November-December 2017 by Doctor's Review

world festivals

MEDICINE ON THE MOVE

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

NOVEMBER / DECEMBER 2017

Take a

Madeira hike Food that entertains

MEXICO IS WEST BEST? Puerto Vallarta

delights

Los Cabos

dazzles Depression and LGBTQ+ mental health Human trials: brilliant to bizarre

WIN

A GREAT CARRY-ON PAGE 14

Now covered on provincial formulary in Quebec by the RAMQ* (exceptional medication†) and in Ontario, Manitoba, Saskatchewan and Alberta (special authorization) Not currently covered in other provinces or territories

When your patients have An Ejection Fraction ≤40%

NYHA Class II or III Symptoms

CONSIDER ENTRESTO

To reduce the incidence of heart failure hospitalization and CV death6

ENTRESTOTM should be used in place of an ACE inhibitor or ARB ENTRESTOTM (sacubitril/valsartan) is indicated for the treatment of heart failure with reduced ejection fraction (HFrEF) in patients with NYHA Class II or III, to reduce the incidence of cardiovascular death and heart failure hospitalization.6 ENTRESTOTM should be administered in combination with other heart failure therapies, in place of an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB).6 Consult the ENTRESTOTM Product Monograph at www.novartis.ca/EntrestoMonograph for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The product monograph is also available by calling 1-800-363-8883. *Official Mark of the Régie de l’assurance maladie du Québec †Sacubitril/Valsartan: For persons suffering from New York Heart Association (NYHA) class II or III heart failure with left ventricular systolic dysfunction (with ejection fraction ≤40%) in association with a beta-blocker unless there is a contraindication or an intolerance and as a replacement for a treatment that has been underway for at least four weeks with an angiotensin-converting enzyme inhibitor (ACE) or angiotensin II receptor antagonist (ARA). Reference: 1. Ontario Drug Benefit Formulary. Summary of Changes. Effective April 27, 2017. Available at: http://www.health.gov.on.ca/en/pro/programs/drugs/edition_42.aspx 2. Régie de l’assurance maladie du Québec. March 22, 2017. Available at: http://www.ramq.gouv.qc.ca/SiteCollectionDocuments/liste_med/liste_med_2017_03_22_en.pdf RAMQ Official Mark of the Régie de l’assurance maladie du Québec. 3. Saskatchewan Exception Drug Status Program. Available at: http://formulary.drugplan.health.gov.sk.ca/PDFs/APPENDIXA.pdf 4. Manitoba Drug Benefits and Interchangeability Formulary Amendments. Available at: https://www.gov.mb.ca/health/mdbif/docs/bulletins/bulletin93.pdf 5. Alberta Health Services Drug Benefit List. September 1, 2017. Available at: https://www.ab.bluecross.ca/dbl/pdfs/sep_dblupdate.pdf 6. ENTRESTOTM Product Monograph. Novartis Pharmaceuticals Canada Inc. August 3rd, 2016.

PRO/ENT/0145E Entresto is a trademark. ©Novartis Pharmaceuticals Canada Inc. 2017

Where have all the “small fishing villages” gone? In beachside tourist town brochures you’ll often find the phrase: “was once a small fishing village.” We’ve got a couple of such places in this issue — Mexico’s Puerto Vallarta (page 30) and Baja’s Los Cabos (page 36). There’s a soft spot in my heart for these places as they once were. In 1948 Puerto Vallarta was known as Puerto Pefias and a single line of white, mostly adobe, cottages faced the Pacific with lush jungle behind. Here and there fishing boats were drawn up on an almost deserted beach. That began to change after 1962 when director John Huston chose PV to shoot the movie The Night of the Iguana. Richard Burton starred along with Ava Gardner and a young Deborah Kerr, and Elizabeth Taylor, soon to be Burton’s wife, was a regular visitor on the set. Ms. Taylor and the cast and crew stayed at the Hotel Rosita (hotelrosita.com), then the town’s first. It’s still there today, in the heart of downtown, and is a considered a jewel of classic Mexican architecture. Los Cabos didn’t really get going until 1974 when the government beefed up the infrastructure. I have a friend who camped out of a VW bus and surfed up and down the Baja in the late ’60s and early ’70s. Now there are 15 golf courses and dozens and dozens of hotels including the new Paradisus Los Cabos covered here yet the beach and the desert still somehow hold their own. I’ve had the great pleasure of staying in a couple of other spots before the hordes descended. On Sunday nights, US Public Television is showing Gerald Durrell’s My Family and other Animals set on Corfu. My wife and I spent a winter there in 1971. We were one of only two “foreign” couples on the island at the time. It was lovely. Torremolinos on Spain’s Costa del Sol was once another small fishing village. Development there was somewhat earlier. Rumour has it that in 1961 dictator Francisco Franco cruised by in his yacht, appalled at what he saw and ordered “Tear it down.” Of course they didn’t and now it’s one of the most densely packed collections of high rises anywhere on the Mediterranean. Peace and quiet can still be found on the Portuguese island of Madeira (page 26) and if you have an urge to let go, what more authentic place than at a world festival (page 40). Happy trails,

Liz Taylor and Richard Burton on the set of The Night of the Iguana in Puerto Vallarta, 1962.

Visit David Elkins, publisher and editor delkins@parkpub.com

doctorsreview.com

facebook.com/doctorsreview

@doctorsreview NOVEMBER / DECEMBER 2017 • Doctor’s

Review

INTRODUCING SHINGRIX NEW FROM GSK COMING IN JANUARY 2018 Learn more about SHINGRIX at ThinkSHINGRIX.ca

02270

10/17

contents NOVEMBER / DECEMBER 2017

30 COVER: JORDAN ADKINS / SHUTTERSTOCK.COM

features

Portugal’s paradise island

An MD from Alberta hikes along Madeira’s old water channels for a unique look at spectacular landscapes by Dr Heather Wrigley

Greetings from Mexico! An insider’s guide to the best beaches, taco stands and more in Puerto Vallarta and the Riviera Nayarit by Anita Draycott

Reasons to celebrate From Día de los Muertos in Mexico to Holi in India, six cultural events that have little to do with Christmas! by Camille Chin

Be my (dinner) guest Tagine spiced chicken and other extra-special dishes from a celebrity caterer for the season of entertaining by Peter Callahan

Peaceful desert, lively sea Los Cabos at the tip of Mexico’s Baja California dazzles visitors with so much more than endless sunshine by Robb Beattie

NOVEMBER / DECEMBER 2017 • Doctor’s

Review

NEW

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

FOR THE TREATMENT OF MODERATE TO SEVERE VASOMOTOR SYMPTOMS

A New Option in hormone therapy for women with a uterus

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

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

Indications and clinical use: DUAVIVE is indicated in women with a uterus for the treatment of moderate to severe vasomotor symptoms associated with menopause. DUAVIVE should not be taken with a progestin, additional estrogens or selective estrogen receptor modulators (SERMs). Not recommended for women >75 years of age. Not indicated for pediatric use. Contraindications: • Active or past history of confirmed venous thromboembolism (VTE) or active thrombophlebitis • Active or past history of arterial thromboembolic disease • Hypersensitivity to estrogens

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

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

Most serious warnings and precautions: Risk of stroke and deep vein thrombosis: estrogen-alone therapy (mean age 63.6 years). Therefore, estrogens with or without progestins: • Should not be prescribed for primary or secondary prevention of cardiovascular diseases • Should be prescribed at the lowest effective dose and for the shortest period possible for the approved indication Other relevant warnings and precautions: • Possible risk of ovarian cancer • Monitor blood pressure with hormone replacement therapy use • Caution in patients with otosclerosis • Caution in women with pre-existing endocrine and metabolic disorders • Caution in patients with rare hereditary galactose intolerance • Abnormal vaginal bleeding • May increase pre-existing uterine leiomyomata • May exacerbate previous diagnosis of endometriosis • May increase the risk of VTE • Risk of gallbladder disease • Caution in patients with history or liver and/or biliary disorders • Caution in women with hepatic hemangiomas • Angioedema • Caution in women with systemic lupus erythematosus • Cerebrovascular insufficiency • May exacerbate epilepsy • Fluid retention • Not recommended in renal impairment • Not recommended in premenopausal women • Women with higher BMIs (≥30 kg/m2) may exhibit decreased bazedoxifene which may be associated with an increased risk of endometrial hyperplasia For more information: Please consult the Product Monograph at http://pfizer.ca/pm/en/duavive.pdf for important information relating to adverse reactions, drug interactions and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-463-6001. * Clinical significance has not been established. † SMART 2: 12-week, double-blind, placebo-controlled trial in 318 women who had 7 moderate to severe hot flushes/day or ≥50/week at baseline who were randomized to DUAVIVE (n=127), CE 0.625 mg/BZA 20 mg (n=128), or placebo (n= 63). Primary endpoint assessed efficacy of vasomotor symptom relief. ‡ SMART 1: 24-month, double-blind, placebo- and active-controlled dose-ranging trial of 3397 women who were randomized to DUAVIVE (n=433), raloxifene 60 mg or placebo. Women took calcium and vitamin D (Caltrate 600 + D™) daily. Primary endpoint was the incidence of endometrial hyperplasia; secondary endpoint was the treatment of vasomotor symptoms. § SMART-5: 12-month, double-blind, placebo- and active-controlled trial of 1843 women who were randomized to DUAVIVE (n=445), CE 0.625 mg/BZA 20 mg (n=474), BZA 20 mg (n=230), conjugated estrogens 0.45 mg / medroxyprogesterone acetate (MPA) 1.5 mg (n=220) or placebo (n=474). Women also took calcium, 600 mg and vitamin D, 400 IU daily. Reference: 1. DUAVIVE Product Monograph. Pfizer Canada Inc., October 20, 2014.

contents NOVEMBER / DECEMBER 2017

regulars

7 LETTERS Siri say what?

9 PRACTICAL TRAVELLER The 2017 Canadian Biennial opens in Ottawa, Downton Abbey arrives in NYC, Toronto’s ROM welcomes Dior, and more! by Camille Chin

GADGETS Carry on with this well-designed carry-on by David Elkins

TOP 25 The best conferences scheduled for next spring

20 DEPRESSION KEYPOINTS Toward better mental health outcomes among LGBTQ+ communities by Alison Palkhivala

23 HISTORY OF MEDICINE Human testing of new cures from the brilliant to the bizarre by Tilke Elkins

48 PHOTO FINISH The calm before the storm by Dr Olivia Sankat

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17 NOVEMBER / DECEMBER 2017 • Doctor’s

Review

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LETTERS

EDITOR

David Elkins

Siri say what?

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

OFFICE MANAGER

Denise Bernier

EDITORIAL BOARD

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

CRUISING THROUGH NEW ZEALAND Great review, Art [“On the road in New Zealand,” I Prescribe a Trip to…, September 2017, page 28]. John Smith and I, and our spouses, did this [road trip] similarly 10 years ago in an 11-passenger hippie van. My wife Gloria and I were the only ones light enough to do tandem hang-gliding in Queenstown. Enjoy your well-deserved retirement. Dr Dave Andrews Via DoctorsReview.com

LIBRARIES BY DESIGN There is a stunning new library in Halifax, which is now a landmark in the city [A new chapter, September 2017, page 40]. Danish architects. Worth a mention. Dr John Finley Via DoctorsReview.com

Dr Arthur Zilbert and his wife in New Zealand.

TRIBAL THOUGHTS Truly fascinating stories [Ancient Ways, October 2017, page 40]. What will today’s hygiene-obsessed women do if asked to live for a week among Namibia’s Himba tribe where women “don’t ever wash with water?” I hope we the tourists don’t flock to these places and destroy their way of life, as we often do. Dr Muri B. Abdurrahman Via DoctorsReview.com

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

MAKING A MEDICAL SWITCH There is a very good Canadian website to help with switching antipsychotics and antidepressants [“Switching anti depressants safely,” Depression Keypoints, October 2017, page 20]: switchrx.ca. Dr Raymond Lam Via DoctorsReview.com

SIRI SOUND OFF I wonder if Google Home [Gadgets, October 2017, page 14] would understand me better than Siri does. I have a South African accent and Siri does not understand me, no matter how much I talk to her! Dr Michele Moss Via DoctorsReview.com

SOUS VIDE SUCCESS Mon traiteur est venu à la maison avec cet appareil [“Get into hot water,” Gadgets, September 2017, page 16] pour un carré d’agneau succulent! • A caterer who came to my house used this device [“Get into hot water,” Gadgets, September 2017, page 16] to cook a succulent rack of lamb Serge Bruneau Via DoctorsReview.com

NOVEMBER / DECEMBER 2017 • Doctor’s

Review

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

C a mi lle C hi n

Ottawa’s big art show The 2017 Canadian Biennial is open now until March 18, 2018 at Ottawa’s National Gallery of Canada. The fourth edition showcases recent acquisitions of Canadian and Indigenous contemporary art as well as, for the first time, international pieces. It features 50 artists and more than 100 works: paintings, photographs, sculptures, and large mixed-media installations. Kent Monkman’s Casualties of Modernity is on view; the Canadian artist of Cree and Irish ancestry was profiled in DR’s September issue. Nick Cave’s Soundsuit is another showstopper: it consists of a mannequin, gramophone horn, ceramic birds, metal flowers, strung beads and more. Cave’s first Soundsuit was created in 1992, as a reaction to the beating of Rodney King by Los Angeles police. BGL’s Canadassimo (Dépanneur) (2015) is on view too; the Quebec artist group represented Canada at the Venice Biennale in 2015. Adults $15, seniors $13, 24 and under/students $7. gallery.ca. NOVEMBER / DECEMBER 2017 • Doctor’s

Review

LEFT: Nick Cave’s mixed media Soundsuit (2015). BELOW: Hoktemberjan, Armavir (2000) by Ursula Schulz-Dornburg.

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

The gift of gab in Dublin

ARNDALE / SHUTTERSTOCK.COM

The Oscar Wilde sculpture at the corner of Merrion Square Park.

Ten of Dublin’s most famous landmarks have been given a voice thanks to a new tourism initiative called Talking Statues. Each of the statues now have a plaque with a QR code that visitors can scan if they would like to receive a phone call on their smartphones from Oscar Wilde, James Joyce and others. The call is placed immediately and is more of a two-minute monologue than a dialogue, but participants will learn more about the lives of some Ireland’s most famous contributors and influencers. More Dublin statues are being considered for animation in 2018. visitdublin.com/see-do/talking-statue.

Doctor’s Review • NOVEMBER / DECEMBER 2017

.CO OC K KALEK HA / SHUT TERS T

K NA

P HA NYA

Imagine being bitten by bedbugs before you arrive at your destination, before you check into your hotel, before you even lay down to sleep. A Canadian mother and her 7-year-old daughter along with the mom’s fiancé have reported being bitten by the critters following a nine-hour British Airways flight from Vancouver to London. They noticed the bugs crawling out of the seat in front of them, but couldn’t be moved because there weren’t any available places. In a recent Toronto Star article, Murray Isman, a UBC professor of entomology and toxicology, said with the increase in personal travel and the spread of the insect globally, it’s not surprising bedbugs are finding their way onto airplanes. To protect themselves, travellers may want to invest in a plastic seat cover and bring their own blankets and pillows on long-haul flights.

Bed bugs take flight

The Golden Age of dressmaking

PHOTOS THIS PAGE LAZIZ HAMANI

Christian Dior (1905–1957), the French fashion designer from Normandy, is often credited with reviving the entire Paris haute couture industry after the devastation of WWII. In 1947, the opening of a new couture house and the introduction of what was known as the “New Look” — soft shoulders, padded hips and long, full skirts — inspired women around the world who’d been sporting masculine wartime shapes. Dior also coined the terms “A-line” and “H-line.” The Christian Dior exhibit, on now until March 18, 2018 at the Royal Ontario Museum in Toronto, focuses on the Frenchman’s designs from 1947 to 1957, and offers insight into the creative process and mechanics of the Paris haute couture industry during the 1950s. Daytime and evening wear are on view. Adults $28. rom.on.ca.

TOP AND FAR RIGHT: Caracas, late afternoon dress, Spring-Summer 1957. LEFT AND CENTRE: Young girl’s formal dress, Spring 1957, exclusive to Holt Renfrew & Co. Ltd. NOVEMBER / DECEMBER 2017 • Doctor’s

Review

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

London’s

new green space Europe’s largest urban wetland nature reserve recently opened to the public for the first time in 150 years and amazingly it’s only a 15-minute Tube ride from central London. Walthamstow Wetlands stretches for 211 hectares and features 21 kilometres of footpath and cycle tracks. The plethora of wildflowers may be gone now, but they’ll reappear in the spring along with all the waterfowl and migrating sandpipers, redshank, lapwings and more. What’s more, the urban green space is home to the largest heronry and also largest recreational fishery in London. Owned by Thames Water, there are 10 onsite reservoirs that are still operational; they provide drinking water to 1.5 million people. The opening of the park was made possible by a £10.6m (about $18 million) investment; 250,000 visitors are expected in its first year. Admission free. Parking from £2 ($3.40) for up to one hour. walthamstowwetlands.com.

Hard Rock

Hotel & Casino, Punta Cana

March 10-17, 2018 Dermatology, Addiction & Chronic Pain

Sandals

Emerald Bay, Exuma

UNICO,

Mayan Riviera

January 21-28, 2018

Cardiology, Internal Medicine & Medical-Legal Updates

February 4-11, 2018 Internal Medicine & Breast Cancer Update

Doctor’s Review • NOVEMBER / DECEMBER 2017

PXL.STORE / SHUTTERSTOCK.COM

Walthamstow Reservoirs.

Downton Abbey: The Exhibition made its US debut in New York City on November 18; it runs through January 2018 at 218 West 57th Street near Carnegie Hall. Based on the popular British TV show — the highestrated PBS drama series of all time! — the touring exhibit will transport visitors back in time to post-Edwardian England. Some of the series’ most recognizable sets are on display from Mrs. Patmore’s hectic kitchen and the gossip-fuelled servants’ quarters to the family’s glamorous dining room and Lady Mary’s bedroom. About 50 costumes and thousands of artifacts are also on view. Visitors will get insight into British society, culture and fashion, from World War I to the Roaring Twenties. Tickets are date and time specific: adults from US$30; kids from US$15. downtonexhibition.com.

Downton Abbey’s US tour debut

NOVEMBER / DECEMBER 2017 • Doctor’s

Review

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

D a v i d Elk i n s

The perfect carry-on? Once upon a time my wife and I went to Greece for almost a year with everything stuffed into two blue duffle bags. We were young and carefree, and ready for anything, which was just as well, but that’s another story. Since then, there’s been a lot of travel — and a lot of bags. The one criterion that hasn’t changed: they have to be carry-ons. I learned that lesson on one of my first jobs. I worked at Montreal’s Dorval airport checking in passengers and their luggage. This was before the days of airline security. Bags were simply tagged and placed on a conveyer belt, which carried them through an opening in the floor and out of sight. My supervisor was a jolly fellow who liked a good laugh as much as the next guy. “Down to the incinerator!” he’d call as each suitcase disappeared perhaps never to be seen again. Bag handling being what it was — and is — that was sometimes the case. I’ve only used carry-on bags ever since. Finding just the right piece of luggage has always been a challenge. For a while I was happy with a stylish canvas affair with leather trim by Ricardo, but I grew weary of lugging it so I switched to a backpack. That didn’t set quite the image I was hoping for so when the first wheelie cases came out, I was pre-sold. My handsome hard-side glided through many airports until ever shrinking airline carry-on sizes caught up to me a couple of years ago. I was consistently asked to “check it” at the gates to be retrieved plane-side at my destination. I rebelled

and, going full circle, acquired a compact backpack, this one on wheels. Convenient. Right size. Wrong look. I’m ready to move on again, this time to a TLS Mother Lode Weekender Convertible. From all the good reviews I’ve read, this could be it. I have my eye on the smaller 19.5-inch model rather than the 22-inch just in case the airlines tighten up the regulations again. Both are 14 inches wide and share the same wonderful features. They open like a suitcase with separate compartments for neat stowing, but also include a stuffable pocket as part of the lid.

Win a TLS Mother Lode Weekender Convertible by entering the Gadget of the Month contest at doctorsreview.com. Compression straps inside and out keep your things firmly in place. Two wellplanned zippered pockets provide a place to keep tickets and passport, and there’s another for toiletries. There’s a secret place for a computer and a water bottle pocket that folds away until you need it. No geeky wheels. You can carry it on a sling strap over one shoulder, by a side handle or like a backpack on straps that fold away. It comes in nine colours. To check it out go to ebags.com and search for TLS Mother Lode Weekender Convertible. There’s a video. $160.

CONGRATULATIONS! The winner of the sous-vide cooker is Dr Brian Poelzer, a family physician from Kamloops, BC. 14

Doctor’s Review • NOVEMBER / DECEMBER 2017

Breathe better. Live better.

PROACTIVE HEALTH It’s all about breathing. Doctor-recommended Xlear® Saline Nasal Spray with xylitol doesn’t just alleviate congestion and dryness due to colds, flu, and allergies, it’s proven to open your airways better than saline alone to help you breathe easier.

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

Go to doctorsreview.com/meetings to search 2500+ top world conferences. Access code: drcme

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Montreal, QC April 19-21, 2018 2018 Annual Scientific Meeting of the Canadian Geriatrics Society canadiangeriatrics.ca

Ottawa, ON April 5-6, 2018 Canadian Women’s Heart Health Summit 2018 cwhhc.ottawaheart.ca/summit Montreal’s famous St-Viateur Bagel.

Quebec City, QC April 26-28, 2018 Congrès annuel de la société Canadienne de néphrologie sqn.qc.ca/congres-annuel-de-la-sqn-2018

Vancouver, BC February 21-24, 2018

Toronto, ON May 9-12, 2018

2018 Annual Scientific Meeting of the Canadian Rheumatology Association rheum.ca/en/events

Pri-Med Canada 2018 pri-med.ca/pct/home.html

February 22-24, 2018

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

The Samuel Beckett Bridge in Dublin.

2018 Scientific Meeting of the Canadian Pediatric Endocrine Group interprofessional.ubc.ca

April 12-14, 2018 2018 Canadian Respiratory Conference cts.lung.ca/crc

Around the world Budapest, Hungary May 9-12, 2018 15th Congress of the European Society of Contraception and Reproductive Health escrh.eu/15th-esc-congress

Dublin, Ireland May 9-12, 2018 9th World Congress of the World Institute of Pain wip2018.kenes.com

Dubrovnik, Croatia April 15-17, 2018 10th Conference on Advances in Diabetes and Insulin Therapy adit-conf.org

MARTIN GOOD / SHUTTERSTOCK.COM

Florence, Italy May 19-22, 2018 13th Congress of the European Glaucoma Congress eugs.org/eng/meetings_symp.asp

Gothenburg, Sweden May 16-18, 2018 4th European Stroke Organisation Conference eso-conference.com/2018

NOVEMBER / DECEMBER 2017 • Doctor’s

Review

For adults with mild to moderate essential HTN for whom combination therapy is appropriate

3.5 mg Perindopril arginine / 2.5 mg Amlodipine

WHEN IT’S TIME TO START TREATMENT…

GET ON BOARD WITH ® VIACORAM VIACORAM® is not indicated for the initiation of treatment in elderly patients.

Indications and clinical use VIACORAM® (perindopril arginine/amlodipine) is indicated for the treatment of mild to moderate essential hypertension in patients for whom combination therapy is appropriate. VIACORAM® 3.5 mg/2.5 mg is indicated for initial therapy in patients with mild to moderate essential hypertension. VIACORAM® is not indicated for switching therapy from the individual drugs currently on the market (perindopril as erbumine or arginine salt, amlodipine). VIACORAM® is not indicated for the initiation of treatment in elderly patients (> 65 years of age). There is no sufficient clinical experience to justify the use in these patients. VIACORAM® is not indicated in pediatric patients < 18 years of age. The efficacy and safety have not been studied in this population. Contraindications VIACORAM® is contraindicated in: • Patients who are hypersensitive to the active ingredients of this drug, to any ingredient in the formulation or component of the container, to any other angiotensin-converting enzyme inhibitor (ACE-inhibitor), or to any other dihydropyridine derivatives • Patients with renal impairment (creatinine clearance < 60 ml/min) • Patients with a history of hereditary/idiopathic angioedema, or angioedema related to previous treatment with an ACE-inhibitor • Women who are pregnant, intend to become pregnant, or of child-bearing potential who are not using adequate contraception • Nursing women • Patients with mitral valve stenosis and left ventricular outflow tract obstruction (e.g. aortic stenosis, hypertrophic cardiomyopathy) • Patients with heart failure • Combination with sacubitril/valsartan due to increased risk of angioedema • Concomitant use with aliskiren-containing drugs in patients with diabetes mellitus (type 1 or 2) or moderate to severe renal impairment (GFR < 60 ml/min/1.73 m2) • Patients with hereditary problems of galactose intolerance, glucose-galactose malabsorption, or the Lapp lactase deficiency as VIACORAM® contains lactose • Patients with extracorporeal treatments leading to contact of blood with negatively charged surfaces • Patients with bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney Most serious warnings and precautions Pregnancy: When used in pregnancy, ACE-inhibitors can cause injury or even death of the developing fetus. When pregnancy is detected, VIACORAM® should be discontinued as soon as possible.

NEW RECOMMENDATION BY HYPERTENSION CANADA: SINGLE-PILL COMBINATION ACEI + CCB AS INITIAL THERAPY Single-pill combination therapy or monotherapy are now recommended as initial therapy for adults with hypertension without other compelling indications for specific agents4

Hyperkalemia (serum potassium > 5.5 mEq/L): Can cause serious, sometimes fatal arrhythmias; serum potassium must be monitored periodically in patients receiving VIACORAM®. Concomitant use with potassium supplements, potassium-sparing diuretics, or potassium-containing salt substitutes is not recommended. Collagen vascular disease, immunosuppressant therapy, treatment with allopurinol or procainamide, or a combination of these complicating factors (especially if there is pre-existing impaired renal function): May lead to serious infections, which may not respond to intensive antibiotic therapy. If VIACORAM® is used in such patients, periodic monitoring of white blood cell counts is advised and patients should be instructed to report any sign of infection to their physician. Angioedema: May be life-threatening and occur at any time during therapy. Where there is involvement of the tongue, glottis or larynx, likely to cause airway obstruction, it may be fatal, emergency therapy should be administered promptly.

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

ACEi: angiotensin-converting enzyme inhibitor; ARB: angiotensin II receptor blockers; CCB: calcium channel blocker; DPP-IV: dipeptidyl peptidase-4; GFR: glomerular filtration rate; HTN: hypertension; mTOR: mechanistic target

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Syndrome starting with cholestatic jaundice with progress to fulminant hepatic necrosis: May lead to death. Use during low-density lipoproteins (LDL) apheresis (with dextran sulphate): May lead to life-threatening anaphylactoid reactions.

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Other relevant warnings and precautions • Caution in driving a vehicle or performing other hazardous tasks • Co-administration of ACE-inhibitors, including the perindopril component of VIACORAM®, with other agents blocking the RAS, such as ARBs or aliskiren-containing drugs, is generally not recommended in patients other than patients with diabetes mellitus (type 1 or type 2) and/or moderate to severe renal impairment (GFR < 60 ml/min/ 1.73 m2) as it is contraindicated in these patients • Concomitant use of mTOR inhibitors, DPP-IV inhibitors, and NEP inhibitors • Risk of hypotension; closely monitor patients at high risk of symptomatic hypotension. Similarly monitor patients with ischemic heart or cerebrovascular disease; an excessive fall in blood pressure could result in a myocardial infarction or cerebrovascular accident • Risk of mild to moderate peripheral edema • Safety and efficacy of VIACORAM® in hypertensive crisis have not been established • Risk of angina worsening/acute myocardial infarction after starting therapy or dose increases • Risk of hyperkalemia; monitor serum potassium periodically • Patients with primary aldosteronism generally will not respond to anti-hypertensive drugs acting through inhibition of the RAS. Therefore, the use of VIACORAM® is not recommended in these patients. • Risk of neutropenia/agranulocytosis, thrombocytopenia and anemia • Increases in serum transaminase and/or bilirubin levels, cholestatic jaundice, cases of hepatocellular injury with or without cholestasis • Not recommended in patients with impaired liver function • Angioedema • Risk of anaphylactoid reactions during desensitization or membrane exposure (hemodialysis patients) • Risk of nitritoid reactions in patients on therapy with injectable gold • Patients undergoing major surgery or during anesthesia with agents that produce hypotension • Risk of angioedema in black patients vs. non-black patients • Not recommended in patients with a recent kidney transplantation • Risk of changes to renal function in susceptible patients; potassium and creatinine should be monitored in these patients • Risk of cough • Dermatological reactions • Not indicated for the initiation of treatment in the elderly (> 65 years) patients; not recommended in pediatrics (children < 18 years of age) • Patients with diabetes treated with oral antidiabetic agents or insulin, glycemic control should be closely monitored during the first month of treatment with VIACORAM® • Patients with unilateral or bilateral renal artery stenosis or stenosis of the artery to a single functioning kidney • Sexual function/reproduction: Reversible biochemical changes observed in the head of spermatozoa

2018 World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases wco-iof-esceo.org

May 24-27, 2018 EA GIVEN / SHUTTERSTOCK.COM

23rd WONCA Europe Conference woncaeurope2018.com/en

Lisbon, Portugal February 28-March 3, 2018 2018 World Meeting on Sexual Medicine issmessm2018.org

May 16-20, 2018 11th International Congress on Autoimmunity autoimmunity.kenes.com/2018

Malmo, Sweden May 28-June 2, 2018 36th Annual Meeting of the European Society for Paediatric Infectious Diseases espidmeeting.org

Marseille, France May 16-18, 2018 2018 International Symposium on HIV and Emerging Infectious Diseases isheid.com/en_GB/

Paris, France April 11-15, 2018

16th World Congress of the World Association for Infant Mental Health waimh.org

4th Biennial Summit of the Thrombosis & Hemostasis Societies of North America thsna.org/web/index.php

5th China Congress on Controversies to Consensus in Diabetes, Obesity and Hypertension codhy.com/china/2018

Sydney, Australia April 8-11, 2018 2018 Conjoint Annual Scientific Meetings of the Australian Pain Society and New Zealand Pain Society dcconferences.com.au/apsnzps2018

Tel Aviv, Israel March 19-21, 2018 2018 International ADHD Congress 2018.adhdcongress.co.il

12th World Congress on Controversies in Neurology comtecmed.com/cony/2018

Rome, Italy May 26-30, 2018

San Diego, CA March, 8-10, 2018

Shanghai, China May 11-13, 2018

Warsaw, Poland March 22-25, 2018

2018 International Liver Congress easl.eu/discover/events/detail/2018/theinternational-liver-congress-2018

VIPR0318E

VIACORAM® is a registered trademark of Servier Canada Inc.

Sydney’s Bondi Beach.

Krakow, Poland April 19-22, 2018

For more information Please consult the Product Monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-363-6093. Please visit www.servier.ca/references/ Viacoram_EN.pdf to access the study parameters and reference list.

of rapamycin; NEP: neutral endopeptidase; RAS: reticular activating system

Code: drcme

MEDICAL QUIPS Cell call Two blood cells met and fell in love... but alas it was all in vein.

NOVEMBER / DECEMBER 2017 • Doctor’s

Review

DE PRESSIO N K EY PO I NT S by

A li son Pa lkhi va la

Depression and suicidality in LGBTQ+ communities Toward better mental health outcomes among this evolving population Defining the terms LGBTQ+ is the acronym used to refer to people who identify as lesbian, gay, bisexual, trans, queer/questioning, and others. Often included in this definition are people whose sexual identify or orientation do not align with social norms. This can include people who identify a having both genders (bigender), who do not feel a desire for partnered sexuality (asexual), who feel their gender presentation or identification shifts (gender fluid), and whose primary or secondary sex characteristics are not clearly male or female (intersex). The terms transgender is most often used to refer to people whose gender identity, expression, or behavior does not match their gender at birth, while genderqueer is increasingly being adopted among younger people to describe any gender identify, expression, or behavior other than exclusively male or female. Transsexual is usually reserved for people who elect to undergo medically or surgically assisted sexual reassignment.1 This is by no means a complete list, and terms and definitions relating to sexual identity and orientation are evolving rapidly.

A population at risk Depression and suicidal behavior in LGBTQ+ populations are recognized as serious public health issues, but the scope of the problem remains unclear, in part because the notion of what is means to be LGBTQ+ continues to evolve. Generally speaking, about 3% of the adolescent and adult population identify

themselves as gay or bisexual, but as many as 7 to 8% of people report some degree of attraction to others of the same sex.1 Research to date suggests that identifying as gay, lesbian, or bisexual is more likely to place individuals at greater risk of anxiety disorders, mood disorders, and suicidal ideation than simply engaging in same-sex attraction or behavior.1 A 2008 meta-analysis of 25 international population-based studies found that, over any 12-month period, LGB adults and adolescents are about twice as likely as their heterosexual counterparts to attempt suicide. Looking at lifetime prevalence suggests there may be gender disparities. LGB men and boys were found to be about four times as likely to attempt suicide, while LGB girls and women were about twice as likely. When it came to suicidal ideation, however, more LGB females were likely to contemplate suicide than LGB males.2 While data on suicidality among transgender populations is sketchier, the problem is likely to be even greater among this vulnerable group. Estimates are that up to one-third of people who seek gender reassignment surgery have a history of at least one lifetime suicide attempt.1 Canadian research has estimated that LGB youth have about 14 times the risk of suicide as their heterosexual peers.3 In addition, a large statistically representative study of transgender people in Ontario found that 77% had seriously considered suicide, and 45% had attempted suicide.4 As with the population as a whole, LGBTQ+ people are at increased risk of suicidality when faced with mental health problems, such as depression, anxiety disorders, conduct disorder,

Table 1. Information for clinicians on LGBTQ+ communities • Asking the Right Questions 2: Talking with Clients about Sexual Orientation and Gender Identity in Mental Health, Counselling and Addiction Settings. Produced by the Centre for Addiction and Mental Health. Available online at http://www.camhx.ca/ Publications/Resources_for_Professionals/ARQ2/arq2.pdf • A glossary of LGBTQ+ terms is available at https://www.lgbthealtheducation.org/wp-content/uploads/LGBT-Glossary_ March2016.pdf • Guidelines and protocols for care of trans clients are available at http://sherbourne.on.ca/guidelines-protocols-for-trans-care/ • First, Do No Harm: guidelines for clinicians for reducing health disparities for LGBTQ+ patients is available at http://www. nccdglobal.org/sites/default/files/publication_pdf/first_do_no_harm.pdf • A positive practices checklist is available at https://docs.hamiltonfht.ca/dsweb/Get/Document-2926 • Are you an Ally: videos and training on how to be an ally for LGBTQ+ populations are available at http://www.mountsinai.on. ca/about_us/human-rights/ally/

Doctor’s Review • NOVEMBER / DECEMBER 2017

Table 2. Support for LGBTQ+ populations • It Gets Better campaign: LGBTQ+ people and their allies share supportive messages through online video. http://www.itgetsbetter.org • Kids Help Phone: Provides non-judgmental support for youth. 1-800-668-6868. • The Lesbian, Gay, Bi & Trans Youthline: offers free peer support for youth 26 and under 1-800-268-9688. • Parents, Friends of Lesbians and Gays (PFLAG): Support for LGBTQ+ and their families. www.pflagcanada.ca

and substance or alcohol abuse. In turn, all of these risk factors have been seen at much higher rates among LGBTQ+ populations in several studies conducted around the world.1 Increased rates of depression and suicidality among LGBTQ+ populations are likely to be explained at least in part by the widespread, systematic discrimination they face over their lifetimes. This can take the form of personal or professional rejection, hostility, harassment, bullying, and/or physical violence. Racial minorities who also identify as LGBTQ+ may face the worst discrimination. Discrimination and prejudice can be particularly damaging when the source is one’s own family. Several studies have linked suicide attempts with parental rejection among LGBTQ+ youths, and it can be particularly problematic if it results in homelessness.1

Role of clinicians Primary care physicians are in a unique position to mitigate the negative impact on mental health of discrimination among LGBTQ+ populations, particularly for younger patients. They can provide a source of adult acceptance and support as well as identify and address modifiable risk factors for depression and suicide, including family rejection, substance abuse, school bullying, other forms of abuse/violence, and homelessness. Mental health needs related to gender identity and sexual orientation were identified as a priority in the 2012 strategy report Changing Directions, Changing Lives by the Mental Health Commission of Canada. They highlight the need for the mental health community to provide care that does not discriminate or stigmatize LGBTQ+ patients or perpetuate negative stereotypes. It is also important to be aware of how much stigma and discrimination LGBTQ+ patients may have experienced in the past, both inside and outside the healthcare system. Older patients in particular may be reluctant to access mental health services because of prior negative experiences.5 Mental health care professionals must become educated about the needs of LGBTQ+ communities and maintain a positive attitude toward this population. It is particularly important to be mindful of women’s health issues within the context of LGBTQ+ communities, in which poverty, unsupported caregiving, and family violence pay a particularly prominent role.5

In a 2014 Position Paper, the Canadian Psychiatric Association (CPA) emphasized that its role in advocating for the decrease of stigma and discrimination among people with mental illnesses should also be extended to those who identify as LGBTQ+.6 Rainbow Health Ontario, a provincial organization which seeks to promote the health of Ontario’s LGBTQ communities, offers the following tips for clinicians when it comes to helping their LGBTQ+ clients with depression and suicidality: • Learn about the broader social and legal context in which LGBTQ+ patients live as well as how internalized discrimination can impact mental health. Resources for clinicians are listed in Table 1. • Recognize that legal and social equity for LGBTQ+ populations is both a political and a health issue. • Provide necessary staff training to ensure that LGBTQ+ patients are not subjected to negative stereotyping or discrimination and that gender is appropriately identified, especially in the context of crisis support for suicidality. • Be aware of resources available for LGBTQ+ populations, both locally and online, especially with regard to suicidality. A list of such resources is presented in Table 2. • Develop understanding of the social determinants of both physical and mental health. • Promote family acceptance of LGBTQ adolescents and encourage them to connect with LGBTQ communities.7

Future directions An emerging field of research is the exploration of mental health treatments that specifically address the stressors known to play a significant role in the mental and emotional well-being of LGBTQ+ populations, notably rumination, rejection sensitivity, and perceived burdensomeness triggered by minority stress. Promising therapeutic interventions include expressive writing that targets gay-related stress and cognitive behavior therapy (CBT) that focuses of stigma-related stressors. Perhaps most importantly for young patients, clinicians can play a pivotal role by educating and engaging parents and other family members to help them affirm patients’ LGBTQ+ identities.8 References 1. Haas AP, Eliason M, Mays VM et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex. 2011 Jan; 58(1): 10–51. 2. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay, and bisexual people. BMC Psychiatry. 2008, August 18;8:70. 3. Benibgui M. Mental health challenges and resilience in lesbian, gay and bisexual young adults: Biological and psychological internalization of minority stress and victimization. 2011. 4. Bauer G, Boyce M, Coleman T, et al. Who are trans people in Ontario? Toronto: Trans PULSE EBulletin; 2010. Report No.: 1(1). 5. Mental Health Commission of Canada (MHCC). Changing directions, changing lives: the mental health strategy for Canada [Internet]. Calgary (AB): MHCC; 2012. 6. Veltman A, Chaimowitz G. Mental health care for people who identify as lesbian, gay, bisexual, transgender, and (or) queer. Can J Psychiatry. 2014 Nov;59(11):1-7, 1-8. 7. Rainbow Health Ontario. Rainbow Health Fact Sheet: LGBTQ Mental Health Fact Sheet. 2015. 8. Russell ST, Fish JN. Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annu Rev Clin Psychol. 2016;12:465-87 NOVEMBER / DECEMBER 2017 • Doctor’s

Review

Count on

for powerful symptom relief

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

In major depressive disorder, her doctor calls it

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

Choose PRISTIQ:

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

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

•

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

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

•

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

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

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

CA0116PRI017E

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

H I S T O R Y O F M E DI CI N E by

T i lk e Elk i n s

The uneven history of clinical trials Human testing of new cures from the brilliant to the bizarre

Professional “guinea pigs” in clinical trials earn as much as $40,000 a year.

uring the unwell is among the noblest acts of our species. On the other hand, the practice of harming other human beings in the name science is one of the least noble.

Historically, involuntary medical testing has been performed on the most vulnerable humans: children, the mentally ill, the physically impaired, prisoners of war, the colonially dominated, the incarcerated, the list goes on. Gruesome operations without anesthetic, infecting infants with syphilis, feeding uranium to pregnant mothers and injecting prisoners with live cancer cells are among the acts that have been carried out in the name of medical progress.

WHAT CONSTITUTES CONSENT? Not until the 1970s was it deemed unethical to use prisoners as subjects for medical tests on the basis that inmates were not adequately equipped to provide informed consent. With the end of that practice, medical pharmaceutical researchers shifted their attention to university centres and soon established relationships that seemed mutually beneficial. Academic researchers could not only design clinical trials, they could also publish the results in credible

journals, which could be used to help market the products that proved effective. Students were a freely available pool of potential test subjects and by the early 1990s much of new drug clinical testing took place at university centres. Since then, priorities have shifted. These days, industry goals are focused on bringing new products to market quickly pushed, in considerable part, by 20-year-patent expiry dates. Swift entry to markets has become the driving force to get medications on pharmacy and hospital shelves. Trials have been moved to the private sector where contract research organizations (CROs) shepherd products through each stage of the trials. About half of all global drug companies contract CROs outside North America, where costs are lower and regulations less stringent. That said, Canada continues to be a major contributor to the research industry — this country is fourth in the world in the number of clinical trials taking place at any given time, according to Health Canada. Human participants in these trials are more richly compensated than they once NOVEMBER / DECEMBER 2017 • Doctor’s

Review

Some physicians argue that selfexperimentation is the only form of research that qualifies as informed consent were. Though the vision of volunteers giving their time and enduring discomfort “for the good of humanity” persists, in truth, most people do it for the money. Professional “guinea pigs” as they call themselves can make as much as $40,000 annually if they manage to pack in eight to 12 phase one trials a year. These trials — when treatments are tested on humans for the first time — are the most lucrative owing to their less certain outcomes. And being a guinea pig can be risky. In France, not long ago, five trial participants were permanently disabled and one died. A recent British trial in England resulted in amputations on some of the subjects and also in dangerous head-swelling. These are cautionary tales; the vast majority of trials cause no lasting damage. CROs favour these “professional” test subjects. They know the drill and are unlikely to back out mid-trial, but just who are the participants in these trials? Who has long stretches of available time and is willing to the endure boredom, discomfort and potential health risks?

The usual suspects include a variety of students, mavericks and those who want to escape the daily grind, but it’s worth noting that many CROs recruit

The guidelines for testing on human subjects were first established in the Nuremberg Code in 1947.

at the gates of prisons, ready to offer a source of income to people who face considerable job-finding challenges. Professional guinea pigs often gripe about the work they do, calling it “mild torture,” and saying that having things “done to them” has replaced a job market where they once did things in the pre-information economy.

BACK TO NUREMBERG The guidelines for testing on human subjects were first established in the Nuremberg Code in 1947 during the Nuremberg trials when Nazi doctors were accused of murdering and torturing victims in valueless experiments. The code states that no experimenter should subject the participants to any procedure they would not be willing to undergo themselves. For these and other reasons, many researchers have done just that: become their own guinea pigs.

Doctor’s Review • NOVEMBER / DECEMBER 2017

Drinking black vomit infected with yellow fever; enduring the subcutaneous injection of 50 hookworms; or surgically implanting a computer chip into the median nerve fibres in the arm are doubtless experiments that would be unacceptable to many human volunteers regardless of the compensation offered. The doctors who performed these experiments reasoned that the only way to test their hypotheses without risking legal consequences was to perform them on themselves. Indeed, some physicians argue that self-experimentation is the only form of research that fully meets the requirement of informed consent. They believe that experimental research is too complex for those without medical backgrounds to understand the potential of untested medications for harm. Dr Eugene G. Laforet, the Boston physician and ethicist, believed volunteers should be given the reassurance that researchers are taking part in the experiment themselves. Another prominent medical researcher, Rosalyn S. Yalow, co-winner of the 1977 Nobel Prize for development of the radioimmunoassay (RIA) technique concurs: “In our laboratory we always used ourselves because we are the only ones who can truly give informed consent.” Self-experimentation has a long history. Nineteenth-century doctor CharlesÉdouard Brown-Séquard, whose selfexperiments led him to the concept of hormones, stated: “I believe you will never fully know the action of certain remedies, if you have not ascertained, on your own person, what effects they produce on the brain, the eye, the ear, the nerves, the muscles, and the principal viscera.” Though the practice is discouraged these days, there are contemporary visionaries willing to put their own bodies on the line. The person who introduced 50 hookworms to his body did so in 2004. Immunologist-biologist Dr David Pritchard spent years in Papua, New Guinea researching the possible power of hookworms to boost the human immune system and prevent allergies, but he needed definitive proof so he volunteered himself. He applied a dressing to his arm that was crawling with pin-size hookworm larvae and left it on for a

Dr David Pritchard injected himself with hookworm larvae in an effort to “turn down” the immune system.

In 1998, Kevin Warwick began Project Cyborg when his GP implanted a silicon chip transponder into his left arm few days to make sure the creatures had made their way into his system. His theory was that the worms have evolved to switch off the human immune system in order to survive in their hosts, reasoning that that was why infected people have fewer allergies. Though hookworm is rampant in the tropics, where it kills 65,000 people a year and afflicts many with anemia, in controlled experiments, Dr Pritchard says the worms have not caused any problems, and serve to “turn down the volume” on the immune system. He winnowed the initial 50 worms down to ten, and in 2006 was given the thumbs up by the ethics committee at the US National Health Service to conduct a study with 30 participants, many of whom were enthusiastic about the disappearance of their allergies. The trial was a success. Some elected to keep the worms after the trial and others who received the placebo asked if they could have worms too! Bionic research may be a logical next step for humanity, but there are few willing to take the risks of becoming

cyborgs themselves. Kevin Warwick, Deputy Vice-Chancellor of Research at Coventry University in England, had no such qualms. In 1998, he began the first phase of Project Cyborg, remaining conscious while his GP surgically implanted a silicon chip transponder into his left arm. If the procedure went awry, he risked brain damage or amputation. Instead, he was able to parade about campus being identified by computers who opened doors and turned on lights for him, in much the way that pets are identified by computer chips today. By 2002, he was able to control a wheelchair and a robotic hand across the Atlantic — with his mind. His next project is to communicate from brainto-brain with another person also equipped with implants. And who was the nutter who willingly drank black vomit? Stubbins Ffirth was a Philadelphia doctor who witnessed the devastating Yellow Fever Epidemic of 1793 and wanted to prove his theory that the disease was not contagious. To make his point, he drank the vomit by the glassful, poured it into open cuts and waded waist-deep in a veritable hot tub of the foul stuff. Remaining uninfected, he declared that that Yellow Fever was noncontagious. But he was, of course, mistaken. As we now know, yellow fever is indeed infectious and can be transmitted only through the bite of an infected mosquito.

MEDICAL QUIPS Put that knife down The quickest way to a man’s heart? A bilateral incision on the upper left region of the sternum.

NOVEMBER / DECEMBER 2017 • Doctor’s

Review

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

Portugal’s paradise Trek along Madeira’s old water channels through some of the most remarkable landscape on the planet

f you follow the World Travel Awards, the so-called “Tourism Oscars,” you may know that Madeira, Portugal, has been getting a lot of attention. The awards named Madeira as Europe’s Leading

Funchal is located on the flattest part of Madeira, but even some of its neighbourhoods are in the mountains.

Island Destination in 2013, 2014 and again in 2016, and the World’s Leading Island Destination in 2015 and 2016. That’s a lot of hype for a place that, until recently, was known mostly for its fortified wine. I’m not much of a wine drinker, but I can attest that as a destination, Madeira doesn’t disappoint. I’ve hiked in a lot of remarkable places, but never anywhere quite like this. My idea of a good time is to take a long walk. I’ve hiked in a lot of remarkable places, but never anywhere quite like this. Unforgettable as the hiking is, there are other reasons to visit. In summer, the beaches and watersports are outstanding — it’s a wind and kitesurfing mecca. There are museums and a culture to discover, and the Portuguese food alone is worth a trip. The island belongs to Portugal, but its location is closer to Africa than Europe. It’s volcanic in origin, and consists almost entirely of steep hills and cliffs. The principal city and port Funchal, population 112,000, occupies the largest valley, but even here some of the neighbourhoods are perched 1200 metres above the sea. The steepness of the land has necessitated an impressive number of bridges and very long tunnels. Madeira’s main airport is an engineering marvel: a full kilometre of its runway hovers above the sea supported by 180 massive concrete pillars. With Funchal occupying the flattest part of a not-very-flat island, Madeira’s smaller towns are left

Dr Heather Wrigley is a family physician practicing in Calgary, AB. For whatever ails you, she recommends a nice long walk.

Doctor’s Review • NOVEMBER / DECEMBER 2017

PHOTOS HEATHER WRIGLEY UNLESS OTHERWISE NOTED

by Dr Heather Wrigley

islands

Lisbon

Spain

Atlantic Ocean

Madeira

Funchal

clinging improbably to hilltops and vertiginous cliffs. The land surrounding each settlement has been painstakingly terraced with stone retaining walls, built by hand over centuries to support kitchen gardens, tiny backyard banana plantations, even smaller vineyards, and sheep pastures. All of this is set amid lush forest foliage and wreathed in wisps of cloud, which makes for immensely captivating scenery. The island is relatively small â&#x20AC;&#x201D; 57 kilometres long by 22 kilometres wide â&#x20AC;&#x201D; but its vertical topography and surrounding weather systems make for remarkably varied conditions in different regions. The higher elevations are chilly, rainy and almost continually covered in clouds. Coastal areas are warmer and slightly drier. The northwest part of the island is much wetter than the southeast.

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Many levadas have footpaths next to them; in other cases hikers can walk on top of the water channel itself.

WALKING THE WATERWAYS Algeria

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Madeira has a long tradition of building levadas, long concrete channels, to capture rainwater in wet regions and carry it to the drier areas, where temperatures and sunlight are more favourable for the cultivation of crops.

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Trail PR 6.1 goes along Levada do Risco, which takes hikers to an impressive waterfall.

Strong winds inhibit the growth of trees in Ponta de São Lourenço so the views to the Atlantic are breathtaking.

The levadas continue to be used for irrigation and now hydroelectric power, but they’ve been adapted to serve a more modern purpose: tourism. An uninterrupted water channel many kilometres long provides an excellent thoroughfare for a walking path. Today, both independent hikers and organized walking tours take advantage of these levadas. Many have footpaths that run alongside the water channel; in other cases it’s possible to walk atop the levada itself. Some walks are easy and relaxing, while others will have you negotiating obstacles, dashing through icecold waterfalls, and clinging to narrow ledges on high cliffsides — truly something for everyone. Madeira also has many conventional hiking trails. These well-maintained paths take you along dramatic cliff edges, through the lush laurel forest, which is a UNESCO World Heritage Site, down through Madeira’s misty valleys, and up to its highest peaks. My partner and I spent 11 glorious days walking in Madeira in January 2017. At that time, temperatures ranged from about 13–17ºC in the city of Funchal, and several degrees cooler at higher elevations. (In the summer, highs are just above 20ºC.) This proved to be excellent weather for the strenuous hiking we had in mind — and certainly more pleasant than the midwinter temperatures we left at home in Alberta!

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The beauty of the Madeira landscape cannot be overstated. We spent many of our days climbing steep inclines to take in spectacular views of the island and ocean, then descending deep into fern-filled, mossy ravines where the vegetation reminded us of Vancouver Island. Along the way were enormous trees, dramatic waterfalls and lots of flowering plants. Other days, we spent following the chuckles of water as it flowed through moss-covered levadas, accompanying it on its gradual course down hills, past tiny vineyards, caves and long-abandoned stone houses, and through long tunnels cut into the rock. Occasionally we would pass through a village where we could get a cup of strong Portuguese coffee and a bolo do caco: traditional Madeiran bread that resembles an enormous dense English muffin that is usually served toasted and slathered in garlic butter. For a change of scenery, there was the Ponta de São Lourenço at the southeastern tip of the island. Here, strong winds inhibit the growth of the large trees found elsewhere on Madeira. Instead the cliffs are covered with rocks and emerald-green grass, in a scene that could be lifted straight out of Ireland. The high clifftop elevation and lack of trees on the peninsula makes for breathtaking views out to the deep blue Atlantic in every direction.

The PR11 Vereda dos Balcoes Walk is described as an easy three kilometres round trip.

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A bolo do caco resembles an enormous English muffin and is usually served toasted and slathered in garlic butter.

An uninterrupted water channel many kilometres long provides an excellent thoroughfare for a walking path GEARING UP If you suffer from serious knee complaints, a fear of heights or vertigo, hiking on Madeira is probably not for you. Trail distances vary from a couple of kilometres to over 30 there and back, walks doable in a day. The landscape ranges from nearly flat to sections that are steeper than the average household staircase. The highest peaks are about 1800 metres above sea level; there are excellent trails leading up to each one. Gear requirements are minimal. A walking stick would be useful for the steep and slippery parts, but there’s no need for specialized carbon-fiber poles: wood and bamboo poles were plentiful on the ground alongside most trails. A small, bright flashlight would be handy in tunnels and caves — indeed, many of the longer tunnels would be impassable without one. When we hiked up the mountains, it was invariably cold, sometimes not far above freezing, with mist or

light rainfall much of the time. Our favoured attire was a T-shirt and fleece layer topped with a light rain jacket. Rain pants might have kept us drier, but would probably have caused us to overheat on the steeper ascents; our thin, quick-drying pants seemed best. Warm gloves were very useful and I carried a toque in my pack; it was a welcome addition at higher altitudes. My favourite item was a pair of waterproof hiking boots. Frequent drizzle and a groundcover of slippery wet leaves made them invaluable. There are numerous tour companies that will escort hikers along Madeira’s trails. Since my partner and I generally prefer to explore independently, we simply picked up some maps and used the Internet to figure out the public transit system. Horarios do Funchal offers two types of transit service: “urbano” public buses around Funchal (cost €1.95 per trip) and “interurbano” service from Funchal to other locations uu CONTINUED ON PAGE 47 NOVEMBER / DECEMBER 2017 • Doctor’s

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Puerto Vallarta’s Church of Our Lady of Guadalupe is topped with a crown that resembles one worn by Empress Carlota of Mexico.

Greetings from An insider’s guide to Puerto Vallarta and the Riviera Nayarit by Anita Draycott

hen we bought a timeshare in Puerto Vallarta 12 years ago, our friends thought we were loco. I thought we would use it to trade for other timeshares around the world. Fact is, we return every year.

We have made Puerto Vallarta and the Riviera Nayarit our winter home away from home. Why here? The weather is ideal. Over our dozen years there it has rained twice for total of three hours. The average daily temperature is about 80°F (27°C) with a breeze. Nights are cool and balmy, and we

Doctor’s Review • NOVEMBER / DECEMBER 2017

sleep with a ceiling fan; no need for air conditioning. The restaurants and markets provide fabulous food options from Mexican to Italian to Thai. The Banderas Bay region appeals to all types: it’s senior friendly, gay friendly, single-women friendly, couples friendly, family friendly, even dog friendly.

You don’t need a car because public transportation is efficient and cheap, albeit not what I’d describe as luxurious. Every bus ride over Puerto Vallarta’s cobbled streets is a free cellulite treatment! I sincerely love the place and its people, and I’m fed up with the negative press that Mexico gets. I feel safer here than I did living in downtown Toronto. Sure, the sun, surf and sunsets are free, but how do you make the most of your pesos? Here’s my insider’s guide on where to save and splurge along the Bay of Banderas.

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Mexico! Star struck at Casa Kimberly Before John Huston’s 1964 film, The Night of the Iguana, Puerto Vallarta was a sleepy fishing village. All that changed when Liz Taylor arrived to keep an eye on her lover, Richard Burton, while he was filming with the voluptuous Ava Gardner. The publicity buzz about Richard and Liz’s torrid affair, plus the success of the movie, put Puerto Vallarta on the tourist map. During their romantic romp in PV, Richard Burton presented Casa Kimberly (casakimberly.com) as a gift NOVEMBER / DECEMBER 2017 • Doctor’s

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to Elizabeth for her 32nd birthday. The totally renovated Casa Kimberly opened in 2015 as a luxury boutique hotel. The opulent Elizabeth Taylor Suite comes with its own private pool, Jacuzzi and wraparound terrace. I think Liz would approve of the massive ensuite bathroom and the vintage pink marble bathtub in the shape of a heart. Six evenings a week, the 12-piece La Joya de Mexico mariachi group serenades guests with everything from traditional mariachi to Hollywood and classical tunes in The Iguana Restaurant & Tequila Bar.

Taco crawl When I read about Vallarta Food Tours (vallarta foodtours.com), I signed up for “An Evening Taco Adventure.” Who would know better then the Vallarta food experts about where to enjoy good street food? Dinner included five kinds of tacos, pozole (a stew of hominy and shredded pork), a shot of Mexcal and churros. Tacos are arguably the best bargain in town and stopping at the various stands is a great opportunity to munch and mingle with locals.

A palapa in Yelapa Accessible primarily by water taxi, Yelapa provides a taste of rustic Mexico without an all-inclusive or high-rise in sight. You’ll find plenty of aging hippies,

Doctor’s Review • NOVEMBER / DECEMBER 2017

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Taco stands are arguably the best bargain in town and a great opportunity to munch and mingle with locals.

artists and laid-back locals. Take a hike or ride a burro to the waterfall, then sprawl out on the golden beach. Buy a slice of pie from one of the lady vendors who balance the homemade goodies in plastic containers on their heads and chill out. Boats leave daily from Marina Vallarta, Boca de Tomatlan, and Los Muertos Pier.

Java jolts with Pacific views Dee’s Coffee Company, my favourite for a good java jolt and daily fresh home baking, is near the beach on Calle Francisca Rodríguez with views of Puerto Vallarta’s stunning new pier. Her sticky buns are outrageously good. Just up the street from Dee’s, there’s a sweet senior gentleman who operates a juice stand and squeezes fresh oranges and grape-

ANITA DRAYCOTT

The cobblestone streets of old Puerto Vallarta are lined with an assortment of inns, galleries and restaurants.

I’m fed up with the negative press that Mexico gets — I feel safer here than I did living in downtown Toronto Bountiful botanical gardens

Rafael Zamarripa’s The Boy on the Seahorse is one of several sculptures along The Malecon promenade.

ANITA DRAYCOTT

Hop on the bus that says El Tuito at the corner of Carranza and Aguacate. The scenic ride takes you along the coast to the Botanical Gardens (vbgardens. org). Wear walking shoes so you can explore the various trails and collections of palms, roses, ferns, agaves, orchids, wildflowers, coffee and vanilla trees. A fascinating variety of birds and butterflies call these gardens home, so bring your camera and binoculars. Take a refreshing dip in the Rio Los Horcones (don’t forget to bring a towel), and then head up to the Hacienda de Oro restaurant for an alfresco lunch. Entrance fee is about $10; free for kids.

fruits while you wait — about $1 for a large glass of liquid sunshine.

Saturday is market day The Old Town Farmers’ Market takes place in the Lazaro Cardenas Square in the Romantic Zone on Saturday mornings. It’s full of vendors selling everything from organic vegetables to artisanal breads to crafts. Plan to have breakfast as you graze from stall to stall.

Make friends Drop into the International Friendship Centre (ifcvallarta.com) in the heart of Puerto Vallarta (Calle Libertad near the bridge) to make amigos, learn new skills and be entertained. The Centre has a busy schedule of activities including bridge, yoga and Spanish lessons, lectures and home tours. A portion of the fees goes to various charities.

Meet me on the Malecon Puerto Vallarta’s lovely seaside promenade, the Malecon was renovated, landscaped and widened in 2011. When the sun goes down, watch a folkloric spectacle in the Los Arcos, the open-air amphitheatre. On Sunday nights a live band plays in the zocalo. Join the locals, young and old, in a sexy salsa number.

Wednesday night Art Walk From the end of October to the end of May you can participate in Art Walk (vallartaartwalk.com) every Wednesday evening. About 20 galleries and studios in the historic centre open from 6 to 10pm. Most serve snacks and drinks; often they’ll have an artist or two on the premises. Café des Artistes (cafedesartistes. com) one of Vallarta’s top restaurants, offers fabulous dinner options in a lush garden setting.

Something fishy The atmosphere is funky and casual, but the cooking at Joe Jack’s (joejacks-fishshack.com) is superb. Located in the Romantic Zone on Basilio Badillo, it’s a fun spot for lunch or dinner. Shrimp and avocado tostados slide down extremely well with a gazpacho Bloody Mary or Ginger Mojito. On Fridays, they serve all-you-can-eat beer battered fish and chips. My husband and I always share the whole red snapper cooked with lime, chillies and garlic. Muy bueno!

Say si to Sergio Arguably the loveliest jewellery/art shop in Puerto Vallarta is that of Sergio Bustamente (coleccionsergio bustamante.com.mx). The famous Mexican artist whose sculpture “Searching for Reason” graces the Malecon, also creates miniature sculptures in the forms of rings, earrings, bracelets and necklaces. Bring back a trinket with one of his stylized suns for fond memories when in colder climes. NOVEMBER / DECEMBER 2017 • Doctor’s

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Bucerias is so popular with Canadians, especially those from the West Coast, it’s been dubbed “BC-rias”

I’

ve noticed a trend. Folks take a weeklong vacation in Puerto Vallarta. They love it and spend two weeks the following year. Weeks become months and often these folks (myself included) start venturing further up the Bay of Banderas and into the state of Nayarit for the entire winter. This paradisiac stretch along the Bay of Banderas, framed by the verdant Sierra Madre Mountains, is also a region of splendid contrasts where visitors have choices about whether to “save or splurge” in every town. You can buy a fresh mango on a stick and a home baked muffin from a beach vendor for a $3 breakfast, or dine under the stars at a five-star resort for dinner.

About 20 kilometres northwest of PV, Bucerias is so popular with Canadians, especially those from the West Coast, it’s been dubbed “BC-rias.” Bucerias has the ambience of a traditional Mexican town, but with all the services and amenities that appeal to gringos. Normally I’m cautious about eating street food, but there’s one taco stand in front of the church on the zocalo in Bucerias that I highly recommend. It’s run by Janie and her mom Raina. Their shrimp and mahi mahi tacos cost about $2 each. What sets this taco joint apart? It’s super clean; the ladies make their corn tortillas and all the sauces — from Hades hot habanera to tamer avocado or tartar — from scratch. Janie won’t divulge the family secret recipe for the light and crunchy tempura-style batter and I can’t blame her. Walk through the door at Trattoria Toscana Mia (trattoriatoscanamia.com) and you’ll think you’ve been transported to Tuscany. Indeed, the family came from Montecatini in 2008 and the authentic, slowcooked recipes are from Mamma Pina’s. The aromas wafting from the brick pizza oven are tantalizing. Pasta and most other things on the menu are made fresh onsite. Reservations are advisable. Reserve a cooking class at My Mexican Kitchen (mymexicankitchen.com) with the dynamic duo of chefs Travis Dietz and Edgar Garcia Cordova, and you’ll be slicing and dicing with about six new friends, and then enjoying the fruits of your labours. Travis and Edgar run several classes per week and they’re constantly changing the menu. The evening ends with

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ANITA DRAYCOTT

Eat your way through Bucerias

Sayulita is a little beach town along the Riviera Nayarit with a relaxed bohemian-chic vibe.

Mexican coffee laced with cinnamon and cane sugar and a shot of almond tequila. Cost per person is about $115 and you may bring your own wine.

Cruise La Cruz de Huanacaxtle This old fishing village is gradually being gentrified and boasts the most modern marina on Mexico’s Pacific Coast. Take a day cruise with Ally Cat Sailing Adventures (allycatsailing.com) to Islas Las Marietas, a wildlife sanctuary and marine preserve. You might spot rare blue-footed boobies, whales, dolphins and sea turtles. The catamaran is equipped with all sorts of water toys. The cost, about $115, includes all your drinks, food and an entertaining crew. Stop by the Mercado del Mar early in the morning to see fishermen arriving with their catch of the day. On Sundays from October to April this same space becomes a bustling organic farmers’ and handicraft market.

Sayulita’s psychedelic beads More than a surfer town, Sayulita gives off a relaxed bohemian-chic vibe with temptations for all budgets and ages. If you want to buy an unusual souvenir, consider an authentic piece of intricate beadwork made by the Huichol Aboriginals. When the Spanish conquistadors

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ANITA DRAYCOTT

Yelapa provides a taste of rustic Mexico without an all-inclusive in sight.

If you want to buy an unusual souvenir, consider intricate beadwork made by the Huichol Aboriginals.

arrived early in the 16th century, the Huichols (also known as the Peyote People) fled to the Sierra Madre Mountains where they were able to retain their religion and customs, which include the ceremonial use of peyote. Their hallucinogenic visions inspire their psychedelic art that comes in the forms of intricately beaded masks, bracelets, bowls, animal figurines and more. Visit the Galeria Tanana (Revolucion #22). Afterwards, test the waves by taking a surf lesson or rent a boogie board from the Sayulita beach vendors. Once you’ve worked up an appetite, head to ChocoBanana beside the town square where they dip bananas in chocolate and serve them frozen, popsicle-style.

ANITA DRAYCOTT

San Francisco for polo

La Cruz de Huanacaxtle has been a fishing village for generations.

Nicknamed San Pancho by the locals, there’s a lot to discover in this laid-back beach town. If you’re keen on watching some earth-pounding chukkas, head to La Patrona Equestrian Center & Polo Club (lapatronapoloclub.com), the only one in the state of Nayarit, founded in 2000. Aside from polo, La Patrona Equestrian Center offers facilities and lessons for riding, jumping and dressage. You may also arrange to go horseback riding along the beach or through the jungles of San Pancho. Sunday Polo Brunches at La Patrona take place from November until April. NOVEMBER / DECEMBER 2017 • Doctor’s

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Peaceful deser by a lively sea Baja Californiaâ&#x20AC;&#x2122;s Los Cabos dazzles visitors with so much more than endless sunshine by Robb Beattie

Cabo San Lucasâ&#x20AC;&#x2122;s iconic Arch is best viewed from twin Lovers and Divorce Beaches.

rts

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ruth be told, I like barren places, the kinds of landscapes that are striking solely

because they are stark, even bleak. They have a beauty as peaceful as it is severe, a tranquillity that hints at the untameable as the empty surroundings make the world more intense, playing tricks with scale, colour and light. Perhaps it’s the Canadian in me, our own tundra and badlands exude this harsh elegance. I recently went on a trip to Mexico and discovered another such dramatic setting, one filled with grandeur and serenity — the rugged splendour of Baja California’s coastline where the desert meets the sea. Actually home to four different deserts, with ocean shorelines twice the length of British Columbia’s, the long, narrow Baja California Peninsula is justly celebrated for its pounding surf, spectacular scenery and prickly expanses of cacti (the towering 19-metrehigh cardón cactus is the world’s tallest). One of the sunniest, driest places anywhere, with a scant 10 days of rain a year, Baja California is located not where the name suggests, but in westernmost Mexico just south of the US border. On maps, the peninsula stands out like a brandished sword as it slices 1200 kilometres south through the Pacific, its southern tip graced by the picturesque seaside resort area of Los Cabos, known simply as “Cabo” to regular visitors. Los Cabos is Mexico’s most popular beach resort after Cancun on the other side of the country. It’s actually three communities joined together: hustling Cabo San Lucas next to the area’s main marina; smaller San José del Cabo, a charming old town now full of galleries and restaurants; and the Corridor, a 30-kilometre strip between the two towns filled with hotels and holiday homes. “Cabo” is that rare destination able to satisfy both the most laidback visitors and those restless guests looking for action. Known variously for its secluded beaches, fervent nightlife, fine dining and xeric thorn scrub, Los Cabos also boasts stunning sea cliffs, 15 top golf courses, lavish resorts, eateries and clubs, and a multitude of scenic desert hikes, drives and views. There are meditation retreats, “ranch spas,” and backcountry and ocean-tour outfitters to channel escape, as well as excellent in-town shopping, a vibrant local music scene, some of the

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world’s best deep-sea fishing where marlin is king and, obviously, water pursuits galore. Step onto the beach and within minutes you can be kayaking, jet skiing, parasailing, diving, snorkelling, kite surfing, swimming with dolphins, or, from January to March, watching whales cavort. If swimming is on your agenda, ask about how safe it is. The two-metre breakers are an obvious hazard, and there are less visible risks, including an undertow, riptides and sharks. The harbour is the centre of three communities that make up “Cabo.”

Baja California is one of the sunniest, driest places anywhere, with a scant 10 days of rain a year

’uckily for me, an ardent dog-paddler, the Cabo resort where I stayed featured a lagoon-sized beachside pool, or rather a series of interlocking pools, which mirrored the blue of the nearby Sea of Cortez, the wide gulf between Baja California and the Mexican mainland. When I arrived, a father and son were playing chess by the pool with oversized pieces nearly as tall as the young boy. As I walked by, I suddenly heard him say, “The sea’s always awake, that’s true; but what about the desert? Is it woken up or sound asleep?” Well, my vote was certainly for slumber after taking the highway to Cabo’s Corridor, the road dreamily folding through a crumpled blanket of hills before tumbling to the seashore and my relaxing all-inclusive resort, the newly opened 350-room Paradisus Los Cabos (melia.com/en/hotels/mexico/ los-cabos/paradisus-los-cabos) situated on a large, swimmable crescent-shaped beach. All rates including all meals and activities start around $320 per couple depending on the season. Operated by Meliá, the international Spanish hotel chain, and just a half-hour drive from San José del Cabo’s International Airport with flights to Canada, the resort spreads over 14 seafront acres encircled by a private golf course. There’s a convention centre and a big ballroom; the resort is also popular for weddings. There’s even a Romance Coordinator. Honeymooners and anyone else would certainly enjoy one of the Royal Service Suites, which pamper guests with butler service and exclusive restaurants, some of which are swim ups. Families are catered to

Doctor’s Review • NOVEMBER / DECEMBER 2017

Hanging egg chairs on the beach at Paradisus Los Cabos make the perfect place to read and doze.

The Laguna is the largest and most popular of four pools on the 14-acre property.

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Paradisus’s Gastro Bar features the cuisine of Michelin-starred Martin Berasategui.

in 30 Concierge Suites, which are especially kid friendly. From the resort’s spectacular open-sided triangular atrium, you can see four swimming pools, seven bars, seven restaurants and a sumptuous spa and fitness centre laid out on the manicured, palmfilled grounds. As I sat there of an evening my eyes turned to the arid curve of the coast. The long strand of sand and golden cliffs turned a violent fuchsia pink, with stains of crimson red and nocturnal black slowly sinking into the dimming, still alert sea. I had a delicious sense that all was right with the world. To cap of a perfect stay, I dined that night at the Gastro Bar, one of the resort’s main attractions, offering food prepared by eight time Michelin-starwinning Basque chef Martin Berasategui whose food is worthy of competing with the scenery. The dishes are simply magical. Exotic confections like sangria-infused watermelon, smoked pork carpaccio with bacon foam, hazelnut, vanilla and coffee powder. A main course of roasted totoaba fish and rice foam with a light bisque. If you’ve never tried the foams, tastes and textures of “molecular gastronomy,” the culinary craze from Spain that can, for example, make what seems like spooned-up cappuccino froth taste exactly like any victual or vegetable imaginable, Gastro Bar is definitely the place to catch up with the trend. On my final morning in Baja California, I took a launch from the Cabo San Lucas marina to Lands End, the offshore collection of stony islets and thrusting sea crags where the surging Pacific swirls around the Baja Peninsula into the Sea of Cortez. Large rock formations carved into fantastic shapes by wind and ocean mark the passage; the most notable is the Arch of Poseidon, best seen from the adjacent Lovers and Divorce Beaches, two small strips of sand separated by the Arch that rise and fall with the tide. I watched the diving pelicans and basking sea lions glory in the perpetual sunshine, and absorbed the battered beauty of the coastline one more time. Still as stark, stirring, and elemental as the day the arriving Spanish Conquistadors mistook it for “the empty frontier of the underworld,” it remains a place where the hyperactive ocean collides with the entombing sand and the desert stoically sleeps, though always with one hypnotic eye open.

IS IT SAFE? In a word, yes. Cruise ships continue to make Los Cabos a key port of call; visitors are up 19 percent this year. Canada has travel warnings for 13 areas in Mexico, but Los Cabos is not one of them. Normal precautions should be taken here as they need to be anywhere one travels these days. Almost two million Canadians will visit Mexico this year. NOVEMBER / DECEMBER 2017 • Doctor’s

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Reasons to celeb SK / FLICKR.COM

From Día de los Muertos in Mexico to Holi in India, six cultural happenings that get people to gather by Camille Chin

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NETHERLANDS THE REAL SAINT NICK

Dutch tradition says that St. Nicholas lives in Madrid and arrives by boat at a different Holland harbour every year.

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In some European countries, particularly The Netherlands, December 5 is the day for gift giving. Saint Nicholas Day commemorates the fourth-century bishop known for his generosity. He was buried in what was Myra, Turkey, but his remains were stolen and brought to Bari, Italy where he became extraordinarily popular during the Middle Ages. In Holland, he’s known as Sinterklaas. His Feast (or Celebration) Day is December 5 (or 6 in Germany, for example), which is when he arrives on horseback accompanied by “Black Peter,” a freed slave or a Moor, depending on your sources. Traditionally kids leave their shoes on windowsills for him to fill with sweets; they leave a bit of grain or a carrot for his horse.

The headdress worn by the dervish during the Rumi Festival represents his ego’s tombstone, the white skirt his ego’s shroud.

TURKEY SUFI POETRY IN MOTION Every December, the Anatolian city of Konya celebrates the 13th-century Sufi poet Mevlâna who taught peace, love and tolerance. Mevlâna is more commonly known as Rumi. The Mevlâna Museum in Konya, three hours south of Ankara, contains Rumi’s tomb and that of his son Sultan Veled. The 10-day Rumi Festival brings together over a million people; many want to see the Order of Mevlevi or the Whirling Dervishes, a Sufi movement that was founded after Rumi’s death. The dervishes rotate in a counter-clockwise direction like the earth’s orbit around the sun; they raise their arms towards heaven. The dance is a symbolic journey through which the dervishes are meant to get closer to God. Traditionally only men dance, but that’s beginning to change.

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In Pingxi, an hour east of Taipei, the Yuanxiaojie Festival sees hundreds of lanterns released every 30 minutes.

TAIWAN HIGH HOPES FOR GROWTH The rural district of Pingxi in New Taipei is home to just 5000 people and yet its Yuanxiaojie (Lantern) Festival is famous around the world; about 1200 sky lanterns are released high in Pingxi’s mountains every year. Sky lanterns were invented during China’s Three Kingdoms period by Zhuge Liang to carry military signals. Traditionally the paper lanterns carry prayers and vows on the cusp of the spring planting season in late February or early March. In days past, people released lanterns on which they’d written requests like “may the harvests be bountiful” or “may a son soon be born.” The Sky Lantern Festival coincides with the end of Chinese New Year so the freeing of lanterns into the night sky also symbolizes the letting go of old ways.

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INDIA THE COLOURS OF HAPPINESS

Holi celebrations are referenced in the Puranas, Indian texts that date back to the fourth century.

Holi is an ancient Hindu festival in India and Nepal that’s recognized as the Festival of Colours around the world. It falls between late February and late March, and celebrates love and fertility, youth, playfulness and vigour, and coincides with the arrival of spring and all the new colours the season brings. Holi is spread over two days — short by Indian standards. Holika Dahan is the night before the big event; it involves a fire as purification ritual, and represents the triumph of good over evil. Rangwali Holi is the next day and when everyone blankets each other in gulal or coloured powder. Non-harmful mixtures are made of food dye, flour and water; people are advised to moisturise their skin and oil their hair beforehand so the powder can be rinsed off afterwards.

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Many Thais express their gratitude to the Water Goddess Phra Mae Kongka with offerings that float.

Depictions of skeletons in fancy French garb, like the figurines here, have been a part of Day of the Dead since the early 1900s.

THAILAND EXPRESSIONS OF GRATITUDE While the origins of the Loi Krathong Festival are obscure — some sources say it began as a Brahmin (Hindu) Festival that evolved into a tradition that worships Buddha, others describe it as gratitude to the Water Goddess for the rice harvest — there’s little debate that it’s an important festival in Thailand. On a full moon every November, adults and children gather around lakes, rivers and canals to release small offerings on the water. Some krathongs are made to resemble rafts using banana leaves, others are made of bread; all are decorated with candles, flowers and incense. Another belief is that people are washing away and freeing themselves of previous transgressions. Some even put a lock of hair in the krathong as a symbolic cleansing.

MEXICO FAMILY REUNIONS Even though it coincides with Halloween, there’s no trick or treating during Día de los Muertos. The centuries-old tradition that originates from the Aztecs is when the gates of heaven are said to open so that the spirits of deceased love ones can visit with family and friends. The souls of deceased children descend on November 1, the Day of the Innocents; the souls of adults on November 2, the Day of the Dead. Altars meant to welcome the spirits are built in homes and cemeteries; they’re laden with the favourite foods and drinks of the weary travellers from heaven. Most importantly are the marigold flowers; they adorn the altars and also gravesites as a way to guide the wandering souls back to their place of rest. NOVEMBER / DECEMBER 2017 • Doctor’s

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Stilton cheesecake with bacon-onion marmalade.

Be my guest Dishes that are special and achievable for the season of entertaining recipes by

Peter Callahan

photos by

Con Poulos

eter Callahan is the most well-known caterer in the US. He’s a contributing editor for Martha Stewart Weddings and has created events for designers

like Valentino and Vera Wang, singer Tony Bennett, politician and environmentalist Al Gore and more. During the holidays, everyone should eat like they’re famous so featured here are three recipes from the new Peter Callahan’s Party Food, published by Clarkson Potter. Known for hors d’oeuvres, particularly

Doctor’s Review • NOVEMBER / DECEMBER 2017

mini versions of comfort foods, Callahan has expanded his repertoire for his second book to offer suggestions for buffets, seated dinners, even bars. All of the dishes in Party Food are beautifully styled and include simple presentation suggestions to help you set the scene for your own holiday gathering.

STILTON CHEESECAKE WITH BACON-ONION MARMALADE This is an unexpected hors d’oeuvre: a savoury cheesecake. The bacon and caramelized onion on top provide the great savoury flavour, the rich, jam-like topping is a reverse play on the graham-cracker crust that a sweet cheesecake would have. This is usually offered as an hors d’oeuvre, but can also be served at the end of a meal as a counterpoint to fresh fruit or as part of a cheese plate. For the cheesecake non-stick cooking spray 8 oz. (250 g) Stilton cheese, at room temperature 1½ packages cream cheese, at room temperature (12 oz. / 375 g) 2 tbsp. (30 ml) sugar 3 large eggs ¹⁄³ c. (80 ml) all-purpose flour 1 c. (250 ml) sour cream

be chewy and not crisp. Transfer the bacon to paper towels to drain and discard all but 1 tablespoon (15 ml) of the bacon fat from the pan. Over medium heat, sauté the onion in the bacon fat until translucent. Add the brown sugar, vinegar, mustard and salt and pepper, and cook until the mixture reaches a thick, jam-like consistency. Let cool completely. Cut the cheesecake into strips about 1½ inches (4-cm) wide, then cut the strips into small triangular wedges. Top each piece of cheesecake with a small spoonful of the marmalade. Makes 32 to 40 small wedges.

RATATOUILLE This deconstructed free-form dish looks as if everything was dropped into the bowl and just happened to fall in really nice places. It doesn’t appear fussed over by a chef, but is arranged in a pleasing, seemingly accidental way. The vegetables are all well caramelized to provide deep, rich flavour. The stems and roots are left on for a great farm-to-table effect. The polenta makes this a hearty first course that works equally well as a vegetarian main.

For the marmalade ½ lb. (250 g) thick-cut bacon, finely diced 1 sweet onion, finely diced ¼ c. (60 ml) packed light brown sugar 1 tbsp. (15 ml) balsamic vinegar 1 tsp. (5 ml) Dijon mustard coarse salt and freshly ground black pepper

Preheat the oven to 325°F (170°C). Lightly coat a pie dish with non-stick cooking spray. In the bowl of a stand mixer fitted with the paddle attachment, mix the Stilton, cream cheese and sugar on medium speed. Add the eggs one at a time, scraping down the bowl after each addition. On low speed, gently blend in the flour and then the sour cream. Pour the mixture into the prepared pie dish and bake just until set and no longer jiggly in the middle, 20 to 30 minutes. Refrigerate until completely cold, about 1 hour. Meanwhile, in a skillet over medium heat, fry the bacon until two-thirds done, about 7 minutes — it should still Ratatouille.

For the polenta 4 c. (1 L) vegetable stock or water 1 c. (250 ml) polenta grated zest of 2 lemons 2 tsp. (10 ml) chopped fresh thyme 2 tsp. (10 ml) coarse salt ½ tsp. (2.5 ml) freshly ground black pepper nonstick cooking spray olive oil, for frying For the tomato broth 1 tbsp. (15 ml) extra-virgin olive oil 3 shallots, roughly chopped 3 garlic cloves, roughly chopped ½ c. (125 ml) dry white wine 1 14-oz. (435 g) can tomatoes, diced or whole peeled 1½ c. (375 ml) vegetable stock 1 bunch of fresh thyme 2 bay leaves coarse salt and freshly ground black pepper For the vegetables 4 yellow pattypan squash, halved 4 baby eggplants, halved 1 zucchini, cut into ½-in. (1.25 ml) rounds

4 cipollini onions, halved 8 maitake mushrooms 4 baby tomatoes on the vine, halved 4 ramps (wild leeks) 4 spring onions (red or white), halved coarse salt and freshly ground black pepper 1 tbsp. (15 ml) extra-virgin olive oil

Pour the vegetable stock into a medium heavy saucepan (if using water instead of stock, add 1 teaspoon/5 ml kosher salt). Bring to a boil over medium heat and stream in the polenta while stirring constantly. Continue to stir until the polenta is completely combined and no lumps remain. Reduce the heat to medium-low and continue to stir until the polenta thickens. Cook, stirring every 10 minutes or so, until very thick, 30 to 45 minutes. Add the lemon zest, thyme, and salt and pepper. Line a baking sheet with parchment paper sprayed with

non-stick spray. Spoon the polenta, about 1/3 cup (80 ml) at a time, into free-form shapes on the parchment. Refrigerate at least 2 hours or overnight. Heat the oil in a medium saucepan over medium heat. Add the shallots and garlic, and sauté just until aromatic. Deglaze the pan with the white wine and continue to cook until the liquid is reduced by half. Add the tomatoes, stock, thyme and bay leaves. Bring the broth back to a boil; reduce the heat to low. Simmer for about 1 hour, then season to taste with salt and pepper. Strain the broth through a finemesh strainer into a medium bowl, discarding the solids. Heat a 10- or 12-inch (25- or 30-cm) skillet over medium-high heat and fill it a quarter of the way with olive oil. Fry the polenta on both sides until golden brown, 1 to 2 minutes per side. Drain on paper towels.

Tagine spiced chicken breast.

Season all of the vegetables with salt and pepper. Heat a large sauté pan over high heat and add the oil. Reduce the heat to medium-high and, working in batches if necessary, give the vegetable pieces a nice hard sear by pressing them down with a spatula. Do not flip until the first side is a deep golden brown. The ramps will take only a few seconds in the pan to soften; do not overcook. Sear the maitake mushrooms a few minutes longer than the rest of the vegetables. Return the broth to the saucepan to reheat. Place one piece of polenta on the plate and assemble the vegetables on top. Pour the broth around the bottom of the plate just before serving. Serves 8 as a first course; 4 as a main.

TAGINE SPICED CHICKEN BREAST When serving chicken, it’s important that it doesn’t dry out. So one thing that makes this dish successful is the great broth; the other is the spices — paprika, cinnamon, turmeric, ginger, crushed red pepper and cardamom— that add a very distinctive flavouring. The dish is served in a shallow bowl; you pour the broth in first, then add the vegetables, and place the chicken on top. One important point about chicken: when you’re preparing it for special-event dinners that need to be delicious, you must have the skin — but it needs to get really, really crispy. So the trick to making any chicken dish delicious is to sear it in as hot a pan as possible to make the skin as crispy as you can get it. Note that the chicken needs to marinate overnight. 1 2-oz. (60g) jar tagine spice 4 or 5 garlic cloves, peeled extra-virgin olive oil to make a paste, plus 1 tbsp. (15 ml) for the pan 4 boneless, skin-on chicken breasts preserved lemon slices, for garnish

Combine the tagine spice and garlic in a food processor. With the motor running, add the oil in small increments until you have a spreadable paste.

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Pat the chicken breasts dry with paper towels and place in a baking pan. Smear the tagine-garlic paste over both sides. Cover the pan with plastic wrap and refrigerate overnight. Bring the chicken up to room temperature at least 30 minutes before cooking. When ready to cook, wipe the chicken clean of all the paste. Preheat the oven to 350°F (180°C). Heat the 1 tablespoon (15 ml) olive oil in a heavy-bottomed, ovenproof sauté pan over high heat until almost smoking. Carefully add the chicken, skin side down. Cook until the skin is crispy, then flip and cook for 2 to 3 minutes more. Transfer the pan to the oven and roast until cooked through, about 20 minutes. To serve, spoon some of the pan juices into the bottom of a bowl, add a mound of Israeli (or pearl) couscous (pictured here with chickpeas, olives and pomegranate seeds), and place the chicken on top. Garnish with a slice of preserved lemon. Serves 4. Excerpted from Peter Callahan’s Party Food by Peter Callahan. © 2017 by Peter Callahan. Photography © 2017 by Con Poulos. Published in the United States by Clarkson Potter/Publishers, an imprint of the Crown Publishing Group, a division of Penguin Random House LLC, New York. Reproduced by arrangement with the Publisher. All rights reserved.

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PORTUGAL’S PARADISE ISLANDS uu CONTINUED FROM PAGE 29

around the island (about €3-4, cost varies by distance). If you plan to use public buses, staying in the Old Town area of Funchal is best. It’s a bit touristy, but it’s also a hub for both the urban and interurban bus lines. For us, the interurban service proved to be an excellent way of accessing hiking trails. These buses offer many stops, not just within the smaller towns, but all along the major roads as well. This meant that as long as we finished our hike somewhere along a highway, we usually found a bus stop nearby. Using the bus rather than a rental car allowed us to finish our walk at a different point than where we began. However, many excellent hiking trails are not accessible by bus so we rented a car for a few days toward the end of our stay. Roads are very steep and winding, with numerous bridges and tunnels, but with a reasonable amount of caution, we found that it was no more challenging than driving in many other places we’ve been.

PORTUGUESE COMFORT FOOD The Portuguese do hearty, warming meals very well, and this was definitely appreciated on the damper, chillier days. We enjoyed charcoal-roasted lamb, braised chicken in a stew of olives and local seafood. The cool weather also gave me an appreciation for thick pureed-vegetable soups. Chain restaurants are almost totally absent on Madeira and there is little international cuisine. Aside from a few unappealing hamburger and pizza places in Funchal, even the restaurants that cater to tourists serve mainly Portuguese food. My partner, a wine aficionado, visited a winery and enjoyed a tasting of Madeira wine. The best trips are the ones where the minor stresses and inconveniences of travel fade to insignificance next to our constant state of marvel over a place. Each day in Madeira, we cheerfully rolled out of bed before first light, did fairly strenuous hikes for hours on end

often in wet and chilly weather, got a little lost at times, slipped, fell and got up again, suffered blisters and sore muscles and irksome knees, and fell into bed in utter exhaustion every night, but I don’t believe either of us ever uttered a word of complaint. We did, however, frequently catch one another’s gaze, grinning in appreciation of some beautiful grove or fantastic vista. We simply could not get over our good fortune at finding ourselves in such a place. At times it was so enchanting that it seemed it could scarcely be real. After several days of hiking from dawn until dusk, twice I attempted to take a rest day. Both times, this resulted in me walking aimlessly for hours around Funchal, my feet apparently still clamouring for the trail. After that, I gave up the idea of rest and hiked all day, every day. Despite all the trails we covered, it never got stale: on my last day, even as darkness was approaching, I found it very hard to tear myself away from the levada. Are there other things to do in Madeira? I know there must be. I have a vague recollection of cobbled streets and old buildings, and of signs for museums, and advertisements for concerts and boat excursions. We’re already talking about going back. Maybe next time we’ll look into some of those things. And then again, maybe not. I think we’ll want to save every minute for the trails. To get a good overview of all there is to see and do, check out Visit Madeira (visitmadeira.pt/en-gb/homepage).

MEDICAL QUIPS Internet speed “Never ask Google for clinical advice. I’ve gone from mild headache to clinically dead in three clicks.”

NOVEMBER / DECEMBER 2017 • Doctor’s

Review

PHOTO FINISH by

D r O li v i a S a n k a t

The calm before the storm

I was greeted by this spectacular iguana on the picturesque island of St. Martin. The iguana’s exterior bears a striking resemblance to a carnival costume. Even more spellbinding was his bold disposition of pride and confidence. The far-from-camerashy iguana became my muse as he stood still on the stony platform. It was impossible to fathom that this graceful iguana — along with every living entity on the island of St. Martin — would, in a matter of hours, experience Irma’s wrath. Knowing impending doom was nearing, made the eerie calmness around capturing this creature an even more surreal event.

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

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Please refer to the product monograph at www.TrajentaPM.ca for important information about: • Contraindications in patients with type 1 diabetes or diabetic ketoacidosis. • Relevant warnings and precautions regarding congestive heart failure, patients using insulin, hypoglycemia, glycemic control, use in patients with severe hepatic insufficiency, pancreatitis, hypersensitivity reactions, use in immunocompromised patients, use in patients with End Stage Renal Disease (ESRD) or on dialysis, skin monitoring, use in special populations (e.g., pregnant and nursing women), hepatic function (should be assessed before starting treatment and periodically thereafter), and interactions with strong inducers of P-gp or CYP3A4 (monitoring recommended). • Conditions of clinical use, adverse reactions, drug interactions and dosing recommendations. The product monograph is also available by calling 1-800-263-5103 ext. 84633. References: 1. Boehringer Ingelheim (Canada) Ltd. Data on File. s00042091-01. 2. Boehringer Ingelheim (Canada) Ltd. Trajenta® Product Monograph. May 14, 2015. Trajenta® is a registered trademark of Boehringer Ingelheim International GmbH, used under license.