Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Tue, 12 Dec 2017 09:20:03 -0500 (EST)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNyhnBHBdsouoYCiRNGOFVOIFVxdgPpdroecoD_9E1frLxnCyGQv6efuqUf8hdq49si46Lo0ndV6i8A3PtycLGAUhNLVCxPaXlCurmMPDCZcN9OJgQX1noIQ7yGngZjVS55aMMeJFwpioL&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
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The Fickenscher Files, Vol. 5, Issue 11
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNyn5xrisvl_Roq_4cKU6Iz9Gl7AmNg3doym2GReenhWvcAn5OrBL3v_MBY1XtPlFs4pO8RBNEGHGP6Y1VhDVKbrG0Q40Ai4WML9Vzp-U77qImPt5pDAlHgd8NP3eK5oC8MqdI48dZFRiPVihkw_5HTrspixavC_i8Ow==&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==],
MD, CPE, FACPE, FAAFP
@MDKev
A compilation of information, thoughts, and perspectives on the issues of the day
related to healthcare, technology, and beyond - including the latest culinary explorations.
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Quote(s) Of The Week
"For as long as there have been humans on Earth, it seems we have struggled with
 the problem of unity and diversity. The dualistic mind, which most of us were taught
to emphasize, is incapable of creating unity. It "smartly" divides reality into 
binaries. It cannot help but choose sides."
Father Richard Rohr, in comments on the First Sunday of Advent about the need for
coming together among the religions
"In Mayberry, there was no illness. There was no war. There was no violence. There
was no graffiti. We all had a good time, and we laughed a lot."
Jim Nabors, on why "The Andy Griffith Show" was so popular in its era.  Our friend
growing up, Gomer passed away last week...
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Consulo Indicium
Information for your Consideration...
Another Cup Of Joe, Please - You can imagine how excited I was when I read that 
a group of researchers reported that caffeine can block some of the effects of UV
radiation.  First, a little education. UVA [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSiIFnasMDIlidUifP_lYfjlRdNn-WbkqkYPpjzCrbwvKG0BO9SzERt8qpyxaL8SgynoCwwQsiHDjgSyoa_jUndQsJ9FyNNq6zqN7LqrhB5cHMkOgHvA7Qmf9DiFAaR4_XgMPeyG9x0vru6lzgfwQ0Bg==&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
or, ultraviolet A (long wave) rays tend to penetrate the skin quite deeply and affect
the dermis or, the layer below the epidermis.  These are the types of waves that
 case the skin to become wrinkled and aged. UVB [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSiIFnasMDIlidUifP_lYfjlRdNn-WbkqkYPpjzCrbwvKG0BO9SzERt8qpyxaL8SgynoCwwQsiHDjgSyoa_jUndQsJ9FyNNq6zqN7LqrhB5cHMkOgHvA7Qmf9DiFAaR4_XgMPeyG9x0vru6lzgfwQ0Bg==&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
or, ultraviolet B (short wave) rays generally only end up penetrating the epidermis
or top layer of the skin and are known to be the major factor in the cause of skin
cancers.  So, what does this have to do with coffee?  A new study was reported in
the International Journal of Cancer [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSyGYbFJfqMaab0V2ijJK71t_kxuTnICV3ccvOT3t0-4FT3qYuXi5u4Qi0Dxmqp8pS20-AC6k8VZc5ninl8rVPQ1my_t_ypvx6rHxC0h8kh3hN6043dplcobjHaG7Gv7EpTPDi1AnmFXRwwzSrx71O8XMu_tPStkg4mCkzLiLtq3w7JmRkpMKAv_Hemumxo-zybpoiify1ip5nV7b7UZPzFNL18UgObtcPLLyEPE5vXca6etGZ4T9qiQ==&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
that found the regular consumption of coffee could significantly lower men's risk
of skin cancer.  The researchers claim that drinking coffee [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYShIm_TiVfCyfYc1Czv05I96SHsN_nQzG_aBHMyvkTcN3B6WdlZ_jG-zWCf0RqJEluzzZZdL2O4aWJGSAFLcgoiUXglvvC2XjWsKPp-fd-6CFQZMpSzLbiYtjE8SoPGf8e&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
could, in fact, have one major health benefit for men. The researchers studied over
500,000 people to uncover the link between a standard old cup of Joe and skin cancer!
 And, the results were not just by a small margin.  In fact, the men who drank caffeinated
coffee were 70% less like to develop melanoma (one of the most lethal forms of skin
cancer).  Now, that is protection!!  What is not well understood is why?  Women 
and decaffeinated coffee drinkers did not have the same reduction in risk.  The 
contributions of coffee to health are quite remarkable.  Not only has it now been
shown to reduce skin cancer in some people (i.e. men), it also has been found to
 help your body burn off its fat layer, reduce the symptoms of Parkinson's disease,
keep your brain healthier for longer and reduce the risk of developing Type 2 diabetes.
 Now this doesn't mean you can stop using the sunscreen.  It does mean that a double
shot latte with 100+ SPF sunscreen fosters an extremely low chance of skin cancer.
 So, don't worry about your coffee intake.  Just apply sunscreen...
The Coming Age of Robotic Medicine - I've been a big proponent on the use of artificial
intelligence and machine learning as a core capability for enhancing health care
 delivery.  In fact, I've dubbed the use of these technologies as "clinically augmented
intelligence" on the notion that the technology will assist clinicians in making
 decisions better, faster, more efficiently.  And, I still hold to that premise.
  But, earlier this month, the Chinese medical robot - Xiaoyi or, "little doctor"
[http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSqJ6ijkdJDqsHsG_ejyEsWpKR7cGqyy3LU4R1NzeLRZ2PVHzE3UfgNl3dlFNtblJrrwGiiV10d7vpSDMu_ZJW_vV26VGMUm0tyXpHqCnelIm5uJAQjzEg42Lj_vY-cub0rUUZmx5bnnCqy-4JC-6aYEj_xnLjZG2z5fG5F-qUM6tcpRw6NPl_bl9LwVkq6HFJ&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
- accomplished something that some physicians fail to achieve.  The "robot" received
a passing score of 456 on the Chinese medical licensing examination where only 360
out of 600 is needed.  The robot uses machine learning to link natural language 
processing with information derived from medical textbooks, medical records and 
journal articles.  But, the docs don't have to worry yet.  The robot has only learned
to pass the medical examination.  It still can't talk with people, hold their hand,
administer medications, perform surgery, do procedures or essentially take care 
of them.  Aside from that; however, the technology could clearly "augment" the clinician.
 It's the type of capability that I predict will be ubiquitous over the next 10 
years (or, sooner) in healthcare - just as radiographs, pathology slides and other
technical support systems are in place today.  Note that the robot did not get a
 perfect score.  It fell down when it had to review actual patient cases and integrate
information with actual case presentations.  Now that is a real doctor...
Coming In At #5 - Telehealth - The Cleveland Clinic conducts an annual listing of
the top innovation for the year.  The Top 10 Medical Innovations for 2018 [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSsjzPnrBquvXqnJi0ncMTJGcZRYNMKEuQQ_8E11b0A6Bxnv7L8hCtAN-EB68qy746suXcR5Jn9d5hgLiIw1m1q1WCGSAjW3e83RwJ_qQGJT1Mkrg9OhmMXXsIRbNVzep0WtQrUl-M-4_ENFk5qXykv0NurcMrXqpJs8uvYFHy8zDll1Iplueen4ehhUs0o_-b1x4UTmk75_o=&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
touted telehealth as its "#5" on the list noting that there are now 7 million regular
users of telehealth services - a 19 fold increase from 2013.  In addition, over 
19 million users are involved in using remote care management devices.  Furthermore,
several recent surveys have shown that the overwhelming number of health care delivery
organizations are involved in developing telehealth programs.  Coupling the users
with the remote devices with the providers of health care seems to be a logical 
next step.  In fact, it is an area that is replete with possibilities for further
development.
Failing By Falling - According to the Centers for Disease Control and Prevention
 [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSjpVe3AQOjdi1ZHXW4wpVUL8s0U-GJlL783IbLk4WlK0duSV9FAB25mBOxlvyeOPdnON7wc29g4wLhDLo4p5rn7IZ64UELt7ArIm_9-Haazg=&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==],
the contribution of falls to the demise of our elder citizens is one of the biggest
overlooked problems in health care.  Falls are one of those incidents that affect
one in three older adults each year - or, a $31 billion dollar cost problem for 
our nation's Medicare program! In 2014 - the latest year for which good data is 
currently available - there were more than 2.8 million people over the age of 65
 whose falls were treated in emergency rooms across the nation.  Of those elders,
800,000 were hospitalized and 27,000 died from the falls.  In fact (scary statistic),
falls are the leading cause of death among adults over 65 and the death rate has
 been increasing over the prior decade.  Now for the policy impact. In 2014, the
 elders represented about 14% of the USA population or 46 million people.  By 2030,
the number of elders will grow to more than 20% over the age of 65. So, the financial
and social impact of falls will balloon over the coming decade. Why?  It relates
 to balance and mobility.  Researchers at the Institute for Aging Research [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYScptZqfpMaFRHrQSZrfKlXKF5Y7P3HrXv0rkcM8ihRcjQ6NA7Zi8Z7o5fbT02UCAdul41V0MxfS0yJaxs1nmuf--AGyGR1D92ui-_4cBqW5J41z8GlfsNWVh8mSJSq5InSvY_r2aCAo4=&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
have been studying the issue and how to foster prevention for more than 30 years.
 They recently reported on a new finding that - on the face of it - makes a lot 
of sense.  Tai chi is being used in a study by the Institute in an effort to enhance
balance and improve mobility among elders.  What they have discovered is that in
 addition to improving balance, flexibility, and mental agility, the exercise program
involved in Tai chi also reduces the incidence of falls.  The researchers have noted
that adherence to the programs enhances the elder's muscular control, coordination,
equilibrium, and also improves brain function. The idea of using Tai chi to deal
 with a major, major problem seems simple.  And, it is!!  It's so simple and it's
easy.  So, I'm on it...
Getting The Right Care At The Right Time - Since I'm blogging about elders, let 
me point to another study by The Commonwealth Fund.  They recently reported out 
their annual International Health Policy Survey which compares the experiences of
elders across various countries including Australia, Canada, France, Germany, the
Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the
USA.  The survey is now in its 20th year.  The disturbing results from the USA respondents
were that 23% of the USA elders cited costs as the reason for not seeking care with
a physician when they were sick, for not filling a prescription or skipping a dose,
or for not obtaining a recommended test or medical treatment. In France, Norway,
 Sweden, and the United Kingdom that figure fell to 5% or less.  Another contributing
factor was that one in four USA elders (22%) spent more than $2,000 in out-of-pocket
expenses for health care last year versus only 10% in all of the remaining countries
except for the Swiss.  In Switzerland, 31% of the seniors reported spending more
 than $2000 in health care expenditures.
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Future Health
Delivering care in the new virtual world...
"Virtualist" Health Care - For the last several years, I've been giving talks about
the use of technology in health care and promoting the notion that we need to develop,
support and train "Healthcare Virtualists".  So, at the urging of a number of colleagues,
I worked with a couple of like-minded individuals to develop an article on the subject
which we dutifully submitted to the various journals.  Unfortunately, we were pre-empted
by an article in the JAMA Network on the promoting the idea of creating a new specialty,
the "Medical Virtualist [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSRMa4w2z73Mc52pSxWJl5Meeq7NQNrhST4nNQFNodc3ZN2GA0Gry6ninLwpNna6ZvPkRS4ujaaYsXs4WYZRA6QwXQRSF0WMAeJrdZTO2rw03dzVRZmL-8mCDmB-oO5gzJj566MImgI1KAgu6RxzErDAAegRI5084u&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]".
 I agree and disagree.  On the notion of "virtualist", I absolutely agree.  We need
to develop criteria, training, educational requirements and the like to support 
this very important addition to medical and health care practice.  On the notion
 of "medical", I absolutely disagree.  Some element of virtualist training should
be a requirement for all clinical specialties (i.e. physicians, nurses, pharmacists,
medical social workers, psychologists, etc.) and all clinicians should have the 
opportunity to become specialists in the use of virtual care delivery.  It is not
a physician only specialty.  On the whole, a very important topic.  Read the JAMA
article.  I've obviously got more to say on the topic but, I'm submitting yet another
article J.  More later...
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The Weekly Whisk
Musings from a foodie...
We recently had the opportunity to visit Kyoto, Japan - a wonderful city and far
 better than the "pass through" city of Tokyo.  First, there was one consistent 
observation about Kyoto - it was about the traffic.  The majority of vehicles on
 the road are clearly hybrid because it was incredibly quiet even when there was
 substantial traffic.  Second, it's a very walkable city with a very large number
of temples from various Asiatic religions.  It is quite the city!  Then, there is
the food...
Our first visit was to Higashiyama Nijo Nanahachi[ * * * * *], a boutique restaurant
that offered up seafood as their specialty which they did with aplomb.  The head
 chef was "Bab Kinji" who was assisted by "Hara Ketivo".  The restaurant opened 
in 2011.  What was interesting is that the two of us were the only patrons that 
evening.  We were told that our weekend in Kyoto was one of the slowest of the year
because it was the week before the height of the change of colors - a major event
in Kyoto.  The dinner started with a shashimi of sea urchin, bonito tuna and sea
 bream served with a wonderful flow (= "perilla") and freshly grated wasabi.  This
was followed by red horsehead (a local fish) served with tofu of steamed wheat flour
and mushrooms.  The third dish was a smoked sea bass - cooked to perfection - with
sea salt and lime sauce on the side but, we never made it to the sauce.  The bass
was outstanding.  The fourth setting was taro accompanied by salted fruit from the
ginko tree, which looked like a small grape but tasted like a chestnut with a bean-like
flavor.  From there the menu continued with all variety of seafood, seafood broth,
miso and very special rice which was harvested from only two fields near Kyoto. 
 The finale was a perfect (my description) pear and grapes.  The only downside was
the use of plastic glasses.  The food was outstanding with only the occasional misstep
and the banter with the chefs offered up a perfect evening.  The place deserves 
more than two patrons in an evening; however, so I heartily recommend if you get
 to Kyoto - check it out!! Higashiyama Nijo Nanahachi - 7-8 Okazaki Tokusei-cho,
 Sakyo-ku, Kyoto, Kyoto - https://savorjapan.com/0006065085/map.php - 075-771-7168
[http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSRTb4li5EHH0lm6fcNzB-kws15lSMFT8tz80QIt9orifpyNdDu4Sa98qWl-59unbJ5VLbcS3YMMZ9cNIPiAJV0aZ4D-pOEQnXXfZKomqStBbs9PvorNYQxdJbXUjnddSenPU51o8P3wRo3CSi32zA3-2b8EW0PTfUB0gSn5RV5YM=&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==].
The next night was dedicated to checking out a traditional Japanese steakhouse. 
 We were able to secure a seating at Askyia[ * * * * *], - the "oldest" traditional
steakhouse in Kyoto.  It was started nearly 65 years ago by Tokiko, the 86 year 
old patroness of the restaurant.  She was more than delightful.  In fact, our discussions
with her - throughout the evening - were the highlight of the visit.  The dinner
 started by first finding the place J.  It was located down a back area pathway 
off of a quiet street in a neighborhood with few signs.  Even the taxi driver had
a hard time locating the place.  The evening started with a tour of the top floor
where we experience a review of the picture gallery of famous types who had visited
the restaurant.  It included Bill Clinton, Barack Obama, both Bush I and Bush II,
Harrison Ford, Tom Hanks and various other movie stars, a bevy of industrial icons
and miscellaneous others.  She committed to hang my picture if I sent one (so far,
I've demurred).  Following the picture gallery, there was a review of the picture
and sculpture gallery of various local artists.  We then started dinner in a classic
steakhouse fashion with a salad of egg tofu with crab and a 1000 island-type dressing.
 This was followed by drunken chicken which had been marinated in sake for at least
24 hours.  Then, we got down to business - steak!!  It was Japanese Waygu steak 
which was incredibly tender and bit more fatty than its American counterpart and
 rich in flavor.  The steaks were cooked to perfection and served with Okido potato,
garlic chips, Japanese eggplant and - of course, tea!  It was a fabulous dinner 
but the real experience was our constant companion - Tokiko.  Again, there were 
only two of us in the restaurant for the entire evening and so we received her full
attention. It was one of "must do" Japanese experiences.  There was no "show" - 
which was one of the best parts of the experience.  The "show" was replaced by talking
with Tokiko and, she was fabulous!  The ending was green tea ice cream served with
grapes soaked in Mandarin orange juice. Check it out: Ashiya Steakhouse and Gallery
- 172-13, 4 Chome Kiyomizzu Matsubara - Higashiyama-ku - Kyoto 605-0862 Japan +75
541-7961.
Finally, on the food front - we fell in love with Yatsuhashi (&#x516b;&#x30c4;&#x6a4b;
or &#x516b;&#x6a4b;) is a Japanese confectionery which is evidently mainly sold 
a sweet morsel (miyagegashi [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSyBJ_pbz8Y_SbNCj5W_TU_mTOmnRYL2OYBDinjRseoPpznm1y1MFsEfE9zFAqpQSD1LBffGSbxI_oUNZLK-rh0Zhm8pBojjknTL37c_tyLDdDBr3N0jLc0we5h5VX6niyrHzBJukl6c0=&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==])
for tourists. It is one of the best known meibutsu [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYS29kZmOdmHXK3U7S3adGRV8BU7gAOKCWK-ViaZ2LpngOpciVoxlWfYiEbawNzBkzIEXhxI-ZPHOJvzqigdYx5Eyp4tabjsbVuF9wUFYUP9QKtuuNAynpE9hf9NObwZUXg&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
(= famous regional products) of Kyoto. It is made from glutinous rice flour (&#x4e0a;&#x65b0;&#x7c89;,j&#x014d;shinko),
sugar and cinnamon. Our favorite was the raw, unbaked version (Nama yatsuhashi) 
which has a soft texture cut like a ravioli serving and is often eaten wrapped around
red bean paste [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNysrYsipZwlYSEI_M1JWRoLyHOKVwN6oT-9-f0X-jA_3cX3ctcHtaLMOu4CcMz-7lwKVEy7MZQhSCU0VmBYDnE1Qt3lJVovwdIAfr9ktPD-jYNk526pe_8J6MytbbvpwFaBTruhpxholxcUpZ_ELyKic=&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
(&#x9921;,an).  My favorite; however, were the chocolate and strawberry versions.
Oh la la...
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - The involvement of Condoleezza Rice (Former US Secretary of State in
 the Bush II Presidency) and Senator Richard Shelby (R-AL) both of whom came out
 in favor of a write-in candidate - even if it means losing the seat - rather than
accepting the current Republican candidate in the Alabama Senate race. They showed
character, principles and ethics...
The Good - Doug Jones appears to be pulling ahead in Alabama...
The Bad - A pedophile in the US Senate?  Come on people...
The Ugly - The expediency on the need for "another vote" as the defining reason 
for supporting the Republican candidate in the Alabama US Senate race...
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001f0oPr0KsnhLOct27MdcZ_t-TzDyDhPAHK0RxK_JmoOf1aGvvunzNyhnBHBdsouoYCiRNGOFVOIFVxdgPpdroecoD_9E1frLxnCyGQv6efuqUf8hdq49si46Lo0ndV6i8A3PtycLGAUhNLVCxPaXlCurmMPDCZcN9OJgQX1noIQ7yGngZjVS55aMMeJFwpioL&c=jLt8JIQ_cA2IiW5LMUYSbNonpRRGMKYFVdZaFRulQQ1SUhgy6J8PwQ==&ch=xCBJvBLTL7Mp7TvTGIVT6ZmSvTNt86-kp5S6rmUDDAGSrVPUpc5UPA==]
are the personal views of Kevin Fickenscher, MD and do not reflect the views or 
policies of any organization with which he is affiliated.
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The Fickenscher Files | PO Box 840 | Kittery | ME | 039