medical tribune september 2013
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September 2013
www.medicaltribune.com
Children beer judges
of their asthma
Managing psoriasis
beyond the skin
CONFERENCE
UK osteoporosis group
updates guidelines
OSTEOPOROSIS
NEWS
AFTER HOURS
Kyoto - Japans cultural
heart
Asymptomatic AF raises stroke risk in
diabetics
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2 September 2013
Asymptomatic AF raises stroke risk in
diabetics
Elvira Manzano
Clinicians should consider screening
for asymptomatic (subclinical or si-
lent) atrial brillation (AF) in type
2 diabetes patients in light of new research
showing that this underlying condition is
relatively more common and signicantly in-creases the risk of stroke in such patients.
In a cohort of 464 patients with type 2 dia-
betes, the prevalence of cerebral infarcts (as
detected by MRI) was signicantly higher in
patients with asymptomatic compared with
those without asymptomatic AF (61 percent
vs 29 percent, respectively). Similarly, stroke
events were signicantly higher in patients
with asymptomatic AF (17.3 percent vs 5.9percent, respectively; p
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3 September 2013
infarcts are probably due to similar AF that
occurred in patients with silent AF before this
study.
In an editorial comment, Dr. Eric N. Prys-
towsky and Dr. Benzy J. Padanilam from St.Vincent Hospital, Indiana, US, said that as AF
is oen asymptomatic, clinicians should do
more to identify AF in diabetes patients and
carefully assess treatment strategies to pre-
serve brain function.
Stroke is the most serious complication of
AF, thus prevention is the key. More stud-ies of AF, with cerebral infarcts and stroke as
endpoints, are therefore needed, they said.
Smart Rx. Every Time.
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4 September 2013
Low vitamin D levels linked to reduced
mobility in seniors
Radha Chitale
Low vitamin D levels among the elderly
may impede mobility and increase the
diculty of performing simple, every-
day tasks, according to a new study. The nd-
ings 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-hy-
droxyvitamin 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. Eve-
lien Sohl, of VU University Medical Center
in Amsterdam, the Netherlands. Older indi-
viduals with these limitations are more likely
to be admied 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. Epubahead of print]
Participants were assessed by six functional
metrics and the degree of diculty perform-
ing them: walking up and down stairs, dress-
ing, siing on a chair and standing again, cut-
ting toenails, walking outside for 5 minutes,
ability to transport oneself or take public
transportation.
Fiy-six percent of the older cohort and
30 percent of the younger cohort had one or
more functional limitations at baseline.
Aer adjusting for compounding factors
(age, sex, body mass index, chronic disease,
education and level of urbanization, vitamin
D deciency), subjects in the older cohort
with the lowest levels of vitamin D (30 ng/mL) (odds
ratio [OR] 1.7).
Those in the younger cohort with vitamin
D levels 30
ng/mL (OR 2.2).
Functional limitations occurred more
quickly among those in the older cohort who
were decient in vitamin D compared with
similarly decient subjects in the younger
cohort. Vitamin D deciency was associated
with more limitations aer just 3 years in the
older cohort (OR 2.0) and aer 6 years in the
younger cohort (OR 3.3).
Although the exact relationship between
vitamin D status and functional abilitiesamong 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 in-
dependence.
Vitamin D supplementation could pro-
vide a way to prevent physical decline, but
the idea needs to be explored further with ad-
ditional studies, Sohl said.
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5 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.
A
dvancements in therapies for arthri-
tis have been very encouraging, but
the access to these therapies has been
hampered by cost and the lack of knowledgeabout these therapies. A group of experts,
healthcare professionals and health institu-
tions have collaborated to produce a set of
recommendations called How to ensure that
people with osteoarthritis and rheumatoid
arthritis (RA) receive optimal care across Eu-
rope: The European Musculoskeletal Condi-
tions Surveillance and Information Network
(Eumusc.net) Recommendations.The Eumusc.net recommendations are fo-
cused on the provision of a patient-centered
standard of care. Arthritis is very common but
there exists a relatively negative aitude 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 adviceabout lifestyle and how to manage their disease.
There have been various surveys on RA
across the world and there are big dierences
in disease activity in RA. Treatments are avail-
able and there are skilled doctors in these plac-
es, 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 op-
tions that are available.
With this knowledge they
can go to the doctor andnot just rely on what the
doctor recommends.
The doctor, who pro-
vides that care, should be
given the right tools and
latest information; to allow
them to measure whether they are actually de-
livering adequate care to their patients. There
are many of us who cant do as much as wewould 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, evi-
dence to go and say we really need to improve
the way we get people referred to us. We re-
ally need to improve our information services
for patients because we are behind others. In
the UK, we have been seing goals for quite awhile 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 high-
lighted musculoskeletal conditions as being
far bigger in impact than anyone had ever ap-
preciated. We knew as experts, but others did
not recognize it. They underestimated how
much people themselves didnt like having
Prof. Woolf
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6 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.
Policymakers want solutions and also we
have to recognize that solutions should be
cost-eective. 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 inexpen-sive drugs if used properly. I think we should
be more public health- and health economic-
minded. We have all these wonderful medi-
cines out there but not many can aord 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, pro-fessionals and scientic organizations that are
relevant to musculoskeletal health which in-
clude rheumatology, orthopedics, rehabilita-
tion and osteoporosis.
This alliance aempts to cooperate on rais-
ing the priority on musculoskeletal health
and one of the key principles of this alliance
is working to try and nd 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 is-sues. Clearly European standards do not al-
ways apply and we have to make them rel-
evant to the region.
We are doing a project in sub-Saharan Af-
rica, which will be applicable to many other
countries. We are training the primary health-
care worker, who works in the village, to bet-
ter recognize musculoskeletal problems and
have a positive aitude about what can bedone for their patient. This could be a sprain
or strain and how to treat it. If it looks like it
could be inammatory 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 meth-
otrexate.
A lot of patients do extremely well
on very inexpensive drugs if used
properly. I think we should be more
public health- and health economic-
minded. We have all these wonderful
medicines out there but not
many can aord them
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7 September 2013 News
Children better judges of their asthma than
their parents
Radha Chitale
Physicians should pay aention 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 dis-agreement between childrens and parents
responses. For example, children tend to re-
port having a beer quality of life compared
with similar reports by parents, suggesting
dierences in perceived limitations due to
asthma between parent and child. [Ann Al-
lergy Asthma Immunol 2013;111:14-19]
Our research shows that physicians
should ask parents and children about the ef-fects 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 oen think symptoms are bet-
ter or worse than what the child is really expe-
riencing, especially if they are not with their
children all day.
Asthma is the most common chronic dis-ease among children, according to the World
Health Organization, and the disease, oen
not well managed, aects 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 Pe-
diatric Asthma Quality of Life Questionnaire
while parents were given the Pediatric Asth-
ma Caregivers Quality of Life Questionnaire,
both of which give scores between 1-7, with a
higher number corresponding to beer qual-ity of life.
The scores were analyzed for the degree of
dierence in responses and paerns of agree-
ment with respect to factors including sex,
age and ethnicity.
Children more oen reported higher qual-
ity of life (mean 4.62) than their parents re-
ported they had (mean 3.49, p
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8 September 2013 News
caretakers.
The researchers recommended the follow-
ing ve areas which doctors should go over
with patients specically for an accurate read
on the eects, real and perceived, of the childscondition:
If asthma prevents the patient from playing
sports or participating in other activities
When and where asthma symptoms be-
come worse
Whether their condition aects their mood
or makes them feel dierent from their
peers
If they miss school due to asthma
If their asthma disappears
Going over these topics with young pa-
tients can help doctors gauge if the asthma
is well managed, what the triggers might be,
and if they might be depressed or feel le out.A related analysis by the same group em-
phasized 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 con-
versation at the oce visit, Burks said, add-
ing that insights from both parent and child
are essential.
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9 September 2013 News
Exercise builds strong bones in young kids
Radha Chitale
Physical activity in the form of weight-
bearing 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 ex-
ercise is a potent stimulus to increase [bone
mineral content] and areal bone mineral den-
sity (aBMD) during childhood and youth, sig-
nicant gains could only be found in BMC of
pre-pubertal subjects, the researchers said.
That is, ecacy of training in terms of bone
mineral accrual is substantially aected by
the maturational status of subjects.
Optimal BMC can help prevent osteoporo-
sis later in life.
The data from 27 studies in which patients
participated in exercise programs that were
capable of signicantly increasing BMC and
aBMD during growth demonstrated that the
weighted overall eect size (ES) for the two
metrics increased among children who ex-
ercised compared with children not in exer-
cise programs (ES 0.17 and 0.26, respectively,
p
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Journal ofPaediatrics, Obstetrics & Gynaecology
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11 September 2013 Conference Coverage
Transition HIV care must be safe, effective
7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 30 June-3 July, Kuala Lumpur, Malaysia
Saras Ramiya
There is a need for child to adult health-
care transition services that are safe
and eective for HIV patients, says an
expert.
Moving from pediatric to adult care, ado-
lescents may nd themselves decreasing theiradherence to medication, erratic appointment
keeping, loss of disease control and loss to fol-
low up, said Linda-Gail Bekker (Ph.D), dep-
uty director of the Desmond Tutu HIV Centre
and Associate Professor of Medicine, Univer-
sity of Cape Town, South Africa.
The Society for Adolescent Medicine in its
consensus statement in 2003 provided six crit-
ical rst steps for the transition from pediatricto adult care, besides other recommendations.
(Table 1)
The current denition of healthcare transi-
tion is the purposeful, planned movement of
adolescents and young adults with chronic
physical and medical conditions from child-
centered to adult-oriented healthcare sys-
tems. This is discussed frequently, but stud-
ied rarely, Bekker said.Barriers to healthcare transition include
inertia created by stability within the health
system; the pediatric provider may nd it dif-
cult 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 pa-
tients and their families may have a sense of
abandonment or loss of control in moving.
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
A specic healthcare provider to be identi-ed to help with the transition.
There should be core competencies withinthe adult services to which the adolescentwas transitioning.
When possible, a portable accessible medi-cal summary should go with the adoles-cent.
There should be detailed and preferablywrien down transition plans.
The same standards of health should beoered at both the pediatric and the adultservices.
Access to services including insurance
cover.
Table 1: Six critical rst steps for child to adulttransition in healthcare.
The plan should be made with the patientand family.
Specic conditions should have specicbest practices developed.
There should be more research on out-comes.
Additional recommendations
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12 September 2013 Conference Coverage
into adulthood. Most of them live in Sub-Sa-
haran Africa and Southeast Asia. [WHO, UN-
AIDS, 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 de-pendence on caregivers and pediatric health
services to adult HIV care systems that em-
phasize self-reliance and individual account-
ability for adherence.
With adult services perceived as intimidat-
ing and impersonal, there are reports of failed
transition with consequences of poor adher-
ence, treatment failure and loss to follow up,
Bekker said.
HIV is unique as a chronic illness becauseof 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
lile recognition of the need to transition ado-lescents to adult care in low- and middle-in-
come seings. Consequently, very lile pub-
lished data are available and systems to track
youth into adult care are inadequate, while
the evaluation of this process and its limita-
tions and successes are not being captured,
Bekker concluded.
Perinatally infected Sexual and injecting drug user transmission
Equal number of girls and boys. More girls than boys in Africa. More boys than girls
elsewhere.Younger. Older.
Developmental stunting. Treatment nave.
Have experienced treatment. Aware of status.
Unaware of status.
Table 2: Pediatric HIV patients.
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13 September 2013 Conference Coverage
Laws continue to marginalize key groups
of HIV patients
Saras Ramiya
R
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 work-ing actively to undermine HIV prevention
and treatment projects, says an expert.
We oen imagine ourselves as having
moved away from the politics of fear and dis-
trust 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 contin-
ues to marginalize and stigmatize key groups
who are infected by HIV designating them as
deserving blame for spreading the virus. This
has ramications for healthcare service and
delivery, she added.
Rather than create a legal and policy envi-
ronment that facilitates disclosure of HIV and
then destigmatizes having the virus, manycountries have laws that do exactly the op-
posite. 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 specically tar-
get people living with HIV.
The recent report of the Global Commission
on HIV and the Law found that over 60 coun-
tries worldwide criminalize exposure to HIV.
These laws have not been eective in prevent-
ing people from contracting HIV. They simplybecome a tool to further marginalize and stig-
matize 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, spiing and biting continue to
be treated as pathways for HIV transmission.
Worldwide, countries and jurisdictions
have promulgated HIV-specic criminal
laws eg, 27 countries in Africa, 14 countries
7th IAS Conference on HIV Pathogenesis, Treatment and Prevention, 30 June-3 July, Kuala Lumpur, Malaysia
Many countries have laws that undermine HIV prevention and treatmentprojects.
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14 September 2013 Conference Coverage
in Eastern Europe and Caucasus (EECA)
and 11 countries in Latin America follow the
NDjamena Model Law (2005). [Global Com-
mission on HIV and the Law, 2012. Available
at: www.hivlawcommission.org/ Accessed on15 August]
Harm reduction is another area that coun-
tries need to look at to reduce HIV trans-
mission. Harm reduction refers to policies,
programs and practices that aim primarily
to reduce the adverse health, social and eco-
nomic consequences of the use of legal and il-
legal psychoactive drugs without necessarily
reducing drug consumption. [Harm Reduc-
tion 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 re-
duction and punitive approaches eg, in Thai-
land and Russia resulted in HIV prevalence
of above 40 percent and 35 percent, respec-tively, among IDUs. [War on Drugs. Report of
the Global Commission on Drug Policy, 2011.
Available at: www.globalcommissionon-
drugs.org/wp-content/themes/gcdp_v1/pdf/
Global_Commission_Report_English.pdfAc-
cessed 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 eective and high quality
HIV care, treatment, and service programs,
and does not discriminate, stigmatize, and
marginalize the very people who need sup-
port and care.
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15 September 2013 Conference Coverage9th Asian Dermatological Congress, July 10-13, Hong Kong
Managing psoriasis beyond the skin
Jenny Ng
The future of psoriasis managementpoints toward a stratied individu-alized approach targeting therapies
to systemic and psychological factors oenoverlooked during treatment.
Psoriasis is not just a skin disease, said Pro-fessor Christopher Griths ofthe Universityof Manchester, England. Management of thewhole patient is paramount. Most cliniciansfail to look beyond the skin disease to bothidentify and manage associated conditions in-cluding depression, non-adherence, psoriaticarthritis and cardiovascular disease.
Evidence is accumulating on the link be-tween the severity of psoriasis and cardio-
vascular mortality. A recent Danish studyshowed an increased risk of atrial brillationand stroke, even in patients with mild psoria-sis. [Eur Heart J 2012;33:2054-2064] It is nowa question of whether early use of systemictreatments can prevent or reduce comorbidi-ties in psoriasis patients.
Good tools that can help identify variousaspects of psoriasis are necessary to guide
treatment. Recently, Griths and colleaguesdeveloped the Simplied Psoriasis Index(SPI) as a holistic approach to assess psoria-sis and beer understand the severity of thedisease. [J Invest Dermatol 2013;133:1956-1962]The SPI replaces the current PASI [Psoria-sis Area and Severity Index] scoring systemwith a composite weighted severity score de-signed to reect the impact of psoriasis aect-ing functionally or psychosocially important
body sites. In addition to current severity ofpsoriasis, it also assesses the psychosocial
impact of the disease and previous interven-tions.
Psychosocial aspects of psoriasis are im-portant for disease management and can bea signicant burden on psoriasis patients,aecting their adherence to treatment andoverall quality of life. To help patients copewith psoriasis, Griths and colleagues havedeveloped a new web-based cognitive be-
havioral therapy (CBT) program known asthe Electronic-Targeted Intervention for Pso-riasis (eTIPS), which is shown to signicantlyreduce anxiety and improve quality of life ofpsoriasis patients with similar results as face-to-face CBT. [Br J Dermatol 2013, e-pub Apr 1;doi: 10.1111/bjd.12350]
With increased understanding of psoria-sis as a disease involving both physiologicaland psychological aspects, a holistic approachof management will help improve patientsprognosis, Griths concluded.
Psoriasis management is not just about treating the skin.
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16 September 2013 Conference Coverage
Non-invasive body contouring: What works?
Christina Lau
With so many non-invasive bodycontouring devices available on themarket, choosing one that works
well requires some due diligence with respectto assessment of the scientic evidence as well
as other considerations.When evaluating a non-invasive bodycontouring device, we need to have proof ofecacy based on patient recognition of sig-nicant improvement, histologic evidence offat cell apoptosis, ultrasound or MRI conr-mation of fat reduction, and circumferencereduction for large treated areas, said Dr.Robert Weiss of the Johns Hopkins UniversitySchool of Medicine, Baltimore, Maryland, US.
Devices emiing dierent forms of radio-frequency (RF) are available for treatment ofthe abdomen, arms and legs. Unipolar RF isnot the most eective because the heating isless controllable, and there is less signicantpenetration to fat cells, said Weiss. Monop-olar RF provides deeper penetration than RF.However, bipolar RF can be used if skin tight-ening is desired because its thermal depth is
limited to a maximum of 8 to 9 mm.
To achieve skin tightening and fat reduc-tion with RF, it is important to sustain skin
temperature at about 42C for about 15 min-utes, because fat temperature is much lowerthan skin temperature, he advised. About85 percent of our patients respond to thisstrategy.
Using a dynamic monopolar RF device, an18 percent reduction in ultrasound-measuredfat thickness was achieved in the arm in pa-
tients with fat thicker than 2 cm, he added.More recently, non-thermal focused ultra-
sound has become available as the newesttechnology for non-invasive fat destruction.It provides immediate, selective and perma-nent fat cell destruction, and is safe and eec-tive for treatment of the abdomen, anks andthighs, noted Weiss.
In a study of 32 Asian patients who received
three sequential treatments with focused ul-trasound in combination with RF, reductionin MRI-measured fat thickness of 21.4 percentand 25 percent was found in the upper andlower abdomen, respectively. [Lasers Med Sci2013; e-pub Mar 24]
In Asians, results of body contouringtreatments tend to be less impressive due totheir smaller body size, thinner fat layer, anddierent dietary intake of saturated and un-saturated fat compared with Caucasians,said Dr. Henry Chan, president of the HongKong College of Dermatologists, at a pressconference held in conjunction with the con-gress. Fat thickness of 2 to 3 cm is requiredfor impressive results.
In clinical practice, accurate objective as-sessment of the degree of improvement isdicult, as patients are usually reluctant to
undergo MRI scans before and aer treat-ment, Chan added.
When evaluating a
non-invasive body
contouring device, we need
to have proof of ecacy
9th Asian Dermatological Congress, July 10-13, Hong Kong
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17 September 2013 Conference Coverage
Delusion a challenge in compulsive skin
picking
Jackey Suen
S
kin picking can be of psychiatric originthat requires a cautious approach as de-lusional patients have unshakable be-
liefs about the cause of their symptoms andare oen resistant to the idea of treatment, ac-cording to an expert from Canada.
Skin picking can result from a variety ofcauses, including underlying dermatologi-cal conditions, pruritus without rash, neu-rologic abnormalities, narcotic medications,drug abuse and psychiatric issues, said Dr.Simon Se-Mang Wong of the University of
British Columbia, Vancouver, Canada. Caseswith a psychiatric origin can be further cat-egorized into delusional and non-delusionaltypes, which require dierent treatment ap-proaches.
As delusional patients usually have un-shakeable beliefs about the cause of theirsymptoms and are oen resistant to the ideaof treatment, we need to suggest psychiatrictreatment with care, he advised. If the pa-tients are not ready for treatment, it may be
best to step away. Once they agree to starttreatment, we can prescribe antipsychotics.
Non-delusional patients are consciousof the self-induced nature of their skin pick-ing. The underlying causes are mainly de-pression, anxiety, or addiction-like picking orscratching, explained Wong. I would treatthese patients with a combination of psycho-
logical treatments and medications includingantidepressants, anxiolytics, and sometimes
low-dose antipsychotics, based on psychiatricdiagnoses.
He suggested using the Modied MiniScreen (MMS) tool to screen for depression,anxiety or delusion in patients presentingwith skin picking. Although MMS is not adiagnostic tool, it provides clues for physi-cians to decide how they should plan thetreatment.
However, other possible causes have to beruled out before a patient is diagnosed withskin picking of psychiatric origin, he added.Dermatologic conditions, such as lichenplanus and insect bites, are relatively easyto identify. For pruritus without rash, weneed to look at patients history and result ofphysical examination to decide if a full work-
up is needed to identify potential systemiccauses.
Skin picking can result from various causes.
9th Asian Dermatological Congress, July 10-13, Hong Kong
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18 September 2013 Conference Coverage
First-ever guidelines for the treatment of
non-transfusion-dependent thalassemia
18th Congress of the European Hematology Association, June 13-16, Stockholm, Sweden
Rajesh Kumar
O
ral therapy for iron chelation shouldbe initiated in non-transfusion-de-pendent thalassemia (NTDT) pa-
tients with liver iron concentrations (LIC) of>5mg Fe/g dry weight and maintained untilthey achieve levels below that threshold, ac-cording to the rst-ever guidelines for treat-ing NTDT.
Patients who achieve levels
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19 September 2013 Conference Coverage
Mini-hormone may tackle iron overload
18th Congress of the European Hematology Association, June 13-16, Stockholm, Sweden
Rajesh Kumar
Anew therapy may prove useful for thetreatment of iron overload disorders.
The cause of iron overload in dis-eases such as hereditary hemochromatosisand thalassemia is the deciency of the hor-
mone hepcidin, which regulates dietary ironabsorption and mobilization of iron fromstores.
Hepcidin deciency results in excessiveiron absorption from the diet and iron loadingof vital organs. This iron overload can lead toorgan damage and even death. Researcherssaid currently available iron chelation thera-pies are burdensome or cause side eects, cre-
ating the need for beer alternatives.Hepcidin replacement oers a potentialnew treatment for iron overload disorders.But natural hepcidin is dicult to synthesizeand has unfavorable pharmacological proper-ties.
By dening the minimal structure of hep-cidin that still retained the hormone activity,researchers developed mini-hepcidins, pep-tide mimics of the hormone, and engineered
them to improve their bioavailability and todecrease the cost of production.
Using hepcidin knockout mice as a modelof the severe form of hereditary hemochro-matosis, we demonstrated that mini-hepci-dins completely prevented iron loading ofmouse organs, said Dr. Elizabeta Nemeth ofthe University of California in Los Angeles,California, US, in a media conference.
In a mouse model of thalassemia, which ischaracterized by both anemia and iron over-load, mini-hepcidin not only prevented ironloading, but also improved anemia, said Ne-meth. Clinical trials in humans are scheduledto begin soon.
Mini-hepcidin not only
prevented iron loading,
but also improved anemia
Hepcidin replacement therapy oers a new, beer alternative to existingiron chelation therapies, say researchers.
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20 September 2013 Osteoporosis
UK osteoporosis group updates guidelines
Rajesh Kumar
The National Osteoporosis Guideline
Group (NOGG) in the UK has up-
dated 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 manage-ment of glucocorticoid-induced osteoporo-
sis, the role of calcium and vitamin D ther-
apy and the benets 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 modications 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 judg-
ment in the care of individuals in clinical
practice.
Women with a prior fragility fracture
should be considered for treatment with-
out the need for further risk assessment al-
though BMD measurement may sometimesbe appropriate, particularly in younger post-
menopausal women, according to the up-
dated guideline.
In the presence of other clinical risk fac-
tors, the 10-year probability of a major os-
teoporotic 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 predniso-lone (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 treat-
ment of glucocorticoid-induced osteoporo-
sis in postmenopausal women. Teriparatide
and zoledronic acid are approved for treat-ment of glucocorticoid-induced osteoporo-
sis in men and women at increased risk of
fracture. Bone-protective treatment should
be started at the onset of glucocorticoid ther-
apy in patients at increased risk of fracture,
they said.
The low cost of generic formulations of
alendronate makes them the rst-line option
in the majority of cases. In individuals whoare 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 terip-
aratide restricts its use to those at very high
risk, particularly for vertebral fractures.
Maintenance of mobility and correction of
nutritional deciencies, particularly of cal-
cium, vitamin D and protein, should be ad-vised.
Treatment with bisphosphonates should
be reviewed every 3 years in case of risedro-
nate, ibandronate and zoledronic acid and
every 5 years for alendronate to consider a
drug holiday. If treatment has been discon-
tinued, fracture risk should be reassessed
whenever a new fracture occurs or aer 2
years irrespective of a new fracture, said the
experts.
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21 September 2013 Osteoporosis
Calcium, vitamin D reduce hip fractures
in postmenopausal women on hormone
therapy
Angeline Woon
P
ostmenopausal women on hormone
therapy seem to have reduced risk of
hip fractures if they supplement with
calcium and vitamin D, nds a US studypublished online inMenopause.
Calcium and vitamin D supplements have
been widely debated before this and recom-
mendations are in conict, such as those
made by the US Preventive Services Task
Force (USPSTF) earlier this year that said
there is no basis recommending either sup-
plementation to prevent fractures.
However, a recent analysis of the WomensHealth Initiative (WHI) project showed that
calcium and vitamin D do help, particularly
for women on hormone therapy. The inter-
action was clear between hormone therapy,
and calcium and vitamin D on hip fractures
(p interaction=0.01). The eect of calcium
and vitamin D supplementation was stron-
ger among women who also took hormone
therapy (HR, 0.59; 95% CI, 0.38-0.93) com-pared 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 hor-
mones 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 hor-
mones at the same time had a synergistic
eect, as taking supplements alone did not
seem signicantly beer than taking no sup-
plements and no hormones.
The authors said the results suggest thatwomen on postmenopausal hormone ther-
apy 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 benets
increased as supplement intake went up. Forexample, women with dietary calcium that
increased their intake to greater than 1,200
mg daily beneted strongly. Similarly, di-
etary vitamin D led to greater benets, but
as the supplements were taken at the same
time, the individual eects could not be de-
termined.
Dosage recommendations depend on
keeping side eects to a minimum eg, toomuch calcium causes constipation.
The study was a prospective, partial-fac-
torial, randomized, controlled, double-blind
trial involving WHI postmenopausal partic-
ipants 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-
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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 in-
take in changes to hip or spine bone mineral
density.
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-
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23 September 2013 Diabetes
Individualized treatment in elderly
diabetes patients brings results
Angeline Woon
Astudy in Europe nds that seing in-
dividualized glycemic targets helps
elderly diabetic patients achieve bet-
ter HbA1c targets, with less complications.
Guidelines typically recommend seing
individualized targets to control type 2 dia-betes mellitus (T2DM) in elderly patients de-
spite the lack of evidence. The study aimed to
investigate if seing such targets will have a
positive eect, and was the rst to introduce
as well as show the feasibility of using indi-
vidualized HbA1c targets as an endpoint.
[Lancet doi:10.1016/S0140-6736(13)60995-2]
The study showed that patients with in-
dividualized treatment who received vilda-gliptin 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
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24 September 2013 Diabetes
HbA1c of between 7.0 percent to 10.0 per-
cent, and who were aged 70 years or older.
Treatment targets were individualized
based on age, baseline HbA1c, comorbidi-
ties and frailty status. Between December 22,2010 and March 14, 2012, a validated and au-
tomated system randomly assigned patients
to either vildagliptin or placebo. The co-
primary ecacy endpoints were deemed to
be the proportion of patients reaching their
individualized, investigator-dened HbA1c
target and HbA1c reduction from baseline to
the end of the study.
Strain added that though it was a smalltrial, the results were quite dramatic and is
the rst strong evidence that individualized
care makes a huge dierence to the lives of
older people with diabetes.
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25 September 2013 In Practice
Chemoprevention of breast cancer in
primary care
Dr. Wong Seng WengMedical Director & Consultant Specialist
in Medical Oncology
The Cancer Centre, a subsidiary of the
Singapore Medical Group
In 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 poten-
tial is largely overlooked and neglected.The population-at-risk for breast cancer is
large. In order for any breast cancer preven-
tion strategy to deliver signicant dividend,
the execution has to reach a fairly large popu-
lation. 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 chemo-prevention of breast cancer to the primary
healthcare scene by discussing three major
areas:
1. Clinical trial data that support chemopre-
vention of breast cancer as an evidence-
based approach;
2. Selection of patients who may benet from
chemoprevention;
3. Practical considerations in selecting treat-
ment 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 oc-
cur 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 gures represent a signicant
disease burden on our society.
Estrogens promote breast cancer forma-
tion in preclinical models and in women with
naturally high levels of the hormone. Inter-
ventions that target the stimulatory eects of
estrogens on breast tissue provide an oppor-
tunity to modify breast cancer risks. To date,
clinical trials have demonstrated the ecacyof tamoxifen, raloxifene and exemestane in
reduction of the incidence of invasive breast
cancers.
Tamoxifen and raloxifene are selective es-
trogen receptor modulators (SERMs) that
exert an anti-estrogenic eect 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 test-ed in both pre- and postmenopausal women
while raloxifene has only been tested in post-
menopausal women. Tamoxifen is compara-
tively more ecacious than raloxifene.
The concerns over the use of SERMS are
the associated increase in the risk of endome-
trial cancer and thromboembolic complica-
tions such as deep vein thrombosis. However,
the risks of such serious complications are
low and remain well below 1 percent. In this
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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, exemes-
tane 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 ofexemestane include the increased loss of bone
mass and a relative short period of follow-up
in current clinical trials. Chemopreventive tri-
als using other AIs are in progress.
The American Society of Clinical Oncology
(ASCO) guidelines last updated in 2009 rec-
ommend the use of tamoxifen and raloxifene
for breast cancer chemoprevention. The Na-
tional 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 pa-
tients 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-si-
tu, 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 per-
cent over 5 years;
4. Women with known BRCA1 or BRCA2
mutations who do not opt to undergo pro-
phylactic mastectomy.
Patients in categories 2 and 4 should be
considered for referral to a specialist for as-
sessment due to higher associated risks and
the need to explore management options oth-
er than chemoprevention.
Practical considerations
Women who t the above criteria for in-
creased risk of breast cancer may benet from
chemoprevention.
For premenopausal women and postmeno-
pausal women who have undergone hyster-
ectomies, 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 trade-
o between the higher anti-cancer ecacy 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 ecacy when compared with SERMs
and a lower risk of endometrial cancer andthromboembolic 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 popu-
lations, the risk of breast cancer in Singapore
should not be ignored. There are many thera-peutic clinical trials on varying diseases upon
which Singapore doctors base treatment deci-
sions for the local population.
The increasing awareness of the threat of
cancer has raised anxiety amongst Singa-
poreans. Many are looking for non-evidence
based strategies of cancer prevention like
health supplements and folk recipes. It is time
the medical community oers them an evi-
dence-based option.
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Professor Nimish Vakiltalks about management o patients withreractory GERD.
Successful treatment of refractory GERDrequires thorough investigation of the patientsituation.
Professor David Liebermanshares his perspective on the present anduture o colorectal cancer screening.
There is a lot of potential to preventmany cancers if we can improve the rateof CRC screening.
Dr Markus Cornbergdiscusses the management o chronichepatitis B.
The aim of therapy should be the cureor control of HBV infection without theneed for life-long treatment.
In this Series, fnd out what these medical experts have to say about latest
updates in the management o reractory GERD, the management o chronichepatitis B and the present & uture o colorectal cancer screening.
Current Opinion in
Gastroenterology
SCAN TO WATCH VIDEO
Brought to you by MIMS
MIMS Video Series eaturesinterviews with leading experts.
Got a spare 5 minutes?Go towww.mims.asia/video_series
BY DOCTORS
FOR DOCTORS
-
7/27/2019 Medical Tribune September 2013
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28 September 2013 Calendar
SEPTEMBER
European Respiratory Society Annual Congress
7/9/2013 to 11/9/2013Location: Barcelona, Spain
Info: ERS 2013 c/o K.I.T. GroupEmail: ers2013registration@kit-group.orgWebsite: www.erscongress2013.org
London College o Clinical Hypnosis Asia
Certifcate in Clinical Hypnosis (UK University
accreditation)
21/9/2013Location: SingaporeInfo: London College of Clinical Hypnosis SecretariatTel: (65) 6809 2238 / 6557 2248Email: info@hypnosis-singapore.com
Website: www.hypnosis-singapore.com
Asian Pacifc Digestive Week
21/9/2013 to 24/9/2013Location: Shanghai, ChinaInfo: APDWF SecretariatTel: (65) 6346 4402Email: congress_international@gastro2013.orgWebsite: www.gastro2013.org
21st World Congress o Neurology
21/9/2013 to 26/9/2013Location: Vienna, AustriaInfo: Kenes InternationalEmail: wcn@kenes.comWebsite: www2.kenes.com/wcn/Pages/Home.aspx
49th Annual Meeting o the European Association
or the Study o Diabetes
23/9/2013 to 27/9/2013Location: Barcelona, SpainInfo: EASD SecretariatEmail: registration@easd.orgWebsite: www.easd.org
13th Asian Federation o Sports Medicine
Congress
25/9/2013 to 28/9/2013
Location: Kuala Lumpur, MalaysiaInfo: AFSM OrganizersEmail: 13afsm@gmail.comWebsite: www.13afsm.com
National Skin Centre Dermatology Update 2013
26/9/2013 to 28/9/2013Location: SingaporeInfo: Mrs. Alice Chew, Conference Secretariat, NationalSkin Centre (S) Pte LtdTel: (65) 6350 8405Email: training@nsc.gov.sg
Website: www.nsc.gov.sg/showcme.asp?id=149
Primary Care Forum 2013 and the 4th Singapore
Health & Biomedical Congress 2013
27/9/2013 to 28/9/2013Location: SingaporeTel: (65) 6496 6684 / (65) 6496 6682Email: secretariat@pca.sgWebsite: www.pca.sg/events
European Cancer Congress 2013 (ECCO-ESMO-
ESTRO)
27/9/2013 to 1/10/2013Location: Amsterdam, NetherlandsInfo: ECCO SecretariatTel: (32) 2 775 02 01Fax: (32) 2 775 02 00Email: ecco@ecco-org.euWebsite: eccamsterdam2013.ecco-org.eu
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29 September 2013 Calendar
OCTOBER
Taiwan Digestive Disease Week 2013
4/10/2013 to 6/10/2013Location: Taipei, Taiwan
Info: Congress SecretariatEmail: service@tddw.orgWebsite: www.tddw.org
7th International Congress o the Asian Society
Against Dementia (ASAD)
10/10/2013 to 12/10/2013Location: Cebu, PhilippinesInfo: Dementia Society of the PhilippinesTel: (632) 749 9707Fax: (632) 740 9725Email: secretariat@dementia.org.phWebsite: www.dementia.org.ph
13th International Workshop on Cardiac
Arrhythmias - Venice Arrhythmias 2013
27/10/2013 to 29/10/2013Location: Venice, ItalyInfo: VeniceArrhythmias 2013 Organizing SecretariatTel: (39) 0541 305830Fax: (39) 0541 305842Email: info@venicearrhythmias.orgWebsite: www.venicearrhythmias.org
UPCOMING
9th International Symposium on Respiratory
Diseases
8/11/2013 to 10/11/2013
Location: Shanghai, ChinaInfo: MIMS, ChinaEmail: secretariat@isrd.orgWebsite: www.isrd.org
18th Congress o the Asian Pacifc Society o
Respirology
11/11/2013 to 14/11/2013Location: Yokohama, JapanInfo: APSR 2013 SecretariatEmail: info@apsr2013.jpWebsite: www.apsr2013.jp
8th World Congress on Developmental Origins o
Health and Disease (DOHaD 2013)
17/11/2013 to 20/11/2013Location: SingaporeInfo: DOHaD 2013 Congress SecretariatTel: (65) 6411 6692Fax: (65) 6496 5599Email: secretariat@dohad2013.orgWebsite: www.dohad2013.org
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30 September 2013 After Hours
Japans Cultural H eart
K Y O T OMonika Stiehl
The curtain rises. Dressed in a light blue
kimono covered all over with white
owers, the Maiko stands stock-still,
with head held low, turning her back to the
audience. Then the music starts. In accor-
dance with the smooth tones of the Koto,the Japanese harp, the Maiko gently begins
moving, rst elegantly her ngers and arms,
then turning to face the audience, raising the
head. The face covered with white make-up,
the lips painted aming red and the coal-
black hair artistically towered, she looks like
a piece of art.
We are in Kyoto, the cultural heart of Ja-
pan, watching the Kyomai, the so-called tra-ditional Kyoto Style Dance, performed by
a Maiko, an apprentice Geisha. Her dance
tells the melancholic story of the life of Mai-
kos 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 entirestructure. It takes its name from the mirac-
ulous waterfall within the complex, which
runs o the nearby hills. The name Kiyo-
mizu 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 Shrinepossesses a pair of love stones placed 6
meters apart. You can try to walk between
them and its said that you will nd 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
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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-no-
michi (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
inuential philosophers of the 20th century
Nishida Kitaro who is said to have prac-
ticed meditation while walking along it each
day to Kyoto University.
Aer all this mental food, a visit to Nishi-
ki market will provoke your appetite for real
food. Known as Kyotos Kitchen, this tradi-
tional food-market is vibrant, full of activity
and Japanese delicacies such as prawns with
teriyaki mayonnaise and stued octopus
heads served on a stick.
Kyoto has oen 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 cul-
tural heart. You will also nd graceful Gei-
shas and Maikos gliding around the corners
of the narrow streets of Gion, dressed in tra-
ditional 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 an-
cient Japan. And aer that, food markets full
of Japanese specialities will bring you sud-
denly back to the present.
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32 September 2013 Humor
There is no reason why you shouldnt be able to live a perectly normal lie,so long as you dont try to walk, run or eat solid oods!
The nurses are saying you are
not swallowing your pills!
Have you considered going
to a tennis court rather thana ood court?
A recent study has concluded that studies may behazardous to our health!
Are you perormingthe surgery?
The nurse in training will bewith you as soon as she isfnished catheterizing the
patient next to you!
This is the partI dread the most!
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7/27/2019 Medical Tribune September 2013
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Medical Tribune is published 12 times a year (23 times in Malaysia) by
MIMS Pte Ltd. Medical Tribune is on controlled circulation publication to
medical practitioners in Asia. It is also available on subscription to members
o allied proessions. The price per annum is US$48 (surace mail) andUS$60 (overseas airmail); back issues at US$5 per copy. Editorial matter
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expressed are not necessarily those o MIMS Pte Ltd. Although great
eort has been made in compiling and checking the inormation given
in this publication to ensure that it is accurate, the authors, the publisher
and their servants or agents shall not be responsible or in any way liable
or the continued currency o the inormation or or any errors, omissions
or inaccuracies in this publication whether arising rom negligence or
otherwise howsoever, or or any consequences arising thererom. The
inclusion or exclusion o any product does not mean that the publisher
advocates or rejects its use either generally or in any particular eld or
elds. The inormation contained within should not be relied upon solely
or nal treatment decisions.
2013 MIMS Pte Ltd. All rights reserved. No part o this publication
may be reproduced in any language, stored in or introduced into aretrieval system, or transmitted, in any orm or by any means (electronic,
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and have no infuence on editorial content or presentation. MIMS Pte
Ltd does not guarantee, directly or indirectly, the quality or ecacy o
any product or service described in the advertisements or other material
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Philippine edition: Entered as second class mail at the Makati Central
Post Oce under Permit No. PS-326-01 NCR, dated 9 Feb 2001. Printed
by KHL Printing Co Pte Ltd, 57 Loyang Drive, Singapore 508968.
ISSN 1608-5086
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