September 2013

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Asymptomatic AF raises stroke risk in diabetics

CONFERENCE Managing psoriasis beyond the skin

NEWS Children better judges of their asthma

OSTEOPOROSIS UK osteoporosis group updates guidelines

AFTER HOURS Kyoto - Japans cultural heart

September 2013

Asymptomatic AF raises stroke risk in diabetics

Elvira Manzano

linicians should consider screening for asymptomatic (subclinical or silent) atrial fibrillation (AF) in type 2 diabetes patients in light of new research showing that this underlying condition is relatively more common and significantly increases the risk of stroke in such patients. In a cohort of 464 patients with type 2 diabetes, the prevalence of cerebral infarcts (as detected by MRI) was significantly higher in patients with asymptomatic compared with those without asymptomatic AF (61 percent vs 29 percent, respectively). Similarly, stroke events were significantly higher in patients with asymptomatic AF (17.3 percent vs 5.9 percent, respectively; p<0.01). Overall, episodes of asymptomatic AF independently predicted cerebral infarct (p=0.001), as did left atrial diameter (p=0.024), systolic blood pressure (p=0.002), and duration of diabetes (p=0.044). [J Am Coll Cardiol 2013;62:525-530] The identification of brief episodes of AF may have some clinical significance even after assessment of target organ damage, said Dr. Rafaelle Marfella, lead study investigator from the Second University of Naples, Italy. Among diabetics without clinical AF, brief episodes of subclinical [asymptomatic] AF were significantly associated with cerebrovascular ischemia and stroke. The researchers matched the diabetic patients to 240 healthy controls. Patients were screened for episodes of asymptomatic AF at

Brief episodes of asymptomatic AF are significantly associated with cerebrovascular ischemia and stroke in patients with diabetes.

3, 6, 9 and 12 months and then yearly for another 3 years using a 48-hour Holter monitor. The mean age of the patients was 52. Those with symptomatic AF at baseline were excluded from the study. After a mean follow-up of 3 years, they found that patients with diabetes were more likely to develop asymptomatic AF than healthy controls (11 percent vs 1.6 percent, respectively; p<0.001). Overall, 27 diabetics with asymptomatic AF developed ischemic stroke compared with 16 without asymptomatic AF. By contrast, rates of cerebral infarct and stroke were lower (1.5 percent and 0.5 percent, respectively) in the control group. The authors said the data indicate that brief episodes of asymptomatic AF are frequent in diabetics. The 11 percent incidence of AF in the study may even be an underestimation given that monitoring was done intermittently. On the basis of these data, we cannot establish a temporal link between silent AF and cerebrovascular disease. The silent cerebral

September 2013 more to identify AF in diabetes patients and carefully assess treatment strategies to preserve brain function. Stroke is the most serious complication of AF, thus prevention is the key. More studies of AF, with cerebral infarcts and stroke as endpoints, are therefore needed, they said.

infarcts are probably due to similar AF that occurred in patients with silent AF before this study. In an editorial comment, Dr. Eric N. Prystowsky and Dr. Benzy J. Padanilam from St. Vincent Hospital, Indiana, US, said that as AF is often asymptomatic, clinicians should do

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September 2013

Low vitamin D levels linked to reduced mobility in seniors

Radha Chitale

ow vitamin D levels among the elderly may impede mobility and increase the difficulty of performing simple, everyday tasks, according to a new study. The findings align with a growing body of evidence that shows how important vitamin D is for well being as people age. Levels of 20 ng/mL or above of 25-hydroxyvitamin D (vitamin D) are required for good bone and overall health. Seniors who have low levels of vitamin D are more likely to have mobility limitations and to see their physical functioning decline over time, said lead study author Ms. Evelien Sohl, of VU University Medical Center in Amsterdam, the Netherlands. Older individuals with these limitations are more likely to be admitted to nursing homes and face a higher risk of mortality. Two cohorts from the Dutch Longitudinal Aging Study Amsterdam one group aged 55-65 years (n=725) and an older group aged 65-88 years (n=1,237) were included in the analysis. [J Clin Endocrinol Metab 2013. Epub ahead of print] Participants were assessed by six functional metrics and the degree of difficulty performing them: walking up and down stairs, dressing, sitting on a chair and standing again, cutting toenails, walking outside for 5 minutes, ability to transport oneself or take public transportation. Fifty-six percent of the older cohort and

30 percent of the younger cohort had one or more functional limitations at baseline. After adjusting for compounding factors (age, sex, body mass index, chronic disease, education and level of urbanization, vitamin D deficiency), subjects in the older cohort with the lowest levels of vitamin D (<20 ng/ mL) were almost twice as likely to have functional limitations as those in the same group with high vitamin D levels (>30 ng/mL) (odds ratio [OR] 1.7). Those in the younger cohort with vitamin D levels <20 ng/mL were more than twice as likely to have functional limitations as those in the same cohort with vitamin D levels >30 ng/mL (OR 2.2). Functional limitations occurred more quickly among those in the older cohort who were deficient in vitamin D compared with similarly deficient subjects in the younger cohort. Vitamin D deficiency was associated with more limitations after just 3 years in the older cohort (OR 2.0) and after 6 years in the younger cohort (OR 3.3). Although the exact relationship between vitamin D status and functional abilities among the elderly is unclear, vitamin D is known to be strongly tied to muscle health and muscle mass and atrophy is a known risk factor for falls, loss of function and loss of independence. Vitamin D supplementation could provide a way to prevent physical decline, but the idea needs to be explored further with additional studies, Sohl said.

September 2013

Forum

Europe collaboration advocating arthritis awareness in Asia

Based on an excerpt of a presentation by Professor Anthony Woolf, chair of the Bone & Joint Decade Foundation and coordinator of Eumusc.net, during the recent European League Against Rheumatism (EULAR) congress held in Madrid, Spain.

dvancements in therapies for arthritis have been very encouraging, but the access to these therapies has been hampered by cost and the lack of knowledge about these therapies. A group of experts, healthcare professionals and health institutions have collaborated to produce a set of recommendations called How to ensure that people with osteoarthritis and rheumatoid arthritis (RA) receive optimal care across Europe: The European Musculoskeletal Conditions Surveillance and Information Network (Eumusc.net) Recommendations. The Eumusc.net recommendations are focused on the provision of a patient-centered standard of care. Arthritis is very common but there exists a relatively negative attitude that nothing can be done to manage it. I would like to make sure that people are aware that things can be done and should be done to get the best outcome. A lot of it is simple and basic like proper diagnosis, education, general advice about lifestyle and how to manage their disease. There have been various surveys on RA across the world and there are big differences in disease activity in RA. Treatments are available and there are skilled doctors in these places, but there is a lack of equity in treatment. In the European community, one of the focuses is ensuring there is equity in outcomes. That gives us the opportunity to try and strive for that. It is important to get patients to under-

stand the treatment options that are available. With this knowledge they can go to the doctor and not just rely on what the doctor recommends. The doctor, who provides that care, should be Prof. Woolf given the right tools and latest information; to allow them to measure whether they are actually delivering adequate care to their patients. There are many of us who cant do as much as we would like because we are constrained by the system that we are working in. We are quite happy to show that we are doing not as well as someone else because that gives us a tool, evidence to go and say we really need to improve the way we get people referred to us. We really need to improve our information services for patients because we are behind others. In the UK, we have been setting goals for quite a while to drive up services. Another important part of the Eumusc.net project is the evidence of burden. We have been involved in recent Lancet papers on the global burden of disease, which has highlighted musculoskeletal conditions as being far bigger in impact than anyone had ever appreciated. We knew as experts, but others did not recognize it. They underestimated how much people themselves didnt like having

September 2013

Forum

pain and physical disability. It enables us to show policymakers that there is a big burden and things can be done, and this is how you can do it.

A lot of patients do extremely well on very inexpensive drugs if used

properly. I think we should be more public health- and health economicminded. We have all these wonderful medicines out there but not many can afford them Policymakers want solutions and also we have to recognize that solutions should be cost-effective. One of the barriers that we have with RA is that it is perceived as an expensive disease to treat. There is a concern that once you open the door, it will be extremely costly. We have these fancy drugs. However, a lot of patients do extremely well on very inexpensive drugs if used properly. I think we should be more public health- and health economicminded. We have all these wonderful medicines out there but not many can afford them. In many parts of Southeast Asia, there is no reimbursement for the expensive drugs and this is an enormous barrier. I am the chair of the Bone and Joint Decade Foundation, a global alliance of patients, professionals and scientific organizations that are relevant to musculoskeletal health which include rheumatology, orthopedics, rehabilitation and osteoporosis. This alliance attempts to cooperate on raising the priority on musculoskeletal health and one of the key principles of this alliance is working to try and find the evidence to support advocacy and teaching people how to advocate. For example, last year we had a

meeting in Vietnam to bring people together and look at how we can move things forward. This is how we get to understand the local issues. Clearly European standards do not always apply and we have to make them relevant to the region. We are doing a project in sub-Saharan Africa, which will be applicable to many other countries. We are training the primary healthcare worker, who works in the village, to better recognize musculoskeletal problems and have a positive attitude about what can be done for their patient. This could be a sprain or strain and how to treat it. If it looks like it could be inflammatory arthritis referring it to someone is capable of treating it. In that way they can go up the system and eventually get the right level of care. It is also important to make sure there are enough people higher up who know how to treat more complicated disease, initially with simple drugs like methotrexate.

September 2013

News

Children better judges of their asthma than their parents

Radha Chitale

hysicians should pay attention to what children with asthma say about their condition to ensure proper diagnosis and treatment, according to an analysis of quality of life questionnaires. Sometimes, such surveys can show disagreement between childrens and parents responses. For example, children tend to report having a better quality of life compared with similar reports by parents, suggesting differences in perceived limitations due to asthma between parent and child. [Ann Allergy Asthma Immunol 2013;111:14-19] Our research shows that physicians should ask parents and children about the effects asthma is having on the childs daily life, said lead author Dr. Margaret Burks, of the University of Texas Health Science Center at San Antonio in San Antonio, Texas, US. Parents can often think symptoms are better or worse than what the child is really experiencing, especially if they are not with their children all day. Asthma is the most common chronic disease among children, according to the World Health Organization, and the disease, often not well managed, affects about 235 million people worldwide. The survey included 79 children with asthma, aged 5-17 years, and their parents or caregivers. The children were given the Pediatric Asthma Quality of Life Questionnaire while parents were given the Pediatric Asthma Caregivers Quality of Life Questionnaire,

Children with asthma often reported higher quality of life than what their parents thought they had.

both of which give scores between 1-7, with a higher number corresponding to better quality of life. The scores were analyzed for the degree of difference in responses and patterns of agreement with respect to factors including sex, age and ethnicity. Children more often reported higher quality of life (mean 4.62) than their parents reported they had (mean 3.49, p<0.001) and scores differed more among males and their caretakers compared with females and their

September 2013

News
If their asthma disappears Going over these topics with young patients can help doctors gauge if the asthma is well managed, what the triggers might be, and if they might be depressed or feel left out. A related analysis by the same group emphasized that parents may be concerned over how they appear to physicians. Caregivers may not want to seem out of touch with their childs day-to-day health, and, in such fear, they may dominate the conversation at the office visit, Burks said, adding that insights from both parent and child are essential.

caretakers. The researchers recommended the following five areas which doctors should go over with patients specifically for an accurate read on the effects, real and perceived, of the childs condition: If asthma prevents the patient from playing sports or participating in other activities  When and where asthma symptoms become worse  Whether their condition affects their mood or makes them feel different from their peers  If they miss school due to asthma

September 2013

News

Exercise builds strong bones in young kids

Radha Chitale

hysical activity in the form of weightbearing exercise may help strengthen the bones of younger children more so than for adolescents, a meta-analysis has shown. Contrary to the widely held belief that exercise is a potent stimulus to increase [bone mineral content] and areal bone mineral density (aBMD) during childhood and youth, significant gains could only be found in BMC of pre-pubertal subjects, the researchers said. That is, efficacy of training in terms of bone mineral accrual is substantially affected by the maturational status of subjects. Optimal BMC can help prevent osteoporosis later in life. The data from 27 studies in which patients participated in exercise programs that were capable of significantly increasing BMC and aBMD during growth demonstrated that the weighted overall effect size (ES) for the two metrics increased among children who exercised compared with children not in exercise programs (ES 0.17 and 0.26, respectively, p<0.05). [J Bone Miner Res 2013. doi:10.1002/ jbmr.2036] The trials included a total of 2,985 children of mean age 10.3 years. The amount of habitual calcium intake and pre-pubertal status as opposed to intra-pubertal or post-pubertal were the most important factors for BMC increase (p<0.01 for both), accounting for over one-third of the ob-

served variance between groups. There were not enough data to determine key factors for aBMD increase. This supports the assumption that the pre-pubertal years are an opportune stage of maturation during which the skeleton is inimitably responsive to exercise, the researchers said. Physical activity in the form of weight-bearing activity in combination with high calcium intake should be encouraged in pre-pubertal years in order to oppose osteoporosis later in life by increasing peak bone mass. Vitamin D is known to be an important aid for bone growth, as well as being associated with impaired bone mineralization when there is a lack of it. The researchers noted that, since vitamin D analysis was either not included in the trials or was not of good quality, they were unable to determine its effects on BMC or aBMD, although they suggested that such data would support and explain even higher proportions of the observed variance. BMC tends to decrease with age, leaving people at increased risk for fractures and progressive diseases like osteoporosis. Capitalizing on the optimal age at which to build up BMC could be one way to prevent losing too much BMC later on. Weight-bearing activity alongside high calcium intake provide a practically relevant method to significantly improve BMC in pre-pubertal children, justifying the application of this exercise form as an osteoporosis prophylaxis in this stage of maturity, they said.

Journal of Paediatrics, Obstetrics & Gynaecology

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11 September 2013 Conference Coverage

7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 30 June-3 July, Kuala Lumpur, Malaysia

Transition HIV care must be safe, effective

Saras Ramiya

Table 1: Six critical first steps for child to adult transition in healthcare. A specific healthcare provider to be identified to help with the transition. There should be core competencies within the adult services to which the adolescent was transitioning. When possible, a portable accessible medical summary should go with the adolescent. There should be detailed and preferably written down transition plans. The same standards of health should be offered at both the pediatric and the adult services. Access to services including insurance cover. Additional recommendations The plan should be made with the patient and family. Specific conditions should have specific best practices developed. There should be more research on outcomes. So, healthcare transition is done badly or not at all, Bekker said. A cross-sectional study of more than 4,000 adolescents with special health needs showed that half had discussed transition with a healthcare practitioner, one third had a plan developed, but only about a quarter had a comprehensive plan. [Pediatrics 2005;115(6):1607-12] There are 3.4 million children under the age of 15 living with HIV and most will live

here is a need for child to adult healthcare transition services that are safe and effective for HIV patients, says an expert. Moving from pediatric to adult care, adolescents may find themselves decreasing their adherence to medication, erratic appointment keeping, loss of disease control and loss to follow up, said Linda-Gail Bekker (Ph.D), deputy director of the Desmond Tutu HIV Centre and Associate Professor of Medicine, University of Cape Town, South Africa. The Society for Adolescent Medicine in its consensus statement in 2003 provided six critical first steps for the transition from pediatric to adult care, besides other recommendations. (Table 1) The current definition of healthcare transition is the purposeful, planned movement of adolescents and young adults with chronic physical and medical conditions from childcentered to adult-oriented healthcare systems. This is discussed frequently, but studied rarely, Bekker said. Barriers to healthcare transition include inertia created by stability within the health system; the pediatric provider may find it difficult to let go of the patients or the patients wont allow themselves to be released from pediatric care; the adult provider may feel intimidated by complex patients due to lack of expertise, time and resources; and the patients and their families may have a sense of abandonment or loss of control in moving.

12 September 2013 Conference Coverage

Table 2: Pediatric HIV patients. Perinatally infected Equal number of girls and boys. Younger. Developmental stunting. Have experienced treatment. Unaware of status. into adulthood. Most of them live in Sub-Saharan Africa and Southeast Asia. [WHO, UNAIDS, UNICEF. Global HIV/AIDS Response Progress Report 2011 Available at: www. unaids.org/en/resources/publications/2011/ Accessed on 14 August] They are made up of perinatally infected younger patients and behaviorally infected older patients. (Table 2) Both groups need to be transitioned into adult care. Challenges confront young people living with HIV as they transition from complete dependence on caregivers and pediatric health services to adult HIV care systems that emphasize self-reliance and individual accountability for adherence. With adult services perceived as intimidating and impersonal, there are reports of failed transition with consequences of poor adherence, treatment failure and loss to follow up, Bekker said. HIV is unique as a chronic illness because of social stigma, the relationship to poverty, the fact that multiple members of one family may be living with or have died from HIV, and the association with sexual, intravenous and maternal transmission. While some resources are available and models of transition proposed, most have been in resourced environments, and there is little recognition of the need to transition adolescents to adult care in low- and middle-income settings. Consequently, very little published data are available and systems to track youth into adult care are inadequate, while the evaluation of this process and its limitations and successes are not being captured, Bekker concluded. Sexual and injecting drug user transmission More girls than boys in Africa. More boys than girls elsewhere. Older. Treatment nave. Aware of status.

13 September 2013 Conference Coverage

7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 30 June-3 July, Kuala Lumpur, Malaysia

Laws continue to marginalize key groups of HIV patients

Saras Ramiya

ather than helping forward the goals set by the international community in slowing the spread of HIV, the current legal and regulatory terrain is actually working actively to undermine HIV prevention and treatment projects, says an expert. We often imagine ourselves as having moved away from the politics of fear and distrust that characterize the early response to the HIV epidemic. Unfortunately, this is far from reality, said Aziza Ahmed, Assistant Professor of Law, Northeastern University School of Law, Boston, US. Today, a range of criminal laws continues to marginalize and stigmatize key groups who are infected by HIV designating them as deserving blame for spreading the virus. This has ramifications for healthcare service and delivery, she added. Rather than create a legal and policy environment that facilitates disclosure of HIV and then destigmatizes having the virus, many countries have laws that do exactly the opposite. One side of these laws are those that criminalize transmission and exposure to HIV in other words, when a person exposes or transmits HIV. These laws specifically target people living with HIV. The recent report of the Global Commission on HIV and the Law found that over 60 countries worldwide criminalize exposure to HIV. These laws have not been effective in prevent-

Many countries have laws that undermine HIV prevention and treatment projects.

ing people from contracting HIV. They simply become a tool to further marginalize and stigmatize individuals who are living with HIV and further spread misinformation about the virus, Ahmed said. In the US, for example, in the context of criminal trials, spitting and biting continue to be treated as pathways for HIV transmission. Worldwide, countries and jurisdictions have promulgated HIV-specific criminal laws eg, 27 countries in Africa, 14 countries

14 September 2013 Conference Coverage

in Eastern Europe and Caucasus (EECA) and 11 countries in Latin America follow the NDjamena Model Law (2005). [Global Commission on HIV and the Law, 2012. Available at: www.hivlawcommission.org/ Accessed on 15 August] Harm reduction is another area that countries need to look at to reduce HIV transmission. Harm reduction refers to policies, programs and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. [Harm Reduction International. Available at: www.ihra. net/what-is-harm-reduction Accessed on 15 August] Comprehensive, consistently implemented harm reduction without punitive approaches in UK, Switzerland, Germany and Australia led to HIV prevalence of less than 5 percent among people who are injection drug users (IDUs). In contrast, consistent resistance to harm reduction and punitive approaches eg, in Thailand and Russia resulted in HIV prevalence of above 40 percent and 35 percent, respectively, among IDUs. [War on Drugs. Report of the Global Commission on Drug Policy, 2011. Availableat: www.globalcommissionondrugs.org/wp-content/themes/gcdp_v1/pdf/ Global_Commission_Report_English.pdf Accessed on 15 August, Lancet 2008;372:1733-45, 2010;375:1014-28] Ahmed called upon delegates to not only produce knowledge about the HIV epidemic, but to accept the responsibility of creating a legal and policy landscape that enables the implementation of effective and high quality HIV care, treatment, and service programs, and does not discriminate, stigmatize, and marginalize the very people who need support and care.

15 September 2013 Conference Coverage

9th Asian Dermatological Congress, July 10-13, Hong Kong

Managing psoriasis beyond the skin

Jenny Ng

he future of psoriasis management points toward a stratified individualized approach targeting therapies to systemic and psychological factors often overlooked during treatment. Psoriasis is not just a skin disease, said Professor Christopher Griffiths of the University of Manchester, England. Management of the whole patient is paramount. Most clinicians fail to look beyond the skin disease to both identify and manage associated conditions including depression, non-adherence, psoriatic arthritis and cardiovascular disease. Evidence is accumulating on the link between the severity of psoriasis and cardiovascular mortality. A recent Danish study showed an increased risk of atrial fibrillation and stroke, even in patients with mild psoriasis. [Eur Heart J 2012;33:2054-2064] It is now a question of whether early use of systemic treatments can prevent or reduce comorbidities in psoriasis patients. Good tools that can help identify various aspects of psoriasis are necessary to guide treatment. Recently, Griffiths and colleagues developed the Simplified Psoriasis Index (SPI) as a holistic approach to assess psoriasis and better understand the severity of the disease. [J Invest Dermatol 2013;133:1956-1962] The SPI replaces the current PASI [Psoriasis Area and Severity Index] scoring system with a composite weighted severity score designed to reflect the impact of psoriasis affecting functionally or psychosocially important body sites. In addition to current severity of psoriasis, it also assesses the psychosocial

Psoriasis management is not just about treating the skin.

impact of the disease and previous interventions. Psychosocial aspects of psoriasis are important for disease management and can be a significant burden on psoriasis patients, affecting their adherence to treatment and overall quality of life. To help patients cope with psoriasis, Griffiths and colleagues have developed a new web-based cognitive behavioral therapy (CBT) program known as the Electronic-Targeted Intervention for Psoriasis (eTIPS), which is shown to significantly reduce anxiety and improve quality of life of psoriasis patients with similar results as faceto-face CBT. [Br J Dermatol 2013, e-pub Apr 1; doi: 10.1111/bjd.12350] With increased understanding of psoriasis as a disease involving both physiological and psychological aspects, a holistic approach of management will help improve patients prognosis, Griffiths concluded.

16 September 2013 Conference Coverage

9th Asian Dermatological Congress, July 10-13, Hong Kong

Non-invasive body contouring: What works?

Christina Lau

ith so many non-invasive body contouring devices available on the market, choosing one that works well requires some due diligence with respect to assessment of the scientific evidence as well as other considerations. When evaluating a non-invasive body contouring device, we need to have proof of efficacy based on patient recognition of significant improvement, histologic evidence of fat cell apoptosis, ultrasound or MRI confirmation of fat reduction, and circumference reduction for large treated areas, said Dr. Robert Weiss of the Johns Hopkins University School of Medicine, Baltimore, Maryland, US. Devices emitting different forms of radiofrequency (RF) are available for treatment of the abdomen, arms and legs. Unipolar RF is not the most effective because the heating is less controllable, and there is less significant penetration to fat cells, said Weiss. Monopolar RF provides deeper penetration than RF. However, bipolar RF can be used if skin tightening is desired because its thermal depth is limited to a maximum of 8 to 9 mm.

When evaluating a non-invasive body

contouring device, we need to have proof of efficacy To achieve skin tightening and fat reduction with RF, it is important to sustain skin

temperature at about 42C for about 15 minutes, because fat temperature is much lower than skin temperature, he advised. About 85 percent of our patients respond to this strategy. Using a dynamic monopolar RF device, an 18 percent reduction in ultrasound-measured fat thickness was achieved in the arm in patients with fat thicker than 2 cm, he added. More recently, non-thermal focused ultrasound has become available as the newest technology for non-invasive fat destruction. It provides immediate, selective and permanent fat cell destruction, and is safe and effective for treatment of the abdomen, flanks and thighs, noted Weiss. In a study of 32 Asian patients who received three sequential treatments with focused ultrasound in combination with RF, reduction in MRI-measured fat thickness of 21.4 percent and 25 percent was found in the upper and lower abdomen, respectively. [Lasers Med Sci 2013; e-pub Mar 24] In Asians, results of body contouring treatments tend to be less impressive due to their smaller body size, thinner fat layer, and different dietary intake of saturated and unsaturated fat compared with Caucasians, said Dr. Henry Chan, president of the Hong Kong College of Dermatologists, at a press conference held in conjunction with the congress. Fat thickness of 2 to 3 cm is required for impressive results. In clinical practice, accurate objective assessment of the degree of improvement is difficult, as patients are usually reluctant to undergo MRI scans before and after treatment, Chan added.

17 September 2013 Conference Coverage

9th Asian Dermatological Congress, July 10-13, Hong Kong

Delusion a challenge in compulsive skin picking

Jackey Suen

kin picking can be of psychiatric origin that requires a cautious approach as delusional patients have unshakable beliefs about the cause of their symptoms and are often resistant to the idea of treatment, according to an expert from Canada. Skin picking can result from a variety of causes, including underlying dermatological conditions, pruritus without rash, neurologic abnormalities, narcotic medications, drug abuse and psychiatric issues, said Dr. Simon Se-Mang Wong of the University of British Columbia, Vancouver, Canada. Cases with a psychiatric origin can be further categorized into delusional and non-delusional types, which require different treatment approaches. As delusional patients usually have unshakeable beliefs about the cause of their symptoms and are often resistant to the idea of treatment, we need to suggest psychiatric treatment with care, he advised. If the patients are not ready for treatment, it may be best to step away. Once they agree to start treatment, we can prescribe antipsychotics. Non-delusional patients are conscious of the self-induced nature of their skin picking. The underlying causes are mainly depression, anxiety, or addiction-like picking or scratching, explained Wong. I would treat these patients with a combination of psychological treatments and medications including antidepressants, anxiolytics, and sometimes

Skin picking can result from various causes.

low-dose antipsychotics, based on psychiatric diagnoses. He suggested using the Modified Mini Screen (MMS) tool to screen for depression, anxiety or delusion in patients presenting with skin picking. Although MMS is not a diagnostic tool, it provides clues for physicians to decide how they should plan the treatment. However, other possible causes have to be ruled out before a patient is diagnosed with skin picking of psychiatric origin, he added. Dermatologic conditions, such as lichen planus and insect bites, are relatively easy to identify. For pruritus without rash, we need to look at patients history and result of physical examination to decide if a full workup is needed to identify potential systemic causes.

18 September 2013 Conference Coverage

18th Congress of the European Hematology Association, June 13-16, Stockholm, Sweden

First-ever guidelines for the treatment of non-transfusion-dependent thalassemia

Rajesh Kumar

ral therapy for iron chelation should be initiated in non-transfusion-dependent thalassemia (NTDT) patients with liver iron concentrations (LIC) of >5mg Fe/g dry weight and maintained until they achieve levels below that threshold, according to the first-ever guidelines for treating NTDT. Patients who achieve levels <5mg Fe/g dry weight could be taken off the chelator and given the opportunity for a drug vacation, a strategy that could potentially lessen the psychological implications of committing to a lifelong treatment. But they should be closely monitored with LIC evaluation every 1-2 years to identify those who may require reintroduction of chelation therapy if liver iron concentrations start increasing again, the guidelines said. Released by the Thalassemia International Federation (TIF), the guidelines provide a consensus of international expert opinion based on the latest data on the field and were developed to give clinicians easy-to-follow protocols to better identify and manage a patient population that is often over-looked or under-diagnosed. Unlike the patients of -thalassemia major, those with NTDT do not require lifelong regular blood transfusions for survival, although they may require occasional or even frequent transfusions in certain clinical settings and for

defined periods. NTDT includes thalassemia intermedia, HbE/thalassemia and a-thalassemia (HbH), and predominantly affects people of South Asian, South East Asian, Mediterranean and Middle Eastern origin. More people suffer from NTDT than -thalassemia major. The guidelines seek to clarify to clinicians that although NTDT patients do not require regular blood transfusions, they can still develop chronic iron overload due to increased iron absorption in the stomach and intestines triggered by the bodys need for more red blood cells. Without proper disease management, people with NTDT can still develop dangerous iron build up in vital organs that can cause serious and potentially life-threatening complications, said TIA medical advisor Dr. Michael Angastiniotis. Prolonged and regular infusions with desferrioxamine for iron chelation affect patients psychosocial stability, quality of life and impacts compliance. That is why oral chelation therapy has been recommended for these patients, the guidelines said. One of our goals in disseminating these guidelines is to help prepare doctors and health systems around the world to better understand and recognize the clinical importance of NTDT and advise those doctors who are less familiar with the disease. This will support better identification and effective treatment of NTDT patients, concluded TIA Executive Director Dr. Androulla Eleftheriou.

19 September 2013 Conference Coverage

18th Congress of the European Hematology Association, June 13-16, Stockholm, Sweden

Mini-hormone may tackle iron overload

Rajesh Kumar

new therapy may prove useful for the treatment of iron overload disorders. The cause of iron overload in diseases such as hereditary hemochromatosis and thalassemia is the deficiency of the hormone hepcidin, which regulates dietary iron absorption and mobilization of iron from stores. Hepcidin deficiency results in excessive iron absorption from the diet and iron loading of vital organs. This iron overload can lead to organ damage and even death. Researchers said currently available iron chelation therapies are burdensome or cause side effects, creating the need for better alternatives. Hepcidin replacement offers a potential new treatment for iron overload disorders. But natural hepcidin is difficult to synthesize and has unfavorable pharmacological properties. By defining the minimal structure of hepcidin that still retained the hormone activity, researchers developed mini-hepcidins, peptide mimics of the hormone, and engineered them to improve their bioavailability and to decrease the cost of production.

Hepcidin replacement therapy offers a new, better alternative to existing iron chelation therapies, say researchers.

Mini-hepcidin not only prevented iron loading, but also improved anemia

Using hepcidin knockout mice as a model of the severe form of hereditary hemochromatosis, we demonstrated that mini-hepcidins completely prevented iron loading of mouse organs, said Dr. Elizabeta Nemeth of the University of California in Los Angeles, California, US, in a media conference. In a mouse model of thalassemia, which is characterized by both anemia and iron overload, mini-hepcidin not only prevented iron loading, but also improved anemia, said Nemeth. Clinical trials in humans are scheduled to begin soon.

20 September 2013 Osteoporosis

UK osteoporosis group updates guidelines

Rajesh Kumar

he National Osteoporosis Guideline Group (NOGG) in the UK has updated its clinical guidelines for the diagnosis and management of osteoporosis in postmenopausal women and older men. [Maturitas 2013;75:392-396] The update to the original 2008 document brings an additional focus on the management of glucocorticoid-induced osteoporosis, the role of calcium and vitamin D therapy and the benefits and risks of long-term bisphosphonate therapy. In all these areas, there have been new developments over the past few years that have had an impact on clinical practice and require modifications and/or additions to previous guidance, the authors said. The recommendations in the guidelines are intended to aid management decisions, but do not replace the need for clinical judgment in the care of individuals in clinical practice. Women with a prior fragility fracture should be considered for treatment without the need for further risk assessment although BMD measurement may sometimes be appropriate, particularly in younger postmenopausal women, according to the updated guideline. In the presence of other clinical risk factors, the 10-year probability of a major osteoporotic fracture of the spine, hip, forearm or humerus should be determined using the WHO fracture risk assessment tool called FRAX (www.shef.ac.uk/FRAX), using BMD if indicated.

In those treated with glucocorticoids, FRAX assumes an average dose of prednisolone (2.57.5 mg/day or its equivalent) and may underestimate fracture risk in patients taking higher doses and overestimate risk in those taking lower doses, wrote the authors. Alendronate, etidronate and risedronate are approved for the prevention and treatment of glucocorticoid-induced osteoporosis in postmenopausal women. Teriparatide and zoledronic acid are approved for treatment of glucocorticoid-induced osteoporosis in men and women at increased risk of fracture. Bone-protective treatment should be started at the onset of glucocorticoid therapy in patients at increased risk of fracture, they said. The low cost of generic formulations of alendronate makes them the first-line option in the majority of cases. In individuals who are intolerant of these agents or in whom it is contraindicated, etidronate, risedronate and zoledronic acid are appropriate options, the NOGG said, adding: The high cost of teriparatide restricts its use to those at very high risk, particularly for vertebral fractures. Maintenance of mobility and correction of nutritional deficiencies, particularly of calcium, vitamin D and protein, should be advised. Treatment with bisphosphonates should be reviewed every 3 years in case of risedronate, ibandronate and zoledronic acid and every 5 years for alendronate to consider a drug holiday. If treatment has been discontinued, fracture risk should be reassessed whenever a new fracture occurs or after 2 years irrespective of a new fracture, said the experts.

21 September 2013 Osteoporosis

Calcium, vitamin D reduce hip fractures in postmenopausal women on hormone therapy

Angeline Woon

ostmenopausal women on hormone therapy seem to have reduced risk of hip fractures if they supplement with calcium and vitamin D, finds a US study published online in Menopause. Calcium and vitamin D supplements have been widely debated before this and recommendations are in conflict, such as those made by the US Preventive Services Task Force (USPSTF) earlier this year that said there is no basis recommending either supplementation to prevent fractures. However, a recent analysis of the Womens Health Initiative (WHI) project showed that calcium and vitamin D do help, particularly for women on hormone therapy. The interaction was clear between hormone therapy, and calcium and vitamin D on hip fractures (p interaction=0.01). The effect of calcium and vitamin D supplementation was stronger among women who also took hormone therapy (HR, 0.59; 95% CI, 0.38-0.93) compared to those who took placebo (HR, 1.20; 95% CI, 0.85-1.69). When it comes to hip fractures, the study found that women who took both hormones and the supplements had fewer incidences of hip fractures (11) per 10,000 women per year, compared to women who took hormones alone (18/10,000 women/year), those who took the supplements alone (25/10,000 women/year) and those who did not take ei-

ther (22/10,000 women/year). Thus, taking both supplements and hormones at the same time had a synergistic effect, as taking supplements alone did not seem significantly better than taking no supplements and no hormones. The authors said the results suggest that women on postmenopausal hormone therapy who are at normal risk for hip fracture should also take supplemental calcium and vitamin D. They noted that they could not specify the exact amount of supplementation women in the study took calcium carbonate 1,000 mg and vitamin D3 400 IU daily the benefits increased as supplement intake went up. For example, women with dietary calcium that increased their intake to greater than 1,200 mg daily benefited strongly. Similarly, dietary vitamin D led to greater benefits, but as the supplements were taken at the same time, the individual effects could not be determined. Dosage recommendations depend on keeping side effects to a minimum eg, too much calcium causes constipation. The study was a prospective, partial-factorial, randomized, controlled, double-blind trial involving WHI postmenopausal participants at 40 centers in the US. The women were aged 50 to 79, and were followed for a mean of 7.2 years. Women in one arm were randomized to hormone therapy (n=27,347) of conjugated estrogens alone, or conjugated equine estro-

22 September 2013 Osteoporosis

gen plus medroxyprogesterone acetate daily. Women in the other arm (n=36,282) received calcium and vitamin D supplements. Both arms were compared with placebo. There was no interaction between either hormone therapy or calcium and vitamin intake in changes to hip or spine bone mineral density.

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23 September 2013 Diabetes

Individualized treatment in elderly diabetes patients brings results

Angeline Woon
study in Europe finds that setting individualized glycemic targets helps elderly diabetic patients achieve better HbA1c targets, with less complications. Guidelines typically recommend setting individualized targets to control type 2 diabetes mellitus (T2DM) in elderly patients despite the lack of evidence. The study aimed to investigate if setting such targets will have a positive effect, and was the first to introduce as well as show the feasibility of using individualized HbA1c targets as an endpoint. [Lancet doi:10.1016/S0140-6736(13)60995-2] The study showed that patients with individualized treatment who received vildagliptin 50 mg once or twice daily as per label (52.6 percent) were three times more likely to reach their target than those not involved in the study (adjusted odds ratio 3.16, 96.2% CI 1.81-5.52; p<0.0001). Interestingly, those who received individualized treatment, but who were in the placebo group, also showed an improvement up to 37 out of 137 patients (27 percent) met their targets by education and interactions with the study team alone, without taking medication. In addition, the researchers also found that among the patients who received individualized treatment, there was a clinically relevant 0.9 percent reduction in HbA1c from a baseline of 7.9 percent of those taking vildagliptin and a between-group difference of -0.6 percent (988% CI 081 to 033;

Study data support individualized glycemic targets for diabetes care.

p<00001). People over the age of 70 are more likely to have multiple complications, such as heart disease, as well as type 2 diabetes. Yet perversely, these patients have so far been excluded from clinical trials, precisely because of these complications, said Dr. David Strain, lead author from the University of Exeter Medical School, UK. Older patients are more susceptible to complications caused by hyperglycemia, and can increase the patients risk of dizziness and falls. According to Strain, most elderly patients are treated with a one-size-fits-all approach. However, setting individual goals and realistic targets, and then spending time talking to patients seems to be more effective than aggressively chasing targets. The study was a multinational, doubleblind study that ran for 24 weeks. Researchers enrolled 139 diabetic patients from 45 outpatient centers across Europe, who were drug-naive or had inadequately controlled

24 September 2013 Diabetes

HbA1c of between 7.0 percent to 10.0 percent, and who were aged 70 years or older. Treatment targets were individualized based on age, baseline HbA1c, comorbidities and frailty status. Between December 22, 2010 and March 14, 2012, a validated and automated system randomly assigned patients to either vildagliptin or placebo. The coprimary efficacy endpoints were deemed to be the proportion of patients reaching their individualized, investigator-defined HbA1c target and HbA1c reduction from baseline to the end of the study. Strain added that though it was a small trial, the results were quite dramatic and is the first strong evidence that individualized care makes a huge difference to the lives of older people with diabetes.

25 September 2013 In Practice

Chemoprevention of breast cancer in primary care

Dr. Wong Seng Weng
Medical Director & Consultant Specialist in Medical Oncology The Cancer Centre, a subsidiary of the Singapore Medical Group

n the 1960s, cancer made up about 15 percent of all causes of death. Today, that number has doubled to 30 percent. One in three Singaporeans will develop cancer in their lifetime and the most common cancer in women is breast cancer. Up to two-thirds of breast cancer cases in women are preventable. However, this potential is largely overlooked and neglected. The population-at-risk for breast cancer is large. In order for any breast cancer prevention strategy to deliver significant dividend, the execution has to reach a fairly large population. For the strategy to realistically reach a large population-at-risk, it has to be executed at the primary care level. The aim of this discussion is to bring the consideration and practice of chemoprevention of breast cancer to the primary healthcare scene by discussing three major areas: 1.  Clinical trial data that support chemoprevention of breast cancer as an evidencebased approach; 2.  Selection of patients who may benefit from chemoprevention; 3.  Practical considerations in selecting treatment options.

The case for chemoprevention of breast cancer According to Singapore Cancer Registry data for the period 2007-2011, approximately 1,600 new cases of breast cancer are diagnosed every year and approximately 380 deaths occur due to breast cancer yearly. This means that about one in 16 Singaporean women will be diagnosed with breast cancer in their lifetime. These alarming figures represent a significant disease burden on our society. Estrogens promote breast cancer formation in preclinical models and in women with naturally high levels of the hormone. Interventions that target the stimulatory effects of estrogens on breast tissue provide an opportunity to modify breast cancer risks. To date, clinical trials have demonstrated the efficacy of tamoxifen, raloxifene and exemestane in reduction of the incidence of invasive breast cancers. Tamoxifen and raloxifene are selective estrogen receptor modulators (SERMs) that exert an anti-estrogenic effect on the breast. Treatment with tamoxifen or raloxifene for 5 years reduces the lifetime risk of breast cancer by about 50 percent. Tamoxifen has been tested in both pre- and postmenopausal women while raloxifene has only been tested in postmenopausal women. Tamoxifen is comparatively more efficacious than raloxifene. The concerns over the use of SERMS are the associated increase in the risk of endometrial cancer and thromboembolic complications such as deep vein thrombosis. However, the risks of such serious complications are low and remain well below 1 percent. In this

26 September 2013 In Practice

aspect, the risks of endometrial cancer and thromboembolism associated with raloxifene are lower than that of tamoxifen. Raloxifene has the added advantage of being indicated for the treatment of osteoporosis. Exemestane is an aromatase inhibitor (AI) that profoundly suppresses estrogen levels in postmenopausal women. However, exemestane is contraindicated in premenopausal women since it may increase estrogen levels. A clinical trial has demonstrated that treatment with exemestane for 5 years in postmenopausal women reduces the risk of breast cancer by 65 percent. The potential concerns over the use of exemestane include the increased loss of bone mass and a relative short period of follow-up in current clinical trials. Chemopreventive trials using other AIs are in progress. The American Society of Clinical Oncology (ASCO) guidelines last updated in 2009 recommend the use of tamoxifen and raloxifene for breast cancer chemoprevention. The National Comprehensive Cancer Network (USA) guidelines in 2013 consider exemestane as an added option together with tamoxifen and raloxifene. Selection of patients for chemoprevention The selection criteria used to identify patients with an increased risk for breast cancer include: 1. Age over 60 years; 2. Age over 35 years with a history of ductal carcinoma-in-situ, lobular carcinoma-in-situ, atypical ductal hyperplasia or atypical lobular hyperplasia; 3.  Age between 35 and 59 years with a Gail model risk of breast cancer of 1.66 percent over 5 years; 4.  Women with known BRCA1 or BRCA2 mutations who do not opt to undergo prophylactic mastectomy. Patients in categories 2 and 4 should be considered for referral to a specialist for assessment due to higher associated risks and the need to explore management options other than chemoprevention. Practical considerations Women who fit the above criteria for increased risk of breast cancer may benefit from chemoprevention. For premenopausal women and postmenopausal women who have undergone hysterectomies, I recommend tamoxifen for 5 years. For postmenopausal women with a uterus, either tamoxifen or raloxifene for 5 years is an option. Doctors must consider the tradeoff between the higher anti-cancer efficacy of tamoxifen and the higher associated risk of endometrial cancer. Exemestane for 5 years is an alternative option for postmenopausal women. It has a higher efficacy when compared with SERMs and a lower risk of endometrial cancer and thromboembolic complications, although long-term follow-up trial data for the drug are still pending Conclusion While most breast cancer risk prediction models are based largely on Western populations, the risk of breast cancer in Singapore should not be ignored. There are many therapeutic clinical trials on varying diseases upon which Singapore doctors base treatment decisions for the local population. The increasing awareness of the threat of cancer has raised anxiety amongst Singaporeans. Many are looking for non-evidence based strategies of cancer prevention like health supplements and folk recipes. It is time the medical community offers them an evidence-based option.

Video Series Current Opinion in

BY DOCTORS FOR DOCTORS

MIMS
By Doctors For Doctors

Gastroenterology

Professor David Lieberman

shares his perspective on the present and future of colorectal cancer screening. There is a lot of potential to prevent many cancers if we can improve the rate of CRC screening.

Professor Nimish Vakil

talks about management of patients with refractory GERD. Successful treatment of refractory GERD requires thorough investigation of the patient situation.

Dr Markus Cornberg

discusses the management of chronic hepatitis B. The aim of therapy should be the cure or control of HBV infection without the need for life-long treatment.

MIMS Video Series features

interviews with leading experts.

In this Series, find out what these medical experts have to say about latest updates in the management of refractory GERD, the management of chronic hepatitis B and the present & future of colorectal cancer screening.

Got a spare 5 minutes? Go to www.mims.asia/video_series

SCAN TO WATCH VIDEO

Brought to you by MIMS

28 September 2013 Calendar

SEPTEMBER
European Respiratory Society Annual Congress
7/9/2013 to 11/9/2013 Location: Barcelona, Spain Info: ERS 2013 c/o K.I.T. Group Email: ers2013registration@kit-group.org Website: www.erscongress2013.org

13th Asian Federation of Sports Medicine Congress

25/9/2013 to 28/9/2013 Location: Kuala Lumpur, Malaysia Info: AFSM Organizers Email: 13afsm@gmail.com Website: www.13afsm.com

London College of Clinical Hypnosis Asia Certificate in Clinical Hypnosis (UK University accreditation)
21/9/2013 Location: Singapore Info: London College of Clinical Hypnosis Secretariat Tel: (65) 6809 2238 / 6557 2248 Email: info@hypnosis-singapore.com Website: www.hypnosis-singapore.com

National Skin Centre Dermatology Update 2013

26/9/2013 to 28/9/2013 Location: Singapore Info: Mrs. Alice Chew, Conference Secretariat, National Skin Centre (S) Pte Ltd Tel: (65) 6350 8405 Email: training@nsc.gov.sg Website: www.nsc.gov.sg/showcme.asp?id=149

Asian Pacific Digestive Week

21/9/2013 to 24/9/2013 Location: Shanghai, China Info: APDWF Secretariat Tel: (65) 6346 4402 Email: congress_international@gastro2013.org Website: www.gastro2013.org

Primary Care Forum 2013 and the 4th Singapore Health & Biomedical Congress 2013
27/9/2013 to 28/9/2013 Location: Singapore Tel: (65) 6496 6684 / (65) 6496 6682 Email: secretariat@pca.sg Website: www.pca.sg/events

21st World Congress of Neurology

21/9/2013 to 26/9/2013 Location: Vienna, Austria Info: Kenes International Email: wcn@kenes.com Website: www2.kenes.com/wcn/Pages/Home.aspx

European Cancer Congress 2013 (ECCO-ESMOESTRO)

27/9/2013 to 1/10/2013 Location: Amsterdam, Netherlands Info: ECCO Secretariat Tel: (32) 2 775 02 01 Fax: (32) 2 775 02 00 Email: ecco@ecco-org.eu Website: eccamsterdam2013.ecco-org.eu

49th Annual Meeting of the European Association for the Study of Diabetes
23/9/2013 to 27/9/2013 Location: Barcelona, Spain Info: EASD Secretariat Email: registration@easd.org Website: www.easd.org

29 September 2013 Calendar

OCTOBER
Taiwan Digestive Disease Week 2013
4/10/2013 to 6/10/2013 Location: Taipei, Taiwan Info: Congress Secretariat Email: service@tddw.org Website: www.tddw.org

UPCOMING
9th International Symposium on Respiratory Diseases
8/11/2013 to 10/11/2013 Location: Shanghai, China Info: MIMS, China Email: secretariat@isrd.org Website: www.isrd.org

7th International Congress of the Asian Society Against Dementia (ASAD)

10/10/2013 to 12/10/2013 Location: Cebu, Philippines Info: Dementia Society of the Philippines Tel: (632) 749 9707 Fax: (632) 740 9725 Email: secretariat@dementia.org.ph Website: www.dementia.org.ph

18th Congress of the Asian Pacific Society of Respirology

11/11/2013 to 14/11/2013 Location: Yokohama, Japan Info: APSR 2013 Secretariat Email: info@apsr2013.jp Website: www.apsr2013.jp

13th International Workshop on Cardiac Arrhythmias - Venice Arrhythmias 2013

27/10/2013 to 29/10/2013 Location: Venice, Italy Info: VeniceArrhythmias 2013 Organizing Secretariat Tel: (39) 0541 305830 Fax: (39) 0541 305842 Email: info@venicearrhythmias.org Website: www.venicearrhythmias.org

8th World Congress on Developmental Origins of Health and Disease (DOHaD 2013)
17/11/2013 to 20/11/2013 Location: Singapore Info: DOHaD 2013 Congress Secretariat Tel: (65) 6411 6692 Fax: (65) 6496 5599 Email: secretariat@dohad2013.org Website: www.dohad2013.org

30 September 2013 After Hours

KYOTO
Monika Stiehl

Ja pa n s C u lt u r a l H e a rt

he curtain rises. Dressed in a light blue kimono covered all over with white flowers, the Maiko stands stock-still, with head held low, turning her back to the audience. Then the music starts. In accordance with the smooth tones of the Koto, the Japanese harp, the Maiko gently begins moving, first elegantly her fingers and arms, then turning to face the audience, raising the head. The face covered with white make-up, the lips painted flaming red and the coalblack hair artistically towered, she looks like a piece of art. We are in Kyoto, the cultural heart of Japan, watching the Kyomai, the so-called traditional Kyoto Style Dance, performed by a Maiko, an apprentice Geisha. Her dance tells the melancholic story of the life of Maikos and Geishas in ancient Japan. Kyoto is the ancestral home of traditional Japanese performances not only of the Kyomai, but also the Chado, a Japanese tea ceremony, the Kyogen, an ancient comic theater and the Bunraku, a traditional puppet play. Kyoto is rich in cultural heritage. One of

the many UNESCO world heritage sites in the city is the Kinkaku-ji temple (or Golden Pavilion). It shimmers in the adjacent lake and is one of the most visited tourist spots in Kyoto. As is the Kiyomizu-dera temple, an ancient Buddhist shrine founded in 798. Its present buildings were constructed in 1633. There is not a single nail used in the entire structure. It takes its name from the miraculous waterfall within the complex, which runs off the nearby hills. The name Kiyomizu means clear or pure water. Visitors can drink the water, which is believed to have wish-granting powers. The temple complex includes several other shrines. Among them the Jishu Shrine, dedicated to Okuninushi, a god of love and good matches. Jishu Shrine possesses a pair of love stones placed 6 meters apart. You can try to walk between them and its said that you will find love or true love when you are able to reach the other stone with your eyes closed. There are always lots of young ladies and men trying their luck. The Ginkaka-ji temple (or Silver Pavillion) charms with its beautiful Japanese garden. An essential element is the impressive Zen

31 September 2013 After Hours

sand garden. The meticulously raked sand is said to visualize the waves of the ocean and a carefully built pile symbolizes Mount Fuji. A relaxing stroll down Tetsugaku-nomichi (or the so-called Philosophers way), a pleasant stone path through the northern part of Kyotos Higashiyama district, which is lined by hundreds of cherry blossom trees, comes highly recommended. Approximately 2 kilometers long, the path begins near the Ginkaku-ji temple and follows a small canal. The path gets its name from one of Japans most famous and influential philosophers of the 20th century Nishida Kitaro who is said to have practiced meditation while walking along it each day to Kyoto University. After all this mental food, a visit to Nishiki market will provoke your appetite for real food. Known as Kyotos Kitchen, this traditional food-market is vibrant, full of activity and Japanese delicacies such as prawns with teriyaki mayonnaise and stuffed octopus heads served on a stick. Kyoto has often been described as the most Japanese part of Japan. Here at Nishiki, one gets the impression that this might well be true. Useful tips for visiting Kyoto Visiting Kyoto requires some well thought out pre-planning, especially if you only have limited time. The city has an abundance of amazing pagodas, temples and shrines to see more than 1,800 altogether. No wonder Kyoto has a reputation for being Japans cultural heart. You will also find graceful Geishas and Maikos gliding around the corners of the narrow streets of Gion, dressed in traditional Kimonos. You can join traditional Japanese ceremonies like the Chado, the tea ceremony, or the Kyomai, the Kyoto Style Dance performanced by Maikos or Geishas, which will make you feel like you are in ancient Japan. And after that, food markets full of Japanese specialities will bring you suddenly back to the present.

32 September 2013 Humor

A recent study has concluded that studies may be hazardous to our health!

Are you performing the surgery?

There is no reason why you shouldnt be able to live a perfectly normal life, so long as you dont try to walk, run or eat solid foods!

The nurse in training will be with you as soon as she is finished catheterizing the patient next to you!

This is the part I dread the most!

Have you considered going to a tennis court rather than a food court?

The nurses are saying you are not swallowing your pills!

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