SUMMER 2013
DOCTORS life + leisure
the celtic charms of
scotland + newfoundland + what type of
insurance is right for you? + roof down— the top new CONVERTIBLES + uncover the mystery of mezcal + discover DUBAI
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DOCTORS life + leisure
contents
SUMMER 2013
SUMMER 2013
Editor Barb Sligl Art Direction BSS Creative
Contributing Editor Janet Gyenes
Editorial Assistant Adam Flint
Contributors Cover photo
Yvette Cardozo Michael DeFreitas Dr. Holly Fong Dr. Chris Pengilly Manfred Purtzki Dr. Kelly Silverthorn Roberta Staley Tallulah Photography B. Sligl
Senior Account Executive Monique Nguyen
Account Executive Wing-Yee Kwong
Sales, Classifieds and Advertising In Print Circulation Office 200 – 896 Cambie St. Vancouver, BC V6B 2P6 Canada Phone: 604-681-1811 Fax: 604-681-0456 Email: info@AdvertisingInPrint.com
Associate Publisher Linh T. Huynh
FEATURES
12 on The Rock Summer in wild + literary Newfoundland 18 Edinburgh stage In the Athens of the North, it’s
Circulation Fulfillment Shereen Hoang
CME Development Adam Flint
Kauai Discovery.com
clockwise from top left: B. Sligl; ©VisitBritain / Ingrid Rasmussen; B. Sligl
Sail along a coastline of majestic cliffs. Hike to a secluded waterfall. Or simply sit and watch the sunset from a pier. It’s all here on Kaua‘i.
one big festival—all summer long
Founding Publisher Denise Heaton
COLUMNS
DEPARTMENTS
9 doctor on a soapbox
5 summer mix
Cholesterol and statins
CONSIDER YOUR BATTERIES RECHARGED.
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Production Manager Ninh Hoang
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Just For Canadian Doctors is published 4 times a year by Jamieson-Quinn Holdings Ltd. dba In Print Publications and distributed to Canadian physicians. Publication of advertisements and any opinions expressed do not constitute endorsement or assumption of liability for any claims made. The contents of this magazine are protected by copyright. None of the contents of the magazine may be reproduced without the written permission of In Print Publications. In Print Publications 200 – 896 Cambie Street Vancouver, BC V6B 2P6 Canada
21 CME calendar
10 photo prescription
27 sudoku
Capturing wildlife
32 employment opportunities
16 the thirsty doctor
38 small talk
The mystery of mezcal
with Dr. Ted Jablonski
17 the hungry doctor Savour summer snapper
cover photo
28 motoring
www.justforcanadiandoctors.com Printed in Canada.
miss an issue? check out our website!
It’s the season for open-roof cars
30 pay it forward Dr. Raghu Venugopal’s inspiring work in Chad
34 the wealthy doctor What type of insurance is right for you?
Newfoundland brims with a passion that stems from its otherworldly landscape and flows out with artistic force through its people. Here, Arches Provincial Park showcases the power of tidal action on the west coast, just north of Gros Morne National Park. Story on page 12.
SUMMER 2013 Just For Canadian Doctors
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Vacation CME Asian cruise • Baltics cruise • Banff • Caribbean cruise Disney World • Las Vegas • Maui • Mediterranean cruise Scottsdale • Tahitian cruise • Waikiki • Whistler (x2)
festival circuit
-C Mainpro s it d cre
CANADA supratentorial medicine
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ummer’s here—the festival season has begun. It’s all about celebrating that joie de vivre that becomes magnified outdoors on green lawns and under balmy skies. Or cobblestone streets… in Edinburgh, Scotland. Long-time reader, Dr. Alexander Shearer, a native Scot who emigrated to Canada to work, takes us to his home town for the summer-long party (page 18). From there, it’s just across the pond, so to speak, for more of that Celtic vibe. Newfoundland, where the Gaelic language and Celtic traditions still run deep, puts on another great summer show in the tiny village of Woody Point. It’s a powerhouse in the literary world: Michael Ondaatje, Richard Ford and Lisa Moore have all graced the words-and-music extravaganza that takes place here: Writers at Woody Point. It’s a wonder-filled celebration like only Newfoundlanders can put on. And, post-party, there’s the requisite colourful clapboard fishing shacks, dramatic coast and beauty to explore (page 12). If that’s not enough, there’s always Wisconsin. Really. It’s surprisingly sophisticated. Milwaukee has taken its storied past (think German beer barons) and imbued it with modern cool, from a stunning monument to architecture in its art gallery to the many microbreweries and distilleries. Then, an easy drive from Milwaukee is the lakeside community of Elkhart Lake with its quintessential cottage scene…albeit with a French cooking school, world-renowned race-car circuit, golf havens and fine dining. So, in Wisconsin, go city and country (page 6). Exuding the same small-town charm with a big jolt of urban sophistication is BC’s capital, Victoria (page 21). Or, up the coast of Vancouver Island, any of the stops along Island Joy Rides bike tour (page 8). Yes, culinary cycling is a perfect mix. And, while you’re sampling, sip some smoky mezcal. Discover why this artisanal spirit is worthy of a spot in your liquor cabinet (page 16). Tell us what you’re up to. We want to know where in the world you’re travelling, photographing, volunteering, working…stay in touch through justforcanadiandoctors.com. Enjoy! feedback@InPrintPublications.com
Just For Canadian Doctors SUMMER 2013
the
great hotel escape
The Ace Hotel lobby in Portland, Oregon.
the hotel has always been ground-zero for cuttingedge cultural + artistic exchange. and Now it’s part of an art exhibit…
mix
check it out Fifties-era bungalows bedecked in far-out colours? Glamour dens, complete with the intimate attention (and utmost discretion) of butlers? Whether it’s a glorified crash-pad on a Kerouac-style road trip or a super-luxe enclave that’s a destination retreat, chosen because it’s the playground for celeb plays, there’s something about hotels that gets cemented into our psyche as a dynamic form of shelter that’s without geographic boundaries. Those are some things to ponder when visiting the Grand Hotel: Redesigning Modern Life exhibition, which “traces the hotel’s impact on geographic space, the world of design and the social structure of society…” writes guest co-curator Jennifer M. Volland in one of her essays published in exhibit’s catalogue. —Janet Gyenes Vancouver Art Gallery, April 13–Sept. 15, 2013, vanartgallery.bc.ca
jeremy pelley
18.0
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what/when/where > summer style | food | shows | festivals | places | getaways | gear…
S
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from the editor
SUMMER 2013 Just For Canadian Doctors
5
mix
summer the unexpected
Midwest
city
Wisconsin wonder
milwaukee
summer
country
5 hot picks
mix
1 true mettle At first blush, Acme Studio’s brass Hatch rollerball pen draws attention for its etched-brass graphics that emulate cell structure. But the writing instrument’s utility extends beyond scribbling ’scripts or shopping lists—it’s a shining example of low-tech smarts. Designer Karl Zahn crafted Hatch from brass to capitalize on the alloy’s antimicrobial abilities, effectively creating a self-sterilizing pen that’s ideal in environments where hygiene is crucial. $160, acmestudio.com —J.G.
elkhart lake
Big city. Quaint town. Both lakeside. Both in Wisconsin. Here’s why you should go to both this summer. —B.S.
getaway
Milwaukee’s history includes a gilded era as the booming town of beer baron Frederick Pabst (visit the mansion that PBRbuilt). And brew is still big here. Go for one of the many microbrews (like Furthermore’s peppery good Knot Stock), take in some stellar art, the bike scene (as in Harley-Davidson), lakeside living, urban kayaking (yes!) and a locavore food scene (including that cheese).
elkhart lake is a couple hours’ drive northwest of the big city, and although this gem of a lake is a lot smaller than Lake Michigan, it’s the state’s deepest. And maybe its bluest. The Caribbean-like hue makes it one of Wisconsin’s go-to summer getaway spots …that and the fine dining, hip boutiques and fast cars (it’s home to the Road America speed course). The beer in Wisconsin— in the city or country—is good. Really good. Try the tasty zing of Furthermore’s peppery pale ale, Knot Stock (furthermorebeer.com).
The Milwaukee Art Museum (above; mam.org), on Lake Michigan, boasts dramatic architecture (with wings that open and close every day) and more than 20,000 works of art.
Sweet Water Organics (sweetwaterorganic.com) is an urban farm that has re-purposed abandoned and unused industrial building space for aquaponics to sustainably grow fresh, organic produce and fish for local Milwaukee residents and restaurants. Stay at the Pfister Hotel (thepfisterhotel.com), is known for its Victorian art collection— the largest of its kind in any hotel—and a working art studio and gallery.
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WISCONSIN WONDER Check out Tourism Wisconsin’s website at travelwisconsin.com or call 800-4328747. For more on Milwaukee, check out Visit Milwaukee at visitmilwaukee.org. Explore all that Elkhart Lake has to offer at elkhartlake.com.
Just For Canadian Doctors SUMMER 2013
bright
idea
In the country, dine on chic cuisine as if in the city, whether at Lake Street Café (left; lakestreetcafe.com) or the Paddock (named for the gambling scene of Elkhart’s Al Capone days; paddockclubelkhartlake.com). Must-try: the upscale version of fried cheese curds. Below, nut-encrusted local goat cheese at Lola’s on the Lake at The Osthoff Resort (osthoff.com).
ATTENTION GEAR-HEADS! Get your speed fix at Road America: roadamerica.com. >> Channel your inner biker at Harley-Davidson: harleydavidson.com. (And re-read Dr. Silverthorn’s column “Midwest Mecca” in the March/April 2012 issue.)
4 not-so-mellow yellow This spring, master the art of French cooking with some help from Le Creuset. The premium cookware’s latest hue— Soleil—takes inspiration from the country’s sun-soaked beaches. True, you can’t bring France’s golden sands home, but the pleasant reverie and sunny shade of the enamelled cast-iron cookware are incentive enough for recreating some of the region’s flavours and aromas. Prepare a comforting Coq au Vin or Spring Lamb Navarin and savour the season. The bonus: classic styling and contemporary colours mean the cookware is versatile enough to go from oven to table. Mais oui! $12-$600, lecreuset.ca —J.G. B. Sligl
Small, unique boutiques line Elkhart Lake’s tiny “downtown” core, like the hip pop-up shop that features consignment goods from Hollywood (one-of-akind designer wear) and vintage finds like this old aerial photo of the lake.
Cheesemonger at Wisconsin Cheese Mart (wisconsincheesemart.com), the place to get the state’s most famous product, from Red Rock cellar-aged cheddar-blue (a heavenly blend) to goat’s-and-sheep’s-milk Mobay.
if you GO
3 Gear up—and go While the idea of a picnic in the park amid a carpet of cherry blossoms exudes romance, dewy grass and brisk winds can dampen spirits. Bring along Pendleton’s camp blanket (shown in Green Heather/Smith Rock Plaid), tucked in a handy leather carrier, for that added layer of warmth. Since the soft wool-cotton blanket is so portable, you’ll want to keep it in the convertible for those days when the sun’s rays won’t suffice, and have it close at hand for cozying up when star-gazing, withstanding the demands of a tailgate party. Approx. $106.00, pendleton-usa.com —J.G.
5 Thin is in Admit it. You’ve often tried to put your wallet on a diet and pare back that collection of cards to the basics. But with multiple spots to stash receipts, movie stubs and other miscellany, in no time your wallet bounces back to its fat form. The binge-purge cycle is over thanks to the RFID-secure (to prevent skimming) HuMn Wallet. This super-slim invention is composed of two thin anodized aluminum or carbon fibre plates and an elasticized strap that keeps your stuff secured without extra bulk. From $75, humnwallet.com —J.G. SUMMER 2013 Just For Canadian Doctors
summer fever!
country + city…in the Midwest
2 GAME ON! We all know that table tennis tourneys can be competitive; after all, the game is an Olympic sport that requires finesse, laser-like reflexes and a dash of “welly.” But leave it to designer Jonathan Adler to add some style to the sport, which is purported to have been played as a parlour game by upperclass Brits who batted about champagne corks, among other objects. Add some pomp to your next match by sheathing your paddle in the 100% wool needlepoint Bargello cover. It’s sure to be a smash hit. $72, modernshop.ca.com —J.G.
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mix
pedal + pamper
summer
d o c t o r o n a s o a p b o x D r . c h r i s p e n g i l ly Dr. Chris Pengilly is Just For Canadian Doctors’ current affairs columnist. Please send your comments to him via his website at drpeng.ca.
villain or cue?
Cholesterol as an indicator or pointer towards heart disease
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It is often clinically obvious who is a high-risk patient
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Just For Canadian Doctors SUMMER 2013
coastal cycle Take a tour on Vancouver
Island’s sheltered east coast, from driftwood-dotted beaches to a bucolic blueberry farm. Be prepared to lose track of countless eagle sightings, eat your fill of local fare and indulge in a sweet mix of exertion and relaxation…on an “island joy ride”
cycle Island Joy Rides is the aptly named venture of two joyful (of course!) women who’ve translated a love of cycling and the Vancouver Island region into bike+ a touring company. They ‘re in season three of sharing the hidden gems of their sample seaside home— the sheltered bit of sublime seashore that edges the Comox Valley—and riding alongside groups 1 on itineraries like Wheels ‘n Whales, West Coast Foodie, Edge of the Islands. The goal (emblazoned on t-shirts 2 ) is all about “exploring fresh experiences and places, new and old friendships, taking the time to appreciate the small stuff.” There’s even a treasure chest of ribbons for guests to write their own “joys” to tie to a trail-side tree 3 . SPA April Point Resort and Spa is just one of the idyllic spots on Quadra Island (reached by ferry across Discovery Passage 4 ). Post ride, a massage in the sanctuary-onstilts spa (the building seems to be floating on water) loosens limbs 5 . scenery A snack break at Rebecca Spit Marine Provincial Park 6 is all about the seaside view (and full-of-goodness homemade energy treats). savour This being a pedal-and-pamper experience, there’s a wine-paired and locally sourced dinner (including chowder with generous dollops of wild salmon and melt-in-your-mouth pork belly) and more spa treatments at the Kingfisher Oceanside Resort and Spa 7 . sip The bike route in Comox Valley includes a picnic at Blue Moon Estate Winery paired with fruit wine made from organic blueberries grown right here—and a side of fresh-picked strawberries—followed by a calorie-burning ride past scenery of old-school farmland and weathered-wood fences 8 . MORE Check out islandjoyrides.com. —B. Sligl
B. Sligl
find your JOY
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find out exactly how statin medications work and who indeed would really benefit from these potentially useful but not entirely benign medications. The last time I wrote an essay on this subject I had quite a bit of feedback (drpeng.ca). About 80% stated that the concept makes sense and is “something I have suspected for a long time.” And 20% were telling me that I was wrong, a menace to society and medicine in general, and I should give up medicine and writing. There was no middle ground. Opinion seems to be polarised. An extreme example of this: one of my GP colleagues was devastated after being told by a cardiologist that “You killed that patient by not giving a statin…”
solution from page 27
bike away
benefit from a statin medication as part of—and I emphasize part of—a riskreduction program. A good question at this point is, does measuring his cholesterol level on an annual basis serve any benefit? He should be treated with a maximum safe tolerated dose regardless of his lipid profile. If he is relatively low risk then maybe 10 or 20 mg of your favourite statin would be satisfactory. This would offer about a 25% risk reduction. Increasing to 40 mg or 80 mg would add only about an extra 1% absolute risk reduction. The health dollars spent on laboratory costs of lipid profiles (about $40 in BC) could be much better used in other areas. I frequently receive consultation reports from cardiologists whom I respect urging, at all costs, to get an LDL below 2.0. These are high-risk patients and need secondary prevention; I would urge the maximum tolerated dose of a statin medication. Statin medications are not entirely benign. Though serious side effects are rare (remember Baycol?), muscle weakness and muscle pains are quite significant and in my experience more common than the 10% frequently quoted. I suspect that sometimes I am looking too hard for these. Many patients do note, however, how much better they feel after discontinuing a statin medication. The pain and weakness are insidious and often not associated in the patient’s mind with the medication. Of more concern is that there is an increased risk of developing diabetes. The incidence is thought to be about 1.5%. Cholesterol is an indicator or pointer towards heart disease and is not the cause of it. I think more research is needed to
sudoku 1 easier solution 8 1 6 9 3 4 2 5 7 5 7 9 8 2 6 1 3 4 2 4 3 5 1 7 9 8 6 9 5 2 4 6 8 3 7 1 7 6 4 1 9 3 8 2 5 1 3 8 7 5 2 6 4 9 4 9 5 3 8 1 7 6 2 3 2 1 6 7 5 4 9 8 6 8 7 2 4 9 5 1 3
Puzzle by websudoku.com
solution from SPRING 2013 contest
I
want to revisit the idea of cholesterol and whether it really is the villain that it is portrayed as. Should we be aiming to reduce laboratory result numbers or patients’ morbidity and mortality? Should the public medical insurance plan be burdened with the cost of repeated lipid profile testing? My argument is that it is often clinically obvious who is a highrisk patient, and this patient, regardless of laboratory cholesterol reading, will benefit from a statin drug—not to reduce cholesterol numbers, but to reduce the inflammatory and endarterial response predisposing to thrombosis of coronary or cerebral arteries. Using the Framingham calculator let us take a 60-year-old male, nonsmoker and normotensive with a total cholesterol of 4.0 and an HDL of 1.5. He will have a fiveyear risk of a cardiovascular event of 9.4%. If the same man’s total cholesterol is 5.0, his five-year risk would be 11.2%. If however his cholesterol remains at 4.0 but he begins to smoke his risk would increase to 18.4%. Even if his total cholesterol increases to 7.0 his calculated risk as a nonsmoker would be 15.6%. So the most cost-effective treatment for this man would be lifestyle counselling. If he were given a statin medication it would reduce his risk by about 25%. It sounds impressive but, in fact, over five years, he would reduce his absolute risk from 9.4% to 7% regardless of the cholesterol measurement. If our 60-year-old man had treated blood pressure 160 systolic and smoked with a positive family history of premature heart disease, his risk factor, regardless of his cholesterol level, would be greater than 30%. He would almost certainly
sudoku 2 harder solution 1 7 8 5 4 9 3 6 2 2 6 3 1 8 7 4 5 9 9 4 5 3 6 2 1 8 7 8 3 2 4 5 6 7 9 1 6 5 4 7 9 1 8 2 3 7 9 1 2 3 8 5 4 6 4 8 6 9 1 3 2 7 5 3 2 9 8 7 5 6 1 4 5 1 7 6 2 4 9 3 8
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SUMMER 2013 Just For Canadian Doctors
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p h o t o p r e s c r i p t i o n m i c h a e l d e f r e i ta s
photo prescription [continued]
Michael DeFreitas is an award-winning photographer who’s been published in a wide variety of travel publications. With his initials, MD, he’s been nicknamed “doc,” making his photography prescriptions apropos.
put the wild back in wildlife Add some bite to tame wildlife images
A
As a starting point, make sure the animal’s eye is in sharp focus. A sharp eye provides a strong and intriguing focal point. An outof-focus eye lacks interest. Then, pick an angle that puts the sun behind and over one of your shoulders. This will produce a nice catch-light in the animal’s eye. Next, make sure your subjects stand out. Use a long focal length lens (300mm or longer), shoot in aperture priority mode with an aperture of f4 or f5.6 and focus on the animal’s head. This technique renders a sharp subject against a blurred background. One of my favourite techniques is to find a shooting angle with a flattering or contrasting background. Try isolating darker subjects by shooting against a lighter background (like white sand, sky or water) and lighter subjects with a darker background (like a shadow or dark vegetation). For added drama, try to capture a bit of animation along with these shooting methods. Capturing an animal doing something adds personality and character to the image. Now combine all these elements. A light-coloured iguana with a dark backdrop will definitely produce a memorable image. The same composition with a touch of sidelight to accentuate the iguana’s spiky back can raise the image to the wow level. Capture the iguana sneezing, yawning or sticking out its tongue (be patient, get comfortable and wait for the right moment) and you’re talking award-winning. Other than sharp-focused eyes there is only one other important rule to remember when you’re shooting wildlife. Keep a safe distance! There is a good reason why we refer to these animals as wildlife. So please, when I say “put some bite” into your wildlife shots, don’t take me literally.
Send your photos and questions to our photography guru at feedback@ inprintpublications.com and your shot may be featured in a future issue!
s we motored to the black, rocky coastline of Punta Espinosa on the northeast coast of Isla Fernandina––the youngest and thirdlargest island in the Galapagos Archipelago–– puzzling, tiny wisps of fine spray backlit by the low morning sun sporadically filled the air. I couldn’t help but wonder what Charles Darwin thought when he witnessed the same scene almost 200 years ago. As it turned out, those mysterious puffs were the “sneezes” of hundreds of black, metre-long marine iguanas blanketing the lava-rock shoreline. According to our guide, marine iguanas ingest lots of saltwater when they feed on sea algae and expel excess salt from their bodies by sneezing. Believe me, snapping a sneezing iguana is virtually impossible. I tried. But there was no way of knowing which one to focus on. Also, shooting these wonderful prehistoric-looking creatures against a black lava backdrop was challenging. They blended right into the black rocks. Many animals mimic their surroundings, which typically results in a Where’s Waldotype image. Some camouflage images work well, but separating your subject from the background usually creates a better shot.
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Just For Canadian Doctors SUMMER 2013
> If possible, keep the animal’s eye in focus. > Separate the animal from its surroundings with an aperture of f4 or f5.6 to blur the background.
> Use a slow, quiet, zigzag approach to get closer to animals. > Wear muted colours and avoid aftershave, scented deodorant, cologne or perfume. Avoid wearing shiny objects like reflective sunglasses or jewelry.
> Cover the shiny parts of your camera equipment with black electrical tape.
> A tripod is a must when using long lenses or waiting for action. > Research your subject’s habits. A cold-blooded iguana must raise
its body temperature after and before a cool night. Shoot it in early morning or late afternoon when it’s basking in the sun.
> Avoid direct eye contact with animals.
Ready to take it to the next level?
gear up In the Galapagos, you can get to within three metres
of the animals––but that’s pretty rare. Normally, you’ll need a long or telephoto lens with a 300mm to 500mm focal length. Most amateurs, however, can’t justify them at $2,000 to $8,000 each. A teleconverter or extender is a much cheaper alternative for increasing the focal length of a lens. It fits between the lens and camera body and works like a magnifying glass. They come in various magnification strengths. A 2x teleconverter on a 200mm lens produces an equivalent 400mm lens, while a 1.5x converter on the same lens produces a 300mm equivalent. Teleconverters run $200 to $400.
it’s your move
michael defreitas
How to put the “wild” back in wildlife: Patience is definitely a virtue. The photo of the vibrant-pink flamingo was taken in the late evening. Knowing that flamingos go to sleep around sunset, capturing this shot entailed waiting for over an hour for the flamingo to stop preening and finally tuck its head under its feathers. The same applies for the sleeping sea lions and marina iguana, which is made even more dramatic by making sure its spikes are set against a light, non-distracting background.
PRO TIPS photographing wildlife
In Alberta you can enjoy one of the best standards of living in the world while working in a leading-edge health-care industry. Investigate opportunities at www.albertadocjobs.ca or call 1-800-423-9911. Funded by the Alberta Rural Physician Action Plan SUMMER 2013 Just For Canadian Doctors
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travel at home
travel at home
newfound
land
The Tablelands walk at Gros Morne National Park on the western coast of Newfoundland.
Welcome to the mind-bending Rock, where otherworldly geology is the backdrop for a heady mix of words + music during the Writers at Woody Point
“This walk will change your life.” It’s the guide’s intro to a morning jaunt through a place unlike any other on earth. We’re in Gros Morne National Park, on the west coast of Newfoundland. And it looks like we’re on another planet. This UNESCO World Heritage Site is like the scientific equivalent of the Pyramids, or Newfoundland’s version of the Great Wall—a massive
geological wall, that is. As UNESCO puts it, “the park provides a rare example of the process of continental drift, where deep ocean crust and the rocks of the earth's mantle lie exposed.” Add some glaciation, and the result is otherworldly scenery: coastal lowland, alpine plateau, fjords, deep valleys, steep cliffs, towering waterfalls and untouched lakes. The story
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Just For Canadian Doctors SUMMER 2013
Lord of the Rings wouldn’t be out of place here. And, fittingly, despite the sun beaming bright and hot, guide Chris Oravec warns that snow could make an appearance—after all, it’s as if we’re in anything-can-happen Middle Earth, if not the ends of the earth. But happily, she adds, “It’s Writers. The week of Writers always has sun.” >>
+ photography by Barb Sligl
SUMMER 2013 Just For Canadian Doctors
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+
travel at home
The fjord and cliffs of Western Brook Pond. >> It’s why a good chunk of us are here, for the Writers at Woody Point festival (although just as many far-flung visitors have come simply to visit this unique place). The fest is a weekend-long extravaganza that brings internationally renowned writers, musicians and literary fans to this remote, wind-swept, literally earth-shattered corner of the globe. Guide Oravec uses phrases like “colliding continents” and “ripping apart” to describe what happened here some 485,000,000 years ago. It’s like Mother Earth gave birth
travel at home if you go
writers at woody point This unique festival, where readers, writers, musicians and locals mingle like old friends, takes place this year from August 14 to 18. writersatwoodypoint.com For more info go to Newfoundland and Labrador Tourism: newfoundlandlabrador.com
“Enjoy our park. Enjoy the silence. Enjoy the sunny weather the writers have brought.” In Woody Point, the festival kicks off with a tribute to one of Newfoundland’s most beloved and iconic writers, Al Pittman. His daughter Emily’s words are a primer for the next few days here: “This passion for Newfoundland was born in places like Woody Point.” The cup runneth over with passion in this fishing village turned literary outpost on the shores of Bonne Bay. It’s the type of fest where you’ll exchange beer-tasting notes
“We put the fun in profundity.” to Gros Morne Mountain, a bald-headed monster of mantle that has no business being this far above sea level. We’re looking at the oldest rock on earth (think 4.5 billion years), igneous rock from far, far below that was effectively “bulldozed” atop the earth’s crust when the tectonic plates collided half a billion years back. That “squishy, taffy-like” rock, as Oravec describes it, is now the flat-topped Tablelands. There’s a hush. A collective sense of awe overcomes the group. The past, unadorned, unchanged, is right here, right now. And, it seems, we’re all standing upon an ancient seabed. Ocean floor is mountaintop and two landmasses that should be separated by thousands of kilometres of water— tabletop-like Gros Morne Mountain and Big Level—are both part of what’s now Newfoundland, and only 12 km apart. There’s no other view like it on the planet. It’s mind bending. Welcome to Newfoundland, also fittingly known as The Rock. Just down the road is the tiny town and base of the writers’ fest, Woody Point, where more mind bending is in store. Oravec leaves us with this send-off:
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with local Clyde Rose, Pittman’s one-time publisher, and guest writer Michael Ondaatje, and get offered an impromptu boat tour of the bay. Characters here are almost comically friendly—in a very good way. One local musician-cum-captain has travelled the world on tour but chose to return here, working the ferry from Woody Point to Norris Point with a twinkle in his eye and ready smile. It’s like the line about Blackhat George in a Pittman poem, “…he’s come home to learn to walk again.” Woody Point seems to have become a rather high-profile beacon for the creativeminds set. Award-winning journalist Stephen Brunt founded the fest after coming to the area on a writing assignment. He “fell head over heels in love with the place,” and his family bought a home the next year. And, after a local group got together to help restore the Woody Point Heritage Theatre, the idea of staging a literary festival here was formed. “I hardly knew what a literary festival looked like, and ours evolved into something different than most,” says Brunt. Now in its tenth year, the fest draws literati and legends like Ondaatje and Pulitzer Prize-winning Richard Ford (this
Just For Canadian Doctors SUMMER 2013
year’s big names are Man Booker Prizewinner Anne Enright from Ireland and Giller Prize-winner Will Ferguson) and is hosted by CBC Radio’s Shelagh Rogers. Singers and songwriters add musical mojo to the mix, from The Sharecroppers (also known as Newfoundland’s West Coast Ambassadors) to Alan Doyle of Great Big Sea (who proves that no one performs music like a Newfoundlander). One local band, All the Wiles, even redefines a walk through the woods. During the Writers in the Wild event, a snaking line of festival-goers on the dappled Lomond River Trail emerges from the forest into a sun-soaked meadow to listen to the band’s poignant folk/roots stylings. One couple finds an inviting patch in the long grass away from the crowd and lays down to listen as if enchanted. Other stops along the way: a fantastical puppet show in another meadow, storytelling around the sun-bleached bones of a moose, and a heart-tugging reading by author Michael Crummey by the river banks. The whole surreal experience begins prophetically with guide Fred Sheppard saying, “Who knows what magic and wonder and beauty will happen on the trail.” That’s the resounding feeling here—every walk, every step, could change your life. Hiking, singing, dancing, laughing, weeping…all in one day, one place. “We put the fun in profundity,” says Brunt, and it may just end up as a quote on a future poster for the fest—that and Ondaatje’s comment that it’s the best writing festival he’s ever attended, anywhere. Perhaps it’s something in the water… or that rock. The Rock. After all the revelry, across the water to the north side of Bonne Bay, the road winds away from the imposing Tablelands, past Big Level, to another jaw-dropping chunk of rock that seems to jut straight out of Western Brook Pond (yes, in Newfoundland, far-reaching fjords are humbly called ponds). The cliffs are taller than the CN Tower and the waterfalls plummeting off them are some of the highest on the east coast. Here, again, Mother Nature reminds us of her power and own brand of poetry. That the Writers at Woody Point takes place in a tiny town between such geological wonders is only fitting. As the guide at the Tablelands put it a few days ago on what was once another continent, “The real lesson of this place is how tenacious life is. Life really, really wants to hang on.” Perhaps that’s why here, in enchanted and otherworldly Newfoundland, the cup runneth over with such passion.
A couple lays down in a meadow to listen to music during Writers in the Wild.
Steve Galliot, local shop owner and long-time festival-goer in Woody Point.
Mike McDonald, musician/captain of the ferry that crosses Bonne Bay. The cliffs of Western Brook Pond… so high their tops are in cloud cover.
Fishing shack with whale bone décor.
Rainbow sighting on the ferry crossing from Norris Point to Woody Point.
Michael Ondaatje reads at the Merchant Warehouse on Water Street during last year’s Writers at Woody Point festival.
Stunning rock formations seem to be found around every corner in Newfoundland, like these cliffs across from Norris Point.
An outdoor reading by Michael Crummey during the Writers in the Wild event. SUMMER 2013 Just For Canadian Doctors
15
the thirsty doctor Janet Gyenes
thirsty [continued]
Janet Gyenes is a magazine writer and editor who likes to dally in spirits, especially when discovering something like corenwyn jenever (a gin-like Dutch spirit)—straight or in cocktails like the “bramble.”
mezcal on the rise
Rediscover mezcal ’s allure (Part 1: tequila)
Make room for tequila’s older and smokier agave counterpart
I
f tequila is one of the most misunderstood spirits, then mezcal is a downright mystery. But bartenders are getting schooled on the smoky spirit says Eric Lorenz, Canada’s first mezcalier, whose knowledge of all things agave is encyclopedic. (He’s also a tequila enthusiast and educator who holds the Distintivo “T” Diploma from the Consejo Regulador del Tequila). After completing the first level of mezcalier training from the pros (including the distiller from Scorpion Mezcal), about 20 bartenders working at establishments such as West, Hawksworth and The Shameful Tiki Shack in Vancouver, are a step closer to earn-
AGAVE
ROASTING
mezcal vs. tequila
Piñas are Piñas are typically pit typically steam roasted. roasted.
AGING
1 Pierde Almas Espadín > Slightly smoky
Artisanal mezcal is Tequila may be not aged. unaged or aged in DENOMIoak for a min. of two NATION months. of ORIGIN Mainly Oaxaca Mainly Jalisco
bouquet with hints of aromatic wood and wild flowers. Prolonged duration on the palate with a velvety texture and smooth, fresh tones of quince and anise in the aftertaste. 100% agave espadín; 51% ABV 2 SOMBRA > Spicy, fruity and high-toned, with
notes of citrus and roasted pineapple. 100% agave espadín, 45% ABV
TRADITIONAL GLASSWARE
3 fidencio clasico > Delicate wood smoke and
green pepper scents highlight the bouquet; flavor profile features pipe tobacco, road tar, cigarette ash and pine needle; tangy, piquant. 100% agave espadín; 44.7% ABV
Jicara cup, made from Caballito (Spanish the guaje gourd for “pony”), a tall alcohol shot glass (diluted to by volume 45-55% bottle proof with lower(ABV) proof alcohol) 40% (diluted to bottle proof with distilled water)
{learn}
agave education 16
“The biggest difference is that tequila is a bit industrial and mezcal stayed more primitive,” says Lorenz. Artisanal mezcal-making is unquestionably rustic, and comparisons are often drawn between moonshiners and mezcaliers. Just a few ingredients are required: agave, water, firewood. And a mule. Piñas (the heart of the agave plant) are roasted for three to five days in a pit. Then they’re mashed with a mule-drawn stone wheel before open-air fermentation takes place, followed by distillation in wood-fired stills. The method dates back to pre-Columbian times. There are 30 to 40 agave species that can be made into mezcal, though blue agave, the hallmark of quality tequila, isn’t one of them. “In most cases it’s a single agave that’s used,” says Lorenz. “Most is 100% espadin [agave]. Tobala is second-most known—it’s almost always wild harvested—and takes 16 years to grow.” Age is another wrinkle in the mystery that shrouds mezcal, where youth reigns. “Artisanal mezcal is always presented un-
4 Agave de Cortes Silver > Subtle notes of
smoke, and a sweetness comparable to cognac with bright, refreshing hints of citrus and herbs on the nose and palate. 100% estate grown agave espadín, 43% ABV
Hold the mariachis and caballitos. Bring on the tequila and mezcal, paired with tasty bites at the Monterey Tequila & Mezcal Expo (Canada’s go-to fest, the Vancouver International Tequila Expo takes place in May). October 12, 2013, Museum of Monterey, California; montereytequilafest. com. Tickets go on sale June 24…make it part of a Cali summer escape!
Just For Canadian Doctors SUMMER 2013
{sip}
Oaxacan Daisy
food photo: dr. holly fong
Min. 80% agave; most mezcal is 100% Min. 51% blue agave espadin to be called “tequila.” agave. Sipping tequila is 100% blue agave.
ing the “mezcalier” moniker. Mezcalerias have already been embraced in U.S. cities such as Austin, Seattle and New York (complete with art gallery and burlesque shows), and they’ve migrated to Europe, with eclectic spots open in Paris (think Mexican wrestling masks married with Marais chairs), London, Berlin and beyond. Considering that Mexico is Canada’s winter playground, mezcal-centric joints have been absent from our cool climes. Until now. Canada’s first, La Mezcaleria, finally opened in Vancouver’s vibrant Commercial Drive neighbourhood. Mezcal and tequila flights are on offer, giving guests a chance to get an appreciation of agaves’ complexity and diversity. There’s truth to the old saying “All tequila is mezcal, but not all mezcal is tequila.” Mezcal has been made in Mexico for roughly 500 years, making it the mother of agave spirits, but politics and propaganda pushed younger upstart tequila to the forefront. Both boozes are made in Mexico from agave plants and involve roasting, fermenting and distilling.
Part 2:
aged,” says Lorenz. “Flavours will almost always be more herbaceous...smoky, hybrid flavours like roasted pineapple, dried fruits, roasted red pepper, pine needles, cigarette ash, railroad ties...but also anise, especially in wild-harvested agave species from around Oaxaca.” The smokiness that’s characteristic of mezcal comes from the pit roasting— which permeates the agaves with the essence of fire and earth—not from resting in oak, which is where tequila gets its chocolate, soy and caramel nuances. The age of the agave pre-harvest is what’s important, Lorenz explains. Some people believe that the longer the plant matures, the more the terroir influences mezcal’s flavour. Arroqueño agave, for example, can mature for upwards of 24 years. In effect, the aging has taken place before the spirit has been bottled. Mezcal is produced in very small quantities, compared to tequila, and because of its primitive production methods, each batch is a singular expression. The variables are boundless: the batch, the village, elevation, variety and age of agave, whether the mezcal is made from a single species or ensamble, a blend of three species. It all adds to mezcal’s mystique. To confound matters more, quality mezcal can be aged in oak. It’s not considered artisanal, though, because like tequila, the piñas are steam-roasted. Lorenz describes the flavour of the extra añejo Agave de Cortés as “...raisins, caramel and just delicious, thick sweet spice.” On the menu at La Mezcaleria? A dozen varieties already, including Fidencio Pechuga, a curious concoction, where distilled mezcal is infused with the essence of, yes, a whole chicken breast. Artisanal or not, expect to see this smoky spirit explode onto the booze scene soon in Canada. The volume of mezcal imported for sippers to savour has expanded exponentially in the past few years, with artisanal brands such as Fidencio, Pierde Almas, and El Jolgorio entering the market. And like mezcal’s more youthful counterpart, tequila, it’s best when sipped neat or matched with ingredients that complement—not mask—its assertive essence.”
1.5 oz Sombra mezcal + 1 oz Cointreau (or Giffard Triple Sec) + 3/4 oz freshly squeezed Meyer lemon juice Shake ingredients together with ice. Serve in a coupe glass; garnish with Meyer lemon peel.
the hungry doctor dr. fong Dr. Holly Fong is a practising speech-language pathologist with three young children who is always trying, adapting and creating dishes.
fresh catch
Serve up a snappy taste of summer
W
hen summer rolls around, the world around me seems to be awash in colour. I love the yellows, shades of light green, blues, reds and pinks. To celebrate the season, I find myself making more fish and serving it simply with a salsa. When I was a child, my family had easy access to a variety of fish and I loved the crispy skin of pan-fried fish. Nowadays, it’s much harder to find fish filets with the skin unless you buy a whole fish and ask the fishmonger to scale and filet it. It’s well worth the effort as the skin has most of the fatty omega acids and adds a welcome crunch to the soft moist flesh. As mangos are in season, it makes a colourful salsa when combined with avocado. Adding some prawns, lime, chili and cilantro brings to mind a refreshing ceviche without the raw seafood. This salsa works well with any fish. If you are using an oily fish, simply add more lime juice. But with a mild or medium fish such as snapper, the juice of 1 lime is sufficient. When choosing a wine with this dish, first consider the type of fish and then the spicy sweetness of the salsa. If it is an oily or meaty
Pair a light fish like snapper with a new-world Sauvignon Blanc or dry Riesling. For denser, meatier fish, go with a Gewürztraminer.
fish such as salmon or halibut, a Gewürztraminer would work well. But for a lighter fish such as snapper, a new world Sauvignon Blanc or dry Riesling would be delicious. A recent find was the Pewsey Vale Eden Valley Riesling 2012. This wine had fruity peach, green apple notes with a slight spicy tangerine and lime taste. The brilliant refreshing acidity worked well with the spicy chili and the long finish left a mouthwatering dryness. (As an aside, the acidity will allow the wine to be cellared, but it is enjoyable now.) Yum.
Pan-fried Snapper with Mango Avocado Salsa (serves 4) 4 pieces of red snapper, approximately 180g each, skin on but scaled salt and fresh ground pepper 2 tablespoons olive oil salsa 1 lime 1 ripe but firm avocado 1 ripe but not overly soft Ataulfo mango 2 medium hot red chili peppers 4 green onions, rinsed with ends cut 1 small clove garlic, peeled smashed and minced 1 teaspoon chopped cilantro 175g prawns 1 tablespoon olive oil a ¼-inch small slice of ginger, cut in half pinch of salt extra virgin olive oil small sprigs of cilantro for garnish
To make the salsa, start by peeling the shrimp. Add salt and pepper to taste. In a heavy fry pan large enough to hold the shrimp in 1 layer, add 1 tablespoon olive oil and heat over medium-high heat. Add ginger. When oil is shimmering, add shrimp. Cook for 2 minutes before turning shrimp for another 2 minutes. Remove and let rest while preparing other salsa ingredients. Discard ginger. Zest lime and juice over a bowl. Dice avocado and mango into ½-inch pieces and add to lime mixture. Add thinly sliced chilies (scrape out seeds but leave some pith for heat), green onions and ½-inch diced shrimp to the salsa. Add minced garlic, chopped cilantro and gently mix all ingredients. Lightly salt to taste and set aside.
Run fingers along the flesh of fish to check for any pin bones and remove. Pat fish dry with a paper towel. Lightly salt and pepper both sides. In a large, heavy non-stick fry pan, heat 1 – 2 tablespoons oil over high heat. Swirl to coat. When oil is shimmering, place fish skin side down. Do not move or poke the fish, otherwise skin will not crisp. Let it cook for 2 ½– 3 minutes depending upon the thickness. When fish is opaque half way through, carefully turn over and cook for another minute. Remove pan from heat to plate so fish does not overcook. To serve, spoon salsa onto 4 plates and arrange a piece of fish on top. Drizzle a little extra virgin olive oil around the edge of plate and garnish with cilantro sprigs.
SUMMER 2013 Just For Canadian Doctors
17
travel the world
Join the party in
Edinburgh,
Scotland’s (and the world’s!) >>
Festival City story by A. F. Shearer
aka
festival
city
©VisitBritain / Britain on View
Athens of the North
T
View of Edinburgh Castle from Princes Street gardens. photo: Simon Winnall/VisitBritain opposite page,
Traditional garb. photo: Pawel Libera right
Just For Canadian Doctors SUMMER 2013
Scotland. It is dominated by the Castle—a stunning structure that’s best seen across the gardens from the open-sided Princes Street. Standing atop this ancient volcanic peak since at least the 12th century, it has evolved over the centuries yet remains a military centre to this day. The spectacle of the famous Royal Edinburgh Military Tattoo is held on the Castle esplanade every summer (this year’s spectacle is from August 2 – 24, and is expected to attract some 220,000 people). Start from the top with a Castle tour and walk down the Royal Mile, the medieval main street running from the Castle to Holyrood Palace. Take a small detour to your right at Bank Street, and right again down the curved Victoria Street to the Grassmarket, site of the old gallows with the appropriately named pub “The Last Drop” nearby. Back on the Royal Mile visit St. Giles Cathedral with its lovely stained glass and explore the “wynds” (narrow alleys) and stairwells. Avoid the tatty tartan tourist traps and meander down to the Palace that’s still used on state occasions by the Royal Family. Dominating the skyline is Arthur’s Seat, another craggy reminder of the region’s volcanic past and an easy walk to outstanding city views. On the grassy slopes below, the first game of golf was played in the 15th century… and
scotland = scotch When
When in Scotland… be sure to sample a wee dram (or more) we’ve been paying the price ever since. To Scotland’s discredit (or credit, depending on opinion), it’s responsible for three of the most toxic inventions known to man: whisky, golf and the deepfried Mars bar. And, to its great credit, Scotland’s capital is known as the world’s Festival City. So, yes, be sure to visit this city (heeding Adams’ words) and, better yet, do so during the biggest event in the city calendar: the annual Edinburgh Festival that takes place every August. Founded in 1947, it’s considered one of the most important cultural celebrations in the world (including opera, dance, music, visual art, theatre) with the legendary Fringe growing up alongside and now almost engulfing it. The beauty of the Fringe is that it is open access—anyone can put on a show. This leads to an eclectic mix of
in Scotland, visit a distillery. Just follow the sign-posted Whisky Trail. Not all are architectural gems but some are quaint, with Edradour being the smallest and cutest. As for whisky itself there are two major categories—single malt and blended (and good blends are by no means necessarily inferior). Single malts are roughly split between Highland and Island. If complex peaty, smoky, seaweed-infused flavour is to your taste then try one from the island of Islay or a Talisker from Skye (my favourite). The better known but middle-of-the-road Glenfiddich, Glen Morangie and Glen Livet are all Highland, as is the upmarket Macallan. Visit the Scotch Whisky Heritage Centre near the Castle, and you’ll learn more than you ever wanted to know about the subject.
celtic cuisine Gone are the days when the odour of boiled cabbage and carrot permeated the corridors of Scottish hotels. I’ve travelled extensively and four of the top 10 meals I have ever had were in Scotland (though admittedly my frequent visits may skew the statistics). Today’s local culinary scene is vibrant. Fresh produce, grass-fed beef and lamb and wonderful seafood are the ingredients for a new breed of young imaginative chefs such as Mark Greenaway. Edinburgh has six Michelin-starred restaurants (the highest in the U.K. outside of London), and Scotland as a whole has 16. In Edinburgh, sample the fare at the Michelin-starred Restaurant Martin Wishart and The Kitchin, both in now-trendy Leith. For high-end vegetarian, there’s David Bann on St. Mary’s Street, or for a quick meal, Hendersons on Hanover street, a city fixture for years with self service or takeaways. And try the haggis—love it or hate it—even a deep-fried mini one from the ubiquitous fish-andchip shops.
/VisitBritain opposite
if you go Find out more
Street performer at the Edinburgh International Festival. photo: Grant
about what Scotland (2013 is being officially promoted as the “Year of Natural Scotland”) has to offer at visitscotland.com. Or check out Visit Britain: visitbritain.com.
page, far right
Pritchard/VisitBritain
18
he autobiography of Douglas Adams, author of A Hitchhiker’s Guide to the Galaxy, starts with the sentence: “Anyone who hasn’t been to Santa Fe is an idiot.” Harsh perhaps, though true, and if you substitute Edinburgh for Santa Fe it would be truer still (as, Adams, a performer himself here at the legendary Fringe in 1976, would likely agree). For decades travellers to Britain missed a European gem by never making it north of York…but people are smarter now. Edinburgh is known as “The Athens of the North,” a name conjured during the Scottish Enlightenment in the mid 1700s because of its classical buildings and the fact that it was a “hotbed of genius” like ancient Athens. A population of 500,000 makes it a compact and walkable city. The “New Town” was built in the late 1700s to provide escape from the foul-smelling and overflowing medieval “Old Town,” and consists of large squares and sweeping terraces of magnificent Georgian architecture—the biggest Georgian city outside of Bath, England. Both the Old Town and New Town were designated UNESCO World Heritage Sites in 1995, and Edinburgh is consistently viewed as one of the world’s most beautiful and liveable cities—“a wee cracker,” as they say in
travel the world
SUMMER 2013 Just For Canadian Doctors
19
travel the world The 2013 Edinburgh International Festival takes place August 9 to September 1. For more info: eif.co.uk
At this year’s fest: a musical performance by Patti Smith and Philip Glass (photo: Stephanie Berger); the opera Dido and Aeneas (photo: Monika Rittershaus), and the dance performance Don Quichotte du Trocadéro (photo: Patrick Berger).
victoria / waikoloa / leiden / la paz / tuscany … | c a l e n d a r
varying quality, embracing the weird to the wonderful and all points in between. There are tens of thousands of performances in some 400 venues, and every school gym, church hall and meeting room is booked well in advance to accommodate acts like a Dallas Methodist high school performing the musical Hair (somewhat underwhelming) or the Canadian Lumberjack show (fabulous comedy). Worldfamous maestros perform next door to drama, revues, comedy, visual arts, lectures, children’s shows, cabaret, street performers, dance and music of all kinds, and the city buzzes with electric excitement. This year’s lineup includes acts that range from rock icon Patti Smith to “a mesmerising deconstruction of Franz Kafka’s seminal novella,” Metamorphosis. Shows can cost as little as $10 or $20 and festival veterans compete to see as many as they can in a day. If that weren’t enough, other festivals have hitched a ride on the juggernaut. In June there’s the International Film Festival and the Jazz and Blues Festival in July. And while the main festival in August is going on there, there’s also that must-see Military Tattoo and The International Book festival. Even walking Edinburgh’s streets is a literary journey itself; a little-known fact is that the city is home to the richest piece of literary real estate in the world known as “Writer’s Block,” where J.K. Rowling, Ian Rankin and Alexander McCall Smith all live as neighbours, with Kate Atkinson also in residence nearby. After a wee dram, I close the way I started. Anyone who doesn’t visit Edinburgh in particular and Scotland in general is an idiot. Simple fact, no offence intended. My only caveat is the weather, which is not a strong point of the country. Go in the summer months when there are at least enough sunny days to showcase Scotland’s many attractions (and, with the pound at record lows to the dollar, the time has never been better). A Gaelic toast, slàinte (health!), awaits you.
cme
A n in ter n ation a l guide to continuing Medical Education
victoria
summe r 2013 + beyond
1
3
2
4
5
Victoria is the grand-dame on Canada’s west coast. Zen-like seaside living + a college vibe contrasts with tradition + colonial charm for old-school cool. (CME events in Victoria are highlighted in blue.)
The Royal Edinburgh Miltary Tattoo takes place on the Castle esplanade this August 2 – 24. Find out more about this fest at edintattoo.co.uk.
20
Just For Canadian Doctors SUMMER 2013
Performers on the Castle Esplanade during the Royal Edinburgh Military Tattoo. photo: P. Tomkins/Visit Scotland
B. Sligl; top left photo: courtesy of Magnolia hotel
R
echarge in Victoria. It may be one of Canada’s stateliest cities, and BC’s capital, but it’s also one of the most zen… Behind a traditional facade, there’s a cool new-school vibe. Get zen! fly If you’re coming from Vancouver, take the shortest—and most scenic—route…by plane. Take off from Vancouver’s downtown harbour, fly over the Lions Gate Bridge and the Gulf Islands right into Victoria’s downtown harbour. It’s the easiest and prettiest commute ever. harbourair.com stay Off the float plane, it’s an easy walk to the Magnolia Hotel. You’ll see the iconic Fairmont Empress seaside, but tucked just behind it is this boutique gem 1 . The concierge will even meet you and guide you there (and deliver your luggage). In the lobby, refresh with watermelon-flavoured water (always on hand) before unloading and getting back out on to Victoria’s harbour. Suppress the desire to hole up in the just-renovated luxury of a sea-view suite (come morning, if you’re lucky, you’ll see the moon setting in a pinky sky 2 ) and get back outside… magnoliahotel.com
do Get out for a jog through Beacon Hill Park (and meet a regal peacock or two 3 ) and along a spectacular seaside trail 4 . Rent a kayak or take a tour with Ocean River Adventures. You’ll paddle by seals, sailors, rowing crews and colourful houseboats—and even a take-out window specifically for water traffic. Zen is starting to take hold… 4 oceanriver.com sample Off the water there’s plenty of microbrews in which to partake in a post-paddle pint. Victoria even has a microbrew trail. Try the Phillips Blue Buck or Ginger beer (apropos with the west-coast mainstay, sushi). phillipsbeer.com The beer may be fortifying, but for healthier fare, head to Rebar restaurant for a matcha smoothie and hip boho dish like the popular almond burger. Rebar even describes itself thus: “fusing hippy-chic neo-noir retro-fitted coolness.” Indeed, it’s a tasty mouthful here. rebarmodernfood.com spa After a paddle and a pint, it’s back to the sanctuary of the Magnolia Hotel, where the spa awaits. The Magnolia Spa boasts the Intelligent Nutrients skincare line (intelligentnutrients.com), created by Horst
Rechelbacher, the man who created Aveda. Everything is USDA organic. In fact, you could eat it and feel great—in many ways (after-tax profits go to enviro groups). Only available in Canada since last year, this is the place to try it. Choose from four spa treatments that use the yummy stuff. spamagnolia.com sip To maintain the serenity, there’s tea at Silk Road. Here, you can do a tea tasting or “cupping” in a zen-like environment complete with minimalist white vessels (all the better to highlight tea’s qualities). Tea master, Daniela Cubelic, explains how high-quality tea is similar to wine, requiring the same see, swirl, sniff, slurp and sip steps to fully appreciate. Terms like “vegetal,” “barn” and “floral” are bandied about. Here, the “whisky of tea” is Pu-erh or, as it was referred to in ancient China, “one of the elixirs of immortality.” Our advice? Take some home with you—stat. Or the Ruby Pagoda, which is like an “inner facial.” silkroadteastore.com Now, consider yourself recharged. —B. Sligl For more info on Victoria, go to tourismvictoria.com; and Vancouver Island in general, vancouverisland.travel.
SUMMER 2013 Just For Canadian Doctors
21
Issue: Fax: Biochemistry
Attn:
topic
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Aug 19-21
Barrie Ontario
Botox And Aesthetic Fillers
Dr. Martin’s Training Centre Canada
800-627-3309 See Ad Page 32
Sep 14-15
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Professional Facial Aesthetics Training
The Physician Skincare and Training Centre
Sep 23-27
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One Week “Everything” Training Course In Botox, Fillers And Medical Aesthetics
Oct 12
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ptcenter.org
Sep 26-29
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18th Annual Scientific Session Of The American Society Of Nuclear Cardiology
American Society of Nuclear Cardiology
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800-627-3309 See Ad Page 32
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Oct 28-30
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20th Annual Coronary Interventions
Scripps Conference Services and CME
858-652-5400
scrippshealth. org
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Las Vegas Nevada
SCAI
202-741-9854
scai.org
ptcenter.org
Dec 08-11
SCAI 2013 Fall Fellows Courses
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The Physician Skincare and Training Centre
Sep 22-24
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2013 Annual Meeting Of American College Of Clinical Pharmacology
American College of Clinical Pharmacology
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Oct 05-09
Alushta Ukraine
Recent Advances In Arythmology
NBScience
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Oct 25-27
Hong Kong China
8th Asian Conference On Pharmacoepidemiology
University of Hong Kong
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Nov 11-17
Las Vegas Nevada
Pharmacology For Advanced Practice Clinicians
Contemporary Forums
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Jul 31Aug 05
Brighton England
Occupational Contact Dermatitis And Skin Surveillance
University of
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Dec 09-21
Singapore to Hong Kong Cruise
Primary Care: Dermatology And Oral Dermatology Review
Continuing Education, Inc./University at Sea
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Dec 27-29
New York New York
Dermatology For The Non Dermatologist
MCE Conferences
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American Academy Of Facial Plastic & Reconstructive Surgery Fall Meeting 2013
Jul 07-09
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International Congress on Naturopathic Medicine
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Jul 12-14
Estes Park Colorado
Colorado Integrative Medicine Conference (cIMc 2013): Focus On Mind-Body Medicine & Lifestyle Management
Altermed Research Foundation
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altermedresearch.org
Sep 11-14
Napa California
14th Annual Conference On Integrative Medicine In Women’s Health
Symposia Medicus
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Oct 04-08
Chantilly Virginia
10th Annual Science And Clinical Application Of Integrative Holistic Medicine
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Jun 26-27
St. Pete Beach Florida
Ultrasound Scanning Skills Workshop
Gulfcoast Ultrasound Institute
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32nd Annual European Society Of Regional Anaesthesia Congress 2013
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43rd Annual Meeting of the International Society of Psychoneuroendocrinology
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New Concepts & Emerging Therapies In Metabolic Disorders & Vascular Disease
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3rd World Congress On Parkinson’s Disease
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Jan 04-22 2014
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59th Annual Meeting Of Canadian Fertility And Andrology Society (CFAS)
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Conference On Practice Improvement
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Cape Breton Island: Great People, Great Place, Great Life The Cape Breton District Health Authority has full-time positions and locums in: Emergency Medicine Family Medicine Medical Oncology Palliative Care Pathology Psychiatry Radiology Hematology General Internal Medicine (interest in Rheumatology) For more information about these positions or our District, contact Dr. Rex Dunn, Vice President, Medicine, Cape Breton District Health Authority 1482 George Street, Sydney, Nova Scotia B1P 1P3 Fax: (902) 567-7255 Cape Breton District E-mail: dunnr@cbdha.nshealth.ca HEALTH AUTHORITY Website: www.cbdha.nshealth.ca M a k i n g H e a l t h i e r C h o i c e s To g e t h e r
26
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________________________________________________________________________ E-mail: ________________________________________________________________ Tel: ______________________________ Fax: _________________________________ Sudoku Puzzle Contest Rules: 1. Entry form must be accompanied by solved puzzle. Only correctly solved puzzles entered into random draw. 2. Send puzzle and entry form to Just For Canadian Doctors, 200 – 896 Cambie Street, Vancouver, BC, V6B 2P6 or by fax to 604-681-0456. Entries must be received no later than September 4, 2013. 3. Prize: 3-month unlimited membership to Bikram Yoga Vancouver (valued at $420) or a $50 Visa gift card. Odds of winning dependent upon number of entries. Winner contacted by telephone and announced in Fall 2013 issue. 4. Contest can be changed and/or cancelled without prior notice. 5. All entries become property of In Print Publications. Employees of In Print Publications and its affiliates are not eligible to participate. SUMMER 2013 Just For Canadian Doctors
27
motoring
D r . k e l ly s i l v e r t h o r n
motoring [continued] Dr. Kelly Silverthorn is a radiologist and Just For Canadian Doctors’ automotive writer.
summer fever Open-air automotive contagions
S
pringtime is new-car-fever season. I seem to be afflicted almost every year. Spring 2013 looks set for an epidemic, with car manufacturers shamelessly flooding the marketplace with highly potent open-air contagions. Forewarned is forearmed! Spring’s arrival heralds annual Canadian automotive rituals. Snow-tires-be-gone. Window scrapers unceremoniously tossed into warmweather hibernation. Our daily drivers are washed by hand for the first time since October. Those fortunate enough to have a special-interest summer car get antsy on the insurance and tire pressures. With the ever-increasing warmth of the sun and length of the days, our thoughts invariably turn to a new open-air car. A sunroof just doesn’t cut it. It won’t give that all-important exposed-to-the-greatoutdoors feel. However, open-air doesn’t have to be the classic canvas-stretchedover-metal-frame convertible either. The marketplace is graced with numerous other approaches including retractible hardtops, removable Targa panels and sliding canvas screens. And in each of these open-top solutions, driving is no longer zone-out drudgery. Car trips now include luxuriating in that solar radiant energy, absorbing every last one of 360-degrees of visual stimulation. Sounds encircle you. Even momentary stops have you conversing with pedestrians and motorcyclists. Drive past a brook and actually hear it babble—and simultaneously feel the humidity change. Despite the attraction of open-air motoring, sales are a small fraction of the overall automotive marketplace, and those extra engineering costs need to be recouped from buyers. It’s not uncommon for an open-air model to cost $5–20K more than its fixed-roof corporate sibling. Manufacturers of limited-production
platforms can also drag out that technology for eight years or more, so beware. Do your research (Wikipedia is a great resource on the age-of-platform front). On the flip side, there has never been another time with so many freshly engineered open-air platforms in the marketplace. Premium brands often bundle open-air, with luxury, and performance—a tantalizing trifecta of motoring indulgence. First, let’s go big in the upper reaches of the openair Canadian marketplace, before getting to the more entry-level models (all pricing relates to MSRP “base” price, recalling that options and taxes can add considerably to the outthe-door cost). And, given Canadian climates, it’s nice to see multiple all-wheel-drive offerings among the open-air models sold. Interestingly, several major brands like Toyota, Honda/Acura and Hyundai don’t offer a single open-air model. Even hardcore Lotus currently offers no open models in Canada. Others offer a single “halo” open-air model, rarely seen on the public roads but featured in the dealer showroom to lend some magic to the surrounding more mundane hardware.
Driving is no longer zone-out drudgery
28
If you have to ask the price, you probably can’t afford it.
The century’s paragon of automotive excess, the Bugatti Grand Sport, has a Canadian dealer. Price is into seven digits, horsepower 4 digits, and the top speed has more mph than the USA has had birthdays. Canadian sales, however, can be counted on the fingers of one hand of an inattentive millworker. The only car that can withstand the Bug’s black-hole shadow is the newly minted Lamborghini Aventador LP700-4 Roadster, with, you guessed it, 700 horsepower and mandatory Lambo rakish style. Stepping down to the merely exotic (yet still with a base price over $200,000), we have a surfeit of open-air choice. From the
Just For Canadian Doctors SUMMER 2013
luxury end of the spectrum, there’s the Rolls Royce Phantom and—moving progressively towards the more performance focused— the Bentley Continental GT Convertible, then the cruise-worthy Ferrari California and Aston Martin DB9, through to the ballistic but GT-ish Mercedes Benz SLS AMG, and on to a quartet of hard-core performance steads: Ferrari 458 Italia, Lamborghini Gallardo, Audi R8 GT Spyder and new entrant McLaren with its impressive MP4-12C. Benchmarks? This is heady company, but it’s hard to argue against Britain’s Rolls Royce or Italy’s Ferrari, perhaps the two most iconic brands in the automotive universe.
Like life itself, the journey is more important than the destination …who or what comes along for the ride matters open air fair: From the
Between $100,000 and $200,000 offers a mix of “exotic” and
more mainstream brands and models, from the many variants of open-air Porsche 911s (though just barely the most potent Turbo S) to multiple Audi R8s Spyders. Aston Martin’s Vantage and Vantage S span this price range, as does the Maserati Gran Turismo Cabrio. Mercedes’ newest allaluminum version of the ever-green opentop SL range also plies these waters, as does the long-serving alloy-bodied Jaguar XK / XKR/ XKR-S. BMW’s 6/M6 Cabriolet range carries the open-air flag for blau mit weiss. If Viper does an open-top version it will be priced here, as will any open variant of the oft-promised new Acura NSX.
C70, starts at $52,500. Infiniti has the G convertible, and Lexus both the 250C and 350C.
Benchmark cars here are all German: Porsche 911, Audi R8, Mercedes SL. A plethora of open-air models are available between $50,000 and $100,000, and this range is where most of the more-established readers may be tempted to tread. Among the Germans, Audi pitches its A5/S5 pair, as well as the TT and TTS fraternal twins. BMW counters with the Z4, and soon-to-be-replaced 3/ M3 Series Cabriolet. Not to be outdone, Mercedes offers the sports SLK variants and the middleweight E350/550. Porsche’s excellent Boxster range starts at $56,500 and now adds great looks to its decathlete-like skill set.
Outside Germany, England’s Jaguar will soon enter this pricespread fray with the stylish new F Type sports car range featuring supercharged V6 and V8 engines with 340–495 horsepower. The full range of upcoming C7 Chevrolet Corvette Targa tops and convertibles will be included here, as are upper-end stablemate Camaros. The open Shelby Mustang GT500 is priced at $66,699. Somewhat less adrenaline-infused, Volvo’s only convertible, the long-running
Benchmarks are, again, all German. Of those with two seats, it’s the Porsche Boxster (although both the new Jag and Vette look promising). Among fourseaters, I’ll have to reserve judgment until the first-ever 4 Series BMW arrives (in deference to the BMW 3 Series’ long stranglehold on this title). Ten choices remain between $25,000 and $50,000. From least- to mostexpensive base price, the list includes: the Beetle Convertible, MINI Roadster, Mazda MX5 (Miata), Ford Mustang V6, MINI Convertible, Chrysler 200, Chev Camaro 1LT, VW Eos, Ford Mustang GT, BMW 1 Series and Nissan 370Z.
top-dollar, paragonof-automotive-excess Bugatti (above) to the affordable, ultra-cute Fiat (left).
The twoseater benchmark is Mazda’s (soon to be replaced) MX5; the four-seater benchmark goes to the BMW 1 Series or Mustang GT.
And the most affordable open-top car in Canada? That
title is currently held by the ultra-cute Fiat 500c at $17,495. Competitors include the also fuel-frugal Smart ForTwo Cabriolet at $20,500 and the rugged go-anywhere Jeep Wrangler at $21,195. No matter what the price or the performance, convertible owners share a bond of mutual understanding. Driving can indeed be more than just getting from A to B. Like life itself, the journey is more important than the destination. Your choices of who and what comes along for this ride matters. So do yourself a favour. When spring fever next strikes, cough up an hour of time to savour the signs and symptoms. Call up the dealer of the open-top car that has captured your fancy, and put your butt in that seat-of-dreams for a test drive. Life’s trajectory starts afresh from today.
SUMMER 2013 Just For Canadian Doctors
29
pay i t f o r w a r d
pay i t f or wa r d [ c o n t i n u e d ]
r o b e r ta s ta l e y
Roberta Staley is an award-winning magazine editor and writer with experience reporting from the developing world and conflict and post-conflict zones. Staley specializes in medical and science reporting and is a magazine instructor at Douglas College and Simon Fraser University.
which is widely practiced in this traditional, conservative Islamic nation of mainly subsistence farmers. Female circumcision causes severe bleeding and infection as well as long-term urinary and menstrual problems, infertility and difficult childbirth. It can even lead to death. Venugopal’s efforts made an impact. Following a meeting with about 150 staff, where he and colleagues talked about the health consequences of genital cutting, one of the
under the medicine tree
A Toronto doctor is the Medical Team Leader for Médecins sans Frontières (MSF) in Chad
So Venugopal did something unorthodox. He had another staff doctor insert a needle into the young woman’s abdomen and withdraw a syringe of bright red blood. Faced with indisputable evidence that the patient was hemorrhaging, staff sprung into action, whisking her into the
30
surgical ward. That “was a very gratifying cousin tuberculosis are also prevalent, as moment,” says Venugopal, who saw the are obstetrical problems. But the allteen a few weeks later, a happy and “healthy pervasive specter of death is countered young woman in African dress.” by sometimes-miraculous recoveries. “We As the Medical Team Leader for see children in critical states and are able Médecins sans Frontières (MSF) in Chad, to resuscitate them. Such incredible stories Venugopal has many such gratifying happen every day, and moments. There are also many tragic and help you regain hope,” frustrating ones. Wracked by decades says Venugopal, who Dr. Raghu of civil war, poverty, famine and spoke to Just for Venugopal drought, Chad has the world’s Canadian Doctors ministering to a highest mortality rate for by telephone from young patient in the Chad. Democratic Republic Venugopal’s of Congo. recent sojourn to Chad was his 10th medical mission to Africa. He has also provided crisis care in Albania and Kosovo and helped develop emergency medical systems in Tanzania, the West Bank and Gaza and Ethiopia. “It’s a very special and rare privilege to work with the highly vulnerable,” says Venugopal, an attending physician at Toronto General Hospital and Toronto Western Hospital and assistant professor of medicine at U of T. As team leader in Chad, Venugopal shouldered many responsibilities. He not only practiced medicine but undertook the administrative work. This included monitoring and ordering drugs, compiling medical statistics and analyzing morbidities, drawing up employment contracts, managing staff children under five, while life expectancy and dealing with complaints. “It’s incredibly hovers at 48. Venugopal and the nation’s difficult,” says Venugopal, who grew up in handful of health care workers combat a New Brunswick to civil servant parents. “In “mind-boggling” child mortality rate of Canada, I have the luxury of just taking care 10 per cent from malnutrition, measles, of patients, which itself is challenging.” diarrheal diseases and respiratory tract Venugopal also undertook to work with infections. HIV-AIDS and its opportunistic Chadians on female genital mutilation,
Just For Canadian Doctors SUMMER 2013
“To have one of their own countrymen speak up against this violation of girls’ rights and women’s rights was another powerful moment”
courtesy of Médecins sans Frontières (MSF)
T
o Dr. Raghu Venugopal, the symptoms were unmistakable. A 17-year-old woman in her first trimester of pregnancy. Vaginal bleeding. Abdomen rigid as a board. Clearly this was an ectopic pregnancy requiring immediate surgery. But staff at Am Timan Hospital in the southeastern region of Chad shook their heads at Venugopal’s diagnosis, even when the portable ultrasound machine he brought from Toronto showed the patient’s “liver and spleen floating in blood.”
Chadian drivers—a respected profession in the north central African nation—stood up and confessed that he had all four of his daughters circumcised. But now, he told the gathering, “things have changed and I will no longer have the women in my family cut because it is the wrong thing to do.” Says Venugopal, “To have one of their own countrymen speak up against this violation of girls’ rights and women’s rights was another powerful moment.” Venugopal’s favourite times in Chad were jumping into a Toyota Landcruiser and driving up to 60 kilometres through the dusty red rutted roadways to one of MSF’s nine rural medical outposts. Three outposts have no actual structure—one is located under a sprawling acacia tree. Its protective boughs give shade from the desert sun and shelter from monsoon rains. The Chadians may not know their age or what year it is, but they always remember MSF’s weekly health care visit, says Venugopal. At the request of the Chadian Ministry of Health, MSF is planning to expand its outreach program, possibly driving up to 100 kilometres away, which will require staff
to stay overnight. It may also mean using boats to cross turgid rivers and even riding horses to navigate rough terrain during the wet season to bring health care to isolated communities, Venugopal says. Venugopal, 38, returned to Toronto this past May to marry his fiancée. He hopes to return to countries like Chad in the near future with new wife Maeve, to continue giving those in need the same level of comfort and care that Canadians enjoy. But even
when a patient is beyond medical aid and is slipping towards death, there is much that can by done, simply by taking the person’s hand. “The exchange of humanity is there. That smile, that moment of solidarity— that’s priceless,” says Venugopal. Read about Venugopal’s medical ministrations to Chadian patients at his MSF blog: blogs.msf.org/raghuv/author/raghuv.
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SUMMER 2013 Just For Canadian Doctors
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office space
RICHMOND, BC — Office space available four days a week for Consultant / Specialist / Podiatrist etc. in a busy group Medical Practice in Richmond BC’s Premier Strip Mall. www. mydoctor.ca/drsinghal For information please phone 604-448-9595 Email: msinghalmd@ gmail.com
NANAIMO, BC — Edgewood, located in beautiful Nanaimo, is an internationally renowned accredited and licensed facility seeking a general practitioner locum from July 2-19, 2013 and December 23 – January 3, 2014. This is a unique offer providing an opportunity to work with a multidisciplinary team in a residential addiction treatment setting. Flexible hours with no on-call requirements. A competitive remuneration as well as accommodation is included in this locum position. Contact: Dr. Gary Richardson. Email: gary@edgewood.ca or telephone: 800-683-0111. LONG TERM ASSOCIATE FAMILY PHYSICIAN POSITION — A Family Physician wanted for a Richmond BC collegial group medical practice with EMR and Chronic Disease Nurse as well as excellent support staff. We wish a current Canadian Licensed non-conditional for selected shifts or to transition a current practice into a group / clinic setting. We anticipate professional satisfaction with excellent earning potential. Full support. 70-30 split. www.mydoctor.ca/drsinghal Please phone: 604-448-9595 Email: msinghalmd@ gmail.com SHORT TERM LOCUM FAMILY PHYSICIAN — Richmond BC (September 30, 2013 - January 5, 2014). A Family Physician wanted for a Richmond BC collegial group medical practice with EMR and Chronic Disease Nurse as well as excellent support staff. We also have a walk in practice. We are flexible for dates and times
Quinte Health Care
worked, breaks, etc. We anticipate professional satisfaction with excellent earning potential. 70-30 split. Coverage is for three physicians who will be away during these times consecutively. www.mydoctor.ca/drsinghal Please phone: 604-448-9595 or email us at msinghalmd@gmail.com Family Practice — Deep Cove, North Vancouver: Play, work, love! Ideal personal environment for family and professional life with all the necessary accoutrements for a rewarding career. Large, young practice with shared 1,860 square foot office and two cross covering colleagues, no locum hassles. EMR installed 2011 MED ACCESS. Flexible transition. doctorb@shaw.ca 1-604-657-5949 position available — MedSleep is seeking part-time associate Respirologists, Internists, Psychiatrists or Family Physicians to join our growing medical team as we expand our services nationally, specifically in Nanaimo BC, Edmonton AB, Niagara Falls and Kingston ON. Our clinics provide clinical assessment and diagnostic sleep studies (portable and in-house polysomnography) for the full spectrum of sleep disorders. Previous sleep medicine experience preferred, however, onsite training in sleep medicine can be provided. Low overhead with opportunity for both feefor-service and additional third-party income. Submit your CV to jobs@medsleep.com and visit our website at www.medsleep.com.
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The four hospitals of Quinte Health Care (QHC) provide primary and secondary services to a population of 160,000 in Hastings and Prince Edward Counties. The region, which has become one of Canada’s most desired locations to live, includes a number of diverse and culturally rich urban and rural communities within an area defined by both its pastoral settings and its proximity to a multitude of waterways. It has a remarkable heritage and a strong sense of community; its residents enjoy some of the best arts, culinary and recreational opportunities in Ontario yet it is less than two hours from Toronto. For more information and a map of the area, please visit www.qhc.on.ca.
Opportunities Pediatrician – Full Time or Locum Work Available: QHC is recruiting a full time or locum Pediatrician to join our current three member department. Paid accommodations may be available for locum work. QHC Belleville General Hospital's Maternal-Child Unit has 10 pediatric beds, an 8-bed intermediate care nursery (special care nursery) for high risk newborns, an operating room for caesarian sections, and a 17 bed obstetrical unit. In February 2010, the Children's Treatment Centre (1 of 18 in the province) was relocated to QHC’s newly built, state-of-the-art, Charlotte Sills wing at QHC Belleville General Hospital. A Pediatrician run clinic also exists within the hospital. Pediatrician – Department Chief: QHC is also recruiting for a full time Department Chief. Reporting to the Chief of Staff, the Department Chief will be a member of the Professional Staff appointed by the Board of Directors and is responsible for the professional standards and quality of care rendered by the members of his/her department within QHC. For a position profile, please contact Rob Callaghan at rcallaghan@medfall.com. Belleville General Hospital Family/Emergency Medicine: Responsibilities for family medicine include: inpatient care, orphan patient care and call obligations. Physicians also have the opportunity to join a Family Health Team, Family Health Network or a family health group. There are also opportunities for ER, surgical assisting and OBS. Trenton Memorial Hospital Family/Emergency Medicine: Responsibilities for family medicine include: inpatient care, orphan patient care and call obligations. The department has an innovative call model which includes hospitalists work as well. Physicians enjoy full specialty support and access to state of the art diagnostic equipment including an onsite multi-slice CT scanner with a Picture Archiving and Communication System (PACS) and an MRI at Belleville General. Physicians have the opportunity to join a family health team. Emergency Medicine (34,000 visits annually) positions are also available. North Hastings Hospital Family/Emergency Medicine: QHC is also recruiting for FM/ER Physicians to work
at our smallest and most rural hospital in North Hastings. Our state-of-the art facility is located in the beautiful town of Bancroft in a Health Care Campus which also includes a Long Term Care Facility, a Satellite Dialysis Clinic, Public Health office, CCAC on site, as well as other Community Care in the building. Emergency Room sees 14,000 visits annually.
Stroke Prevention Clinic – Belleville General Site: Seeking a Neurologist/ Internal Medicine Generalist/ or
Family Practitioner for the Quinte Health Care Stroke Prevention Clinic. The Stroke Prevention Clinic currently runs 4-5 days/week. Quinte Health Care is seeking one or more physicians to fill this full-time position.
Exceptional Care, Inspired By You One week "Everything" course includes Botox, Dermal Fillers, Sclerotherapy, Laser, Microderm and Business. Our courses meet or exceed the accreditation criteria of the College of Family Physicians of Canada. Partial classes are available, please enquire. Jul 15-17, Aug 19-21 (no sclero) • Sep 23-27 • Oct 21-25 training@botoxtrainingcanada.com Dr. Deborah Martin, MD, CCFP (EM) www.botoxtrainingcanada.com 570 Bryne Drive, Barrie, ON
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Interested candidates please contact: Bree Ricketts-Gaber Ph: 613-969-7400 or 1-800-483-2811 x 2600 bricketts@qhc.on.ca www.qhc.on.ca SUMMER 2013 Just For Canadian Doctors
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t he w e a lt hy do ctor manf r ed pur tz ki, c .a.
Rigorous clinical monitoring for suicidal ideation or other indicators of potential for suicidal behaviour is advised in patients of all ages especially when initiating therapy or during any change in dose or dosage regimen. This includes monitoring for agitation-type emotional and behavioural changes.
Manfred Purtzki is the principal of Purtzki & Associates Chartered Accountants. You can reach him at manfred@purtzki.com.
to insure or not to insure Should you avoid universal life?
T
here are two types of life insurance policies: term insurance and permanent insurance. Term insurance gives you the most amount of coverage for the least amount of premiums. However, most term insurance expires at age 75 or 80. Permanent insurance, on the other hand, is designed to be in force when you die and will usually pay out the death benefit and accumulated cash value. Permanent insurance mainly consists of universal life, whole life or term to 100.
The desirable feature of a universal life policy is its flexibility. A universal life policy can be tailored to suit your needs. You can decrease or increase premiums to match your cash flow or even skip a payment, which assumes that you have enough investment reserve built up inside the policy to fund the premiums. The universal life policy is a long-term proposition. The cash surrender charges can be prohibitive, virtually eliminating any accumulated cash value over the initial life of the policy.
1. Universal Life In simple terms,
2. Whole Life The death benefit
the premiums paid under a universal life policy fund three items: term insurance, investments and administrative expenses.
and premiums on a whole life policy are established at the beginning and remain in force until you die. Depending on the investment performance of the particular insurance company, you will be credited with the dividends earned on your premium dollars. The insurance company assumes all the investment risk, unlike a universal life policy in which you assume the risk.
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3. Term to 100 If you are looking for “no-frills” insurance with the lowest premium, the “Term to 100” is the answer. Both death benefits and premiums are set when the policy is first taken out and cannot be changed or cancelled by the insurance company. Generally, these policies do not have any cash value. The challenge is to keep up the payments over a great many years. If the payments stop, so will the coverage. It is amazing how many doctors have purchased universal life and whole life policies only to regret it later on. Doctors have bought into the universal life concept for what it is not: an investment and tax shelter. Universal life is foremost a life insurance product, and like any other insurance, is there to provide cash to cover a financial loss. Insurance is not an investment per se. This may seem obvious, but many purchase a universal life policy to gain access to its tax-sheltered investment aspects without having any need for the death benefit. If you have no real need for life insurance coverage, paying premiums into a universal life policy is a waste of your
Doctors SUMMER 2013
precious cash flow as a large chunk of the premiums are used to fund the mortality charges. When making the decision to purchase a universal life or whole life policy, the first question you should ask yourself is, “Do I have a need for a guaranteed life insurance payout on my death”? For the vast majority of doctors the answer is NO. There are situations where such a policy is the perfect solution. For instance, if you wish to provide for a disabled child after your death, or if you need cash for your estate to pay capital gains taxes to avoid liquidating your investments. The universal life policy is mainly sold to doctors as a vehicle to provide tax-free retirement income. The concept is simple: a participating bank arranges for a loan based on the cash value of the policy. The security for the loan is the policy. On your death, the bank deducts the loan amount and accumulated interest from the tax-free insurance proceeds, including cash value. It looks great on paper, but in many cases the projected cash value of the universal life policy falls short of the actual cash in the policy, making this tax-free leveraged loan strategy not feasible. On the topic of tax-sheltered insurance policies, the March 21, 2013 Federal Budget has reined in the use of leveraged insurance contracts, including the 10/8 strategy. This is an arrangement where you pay premiums into a policy with accumulating cash value. The bank takes the policy as collateral for a loan at a 10% interest. The bank guarantees an investment return of 8%. The benefit here is that the 8% investment income is not taxable, while you can deduct for tax purposes the interest expense of 10%, resulting in an after-tax cost of only 5.5%. No matter how much you dress up universal life as a retirement nest egg, the universal life policy is a poor investment unless you have the absolute need for life insurance and a guaranteed payout on death.
Patients currently taking PRISTIQ should NOT be discontinued abruptly, due to risk of discontinuation symptoms (see WARNINGS AND PRECAUTIONS, Discontinuation Symptoms). At the time that a medical decision is made to discontinue an SSRI or other newer antidepressant drug, a gradual reduction in the dose, rather than an abrupt cessation, is recommended. (See DOSAGE AND ADmINISTRATION.)
Prescribing Summary Patient Selection Criteria Therapeutic Category: Antidepressant Action: Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) Indications and Clinical Use Adults: PRISTIQ® desvenlafaxine Extended-Release Tablets is indicated for: the symptomatic relief of major depressive disorder. The short-term efficacy of PRISTIQ extended-release tablets has been demonstrated in placebo-controlled trials of up to 8 weeks. Pediatrics (<18 years of age): PRISTIQ is not indicated for use in children under the age of 18. Safety and efficacy in the pediatric population have not been established (see WARNINGS AND PRECAUTIONS, POTENTIAl ASSOCIATION WITh bEhAvIOURAl AND EmOTIONAl ChANGES, INClUDING SElf-hARm). CONTRAINDICATIONS • Desvenlafaxine must not be used concomitantly in patients taking monoamine oxidase inhibitors (MAOIs), including linezolid, an antibiotic, methylene blue, a dye used in certain surgeries, or in patients who have taken MAOIs within the preceding 14 days due to the risk of serious, sometimes fatal, drug interactions with selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI) treatment or with other serotonergic drugs. These interactions have been associated with symptoms that include tremor, myoclonus, diaphoresis, nausea, vomiting, flushing, dizziness, hyperthermia with features resembling neuroleptic malignant syndrome, seizures, rigidity, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes that include extreme agitation progressing to delirium and coma. Based on the half-life of desvenlafaxine succinate, at least 7 days should be allowed after stopping desvenlafaxine succinate and before starting an MAOI • Hypersensitivity to desvenlafaxine succinate extended-release, venlafaxine hydrochloride or to any excipients in the desvenlafaxine formulation. For a complete listing, see the DOSAGE fORmS, COmPOSITION AND PACKAGING section of the Product Monograph Special Populations Pregnant Women: the safety of desvenlafaxine in human pregnancy has not been established. The extent of exposure to PRISTIQ in pregnancy during clinical trials was very limited. There are no adequate and well-controlled studies in pregnant women. Therefore, desvenlafaxine should be used during pregnancy only if the potential benefits justify the potential risks. If desvenlafaxine succinate is used until or shortly before birth, discontinuation effects in the newborn should be considered. Post-marketing reports indicate that some neonates exposed to SNRIs, SSRIs, or other newer antidepressants late in the third trimester have developed complications requiring prolonged hospitalization, respiratory support, and tube feeding. Such complications can arise immediately upon delivery. Reported clinical findings have included respiratory distress, cyanosis, apnea, seizures, temperature instability, feeding difficulty, vomiting, hypoglycemia, hypotonia, hypertonia, hyperreflexia, tremor, jitteriness, irritability, and constant crying. These features are consistent with either a direct toxic effect of SNRIs, SSRIs and other newer antidepressants, or, possibly a drug discontinuation syndrome. It should be noted that, in some cases, the clinical picture is consistent with serotonin syndrome (see DRUG INTERACTIONS). When treating a pregnant woman with PRISTIQ during the third trimester, the physician should carefully consider the potential risks and benefits of treatment. Patients should be advised to notify their physician if they become pregnant or intend to become pregnant during therapy. Labour and Delivery: the effect of desvenlafaxine on labour and delivery in humans is unknown. PRISTIQ should be used during labour and delivery only if the potential benefits justify the potential risks. Nursing Women: desvenlafaxine (O-desmethylvenlafaxine) is excreted in human milk. Because of the potential for serious adverse reactions in nursing infants from PRISTIQ, a decision should be made whether or not to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. Only administer PRISTIQ to breastfeeding women if the expected benefits outweigh any possible risk. Pediatric: safety and effectiveness in patients less than 18 years of age have not been established. Geriatrics ( ≥65 years of age): of the 3,292 patients in clinical trials with PRISTIQ, 5% were 65 years of age or older. No overall differences in safety or efficacy were detected between these subjects and younger subjects; however in the short-term placebo-controlled trials, there was a higher incidence of systolic orthostatic hypotension in patients ≥65 years of age compared to all adults treated with desvenlafaxine. For elderly patients, possible reduced renal clearance of desvenlafaxine should be considered when determining dose (see Dosing Considerations, Geriatrics and ACTION AND ClINICAl PhARmACOlOGY, Geriatrics). Greater sensitivity of some older individuals cannot be ruled out.
Safety Information WARNINGS AND PRECAUTIONS POTENTIAl ASSOCIATION WITh bEhAvIOURAl AND EmOTIONAl ChANGES, INClUDING SElf-hARm. Pediatrics: Placebo-Controlled Clinical Trial Data Recent analyses of placebo-controlled clinical trial safety databases from Selective Serotonin Reuptake Inhibitors (SSRIs) and other newer anti-depressants suggest that use of these drugs in patients under the age of 18 may be associated with behavioural and emotional changes, including an increased risk of suicidal ideation and behaviour over that of placebo. The small denominators in the clinical trial database, as well as the variability in placebo rates, preclude reliable conclusions on the relative safety profiles among the drugs in the class. Adults and Pediatrics: Additional Data There are clinical trial and post-marketing reports with SSRIs and other newer antidepressants, in both pediatrics and adults, of severe agitation-type adverse events coupled with self-harm or harm to others. The agitation-type events include: akathisia, agitation, disinhibition, emotional lability, hostility, aggression, depersonalization. In some cases, the events occurred within several weeks of starting treatment.
Concomitant Use of PRISTIQ with venlafaxine Since desvenlafaxine is the major active metabolite of venlafaxine, concomitant use of PRISTIQ with products containing venlafaxine is not recommended since the combination of the two will lead to additive desvenlafaxine exposure. monitoring and laboratory Tests Serum Lipids: increases in cholesterol (total and LDL) and triglycerides were observed in some patients treated with desvenlafaxine succinate in placebo-controlled pre-marketing clinical trials, particularly with higher doses. Measurement of serum lipid levels should be considered during treatment. Heart Rate and Blood Pressure: increases in heart rate and blood pressure were observed in some patients in clinical trials, particularly with higher doses. Measurement of blood pressure is recommended prior to initiating treatment and regularly during treatment with desvenlafaxine succinate (see ADvERSE REACTIONS, vital Sign Changes). Self-Harm: rigorous clinical monitoring for suicidal ideation or other indicators of potential for suicidal behaviour is advised in patients of all ages. Patients, their families, and their caregivers should be encouraged to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behaviour, worsening of depression, and suicidal ideation, especially when initiating therapy or during any change in dose or dosage regimen. (See WARNINGS AND PRECAUTIONS, POTENTIAl ASSOCIATION WITh bEhAvIOURAl AND EmOTIONAl ChANGES, INClUDING SElf-hARm.) Psychiatric Mania/hypomania: mania/hypomania may occur in a small proportion of patients with mood disorders who have received medication to treat depression, including desvenlafaxine succinate. During phase 2 and phase 3 studies, mania was reported for approximately 0.1% of patients treated with PRISTIQ. Activation of mania/hypomania has also been reported in a small proportion of patients with major affective disorder who were treated with other marketed antidepressants. As with all antidepressants, PRISTIQ should be used cautiously in patients with a history or family history of mania or hypomania. Neurologic Seizures: cases of seizures have been reported in pre-marketing trials with PRISTIQ. Desvenlafaxine succinate should be prescribed with caution in patients with a seizure disorder. Desvenlafaxine has not been systematically evaluated in patients with a seizure disorder. Serotonin Syndrome or Neuroleptic Malignant Syndrome (NMS)-Like Reactions: as with other serotonergic agents, serotonin syndrome or Neuroleptic Malignant Syndrome (NMS)-like reactions, a potentially life-threatening condition, have been reported with SNRIs and SSRIs alone, including PRISTIQ treatment, particularly with concomitant use of other agents that may affect the serotonergic neurotransmitter systems (such as triptans, serotonin reuptake inhibitors, sibutramine, MAOIs [including linezolid, an antibiotic, and methylene blue], St. John’s Wort [Hypericum perforatum] and/ or lithium) and with drugs that impair metabolism of serotonin or with antipsychotics or other dopamine antagonists. Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, and hyperthermia), neuromuscular aberrations (e.g., hyperreflexia, incoordination) and/or gastrointestinal symptoms (e.g., nausea, vomiting, and diarrhea). Serotonin syndrome, in its most severe form, can resemble NMS, which includes hyperthermia, muscle rigidity, autonomic instability with possible rapid fluctuation of vital signs, and mental status changes. If concomitant treatment with desvenlafaxine and other agents that may affect the serotonergic and/or dopaminergic neurotransmitter system such as another SSRI, a Selective Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) or a 5-hydroxytryptamine receptor agonist (triptan) is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases. The concomitant use of desvenlafaxine with serotonin precursors (such as tryptophan supplements) is not recommended (see DRUG INTERACTIONS, Serotonin syndrome). Treatment with PRISTIQ and any concomitant serotonergic or antidopaminergic agents, including antipsychotics, should be discontinued immediately if the above events occur and supportive symptomatic treatment should be initiated. Ophthalmologic Narrow Angle Glaucoma: mydriasis has been reported in association with desvenlafaxine; therefore, patients with raised intraocular pressure or those at risk of acute narrow-angle glaucoma (angle-closure glaucoma) should be monitored (see ADvERSE REACTIONS). Gastrointestinal Potential for Gastrointestinal Obstruction: because the PRISTIQ tablet does not appreciably change in shape in the gastrointestinal tract, PRISTIQ should not be administered to patients with pre-existing gastrointestinal narrowing (pathologic or iatrogenic, such as small bowel inflammatory disease, “short gut” syndrome due to adhesions or decreased transit time, past history of peritonitis, cystic fibrosis, chronic intestinal pseudo-obstruction, or Meckel’s diverticulum). There have been rare reports of obstructive symptoms in patients with known strictures in association with the ingestion of other drugs in nondeformable controlled-release formulations, and very rare reports of obstructive symptoms associated with the use of nondeformable controlled-release formulations in patients without known gastrointestinal stricture. Due to the controlled-release design, PRISTIQ tablets should only be used in patients who are able to swallow the tablets whole. (See DOSAGE AND ADmINISTRATION; Recommended Dose and Dosage Adjustment.) ADvERSE REACTIONS The safety of PRISTIQ in major depressive disorder was evaluated in 3,292 patients exposed to at least one dose of PRISTIQ. The most commonly observed adverse reactions (incidence of 5% or greater for the DVS SR pooled 50- to 400-mg doses, and incidence higher than placebo) in DVS SR-treated MDD patients in short-term placebo controlled trials were: nausea, headache, dry mouth, hyperhydrosis, dizziness, insomnia, constipation, decreased appetite, somnolence, fatigue, tremor, and vomiting, and, in men, erectile dysfunction and ejaculation delayed. Adverse Events Reported as Reasons for Discontinuation of Treatment in mDD Clinical Trials In the 8-week placebo-controlled, pre-marketing trials for MDD, 12% of the 1,834 patients who received PRISTIQ (50-400 mg/day) discontinued treatment due to an adverse experience, compared with 3% of the 1,116 placebo-treated patients in those trials.
At the recommended dose of 50 mg, the discontinuation rate due to an adverse experience for PRISTIQ (4.1%) was similar to the rate for placebo (3.8%) and only 1% of patients discontinued due to nausea. The most common adverse reactions leading to discontinuation (i.e., leading to discontinuation in at least 2% and incidence higher than placebo) of the PRISTIQtreated patients in short-term trials of up to 8 weeks were: nausea (4%); dizziness, headache and vomiting (2% each).
Use in patients with hepatic impairment: no dosage adjustment is necessary for patients with hepatic impairment (see ACTION AND ClINICAl PhARmACOlOGY, hepatic Insufficiency).
If you suspect you have a serious or unexpected reaction to this drug, you may notify Health Canada by telephone at 1-866-234-2345 or Pfizer Canada at 1-800-463-6001.
Discontinuation of Therapy: a gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. Discontinuation regimens should take into account the individual circumstances of the patient, such as duration of treatment and dose at discontinuation (see WARNINGS AND PRECAUTIONS and ADvERSE REACTIONS).
DRUG-DRUG INTERACTIONS Monoamine Oxidase Inhibitors: desvenlafaxine succinate is contraindicated in patients taking MAOIs. Desvenlafaxine succinate must not be used in combination with a monoamine oxidase inhibitor (MAOI), or within at least 14 days of discontinuing treatment with an MAOI. Based on the half-life of desvenlafaxine succinate, at least 7 days should be allowed after stopping desvenlafaxine succinate before starting an MAOI (see CONTRAINDICATIONS). Serotonin Syndrome: as with other serotonergic agents, serotonin syndrome, a potentially life-threatening condition, may occur with desvenlafaxine treatment, particularly with concomitant use of other agents that may affect the serotonergic neurotransmitter system (including triptans, SSRIs, other SNRIs, lithium, sibutramine, tramadol, or St. John’s Wort [Hypericum perforatum]), with drugs which impair metabolism of serotonin (such as MAOIs, including linezolid [an antibiotic which is a reversible non-selective MAOI], and methylene blue; see CONTRAINDICATIONS), or with serotonin precursors (such as tryptophan supplements). Serotonin syndrome symptoms may include mental status changes, autonomic instability, neuromuscular aberrations and/or gastrointestinal symptoms (see WARNINGS AND PRECAUTIONS). If concomitant treatment of desvenlafaxine with an SSRI, an SNRI or a 5-hydroxytryptamine receptor agonist (triptan) is clinically warranted, careful observation of the patient is advised, particularly during treatment initiation and dose increases. The concomitant use of desvenlafaxine with serotonin precursors (such as tryptophan supplements) is not recommended. Central Nervous System (CNS) Active Agents The risk of using desvenlafaxine succinate in combination with other CNS-active drugs has not been systematically evaluated. Consequently, caution is advised when desvenlafaxine succinate is taken in combination with other CNS-active drugs. Drugs that Interfere with hemostasis (e.g., NSAIDs, Aspirin, and Warfarin) Serotonin release by platelets plays an important role in hemostasis. Epidemiological studies of case-control and cohort design that have demonstrated an association between use of psychotropic drugs that interfere with serotonin reuptake and the occurrence of upper gastrointestinal bleeding. These studies have also shown that concurrent use of an NSAID or aspirin may potentiate this risk of bleeding. Altered anticoagulant effects, including increased bleeding, have been reported when SSRIs and SNRIs are coadministered with warfarin. Patients receiving warfarin therapy should be carefully monitored when PRISTIQ is initiated or discontinued.
General Administration GENERAl PRISTIQ is not indicated for use in children under 18 years of age (see WARNINGS AND PRECAUTIONS, Potential Association with behavioural and Emotional Changes, Including Self-harm). Recommended Dose and Dosage Adjustment Initial Treatment: the recommended dose of PRISTIQ (desvenlafaxine succinate) extended-release tablets is 50 mg once daily, with or without food. In clinical studies, no additional benefit was demonstrated at doses greater than 50 mg/day. In clinical studies, doses of 50-400 mg/day were shown to be effective, although no additional benefit was demonstrated at doses greater than 50 mg/day, and adverse events and discontinuations were more frequent at higher doses. If the physician, based on clinical judgment, decides a dose increase above 50 mg/day is warranted for an individual patient the maximum dose should not exceed 100 mg/day. Patients should be periodically reassessed to determine the need for continued treatment. It is recommended that PRISTIQ be taken at approximately the same time each day. PRISTIQ tablets must be swallowed whole with liquids, and must not be chewed, divided or crushed. The medication is contained within a non-absorbable shell designed to release the drug at a controlled rate. The tablet shell, along with insoluble core components, is eliminated from the body; patients should not be concerned if they occasionally notice something that looks like a tablet in their stool. Due to the controlled-release design, PRISTIQ tablets should only be used in patients who are able to swallow the tablets whole. Missed Dose: a patient missing a dose should take it as soon as they remember to. If it is almost time for the next dose, the missed dose should be skipped. The patient should be cautioned against taking two doses concomitantly to “make up” for the missed dose. Discontinuing PRISTIQ: symptoms associated with discontinuation of PRISTIQ, other SNRIs and SSRIs have been reported (see WARNINGS AND PRECAUTIONS, Discontinuation Symptoms and ADvERSE REACTIONS, Discontinuation symptoms). Patients should be monitored for these symptoms when discontinuing treatment. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose, but at a more gradual rate. As the lowest dosage strength of PRISTIQ is 50 mg, it is recommended that dose reduction from 50 mg/day should proceed to 50 mg every other day before discontinuation. Switching Patients from Other Antidepressants to PRISTIQ Discontinuation symptoms have been reported when switching patients from other antidepressants, including venlafaxine, to PRISTIQ. Tapering of the initial antidepressant may be necessary to minimize discontinuation symptoms (see CONTRAINDICATIONS). Switching Patients to or from a monoamine Oxidase Inhibitor At least 14 days should elapse between discontinuation of an MAOI and the initiation of therapy with desvenlafaxine succinate. In addition, based on the half-life of desvenlafaxine succinate, at least 7 days should be allowed after stopping desvenlafaxine succinate before starting an MAOI. Dosing Considerations Patients with severe renal impairment and end-stage renal disease: the recommended dose in patients with severe renal impairment (24-hr CrCl <30 mL/min) or end-stage renal disease (ESRD) is 50 mg every other day. Because of individual variability in clearance in these patients, individualization of dosage may be desirable. Supplemental doses should not be given to patients after dialysis (see ACTION AND ClINICAl PhARmACOlOGY, Renal Insufficiency).
Geriatrics (≥65 years of age): no dosage adjustment is required solely on the basis of age; however, possible reduced clearance of PRISTIQ should be considered when determining dose (see ACTION AND ClINICAl PhARmACOlOGY, Geriatrics).
SUPPlEmENTAl PRODUCT INfORmATION Adverse Reactions in mDD Clinical Trials PRISTIQ was evaluated for safety in 3,292 patients diagnosed with major depressive disorder who participated in multiple-dose pre-marketing trials, representing 1,289 patient-years of exposure. Among these 3,292 PRISTIQ-treated patients, 1,834 patients participated in 8-week, placebo-controlled trials at doses ranging from 50 to 400 mg/day. Of the total 3,292 subjects exposed to at least 1 dose of PRISTIQ, 1,070 were exposed to PRISTIQ for greater than 6 months and 274 were exposed for 1 year. Adverse Reactions Occurring at an Incidence of ≥1% Among PRISTIQ-Treated Patients in Short-Term Placebo-Controlled Trials The following adverse reactions (Table 1) occurred at ≥1% and are listed alphabetically by body system. Reported adverse events were classified using a standard MedDRA-based Dictionary terminology. Table 1: Adverse Reactions (≥1% in Any PRISTIQ Group): Percentage of Subjects in Short-Term, Placebo-Controlled mDD Studies System Organ Class Preferred Term
PRISTIQ
Table 2: Sexual Dysfunction Adverse Reactions (≥1% in men or Women in Any PRISTIQ Group) During the On-Therapy Period: Percentage of Subjects in Short-Term, Placebo-Controlled mDD Studies Placebo b
DVS SR 50 mgc
DVS SR 100 mgc
DVS SR 200 mgc
DVS SR 400 mgc
DVS SR 50-400 mg b
men only d Erectile dysfunction Ejaculation delayed Anorgasmia Libido decreased Ejaculation disorder Ejaculation failure Orgasm abnormal
1 <1 0 1 <1 0 0
3 1 0 4 0 1 0
6 5 3 5 1 0 1
8 7 5 6 2 2 2
11 6 8 3 5 2 3
7 5 4 4 2 1 1
Women only e Anorgasmia Libido decreased Orgasm abnormal
0 <1 <1
1 1 1
1 2 1
0 1 1
3 1 1
1 1 1
Preferred Terma
a. Medical Dictionary for Regulatory Activities (MedDRA) terms. b. Includes data from all short-term, placebo-controlled studies including fixed-dose and flexible-dose studies. c. Only includes data from short-term, placebo-controlled, fixed-dose studies. d. Percentage based on the number of men (placebo, n=403; DVS SR 50 mg, n=108; DVS SR 100 mg, n=157; DVS SR 200 mg, n=131; DVS SR 400 mg=154; DVS SR 50-400 mg, n=723). e. Percentage based on the number of women (placebo, n=713; DVS SR 50 mg, n=209; DVS SR 100 mg, n=267; DVS SR 200 mg, n=176; DVS SR 400 mg=163; DVS SR 50-400 mg, n=1111).
Placeboa n=1116
50 mg b n=317
100 mgb n=424
200 mgb n=307
400 mgb n=317
50-400 mga n=1834
2 1
1 1
3 <1
2 1
3 2
2 1
ADvERSE DRUG REACTIONS — All mDD ClINICAl TRIAlS A total of 3,292 subjects were exposed to at least 1 dose of PRISTIQ ranging from 50 to 400 mg/day in MDD clinical trials. Long-term safety was evaluated in 1,070 subjects in MDD who were exposed to desvenlafaxine succinate for at least 6 months (180 days) and 274 subjects in MDD who were exposed for 1 year (356 days).
1
2
1
1
2
1
The following list is a list of MedDRA preferred terms that reflect adverse events that have been determined to be adverse drug reactions throughout the dose range studied (50 to 400 mg) during any pre-marketing MDD trials.
Mydriasis <1 Vision blurred 1 Gastrointestinal disorders Nausea 11 Dry mouth 8 Constipation 4 Diarrhea 9 Vomiting 2 General disorders and administration site conditions Fatigue 4 Chills 1 Feeling jittery 1 Asthenia 1
2 3
2 4
6 4
6 4
4 4
22 11 9 11 3
26 17 9 9 4
36 21 10 7 6
41 25 14 5 9
32 20 11 8 6
Cardiac disorders Palpitations Tachycardia Ear and labyrinth disorders Tinnitus Eye disorders
7 1 1 1
7 <1 2 2
10 3 3 1
11 4 3 1
8 2 2 1
1 1
1 2
1 1
2 1
2 2
2 1
2
5
8
10
10
9
1
1
<1
1
1
1
25 6 4 2 1 1 <1
20 13 4 2 2 1 <1
22 10 9 3 2 1 1
29 15 12 9 1 1 2
25 16 12 9 3 2 1
25 13 9 6 2 2 1
6 3 2 0 1 <1 1
9 3 2 <1 2 1 <1
12 5 3 2 3 1 1
14 4 2 2 3 1 2
15 4 4 6 2 2 2
12 4 3 2 2 1 1
<1
<1
1
2
2
1
Investigations Blood pressure increased Weight decreased metabolism and nutrition disorders Decreased appetite musculoskeletal and connective tissue disorders Musculoskeletal stiffness Nervous system disorders Headache Dizziness Somnolence Tremor Paraesthesia Dysgeusia Disturbance in attention Psychiatric disorders Insomnia Anxiety Abnormal dreams Anorgasmia Libido decreased Orgasm abnormal Nervousness Renal and urinary disorders Urinary hesitation Respiratory, thoracic and mediastinal disorders Yawning
<1
1
1
4
3
3
Skin and subcutaneous tissue disorders Hyperhidrosis Rash
Cardiac disorders: Common: palpitations, tachycardia. Ear and labyrinth disorders: Common: tinnitus. Eye disorders: Common: mydriasis, vision blurred. Gastrointestinal disorders: Very common: nausea, dry mouth, constipation; Common: vomiting, diarrhea. General disorders and administration site conditions: Very common: fatigue; Common: asthenia, chills, feeling jittery, irritability; Uncommon: drug withdrawal syndrome. Immune system disorders: Uncommon: hypersensitivity. Investigations: Common: weight decreased, weight increased, blood pressure increased; Uncommon: blood cholesterol increased, blood prolactin increased, blood triglycerides increased, liver function test abnormal. metabolism and nutrition disorders: Very common: decreased appetite. musculoskeletal, connective tissue, and bone disorders: Common: musculoskeletal stiffness. Nervous system disorders: Very common: headache, dizziness; Common: somnolence, tremor, disturbance in attention, paraesthesia, dysgeusia; Uncommon: syncope; Rare: convulsion, dystonia. Psychiatric disorders: Very common: insomnia; Common: orgasm abnormal, anorgasmia, anxiety, nervousness, libido decreased, abnormal dreams; Uncommon: depersonalization, hypomania. Renal and urinary disorders: Common: urinary hesitation; Rare: proteinuria. Reproductive system and breast disorders: Common: erectile dysfunction,* ejaculation delayed,* ejaculation disorder,* ejaculation failure*; Uncommon: sexual dysfunction. Respiratory, thoracic, and mediastinal disorders: Common: yawning; Uncommon: epistaxis. Skin and subcutaneous tissue disorders: Very common: hyperhidrosis; Common: rash. vascular disorders: Common: hot flush; Uncommon: orthostatic hypotension. * Frequency is calculated based on men only.
4 1
10 1
11 1
18 2
21 <1
15 1
<1
1
1
2
2
2
MDD=major depressive disorder. a. Includes data from all short-term, placebo-controlled studies including fixed-dose and flexible-dose studies. b. Only includes data from short-term, placebo-controlled, fixed-dose studies. Classifications of adverse events are based on the Medical Dictionary for Regulatory Activities (MedDRA). Note: <1% indicates an incidence less than 0.5%, but greater than zero.
SExUAl fUNCTION ADvERSE REACTIONS Table 2 shows the incidence of sexual function adverse reactions that occurred in 1% or more of PRISTIQ-treated MDD patients in the 50 mg dose group (8-week, placebo-controlled, fixed and flexible-dose, pre-marketing clinical trials).
PRISTIQ Placeboa n=1116
50 mg n=317
100 mg n=424
200 mg n=307
400 mg n=317
50-400 mga n=1834
2
3
4
4
10
5
<1
1
0
1
2
1
3
2
1
4
6
3
Total Cholesterol Increase ≥1.29 mmol/L and absolute value ≥6.75 mmol/L lDl Cholesterol Increase ≥1.29 mmol/L and absolute value ≥4.91 mmol/L Triglycerides ≥3.7 mmol/L
a. Includes data from all short-term, placebo-controlled studies including fixed-dose and flexible-dose studies. Proteinuria In placebo-controlled studies 6.4% of subjects treated with PRISTIQ had treatment-emergent proteinuria. Proteinuria was usually of trace amounts, and was not associated with increases in BUN or creatinine or adverse events. The mechanism of the enhanced protein excretion is not clear but may be related to noradrenergic stimulation. vital Sign Changes Tables 5 and 6 summarize the changes that were observed in placebo-controlled, short-term, pre-marketing trials with PRISTIQ in patients with MDD. Table 5: mean Changes, vital Signs, at final On-Therapy for All Short-Term, fixed-Dose Controlled Trials PRISTIQ Placebo
50 mg
100 mg
200 mg
400 mg
-1.4 -0.6
1.2 0.7
2.0 0.8
2.5 1.8
2.1 2.3
-0.3 0.0
1.3 -0.4
1.3 -0.6
0.9 -0.9
4.1 -1.1
blood Pressure Supine systolic bp (mm Hg) Supine diastolic bp (mm Hg) Pulse rate Supine pulse (bpm) Weight (kg)
At the final on-therapy assessment in the 6-month, double-blind, placebo-controlled phase of a long-term trial in patients who had responded to PRISTIQ during the initial 12-week, open-label phase, there was no statistical difference in mean weight change between PRISTIQ- and placebo-treated patients. Table 6 provides the incidence of patients meeting criteria for sustained hypertension (defined as treatment-emergent supine diastolic blood pressure ≥90 mm Hg and ≥10 mm Hg above baseline for 3 consecutive visits). Table 6: Incidence (%) of Patients with Sustained hypertension for All Short-Term fixed-Dose Clinical Trials PRISTIQ Placebo Sustained hypertension
0.5
50 mg 1.3
100 mg 0.7
200 mg 1.1
400 mg 2.3
Adverse Reactions Identified During Post-Approval Use The following adverse reactions have been identified during post-approval use of PRISTIQ. Because post-approval reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency. Skin and subcutaneous tissue disorders – angioedema Ear and labyrinth disorders – vertigo Adverse Events Identified During Post-Approval Use The following adverse events have been identified during post-approval use of PRISTIQ. Because post-approval events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure. Gastrointestinal – gastrointestinal bleeding Psychiatric – hallucinations Immunologic – photosensitivity reactions Skin and subcutaneous tissue disorders – severe cutaneous reactions (such as Stevens-Johnson Syndrome, toxic epidermal necrolysis, and/or erythema multiforme) DRUG-DRUG INTERACTIONS
Ischemic cardiac adverse events: in clinical trials, there were uncommon reports of ischemic cardiac adverse events, including myocardial ischemia, myocardial infarction, and coronary occlusion requiring revascularization; these patients had multiple underlying cardiac risk factors. More patients experienced these events during desvenlafaxine treatment as compared to placebo (see WARNINGS AND PRECAUTIONS/Cardiovascular/ Cerebrovascular).
Potential for other drugs to affect desvenlafaxine succinate (see also ACTION AND ClINICAl PhARmACOlOGY)
Discontinuation Symptoms: adverse drug reactions reported in association with abrupt discontinuation, dose reduction or tapering of treatment in MDD clinical trials at a rate of ≥5% include: dizziness, nausea, headache, irritability, diarrhea, anxiety, abnormal dreams, fatigue, and hyperhidrosis. In general, discontinuation events occurred more frequently with longer duration of therapy (see DOSAGE AND ADmINISTRATION and WARNINGS AND PRECAUTIONS).
Inhibitors of other CYP enzymes: based on in vitro data, drugs that inhibit CYP isozymes 1A1, 1A2, 2A6, 2D6, 2C8, 2C9, 2C19, and 2E1 are not expected to have significant impact on the pharmacokinetic profile of desvenlafaxine.
Orthostatic Hypotension: Of the 3,292 patients in clinical trials with PRISTIQ, 5% were 65 years of age or older. No overall differences in safety or efficacy were detected between these subjects and younger subjects; however, in the short-term placebo-controlled trials, there was a higher incidence of orthostatic hypotension in patients ≥65 years of age compared to patients <65 years of age treated with desvenlafaxine. Greater sensitivity of some older individuals cannot be ruled out. For elderly patients, possible reduced renal clearance of desvenlafaxine should be considered when determining dose (see Dosing Considerations, Geriatrics and ACTION AND ClINICAl PhARmACOlOGY, Geriatrics). ECG Changes: electrocardiograms were obtained from 1,492 PRISTIQ-treated patients with major depressive disorder and 984 placebo-treated patients in clinical trials lasting up to 8 weeks. No clinically relevant differences were observed between PRISTIQ-treated and placebo-treated patients for QT, QTc, PR, and QRS intervals. In a thorough QTc study with prospectively determined criteria, desvenlafaxine did not cause QT prolongation. No difference was observed between placebo and desvenlafaxine treatments for the QRS interval (see ACTION AND ClINICAl PhARmACOlOGY). A thorough QTc study was designed to assess the potential effect of 200 and 600 mg of PRISTIQ on QT interval prolongation. Table 3: Estimated and 90% Confidence Interval for QTc Changes from Time-matched baseline Relative to Placebo at hour 8 after Dose with Different heart Rate Corrections a Treatment
vascular disorders Hot flush
Adverse reactions are categorized by system organ class and listed in order of decreasing frequency using the following definitions: Very common: ≥10% of patients Common: ≥1% and <10% of patients Uncommon: ≥0.1% and <1% of patients Rare: ≥0.01% and <0.1% of patients Very rare: <0.01% of patients
Table 4: Proportion (%) of Subjects With lipid Abnormalities of Potential Clinical Significance for All Short-Term, Placebo-Controlled Clinical Trials
fridericia’s QT Correction (ms)
Population QT Correction (ms)
PRISTIQ 200 mg b
1.5 (-0.88, 3.88)
3.18 (0.87, 5.50)
PRISTIQ 600 mg b
-2.43 (-4.90, 0.04)
0.98 (-1.42, 3.38)
Moxifloxacin 400 mg (Active control)
10.80 (8.44, 13.16)
10.92 (8.62, 13.22)
a. Mean (90% confidence intervals) b. The PRISTIQ doses of 200 and 600 mg were 2 and 6 times the maximum recommended dose, respectively. Abnormal hematologic and Clinical Chemistry findings Serum Lipids Elevations in fasting serum total cholesterol, LDL cholesterol, and triglycerides occurred in the controlled trials. Some of these abnormalities were considered potentially clinically significant (see WARNINGS AND PRECAUTIONS, Serum Cholesterol Elevation and monitoring and laboratory Tests, Serum lipids). The percentage of subjects who exceeded a predetermined threshold for values of outliers is represented in Table 4.
Inhibitors of CYP3A4: CYP3A4 is a minor pathway for the metabolism of PRISTIQ. In a clinical study, ketoconazole (200 mg BID) increased the area under the concentration vs. time curve AUC of PRISTIQ (400 mg single dose) by about 43% and Cmax by about 8%. Concomitant use of PRISTIQ with potent inhibitors of CYP3A4 may result in higher concentrations of PRISTIQ.
Potential for desvenlafaxine to affect other drugs (see also ACTION AND ClINICAl PhARmACOlOGY) Drugs metabolized by CYP2D6: clinical studies have shown that desvenlafaxine does not have a clinically relevant effect on CYP2D6 metabolism at the dose of 100 mg daily. When desvenlafaxine succinate was administered at a dose of 100 mg daily in conjunction with a single 50 mg dose of desipramine, a CYP2D6 substrate, the AUC of desipramine increased approximately 17%. When 400 mg of desvenlafaxine was administered (8 times the recommended 50 mg dose), the AUC of desipramine increased approximately 90%. Concomitant use of desvenlafaxine with a drug metabolized by CYP2D6 may result in higher concentrations of that drug. Drugs metabolized by CYP3A4: in vitro, desvenlafaxine does not inhibit or induce the CYP3A4 isozyme. In a clinical study, PRISTIQ (400 mg daily) was co-administered with a single 4 mg dose of midazolam (a CYP3A4 substrate). The AUC and Cmax of midazolam decreased by approximately 31% and 16%, respectively. Concomitant use of PRISTIQ with a drug metabolized by CYP3A4 may result in lower exposure to that drug. Drugs metabolized by CYP1A2, 2A6, 2C8, 2C9 and 2C19: in vitro, desvenlafaxine does not inhibit CYP1A2, 2A6, 2C8, 2C9, and 2C19 isozymes and would not be expected to affect the pharmacokinetics of drugs that are metabolized by these CYP isozymes. P-glycoprotein transporter In vitro, desvenlafaxine is not a substrate or an inhibitor for the P-glycoprotein transporter. The pharmacokinetics of desvenlafaxine are unlikely to be affected by drugs that inhibit the P-glycoprotein transporter and desvenlafaxine is not likely to affect the pharmacokinetics of drugs that are substrates of the P-glycoprotein transporter. Drug-food Interactions Food does not alter the bioavailability of desvenlafaxine. Drug-herb Interactions St. John’s Wort: in common with SSRI's, pharmacodynamic interactions between PRISTIQ and the herbal remedy St. John’s Wort may occur and may result in an increase in undesirable effects (see DRUG INTERACTIONS, Serotonin Syndrome). Drug-lifestyle Interactions Ethanol: as with all CNS-active drugs, patients should be advised to avoid alcohol consumption while taking desvenlafaxine succinate. for complete prescribing information please refer to the Product monograph. Reference: PRISTIQ Product Monograph, Pfizer Canada Inc. June 24, 2011. PRISTIQ ® Wyeth LLC, owner/Pfizer Canada Inc., Licensee TM Pfizer Inc., used under license © 2012 Pfizer Canada Inc. Kirkland, Quebec H9J 2M5 D000042552
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Dr. Ted Jablonski runs a large family practice, but he also moonlights as a multi-instrumentalist, folk/blues singer-songwriter under the name “dr j.” What’s more, his son, Eric is also a physician and musician (see our next issue for his “small talk”). They even make music together—in fact, the whole family has music in its veins. dr. j’s latest album, “just desserts” (see album cover, right), features son Eric on drums, daughter Gabrielle on saxophone, and wife Monique singing some background vocals. It’s all about dr. j’s motto: Go For It! So, if you’re in Calgary and in need of a doctor’s note…
I live and practise in: Calgary, Alberta
A favourite place that I keep returning to: Kelowna, BC (as often as possible through the summer)
My degrees and training: BSC Med MD CCFP FCFP University of Manitoba
My ultimate dream vacation: An unending hot, sandy beach (anywhere)
Why I was drawn to medicine and my specialty: Always fascinated by science and the human body and still love the challenge and incredible diversity of family medicine
If I could travel to any time, I’d go…: Right here – right now (it’s as good as it gets!)
My name: Ted Jablonski
My last trip: Bucerias, Mexico for a quick winter break The most exotic place I’ve travelled to: Most recently, up the lunar landscape
My favourite book: The Book of Answers by Carol Bolt My favourite film: The Rocky Horror Picture Show (still) Must-see TV: Honestly—none… My favourite CD/album or song: Hejira Joni Mitchell (still)
Ted “dr j” Jablonski alongside the Mona Lisa; with son Eric in Nova Scotia (on Ted’s “Sad No More Tour 2010” of 7,500+ km of running + cycling); at the Mont Ventoux summit with wife Monique and friends; and in full-on crooner mode.
My first job: Selling Dickie Dee ice cream (crazy fridge on a bike get-up)
The gadget or gear I could not do without: Asics Gel Nimbus running shoes (the barefoot trend would KILL me)
My favourite room: The “piano” room My car: ¾ of time Acura TL, in summer BMW Z4 convertible My last purchase: New York style loft in Calgary—time to move! Last splurge: Going back into a real studio to record another musical album Most-frequented store: Bowcycle and Kelowna Cycle—they are both doing great business from me! My closet has too many: Hangers—just did a major “clean out” of old clothes
of Mont Ventoux in France The best souvenir I’ve brought back from a trip: An oversized but spectacular mobile from an art gallery in Chicago
38
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My fridge is always stocked with: Fruit—love my daily apple (or two) My medicine cabinet is always stocked with: John Varvatos cologne Guilty pleasure: Desserts (of any kind) My favourite exercise/sports activity: Running and cycling (my daily fix)
Outstanding Value for your Time and Resources Combine Live CME and Personal Renewal Time with Family and Friends All Activities provide up to 14 AMA PRA Category 1 Credits™, 14 ANCC Contact Hours and 13-14 AAFP Prescribed credits unless otherwise noted Course Fees for all 14 hour courses; MD/DO/PhD/DDS/DMD—US$695 • RN/NP/PA—US$450
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Celebrity crush: If we don’t call it a crush (please…), Paul Simon I’d want this item with me if stranded on a desert island: Unlimited sunscreen (as I might want to stay for a long, long time…)see * below
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My secret to relaxing: Live in the moment and enjoy it all A characteristic I wish I had: More patience My scariest moment: Cycling accident on TransCanada highway in 2009 My fondest memory: Family trip to East Coast, especially Cavendish beach PEI My biggest challenge: Juggling too many “balls” and trying to be true to each one of these “careers”
October 6, 2013 Family Medicine: Women's Health 10-Night Mediterranean Barcelona, Spain to Athens, Greece Experience the Luxury on Seabourn's Quest
One thing I’d change about myself: * My pervasive introversion
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The word that best describes me: Intense
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I’m inspired by: Heroics of everyday people in tragic situations My biggest ego boost: Being accepted as a legitimate artist My biggest ego blow: Not being accepted as a legitimate artist I’m happiest when: Being creative in any media My greatest fear: Running out of time My motto: Go For It!! A cause that’s close to my heart: Alberta Tour for Kids (annual 3 day cycling fund-raiser) On my must-do list: Write and publish a book (format to be determined!) If I wasn’t a doctor I’d be: Going broke running a multimedia company
photos courtesy Dr. ted Jablonski
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Richness is:
You define richness. With the Scotia Professional ® Plan, we can help with the money part. You’ve worked long and hard to build your career. It only makes sense to do everything you can to ensure your continued success, both professionally and personally. The Professional Plan is a fully customized banking package designed to help you build a strong, profitable business while ensuring your personal finances receive the attention they deserve. Which is the kind of good feeling we’d like to spread around. To learn more about Scotia Professional Plan, visit your nearest Scotiabank branch or visit scotiabank.com/professional today.
Scotia Professional Plan ®
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