September 2017

Libraries by design

MEDICINE ON THE MOVE

Dining the hygge way

New Zealand

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

SEPTEMBER 2017

as the MD ordered

WIN

A SOUS VIDE COOKER PAGE 16

Hong Kong NOW! The depression/ addiction combo Back to school with Miss Chief

FROM THE GSK COPD PORTFOLIO...

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

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

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

BREO® ELLIPTA®

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

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

Please consult the Product Monograph for INCRUSEÂ&#x2122; ELLIPTA® . #-& %) ,/-! !) ) ® ELLIPTA® . #-& ,!* !) "*, %(+*,. ). %)"*,( .%*) ,!' .%)# .* *) %.%*)- *" '%)% ' /-! *)., %) % .%*)- 1 ,)%)#- precautions, adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monographs are also available by calling 1-800-387-7374.

To report an adverse event, please call 1-800-387-7374. $,*)% * -.,/ .%0! +/'(*) ,3 %-! -! *)# .%)# (/- ,%)% ). #*)%-. '-* &)*1) - '*)# .%)# ).% $*'%)!,#% %)$ '! *,.% *-.!,*%

'*)# .%)# !. 2-adrenergic agonist.

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

01633 09/16

100/25 mcg for COPD

LAMA

Action, not sympathy As Dr David Suzuki of The Nature of Things put it recently, “[Indigenous people] were guaranteed in the treaties that they would be able to live the way they want to live as long as the sun shines, the wind blows and the rivers flow.”

And what do Indigenous people want now?

Suzuki, grandfather to two Haida boys, has the answer: “They trusted us and believed us, and to this day this is all Indigenous leaders tell me, we just want Canada to live up to what they say.”

Just before the 2016 federal election, John Ralston Saul, the philosopher and writer who’s married to former Governor General Adrienne Clarkson, on the strength of his research into the wrongs that had been perpetrated on the Indigeneous people, wrote The Comeback which flatly states that the only issue facing the country is Indigenous rights and strongly advises citizens to vote only for the party that promises to do something about it.

Justin Trudeau made all the right noises and has continued to talk the talk since being in power. His government has, until now, been less effective at walking the walk.

The near collapse of the Commission on missing and murdered Indigenous women, which the CBC calls a fortress of bureaucratic incompetence, has become a serious black mark on the government’s effectiveness. That could be about to change.

In late August, Trudeau shuffled his cabinet. The biggest change was the splitting of the Ministry of Indigenous and Northern Affairs into two new departments. Dr Carolyn Bennett is now Minister of Crown-Indigenous Relations and Northern Affairs, and Dr Jane Philpott, who’s been very effective at Health, becomes Minister of Indigenous Services.

Surely with two women physicians in charge, things are about to change for the better.

And why am I telling you all this? To find out, turn to “Back to School with Miss Chief,” page 24. Kent Monkman, an Indigenous painter and from Winnipeg, has had considerable success with his graphic depictions of the other side of Canadian history. Spoiler alert: his work is powerful and may be disturbing to some readers.

As an antidote, read Jeremy Ferguson’s delightful take on Hong Kong, page 34. He knows the city well and the writing and photos are superb.

Happy trails,

Indications and Clinical Use: Monotherapy: JARDIANCE® (empagliflozin) is indicated for use as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance.

Add-on combination: JARDIANCE® is indicated in adult patients with type 2 diabetes mellitus to improve glycemic control, when metformin used alone does not provide adequate glycemic control, in combination with: • metformin, • pioglitazone (alone or with metformin), • metformin and a sulfonylurea, • basal or prandial insulin (alone or with metformin), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control.

Add-on combination in patients with established cardiovascular disease: JARDIANCE® is indicated as an adjunct to diet, exercise and standard care therapy to reduce the incidence of cardiovascular death in patients with type 2 diabetes mellitus and established cardiovascular disease who have inadequate glycemic control.

Important Limitation of Use: Use of JARDIANCE® with insulin mix (regular or analogue mix) has not been studied. Therefore, JARDIANCE® should not be used with insulin mix.

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

For important safety information on SGLT2 inhibitors and the risk of DKA, please refer to http:// www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2016/58404a-eng.php.

References: 1. JARDIANCE Product Monograph. Boehringer Ingelheim, September 12, 2016. 2. Boehringer Ingelheim (Canada) Ltd. Data on File. Medical Letter. September 6, 2016.

David Elkins, publisher and editor delkins@parkpub.com

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

CA/EMP/00086 BI/EMP/00086

NEW INDICATION

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

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

JARDIANCE® is not recommended for use in patients who are volume depleted.

Due to its mechanism of action, JARDIANCE® causes diuresis that may be associated with decreases in blood pressure. Caution should be exercised in patients for whom an empagliflozin induced drop in blood pressure could pose a risk, such as patients with known cardiovascular disease, patients on antihypertensive therapy (particularly loop diuretics), elderly patients, patients with low systolic blood pressure, or in case of intercurrent conditions that may lead to volume depletion (such as gastrointestinal illness).

Careful monitoring of volume status is recommended.

Temporary interruption of JARDIANCE® should be considered for patients who develop volume depletion until the depletion is corrected.

CV=cardiovascular; T2D=type 2 diabetes. *Comparative clinical significance is unknown.

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 SEPTEMBER 2017

34 COVER: LEE YIU TUNG / SHUTTERSTOCK.COM

features

40

28 On the road again in New Zealand

34

A new chapter for libraries Four public buildings in Canada, Europe and the US that are rethinking traditional architecture and design

by Camille Chin

An MD from Halifax celebrates his retirement by driving through the North and South Islands by station wagon

by Dr Arthur Zilbert

40

High on Hong Kong The 10 best markets, restaurants and tours 20 years after HK was handed back to China

by Jeremy Ferguson

44

Dining the Danish way Cauliflower salad, meatballs in sauce plus five-grain bread â&#x20AC;&#x201D; recipes to help you embrace the Danish concept of hygge

by Trine Hahnemann

28 44

You’re ready for your practice to succeed.

So are we.

The Official Partner of Big Dreams.

A medical practice is a business like no other. While you’re relentlessly focused on caring for your patients, you also have to plan around a wide range of financial realities. Let TD help. Our experienced business banking specialists have advice and financial solutions that are specific to the needs of a medical practice.

Visit a branch or td.com/doctors ® The TD logo and other trade-marks are the property of The Toronto-Dominion Bank.

contents SEPTEMBER 2017

16

regulars

11

9 LETTERS

Kent Monkman turns the tables

by Tilke Elkins

An MD on a mission

11

PRACTICAL TRAVELLER The longest bridge in the world opens in the Swiss Alps, Hilton’s new midrange hotels, Montreal’s redesigned Fairmont reopens and more

by Camille Chin

B:11”

T:10.75”

S:10”

16

GADGETS The Anova Precision Cooker with Bluetooth for sous vide cooking

by David Elkins

19

24 MEDICINE AND THE ARTS

TOP 25

48 PHOTO FINISH When in Rome

by Dr Marilène Hivon

contest!

34

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

Turn to page 10 for details.

The best conferences scheduled for the beginning of 2018

22 DEPRESSION KEYPOINTS Co-occuring depression and addiction

by Alison Palkhivala

Coming in

October

Cape Town: the beauty and the challenge A doctor visits 20 years after the end of apartheid Nashville surprises The art beyond the music Budapest forward and back Hungarian culture finds a new footing

24

SEPTEMBER 2017 • Doctor’s

Review

7

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

LETTERS

EDITOR

David Elkins

An MD on a mission

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

WRITE TO WIN Congratulations to the Society of American Travel Writers 2017 Canadian Chapter Award Winners whose work appeared in these pages.

Best story Canada 1st place: Anita Draycott for Thrills on the Cabot Cliffs, Doctor’s Review, March 2016

Stephanie Gazo / Toronto

OFFICE MANAGER

Denise Bernier

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

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

MONTREAL HEAD OFFICE

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

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None of the contents of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means, without prior permission of the publishers. ISSN 0821-5758 Canadian Publications Mail Sales Product Agreement No. 40063504 Post-paid at St. Laurent, QC. Return undeliverable Canadian addresses to: Circulation Department, Parkhurst Publishing Ltd., 3 Place Ville Marie, 4th floor, Montreal, QC H3B 2E3.

Subscription rates: One year (12 issues) – $17.95 Two years (24 issues) – $27.95* One year U.S. residents – $48.00 *Quebec residents add PST. All prescription drug advertisements appearing in this publication have been precleared by the Pharmaceutical Advertising Advisory Board.

Best story international 2nd place: Anita Draycott for Flavours of the Veneto, Doctor’s Review, September 2016 Photo — places 3rd place: Gary Crallé for his photo of Pingyao, China, Silk Road rising, Doctor’s Review, April 2016

DRIVE NO MORE As an activist for safer, more environmentally-friendly transportation, I was delighted with the opening pages of the latest issue. First an editorial extolling the virtues of train travel [“Always take the train,” Editorial, June 2017, page 1] and then a letter by Dr Bowdridge boasting about her regular cycling habit [“In your own words,” Letters, June 2017, page 8]!

Just as the medical community has mobilized to expose the dangers of cigarette smoking, I think we physicians should actively campaign for alternatives to driving. Worldwide, motor vehicle accidents cost the lives of 1.2 MILLION people annually, and badly injure another 50 million! Personal motor transport also contributes heavily to air pollution, noise pollution, global warming, stress levels, loss of green space and obesity! But to be credible advocates, like Dr Bowdridge, we must lead by example.

Dr Thomas Demarco Whistler, BC

Pingyao, China, photographed by Gary Crallé.

INDIA ON MY MIND A brilliant article enhanced with stunning photography [A float down the Ganges, July/August 2017, page 38]!

[Jeremy Ferguson’s] comments on the food notwithstanding we are planning to follow in [his] footsteps and cruise the Ganges next winter if at all possible.

Priscille Leblanc, ex-Vice President, Air Canada Toronto, ON

[Jeremy Ferguson] is now my favourite travel writer. What a fabulous piece.

Thank you for sharing it. I am certain there must be many other publications that would fight for the opportunity to present this piece.

Bruce Stanley Via email

An engaging, thoughtful and beautifully written article illustrated with lovely photographs. I thoroughly enjoyed it.

(Had a chuckle over [the author’s] unfortunate experience with the “nursing-home food” on board.)

Laszlo Buhasz, ex-Travel Editor, Globe and Mail Via email

SEPTEMBER 2017 • Doctor’s

Review

9

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!

Plan now

for nov. 3-10, 2018

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

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

C a mi lle C hi n

PHOTOS THIS PAGE VALENTIN FLAURAUD

Hanging in the Swiss Alps It’ll take hikers 10 minutes to walk across the new suspension bridge that hovers above the Zermatt Valley in the Swiss Alps so anyone seriously afraid of heights should probably avoid it. At the highest point it’s 85 metres above the ground. The 494-metre-long Charles Kuonen Suspension Bridge — named for its primary sponsor, a psychologist and winery co-owner — near the village of Randa is now the longest such bridge in the world. What’s more, it reaches heights 2200 metres above sea level. Part of the two-day Europaweg Trail, it connects Grächen and Zermatt, and cuts travel time across the valley by nearly four hours.

It isn’t the highest bridge above sea level in the world. That honour goes to Aiguille du Midi Bridge in the French Alps at 3800 metres above sea level; the Titlis Cliff Walk along the alpine Mount Titlis in Engelberg, Switzerland is 3000 metres above sea level. zermatt.ch/en.

SEPTEMBER 2017 • Doctor’s

Review

11

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

Tokyo to infinity and beyond STUDIO MONDO / FLICKR.COM

If you don’t know the name Yayoi Kusama, you’ve certainly seen her work: the Japanese artist is known for her obsession with polka dots, psychedelic pumpkins and infinity rooms.

In October, the 88-year-old artist will open her own museum in Tokyo. It’ll be located in a five-storey building in the Shinjuku neighbourhood. One floor will house her popular infinity rooms and other installations; there will be two rotating exhibits a year.

The inaugural show Creation is a Solitary Pursuit, Love is What Brings You Closer to Art will run until February 25 and feature a series of paintings titled My Eternal Soul. Timed tickets will be priced at 1000 yen, about $11.50. Kusama’s touring world show, Infinity Mirrors, kicked off in Washington, DC this past February; it’ll stop at the Art Gallery of Ontario in Toronto next spring.

The Queen E reopens Montreal’s Fairmont The Queen Elizabeth reopened in July following the Phase 1 completion of a more than $140-million renovation. The largest hotel east of Toronto was built in 1958 and based on sneak peeks, the revamped hotel will be sophisticated and modern with a glamorous 1960’s flair. It consists of 21 storeys and 950 rooms; only 500 rooms are open now, but all of the common areas, meeting spaces, and the majority of the new cafes and restaurants are ready for business. Rosélys, which specializes in bistronomie cuisine, blends Parisian elegance and English style; Krema café serves high-end hot and cold drinks; Nacarat bar features innovative cocktails and local craft brews. More new features will be unveiled in the weeks to come, including The Artisan Markets, Canada’s first-ever urban market located in a hotel. fairmontmontreal.com/en.

12

Doctor’s Review • SEPTEMBER 2017

THANAT SASIPATANAPA / SHUTTERSTOCK.COM

National Museum of China.

Museums by the numbers The National Museum of China in Beijing’s Tiananmen Square includes a 2000-year-old jade burial suit made for King Liu Xiu, a life-sized bronze acupuncture statue from the 15th century and ancient Chinese money on the top floor, and it ranks as the most visited museum in the world. According to numbers released by the international non-profit Themed Entertainment Association based in California, the Beijing landmark welcomed over 7.5 million people last year. Admission is free. The National Air and Space Museum in Washington, DC (also free to enter) received almost as many visitors; the Louvre (admission €15) was the third most visited, though attendance there and at London’s British Museum were the only two museums in the top 10 where attendance dropped last year compared to 2015.

C

THE TOP 10 MOST VISITED MUSEUMS AROUND THE WORLD

M

Y

CM

1. National Museum of China, Beijing, 7,550,000 2. National Air and Space Museum, Washington, DC, 7,500,000 3. Louvre, Paris, 7,400,000 4. National Museum of Natural History, Washington, DC, 7,100,000 5. The Metropolitan Museum of Art, NYC, 6,700,000 6. British Museum, London, 6,420,000 7. Shanghai Science and Technology Museum, Shanghai, 6,316,000 8. National Gallery, London, 6,263,000 9. Vatican Museums, Vatican City, 6,067,000 10. Tate Modern, London, 5,839,000

MY

CY

CMY

K

Celebrating 20-years serving Physicians from coast-to-coast

P R AC T I C AL T R A V E L L E R Tru by Hilton Oklahoma City Airport.

Hilton’s Tru midrange hotels The first three Tru by Hilton hotels opened in Oklahoma City, McDonough, Georgia and Lancaster, Pennsylvania this summer; 425 more are in the works. Described as “vibrant, affordable and young-at-heart,” the new chain has small rooms — they’re only 230 to 275 square feet albeit fitted out with 55 inch-TVs and with access to big common spaces.

The idea is to get people to socialize. Lobbies are about 3000 square feet with colourful lounge spaces and semi-private, sound absorbing alcoves. There’s free Wi-Fi, free wireless printing and lots of easy-to-reach charging outlets. Play zones have pool tables and oversized board games. There’s complimentary coffee, tea and hot chocolate 24/7, as well as a full morning breakfast bar. Rates range from US$90 to US$100 a night. http://tru3.hilton.com.

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For a complete listing of all our upcoming cruise, resort and land CME offerings, check out seacourses.com Also make sure you sign up for our newsletter to stay up to date on all deals and new releases!

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Doctor’s Review • SEPTEMBER 2017

Wondering if ASMANEX® Twisthaler® (mometasone furoate) can help your asthmatic patients?

Compared to PULMICORT* Turbuhaler* (budesonide) 400 mcg BID, ASMANEX® Twisthaler® 200 mcg BID demonstrated a: Statistically significant greater improvement in FEV1 in patients ≥12 years of age (p <0.05†)1‡ Change in FEV1 from Baseline to Endpoint

2.6x

Change from baseline (L)

0.25

greater improvement

in FEV1 at endpoint (p <0.05)

0.20

0.15

ASMANEX® Twisthaler® (mometasone furoate) 200 mcg BID (n=176); baseline 2.52 L

0.10

0.05

0.00 0

2

4

6 Time (weeks)

8

10

12

PULMICORT* Turbuhaler* (budesonide) 400 mcg BID (n=181); baseline 2.47 L

Adapted from Bousquet et al., 2000.1

ASMANEX® Twisthaler®: The flexibility of three dosage strengths with the convenience of once-daily dosing in many patients.2§

ASMANEX® Twisthaler®, a preventative agent, is indicated for the prophylactic management of steroid-responsive bronchial asthma in patients 4 years of age and older.2 Refer to the page in the bottom-right hand icon for additional safety information and a web link to the product monograph discussing: • Contraindications in patients hypersensitive to this drug, milk proteins (from the excipient lactose), or any component of the container; in the primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required; in untreated systemic fungal, bacterial, viral or parasitic infections, active or quiet tuberculous infection of the respiratory tract, or ocular herpes simplex.2 • Other relevant warnings and precautions regarding abrupt discontinuation, risk of adrenal insufficiency in patients transferred from systemically active corticosteroids, oropharyngeal candidiasis, risk of systemic effects of inhaled corticosteroids, risk of dose-dependent bone loss, enhanced effect of corticosteroids in patients with cirrhosis or hypothyroidism, exceeding the recommended dose, rare systemic eosinophilic conditions, use with acetylsalicylic acid in hypoprothrombinemia, risk of immunosuppression, relief of acute asthma episodes, possible inhalation induced bronchospasm, pregnant/nursing women, hypoadrenalism in infants born to women receiving corticosteroids, monitoring of HPA axis function and haematological status, use of short-acting inhaled bronchodilators, bone and ocular effects, height of children and adolescents.2 • Conditions of clinical use, adverse reactions, drug interactions and dosing/administration instructions.2 The Product Monograph is also available by calling us at 1-800-567-2594. *All trademarks are properties of their respective owner(s). † p<0.05 for the 200 mcg BID ASMANEX® Twisthaler® vs. PULMICORT* Turbuhaler* (budesonide) 400 mcg BID at Week 12 (endpoint). ‡ This was a 12-week, randomized, active-controlled, evaluator blind, international study of 730 patients from 57 centres, which included researchers from multiple Canadian institutions. All patients were ≥12 years of age and previously maintained on daily inhaled corticosteroids for treatment of moderate persistent asthma. Patients were randomized with no inhaled corticosteroid wash-out period to BID treatment with ASMANEX® Twisthaler® (mometasone furoate) 200 mcg or PULMICORT* Turbuhaler* (budesonide) 400 mcg. The mean change from baseline to endpoint in FEV1 was the primary efficacy endpoint. All study medications were taken as one inhalation, twice daily.1 § ASMANEX® Twisthaler® should be taken regularly, even when the patient is asymptomatic. Improvement in asthma control following inhaled administration of ASMANEX® Twisthaler® can occur within 24 hours of beginning treatment, although maximum benefit may not be achieved for 1 to 2 weeks or longer. The lowest dose required to maintain good asthma control should be used. Attempt at dose reduction should be carried out on a regular basis. For patients ≥12 years of age, the recommended dose is 200 mcg or 400 mcg administered by oral inhalation once daily in the evening. In some patients ≥12 years of age, such as those previously on high doses of inhaled corticosteroids, 200 mcg given twice daily may provide more adequate asthma control. For patients ≥12 years of age who require systemic corticosteroids, the recommended starting dose is 400 mcg twice daily (maximum dose). Once reduction of the oral steroid dose is complete, titrate ASMANEX® Twisthaler® to the lowest effective dose. In pediatric patients 4 to 11 years of age, the recommended dose is 100 mcg administered by oral inhalation once daily in the evening.2 BID=twice daily. FEV1=forced expiratory volume in 1 second. ® MSD International Holdings GmbH. Used under license. © 2017 Merck Canada Inc. All rights reserved.

See additional safety information on page xx 47

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

D a v i d Elk i n s

Get into hot water When I first read about “sous vide” cooking seven or eight years ago, I thought it was just another odd French take on cooking that was little more than a curiosity. Not any more. Essentially the method requires that meat or veggies be sealed in a plastic pouch and placed in carefully controlled hot water, usually between 55 and 60°C, for one to seven hours. The idea is to cook the item evenly, ensuring that the inside is properly cooked without overcooking the outside, and to retain moisture.

Sous vide is especially effective with meats. Tough collagen is hydrolyzed into gelatin, without heating proteins enough to toughen the meat. The end result is especially succulent cuts.

Vegetables retain their colour and are crisper than by other cooking methods.

Until recently, sous vide was the purview of fine restaurants; Paul Bocuse was an early convert. These days it shows up often on shows like Top Chef and now you can put it to use at home.

This month’s gadget, the 800-watt Anova Precision Cooker with Bluetooth, will do the trick in the comfort of your own kitchen. The device is immersed in a pot of water and keeps it at a constant temperature for as long as the recipe requires. The Bluetooth feature allows you to remotely track cooking progress, and adjust time and temperature from a smartphone. It’s ideal for busy practitioners who can pop

Win an 800-watt Anova Precision Cooker with Bluetooth by entering the Gadget of the Month contest at doctorsreview.com. supper in a bag at breakfast and have a succulent cut perfectly cooked by dinnertime.

If it’s an entirely new cooking method to you, go first to chefsteps.com/sous-vide for an overview of how to get the best results from cooking in bags and water.

A caveat: Ziplock bags are popular and are a BPA-free choice. If the idea of cooking in plastic is abhorrent to you,

it’s worth doing some research on the net to consider alternatives. Here’s a good place to start: nomnompaleo. com/post/12463202060/cooking-sousvide-plastic-safety.

Find the 800-watt Anova Precision Cooker with Bluetooth at a kitchen store near you or at Target or Best Buy. Prices range from $119 to $150. anovaculinary.com.

CONGRATULATIONS! The winner of the LED lighted patio umbrella is Dr Kristy Penner, a family physician from Coleman, AB. 16

Doctor’s Review • SEPTEMBER 2017

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THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Mont Tremblant, QC February 9-11, 2018 15th Annual International Winter Arrhythmia School winterarrhythmia.com

10th Annual Ottawa Conference: State of the Art Clinical Approaches to Smoking Cessation ottawamodel.ottawaheart.ca/ottawa-conference

Toronto, ON February 9-12, 2018 Canadian Digestive Disease Week cag-acg.org

Whistler, BC February 4-6, 2018

VICKI SMITH / SHUTTERSTOCK.COM

Ottawa, ON January 19-20, 2018

The ship Constellation docked at the Inner Harbor in Baltimore.

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

10th Annual Meeting of the Canadian Neuromodulation Society neuromodulation.ca

Anaheim, CA February 9-11, 2018

Around the world

56th Annual Conference of the Pediatric Anesthesiology Foundation pediatric-anesthesiology-foundation.com

Abu Dhabi, UAE January 12-13, 2018

Baltimore, MD February 8-10, 2018

10th Clinical Update of the European Society of Endocrinology ese-hormones.org/education/clinicalupdate.aspx

Edmund G. Beacham 45th Annual Current Topics in Geriatrics hopkinscme.cloud-cme.com Houston’s downtown skyline at sunset.

Buenos Aires, Argentina March 1-4, 2018 18th International Congress on Infectious Diseases isid.org/events/events.shtml

Coronado, CA February 16-18, 2018 28th Annual Meeting of the North American Skull Base Society nasbs.org/future_meetings

Dubai, UAE January 25-27, 2018 2018 Edition of the Gulf Arrhythmia Congress gulfarrhythmia.org

Houston, TX February 15-17, 2018

ROMAN SLAVIK / SHUTTERSTOCK.COM

Houston Aortic Symposium 2018 houstonaorticsymposium.com

London, England January 3-5, 2018 2018 Annual Conference of the British Paediatric Neurology Association bpna.org.uk/conference/2018 SEPTEMBER 2017 • Doctor’s

Review

19

THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Los Angeles, CA January 24-26, 2018 International Stroke Conference 2018 professional.heart.org/professional/index.jsp

Madrid, Spain February 7-9, 2018 11th Annual Congress of the European Association for Haemophilia and Allied Disorders eahadcongress.com

Maui, HI February 24-March 2, 2018

Melbourne, Australia February 25-28, 2018 2018 World Psychiatric Association’s Thematic Congress, Innovation in Psychiatry: Effective Interventions for Health and Society wpamelbourne.kenes.com

Mexico City, Mexico March 7-10, 2018

ANATOLY VARTANOV / SHUTTERSTOCK.COM

Pediatric Potpourri: State of the Art 2018 childrenshospitallamedicalgroup.org

A family gondola ride on the Grand Canal in Venice.

20th Annual Conference of the International Society for Bipolar Disorders isbd2018.com

Paris, France January 17-20, 2018

Nice, France March 3-6, 2018

28es Journées Européennes de la Société Française de Cardiologie jesfc.fr

26th Congress of the European Psychiatric

March 1-3, 2018

Association epa-congress.org/2018

MEDICAL QUIPS Don’t Google it!

Reason for not consulting the internet for medical advice: You go from mild headache to clinically dead in three clicks.

20

Doctor’s Review • SEPTEMBER 2017

5th International Conference on Nutrition and Growth 2018.nutrition-growth.kenes.com

San Diego, CA February 8-11, 2018 2018 Annual Meeting of the International Society for the Study of Women’s Sexual Health isswshmeeting.org

Tel Aviv, Israel February 21-23, 2018 6th World Congress on Controversies to Consensus in Diabetes, Obesity and Hypertension codhy.com/2018/Default.aspx

To register and to search 2500+ conferences, visit doctorsreview.com/meetings Venice, Italy February 22-25, 2018 5th International Conference on Prehypertension, Hypertension and Cardio Metabolic Syndrome 2018.prehypertension.org

Vienna, Austria February 14-17, 2018 11th International Conference on Advanced Technologies and Treatments for Diabetes attd.kenes.com

Washington, DC February 14-17, 2018 46th Annual Meeting of the International Neuropsychological Society the-ins.org/future-ins-meetings

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

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

•

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

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

For more information: Please consult the Product Monograph at http://pfizer.ca/ pm/en/Pristiq.pdf for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece.

The Product Monograph is also available by calling 1-800-463-6001.

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

References: 1. PRISTIQ Product Monograph, Pfizer Canada Inc., October 26, 2016. 2. Boyer P, et al. Efficacy, safety, and tolerability of fixed-dose desvenlafaxine 50 and 100 mg/day for major depressive disorder in a placebo-controlled trial.

Int Clin Psychopharmacol 2008;23:243-253. 3. Sheehan DV. Sheehan Disability Scale in: Rush AJ, Pincus HA, First MB, et al. eds. Handbook of psychiatric measures. Washington, DC: American Psychiatric Association; 2000:113-115.

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

CA0116PRI017E

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

DE PRESSIO N K EY PO I NT S by

A li son Pa lkhi va la

Depressive disorders and cooccurring substance use disorders Unique and challenging diagnoses

B

oth together and in combination, substance use disorders (SUDs) and depressive disorders represent a substantial portion of the global burden of disease.1 Primary care physicians will frequently see both conditions occurring comorbidly in patients, and this particular combination of disorders comes with some unique diagnostic and treatment challenges.

A complex relationship The relationship between SUDs and depressive disorders is a complex, two-way street. The presence of a mood disorder, particularly early-onset bipolar disorder (BD), appears to increase the risk of developing SUD, while the presence of SUD increases the risk of developing a mood disorder, particularly BD.2,3,4,5 In one Canadian epidemiological study, an average of 29% of patients with BD and 14% of patients with major depressive disorder (MDD) suffered in the previous year from a problematic SUD.6 Patients with mood disorders who also have a comorbid SUD face a worse clinical course.7,8 In particular, patients with BD who have a comorbid SUD have been shown to have an earlier age of onset of BD, a greater likelihood of having other psychiatric comorbidities, poorer adherence to therapy, a more severe course of affective illness, longer and more severe mood episodes, lower functional recovery between mood episodes (even during times of abstinence), a greater number of hospitalizations, and greater utilization of emergency services.7 In addition, the presence of SUDs can often mask an underly-

ing mood disorder, which can delay appropriate diagnosis and treatment.8

A diagnostic challenge Diagnosis of comorbid SUDs and depressive disorders remains a clinical challenge. Mood symptoms are commonly seen among patients in treatment for substance abuse, and states of intoxication and withdrawal can mimic depressive states.7 Despite this reality, it is important not to assume that all the affective symptoms of patients with SUDs are exclusively related to substance use or withdrawal. The latest evidence suggests that these most often serve to exacerbate an underlying depressive disorder.9,10 There is also evidence that a large proportion of patients who seek help for SUD — ­ more than 40% in one analysis — also suffer from a mood disorder.10 Experts stress the need to obtain a comprehensive history of psychiatric disorders in patients who present with SUD and a comprehensive history of alcohol and substance use among patients who present with depressive disorders. If there is doubt as to the veracity of patients’ histories of alcohol or substance use, laboratory testing or urine drug screening may be warranted.7 Clinicians should be particularly suspicious of an underlying SUD in patients who present with mood disorders in addition to: • A personal or family history of substance abuse or legal problems typically associated with substance abuse (including domestic violence) • Co-occurring or past medical disorders associated with alcohol or substance abuse

Table 1. CANMAT-recommended pharmacological management of mood disorders combined with alcohol abuse Disorder

First choice

Second choice

Third choice

Not recommended

MDD

Mirtazapine Add-on naltrexone or alone Add-on naltrexone to sertraline

Add-on disulfiram

Valproic acid Amitriptyline Desipramine Imipramine Escitalopram Memantine

Fluoxetine Lithium Sertraline Nefazodone

BD

Add-on naltrexone

Add-on lamotrigine or alone Add-on valproic acid or alone Add-on disulfiram

Add-on gabapentin Add-on topiramate Lithium

Add-on quetiapine or alone

22

Doctor’s Review • SEPTEMBER 2017

Table 2: CANMAT-recommended pharmacological management of mood disorders combined with other SUDs Substance

MDD

BD

Cannabis

Not recommended: Fluoxetine

Add-on valproic acid to lithium Lithium Add-on valproic acid or alone

Cocaine

Add-on risperidone or alone

Add-on valproic acid to lithium Add-on lamotrigine or alone Lithium Add-on valproic acid or alone Add-on quetiapine or alone Add-on risperidone or alone Add-on citicoline

Not recommended: Carbamazepine Desipramine Imipramine Nefazodone Fluoxetine Lithium

Not recommended: Carbamazepine

Heroin

Add-on buprenorphine or alone

Methadone

Opiate

Add-on imipramine to methadone

No recommendations

Not recommended: Add-on fluoxetine to methadone Add-on sertraline to methadone maintenance for opiate-dependent patients Amphetamine/ Methamphetamine

No recommendations

Polypharmacy

Not recommended: Specifically for opiate plus cocaine polysubstance: Add-on desipramine to buprenorphine maintenance for opiate-dependent patients Add-on desipramine to methadone maintenance for opiate-dependent patients

• Complaints of chronic pain • Multiple relationship problems • Numerous job changes7 Among patients who present with both SUDs and mood symptoms, the traditional approach diagnosis has been to delay pharmacologic treatment for depression for a period of at least one month after abstinence from substances. Current recommendations have evolved with the recognition that delaying treatment for depression can increase the risk of relapse during that first month and may also increase the risk of suicide.11

Treatment questions remain Unfortunately, substantial evidence on the best course of action for patients with comorbid depressive disorders and SUD is lacking, and many unanswered questions remain. On its own, SUD is typically treated with psychosocial counseling, either in individual or group settings, and this remains the standard of care for patients also suffering from mood disorders. To manage the mood disorder itself, the bulk of evidence has addressed pharmacological management.7 The Canadian Network for Mood and Anxiety Treatments (CANMAT) offers evidence-based guidelines for the pharmacological management of patients with MDD or BD and alcohol abuse.12 These are summarized in Table 1.

Add-on quetiapine or alone Add-on risperidone or alone (methamphetamine only)

In their review of the literature, CANMAT determined that there is a lack of good evidence to guide pharmacological management of mood disorders when they occur in combination with abuse of substances other than alcohol. Based on the scant evidence available, CANMAT recommendations are presented in Table 2. It is important to note that most of these recommendations represent second- and third-choice options, due to a lack of Level 1 (meta-analysis or replicated double-blind randomized controlled trial that includes a placebo condition) and Level 2 (at least 1 double-blind randomized controlled trial with placebo or active comparison condition) evidence.12 With regard to psychological and psychosocial treatments for patients with comorbid SUDs and mood disorders, CANMAT again warns that evidence for the best approach is scant. Many studies lump all mental disorders together rather than examining mood disorders specifically, for instance. Based on their review of the available evidence, CANMAT concluded the following: • Cognitive behavior therapy (CBT): Only a CBT intervention designed specifically for patients with BD and concomitant SUDs developed by Weiss et al13 has been shown to be more effective than alternate treatments.

• Motivational therapy (MI): Evidence for small benefits in substance use over the short-term. uu CONTINUED ON PAGE 47 SEPTEMBER 2017 • Doctor’s

Review

23

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

T i lk e Elk i n s

Back to school with Miss Chief THE BUFFALO NEWS

Indigenous artist Kent Monkman turns the tables on the Europeans

Monkman’s alter ego Miss Chief made a memorable appearance at Toronto’s ROM in 2007.

KENT MONKMAN

The Daddies (2016): Monkman’s version of Robert Harrison’s 1863 Fathers of Confederation with Miss Chief posed naked in the foreground.

24

Doctor’s Review • SEPTEMBER 2017

K

ent Monkman, 51, runs his Toronto studio like a classical European atelier. On any given day, as many as six assistants accompany him as he works,

translating small sketches and photo images onto large canvases or painstakingly brushing in highly detailed landscape elements. The paintings themselves have the seductive allure of the grand luminous 19th century scenes so familiar to regular museum-goers. Draw closer, however, and the vast landscapes or epic scenes of brightly-hued figures draped in billowing fabric transform into a barrage of unexpected, at times

highly sexual imagery, that sends your mind reeling with associations.

Monkman is a prominent painter of Cree-Irish ancestry whose reputation has soared in recent years. He’s one of the very few artists who, at mid-career, has seen his work enter the auction market, the near exclusive domain to the very famous or the long dead. His paintings are in the collections of the National Gallery of Canada, the Glenbow

KENT MONKMAN

The Scream (2017): the horrors of a residential school re-imagined.

Museum and the Montreal Museum of Fine Arts. He’s represented by top galleries in Toronto, Montreal and Santa Fe, New Mexico where his work fetches $50,000–$150,000 and up. Not bad for a kid from Winnipeg.

GROWING UP He self-identified as an artist at age four and was encouraged by his school-teacher mother to flourish creatively, further blossoming when he was one of two students chosen to receive free Saturday art classes at the Winnipeg Art Gallery.

Believing he needed a plan to earn a living from his drawing, he went on to study at Brampton’s Sheridan College.

A short career as an illustrator for hundreds of TV commercials improved his drawing and taught him to work fast.

“That skill is something I really value,” he says. “I’m rarely hindered by the inability to express an idea. If I can imagine it, I can draw it.”

He went on to a decade of “pushing paint around” in an effort to develop his own style as an abstract expressionist.

Around 2000 he found Cree figures began to creep into his work, often in the form of male bodies grappling with each other. The images soon evolved into those of cowboys and Indians performing acts you would never see be-

tween The Lone Ranger and Tonto.

Though he grew up in Winnipeg’s mainly white neighbourhood of River Heights, he spent the bulk of his time with his father’s Cree family. His greatgrandmother spoke Cree almost exclusively and, after suffering the trauma of residential schools, was one of only two of 13 siblings to survive into adulthood. As a boy, Monkman was moved by the dioramas of pre-contact Indigenous life at the Manitoba Museum, but

ures to those romanticized images and disrupt its racist, homophobic, colonialist themes, creating the presence of an Indigenous world view inside paintings made by Europeans.

“I wanted to work within the conventions to shock or surprise people,” he says. “They feel like they’re approaching a familiar form of landscape picture-making, but as they spend time with it, they’re dislocated. They have to question everything they’ve re-

He’s one of the very few artists who, at mid-career, has seen his work enter the auction market was disturbed by the dissonance between those peaceful images and the drunk Indigenous people he saw tumbling out of bars outside the museum.

As an adult, he realized that museums like the ones he loved as a child played a role in perpetuating the story that Indigenous people were a vanishing race with a past but no future. By adopting the style of 19th-century European painters like that of Paul Kane and George Catlin, he could turn history on its head by adding his own rollicking fig-

ceived. That was a kind of disconnect I wanted the audience to have.”

Monkman, who identifies as TwoSpirit, an Indigenous term for a person whose gender falls between male and female, expresses his mixed-race, mixedgender identity through an alter-ego persona he calls Miss Chief Eagle Testickle. Miss Chief is a trickster figure who challenges hierarchies and colonized sexuality by subverting the Western gaze which eroticizes Indigenous people, turning it back in a gesture of “you’ve SEPTEMBER 2017 • Doctor’s

Review

25

NEW

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

FOR THE TREATMENT OF MODERATE TO SEVERE VASOMOTOR SYMPTOMS

A New Option in hormone therapy for women with a uterus

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

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

Indications and clinical use: DUAVIVE is indicated in women with a uterus for the treatment of moderate to severe vasomotor symptoms associated with menopause.

DUAVIVE should not be taken with a progestin, additional estrogens or selective estrogen receptor modulators (SERMs).

Not recommended for women >75 years of age.

Not indicated for pediatric use.

Contraindications: • Active or past history of confirmed venous thromboembolism (VTE) or active thrombophlebitis • Active or past history of arterial thromboembolic disease • Hypersensitivity to estrogens

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

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

Most serious warnings and precautions: Risk of stroke and deep vein thrombosis: estrogen-alone therapy (mean age 63.6 years).

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

Reference: 1. DUAVIVE Product Monograph. Pfizer Canada Inc., October 20, 2014.

DUAVIVETM Wyeth LLC, Pfizer Canada Inc. Licensee ® Pfizer Inc., used under license © 2017 Pfizer Canada Inc., Kirkland, Quebec H9J 2M5

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Cowboys and Indians perform acts you’d never see between The Lone Ranger and Tonto been looking at us but we’ve been looking at you.”

Miss Chief came into being when Monkman decided to put himself in his own paintings, in playful mockery of the 19th-century painters’ habit of including themselves in self-adulatory attitudes on their own canvases. “Eagle Testickle,” is a play on “egotistical.”

Inspired by the singer Cher, Miss Chief also appears on stage as performance art, or film, mediums which Monkman says can sometimes communicate a message in a more direct and raw form than a painting can. In one notable performance in the soaring lobby of Toronto’s Royal Ontario Museum (ROM) in 2007, Miss Chief appeared in billowing smoke to the final Chords of Mahler’s Fourth Symphony and evoked the spirits of 19th-century artists Eugène Delacroix, Paul Kane and George Catlin. The evening ended in “a dance to the berdache [a colonialist term for a two-spirit person; considered derogatory] — we are about to bring it back, more unaccountable and disgusting than ever” in which the crowd of 500 joined in.

The trickster and her dioramas function not to resurrect a past as it was but to wreak havoc with order and reason in order to represent and affirm Indigenous subjectivity, agency and survival or rather, “survivance,” a term that refers to an active sense of presence and the continuance of native stories, not a mere reaction or a survivable name.

Three years ago, Barbara Fischer, the gallery director at the University of Toronto Art Museum, invited Monkman to do a response exhibition to Canada 150 for the museum, and he jumped at the chance. He wanted to increase public awareness of the fact that the last 150 years corresponds directly with a devastating period of incarceration, institutionalization and attempted cultural erasure for Indigenous people, to “revisit this very harsh period in history and lens it through my own artistic

vision.” Part of that vision included a dialogue with the forms of abstraction that revolutionized painting in the late 19th and early 20th centuries. He references various figures from Picasso’s cubist paintings, for example, finding the “butchering of the female nude” useful as a representation of violence towards Indigenous women.

After spending a year travelling across the country selecting Indigenous artifacts from various museum collections, he put together a show that integrated the objects with paintings of historic Canadian events re-imagined to include the Indigenous perspective.

The Daddies is modelled on Robert Harrison’s 1883 rendition of the 1864 Charlottetown Conference Fathers of the Confederation, a dull painting featuring 23 men in velveteen suits, a reproduction of which hangs in Parliament (the original was destroyed in a fire). In Monkman’s version, a naked Miss Chief is poised on a Hudson’s Bay blanket-covered wooden box in the centre of the painting, back to the viewer, the focus of the room though not everyone chooses to look at her.

The Scream, also painted for the response to Canada 150, went viral on Facebook as soon as Monkman posted it, attracting 300,000 views in three days. The scene depicts nuns, priests and red-coated mounties wrenching children away from their grief-stricken parents’ arms, a scene which went deep for the many Indigenous people whose lives were irreparably damaged by the residential schools.

Monkman’s message is many-layered but uncomplicated: Canadians need to educate themselves about Indigenous people and be open-minded about Indigenous culture. Now that the Truth and Reconcilliation Report is available, the information is there, he says. He encourages Canadians to read the report and to make steps towards reconciliation, emphasizing that this has to come from Canadians, and not from Indigenous people.

SEPTEMBER 2017 • Doctor’s

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

NEW ZEALAND

On the road again An MD from Halifax celebrates his retirement by driving through the North and South Islands in a station wagon

A

fter 35 years of OB/GYN practice in Halifax, I retired in July 2016.

My wife Kathy and I went to New Zealand for two months of their summer, February and March 2017, to celebrate. We had

Kaitaia

Bay of Islands

th or nd N la Is

Tas man Sea

Feilding

Co ok Str ait Wellington

Abel Tasman National Park Nelson

Blenheim

Kaikoura

Christchurch Aoraki / Mount Cook National Park

Queenstown

28

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ou

th

Is

l

d an

Doctor’s Review • SEPTEMBER 2017

Pacific Ocean

been to New Zealand in 2003 and travelled the South Island south of Christchurch. This time we concentrated on new adventures.

We rented an old station wagon in Queenstown for $1800. It was great on gas, which we appreciated because fuel was about $2 a litre.

Queenstown is beautiful. We enjoyed great walks, the highlight being the Queenstown Hill trail which leads to magnificent views of Lake Wakatipu and the town. We did side trips to Arrowtown, Wanaka and Glenorchy as well as a number of the Central Otago wineries that excel in Pinot Noir. Wet Jacket was our favourite.

We drove to Aoraki / Mount Cook National Park and stayed at Lake Tekapo for a few days after doing the Hooker Valley Trail hike (about 10 kilometres) into Mount Cook. We had done this 14 years earlier with my brother and sister-in-law so it was interesting to see improvements in the trail, but sad to see the receding glaciers. At the top of Hooker Glacier Lake, we spread some of my late brother-inlaw’s ashes. He had been to New Zealand several times and this was his piece of paradise.

Lake Tekapo is a stunning glacial lake with aqua coloured water resulting from settled glacial silt. We did a fixed-wing flight over Mount Cook, Mount Tasman and several other mountains, glaciers and lakes. Absolutely breathtaking!

Our next stop was Kaikoura, the whale capital.

In November 2016, a 7.8-magnitude earthquake created havoc in the town. The seafloor lifted several metres so sightseeing boats can only leave port at high tide. Many whales have moved on to better locations. We did a fixed-wing flight because all

ALL PHOTOS COURTESY ARTHUR ZILBERT

by Dr Arthur Zilbert

Dr Zilbert and his wife took the ferry to Russell, which has a charming seaside setting of restaurants.

The 1.5-kilometre Queenstown Hill trail leads to magnificent views of Lake Wakatipu and Queenstown.

Dr Arthur Zilbert retired from practice in July 2016.

He and his wife moved to Toronto in August 2016 to be closer to their two children. They’re expecting their first grandchild in October.

Their travel plans include Florida this year, but they hope to do Southeast Asia again in 2019.

Locals told us that it was a cool summer, but compared to a Canadian winter, it was great; temperatures averaged 20°C the boat spaces were taken and saw a massive sperm whale, which kindly stayed on the surface for over 15 minutes.

It was sad to see the devastation the earthquake brought on this little town. It’ll take a very long time, if ever, for the people and businesses to recover.

NELSON AT THE TOP OF THE ISLAND After a few busy weeks, we had scheduled a long stay in Nelson on Cook Strait at the top of the South Island. There was a great movie theatre in the heart of the town, a five-minute walk from our motel. We caught up on the Oscar-nominated films.

Tahunanui Beach in Nelson is gorgeous, long and sandy. When it’s low tide, you can walk out for a long time, though the water temperature is only around 19°C that time of year.

From Nelson we did a day trip to Golden Bay to tour Cape Farewell and Farewell Spit. The drive going over/around Takaka Hill was death defying, but worth

it to see the very tip of the South Island. Unfortunately, there were 400 beached pilot whales in Golden Bay that day. Although whales become beached every year, this was one of the worst disasters ever.

Hundreds of volunteers came to help, but after a few days, it was obvious that most of the whales would die.

The Farewell Spit Eco Tour (farewellspit.com) leaves from Collingwood on a large four-wheel drive bus that takes you to the top of Golden Bay. These are the only vehicles allowed to drive the 15 kilometres on the spit to the lighthouse at the end of a long stretch of white powdery sand dunes. The spit is a nesting area for gannets, other birds and seals.

This was a tremendous day that we’d highly recommend if your nerves can handle the drive to and from Golden Bay. Hopgood’s Restaurant (hopgoods.co.nz) in Nelson was the provider of a fabulous meal during our stay.

On Saturdays, there is a very good market with foods and crafts in the centre of town.

Rested and ready for our next adventure, we left Nelson for Abel Tasman National Park. Our three-day hike began in Marahau, which I did with the aid of SEPTEMBER 2017 • Doctor’s

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29

Mount Cook is the tallest mountain in New Zealand with a height of 3754 metres.

Director James Cameron bought Greytown’s Baillie House in 2014 and will reportedly open a restaurant.

Don’t miss the famous Mine Bay Maori Rock Carvings in the Great Lake Taupo region.

a lovely guide named Cab. Kathy’s back didn’t permit her to walk the track, but she did it by aqua taxi, meeting the guide and I at the end of each day.

We walked 15 kilometres to Anchorage on day one then took the aqua taxi back to Marahau and stayed at the Abel Tasman Lodge (abeltasmanlodge.co.nz).

The next day we packed our bags and took the boat to Torrent Bay. We walked 16.5 kilometres to Awaroa.

Our bags were delivered to the Awaroa Eco Lodge.

The track is broken up by ferry stops. The walk between Torrent Bay and Bark Bay is about two hours, but it was swarmed with people. There are some tracks that have strict access rules, but not here. After Bark Bay, the foot traffic thinned dramatically in both directions.

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Doctor’s Review • SEPTEMBER 2017

The next day we waded through a stream and went to Totaranui, 10 kilometres away. We came across several wekas, which are often mistaken for kiwis. The walking track was blessed with fabulous views, but it was a bit strenuous for an out-of-shape retiree. My toes objected to my hiking shoes and I was hobbled for a couple of days.

Kathy enjoyed the beaches along the track and even managed a swim in the cool, but pristine Tasman Sea. We met her at Totaranui and then took a magnificent water taxi ride back to Marahau where we had left our car and most of our luggage.

Our last stop on the South Island was Blenheim to enjoy some of the famous Marlborough Sauvignon Blanc. The view from Brancott Estate was spectacular and their wines excellent.

We had a marvelous month in the South Island.

The roads were challenging — narrow and very windy with crazy road signs — but well worth the aggravation to see beautiful sites. Locals told us that it was a cool summer, but compared to a Canadian winter, it was great. We experienced very little rain and temperatures averaged 20°C.

THE NORTH ISLAND The Interislander Ferry (greatjourneysofnz.co.nz) leaves Picton and goes to Wellington on the North Island.

It sails through the Queen Charlotte Sound into Cook Strait and takes about three hours.

We explored the downtown and waterfront area easily, and did the very informative hop-on, hop-off bus tour. We went to the Te Papa Museum (tepapa. govt.nz), which is a free national museum. They had an exhibit about the Anzac involvement in the Gallipoli

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Otehei Bay is very popular for its water sports and walking trails.

New Zealand has many public restrooms that are well located and marked — a distinct bonus as we age! campaign of 1915 that was riveting. We went to the Whitebait Restaurant (white-bait.nz) for dinner. It was one of the best meals of the entire trip.

We departed Wellington for Greytown and more wineries in the Wairarapa region, then drove 2½ hours to visit friends from Dartmouth, NS who had a farm in Feilding. Besides having the best lamb dinner ever, we got a tour of their daughter’s sheep and cattle station, which was close by. Beautiful and huge, it requires tremendous organization to manage.

We were treated to a display of talent as the sheepdogs herded the sheep from one pasture to the next.

One feature of New Zealand that is different from most places that I have gone is that they have many public restrooms that are well located and marked.

This was apparent even in the small villages and a distinct bonus as we age!

Lake Taupo and Rotarua are in the thermal areas so hot springs, geysers and mud pools are easy to find.

In Rotarua, there is a large Maori presence. Te Puia

ZEALAND

TIPS NEW

New Zealand is relatively easy to get around in spite of driving on the left. The roads on the North Island are straighter and seemingly less treacherous than the South.

New Zealand is good value against the Canadian dollar at the moment. All prices include tax; tipping is not expected.

For info on travel to the region, visit New Zealand Parks and Recreation (doc.govt.nz/parks-and-recreation) and Tourism New Zealand (newzealand.com).

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Doctor’s Review • SEPTEMBER 2017

(tepuia.com), owned and run by a local Maori tribe in the Te Whakarewarewa Geothermal Valley, houses areas for Maori to learn wood carving, weaving and other native skills from trained masters. The Maori show and traditional dinner were both excellent.

We finished our trip in the Bay of Islands staying not far from the centre of Paihia. Our logic was that this was the most northerly part of New Zealand and thus would still have the best weather in the early fall.

The day we arrived the heavens opened up for four days of tropical rainstorms. Many areas outside of Auckland had major flood damage. When the weather finally cleared we went across to Russell on the ferry to the Duke of Marlborough Restaurant (theduke.co.nz). It was a spectacular spot for dinner with great views of the sun setting over the bay. We went twice — the food was stellar.

We drove 90 minutes to Kaitaia to do Harrison’s Dune Rider tour (harrisonscapereingatours.co.nz) of Cape Reinga and the 90 Mile Beach (actually only 90 kilometres). We had a wonderful sunny day with fabulous views of the spot where the Tasman Sea and Pacific Ocean meet.

We did an Explore Group cruise (exploregroup. co.nz/en/new-zealand) of the Bay of Islands that goes out into the Pacific to the Cape Brett Lighthouse and Hole in the Rock. We also did a day trip to Otehei Bay where you can do water sports and walking trails.

We found Vinnies Takeaways in Paihia had the best fish and chips ever.

After two months, we reluctantly drove our serviceable old car to Auckland Airport to fly to Sydney for a few days before we headed back to face the tough Canadian weather.

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Victoria Peak is the best place to see Centralâ&#x20AC;&#x2122;s colourful lights at night.

BENNY MARTY / SHUTTERSTOCK.COM

High on

Hong Kong The 10 best markets, restaurants, tours and more in the city that continues to surprise travellers 20 years after it was handed back to China

by Jeremy Ferguson

T

wenty years — yes, 20 — have passed since Hong Kong was returned to China, designated an autonomous territory with Beijing vowing hands-off when it came to the former Crown Colony’s

SEPTEMBER 2017 • Doctor’s

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35

workaholic ways and entrenched entrepreneurial culture.

Doomster predictions haven’t materialized, although political tremors surface on a regular basis, Beijing in cranky control mode, Hong Kong on the barricades to preserve its freedoms.

But China needs Hong Kong as a turnstile to the rest of the world and a conveyer of currencies. This accounts, says the Economist, for two-thirds of foreign investment in China. “Hong Kong,” notes a veteran observer, “knows how to make the money sing.”

Its fascinations for the traveller have never been more alluring. This entity of only seven million people on the lip of China is a tourism juggernaut, drawing almost 14 million foreign visitors yearly, not to mention more than 50 million mainland Chinese.

(The worldly Hong Kongese tend to regard the latter as yokels).

Doctor’s Review visited again in search of the remarkable experiences we interlopers can have in the city that reinvents (and recycles) itself at a pace to leave a cheetah feeling like an escargot. Here’s our very best of HK for 2017.

1. PANORAMIC VIEWS The new ICC Tower (sky100.com.hk.zh-hant) on Kowloon side looms over Hong Kong Harbour at a record 118 storeys, its 360-degree, all-indoors Sky

36

Doctor’s Review • SEPTEMBER 2017

TramOramic Tour offers two sightseeing routes that are each an hour long.

JEREMY FERGUSON

TOPZAFOTO / SHUTTERSTOCK.COM

JEREMY FERGUSON

The Peak’s Sky Terrace 428 is the city’s highest viewing platform at 428 metres above sea level.

100 observation deck delivering a bigger-thanIMAX perspective. It impresses, but only when the tsunami of air pollution rolling from industrial Shenzhen stays home.

The unbeatable view remains the Hong Kong panorama from Victoria Peak (thepeak.com.hk/en/ home.asp). Catch the aerial tram to the top and hang around until Central’s lights pulse into a glowing

The Kwong Fuk I Tsz Temple houses tablets of mainland Chinese who worked and died in Hong Kong.

JEREMY FERGUSON

The Mong Kok neighbourhood contains the popular bird and fish markets.

Catch the tram to Victoria Peak and hang around until Central’s lights pulse into a glowing cauldron of light and colour cauldron of light and colour and the harbour takes on the appearance of molten lava.

2. SIGHTSEEING TOUR HK public transit by trolley has long proven a favourite way to cross-section the neighbourhoods, but its 65 stops make for a pokey trip. The new doubledecker Tramoramic trolley (hktramways.com.en/ tramoramic) streamlines the venture, lurching over the tracks from Western Market to the Happy Valley Racecourse in an hour.

3. NATURAL ATTRACTION The Hong Kong UNESCO Global Geopark (discoverhongkong.com/us/see-do/great-outdoors/natureparks/hong-kong-unesco-global-geopark.jsp) surprises with 140-million-year-old rock formations recalling Ireland’s Giant’s Causeway. A hike among the hexagonal rock columns at the High Island Reservoir East Dam fairly stuns the eye and may just coax out your inner geologist. The unattended cows wandering about?

Farmers who abandoned the area simply left them here — and moooooooooo to you.

Moreover, the journey to the Sai Kung peninsula reveals sumptuous scenic beauty showcasing the natural beauty of HK’s many islands. Nine land tours and two boat tours get you there.

4. TEMPLE Unique among HK temples, Taoist Kwong Fuk I Tsz on Tai Ping Shan St. delivers an armload of culture. You may catch a Taoist prayer or walk in on a blessing ritual in progress. A literally haunting chamber is devoted to ancestral tablets bearing images of the dead. Historically, without a tablet the deceased could not be reborn as human. And a single woman had to marry to attain one or end up a ghost. Will sexism never end?

5. MARKET WALK The dirty, sprawling, rambunctious street markets that colour early HK memories are gone, all given way to tidiness and order. But a stroll through shops in the Mong Kok neighbourhood (discoverhongkong. com/ca/shop/where-to-shop/shopping-areas/mong-kok. jsp) remains an exploration of revealing fascinations.

The Yuen Po Street Bird Garden is no longer the social affair it used to be for HK seniors. You’ll see as many tourists as locals making their way among ornate bamboo birdcages and little singing birds. The sidewalk-side Yuen Po Gold Fish Market intrigues with exotic fish hanging in plastic bags for easy take-home and tiny baby frogs for their lunch.

Both markets connect ultra-urban HKers to the natural world.

SEPTEMBER 2017 • Doctor’s

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JEREMY FERGUSON

At Yum Cha, cold eggplant and hot chilies dance the yin and yang.

There are beaches, hiking trails and plenty of seafood restaurants in the village of Sai Kung.

Sai Kung on the New Territories coast could be the best of all HK outings — welcome to Saint Tropez with chopsticks 6. WALKING TOUR Meet HK’s working class in Sham Shui Po, the neighbourhood that feeds folk so poor, as many as 100,000 live in coffin-size “rabbit cages” piled like drawers in a filing cabinet. The leisurely itinerary of the Sham Shui Po Foodie Tour (hongkkongfoodietours. com) encompasses noodle houses, snack shops, holein-the wall eateries and Chinese medicinal emporia, all with enlightening social commentary. Did you know gecko soup alleviates asthma?

The HK underclass begins its day with a pineapple bun, a fluffy sweet pastry oddly containing no pineapple. Another fave is rice roll served with soyand-peanut butter sauce. (The unpretentious eating hole was recommended by Michelin, prompting the rent to soar). Egg noodles from an 87-year-old artisan hit the high notes in a deeply fishy broth with a dash of chili. Pork belly and pork knuckle make a lunchtime duet of crrrrrunch and crrrrackle.

7. DIM SUM Busy, busy Yum Cha (yumchahk.com) is one of countless restaurants preaching the religion of bitesized wonders and its sprawling menu offers bankable excellence. It’s all about harmony: colours, aromas, flavours, textures, aftertastes. Dancing the yin-yang, eggplant comes stacked like firewood and served

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Doctor’s Review • SEPTEMBER 2017

cold with hot chilies. Deep-fry, the ultimate Cantonese art, turns up as crisp wontons stuffed with pork and shrimp, a perfect Chinese marriage (and one condemned by two of three Middle Eastern religions).

Close with pineapple puffs, delicate little pastries made to appear as birds in a cage.

8. SEAFOOD Sai Kung (discoverhongkong.com/eng/dine-drink/ where-to-eat/sai-kung.jsp) on the New Territories coast could be the best of all HK outings, marrying a charming maritime village atmosphere, fishing fleet, fish tanks qualifying as art and seafood restaurants run by maestros. Welcome to Saint Tropez with chopsticks.

Michelin-starred Sing Kee Seafood is the superstar in this august crowd. Find a table facing the marina and let the HK feast begin. An opener of silken, deep-fried tofu floats out in a haze of five-spice. Fat shrimps turn up subtly sauced in cheese. Asian classic chili crab brings sweet crustacean flesh. Whole grouper comes lightly breaded and fried to golden crispness, its bones a delicacy in themselves.

9. CHINESE CUISINE Subtlety still prevails in this most Cantonese of cities, but China’s regional cuisines have roared over the

CAROL CLEMENS CAROL CLEMENS

JEREMY FERGUSON

barriers, and the excitement meter soars at Qi-Nine Dragons (qi-ninedragons.hk), owned by Vancouver’s Peter Tsu. It’s Sichuan: chilies, garlic, ginger, star anise, orange peel and Sichuan peppercorns boogie across the stations of the palate.

One of the greatest dishes of 5000 years of culinary tinkering, garlic-and-chili-loaded Sichuan eggplant grabs you by the lapels and has its way with you. Deep-fried pork ribs come zapped with cumin.

And how about braised mandarin fish in chili oil soup? As your tongue goes numb — the defining character of Sichuan peppercorns — you’re shocked at how much you’re enjoying it.

The mysteries of Chinese medicine are revealed on the Sham Shui Po Foodie Tour.

10. WORLD CUISINE

ORIENTATION

Skye (parklane.com.hk.skye.htm) at the Park Lane Hotel is a swank rooftop restaurant with a raucous alfresco bar that bolsters HK’s standing as Asia’s foodie capital.

Be prepared to take your time with chef Lee Adams’ dazzling menu degustation.

Heirloom tomato tartare, seamlessly melding heirloom tomatoes, tomato sorbet and tomato foam made from seeds, is the storytelling warm-up for slow-poached New England lobster, the sweet, tender flesh out of the shell and lolling in butter; veal sweetbreads, the celestial gland sauced in Madeira and garnished with black truffle; melt-in-the-mouth Japanese wagyu beef tenderloin; and for dessert, chocolate guanaja with peanut gel and salted popcorn ice cream. Salted popcorn? You bet. And it’s absolutely wonderful.

Air Canada (aircanada.com) flies from Vancouver and Toronto daily. Cathay Pacific (cathaypacific.com) flies from Vancouver 17 times a week and from Toronto 10 times per week (plus twice daily from June to Sept.)

The writer stayed at the Madera Hollywood Hotel (maderagroup.com/group) in HK’s antique-laden SoHo District. The 38-suite Madera takes its cue from the Hollywood Regency style —1930s glamour — dedicating exteriors and interiors to Monroe, Chaplin and others (although Joan Crawford was its great proponent).

Suites come themed — Monroe’s luridly pink — with reproduction memorabilia. Luxe touches include rainforest showers, Nespresso coffee makers and lounge with complimentary coffee and beer.

For more information on travel to the region, contact the Hong Kong Tourist Board (discoverhongkong.com/Canada).

The Library of Birmingham is wrapped in aluminium filigree that stretches from the first floor up to the eighth.

A new chapter Four public libraries that are rethinking traditional architecture and design

by Camille Chin

C.

onsidering that everything is online these days — books, magazines, music, TV shows, movies, friends — public libraries should be struggling. Despite the digital times, however, new libraries have been popping up all over the world.

Modern facilities feature books in every form and format, and are multi-use and often multi-level. The architecture is being reinvented to include quiet solitary havens, but also bustling community hubs with gardens, playgrounds and more.

Designs are hardly by the book. Here are four new libraries that make the point.

The glass building has 10 storeys that offer opportunities for peoplewatching over Centenary Square.

PHOTOS BOTH PAGES COURTESY MECANOO

THE LIBRARY OF BIRMINGHAM, ENGLAND

The book-lined rotunda has elevators and cylindrical escalators that connect eight circular spaces.

About 40 percent of British jewellery is made in Birmingham’s Jewellery Quarter so it’s only fitting that the Library of Birmingham is draped in delicate filigree. But the 5357 interlocking circles inspired by the artisan tradition of metalwork also symbolize the assemblage of people, a bit like the Olympic rings.

The circles are ever-present inside too as shadows and reflections twirling past desks and up shelves and over white ceramic floors. Escalators and cylindrical elevators connect the library’s main circular spaces; book-lined rotundas provide daylight deep into the building. The cantilever doubles as shelter and a balcony with a rooftop garden and views over Centenary Square.

The golden rooftop rotunda is home to the Shakespeare Memorial Room, designed in 1882. The Victorian reading room was originally part of Birmingham’s first Central Library. Its wood panelling and glass cabinets were first dismantled in 1974 and then painstakingly restored as part of the School of Music complex in 1986. libraryofbirmingham.com.

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There’s no telling where the front and back of the Dokk1 library is, and that’s exactly what the Scandinavian architects intended when they designed the defiant-looking polygonal structure. Located on the Aarhus harbourfront in Denmark, it’s accessible from a few sides via four large sculptural staircases that also entice people to sit and stay awhile à la Spanish Steps in Rome. At the top, there are outdoor play spaces that feature an American eagle with outstretched wings, an African monkey on the savannah and a Russian bear carrying a hollow tree trunk that kids can slide through. All of the figures are artful, climbable and extremely popular. The library is modern and open with interconnected spaces of concrete, metal and wood. The bookshelves and furniture are movable. Oh — and that bronze column near the main staircase? It’s a bell that new parents can ring from the hospital nearby when their baby is born. dokk1.dk/english.

You know the saying “good things come in small packages?” How about the one “the best things in life are free?” If you’re not convinced that either is true, the Story Pod in Newmarket, ON, about 60 kilometres north of Toronto, may change your mind. The modest black pod in Riverwalk Commons, the city’s new town square, is 2.5 by 2.5 metres with big doors that unfurl like wings. Inside, there are sleek mahogany benches and shelves lined with books. All have been donated and passersby can take one or leave one, or linger and read by the river. The pod is closed and locked at night and recessed, energy efficient LEDs, powered by solar panels, light it up. The architects Atelier Kastelic Buffey designed the pod pro bono; town parks staff constructed it.

Book exchanges called Little Free Libraries have been popping up across North America. Most look like big birdhouses; all are equally delightful. newmarket.ca.

STORY POD, NEWMARKET, ON

COURTESY OF THE NED

COURTESY ATELIER KASTELIC BUFFEY / SHAI GIL

DOKK1, AARHUS, DENMARK

COURTESY AARHUS PUBLIC LIBRARIES

A centrepiece of the Dokk1 library is a tubular bell by artist Kirstine Roepstorff that rings when a baby is born.

The Story Pod opens like a book to reveal shelves and seating inside.

The rounded triangular form of the Chicago Public Library in Chinatown was inspired by Feng Shui principles.

PHOTOS THIS PAGE COURTESY SOM / JON MILLER © HEDRICH BLESSING

CHINATOWN BRANCH PUBLIC LIBRARY, CHICAGO, IL

The mural by CJ Hungerman on the second floor was inspired by Chinatown’s development.

Buildings with walls that meet at 90 degree angles are sooo last century. There aren’t any on the outside walls of the Chinatown branch of the Chicago Public Library. A glass and aluminum triangle with rounded edges that has been described as a pebble and also as a glowing lantern at night, the structure sits at the intersection of Archer and Wentworth Avenues, and acknowledges Feng Shui principles by aligning with both streets sans any sharp corners. Gingko trees soften the urban vibe; the building’s green roof is covered in grass. Designed by the firm SOM, the minds behind NYC’s One World Trade Center and Dubai’s Burj Khalifa, the interior is modelled after a Chinese courtyard. All spaces are connected to an atrium that’s lit by an oculus; a grand staircase brings members from the ground-floor kids’ zone to the adult and teen zones, where a huge mixed media mural by C.J. Hungerman dances overhead. chipublib.org/ about-chinatown-branch.

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Meatballs with celeriac and apples.

Dining the Nordic way Three recipes to help you embrace the Danish concept of hygge recipes by

Trine Hahnemann Columbus Leth

photos by

D

anish cook Trine Hahnemann wants you to let some hygge into your life and she’s written Scandinavian Comfort Food (Quadrille Publishing) to help.

Hahnemann describes hygge as the atmosphere created by hanging out. It can occur anywhere, alone or with company, and go on for hours, as long as the ambience is relaxed and intimate.

A long, formal dinner with high-end service would never be considered hyggelig; an evening at a friend’s, eating, relaxing, tuning in and out to read the

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paper or watch TV, and then eating again, would be. Hygge alone might involve a candle, a cup of tea, a movie or a book.

Danes use the word hygge and hyggelig all the time, but, most importantly, they feel it. Cooking plays an important role when the food is comforting and makes you feel good. The dishes here will do just that.

MEATBALLS WITH CELERIAC AND APPLES Meatballs aren’t just for frying. In Scandinavia, there are a lot of dishes with boiled meatballs, and when you look in old cookbooks, like the 1837 one by Danish cook Madam Mangor, she includes recipes for meatballs in sauce. This classic dish is an ultimate comfort dish.

For the meatballs 1 lb. 2 oz. (500g) minced (ground) pork 1 small onion, finely grated ½ tsp. (2.5 ml) freshly grated nutmeg 2 eggs, lightly beaten 2 tbsp. (30 ml) plain (all-purpose) flour 2 tbsp. (30 ml) breadcrumbs 1 tsp. (5 ml) each of sea salt and freshly ground black pepper

the reserved broth a little at a time, stirring constantly until the sauce is smooth, without any lumps. Add the leeks and celeriac, and let simmer for 20 minutes. Add the meatballs and apples about 5 minutes before the end of cooking, and cook until the meatballs are warmed through.

Meanwhile, rinse the spelt grain in several changes of cold water. Cook in lightly salted water for 15–20 minutes, then drain. Season the meatball sauce to taste with salt and pepper, sprinkle with parsley or chervil and serve with the spelt. Serves 8.

CAULIFLOWER AND PRAWN SALAD When Trine Hahnemann was growing up, her family ate cauliflower two ways: raw with a dip as crudité or in a gratin.

Another popular dish at the time was

For the broth 8½ c. (2 L) water 1 tbsp. (15 ml) sea salt 3 bay leaves 5 thyme sprigs 1 lb. 5oz. (600 g) celeriac 2 leeks 3 apples 7 tbsp. (105 g) butter 3 tbsp. (45 ml) plain (all-purpose) flour 1¼ c. (310 ml) spelt grain sea salt and freshly ground black pepper small bunch of parsley or chervil, chopped, to serve

Mix the minced pork with all the other meatball ingredients. For the broth, pour the water into a saucepan, add the salt and herbs, and bring to the boil.

Use a spoon to form the meatball mixture into balls, lower them into the boiling water and let them cook for 10–15 minutes until they rise to the surface, which means they are done. Remove them from the broth with a slotted spoon and set aside. Strain 3½ cups (875 ml) of the broth into a jug.

Meanwhile, peel the celeriac and cut into 2-centimetre (¾-in) cubes.

Slice the leeks and rinse well. Cut the apples into slices 1 centimetre (½ in) thick.

Melt the butter in a large saucepan.

Add the flour and stir well, then add Cauliflower, prawn and dill salad.

cauliflower in disguise — apparently its real name: boiled cauliflower with white sauce, covered in prawns. Trine never ate it, but it inspired her to make this summer prawn salad.

1 small cauliflower, about 14 oz.

(400 g) trimmed weight 10 radishes 7 oz. (200g) cooked peeled prawns (shrimp) For the dressing 6 tbsp. (90 ml) chopped dill 6 tbsp. (90 ml) chopped chives ²⁄³ c. (160 ml) Greek yogurt 1 tbsp. (15 ml) grated unwaxed lemon zest and 1–2 tbsp. (15–30 ml) juice sea salt and freshly ground black pepper

Cut the cauliflower florets and stalk into thin slices, rinse well in cold water then drain in a colander. Slice the radishes.

Mix all the dressing ingredients together, with salt and pepper to taste.

Mix the cauliflower slices, radishes and prawns together in a big mixing bowl, then mix in the dressing. Season to taste with salt and pepper, and perhaps a little more lemon juice for acidity.

Leave for 10 minutes then season again and serve. Serves 4–6.

FIVE-GRAIN BREAD Whole grains are superfoods because of all the fibre and vitamins they contain, and they are vital for us. But healthy food has to be delicious as well or we won’t eat it, so it won’t benefit us. This bread is tasty, has a great texture because of all the grains and also stays moist for a long time. ½ oz. (75 g) whole barley grains 2 2½ oz. (75 g) whole rye grains 2½ c. (625 ml) water ¹⁄³ oz. (10 g) fresh yeast

10½ oz. (315 g) strong white bread flour, plus extra for dusting 3½ oz. (105 g) wholegrain spelt flour 3½ oz. (105 g) jumbo oats, plus extra for sprinkling 1 oz. (30 g) linseeds (flaxseeds) ¹⁄³ oz. (10 g) sea salt ¾ oz. (20 g) spelt flakes

Boil the barley and rye grains in the water for about 20 minutes until cooked, then strain, saving the cooking water. Measure the cooking water and add fresh water to top it up to 2½ cups (625 ml) again.

When the grains and water have cooled to lukewarm, mix the yeast into the water in a mixing bowl, then add the boiled grains, both flours, oats, linseeds (flaxseeds) and salt, and mix well with a wooden spoon. Leave to rest for 5 minutes, stir well again and leave for another 5 minutes, then stir again, cover with cling film and refrigerate overnight.

The next day, place the dough on a floured surface and knead lightly (the dough will be sticky). Line a 25-centimetre (10-in) proofing basket with a tea towel and sprinkle the spelt flakes inside. Form a large round bread, place in the proofing basket, cover with a tea towel and leave to rise for about 1 hour or until the dough has risen to the rim of the basket. When nearly ready to bake, preheat the oven to 450°F (230°C) / gas mark 8.

Turn the dough out of the proofing basket onto a baking sheet lined with baking parchment. Sprinkle with oats and bake in the hot oven for 15 minutes, then turn down the oven temperature to 400°F (200°C) / gas mark 6 and bake for another 45 minutes. Transfer to a wire rack to cool before slicing. Makes 1 large round loaf.

Recipes and photos from Scandinavian Comfort Food: Embracing the Art of Hygge (Quadrille Publishing, 2016).

advertisers index ABBOTT Freestyle Libre...........................................4 ALLERGAN INC. Fibristal................................................... 31 BOEHRINGER INGELHEIM (CANADA) LTD Trajenta...............................................OBC Jardiance................................................ 2,3 GLAXOSMITHKLINE Breo Asthma......................................IFC, 1 MERCK FROSST Asmanex................................................. 15 PFIZER CANADA INC. Duavive............................................. 26, 27 Epipen.......................................................8 Pristiq...................................................... 21 RECORD STORAGE & RETRIEVAL SERVICES....................... 13 SEA COURSES INC. Corporate................................................ 14 TD BANK Small business............................................6 Merchant solutions.................................. 18 XLEAR INC. Xlear nasal spray...................................... 17

FAIR BALANCE INFORMATION Asmanex................................................. 47 Five-grain bread.

DEPRESSION KEYPOINTS uu CONTINUED FROM PAGE 23

• CBT + MI: Evidence to date does not indicate there are benefits to combining both modalities.

• Assertive community treatment (ACT): Equivocal data on whether ACT is superior to standard case management.

• Contingency management (CM): Some evidence of improvement in drug and alcohol use outcomes.12 It is clear that good quality research is sorely needed in the management of patients with mood disorders and comorbid SUDs. However, available evidence can, at the very least, provide some guidance.

References 1. Murray C, Lopez A. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet. 1997;349:1436-1442.

2. Goldstein BI, Bukstein OG. Comorbid substance use disorders among youth with bipolar disorder: opportunities for early identification and prevention.

J Clin Psychiatry. 2010;71:348-358.

3. Kessler RC. Comorbidity of unipolar and bipolar depression with other psychiatric disorders in a general population survey. In: Tohen M, ed.

Comorbidity in affective disorders. New York, NY: Marcel Dekker Inc.; 1999:1-26.

4. Strakowski SM, DelBello MP, Fleck DE, et al. Effects of co-occurring alcohol abuse on the course of bipolar disorder following a first hospitalization for mania. Arch Gen Psychiatry. 2005;62:851-858.

5. Strakowski SM, DelBello MP, Fleck DE, et al.

Effects of co-occurring cannabis use disorders on the course of bipolar disorder after a first hospitalization for mania. Arch Gen Psychiatry.

2007;64:57-64.

6. Schaffer A, Cairney J, Veldhuizen S, et al. A population-based analysis of distinguishers of bipolar disorder from major depressive disorder. J Affect Disord. 2010; 125:103-110.

7. Tolliver BK, Anton, RF. Assessment and treatment of mood disorders in the context of substance abuse.

Dialogues Clin Neurosci. 2015;17(2):181-90.

8. Swann AC. The strong relationship between bipolar and substance-use disorder. Ann N Y Acad Sci. 2010;1187:276-293.

9. Hasin DS, Grant BF. Major depression in 6050 former drinkers: Association with past alcohol dependence. Arch Gen Psychiatry. 2002;59:794-800.

10. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders.

Results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61:807-816.

INDICATION: ASMANEX® Twisthaler®, a preventative agent, is indicated for the prophylactic management of steroid-responsive bronchial asthma in patients 4 years of age and older.2 CONTRAINDICATIONS:2 • Hypersensitivity to this drug, milk proteins (from the excipient lactose), or any component of the container • Primary treatment of status asthmaticus or other acute episodes of asthma where intensive measures are required • Untreated systemic fungal, bacterial, viral or parasitic infections, active or quiet tuberculous infection of the respiratory tract, or ocular herpes simplex RELEVANT WARNINGS AND PRECAUTIONS:2

• Should not be stopped abruptly • Risk of adrenal insufficiency in patients transferred from

systemically active corticosteroids

• Oropharyngeal candidiasis • Risk of systemic effects of inhaled corticosteroids

• Hypercorticism, adrenal suppression, growth retardation in children/adolescents, reduced bone mineral density, osteoporosis, fracture, cataracts, glaucoma • Risk of dose-dependent bone loss • Enhanced effect of corticosteroids in patients with cirrhosis or hypothyroidism • Do not exceed recommended dose • Rare systemic eosinophilic conditions

11. Aharonovich E, Liu X, Nunes E, Hasin DS. Suicide attempts in substance abusers: Effects of major depression in relation to substance use disorders.

Am J Psychiatry. 2002;159:1600-1602.

12. Beaulieu S, Saury S, Sareen J, et al. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and comorbid substance use disorders. Ann Clin Psychiatry. 2012;24(1):38-55.

13. Weiss RD, Griffin ML, Greenfield SF, et al. Group therapy for patients with bipolar disorder and substance dependence: Results of a pilot study.

J Clin Psychiatry. 2000;61:361-367.

MEDICAL QUIPS Do no harm!

“Though the doctors treated him, let his blood, and gave him medications to drink, he nevertheless recovered.”

— Leo Tolstoy, War and Peace

• Caution when used with acetylsalicylic acid

in hypoprothrombinemia

• Risk of immunosuppression • Not for rapid relief of bronchospasm • Possible inhalation induced bronchospasm • No adequate studies in pregnant/nursing women • Risk of hypoadrenalism in infants born to women

receiving corticosteroids

• Monitoring of: HPA axis function and haematological status

periodically during long term therapy, use of short-acting inhaled bronchodilators, bone and ocular effects, height of children and adolescents

For more information: Please consult the Product Monograph at http://www.merck.ca/ assets/en/pdf/products/ASMANEX_Twisthaler-PM_E.pdf for important information relating to adverse reactions, drug interactions, and dosing/administration information (particularly dose reduction to the lowest possible dose required to maintain asthma control) which have not been discussed in this advertisement.

The Product Monograph is also available by calling us at 1-800-567-2594.

References: 1. Bousquet J et al. Comparison of the efficacy and safety of mometasone furoate dry powder inhaler to budesonide Turbuhaler®. Eur Respir J. 2000;16:808-816. 2. ASMANEX® Twisthaler® Product Monograph. Merck Canada Inc., March 18, 2015.

® MSD International Holdings GmbH. Used under license. © 2017 Merck Canada Inc. All rights reserved. RESP-1206327-0000 FE 2018

SEPTEMBER 2017 • Doctor’s

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PHOTO FINISH by

D r M a r i lè n e H i v on

When in Rome

This picture is of the Pantheon, a temple dedicated to all the gods of pagan Rome. It’s believed that the current Pantheon was built during Hadrian’s time between 118-125 CE. Piazza della Rotonda is the square right outside. The fountain was built in 1575; the obelisk added in 1711.

MDs, submit a photo!

Please send a high-resolution photo along with a 150- to 300-word article to:

editors@doctorsreview.com

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Picture yourself in Africa.

Doctorâ&#x20AC;&#x2122;s Review makes planning your personal and professional travel easier.

Go to doctorsreview.com/meetings to search 2500+ top world conferences.

Access code: drcme

For your adult patients with type 2 diabetes

Equipped for glycemic control.

~5 million patient-years of experience.1

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

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

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

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

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

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

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

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

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

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

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

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