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Merkel cell carcinoma
Merkel cell carcinoma: This rare skin cancer can appear on the skin as a hard patch (1) or firm bump (2).
Merkel cell carcinoma: Overview
What is Merkel cell carcinoma?
Merkel cell carcinoma (MCC) is a rare skin cancer. It is also an aggressive skin cancer. MCC is considered aggressive because it can:
- Grow quickly and spread.
- Return after treatment.
Because MCC is aggressive, doctors recommend prompt treatment. The sooner this skin cancer is treated the better the outcome. To improve a patient's outcome, a team of doctors usually creates the treatment plan for MCC. This approach allows the patient to benefit from the expertise of specialists in different areas of medicine. The team often includes a dermatologist, a medical oncologist (cancer specialist), and a radiation oncologist (specialist in treating cancer with radiation.) Other doctors may also be a part of this team.
It is important for patients diagnosed with MCC to:
- Keep all appointments with their doctors.
- Check their skin and lymph nodes for signs of cancer as recommended.
These actions help find cancer as early as possible.
Images used with permission of Journal of the American Academy of Dermatology: J Am Acad Dermatol.2012; 66:923-7
Harting MS, Ludgate MW, Fullen DR et al. "Dermatoscopic vascular patterns in cutaneous Merkel cell carcinoma," J Am Acad Dermatol 2012; 66(6): pages 923-7.
Heath M, Jaimes N, Lemos BD et al. "Clinical characteristics of Merkel cell carcinoma at diagnosis in 195 patients: the AEIOU features." J Am Acad Dermatol 2008; 58:375-81.
Lemos BD, Storer BE, Iyer JG et al. "Pathologic nodal evaluation improves prognostic accuracy in Merkel cell carcinoma: analysis of 5823 cases as the basis of the first consensus staging system." J Am Acad Dermatol 2010; 63:751-61.
Nghiem P, Jaimes N. "Merkel Cell Carcinoma." In: Wolff K, Goldsmith LA, Katz SI, et al. editors. Fitzpatrick's Dermatology in General Medicine, 7th ed. United States of America, McGraw Hill Medical; 2008. p. 1087-94.
Merkel cell carcinoma: This rare skin cancer most commonly looks like a shiny, dome-shaped growth that has visible blood vessels.
Merkel cell carcinoma: Signs and symptoms
This rare skin cancer often looks harmless. Many people mistake it for a pimple, bug bite, or cyst. If you see a lump or hardened patch on your skin that looks like any pictures on this page, you should immediately make an appointment to see a dermatologist.
This appointment is especially important if you have:
- Fair skin and are 50 years of age or older.
- A disease that weakens your immune system, such as HIV or chronic lymphocytic leukemia (a cancer of the blood and bone marrow).
- Received an organ transplant.
- Had Merkel cell carcinoma (MCC) or another skin cancer.
Merkel cell carcinoma: What it looks like
MCC often appears on skin that has had lots of sun exposure. The MCC tumor tends to:
- Feel firm.
- Grow quickly (in a few weeks or months).
- Have one color, either red, pink, blue, or violet.
MCC also can appear as a rough, hardened patch of skin. This patch tends to form on the trunk of the body.
Merkel cell carcinoma: Symptoms
People diagnosed with MCC often say that the lump or patch was painless.
Merkel cell carcinoma: Where it appears on the body
This rare skin cancer can develop anywhere on the skin. Most MCCs, however, appear on skin that has received lots of sun exposure. About half of MCCs develop on the head or neck, with many of these forming on the eyelid. Other places that MCC tends to develop are the legs, arms, feet, buttocks, and genitals.
One of the greatest risk factors for MCC is age. Most MCCs develop in people who are 50 years of age or older. Other risk factors for MCC also increase the likelihood of developing this rare skin cancer.
Images used with permission of Journal of the American Academy of Dermatology: 1 J Am Acad Dermatol. 2011; 65:983-90
Akhtar S, Oza KK, Wright J. "Merkel cell carcinoma: report of 10 cases and review of the literature." J Am Acad Dermatol 2000 Nov; 43(5 Pt 1):755-67.
Becker JC. "Merkel cell carcinoma." Ann Oncol 2010; 21(suppl 7)vii81-5.
Gao L. "Merkel cell carcinoma: Tips and advancements in management." Educational session presented at the 2013 American Academy of Dermatology Annual Meeting: Miami. Mar 2013.
Heath M, Jaimes N, Lemos BD, et al. "Clinical characteristics of Merkel cell carcinoma at diagnosis in 195 patients: the AEIOU features." J Am Acad Dermatol 2008; 58:375-81.
Pape E, Rezvov N, Penel N, et al. "Radiotherapy alone for Merkel cell carcinoma: a comparative and retrospective study of 25 patients." J Am Acad Dermatol 2011; 65:983-90.
Merkel cell carcinoma: Who gets and causes
Who gets Merkel cell carcinoma?
Most Merkel cell cancers are diagnosed in people who are:
- 50 years of age or older (90%).
- Fair skinned and did not protect their skin from the sun (98%).
According to research studies, gender also seems to play a role. Men are twice as likely to get to MCC.
Other risk factors
Anything that increases your risk of getting a disease is a risk factor. Age, fair skin, and lots of sun exposure are the most common risk factors for MCC. Other risk factors for MCC are:
Illness that weakens your immune system: Your immune system helps you stay healthy. Some illnesses, however, weaken your immune system. Illnesses that weaken the immune system include HIV and chronic lymphocytic leukemia (a cancer of the blood and bone marrow).
Medicine that weakens your immune system: People who received an organ transplant must take medicine for life. This medicine prevents the body from rejecting the transplanted organ. It also weakens the immune system. Other medicines can also weaken the immune system.
Exposure to arsenic or infrared light: Being exposed to arsenic for a long time seems to increase the risk. Long-term exposure can come from drinking well water that contains arsenic. Some people are exposed to arsenic in the workplace. Infrared light is common in some workplaces and homes. Common sources of infrared light are lasers, some furnaces, and heat lamps.
PUVA therapy, using methoxsalen (meth-OX-a-len): Some patients treated with PUVA therapy receive a medicine called methoxsalen. In one study, researchers found that 3 of the 1,380 patients taking methoxsalen developed MCC. The cancer developed many years later. All of the patients had taken methoxsalen during their PUVA therapy. Two of these patients received more than 300 PUVA treatments.
What causes Merkel cell carcinoma?
Scientists are still studying what causes this skin cancer.
A research breakthrough came in 2008 when scientists discovered a virus called the Merkel cell polyomavirus. This virus is found in many Merkel cell tumors. To gain a better understanding of this cancer, scientists are studying this virus.
If you have risk factors for Merkel cell carcinoma
Having risk factors does not mean that you will get MCC. This skin cancer is rare. You can reduce your risk by protecting your skin from the sun. This can also reduce your risk for getting other types of skin cancer.
If you are concerned that you may have MCC, you should immediately make an appointment to see a dermatologist.
Bichakjian CK, Alam M, Andersen J, et al. "Merkel cell carcinoma: Clinical practice guidelines in oncology." National Comprehensive Cancer Network. Version 2.2013.
Feng H, Shuda M, Chang Y, et al. "Clonal integration of a polyomavirus in human Merkel cell carcinoma." Science 2008; 319:1096-100.
Heath M, Jaimes N, Lemos BD, et al. "Clinical characteristics of Merkel cell carcinoma at diagnosis in 195 patients: the AEIOU features." J Am Acad Dermatol 2008; 58:375-81.
Lemos BD, Storer BE, Iyer JG, et al. "Pathologic nodal evaluation improves prognostic accuracy in Merkel cell carcinoma: analysis of 5823 cases as the basis of the first consensus staging system." J Am Acad Dermatol 2010; 63:751-61.
Lunder EJ, Stern RS, "Merkel-cell carcinomas in patients treated with methoxsalen and ultraviolet A radiation." (Letters to the editor). N Engl J Med. 1998; 339:1247-8.
Reisinger DM, Shiffer JD, Cognetta AB, et al. "Lack of evidence for basal or squamous cell carcinoma infection with Merkel cell polyomavirus in immunocompetent patients with Merkel cell carcinoma." J Am Acad Dermatol 2010; 63:400-3
Merkel cell carcinoma: Diagnosis and treatment
How is Merkel cell carcinoma diagnosed?
Diagnosis begins with an exam. Your dermatologist (or other doctor) will closely examine your skin and lymph nodes. We have lymph nodes in our neck, underarms, and other areas of the body. Lymph nodes help to protect us from illness. They often swell when we are sick.
If your doctor suspects Merkel cell carcinoma (MCC), you will need a skin biopsy. This is the only way to diagnose skin cancer. Your dermatologist can safely perform a skin biopsy during an office visit. To perform a skin biopsy, a dermatologist removes either the entire tumor or part of it.
What your dermatologist removes will be examined under a microscope. This magnified view allows a doctor to look for cancer cells.
How is Merkel cell carcinoma treated?
When the diagnosis is MCC, doctors with experience treating this rare skin cancer should be consulted. Each of these doctors should have expertise in a different field of medicine, such as dermatology, surgery, oncology, and radiation oncology. Working together, these doctors can create a treatment plan.
Before the doctors create a treatment plan, they want to find the stage of the cancer. Treatment differs for each stage. The stage tells doctors how deep the MCC has grown and whether the cancer has spread.
Finding the stage: To find the stage, a patient undergoes a process called staging. Staging for MCC often begins with an imaging test, such as a PET/CT scan. This allows the doctors to see if cancer has spread to organs inside the body.
After imaging tests, many patients diagnosed with MCC have a surgical procedure called a sentinel lymph node biopsy (SLNB). A SLNB can tell doctors if the cancer has spread to a patient's lymph nodes. When MCC begins to spread, it often travels to a certain lymph node first. A SLNB can tell doctors to which lymph node the cancer would travel first and whether that lymph node or nearby lymph nodes contain cancer cells.
What happens during a SLNB
For many patients, a SLNB is an outpatient procedure. In some cases, getting a SLNB requires a short hospital stay. During this surgery, the following happens:
- The surgeon injects a dye, radioactive substance, or both into the patient. The injection is made near the MCC tumor.
- The surgeon uses a special device to follow the injected substance, which travels to the sentinel node (first node to which the cancer is likely to spread).
- The surgeon makes a small incision and removes the sentinel lymph node, and in some cases, other lymph nodes.
- A specially trained doctor, a pathologist, checks the removed lymph node(s) for cancer.
- If the pathologist finds cancer, the surgeon may remove more lymph nodes. Sometimes, the surgeon can do this during the same surgery. Sometimes, the patient needs a second surgery.
After finding and removing the lymph node(s), the surgeon may remove the Merkel cell tumor. Sometimes, removing the tumor requires another surgery.
Some patients need more imaging tests to help the doctors determine the stage of the cancer. A patient may need a CT scan, MRI, or CT/PET scan.
The stage of the cancer is determined by where it appears. The following summarizes the stages:
- Local: Skin only.
- Nodal: Skin and lymph nodes.
- Metastatic: Cancer has spread beyond the skin and lymph nodes to other areas of the body.
The patient's stage plays an important role in the treatment plan. The doctors also consider the patient's age, overall health, and personal preferences. A treatment plan for MCC will consist of one or more of these treatments:
- Surgery to remove the tumor.
- Surgery to remove lymph nodes.
- Radiation treatments.
- Chemotherapy.
- Clinical trial.
Excision (surgery): During this surgery, the surgeon removes the tumor and some surrounding tissue that looks healthy. Removing healthy looking tissue helps to catch cancer that may have traveled to an area that still looks healthy. An area can look healthy if it contains just a few cancer cells.
Mohs surgery: Because MCC often develops on the face and other areas with little fat, Mohs (pronounced "Moes") surgery may be recommended. This specialized surgery is used only to treat skin cancer. This surgery allows the Mohs surgeon to remove less healthy looking tissue.
During Mohs surgery, the Mohs surgeon cuts out the tumor plus a very small amount of healthy looking tissue surrounding the tumor. While the patient waits, the Mohs surgeon uses a microscope to look at what was removed. The surgeon is looking for cancer cells.
If the Mohs surgeon finds cancer cells in the healthy looking tissue, the surgeon will remove another small amount of healthy looking tissue and look at it under the microscope. This process continues until the surgeon no longer sees cancer cells.
MCC can grow deep, so some patients need reconstructive surgery. This surgery is usually performed immediately after the cancer surgery.
Lymphadenectomy: This is surgery to remove lymph nodes. This surgery is also called lymph node dissection.
Radiation treatments: This is often part of the treatment plan for MCC because this cancer has a high risk of returning after surgery. Studies show that radiation treatments reduce the risk of MCC returning. Patients usually begin radiation treatments within 4 weeks of having surgery to remove the cancer.
Radiation treatments also are given to patients who cannot undergo surgery. Findings from a study suggest that radiation alone can be an effective treatment.
Some patients receive radiation treatments to help them feel more comfortable. Your doctor may refer to this as palliative therapy. This therapy does not treat the disease. It helps people feel better.
Most patients receive radiation treatments in a hospital or outpatient facility. The treatments are usually given 5 days a week, Monday through Friday, for 5 weeks.
Chemotherapy: Doctors recommend chemotherapy for some patients who have MCC that has spread beyond the skin and lymph nodes. Chemotherapy treats the cancer with drugs that can kill the cancer cells.
Clinical trial: Some patients are encouraged to join a clinical trial. A clinical trial is a type of research study. This study tests how well new a treatment or a new way of treating a disease works. For some patients joining a clinical trial may be the best treatment option.
What is the outcome for patients with MCC?
MCC is an aggressive cancer. It can return after treatment. It often returns within the first 6 to 12 months after diagnosis. For this reason, it is essential to keep all follow-up appointments with your doctors.
On a positive note, findings from a research study show that patients who do not have cancer in their lymph nodes have an excellent prognosis (outcome). Patients who have stage I, II, or III MCC tend to do better than patients who have MCC that has spread beyond the lymph nodes.
Every patient treated for MCC needs to keep all follow-up appointments.
Allen PJ, Bowne WB, Jaques DP, et al. "Merkel cell carcinoma: Prognosis and treatment of patients from a single institution." J Clin Oncol. 2005; 23:2300-9.
Bichakjian CK, Alam M, Andersen J et al. "Merkel cell carcinoma: Clinical practice guidelines in oncology." National Comprehensive Cancer Network. Version 2.2013.
Colgan MB, Tarantola TI, Wearver AL et al. "The predictive value of imaging studies in evaluating regional lymph node involvement in Merkel cell carcinoma." J Am Acad Dermatol. 2012; 67:1250-6.
Hawryluk EB, O'Regan KN, Sheehy N, et al. "Positron emission tomography/computed tomography imaging in Merkel cell carcinoma: a study of 270 scans in 97 patients at the Dana-Farber/Brigham and Women's Cancer Center." J Am Acad Dermatol. 2013; 68:592-9.
Howle JR, Hughes TM, Gebski V et al. "Merkel cell carcinoma: an Australian perspective and the importance of addressing the regional lymph nodes in clinically node-negative patients." J Am Acad Dermatol. 2012; 67:33-40.
Pape E, Rezvov N, Penel N, et al. "Radiotherapy alone for Merkel cell carcinoma: a comparative and retrospective study of 25 patients." J Am Acad Dermatol 2011; 65:983-90.
Tarantola TI, Vallow LA, Halyard MY, et al. "Prognostic factors in Merkel cell carcinoma: Analysis of 240 cases." J Am Acad Dermatol. 2013; 68:425-32.
Tarantola TI, Vallow LA, Halyard MY, et al. "Unknown primary Merkel cell carcinoma: 23 new cases and a review." J Am Acad Dermatol. 2013 68:433-40
Merkel cell carcinoma: Tips for managing
Findings from research studies suggest that patients treated for Merkel cell carcinoma (MCC) should:
1. Keep all follow-up appointments with your doctors. MCC is an aggressive skin cancer. It can return after treatment. For this reason, doctors who have expertise in treating MCC recommend:
- Every patient treated for MCC needs a follow-up visit every 3 to 6 months for the first 2 years.
- After 2 years of cancer-free exams, the patient should return every 6 to 12 months for a complete exam.
- Each exam should include a complete skin exam and an exam of certain lymph nodes.
These follow-up visits help find skin cancer in the earliest stage. The sooner the cancer is found and treated, the better the outcome.
2. Perform skin self-exams as often as your dermatologist recommends. If you have received treatment for MCC, it is essential that you learn how to perform a skin self-exam. Your dermatologist or someone in your dermatologist's office can teach you exactly what you need to know, including how to examine certain lymph nodes.
3. Protect your skin from the sun. If you have had MCC, you must always protect your skin from the sun. The sun's rays damage skin. Your dermatologist can offer you specific tips that meet your needs.
4. Ask your doctors what else you can do to improve your outcome. Some doctors recommend eating a healthy diet and exercising to keep the immune system strong. Getting enough sleep also is important. Be sure to ask your doctors what could help you.
Related resources:
- Merkel cell carcinoma: Information for patients and their physicians
- Discussion and support group
- Merkel Cell Carcinoma Seattle Support Group: offers a robust library of resources for MCC patients
Akhtar S, Oza KK, Wright J. "Merkel cell carcinoma: report of 10 cases and review of the literature." J Am Acad Dermatol 2000 Nov; 43(5 Pt 1):755-67.
Bichakjian CK, Alam M, Andersen J, et al. "Merkel cell carcinoma: Clinical practice guidelines in oncology." National Comprehensive Cancer Network. Version 2.2013.
Gao L. "Merkel cell carcinoma: Tips and advancements in management." Educational session presented at the 2013 American Academy of Dermatology Annual Meeting: Miami. Mar 2013.
© 2019 American Academy of Dermatology. All rights reserved. Reproduction or republication strictly prohibited without prior written permission. Use of these materials is subject to the legal notice and terms of use located at https://www.aad.org/about/legal


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Italian Prime Minister Silvio Berlusconi is leaving for vacation in a very bad mood. On Thursday, the House of Deputies, although dominated by Berlusconi's center-right coalition, decided to postpone until September its vote on a wiretap bill that had been considered a bellwether by a government wracked by internecine wars and confronted with ominous poll predictions.
Berlusconi's phone-tapping initiative was aimed at sharply limiting the use of wiretaps issued by magistrates in the context of police investigations and at harshly penalizing journalists who would publicize the contents of these recordings.
Presented by its sponsors as a tool to protect privacy, the bill was denounced as an attempt by the prime minister to protect himself and his political friends from accusations of corruption, mafia connections, and "loose morality." As Rachel Donadio of The New York Times put it, "in recent months Italians have learned through leaked wiretaps about Monica, a Brazilian masseuse hired by Guido Bertolaso, the head of the Civil Protection Agency, who is under investigation for corruption" and about "Angelo Balducci, a former member of the board of Italy's public works department" who was caught in a wiretapped conversation "asking a singer in a Vatican choir about a potential date."
Among many other contentious clauses, like the requirement "for all those responsible for information websites" to issue corrections within 48 hours to any complaint regarding content, the bill would have limited police wiretaps to two months for most criminal investigations. To the ire of Italian journalists, it would also have forbidden the publication of any kind of information obtained through leaked phone-tapping before the start of a criminal trial, a process that in the long-winding ways of Italian justice may take up to five years.
Silvio Berlusconi was confident that his appeal to the grand principles of the sanctity of private life, his control over most of Italy's audiovisual media, both private and public, and his parliamentary majority would allow him to push the bill through Congress.
Although the bill was passed in the Italian senate on June 10, it hit unexpectedly bumpy roads everywhere else. Most of the press rebelled against the legge bavaglio (gag law), enlisting even media institutions owned by Il Cavagliere. On July 9, most newspaper, radio and TV journalists went on a 24-hour strike, shutting down news around the country to protest the law.
The judiciary and the police also reacted angrily, insisting that the proposed law would, in the words of Antonio Ingroia, a famous anti-mafia attorney in Palermo, "strike a lethal blow to inquiries on corruption, organized crime and its political collusion."
The "no" campaign became international when Frank La Rue, the UN special rapporteur on the promotion and protection of the right to freedom of information and expression, called on the Italian government to "abolish or revise" the bill, and the media freedom representative of the Organization for Security and Co-operation in Europe "urged Italy to amend the bill."
In addition, the European Union committed itself to reviewing the measure and U.S. Assistant Attorney General Lanny Beuer, according to The New York Times, "expressed concern about the bill's impact on the longstanding collaboration between the American and Italian authorities in organized crime and counterterrorism investigations.
Finally the "gag law" gave an argument to Gianfranco Fini, Berlusconi's main rival in his ruling coalition, The People of Liberty. Referring to the need to combat corruption, the president of the House of Deputies expressed his opposition to the bill and actively maneuvered to have it amended or postponed. This is exactly what happened: The law was watered down on July 22, and then action was postponed entirely on Thursday. The air is so poisoned within the coalition that some pundits predict early elections that might have dire consequences for Berlusconi's party.
Many Italian journalists concede that violations of privacy are at times a real issue in Italy. On June 10, The Economist underlined that aspect by referring to "the routine trampling on the rights of suspects and others caught up in investigations … often creating a presumption of guilt that is difficult to reverse."
Most journalists, however, congratulate themselves on the impact of their campaign. They see it as a first victory in the midst of an Italian media scene that has been excessively dominated by Berlusconi's "private empire" and by his crude intervention in the public service broadcasting system.
As important, the rebellion against the bill also turned what might have been denounced as a "corporatist reaction"—the protection of a journalistic "peeping" privilege—into an issue for the whole Italian society: the press as a watchdog defending its freedom to report in order to expose the abuses of power.
At the international level this Italian controversy also reminds everyone that an attack against press freedom in a specific country has an impact outside of its borders, not only because it reduces access to essential information in transnational criminal investigations, but also because it tends to establish a precedent that may inspire other governments facing accusations of corruption or bad governance.
(Reporting from Brussels)

subset: commoncrawl


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Apple's newest iPad already has CIOs and IT professionals planning accordingly. In a recent ChangeWave Research survey, more than one in five business IT buyers said they now plan to buy the new iPad, which goes on sale March 16, during the second quarter of 2012.
That 22 percent, according to ChangeWave, represents the highest level of corporate iPad demand ever found in its surveys.
As of February, 84 percent of the companies that said they plan to buy tablets in the second quarter now say they'll purchase iPads, ChangeWave reported March 13. That figure represents a seven-point jump from a similar November survey.
What's good for Apple, of course, is lousy for the competition.
"The impending release of the new iPad is also having an impact on business purchases of tablets made by other manufacturers," ChangeWave said in a report excerpt.
While Apple's November through February change was a seven-point bump, company plans for buying tablets from other manufacturers fell in every instance. Samsung dipped from 10 percent in November to 8 percent in February, Amazon's tablets from 7 percent to 6 percent, Hewlett-Packard from 5 to 4 percent, Asus from 4 to 3 percent, Dell and Research In Motion each fell from 5 to 3 percent, Lenovo from 3 to 2 percent, and Motorola–representing a 50 percent change, the worst of all–fell from 4 percent saying they planned to buy Motorola tablets to just 2 percent.
Any good luck beyond Apple falls to AT&T and Verizon Wireless. While WiFi-only tablets have been a preference for consumers, more business users than not plan to purchase wireless services, 30 percent from AT&T, 29 percent from Verizon and 4 percent from Sprint, which, despite finally offering the iPhone, will not be privy to the brand-new iPad.
Another 11 percent said they'd do without, leaning on WiFi alone.
Analysts have expected the new iPad to be a hit with IT professionals–though it may bring some challenges, too.
Gartner Research Vice President Carolina Milanesi told eWEEK that the iPad's increased resolution is likely to resonate with users needing to "show brochures or other marketing material."
In the United States, she added, "the addition of LTE Long-Term Evolution might appeal to some organizations whose users are particularly mobile and therefore more reliant on cellular coverage and speed."
IHS iSuppli expects specialty markets such as health care and transportation to be strong verticals for Apple, and most especially education. Earlier this year, Apple launched a textbook program, and it has been aggressively wooing educators.
Apple's new A5X chip will markedly speed things up, and users excited to enjoy content on the high-definition display may quickly speed through monthly data allotments. Those hopping on WiFi, as a work-around, could quickly bog down a corporate network, some fear.
Milanesi speculated that the cost of the iPad, often being shouldered by individuals though used in the enterprise, may help temper the rollout. If business IT buyers stay true to their survey answers, however, during the second quarter, WiFi and wireless broadband networks may quickly feel the impact of a new tablet in town.
To read the original eWeek article, click here: New iPad Is Tablet of Choice for Businesses: Report


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Brace yourselves -- it looks like Obamacare premiums could jump by double digits again next year.
Insurers in several states have requested large rate hikes for 2019, with many pointing to steps taken by President Donald Trump and Republicans in Congress as the main reasons why.
New York insurers want to hike rates by 24%, on average, while carriers in Washington are looking for a 19% average premium increase. In Maryland, CareFirst is asking for an average 18.5% rate bump for its HMO plans and a 91% spike for its PPO policies (which have far fewer enrollees), while Kaiser Permanente wants to boost premiums by more than 37%, on average.
Many insurers cite two key drivers of the increases: Congress' elimination of the penalty for the individual mandate -- which requires nearly all Americans to have coverage or pay up -- and the Trump administration's expected expansion of two types of health plans that don't have to adhere to Obamacare's regulations.
"Health insurance providers are now making decisions about market participation and pricing for the 2019 plan year in a market that continues to face uncertainty and instability challenges," America's Health Insurance Plans, an industry group, wrote in a recent report.
Jettisoning the individual mandate penalty is expected to cause premiums to rise by about 10%, the industry group said, citing reports by the Congressional Budget Office and independent actuaries. That's because younger and healthier people will be more likely to forgo insurance since they will no longer have to pay a penalty. Insurers fear they will then be left with sicker and older policyholders, prompting them to request higher rates to cover the anticipated increase in claims.
Also, Trump last year issued an executive order directing federal agencies to make it easier to buy two alternatives to Obamacare plans. One would allow small businesses to band together to buy coverage through association health plans, while the other would let Americans buy short-term coverage that would last less than a year, rather than the current 90-day limit. Both of these types of policies are expected to have lower premiums, but would cover fewer benefits -- making them more attractive to healthier Americans who don't need comprehensive coverage.
Insurers in remaining states will file proposed rates in coming weeks. Regulators will review the requests and could change them significantly. Premiums will be finalized in September and open enrollment starts November 1.
There are some bright spots in the 2019 Obamacare landscape. Insurers in some states, such as Pennsylvania and Vermont, have requested relatively modest increases. In the Keystone State, insurers are asking for a boost of 4.9% on average. Meanwhile, BlueCross BlueShield of Vermont and MVP Health Care are asking for 7.5% and 10.9% bumps, respectively.
Pennsylvania Insurance Commissioner Jessica Altman attributed the relatively small increase to the state's efforts to maintain enrollment this year after the Trump administration slashed support. Also, the state's individual market remains competitive: Nearly half of counties will have a greater choice of insurers next year, and only eight will have just one carrier, down from 20 this year.
Another plus: Insurers so far haven't pulled out completely from any market in the nation. At various points last year, tens of thousands of Americans in dozens of counties were facing the prospect of having no choice of carriers on their Obamacare exchanges. State regulators, however, were able to convince insurers to offer policies in every county by the time open enrollment began in November.
Also, most Obamacare enrollees won't have to pay more for coverage next year, regardless of how much insurers hike premiums. That's because they receive federal subsidies that limit their rates to less than 10% of their income.
However, the rate hikes will hit the millions of Americans who earn too much for subsidies or who buy individual coverage outside of the Obamacare exchanges.


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The drug maker Pfizer agreed to pay $491 million to settle criminal and civil charges over the illegal marketing of the kidney-transplant drug Rapamune, the Justice Department announced on Tuesday.
In particular,
The recent case centers on the practices of Wyeth Pharmaceuticals, which Pfizer acquired in 2009.
Rapamune, which prevents the body's immune system from rejecting a transplanted organ, was approved by the Food and Drug Administration in 1999 for use in patients receiving a kidney transplant. However, federal officials said Wyeth aggressively promoted the drug for use in patients receiving other organ transplants, even offering financial incentives to its sales force to do so.Accusations of Wyeth's practices became public in 2010 after a whistle-blower lawsuit filed by two former employees was unsealed.After lawmakers announced a Congressional inquiry, the Justice Department opted to join the lawsuit. The settlement announced Tuesday, which also resolves a second, similar whistle-blower suit, includes a criminal fine and forfeiture of $233.5 million, and a civil settlement of $257.4 million with the federal government, all 50 states and the District of Columbia.
The case did not get much media coverage. So far, the only other somewhat detailed article on it was put out by Bloomberg. In fact, the lawyer for two of the whistle-blowers who alerted federal authorities to what Wyeth was doing had to say
the spate of pharmaceutical settlements in recent years had blunted reaction to what he said were shameful practices. 'Everybody's been asking me why this case is different than any other,' he said. 'We used to trust these companies. You can't trust these companies anymore.'
However, we should not be too blase. This case was not only about money. The over-promotion of a potentially dangerous drug likely lead to patients being harmed in the absence of any benefits. Rapamune suppresses the immune system and increases risks of serious infections and malignancy. Specific serious adverse events have been reported when it is used in transplants of organs other than the kidney (e.g., lung and liver transplants). (See full prescribing information here.) Bloomberg reported that 90% of Wyeth's revenues from Rapamune came from off-label uses, suggesting that quite a few people may have been adversely affected by its excess use.
As in most other members of the march of legal settlements by big health care organizations, this case involved no negative consequences for anybody who authorized, directed, or implemented the improper marketing practices. While such people must have existed, they were not even named in the press coverage. At least this settlement involved a guilty plea to a crime, albeit a misdemeanor (misbranding as reported by Bloomberg), so the company did have to admit some wrongdoing.
A Pfizer manager, however, tried to disavow responsibility, as noted by Bloomberg,
'Pfizer was not a subject or target of this matter, and cooperated fully with the government from the time it learned of this investigation in October 2009,' Chris Loder, a Pfizer spokesman,...
But Pfizer had purchased Wyeth, and in doing so got not only assets and profits, but responsibility for actions.
Also, neither the settlement nor the criminal plea seemed to take into account Pfizer's amazingly sorry recent track record. I am losing count of all of Pfizer's settlements and/or guilty plea or convictions since 2000. (The updated list of previous legal results is in the Appendix.)
People found guilty of small-time Medicaid or Medicare fraud often forfeit all their assets and go to jail. Yet actions by large pharmaceutical companies that may harm patients and cost many millions of dollars almost never result in any individual facing any negative consequences, or even being named and shamed. Meanwhile, the managers of these companies may make gargantuan amounts of money partially rationalized by the revenues produced by such recurrent misbehavior. In 2012, according to the company's 2013 proxy filing, Pfizer CEO Ian Reed's total compensation was $25,634,136, and the four next most highly paid executives all made more than $5,000,000.
So the Kabuki play that is regulation of and law enforcement for large health care organizations goes on. As our society is being increasingly divided into a huge majority in increasingly difficult economic circumstances and a small and increasingly rich minority, it also seems to be increasingly divided into little people who may be ruined by lawsuits, and imprisoned for even minor infractions, and big people who have impunity.
True health care reform would need to start by making leaders of big health care organizations accountable for their organizations' misbehavior.
APPENDIX - Pfizer's Settlements


text:
"If a practitioner cannot define what they are feeling for in any realistic, scientific manner, then what is the outcome measures guiding their treatment? By this I don't mean the outcome measure used to define success in the eyes of patients such as pain or range of motion. I mean what is the tactile finding that, on a moment-by-moment basis, guidance the practitioners treatment? How does one know when soft tissue 'release' procedures are appropriate vs. passive modalities? How does one know the needed amplitude and direction of force to apply? How does one know when the treatment is over? These and many other questions require that the practitioner is able to palpably distinguish between normal and abnormal anatomic structure, and further that they have a working definition/understanding of what they are looking for."
- Andreo Spina
Interview by Patrick Ward, http://optimumsportsperformance.com
1) Thanks for taking the time out of your busy clinical and teaching schedule to do this interview, Dr. Spina. Can you please give the readers a short overview of your background??
Sure thing…
I studied Kinesiology at McMaster University in Hamilton, Ontario, Canada. I later graduated with summa cum laude and clinic honors from the Canadian Memorial Chiropractic College as a Doctor of Chiropractic and subsequently completed the two-year post-graduate fellowship in sports sciences. During my time studying Chiropractic, I became the first pre-graduate student to tutor in the cadaver laboratory in the department of Human Anatomy, a position that continued throughout my post-graduate fellowship program.
Stemming from my passion of studying and teaching anatomy, in 2006 I created Functional Anatomic Palpation Systems (F.A.P.)™ which is a systematic approach to soft tissue assessment and palpation. Following the success of F.A.P. seminars, I later created a follow up system of soft tissue release and rehabilitation called Functional Range Release (F.R.)® technique which is now being utilized by manual practitioners around the world including the medical staffs of various professional sports organizations. I then combined the scientific knowledge gained during my studies with my 29 years of martial arts training in various disciplines to create the third installment of my curriculum, Functional Range Conditioning (FRC)™, which is a system of mobility conditioning and joint strengthening.
Aside from my work teaching seminars, I also own a sports centre in Toronto, Ontario where I practice and train clients. I am a published researcher, and I have authored chapters in various sports medicine textbooks.
2) You approach to soft tissue therapy is extremely comprehensive and, after having attending one of your courses before, it is obvious that you have spent a lot of time reading research in order to develop your thought processes and theories about what may be taking place when we apply contact to another person's body. The fascial system is a big part of your approach and the concept of the fascial system and how the body is connected has gained a lot of popularity in recent years. Can you please explain your approach and this concept you refer to as "Bioflow Anatomy"?
To say that the Functional Range Release system has a sole focus on fascia is not entirely accurate actually, although it might have been in the not so distant past. Further examination of literature has led/forced me to be more inclusive of other tissues, which together constitute the most abundant type of tissue in the human body, namely Connective Tissue (CT). Examples of other tissues inclusive in CT other than fascia include bone, cartilage, tendons, ligaments, blood vessels, lymphatic tissues…and even 80% of nerve structure. When contemplating the effects of manual therapy 'inputs,' or even training inputs for that matter, we must be inclusive of all of these tissue types as each of them will equally adapt to applied inputs. To say that with a particular soft tissue technique application I am affecting one tissue vs. another is as inaccurate as claiming that any particular exercise targets a single tissue, which is in fact impossible. This line of thought stems from literature examining the effects of load inputs on cellular/subcellular processes…a topic that we dive into deeply in the FR Release curriculum.
Continue to read the rest of this article by clicking HERE
Thanks to Patrick Ward for this interview!
Register for Andreo Spina's FAP/FR SPINE course in Boston, May 22-24, 2015 HERE.


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on this report, or find
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Our Mystery Worshippers are volunteers who warm church pews for us around the world. If you'd like to become a Mystery Worshipper,
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2445: All Saints, Freshwater, Isle of Wight
Mystery Worshipper:
Mr Kipling.
The church:
All Saints, Freshwater, Isle of Wight.
Church of England
Diocese of Portsmouth
The building:
All Saints is a beautiful village church and is one of the oldest churches on the island, listed in the Domesday Book of 1086. The tower has a peal of six bells and a striking clock. Inside, there is a memorial to Alfred, Lord Tennyson, and Lady Tennyson. The earthly remains of Lady Tennyson rest in the church's graveyard, although Lord Tennyson himself is, of course, buried at Westminster Abbey.
The church:
This is part of a united benefice and there appears to be an active congregation here. The news sheet advertised a house group and men's breakfast, and there are weekday services and events held in all three churches.
The neighbourhood:
The Isle of Wight is the largest island off the coast of England and is also England's smallest county. The island has been a popular holiday destination for many years. Queen Victoria had her holiday home, Osborne House, here. The village of Freshwater is located on the western end of the island and is more rural than the more popular holiday resorts to the north and east. Tennyson lived in the village from 1853 until his death in 1892.
The cast:
No name was published, but I assume the president and preacher was the rector, the Revd Mark Whatson.
The date & time:
16 September 2012, 10.00am.
We have received a
on this report.
What was the name of the service?
Parish Communion.
How full was the building?
Almost full to capacity.
Did anyone welcome you personally?
A lady smiled and said "Good morning, nice to have you with us" as she handed me the books for the service.
Was your pew comfortable?
Can't say I noticed, so it must have been OK.
How would you describe the pre-service atmosphere?
There was a lot of chatter. About two minutes before the service started, the organ started playing quietly, which most people took as the cue to stop talking, but there were still two people having a rather loud conversation at the back of the church.
What were the exact opening words of the service?
"Hymn number 716."
What books did the congregation use during the service?
Complete Anglican Hymns Old And New
and a leaflet published by Redemptorist Publications with the day's readings and collect on one side and the parish notices on the other.
What musical instruments were played?
Organ, an opus of Henry Speechley and Sons dating from 1905. There was also a fairly elderly choir.
Did anything distract you?
I couldn't help noticing the lack of any children anywhere. But then at the communion, a small group of children appeared. I wondered where they'd been hiding them up until that point.
Was the worship stiff-upper-lip, happy clappy, or what?
Fairly standard Anglican middle of the road. There were two candles on the altar and the priest wore eucharistic vestments. There was no genuflecting, but a few people made the sign of the cross at the absolution and the final blessing. There was a a good mix of traditional hymns and contemporary worship songs. There were two readings but, disappointingly, no psalm. The gospel was read from the nave. There was very little lay involvement. A member of the congregation gave the New Testament reading, but all other speaking parts, including the intercessions, were led by the priest.
Exactly how long was the sermon?
10 minutes.
On a scale of 1-10, how good was the preacher?
8 The preacher spoke clearly and held my attention throughout. He had notes that he referred to from time to time, but was not reading from a script.
In a nutshell, what was the sermon about?
Jesus said, "Who do you say I am?" We need to identify who we are in order to identify God, but we must be careful to recognise God for who he really is and not to form him in our own image.
Which part of the service was like being in heaven?
Worshipping in such a beautiful ancient building where countless other Christians have worshiped for many centuries.
And which part was like being in... er... the other place?
Immediately after the opening hymn and procession, just as we were getting fired up for worship, the service came to an abrupt halt. I should clarify: this is where the notices were read. I realise that it is hard to find the right place for notices, but immediately after the first hymn is definitely not the right place!
What happened when you hung around after the service looking lost?
I hung around feeling lost. Eventually, after about ten minutes, a lady came up and spoke to me. Interestingly, after I had left the building, quite a number of people approached me in the churchyard and struck up conversation.
How would you describe the after-service coffee?
Nescafé. Admittedly, it was the coffee that makes up one per cent of Nestlé's fair trade coffee production, but I was still disappointed to see a Nestlé product being served in church.
How would you feel about making this church your regular (where 10 = ecstatic, 0 = terminal)?
6 I was merely a visitor to the Isle of Wight, so I couldn't make it my regular. But the liturgy was dignified and the preaching good, although it was jarring to have the service interrupted by notices as it was.
Did the service make you feel glad to be a Christian?
What one thing will you remember about all this in seven days' time?
The beautiful old building and its surroundings.
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text:
Friday, April 9, 2010
Maui: Surfing Goat Dairy
77 comments:
- Scott said...
Jorge! you're wearing the left coast toe shoes that I have heard about forever but have never seen (in pictures or in real life). How about an expose on them for a east coast suburbaner?
- April 9, 2010 at 11:13 AM
- Kat said...
Nice shoes! I have those too :)
- April 9, 2010 at 11:14 AM
- Hairbig said...
Jorge, what are your favorite places in Kauai I am going there this summer, got any tips?
- April 9, 2010 at 11:14 AM
- Carthagegeneral said...
O thats cool i like the kids, ive never seen any goats in real life , but i guess thats cause its not any goats in Va
- April 9, 2010 at 11:33 AM
- lauren said...
Tell me about how you like your crazy shoes! I have been thinking about getting some. Are they comfy?
- April 9, 2010 at 11:35 AM
- aimymichelle said...
hhahaha i love goats
- April 9, 2010 at 11:55 AM
- Jenn said...
Those are some interesting shoes you're wearing there. What are they?
- April 9, 2010 at 12:19 PM
- Kara said...
awwww what adorable baby kids!
I see you have those "FiveFingers" sneakers - are they really as comfortable as they claim to be? - April 9, 2010 at 12:23 PM
- Unknown said...
So sweet pictures Jorge!
Love the little goat:) - April 9, 2010 at 12:48 PM
- Alisha Rene' said...
you've got those cool shoes!!! been thinking of getting pair myself for running - how do you like them????
aw, kid goats ♥ - April 9, 2010 at 12:48 PM
- Acacia said...
Dude, those shoes rock! One question, how do they get the goats to stay up on the surfboards?
- April 9, 2010 at 1:00 PM
- Tiffany said...
Are you wearing FiveFingers? I *love* them!
- April 9, 2010 at 1:13 PM
- Beena said...
They are too adorable!
- April 9, 2010 at 1:17 PM
- Cassie Hill said...
- April 9, 2010 at 1:21 PM
- IronBrandon said...
You're the only person other than me who has that color Vibram's! Awesome!
- April 9, 2010 at 1:50 PM
- Lord_Shin said...
Hi! I like your shoes, where i can buy ones?
- April 9, 2010 at 1:58 PM
- Galkafisher said...
wow so cute!
- April 9, 2010 at 2:00 PM
these goats are so funny and nice!
you look very happy with them.
cute pics and you ;) - April 9, 2010 at 2:02 PM
- Casey S. Pitman said...
You should have bought a goat! They make wonderful pets. No kidding.
- April 9, 2010 at 2:06 PM
- Bumpshack.com said...
Jorge how do you like your Vibram Five Finger shoes? I am debating getting some. Thanks
- April 9, 2010 at 2:06 PM
- corofin said...
Your sandals. What are they called?
- April 9, 2010 at 2:16 PM
- PJSander said...
Oh mylanta. Those kids are way too cute! Thanks for making me smile!
: ) P - April 9, 2010 at 2:23 PM
- Unknown said...
Hola Jorge,
Que lugar mas bonito el Surfing Goat Dairy. A ese cabritillo seguro que el color verde de tu pantalón le ha recordado al verde de la hierba y por eso te lo estaba mordiendo. Unas fotos realmente entrañables. Un saludo. - April 9, 2010 at 2:29 PM
- mrs.mao said...
Were these the kind that faint? They sure looked cute. By the way, did they show them surfing?
- April 9, 2010 at 2:40 PM
- Deb said...
Very cool. Do they make/sell goat milk soap there? Have you ever tried goat milk soap?
(Hehe, yes, I do make and sell my own goat milk soap and would love to send you some, Jorge!) - April 9, 2010 at 2:42 PM
- Mcarr31 said...
I notice you have some sweet 'shoes' on, we've been thinking of getting some, where did you get yours (kailua? online?) and what do you think of them? - April 9, 2010 at 3:08 PM
- SayWhat12 said...
That baby goat is so adorable!
Jorge, your shoes look uncomfortable. I couldn't stand that between my toes. - April 9, 2010 at 3:28 PM
- Unknown said...
awwww cute little baby goats!
I like the name of the dairy too - April 9, 2010 at 3:35 PM
- GuinGuin said...
Was the little guy for sale? Maybe Nunu would like a new friend : )
P.S. Cool footwear. - April 9, 2010 at 3:39 PM
- Erin said...
Ahhhhhh!!!! Cuteness overload!!! :D
- April 9, 2010 at 3:56 PM
- Unknown said...
How cute! He thought you were his mommy. :-)
- April 9, 2010 at 4:32 PM
- SuperC142 said...
The post says "As you would expect they had goats."; but, actually, I was expecting the goats to be surfing. I think you kinda got ripped off, man. ;-)
- April 9, 2010 at 4:49 PM
- Linda said...
How did you not take that little baby goat home with you? So cute! Thanks for sharing.
- April 9, 2010 at 5:11 PM
- Kel said...
What are your shoes? They look kind of like Vibram Five Fingers (which I adore), but not quite the same...
- April 9, 2010 at 5:14 PM
- Library Cat said...
How precious! My friend Mia is heading to Hawaii - she will love this place I think. I would just like some goat cheese.
How will you ever live anywhere else? - April 9, 2010 at 5:14 PM
- Alysia said...
Cuteness overload!
- April 9, 2010 at 5:28 PM
- HektikLyfe said...
Awesome. What's up with their heads though. I don't know goats but are they getting cut off?
- April 9, 2010 at 5:34 PM
- moon said...
I very much enjoy your travel entries-hope you've got some great vacation plans cooking up!
Looked like the kid was droolin over the FiveFingers. Are they comfy or hot n sweaty? - April 9, 2010 at 5:59 PM
- Charyse said...
Great pictures Jorge! I was in Maui this time last year and I miss it a LOT.
Also, are those Vibram Five Finger shoes you've got on? - April 9, 2010 at 6:14 PM
- Kristy Gee said...
AWWW. Those babies are super adorable.
- April 9, 2010 at 6:56 PM
- yellowdoggranny said...
what? you got out of there without beth adopting a kid?...
- April 9, 2010 at 7:09 PM
- LOLA said...
so cute. I want a goat . mmm goat cheese and a natural lawn mower.. haha
- April 9, 2010 at 7:16 PM
- Tiffany Noélli said...
That good place to go... I loved goatlings babies!!! You are very affectionate with animals... Quality I admire very. Many kisses =)
- April 9, 2010 at 7:49 PM
- susanthe said...
Jorge, how do you like the barefoot shoes?
Love the goats. - April 9, 2010 at 8:04 PM
- Linda Jividen said...
Goats... Hmmmmmm... Didn't STARE at any of them, did you? :)
- April 9, 2010 at 8:37 PM
- Michele said...
Those kids are adorable! However, I don't know enough about kids/goats to know if the horns have not yet grown in or if they were cut off. The tops of their heads are freaking me out a little bit.
:-0 - April 9, 2010 at 9:15 PM
- Kathy said...
SQUEE! Those "kids" are mighty cute! Even attempting to eat your pants :P
- April 9, 2010 at 11:04 PM
- ryan said...
Nice shoes. What are they?
- April 9, 2010 at 11:23 PM
- reAnimated said...
Do you have Vibram shoes?
- April 9, 2010 at 11:42 PM
- Mom2haylil said...
Forget the pants, tell us about those shoes......
- April 9, 2010 at 11:54 PM
- Michelle said...
Hey, now I'm curious about your VFFs. Since you've given some awesome product reviews in the past - what do you think of them? How do you like them? Recommend?
And aren't baby goats the CUTEST things?! (Well, next to certain lil' black chihuahuas, at least?)
...Michelle - April 10, 2010 at 12:02 AM
Oh my, this reminds me of how much my Mom wanted a "fainting" goat. Your pix are way too cute.
- April 10, 2010 at 12:27 AM
- bgprodarts said...
Dear Jorge,
I used to enjoy your blog, but as someone who was attacked by goats at a petting zoo as a child I'm not not so sure anymore. I was not attacked by one or two, but the entire herd of goats at the zoo!!! They bit me and stampeded me to the point that I had hoof prints and teeth marks from head to toe. I finally broke free with tears streaming down my face. Running to my mothers arms only to find her laughing hysterically like it was the funniest thing in the world. So to that I say Thank you. Yes this actually happened, and I will continue to read your blog. - April 10, 2010 at 6:24 AM
Absolutely adorable. And what a clever name -- Surfing Goat! What images it brings up! Thanks for the photos.
- April 10, 2010 at 8:14 AM
- Kaileigh Blue said...
Daawww Goats and their creepy creepy eyes.
- April 10, 2010 at 8:27 AM
- Jorge Garcia said...
That's crazy Double Dad. when I was little a goat ate my ticket. It was one of those all access tickets that you wore. I had mine around a belt loop and I watched the goat eat the entire thing off.
- April 10, 2010 at 12:18 PM
- James Hernandez said...
I am a little disappointed. I think your headline was a teaser. I want to see a surfing goat dude! - April 10, 2010 at 1:59 PM
- Aynna banahna said...
Yay for five fingers!
- April 10, 2010 at 2:02 PM
Woah... your sandals are awesome!
- April 10, 2010 at 2:47 PM
- ruth said...
well... those are some interesting looking shoes~~
- April 10, 2010 at 6:03 PM
- Unknown said...
OMG!!! I LOVE goats! They have such cool personalities!!
- April 11, 2010 at 3:52 PM
- DharmaMeetsDogma said...
I have 5 pair of VFF myself. You are now even cooler in my book.
- April 12, 2010 at 6:47 AM
- Hadley said...
Love Surfing Goat Dairy - it's one of my favorite places to hit when we go to Maui.
- April 12, 2010 at 7:52 AM
- Unknown said...
big ups five fingers!
- April 12, 2010 at 8:38 AM
- Susi said...
I luv the shoes too - I got mine a couple of months ago and wear them all the time - played golf, racquetball, shopped til I dropped(with these, I'll never drop - my feet never tire!) Haven't tried playing tennis - going to try next time and see; stay tuned.
- April 12, 2010 at 11:05 AM
- Janelle said...
There's a zoo here where a whole section is just a goat petting zoo. Endless fun.
- April 12, 2010 at 11:32 AM
- Stacey B said...
I don't know, I'm thinking he was more interested in your toe shoes!!
- April 12, 2010 at 11:43 AM
- Unknown said...
Vibram Fivefinger are actually from the east coast.
- April 12, 2010 at 4:33 PM
- Unknown said...
Jorge, love the VFF's. I have the blue cammo pattern, I love them.
- April 13, 2010 at 2:23 AM
- ToNee said...
i buy it!
- April 13, 2010 at 10:37 AM
hey jorge!
you are awesome and you rock! i'm such a Lost fan!
i think you would be great on The Office too!
ah, the beloved five fingers....my go-to shoe since last august when i got a couple of pairs. i hate wearing shoes, and these just feel fantastic on my flat feet! this is the first i've seen of anyone else wearing them! i have them in black (gorilla) and brown (sasquatch)
love ya,
matthew sweet (singer, matthewsweet.com) - April 13, 2010 at 12:06 PM
- Author said...
It looks like there is a lot of demand here for you to review your FiveFingers. I came here to ask how you liked them since I'm thinking about getting a pair, but now I see this is in no way an original comment...
- April 15, 2010 at 5:17 AM
- Unknown said...
Don't know if anyone commented on the Vibram FF shoes, but I have some and they are fantastic for running, kickbox, step, etc.! I wear them for everything! Has Mr. Garcia chimed in yet? Haven't been able to get through all of the posts!
- April 15, 2010 at 3:21 PM
- Frank Pulaski - Dreamtyme Films said...
So cool you guys were visiting Maui, wish I could of bumped into you during your visit..I bet you were staying in the B&B in Kula, right down the street from me...thanks for posting the surfing goat pics, cool to see my home from a different perspective...Aloha!
- April 16, 2010 at 8:22 PM
- Sheralyn said...
Thanks for posting all the pics!
I hadn't heard about this place yet... after browsing their site, and reading up on them on TripAdvisor (granted, some of the reviews aren't exactly glowing... but there are also a lot of people who really liked it!), I think we'll try to include it on our next trip to Maui!
I have a couple of toddlers who will enjoy seeing the goats, and I will enjoy tasting their cheeses! YUM! :)
P.S. I just have to say that I'm a huge fan of Lost! :) I'll be sad to see the series end this year! - April 19, 2010 at 1:26 PM
- Anna Schafer said...
I notice you have some sweet 'shoes' on, we've been thinking of getting some, where did you get yours (kailua? online?) and what do you think of them? tours on wailea
- November 14, 2015 at 12:53 AM
- Robert said...
Great info! I recently came across your blog and have been reading along. I thought I would leave my first comment. I don't know what to say except that I have. limousine maui
- February 25, 2016 at 1:57 AM


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The four Americans who were shot at and abducted in Mexico were reportedly visiting for medical tourism — making them part of a booming industry that is vital to Mexico's economy.
"Pre-pandemic, some 1.2 million American citizens traveled to Mexico for elective medical treatment," Josef Woodman, CEO of Patients Beyond Borders, told NPR. His firm publishes a guide to international medical travel.
Here's an update on medical tourism, and the recent tragedy:
U.S. medical travel is rising sharply
"Today, the market is recovering rapidly in Mexico, nearly back to its pre-pandemic levels," Woodman said.
Nearly 780,000 people were projected to leave the U.S. for health care in 2022, according to Healthcare.com, citing data from the medical travel website Medical Departures.
That outburst of activity got a big boost in late 2021, when the U.S. relaxed key border restrictions with Mexico.
Costa Rica is the second-most popular destination for U.S. visitors seeking medical care elsewhere, Woodman said. It's a particular draw, he added, for people in the Northeast and Southeast.
Most people travel for dental and cosmetic work
Cosmetic surgeries are just one of the procedures that are far cheaper in Mexico — for years, people have been visiting from the U.S. to get elaborate dental work or cosmetic treatments done, or to pick up antibiotics and other medicines at favorable prices.
Many people also travel to get orthopedic work done, replacing knees or hips for less than half the cost of such procedures in the U.S.
"North American patients travel to Mexico for care primarily to save 50-70% over what they would pay in the United States for an elective treatment," according to Woodman.
Medical tourism does bring risks, experts say
While an element of risk is inherent in many procedures no matter where they're performed, medical tourism can heighten complications, according to the Centers for Disease Control and Prevention.
Potential problems range from the dangers of flying in a pressurized plane cabin too soon after a surgery to the complications of getting follow-up care for a procedure done in another country.
Some of the most serious warnings from the CDC are for infections, from wound and blood infections to pathogens that might be more common or resistant in the host country than in the U.S.
"Recent examples include surgical site infections caused by nontuberculous mycobacteria in patients who underwent cosmetic surgery in the Dominican Republic," the CDC says, "and Q fever in patients who received fetal sheep cell injections in Germany."
U.S. medical tourists rate Mexico highly
A 2020 research paper that surveyed some 427 Americans crossing the U.S.-Mexico border in California for medical services found that most of the respondents "felt that Mexican health care services are of the same or better quality compared with those in the United States, for a lower cost."
People had come from 29 states across the U.S. to get care in Mexico, with the vast majority driven by cost concerns, according to the paper, published in the Journal of the American Pharmacists Association.
The researchers also collected data about the medical tourists themselves, reporting an average age of 64.5 years. Their most common yearly income range was reported to be between $25,001 and $50,000 — but that reflects less than a quarter of the respondents.
More than 400 of the survey's 427 participants said they would undertake more medical tourism in the future, the paper said.
Most of Mexico's hospitals follow U.S. standards
Mexico has worked for years to promote medical tourism to draw patients across the U.S. border. That includes improving its health system and following international standards.
"About 10 years ago, the Mexican federal government licensed the Joint Commission accreditation standards, which are used to accredit U.S. hospitals," as David Vequist, who runs the Center of Medical Tourism Research at the University of the Incarnate Word in San Antonio, told NPR's All Things Considered.
"So most Mexican hospitals are now basically using the same standards we use in hospitals in the United States," Vequist added.
Details of the recent violence are still emerging
At least one of the U.S. citizens who were caught up in the recent tragedy was reportedly going to Mexico for a tummy tuck operation. But the group's vehicle came under fire hours after entering the border city of Matamoros, Mexico, from Brownsville, Texas.
Two of the four died; all are reported to be natives of Lake City, S.C. Their identities have not been released, but relatives have been speaking to NPR and other outlets.
Mexican officials say they believe the four were caught in the middle of a conflict between drug cartels in the state of Tamaulipas — an area that is under a do-not-travel advisory from the U.S. State Department.
Copyright 2023 NPR. To see more, visit https://www.npr.org.


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Mobile | Feature
The University of Washington Tacoma is hoping to improve retention with a daily support message sent to each student's mobile device.
Retention and student success have long been among the biggest issues facing institutions of higher education, but a new generation of students is complicating matters. "There has been a change in who goes to college," according to Colleen Carmean, assistant chancellor for academic technologies at the University of Washington Tacoma. "We think of the traditional student as the person right out of high school; but now the demographic is across the board. What in the past was a small percentage of students returning to college is now the majority. We are a nation going to college, as people realize they need a college degree in order to have a more successful life."
As an urban-serving university in the downtown hub of Tacoma, WA, UWT has first-hand experience with today's "post-traditional" or "new traditional" learners. Many of its 4,300 students are first-generation, part-time, low-income or underprepared for college. What's more, research indicates that young people going to college are not as mature as in previous generations, noted Carmean. "This is a change for American higher education," she said. "This is a more protected generation, coming into adulthood much later. They arrive at college not prepared for their new responsibilities. So how does the infrastructure of a university, with certain expectations, change to accommodate this fact?"
The Mobile Nudge Looking for a way to help these "new traditionals" persist from freshman year into succeeding years, UWT turned to a technology that is already ubiquitous to most students: mobile. The institution was the first school to use Persistence Plus, a personalized mobile support system that uses behavioral interventions to reach out to, engage and support students throughout their college years. The service helps keep students on track by delivering a mobile "nudge", a daily text message that reminds them about quizzes and tests, helps with time, stress, and performance management, and encourages appropriate behavioral responses.
"We deliver support through the channel that students use most," explained Jill Frankfort, CEO and cofounder of Persistence Plus, a two-year-old company that uses behavioral science, mobile technology and data analytics to foster the behaviors and mindsets associated with college success. Students receive Persistence Plus mobile nudges via SMS or through an Android or iOS smartphone app. The cost of the service is structured around a setup fee and a license based on per-student cost and the customization level required.
Regular behavioral nudges are designed to enhance resiliency, planning skills and progress tracking. The service aims to help students learn how to prepare for and deal with academic setbacks and external obstacles; organize their time and responsibilities; and make progress toward short‐ and long-term goals. "There is growing research showing that students drop out of college not just because of lack of finances or weak academic skills," Frankfort said. "Increasingly, students do not 'persist' because of non-cognitive factors: lack of confidence, lack of connection, feeling overwhelmed."
UWT course instructors work with Persistence Plus to code assignments and test deadlines into the daily nudges, as well as reminder dates for the university's academic calendar. Deadlines are turned into timely, supportive nudges. A learning algorithm monitors students' response to the messages and determines appropriate support replies.
As Frankfort explained, "We work with behavioral experts, both on staff and externally. Studies show that if you help people identify time and place to complete a certain task, they are far more likely to complete the behavior that is prompted. One way we help students is to help them plan their time, or to create a mental map, if you will." The complexity, according to Frankfort, lies in identifying the right nudge for the right student at the right time: what the message looks like; when it should be delivered; and the type of response that is solicited.
Student Support "Our mission is to do what we can to get our students to the finish line," said Carmean. "If this support helps, if we can help them to stay on track, our students will be better prepared, more successful." Carmean compared the daily nudge to the Microsoft Calendar "ding." "We're hoping to create mobile 'dings' that help with time, stress and information management, that give [learners] the research information they need about what makes a successful student, that help them with their mental and emotional needs as students."
As an example, she cited the full-time working mother with children at home. "She is stressed; her commitments are high across many different obligations. Anything we can do to help her could make the difference between whether or not she makes it to graduation." She added that the same goes for first-generation students who don't know what to expect from the college experience. "There's no one at home to mentor or support them in this experience, and there is high anxiety among them."
"This is the new majority," Carmean emphasized. "We need to start thinking about how to serve the needs of these students, rather than thinking of the typical college student as ourselves years later."
At UWT, the greatest retention struggle is often the first year. Students are discovering the commitment is long and difficult, with much sacrifice ahead. Carmean explained that their greatest challenge is coming back after the summer off: "It's hard," she said, adding that, hopefully, daily support nudges over the summer keep students feeling connected and curtail "summer melt." The evidence, for Carmean and her associates, will be in September, when they see how many students return for sophomore year.
"There has been a huge change in the way we think about supporting our students," concluded Carmean. "We have to get around that at the institutional level. Behavioral reminders need to be the default, not the option. To increase access to disadvantaged populations without recognizing the need for new forms of engagement is a venture sure to fail."


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Our History
The history of Zippo Manufacturing Company is the story of its people. From its founder George G. Blaisdell, to the many Zippo employees, customers, and collectors who have all played a vital role in the company's rich history. Their loyalty and dedication has made Zippo one of America's greatest and most recognizable icons.
The Zippo timeline begins in the early 1930s, at the Bradford Country Club in Bradford, Pennsylvania. Mr. Blaisdell watched a friend struggle awkwardly to use a cumbersome, Austrian-made lighter. Mr. Blaisdell noted that the lighter worked well, even in the wind, due to the unique chimney, but the appearance and design was utilitarian and inefficient. The lighter required the use of two hands to operate and its thin metal surface was easily dented.
In late 1932 Mr. Blaisdell decided to reconstruct the Austrian lighter. He fabricated a small rectangular case and attached a lid with a hinge. He preserved the chimney design which protected the flame. The result was an attractive lighter that was easily operated with one hand. The name "Zippo" was created by Mr Blaisdell. He liked the sound of the word "zipper" so he formed variations on the word until he settled on "Zippo," which he felt had a "modern" sound.
The new pocket lighter sold for $1.95 each and was backed by Mr. Blaisdell's, now famous, unconditional lifetime guarantee –"It works or we fix it free.™" The application for the original Zippo patent was filed on May 17, 1934, and patent number 2032695 was granted on March 3, 1936. That first Zippo pocket lighter, produced in 1933, is on display at the Zippo/Case Museum in Bradford.
In the mid-30's, Kendall Refining Company in Bradford, placed an order for 500 Zippo lighters. These lighters are believed to be the first company-advertised lighters produced by Zippo and are highly prized collectibles.
World War II had a profound impact on Zippo. Upon America's entry into the war in 1941, Zippo ceased production of lighters for consumer markets and dedicated all production to the U.S. military. This initiative led to the production of the steel-case Zippo lighter with black crackle finish. The fact that millions of American military personnel carried the lighter into battle was a significant catalyst in establishing Zippo as an American icon throughout the world. Supplying the military market resulted in full production for the plant and enabled Zippo to become financially strong and made it a viable company.
At the end of the war in 1945, Zippo returned to selling lighters to a peacetime America and resumed producing lighters for the consumer market. A promoter at heart, Mr. Blaisdell wanted to hit the road with a car that looked like a Zippo lighter and in 1947 the Zippo Car was born.
On August 1, 1950 Zippo was issued its second patent, number 2517191. The design of the Zippo lighter remains basically the same to this day, with minor improvements.
Beginning in the mid-50's, date codes were stamped on the bottom of every Zippo lighter. The original purpose was for quality control, but the codes have become an invaluable tool for collectors.
In 1956 Zippo launched the Slim lighter, which was a major milestone. This slightly smaller version of the Zippo lighter was designed to appeal to women but much to his surprise also appealed to men.
In the 1960's concert-goers began raising the Zippo flame as a salute to favorite performers, a gesture later dubbed the "Zippo Moment."
In 1962 Zippo produced its first non-lighter product. The steel pocket tape measure, or "rule," as it was called, had a design that resembled the famous lighter. Other items have been added and deleted from the Zippo line since the 1960s. Many were primarily geared to the promotional products division including key chains, golf greenskeepers, pen-and-pencil sets and the ZipLight pocket flashlight.
Mr. Blaisdell passed away on October 3, 1978. He is remembered not only for inventing the Zippo lighter, but also for his generosity and kind spirit. After his passing, his daughters, Harriett B. Wick and Sarah B. Dorn, inherited the business.
During the 1970s Zippo began expanding to overseas markets.
In the 1980s the company was owned by six members of the Blaisdell family, including Mr. Blaisdell's daughters and their children.
In 1993 Zippo acquired W.R. Case & Sons Cutlery Company. Case's rich heritage began when it was founded in 1889. The company moved to Bradford in 1905. Case manufacturers premium hand-crafted knives including traditional folding pocket knives and fixed blade sporting knives to limited-edition commemoratives and collectibles.
The Zippo/Case Museum opened in July 1997. The 15,000-square-foot facility includes a store and museum. It is also home to the world-famous Zippo Repair Clinic, where visitors can watch the repair process take place.
In the fall of 2002, Zippo obtained trademark registration for the shape of the Zippo lighter. This was a major milestone to help protect the brand from counterfeiters.
Also in the early 2000's Zippo launched the first Zippo MPL®, multi-purpose lighter, a refillable utility-style lighter.
In February 2010 Zippo acquired the Ronson brand of lighters and Ronsonol brand of fuel.
In 2010 the company introduced an all-metal hand warmer, launching the Zippo Outdoor products. The hand warmer uses Zippo premium lighter fluid and provides a steady source of heat longer than any other product on the market.
Zippo's continued expansion in overseas markets, particularly India and China, as well as strong domestic sales led to record sales increases in 2011 and 2012.
In 2011 the Zippo Outdoor product selection expanded to include an emergency fire starter kit and flex neck utility lighter.
In 2012, during its 80th anniversary year, Zippo production surpassed the landmark 500 millionth lighter.
Also in 2012, the Zippo/Case Museum was remodeled to better reflect the Zippo brand. The modern design features a combination of rich and rugged textures, like leather and brick, and a mix of vintage artwork and lifestyle photography.
In 2013 Zippo launched a line of robust Zippo-branded camping gear and fire accessories.
Today, George B. Duke, Mr. Blaisdell's grandson, is the sole owner and Chairman of the Board of Zippo. Mark Paup is the company's President and CEO.
Zippo's diverse product line continues to grow, and now includes lighter accessories, butane multi-purpose lighters, men's and women's fragrances, lifestyle accessories, eyewear, and products for outdoor enthusiasts.
There are many Zippo collectors around the world. Their fervor and dedication to the brand is unparalleled. To enhance the collecting experience, Zippo collector clubs around the world hold meet ups and other events throughout the year.
Companies around the world continue to use Zippo lighters as an advertising and promotional tool. These "advertiser" lighters continue to be among collectors' favorites.
Perhaps one of the biggest influences on collecting is Zippo's ties to popular culture, Hollywood, Broadway, and the music industry. The Zippo lighter has been featured in more than 2,000 movies, stage plays and television shows over the years. Zippo lighters have "starred" in such diverse productions as "I Love Lucy" "The X-Men" and "Hairspray – the Musical." Often the lighter is a key prop, used as a device to move the plot forward or to reflect the personality of a character or time period being depicted. The famous Zippo "click" sound has been sampled on songs, and the lighters themselves have been featured on album covers, tattooed on rockers' skin, and wielded in Rolling Stone photo shoots.
In a world where most products are simply disposable or available with limited warranties, the Zippo pocket lighter remains backed by its famous lifetime guarantee. In more than 90 years, no one has ever spent a cent on the mechanical repair of a Zippo pocket lighter regardless of the lighter's age or condition. The Zippo pocket lighter is ingrained in American culture and is a global icon of durability and reliability.


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Cas d'application
SMART Digital solves off-gassing problem
Beaufort-Jasper Water and Sewer Authority solves off-gassing problem with Grundfos SMART Digital
The Beaufort – Jasper Water and Sewer Authority (BJWSA), is a nonprofit authority established by the State of South Carolina to provide drinking water and treat wastewater in Beaufort and Jasper counties of South Carolina. Beaufort and Jasper counties are located in the southeastern corner of South Carolina and include the communities of Hilton Head, Beaufort and Bluffton. Currently BJWSA has two modern water plants and multiple well sites capable of producing up to 39 MGD of drinking water and six wastewater facilities capable of treating up to 16 MGD. BJWSA is a leader in water reuse and is capable of reclaiming up to 5 MGD of water for irrigation, including South Carolina's first residential irrigation service.
The situation
BJWSA operates a lagoon style wastewater treatment plant (WWTP) at Point South, SC. The .35 MGD plant was upgraded in 2009 to collect and treat wastewater from the small community of Point South, situated immediately off Interstate 95, as well as a new planned community designed for 2500 homes. Due to the recession of 2009 the planned community was put on hold and to date, no homes have been built. As a result, monthly flow to the new plant averages only 50,000 gallons per day, with night time flows falling to as little as 12 gpm.
The Point South WWTP plant discharges effluent by pumping to a spray field. BJWSA's goal is to maintain a 1.5 ppm chlorine residual in the final effluent. During the upgrade of the plant, the contractor installed two ½ HP motor-driven mechanical diaphragm pumps, equipped with an auto-degassing liquid end to dose 12.5 percent sodium hypochlorite. The mechanical diaphragm pumps, equipped with an internal variable frequency drive (VFD) and stroke length adjustment, were sized for up to 26.7 gph at 150 psi. The amount of 12.5 percent hypochlorite required to treat the effluent ranged from a high of 2.5 gph on summer weekends and major rain events to a low of .1 gph during the winter months.
The original pumps worked satisfactorily at higher chemical flow rates but repeatedly vapor locked at lower flows. To manage the problem of off-gassing and the resultant vapor lock, plant personnel were maintaining higher rates of chemical injection than required, and constantly bleeding off the vapors from the pump head during their morning inspection. The degassing device on the pumps failed to evacuate the gas from the pump head. Eventually plant personnel were forced to cut the sodium hypochlorite concentration from 12.5 percent to 6 percent in order to increase the reliability of the chemical metering pumps. This manual dilution operation had to be done by the plant operator about every 7 days, resulting in increased operational and chemical costs for BJWSA.
The existing system piping was very well done. All accessories, to include a back pressure and pressure relief valve, as well as pulsation dampeners and gages were installed and correctly placed. There was a vent on the suction line and the suction piping had a gentle upward slope.
The Grundfos solution
BJWSA was already familiar with the Grundfos DME dosing pump and digital dosing technology. Their engineering group had recently specified two DMEs on an ammonia hydroxide application at a water distribution pump station to "try" the technology and the Purrysburg WTP had purchased a DME to replace an aging hydraulic pump that was feeding fluoride. BJWSA understood the advantages of digital dosing technology.
When asked about a Beta test opportunity with Grundfos' new SMART Digital dosing pump, BJWSA mentioned the Point South WWT plant and the problems they were having with vapor lock. Their interest was to go back to using full strength 12.5 percent hypochlorite and avoid the process of diluting the chemical to accommodate the existing pumps. In this application, the Beta pump (SMART Digital DDA) would be required to follow a 4-20 mA signal from an open channel flow meter installed in the chlorine contact chamber. It was agreed that this was the right opportunity to test the new pump's ability to handle off gassing liquids while operating at low flows.
The outcome
With significant support from BJWSA , the Beta version of the SMART Digital DDA was installed. It was powered up and primed still using the dilute 6 percent hypochlorite. Everyone was pleased to see dozens of hypochlorite bubbles the size of a dime move up the clear plastic tubing through the pump head and out the discharge, an assurance that the pump was performing as desired.
The SMART Digital controls were set to Auto deaeration, Flow Control, and AutoFlowAdapt. These "intelligent features" allow the pump to automatically adjust the speed to remove air bubbles while matching the capacity set point, even if there are pressure fluctuations in the line. The 4-20mA input was scaled to match the minimum and maximum flow desired.
BJWSA watched the pump closely for a little over a week and noted that it performed perfectly without experiencing a single incidence of vapor lock. The decision was then made to try the SMART Digital DDA on the full strength 12.5 percent solution. After the switch to the full strength chemical, the pump continued to perform without a problem. In the weeks following, coastal South Carolina experienced a very hot summer with temperatures often exceeding 100° F and not often below the 90°F range. Throughout the hot summer, the fall and winter, the SMART Digital DDA never experienced a vapor lock problem.
Beyond the substantial increase in reliability and the ability to meter full strength sodium hypochlorite, BJWSA noted two additional benefits. First, their chemical usage dropped from an average of 11 gpd with the 6 percent concentration and down to 2 gpd with the 12.5 percent concentration. This has been acknowledged as a cost savings to BJWSA. Secondly, the SMART Digital DDA installation is connected to a Universal Power Supply which displays the electrical load. The pump consumes only 1 percent of the UPC load.
The original pumps were not reconnected to determine the load, but the plant operator noted that during a power failure the UPC would last only 15 minutes with the motor-driven pumps and now lasts 45 minutes with the SMART Digital DDA. By reducing chemical use and power consumption through the use of the SMART digital, BJWSA is also reducing their foot print and environmental impact.
BJWSA reports they are extremely pleased with the performance of the Beta version of the SMART Digital.


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Endless Reader
Winner of Apple's App Store Best of 2013 award!
As a follow-up to Endless Alphabet, set the stage for early reading success with Endless Reader! This app introduces "sight words", the most commonly used words in school, library, and children's books. Kids need to recognize these words by sight in order to achieve reading fluency. Recognizing sight words is advantageous for beginning readers because many of these words have unusual spelling, cannot be sounded out using phonics knowledge, and often cannot be represented using pictures.
Kids will have a blast learning sight words and their context and usage with the adorable Endless monsters. Each word features an interactive word puzzle with letters that come alive, and then a sentence puzzle with words that become what they describe. See the word "dog" as a barking dog, and the word "up" reach for the sky!
- 6 words free to try with additional word packs available for purchase. Even more Reader Packs will be available for purchase in the future.
- Delightful animations reinforce sight recognition of words in a fun and interactive way.
- Word puzzles reinforce spelling using lower-case letters and the sentence puzzles teach definition and usage (in addition to sight recognition).
- Endless Reader was designed with your children in mind. There are no high scores, failures, limits or stress. Your children can interact with the app at their own pace.
Have a problem or suggestion?
Email us at email@example.com.


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Salt Pepper Grinders In Higashiazabu
A 2017 Wall Street Journal survey found that employers have a very or somewhat difficult time finding people with the requisite soft skills. But what if employers are looking for soft skills and are not seeing them? The vast majority of mid-size and large employers in the US, UK and Canada utilize Applicant Tracking Systems.
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