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Pulsatile Tinnitus: One Patient’s Quest to End Ominous Ringing in Her Ear

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Talking with patient Alla and UCSF Radiologist Dr. Matt Amans about this case was one of the highlights of my year. It demonstrates what can happen when someone finds the right resource at the right time.

 It started with a small but persistent noise in her right ear.

Alla and Sergei pose while hiking at the Sea Ranch in Sonoma County, California.

Alla and Sergei pose while hiking at the Sea Ranch in Sonoma County, California.

 

The noise seemed in rhythm with Alla’s heartbeat. Within a month, it seemed more related to her heart than ever—the noise transformed into a clamorous “whoosh” with every beat. Far beyond annoying, the noise was disturbing, even debilitating. Activities like reading and watching TV were suddenly difficult, at times impossible. The noise often prevented her from falling asleep, and broke her sleep when it didn’t. 

Born and raised in Moscow, Alla arrived in the Bay Area in 1992 for a career in civil engineering. She quickly made new friendships, enjoyed hobbies like traveling, skiing, and pottery, married the love of her life, Sergei, and eventually became mother to their two boys. Family life was going along quite well for Alla, until June 2015.

That’s when the noise started. She began two-months of nearly nonstop diagnostic imaging and medical appointments, but no one could identify the source of the noise, much less suggest how to stop it. 

By July’s end, Alla was in survival mode. She and Sergei were desperate to find solutions.

Finally, thanks to Alla’s primary care physician, otolaryngologist Dr. Lloyd Ford, and nerve specialist Dr. Ziv Peled, she was referred to the UCSF Pulsatile Tinnitus Clinic. The clinic is co-directed by Drs. Matthew Amans and Karl Meisel from the departments of Radiology and Neurology, respectively. Images taken during her prior medical exams allowed Dr. Amans to quickly inform Alla she had a dural arteriovenous fistula (DAVF) in her right sigmoid sinus.

“No one could read the MRI the way Dr. Amans could,” explained Alla. 

“DAVF is a very rare abnormal connection of vessels surrounding the brain,” said Dr. Amans. “It happens where several arteries connect directly to a vein or venous sinus.”

Arteries are high-pressure vessels that carry blood from heart to tissues, while veins are vessels that take blood back from tissues to heart. They are especially sensitive to pressure changes. With DAVF, the direct connection between one or more arteries and the vein or sinuses pressurizes cerebral veins and can lead to stroke.

Surgery to treat Alla’s DAVF was scheduled within a few days of diagnosis. The nine hour procedure was performed by Dr. Amans and his team, including several experienced neuro interventional radiologists, anesthesiologists, technicians, and nurses. “Dr. Amans was direct, but reassuring. He was very optimistic, which gave me a lot of strength,” added Alla. 

“After waking up, I remember there were people talking to me, checking my vitals and smiling. ‘That’s a good sign,’ I thought. But the best part was yet to come. When everybody left the room, it felt different, like something I’d been missing for a long time: It was quiet,” recalls Alla. “There was no whooshing or pulsing sound in my ear anymore. I was scared to move and discover it again, so I turned my head a little to the right, a little more, then to the left, and a little more, and the sound didn’t come back. I couldn’t help myself, so I kept doing it and couldn’t stop smiling. Nurses were probably wondering what was going on, but it truly was the best feeling ever. I was cured. It was quiet!”

Only later did Alla learn about the complexity of the surgery, which consisted of three hours of detailed angiographic mapping of the complex network involved and six hours of embolization procedure. It went smoothly but took time, and required an enormous amount of concentration and skill operating extremely sophisticated equipment. 

“I am very thankful to the UCSF Pulsatile Tinnitus Clinic and personally to Dr. Amans, and his fellow Dr. Darflinger, for taking such good care of me. They didn’t just perform state-of-the-artendovascular surgery, but also spent hours talking to me and Sergei and helping us deal with the absolutely unexpected and unreasonable condition of DAVF,” explained Alla. “I owe so much thanks to Sergei’s kindness and patience. And kudos to the medical team and each of the individuals including the office staff, Yuen and Hanh, who were accommodating, understanding, and patient with me. Big thanks from the bottom of my heart!”

On February 23, 2016, six months after her procedure, an angiogram performed by Dr. Amans showed that Alla’s DAVF was entirely cured, with no follow-ups necessary. She and Sergei are now able to get back to the things they loved in life, including quiet. 

Alla is a sanitary engineer who works in water regulation for the Division of Drinking Water. Her background in fluid dynamics helped her appreciate the combined engineering and medical excellence of the UCSF Pulsatile Tinnitus Clinic. 

New Years as a right of passage

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Wrapping up, letting go = moving forward with clarity

 

“Nothing gets left undone,” commented my dad, Robert Skurko, when I reflected with him about the energy that gets expressed in Japanese companies during the time of the New Year.

 

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This New Year, I read Marie Kondo’s “Art of Tidying” and reflecting on the little-known secret of the New Year’s in Japan. More than anything, the season is about wrapping up and clearing the slate. It’s less about “having fun” and “celebrating” than renewal.

 

How does clearing the slate manifest itself?
From Ito Yokado to Sony, with every company I have worked in Japan, when the New Year came, we turned our office space inside out in order to clean. All old paperwork was tossed. There was dusting and cleaning. And then, last, but not least, was the creation of a slogan to help unify us in the year ahead. Then, as the New Year unfolded, we set about greeting those near and dear to us. In families, this involved extended days of eating New Year’s food. In the corporate setting, we were ready for quick cups of tea, or a personal phone call, to “greet” those whom we considered important to us.

 

Years later, living in Singapore during the New Year and then marrying into a Chinese family, I got to experience this all over again. As one friend confided, “We have parties as an excuse to clean.” She talked about the art of clearing and cleaning, at least once in the year, which was followed by greeting friends and relatives. Again, in Singapore, after all the clearing, lucky statements (couplets and Chinese New Year decorations) were placed in the appropriate spots.

 

What does this lead to?

 

Letting go of the past is not easy. In Asian cultures, they create momentum behind this act and encourage people to clean up, I believe, in order to move on.
This year, as we sorted and tossed in our own home and office, after reading Kondo’s book, I reflected more deeply on the force behind this act.

 

One image comes to mind today – seeing the beautiful Daruma, upon whose face we had inscribed our wishes with a single eye, burning at temples. Seeing Daruma and other beautiful New Years decorations from the prior year being burned (especially b/c they were so expensive and precious!) was, at first, a shock to me. Today, it reminds me of the bitter-sweet act of letting go.

Dr. Darrell Kirch on the rapidly arriving future

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“None of us – globally – has gotten health care right.” Those are dramatic words, uttered by one who should know, and, thankfully, one who is in a position to identify and support needed improvements.

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Darrell Kirch, MD, president and CEO of the Association of American Medical Colleges, spoke at a special session following the keynote by UCSF Department of Radiology Chair and outgoing RSNA President, Ronald Arenson, MD, at the 101st meeting of the Radiology Society of North America. RSNA is consistently one of the country’s top three medical conferences, drawing nearly 55,000 attendees.  

 

In his talk, “Radiology, Medicine, and Healthcare: Will Inaction or Innovation Determine Our Future?” Dr. Kirch did not sugarcoat the problems facing modern health care. “There’s a great transformation going on in health care around the world, and we need to take steps to prepare for this change,” he said. Among the coming changes he noted:

 

-increased cost-cutting pressures that impact patient care;

-NIH funding and the education of the next generation of physicians;

-the global shortage of physicians, due to an aging population.

 

He also noted that, as income from patient care and NIH funding is reduced, students are shouldering a heavier cost-burden for their education.

 

Kirch had straight talk about problems, but he was also ready with hope– and thoughtful solutions. Kirch suggested a two-pronged approach. First, “We need more doctors to solve the shortage,” he said. “We have not had an increase in budget to train students in the residency pipeline in the last 18 years. The physician shortage is a real issue linked to aging population.”

 

Second, organizations need to be open to and ready to take on change. That requires they focus on their culture to develop the skills necessary to be flexible to the changing demands of the market.

 

He pointed out that academic medical centers can take the lead and set a good example of cultural nimbleness. “Academic centers are indispensable, and as such can’t afford complacency,” he said.

 

We often hear the call for medical organizations to remake our internal and patient-facing operations, and move from top-down management to a culture of teams, but what does that really mean in the daily work environment?  What is your institution or department doing to innovate out-of-date practices and prepare for the rapidly arriving changes in health care?  

A Thanksgiving Message Inspired by a Brave Teen

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I am in awe of a girl who would have turned 16 this coming spring.  

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The week of her 14th birthday, Rebecca (aka Becca) was diagnosed with osteosarcoma, a cancer of the cells that builds bones. She underwent chemo, and after ten months was on the path to recovery – or so we thought. Then, a few short months later, her mother called with news which even now I find difficult to believe. The mind and heart are at complete odds when we have to say goodbye to a young one –  the mind knowing a tragedy is at hand, the heart holding on to our relationship with a girl who is growing beautifully and looking full of life.

 

Becca was among my daughter’s first true friends. I came to know her through the magic of their friendship and thanks to her generous family, who opened wide the doors to their vulnerability and shared their journey. They have demonstrated a remarkable ability to love one another and those around them with equal exuberance, and do this with strength and grace, against all odds.

 

Becca was joyful and energized by the world and requested that she spend her last months living a normal teenage life. She started high school as soon as she could after completing chemo, and became an active member of her school community. In return, teachers, parents and peers welcomed her with open arms. We were graced by her smiles and her appetite to live and experience every opportunity life has to offer, from a Benioff Children’s Hospital prom last spring (she wore an elegant tiara and got to have her portrait taken with the SF 49ers) to laughing about Instagram posts the last day we saw her.

 

One of her friends shared a poignant story from Becca’s final months in school. Becca and this friend, who had also experienced childhood cancer, wanted to give a talk to their fellow students to help dispel myths and open the door to conversation about cancer, theirs and others. On the day they had planned to do this, the school came to them and said the timing wasn’t right to share “sad” stories and that they should consider this the following year. But the girls persisted, Becca explaining, “I may not be here next year to share my story.”

 

Until then, Becca had resisted speaking of, or seemingly even thinking about, her cancer. But at that moment, she rose above her desire to live a “normal teenage life” in order to share an intensely important message with her fellow students before she died. That message, her friend told me, was that it can be okay, even a good thing, to ask people about their cancer, to talk with them about it, ask questions if you have them. The message is a valuable one for all of us – don’t assume cancer patients do not want to talk about their illness. Ask how they feel about talking, of course. Then, if it is okay, be willing to talk, ask questions, learn from them.

 

Along with the grief and loss that we experienced with Becca’s passing, we are left with a very clear sense of how precious life is. Of how intensely beautiful the world is in ways we had not fully perceived before. We also have a new appreciation of the medical teams that helped Becca in every way possible. I can only hope to offer what gifts I have with the same selflessness.

 

To all who fight for the lives of others — through great medicine, service to your  friends, your country, teaching someone else’s children, loving your own, or in whatever way you do, may we support you with our encouragement and gratitude.


To Becca, who offered the gift of being gracious and ready to smile even in the struggle of those final months and days — our world will never be the same without you. Thank you for the gift of your friendship, and for taking a stand for what you believed in. We will help carry your torch.

Vietnam Vet shares heartwarming story of his stroke treatment at the SF VA Medical Center

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“The San Francisco VA has taken care of me from head to toe. I owe them my life.”

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These were the words from James K. Theriault, who shared the story of his recent journey from Salt Lake City to San Francisco, where he underwent a crucial procedure concerning his blocked carotid and vertebral arteries, performed by the world-renowned interventional radiology department at the San Francisco VA Medical Center (SFVAMC).

Theriault is a Vietnam veteran who served for three years immediately following his high school graduation. Born in Canada, Theriault became a U.S. citizen at 16 and was not required to serve in Vietnam. However, as an avid supporter of the United States, he enlisted, and enthusiastically served his tour of duty and the team with whom he trained. Teamwork was also the theme of his recent medical care at the San Francisco VA Medical Center.

Theriault, a stroke victim, was referred to Daniel Cooke, MD, chief of neurointerventional radiology at SFVAMC, to evaluate his blocked carotid and vertebral arteries. He had been experiencing dizziness and falling, and his doctors in Utah were concerned he was at risk for another stroke. Because of the location of the occlusion, and the complexity of his case, he was a candidate for this procedure at the SFVAMC.

The care team included Theriault’s referring physician from Utah, Daniel Abenroth, MD, of the Department of Neurology at University of Utah’s School of Medicine; his neurointerventional radiologist, Dr. Cooke, of the UCSF Department of Radiology; and his care coordinator, Danny Langston, NP, CNS, RCP.

“I received a detailed letter with my entire list of appointments, and everything was perfect,” remembered Theriault. He described how Langston, the team’s nurse practitioner care coordinator, helped him with his entire journey, from prescribing his antiplatelet medications to scheduling lab appointments, so that, within 10 minutes of his arrival at the VA, he was ready to go.

Abenroth also referenced the collaborative nature of working as a virtual team, saying, “We initiallyreferred the patient to the San Francisco team due to the recommendation of our staff neurosurgeon at the Salt Lake City VA, who felt the patient would be well served by the San Francisco team.” He emphasized that the manner in which they worked with his group added enormous value to the outcome. “We received the results immediately and worked as a virtual stroke team to determine next steps.” Abenroth explained that the team consisted of a range of specialists to insure that Theriault’s health was reviewed holistically. Before the experience of transferring a patient to San Francisco VA Medical Center, Dr. Abenroth hadn’t realized that this resource was available to their patients in Utah. “Knowing we have access to this group is going to open the door to other patients like James.” In fact, the UCSF neurointerventional radiology team in San Francisco is a specialized referral center for the VA system and available to all VA centers nationwide.

Stroke is the fourth leading cause of death nationwide. To combat stroke, UCSF neurointerventional radiologists use advanced imaging methods to treat those affected by it as well as to help identify those at risk before stroke occurs. These radiologists, in collaboration with their neurology and neurosurgical colleagues, provide these services to the patients at the San Francisco VA. According to Dr. Cooke, “There is new evidence that, more than ever, intervention can benefit patients with stroke.”

For such patients, Dr. Cooke and his colleague Steven Hetts, MD, chief of interventional neuroradiology at San Francisco General Hospital, use cutting-edge X-ray technology. As university physicians, they are able to apply the latest scientific research to their work.  At the SFVAMC, the number one research program in the VA system, with over $90 million in funding, research also plays a vital role in ensuring the latest, most frontline procedures and technologies are used.

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In cases like Theriault’s, the team uses an interventional radiology technique called angioplasty and stenting to non-invasively treat the arterial blockages, thereby restoring blood flow to the brain. They hope that other patients who suffer from blocked vertebral arteries and are at risk for strokes might become aware of a minimally invasive alternative to neurosurgery.

The field of neurointerventional radiology is relatively new, qualifying Dr. Cooke and his colleagues at UCSF as true pioneers. Dr. Cooke explained that his father was a neurologist and that he, himself, was interested in the surgical aspect of neurology. He found his passion using radiology to treat patients at the University of Washington. Today, at UCSF Radiology, a leading institution for the use of this technique, he says, “I am happy to provide patients an alternative to surgery because there is minimal scarring and rapid recovery time.” He and his team at UCSF divide their time between treating patients, training the next generation of radiologists, and researching new techniques to improve outcomes for patients going forward. To learn more about their work, please click here.

Today, Theriault is full of a vigor that belies his age. Now retired after a fascinating career in the military and defense logistics, he and his wife of 10 years just completed a cruise to Alaska with friends he made in Vietnam. Theriault is also an avid scuba diver (his favorite spot is Borneo), and has recently taken up a culinary arts program.

Thank you to James and his wife of Salt Lake City, Utah, for sharing your experience. We hope that your story helps other veterans understand alternatives and resources available to them when navigating complex issues surrounding their health.

Marketing & Analytics Meets Patient Outcomes at Dreamforce 2015

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Members of the UCSF Radiology marketing team were among 170,000 people to attend the annual Dreamforce conference in downtown San Francisco last week.

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The conference lived up to its reputation for over-the-top exhibits. Between 8:30 am last Monday and about 2:00 pm Friday, attendees rallied in virtual reality race cars, rode in rickshaws, took their breaks in hammocks strung over lawns installed just for the occasion, and lounged in colorful bean bags while tapping away on their laptops. And though there were plenty of opportunities to play, there wasn’t a single unbooked moment on the conference agenda– Emil Michael, Uber’s senior vice president for business, took the stage at the conference’s opening bell and began speaking with Salesforce Founder, Chairman and CEO, Marc Benioff, about his vision for seamless customer service.

In fact, the entire conference was a celebration of what it means to be customer focused. Reiterated throughout the week was how to ensure that organizations remove the silos between marketing, sales and customer service – the silos that prevent them from achieving their vision. The twin mantras of “great marketing looks like great customer service” and “great customer service looks like great sales,”  reinforced Salesforce’s belief in maximizing value to the end-user.

Thanks to Benioff’s dedication to UCSF, the institution was at the helm of the conference, with UCSF surgeon and oncologist Laura Esserman, MD, MBA, featured during the keynote address. During minute 7:40 of this 18-minute video, Benioff introduces the work of Esserman and the WISDOM study, a broad-based data study supported by the Salesforce platform which assesses breast cancer screening methods. In this clip, Esserman also elaborates on the critical need for precision medicine and draws an analogy between the concept of fantasy sports teams and the book and movie “Moneyball,” which demonstrated big data’s role in creating a winning baseball team, and the need for precise tech tools to deliver better patient outcomes. As she told Benioff  and the Dreamforce audience, “I saw the vision that you had, and I thought, ‘This is what I want!’”

Thank you to UCSF Imaging manager Cynthia Hammond and others from the UCSF Imaging team for your contribution to the success of the WISDOM study. Your dedication helps us all realize what it takes to move from dreams in “the cloud” to reality and, most importantly, to customer outcomes.

Summer Dreamin’

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images-1As I walked during a beautiful summer sunset here in the Presidio of San Francisco, young sparrows were darting across my path, evoking fond memories of this season in Japan, where I spent 13 years as an American expatriate. The swallow is a symbol of the hottest days in August, and their beautiful silhouette equates the summer treat, “shaved ice.” Their image is used to advertise shaved ice on fluttering cloth banners to this day. I remember the one that hung at the temple grounds where I studied gymnastics for a few years when I first moved to Tokyo from Silicon Valley at the age of 13.

 

This morning, as I did yoga, I began to reflect on the sweaty days training in the dilapidated little gym off the grand grounds of Ikegami Honmon-ji (池上本門寺), dating to 1608. I enjoyed reminiscing about the experiences that stood out to me at that time.  As I spend a moment doing some summer dreaming, I realize how much these memories are a paimgresrt of the fabric of my life today – shaping my approach to business and to life.

 

I was a competitive gymnast and came to know the temple where the summer swallow banner hangs because we had been introduced to the gym’s founder, an Olympic gold medalist, by the Danish coach my brother and I trained with in US. The opportunity to pursue my passion for gymnastics in two cultures and two contexts left a deep impression.

 

Though I don’t have easy access to my dairy at 13, here’s what it would have said on this summer day, many years ago:

  • We train very differently in Japan, starting each session by chanting a Buddhist scripture on the wall, written in beautiful characters. The kids have a staccato way of saying the words, which I’m learning to mimic.
  • Our warm-ups are exotic to me – we do yoga movements, not the jumping jacks I did in the US. I like the way my gymnast friends pummel me too. There is a degree of intensity that inspires me here. I will progress at a new rate because the kids and teachers are expecting it of me.
  • The girls are intrigued with my being a foreigner and are giving me all kinds of special attention and smiles. (Meanwhile, my brother is getting into fights with the boys who are taunting him for being different….He learns to swear in Japanese quicker and better than I do.)
  • These new friends are not like the tougher teens at my junior high school in America. They are cuddly and familial, and like things like “Little Kitty” (while my friends back home in American are writing to me about parties without parents and all the ensuing gossip.) My gymnast friends take me under their wing, explaining all the etiquette needed to follow at a the temple – how to enter and leave the sacred grounds – turning to bow to the grand tori gates. Of course, because its a temple, there are many, many steps to climb (this is where I learn to count in Japanese). When there’s time, we also wash our hands with bamboo ladles to purify ourselves. Sometimes, when it’s “needed,” we scrub the statue to relieve our gymnasts’ aches and pains. We’re also sure to use our hands to wave the burning incense toward our heads during exam season – apparently it helps! In the gym, we bow and express words of deep respect and humility to each piece of equipment before we began our training. Of course, teachers are not just teachers, they are “sensei.” Some translate this word as “master,” but I would say “mentor.” What they  teach us goes far beyond gymnastics. It is a “way” – a way of thinking and being both inside- and outside the gym.
  • During the New Year, we get to experience a true sense of transition with the heavy drumming emanating from the inner temples. Your entire body feels the vibrations and you sense that something has truly changed when New Years strikes. The ringing of the temple bells is another element of the occasion that makes the New Year feel like a fresh start.
  • In the spring, when the blossoms are at the peak, we are invited to picnic – right in the temple graveyard. The adults are drinking sake. Fluttering white and pink blossoms, salted plum rice balls and laughter were not something I had associated with graveyards before.
  • As summer draws to a close, we are at a pond, lighting lanterns that float across the water for those who have come before us. It is to light their way back to visit us again on earth. One older women asked me to help her find the one that belonged to her deceased son. Her eyes weren’t so good and she couldn’t tell that I was a foreigner. I felt a deep sense of responsibility towards her and her son. Here in Japan, we feel that the other world is very close to us – nature and people, living or dead. The hot, humid air of this island country on a summer’s day makes me feel that I trust humanity.
  • Every day I am here, I am acutely aware that there is so much that is not articulated. Beneath the surface, around the corner, imbedded deep within the realm of the intuition, there is something that seems to shimmer. It is yet-to-be-discovered and provides my life with an element of mystery – a puzzle, a gift…. a bit of magic.

 

Taking the mystery out of SEO – go directly to the source

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As we all experience in our day-to-day lives, Google searches have became the place where marketing issues play out for many organizations. When customers need information, they need it now, and are most likely to turn to a Google search. What does this mean for marketers? It means we all need to be aware of how Google ranks and what customers want to know.

Take a moment to see what SEO leaders at large companies like Walmart ask when they get the opportunity to speak directly with our Google gods. Particularly reassuring is that Google simply rewards those who use common-sense marketing practices that appeal to customers – great content that is responding to what customers want to know.  Also, of note,  in this clip is the fallout after major changes announced by Google last April (“sites that are not mobile will be penalized”).

Thanks, Jason Youk, SEO Internet Marketing Manager at Walmart, for your professional guidance in staying close to evolving SEO issues in our market. You gave me great tools to roll up my sleeves and stay abreast of issues as they unfold. Anyone can become an SEO expert by listening in on this conversation, and by spending an hour a week reviewing their Google Analytics.

 

Happy New Year

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BUJI and was written by Hosoai Katsudo (1919~1985) who was a Rinzai sect Daitokuji Ryugenin temple abbot. Photo by Larry Tiscornia, 1/1/15.

BUJI and was written by Hosoai Katsudo (1919~1985) who was a Rinzai sect Daitokuji Ryugenin temple abbot. Photo by Larry Tiscornia, 1/1/15.

In Japan, it is the tradition to choose a single theme for the year ahead. From the emperor, to CEO’s and to all those who seek focus in their efforts, a single word suffices. During a year-end tea ceremony, I was greeted by the words of the Zen priest Hosoai Katsudo (1919~1985), who was a Rinzai sect Daitokuji Ryugenin temple abbot.  His calligraphy said,  “Buji,” or “without worry.” The scroll suggested that we separate from the many issues that could distract us from that which is true and meaningful and forward-looking in our world. On this new day of the new year, wishing you a year without worry and full focus on that which is essential.