher, turned us from nervous beginners into eager ones. He selected very light shotguns for us and his instruction was instrumental in our success because we actually did hit those flying discs. Then… “Do we want to go jeeping?” We were off on a guided history of timbering in the Alleghenies, the oil boom, current forest husbandry, selective logging and the changing nature of forest growth around Glendorn.

SARGENT PHOTO

COURTESY JEAN MARMOREO

Dr Marmoreo (pictured right) is a family doctor in Toronto; she stayed at the resort with her two sisters during their annual getaway.

SARGENT PHOTO

When it’s warm out, the Main Lodge’s outdoor terrace is the best place for an alfresco meal.

Damon earned his spurs as a guide in the south, but he returned home to ply his trade as a top woodsman and fly-fishing guide. Sitting with him atop the Allegheny plateau at 640 metres, he pointed to his home two hilltops over where he and his wife would hike a virginal stand of eastern hemlock and white pine that evening after work. He’s worked at the lodge for 21 years and clearly has never lost his patience with the uninitiated or the love of his craft. But it’s around fish that you can feel you are in the hands of a trout-whisperer: “they will get skittish if you don’t land the fly correctly; there’s only one chance at this.” This is said as we gaze into a swirl of trout visible in the lowest water levels seen in years. For us, they just won’t bite. He offers to lay out a hike for the next day and asks if we want to have lunch delivered to the top of the hill so we don’t have to carry our food all the way up. “Absolutely.” “Leave it to me.” We then head back to the lodge and into the spa for facials that leave us plenty of time to explore the grounds and chat with staff. We learn stories that have clearly endured through the decades. The miniature fire wheel truck, constructed to haul 18 kids around the property, has been faithfully restored and is operable. The playroom stocks ‘round-the-

clock ice cream and a corn-popping machine for snacking between pool rounds. Tennis courts hug shuffleboard areas, bikes abound. But it is the flyfishing and shooting cabin centres that signal you are in the presence of hallowed ground.

DINNER AT THE HIDEOUT Orvis waders and boots are racked outside the outfitters, and the gunroom boasts exquisitely ordered cabinets of shotguns. No gear? No problem. Faded pictures attest that every Dorn child rode, shot, fished, tramped, swam — and bits of that legacy are on the walls to ignite our own sense of nostalgia. When it comes to meals, there is nothing rustic about Glendorn. A four course tasting menu of French cuisine changes daily. The wine list is appropriately expansive, the service efficient under the great chandelier. We overeat. We love it. We groan our way to deep, silky-sheeted beds, each in our own quarter, the silence of the place almost a resounding force in itself. The highlight of our stay occurred during our hike and was part of Damon’s plan that we not carry packed lunches. uu CONTINUED ON PAGE 47 JULY / AUGUST 2017 • Doctor’s

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A float down the New fascinations stud the path of the ancient river text and photos by Jeremy Ferguson

Doctor’s Review • JULY / AUGUST 2017

The cruise ship the Rajmahal, in a polluted haze, greets a riverside throng at its daily bath.

Ganges T

he timeless Nile was the first of the great rivers to invite the world for a cruise, and the rivers of sophisticated European culture followed: the Rhine, Rhone, Seine. Then the New World upstarts:

the Amazon, Mississippi and Columbia. And more recently, the beguiling rivers of Asia — the Mekong, Yangtze and Myanmar’s Irrawaddy. The latecomer to this floating party is India’s Ganges. Riverboats promising palatial trappings and services worthy of maharajas now ply an 874kilometre stretch of eastern India between Kolkata (formerly Calcutta) and Patna. This is untouristed territory and it might give you a giddying sense of being one of the first. Our boat was the ABN Rajmahal, a smartly appointed river cruiser built for Assam Bengal Navigation, the British-Indian company that has pioneered Ganges cruising over the past decade. The Rajmahal’s 22 cabins come with air-conditioning and floor-toceiling picture windows. The canopied upper deck and bar is for devout river-watchers, and for boisterous performances from local troupes of dancers and musicians. There’s also a civilized library bar (domestic whisky is serviceable; wine is not) and a small spa facility.

A sadhu. a Hindu holy man, dispensing blessings for a price.

On Varanasi’s burning ghat, you can almost hear the turnstile to heaven spinning.

he dining room’s centrepiece is a phalanx of chafing dishes (or to be uncharitable, a trough) and there were 36 meals at it. The fare is western — Waldorf salad, anyone? — and Indian. Indian cuisine is, uniquely, a blessed symphony of spices, but not Rajmahal Indian. This is Indian purged of its spices in order, according to the management, to prevent a mass outbreak of diarrhea among the geezers (which was all of us). So one sees the Ganges fuelled on cuisine gériatrique, and when you see the steam table no more, it feels like a gastronomic prison break. The itinerary, however, compels: 15 days of prime discovery, 12 on the Ganges and its tributary, the Hooghly, and three days overland to the Buddhist pilgrimage site of Bodh Gaya and the holy city of Varanasi. Kolkata was our starting point. Founded by the British East India Company in the late 17th century, it was the toehold that became the Raj, and the capital of British India until 1911, when London moved the capital to Delhi. Today, with a population of 21 million, it ranks as India’s heart of creativity in art, literature, poetry, music and film. Raj-fixated British tourists run off to stately imperial glories embodied in the Victoria Memorial. But the city’s great vitality, as with so much of India, lies in the streets. Demonstrating this point is Manjit Singh Hoonjan, whose enterprise is Calcutta Photo Tours. Erudite, insightful and amusing, Manjit is a man in love with his city. His walking tours, which start at six in the morning, pack years into four hours. One such tour immerses visitors in that most vibrant of Indian institutions, the market. This in-

Doctor’s Review • JULY / AUGUST 2017

A doorway to another world, in the streets of old Varanasi.

Varanasi is the most sacred city in India; it feels older than the pyramids, older than China, older than Nineveh cludes the rambunctious flower market, the largest in Asia, afire with the yellows and oranges of hundreds of thousands of marigolds. Another takes you to the potters’ quarter to see craftsmen shaping voluptuous, bug-eyed and even grotesque sculptures to enliven Bengali Festivals, and then to be tossed in the Ganges.

Bodh Gaya’s Mahabodhi Temple marks the place where, under a Bodhi tree, the Buddha found Enlightenment.

Human camels in Kolkata.

Market sellers invite foreigners to sample the local water chestnuts.

nd the river, the sacred Ganga, worshipped as a goddess by Hindus, is far from wholly holy. It’s a deluge of filth. George Black, author of a forthcoming book on the Ganges, estimates 17 million tonnes of industrial and human waste are dumped into the river every day, surely no way to treat a goddess. Ambitious clean-up projects are announced regularly, and the nation yawns. Yet the river is far from unpleasurable to look at. Vast tracts of jute and pampas grass form wavering river banks as the Rajmahal penetrates the West Bengal countryside. Cantilevered fishing boats dart about like dragonflies. Passengers frequently spot Ganges river dolphins, which are blind, and among the world’s most ancient creatures. This India comes studded with fascinations, and the Rajmahal’s shore excursions miss none: an ancient Buddhist university; Hindu, Sikh and Jain temples; deconsecrated mosques of golden-age elegance; remnants of the Nawabs, Muslim governors who ruled the east until the British colonization. It is much to the credit of the Archaeological Survey of India that they are excellently maintained. Original architecture is rarely associated with Hindu temples, usually festooned with riotous gods and goddesses. But the Kalna 108 Shiva Temples in West Bengal is a rare beauty, built in 1809, two concentric rings of 108 temples, each containing a Shiva lingam (the phallic signature of the god). Lingering here — perhaps envying the certainty of the faithful — proves one of the unforgettable pleasures of the journey. Time is spent at a crumbling manse in the state of Bihar. This fabulous old house once belonged to JULY / AUGUST 2017 • Doctor’s

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A life of toil and survival on the Ganges.

What romances the eye are its curiously un-Indian pastel hues — you might think you’re on the Mediterranean the Nawabs of Bengal. What romances the eye are its curiously un-Indian pastel hues stunning even in their faded beauty. You might think you’re on the Mediterranean and that the house painters were Impressionists. The catalogue of wonders swells with the 14thcentury Adina Mosque, its Bengali, Persian, Arab and Byzantine flourishes a magnificent cross-section of Indian history. Nalanda University was a centre of learning when Buddhism prevailed from the 5th to 12th centuries. The 18th-century Katra Mosque entombs a Nawab under 14 flights of stairs. (When you’re a senior, it’s all too easy to have an affinity for ruins). We were taken to Matiari, a brass-making town where a man with a work space the size of a coffin is called an “industry.” But Matiari is as vibrant a symbol of everyday India as any, in which its inhabitants accept their place in the scheme of things and wear it with the easiness of a favourite dhoti or sari. Westerners do not get this. So welcome to Village India, home to millions of human beings whose future comes defined — and denied — by the monstrously exploitive caste system. India’s villagers are dirt-poor by our standards, and they’re also kind and welcoming. Deer Forest is a fishing village on an island. It has a single public toilet provided by the government, (and it looks unused). But we have the sense these humble, smiling villagers are at least as happy as we might be, just as we wonder about the human capacity to find meaning within the narrowest of parameters.

hen, the voyage ended, we left behind the boat’s nursing-home food and bussed to Bodh Gaya, which is to Buddhists what Jerusalem is to Christians and Mecca to Muslims: its most sacred place of pilgrimage. It was here, so it goes, that the Buddha achieved Enlightenment under the Bodhi Tree, liberating his soul from some of humanity’s most defining traits: delusion, greed, lust, hatred, the works.

Doctor’s Review • JULY / AUGUST 2017

Hindu pilgrims pause to worship at each temple containing a Shiva phallus at the Kalns 108 Shiva Temples.

The splendid 14th-century Adina Mosque, with its Bengali, Persian, Arab and Byzantine flourishes.

An alley leads into Kolkata’s dazzling and chaotic flower market.

A sadhu quartet, ascetic holy men, a familiar presence in Hindu India.

Bodh Gaya’s heart is the ancient and beautiful Mahabodhi Temple. Thousands of pilgrims from the Buddhist world — Sri Lanka, Thailand, China, Japan, Vietnam and many western countries — arrive to circle the floodlit stupa clockwise, carrying candles, prostrating themselves, chanting, praying, lost in faith. Even the skeptic may be dumbstruck at such intensity. Last there is Varanasi. The most sacred city in India, it feels older than the pyramids, older than China, older than Nineveh. Perhaps it has squatted, crumbling and tumbling on the edge of the Ganges since the beginning of the great river itself (or even before there was a Ganges). The Hindu millions come here to save their souls. Mysticism infuses its oxygen. If Varanasi is India’s holiest city in which to live, it is also the holiest city in which to die. The Marikarnika is Varanasi’s main burning ghat, steps leading down to the Ganges. More than 200 corpses, wrapped in saffron-hued cloth, are publicly cremated every day. To be cremated here, and have one’s ashes flung into the sacred river Ganges is to have all sins expunged and to go straight to Nirvana. Even lawyers and mass murderers get a free pass to eternal peace and happiness by dying in Varanasi. At the burning ghat, you can almost hear the turnstile to heaven spinning. Every dawn, by the thousands, the faithful arrive at the river to cleanse body and soul in water that is both vile and so desirable, it is bottled and sold on Amazon. On festive days, women bathe in their most shimmering and colourful saris, a Technicolor fantasia. Varanasi, with its beauty, mysticism, chaos, thousands of years of history and enough contradictions to overload the Internet, is India’s signature. I have been to India 10 times and can say with some authority that if you feel the need to escape your own privileged skin and plunge into a reality more different than Jupiter, there is no better or more exhilarating place on earth.

IF YOU GO Because Kolkata lies on India’s east coast, flying transPacific is sensible, but there are no direct flights. Cathay Pacific (cathaypacific.com), with a Hong Kong stopover, is one way to get there. This means a layover, and a day room in the airport’s Regal Hotel (regalhotel.com) solves that one. Then Cathay Dragon, a subsidiary of Cathay Pacific, takes you on to Kolkata. For Calcutta photo tours: info@calcuttaphototours. com For Rajmahal information: assambengalnavigation. com For tourist information: incredibleindia.com

Returning to the Rajmahal as the sun goes down.

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Review

Streetcorn two ways.

A Mexican fiesta Add some spice to your summer — and more avocado too! — with modern recipes ideal for warm-weather eating recipes by Paul Wilson

hef Paul Wilson has travelled all around the world, but he confesses that nowhere has inspired him as much as Mexico. Based in Australia, the

British-born chef describes Mexico’s cooks, street food vendors, market traders, restaurant owners and bar aficionados as passionate, humble and unselfish, always ready to share their food experiences and knowhow. In Taqueria, published by Hardie Grant Books, Wilson showcases the country’s most popular feel-good foods, some with a modern twist. The bright, citrusy flavours of the Yucatan Peninsula are represented, as are the rich, earthy sauces of Oaxaca. And yes, there are lots of taco and salsa recipes too. Read on to find out how to make Mexico’s famous streetcorn and a guacamole with no shortage of gusto.

STREETCORN TWO WAYS

Tourists, families and children congregate around the aromas of streetcorn

Doctor’s Review • JULY / AUGUST 2017

photos by Chris Middleton

vendors in Oaxaca. Once one gets started, a flurry of other vendors always set up shop nearby as crowds are guaranteed. For the corn: 4–6 corn cobs in their husks

Preheat a barbecue chargrill (ideally a wood and charcoal combination) to medium. Moisten the husks with water to help prevent burning, then place the corn on the barbecue, cover with a lid and grill, turning occasionally for 15 minutes or until the husks are charred and the corn appears tender. Leave to cool slightly while you prepare your choice of topping. For the avocado crema topping: 7 oz. (200 g) streaky bacon or pancetta, diced 1 tbsp. (15 ml) olive oil

1 garlic clove, grated sea salt to taste 5½ oz. (150 g) hard goat’s cheese, finely chopped or coarsely grated 1-2 tsp. (5-10 ml) chili powder (optional) 1 lime to serve (optional)

Preheat the oven to 100°C (210°F). Scatter the olives over a lined tray and cook for at least 8 hours, or overnight, until dried to a stale bread-like texture, then finely chop. Combine the goat’s curd, sour cream, basil and garlic in a food processor, and blend to make a smooth cream. Season lightly with salt. To serve, place the goat’s crema in a shallow tray and roll the hot corn around to generously coat, then sprinkle with goat’s cheese and olive crumbs. Dust with chili powder, if desired, for a fiery and colourful finish. Serve with a squeeze of lime, if desired. Serves 4–6.

SUPER SOUL FOOD GUACAMOLE

We all know avocados, packed as they are full of vitamins, good fatty omega-3s

3 overripe avocados, stones removed juice of 4 limes, plus extra to serve ¹⁄³ c. (80 ml) sour cream 1 garlic clove, grated 1½ tsp. (7.5 ml) ground cumin 1 tsp. (5 ml) smoked paprika ¼ tsp. (1.25 ml) ground allspice pinch of onion powder pinch of ground coriander sea salt to taste 5½ oz. (160 g) salted ricotta, grated

Fry the bacon in the oil until crispy, then drain. Combine the avocado, lime juice, sour cream, garlic and spices in a food processor, and blend to make a smooth thick sauce. Season to taste, then add a little water to reduce it to a coating consistency. Serve the crispy bacon, avocado crema and salted ricotta alongside the corn, and allow your guests to help themselves, adding a squeeze of lime if desired. For the goat’s crema topping: 1¼ c. (310 ml) pitted manzanilla olives 5½ oz. (150 g) soft goat’s curd ¼ c. (60 ml) sour cream 1 large handful basil leaves Super soul food guacamole.

and fibre, are one of the healthiest foods available to us. Continue nature’s good work by adding raw seasonal vegetables and feel-good toppings from your local health-food store. 1 lb. 2 oz. (500 g) ripe Hass avocados (about 2–3) 2 tbsp. (30 ml) avocado oil juice of 2 limes 2 tsp. (10 ml) ground cumin ½ tsp. (2.5 ml) ground allspice 1 tsp. (5 ml) sea salt 9 oz. (250 g) cherry tomatoes 2 red onions, finely chopped 1 jalapeño, finely chopped 1 bunch coriander (cilantro) leaves, chopped ¾ c. (180 ml) Tomatillo verde (recipe follows) Toppings 1¾ oz. (50 g) pepitas (pumpkin seeds) 1¾ oz. (50 g) sunflower seeds 1¾ oz. (50 g) chia seeds 5½ oz. (150 g) mixed nuts such as walnuts, almonds, macadamias or cashew nuts

sea salt to taste 1¾ oz. (50 g) desiccated (shredded) coconut 1¾ oz. (50 g) goji berries 2 jicamas (aka the Mexican potato) or 1 daikon (white radish) 3½ oz. (100 g) mixed shaved vegetables such as breakfast radish, baby carrots or zucchini 3½ oz. (100 g) baby spinach or baby kale leaves coriander (cilantro) leaves, to garnish

Preheat the oven to 180°C (350°F). Cut the avocados in half lengthways and remove the stones. Scoop out the flesh using a large spoon and add to a mixing bowl, then begin to crush with a large fork, adding the avocado oil and lime juice as required. Season with the cumin, allspice and salt to taste. Carefully stir the tomatoes, onion, jalapeño and coriander into the guacamole, taking care not to over-mix. Cover with plastic wrap and refrigerate for

Roasted salmon tacos Baja-Med style.

at least 30 minutes to allow the flavours to mingle. For the toppings, arrange the nuts and seeds on two baking trays. Season lightly with salt and spray with sunflower oil. Bake for 8–10 minutes, then add the coconut and goji berries, and bake for a further minute until lightly golden. Remove from the oven and leave to cool. Using a mandoline, shave the jicamas, radish, carrot and zucchini into long strips. To serve, transfer the guacamole to a large attractive dish, top with the shaved vegetables and spinach leaves, and scatter over a handful of the toasted seed and nut mix. Drizzle over the tomatillo verde, sprinkle with coriander leaves and serve with your favourite raw vegetables or baked corn (tortilla) chips for dipping. Serves 8. Tip: Any leftover seed and nut mix can be stored in an airtight container and is great sprinkled over other vegetable dishes and salads.

Tomatillo verde This is a great sauce for white meats, fish and vegetables. Tomatillos are similar to green tomatoes or gooseberries. 9 oz. (250 g) tinned or fresh tomatillos, drained if tinned or outside leaves removed if fresh 1 red onion, thickly sliced into rounds 2 green jalapeños 3 garlic cloves 4½ oz. (125 g) cherry tomatoes ¼ c. (60 ml) chicken or vegetable stock juice of 3 limes 1 large handful coriander (cilantro) leaves 1 small handful oregano leaves 2 tsp. (10 ml) ground cumin sugar to taste sea salt to taste

Preheat an overhead grill (broiler) to high heat. Place the tomatillos, onion, jalapeños and garlic on a grill tray and grill, turning occasionally, for 10-15 minutes, until soft, caramelized and charred black. Allow to cool slightly then roughly chop. Place the charred vegetable mixture into a food processor or blender. Add the tomatoes, stock, lime juice, coriander, oregano and cumin, and process to make a smooth sauce. Season with sugar and salt. Depending on how thick you like your sauce, either strain through a finemesh sieve for a thin sauce or leave as is if you prefer a thicker sauce. Store in an airtight container in the refrigerator for up to 1 week. Makes 1²∕³ cups (400 ml).

ROASTED SALMON TACOS BAJA-MED STYLE Baja-med is a delicious fusion of Mexican and Mediterranean cookery found in the border town of Tijuana and elsewhere in Mexico’s Baja California. 12 store-bought tortillas tamarind chili mole (optional, recipe at doctorsreview.com)

For the salmon 1 x 14 oz. (400 g) pin-boned Atlantic salmon fillet, skin on olive oil, for frying 2 garlic cloves, finely sliced 1 large salad onion, sliced ½ small dried chipotle chili, finely sliced 1 yellow bullhorn chili, sliced into rounds 7 oz. (200 g) mixed red and yellow cherry tomatoes, halved 2¾ oz. (75 g) kalamata olives, halved 5 tbsp. (75 ml) sherry vinegar juice of 1 orange 5 tbsp. (75 ml) agave syrup 1 bunch basil leaves, shredded For the cucumber salsa 2 peeled Lebanese (short) cucumbers, finely diced ½ bunch dill ½ tsp. (2.5 ml) caraway seeds, toasted ½ tsp. (2.5 ml) sugar ½ tsp. (2.5 ml) salt juice of 2 limes 3 tbsp. (45 ml) extra-virgin olive oil

Preheat the oven to 180°C (350°F). To prepare the salmon, using a sharp knife, cut the salmon fillet along the seam of flesh that separates the belly

from the loin. Cut into two pieces, separating the belly from the loin. Heat a splash of olive oil in a large, non-stick frying pan over high heat. Season the salmon pieces with salt, then place them in the hot pan, skin side down, and cook for 2 minutes, pressing the pieces down with your hands to ensure they cook flat. Cook for a further 1 minute, then transfer to the oven, skin side down, and cook for 2 minutes. Remove the salmon from the oven and leave to cool on a wire rack, then cut into 2.5-cm (1-in) thick slices using a sharp knife. Add another splash of olive oil to the pan together with the garlic, onion, chipotle, bullhorn chili, tomatoes and olives, and cook over low heat for 5 minutes, until softened. Add the vinegar and orange juice, bring to a simmer and cook until the liquid has almost evaporated, then add the agave syrup and simmer until reduced to a thick, sticky coating. Transfer the vegetable mixture to a small bowl, add the basil leaves and season to taste. Set aside to cool. Heat a medium non-stick pan over high heat. Lightly spray with oil and briefly fry the tortillas to warm them.

INDULGE IN GLENDORN'S UNDERSTATED LUXURY uu CONTINUED FROM PAGE 37

“Hike up to the Hideout,” he suggested. “Feed the fish along the way at the fish hatchery and let us deliver lunch.” The Hideout was the secluded haunt of the master Dorn Sr. and boasted its own workshop for him to add to the build-ins. If there was a light on, visitors were welcome; if not, don’t bother slugging it up the last of the stiff hike up from the valley. So, having done just that, we were enchanted with the setting, but even more so when three SUVs pulled up. Three staffers leapt out to light up the BBQ, setting a fine table and presenting us with generous servings of roasted sirloin tips, mashed potatoes, arugula/goat cheese salad, and gluten-free berry crumble, all presented piping hot in elegant copper cookware. Only after we nosed around in the Hideout, exploring its own exquisite cabinetry, did we push on with our hike, now even more necessary to burn off some calories. In the glow of the warm October light, we not only finished our hike, but carried on to Bondieu Lake where the kayaks, paddleboards and canoes were beached. Where else to try paddle-boarding if not on this jewel of a man-made lake? By sunset, we’d come full circle and were back in the Roost, preparing for yet another dining extravaganza.

Stack the tortillas, wrap in a warm damp tea towel and set aside to keep warm. To make the salsa, combine all the ingredients in a bowl and mix well. To serve, divide the tortillas among serving plates. Spoon over a little tamarind chili mole, if using, and top with the salmon slices, vegetable mix and a pile of the salsa. Serve immediately with more tamarind chili mole on the side for dipping. Serves 6. Recipes and photos from Taquerai: New-Style Fun and Friendly Mexican Cooking (Hardie Grant Books, 2016).

MEDICAL QUIPS Ups and downs Elderly man to MD: “Doc, I think I’m getting senile. Several times lately, I have forgotten to zip up.” MD: “That’s not senility. Senility is when you forget to zip down.”

Glendorn is open year-round, and its winter activities promise equal measures of indoor luxury and outdoor fun with snow-shoeing, ski-doo and cross-country ski trails replacing the 29 kilometres of hiking trails. Then again, there are those 41 working fireplaces. The Lodge at Glendorn (from $525 a night, double occupancy; glendorn.com) has 16 distinct accommodations, most in standalone cabins. The Main Lodge features four distinct rooms and suites.

The old “schoolhouse” is now a popular spot for picnics and barbecues.

JULY / AUGUST 2017 • Doctor’s

Review

P H OT O FI NI SH by

Dr Dub r a v k a R a k i c

Another Rocky Mountain high

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Late last summer, I hiked Sarrail Ridge in Peter Lougheed Provincial Park, Alberta. The famous Sarrail Ridge Trail, which completely encircles Rawson Lake, is the finest long hike in Alberta and considered by many to be one of the best in the Rocky Mountains. It was late August and we encountered sun, rain and snow all in one day before reaching the summit. By literally grasping at branches and long grass, I advanced my way up the steep and slippery terrain. Just above the tree line, I encountered the most beautiful meadow filled with blooming wildflowers. Upon reaching an altitude of 2380 metres, I was rewarded with the staggering view pictured here. What you see is Upper and Lower Kananaskis Lakes. This view will stay etched in my memory for the rest of my life. I took this photo using a Nikon D500 camera.

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MEDICAL QUIPS Ba-da-boom

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

editors@doctorsreview.com

Doctor’s Review • JULY / AUGUST 2017

Beautiful woman presents with sore knee. MD to knee: “What’s a joint like you doing in a nice girl like this?”

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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.