text:
For Immediate Release
Office of the Press Secretary
October 23, 2001
Press Briefing by Ari Fleischer
Listen to the Briefing
MR. FLEISCHER: Good afternoon. Let me give you an update on the President's
day and I'll be pleased to take questions.
The President this morning met for breakfast with Speaker Hastert, Leader Daschle, Minority Leader Gephardt, and Minority Leader Lott. They discussed the war in Afghanistan, the anthrax situation in the nation, as well as the upcoming congressional agenda. On the congressional agenda, they focused on getting the counterterrorism legislation passed through the Congress as quickly as possible; aviation security legislation; a stimulus package.
They discussed the energy bill pending on the Hill, as well as the importance of confirming judges before the session is out.
The President also convened a meeting of his National Security Council earlier this morning. Later this afternoon, the President will attend -- will drop by a meeting that Dr. Condoleezza Rice, the National Security Advisor, is having with Israeli Foreign Minister Peres. I anticipate that at that meeting, the President will convey his condolences over the assassination of Minister Zeevi, as well as urge Israel to withdraw from Palestinian areas.
Following that, the President, in the mid-afternoon will have a meeting with members of Congress to discuss the results of his trip to Asia, where he just returned from Shanghai the other night.
Let me give you an update on one other item involving the Postal Service and the anthrax issue, then I'll be happy to take questions.
The Postal Service is taking a number of preventative measures to protect our nation's postal workers, as well as the public. As Postmaster General Potter said yesterday, the United States Postal Service is engaged in simultaneous efforts on three fronts to combat the threat, and those fronts are: education, investigation and intervention.
The United States Postal Service is continually updating its employees through a series of talks and through informational visits by medical experts who are meeting with employees of the Postal Service.
A postcard with information about what to look for in suspicious letters and packages is on its way to every home and business in America, and the Postal Service is also looking into what type of gloves will best protect postal employees who work in back room handling and sorting mail.
The post office also will now vacuum their scanning machines to make sure that all the dust is collected. Previously, the Postal Service used a technique that was referred to as a blowing technique, where they would blow out the machines using an air gun to blow out the dust. That procedure will now be changed.
And finally, the Postal Service is moving as quickly as possible to identify, acquire and deploy new technology, new technologically advanced equipment to sanitize the mail. There's equipment already available that used irradiation or ultraviolet techniques to kill bacteria. So the Postal Service is moving on multiple fronts as far as the investigation and protection is concerned.
With that, I'm happy to take questions. Helen.
Q In that respect, is there any plan to vaccinate all of the postal workers in the country against anthrax?
MR. FLEISCHER: No, there is no such plan.
Q Why not?
MR. FLEISCHER: Well, as was stressed yesterday by one of the medical professionals from here, the procedure that, in the estimation of the Centers for Disease Control, the scientists and the medical community, that works best is in cases where there is belief that anthrax may have occurred, to move in quickly and provide antibiotics.
For people who have no contact with anything involving anthrax, providing antibiotics can actually have a harmful effect. It can lead to a buildup of an immune system that can be counterproductive in case people do later contract an illness. Providing people with antibiotics for problems which have not occurred can lead to more problems than solutions. And that's why the medical community generally does not prescribe medicine for people who have not been impacted by any type of illness.
Q So there is no real preventive, per se.
MR. FLEISCHER: But that's the problem, according to the medical community. It's not simply a preventive step in that nature.
Q But, Ari, does the President now believe that given that these two Washington, D.C. postal workers have now confirmed -- that have died of anthrax, that these treatment protocols are too conservative, that not enough was done to test and treat postal workers in Washington, D.C., and that, going forward, they need to be more aggressive?
MR. FLEISCHER: Terry, the President believes that the cause of death was not the treatment made by the federal government or the local officials, or anybody else, that the cause of deaths was the attack that was made on our nation as a result of people mailing anthrax through the mail.
And that's why the President, working through the FBI, is determined to find out, as quickly as possible, who was behind these attacks. It's another reason the Postal Service, for example, has offered a $1 million reward for anybody who can provide information to the federal government who may be behind these attacks.
Q It was a terrible lesson learned, essentially, that the treatment protocols, limiting testing and treatment to those right close to the hot spot, that was too conservative, and that people died as a result.
MR. FLEISCHER: Well, in New Jersey, as you see, there's been announced earlier today, there's a confirmed case of inhalation anthrax, where somebody had previously been treated, and his prognosis is sound. So there is existing protocol, existing evidence, based on how people were treated in New Jersey and in Florida that was the best response.
Clearly in the case of Washington, the procedure that was in place was after the mail was received in Senator Daschle's office, to trace backwards all the points at which the mail was received. And they moved as quickly as they possibly could on that. And I think that hopefully there will not be any future incidents like this; but if there are, I think that from each incident, the government learns as best as it can from every previous incident, and takes every action based on what they've learned.
Q Ari, there have been criticisms of the government for a long time now that it was ill prepared to deal with a bio-terror attack. The fact that these postal workers have become infected, does that not represent a real sort of break in the chain here, that the Centers for Disease Control had not sought through -- not thought through completely the methods of transmission?
And again, to the question of the difference in response between what happened on Capitol Hill and what happened at Brentwood, a lot of postal workers are saying, you shut down the government, but you told us to keep working.
MR. FLEISCHER: Well, again, the procedures that were put in place were put in place the same way they were done in Florida, successfully, the same way they were done in New York City, where media outlets received anthrax in the mail.
As soon as the anthrax was received, they took all the same actions in Senator Daschle's office they did at NBC, for example, or that they did at AMI in Boca Raton, for example. So you can make it an analogous situation between the way government workers and Senator Daschle's office were treated and the media was treated.
Then, they walked backwards to determine where the letter could have come from. And as a result of what they learned, they started treating in Trenton, for example -- the postal workers there were given the antibiotics as they identified the hot spots in the facilities there.
Q Well, why --
Q So you're denying any implication that there might have been a discrimination in the way a certain group was treated versus the other?
MR. FLEISCHER: Yes, I don't see any evidence to support that, Helen.
Q Even as recently as Thursday, though, even as recently as Thursday, there were postal workers in Trenton who were discovered with possibly having skin anthrax, and there wasn't any action on the part of Washington, D.C., federal or state or local officials to treat postal workers here. If there are some handlers in Trenton that may have skin anthrax, there was really nothing in terms of testing antibiotics, even any advisory to the postal workers here. Why?
MR. FLEISCHER: It all depends on tracing back the source of the letters. And in the case of Trenton, of course, based on the postmarks, people knew where the letters had come from. In the case of the mail that Senator Daschle's office, it took an amount of time to trace back where the letters had come through, which post offices it came through.
They traced it back from Senator Daschle's office to the P Street postal station, to the Brentwood facility, and that took some time.
Q But they always know, all mail, they know that all mail goes from that central mail facility at Brentwood to Capitol Hill. So any mail that would end up in Senator Daschle's desk, they would know right from the outset that mail starts in Brentwood.
MR. FLEISCHER: And they traced it back as quickly as they could, and took the steps that they did, based on what took place in Florida and in New York City.
Q Even after what happened at this Brentwood facility, you're saying that the government will not change its protocols in terms of where and when the testing occurs?
MR. FLEISCHER: No, I indicated that with each case, the government takes a look at every step that was taken to try to be as helpful as possible to move as quickly as possible.
Q So the protocol will be changed?
MR. FLEISCHER: As I said, as with each case, the government analyzes what took place, and tries to learn from one incident to the next incident; hopefully, there won't be.
Q But you're not speaking definitively here. Why can't you say specifically?
MR. FLEISCHER: Because these are determinations that are going to be made on the ground depending on considered judgment from the Centers For Disease Control, the Department of Health and Human Services, the law enforcement officials on the ground, to try to determine what steps need to be done to trace it where.
For example, there can be cases where mail arrives via courier, mail arrives via sources other than the Postal Service. And so, it's always important for the people on the ground and the incident affected, to analyze what the possible links could be and to go backward and explore those links quickly.
Q Isn't it reasonable for people watching you now to say we've lost two people because of anthrax in these postal centers; why haven't these protocols been changed already? What more do they need?
MR. FLEISCHER: For just the reason I gave. And as I indicated, with each incident, the government is always going to take a careful look about what was done and try to move as rapidly as possible to move backwards in any chain, wherever the chain may be established, to get antibiotics to people who have been affected.
Q At this point, nothing is going to be done differently?
MR. FLEISCHER: No, I didn't indicate that. I said with each incident, the government is going to take a look to determine --
Q So the protocols have been changed, or they haven't, as we sit here now?
MR. FLEISCHER: The protocols are going to depend on the evaluations made on the ground by the relevant officials. And every incident will have its own set of protocols, but the guiding rule is going to be to get help to the people who need help as quickly as possible, wherever they may be.
Q Ari, you didn't answer the first part of the question that I asked you, if I could just come back to that for a second. Does this not represent, the infection at Brentwood, a lack of understanding by the Centers for Disease Control of the route of transmission of anthrax; that they missed this idea that it could have gotten puffed out of an envelope as it went through a sorting machine?
Is that really an indication that they don't fully know what they're dealing with?
MR. FLEISCHER: Well, I think they're also reviewing exactly what the cause is at the Brentwood facility. As you know, there's speculation about whether this is the letter received by Senator Daschle, or whether there could be other mail that is received at the facility, and so all these are the matters that they are looking at.
Obviously, nobody wants to see any loss of life, whether it's a loss of life in the first case of Mr. Stevens at AMI in Boca Raton, or any of the people who have lost their life now in Washington, D.C. at the postal facility, where a letter went through on its way to Senator Daschle's office. And the fact of the matter is, with each one of these cases, the government is going to continue to review all its protocols and to make all available adjustments as necessary. And the decisions will continue to be made by all the people on the ground.
But let me broaden this for one step, because you asked, I think, a very fair question about the CDC and what took place at post offices, et cetera. The fact of the matter is, we were a nation at peace. Some 200 billion pieces of mail are sent every year, and until last month not a single time ever had anthrax been mailed.
So what's happened now is, frankly, just as you're seeing in the military a mobilization in Afghanistan, you're also seeing a nation at home mobilized. The fact of the matter is we've been a very fortunate nation where this has never happened before. We had plans that were put in place, contingencies that were put in place. But no contingency and no plan can ever be 100 percent effective and anticipate all possible attacks on a nation. And the fact of the matter is, our nation is under attack as a result of these mailings and these cases.
We have a war going on overseas and we have a need to defend at home, as well, as Governor Ridge said yesterday. And as part of defending at home, we have a mobilization that is underway, and that's why I referred to some of the actions that the Postal Service is taking. That's why you see Governor Ridge acting in the manner that he is acting, to bring the federal agencies together on a homeland defense. We have not had to deal with these issues before; we are rapidly adjusting to deal with all of them.
Q Part of homeland defense, though, is let the American people know if we have been defended appropriately and as well as we can be every time there's been a casualty in this war. Last week, when a letter went to Senator Daschle's office, it has to be clear to people that it had to come through the Brentwood -- at least in hindsight now, it's very clear it had to come through that -- all the mail going there comes through the Brentwood site. Why was there not immediately tests done on Brentwood and people given antibiotics? Looking back, were those people as well protected as they should have been?
MR. FLEISCHER: Because based on the two previous incidents, in Boca Raton and in New York City, the same things that took place in Brentwood did not develop in Boca Raton and in Trenton, New Jersey, the way they did here in Washington.
And as a result of the experiences in Boca Raton and the experiences in New York City, people walked back, looked at the post office, and there was not evidence to suggest that what took place in Brentwood, what took place did take place based on the scientific information that was available. And as I indicated, with each incident, the government will continue to analyze fully what took place, and if another incident develops, to move rapidly, based on what has been ascertained.
Q Can you tell people, since we're in this war now, and we're all trying to figure out how to defend ourselves, will we move quicker the next time a letter comes to a post office?
MR. FLEISCHER: I think I have indicated that, that the government will move quicker -- the government will move as quickly as possible. But those decisions will continue to be made by the people on the ground who are -- who have the most relevant facts available, which is going to be a combination, a collaboration, of state and federal officials from the health side and the law enforcement side.
Q Ari, when Representative Gephardt came out of the breakfast meeting today, he said that we all believe, he said, that the anthrax was linked to September 11th. But he did not say what led him to believe that. Over the course of this meeting, or other meetings you're aware of, has there been a new linkage developed? He said there wasn't any hard evidence, but I'm wondering whether there is a developing line of intelligence? He did make reference to the milled nature of the anthrax.
MR. FLEISCHER: No, it remains the same suspicions that you've heard articulated from several people in the White House for several weeks now. There is a suspicion that this connected to international terrorists. Having said that, the investigators also do not rule out that it could be something domestic, that it could be a lone person operating, doing this, or it could be terrorism. The suspicion is that it's terrorism, but there is no hard evidence yet at this point to lead anybody who is investigating these matters to reach a conclusion on any of those sources.
Q Given that you're now dealing with new issues that you didn't anticipate even a couple of weeks ago, does the government think it may need more than the $40 billion that Congress has already set aside in dealing with the immediate aftermath of September 11th? Is it going to need more funding to deal with these kinds of threats, new postal machines, et cetera, et cetera?
MR. FLEISCHER: No, Director Daniels stated last week that the $40 billion, in his estimation, will be adequate to deal with a variety of the responses, including the rebuilding of New York, including the victims' funds, including money for the Pentagon to wage the war, as well as for the increase in funding for bioterrorism at home, and for additional stockpiling of the national pharmaceutical stockpile. So there is nothing else anticipated for this session of Congress, for the first session.
Q Trying to anticipate -- you say every day we learn something new. We've seen the Postmaster General, we've seen all the problems with the U.S. Post Office. How about the private mail carrier? Is anything being done in advance, before we get a case, to them? Are there contacts between the office of Tom Ridge or the White House, or whichever, with the private mail carriers? There's a whole bunch of mail being carried by them also.
MR. FLEISCHER: I believe the answer to that is yes. I haven't asked that directly to the Governor. I have heard some conversations about that, and I can tell you that one of the things that the U.S. Postal Service is doing -- and I brought it with me -- is that the postcard that they're mailing to every business and every individual will address things that are as relevant to the Postal Service as it is to private carriers.
For example, this says -- and this will be the card -- "What should make a piece of mail suspect?" Let me take a moment to read from this, because I think this will be constructive for people who are paying attention to this. If a package is unexpected or from someone you do not know; if it's addressed to someone no longer at your address; if it's handwritten, has no return address or bears one that you cannot confirm is a legitimate return address; if the package you receive is lopsided or lumpy in its appearance, is sealed with excessive amounts of tape; if it's marked with restrictive endorsements, such as "personal," or "confidential," or if it has excessive postage -- all of those should lead a recipient to believe that this could be a suspicious package or envelope.
If that is the case, the citizen should take the following actions: Do not handle the letter or package that you suspect is contaminated. Put it down immediately. Do not shake it, bump it, or sniff it. Put the mail piece in a plastic bag, wash your hands thoroughly with soap and water, and notify local law enforcement officials.
Those are the actions that are being advised to all citizens in this postcard, and that would apply to all mail, whether it's publicly or privately delivered.
Q Yesterday, Governor Ridge said he had no reason or information to go back on what he said Friday about the letter -- the anthrax coming to Washington being indistinguishable, the same.
MR. FLEISCHER: That's correct.
Q Does the government still have no reason to believe that it was mailed any differently or that it was manipulated in any way differently than what had gone to Florida and New York?
MR. FLEISCHER: The Governor's statement still stands about it being indistinguishable.
Q Ari, two questions about White House mail. Can you tell us whether or not the White House mail is irradiated for bacteria? And the letters that American kids are sending in with dollars for Afghan children, is that being treated in any special way so that doesn't become a vehicle for --
MR. FLEISCHER: Martha, as with the case of all security at the White House, that would apply to the mail, as well; that's just a matter that we do not discuss. We don't reveal what type of security measures are in place. And the reason for that is, is people who might want to do harm to the White House, which obviously is always a target of people, as information is revealed about what security measures are in place, clever people will try to find a way to get around those procedures. So we, as a rule, do not discuss those procedures.
Q -- the details, can you say if there have been any special precautions in the case of the letters being sent for -- the dollars for the Afghan children? Even without revealing what the precautions are, is there anything special being done with them?
MR. FLEISCHER: Let me check on that and I'll post that for you.
Q Let me follow on that? Has there been any mail received in the West Wing, OEOB, or the off-site mail facility that has tested positive for anthrax?
MR. FLEISCHER: Having said what I said about the security procedures, let me also advise you that in the event that there would be something that was a health issue, where something was tested positive, the White House would share that information.
Q Would?
MR. FLEISCHER: Would. Yes, of course, we would. And that there is nothing to report. There's nothing to share.
Q Ari, you mentioned that aviation security was a topic in the meeting this morning. One way or the other, either by executive order or legislation, what do you think the prospects are for passage of that or enactment of it by the Thanksgiving travel period?
MR. FLEISCHER: Well, based on the meeting this morning, on the antiterrorism legislation, I think it's fair to say that there's a real strong sense of moving together quickly. The Senate and the House have passed slightly different versions. They're really very similar on the antiterrorism legislation. That's the legislation to give the law enforcement community more tools to prevent future attacks on the country. I think the prognosis for that is strong.
On the aviation bill, I think it's a little more complicated. The President made very clear in the meeting this morning that he hopes that the House will be able to take up legislation on aviation security. The Senate has done it; he hopes the House will be able to do it, as well. Because the President does think it's important for Congress to get the business of the nation done when it comes to protecting the traveling public.
He does have --
Q Did he put down any markers about the Thanksgiving holiday, which is the next busy travel period?
MR. FLEISCHER: He did not lay down a specific marker like that. He just urged them to move as quickly as possible.
Q Have they gotten any closer to compromise, or any movement at all on this issue of federalizing the baggage --
MR. FLEISCHER: I think that remains one of the largest outstanding issues, and that's an issue of some contention in the House. And the President has urged the House to get together with him, try to reach an accommodation, try to figure out how to reach a solution on that issue; work together with the Senate, and that way legislation can be sent to the President that he can sign.
Q Ari, it's not just a contention in the House. He opposes that himself, right? I mean, he hasn't changed, has he?
MR. FLEISCHER: The President has a lot of concerns about whether or not federalizing all baggage screeners is the most effective way to provide security at the airports. The President does believe strongly in protecting the cockpit doors and increasing the number of air marshals on the flights. He's already taken actions with his own authority as a result of the emergency appropriation bill to fund those initiatives. They are up there, going there, underway.
The President does believe that we need to federalize the background checks and some of the security procedures at those gates. The question of whether or not putting everybody who is currently at those gates on the federal payroll, whether that is an effective way to increase safety, as opposed to increasing standards, which is where the President is focused, is an open issue. But the President is going to work with Congress on that.
Q You mentioned irradiation technology. Has the administration now made a decision to deploy irradiation technology in all major post offices, or at least in sorting centers? And how long will that take? And do you have any sense of how much it will cost?
MR. FLEISCHER: No. As I indicated, the Postal Service is reviewing that right now as one of their options. They're taking a look at its effectiveness, the number of facilities that it would be available to. So that's a matter that is under review as we speak.
Q And if I could just follow up on that, what -- obviously, you can't do that overnight, you just can't bring in the equipment. Is there a sense that this would take some time, that it would take months, weeks?
MR. FLEISCHER: There's no question it would take some time, and again, it just depends on the type of machines, their availability, and how widespread they make the judgment that it would need to be if they go down that road.
Q Ari, since were in a time of war and terrorism, and there's been Hill testimony this morning about more smallpox vaccines, does the President favor resuming smallpox vaccinations for all young children?
MR. FLEISCHER: Well, that also -- that's a very complicated question; and that, too, it really comes down to medicine and what doctors' judgments are about the best use of medicine. The smallpox vaccine has a lot of unanticipated effects, also. There are people who are allergic to the vaccine. There are a host of issues that can arise by providing that vaccine to people that can also do more harm than good. And so all of that is being analyzed, it's being weighed. And those are very complicated judgments. The President has not arrived at any conclusion about that.
Q Ari, the Bush budget cut Nunn-Lugar funds to safeguard nuclear weapons.
MR. FLEISCHER: Which ones?
Q Nunn-Lugar funds.
MR. FLEISCHER: Oh, Nunn-Lugar funds. Right.
Q Are you thinking particularly of rethinking that, and especially in regards to perhaps safeguarding chemical or other kinds of weapons, and biological weapons?
MR. FLEISCHER: Let me do this, Ellen, let me take that and get back to you on it. I don't have the budget in front of me, with the funding levels, because I believe there were substantial plus-ups in the funding to work with Russia on decommissioning its nuclear programs. So you've mentioned one particular aspect of it. There actually are several programs under Nunn-Lugar. And if I recall, some received big increases. Let me look at it in its entirety.
Q Ari, Attorney General Ashcroft said there's new information today regarding the possible link between the anthrax and September 11th attacks. Can you at all characterize that information as scientific or part of the law enforcement investigation? And also, is that new information the reason why we're hearing from the White House and Congressman Gephardt today that there is this suspicion that there is a connection?
MR. FLEISCHER: Let me see exactly what General Ashcroft said, because when I talked to him this morning, that's why I indicated there's no new hard evidence. Every day, of course, the investigators who work with raw data receive new evidence. There's not a day that goes by that they don't have new things to look at. But the question of any hard evidence that is conclusive, that would lead anybody to determine that this is tied to September 11th, is not there. So I think that would be the difference. That's what the General is referring to -- Attorney General is referring to.
Q Ari, what's the President's position on U.S. bombing during Ramadan?
MR. FLEISCHER: That's an operational matter, and frankly was addressed by Secretary Rumsfeld the other day.
Q Is the President talking -- rather, is he leaving that decision up to military leaders, or is he weighing in on that matter?
MR. FLEISCHER: I think as you heard from the Secretary, that issue's already been addressed. But I'm not, as a matter of routine, going to comment on operational details.
Q When the subject of the aviation security legislation come up today and the President suggested he might have to use an executive order to achieve the same, what reaction was there from the congressional --
MR. FLEISCHER: Well, the President's message was that it's important for Congress to take action on aviation security. That's what he said directly to the House leaders. He urged them to move quickly to pass legislation, because he said directly, that is preferable than exacting an executive order.
Q -- can strike a deal to avoid that?
MR. FLEISCHER: Well, they indicated that they're going to do their best, and try. And there's several weeks remaining in the session. Who knows how much longer there remains in the session. So I think we'll have to see.
Q The Taliban continues to put its own construction on events in the region. Other than making U.S. officials available for interviews into the Middle East, does the White House have any institutional plans to deal with this public diplomacy problem that's been pretty well ventilated by now?
MR. FLEISCHER: Well, I'm not sure that Taliban statements present anybody with a public diplomacy problem. I think the credibility of the Taliban does not run very high in anywhere outside of Taliban circles. And so I don't think it's really an issue that the government worries about, or that the President worries about very much.
Q You don't think there's a need -- in view of over the last few years, that whole capability in the State Department has been diminished -- you don't see a need to rebuild that?
MR. FLEISCHER: Okay, separately from reaction to anything the Taliban is doing, no, the President does think that there is a need for an increased role by the Voice of America to make sure people understand the message the United States government is saying; that people not only in Afghanistan, the people of Afghanistan, to receive that message, but people in the Arab world to hear the message about who the United States is and what the United States represents. The President does think that's an important part of public diplomacy. And he's had several conversations about how public diplomacy can play that role.
For example, in Afghanistan, as you know, leaflets are being dropped. Voice of America is broadcasting in there. But generally speaking, the very best way to deal with anybody around the world who suggest the United States is doing things in these statements they make are often lies, is for public officials to take to the podium, to take the microphones, as Secretary Rumsfeld has been doing, and speak forthrightly, to answer people's questions and to reveal what it is the government is doing. There are, of course, as Secretary Rumsfeld said yesterday, times when he's not going to be in a position to reveal what we're doing. It is a war and he's not going to pass on information that could be used by those who would do the United States harm.
But, by and large, the best antidote to any types of lie campaigns against the United States are for government officials to speak forthrightly.
Q Ari, you said the President is going to ask Shimon Peres today to convey to Sharon to withdraw from the West Bank areas. The President, of course, has urged restraint in the past. I'm wondering, is this somehow different? Is this new six-day offensive causing new stresses on the coalition, particularly in the Arab and Islamic world?
MR. FLEISCHER: Well, let me do this. What I want to do -- the meeting is going to take place in about a couple hours, I think, so let me see if there is any report following that meeting -- I think I'm going to go to it. And so if I have anything I can shed light on after the meeting, I will. I've given you what the President's intentions are going into that meeting.
Q So there is no reaction -- just as a quick follow-up, there is no reaction to Israel's flat rejection of U.S. urging for withdrawal from the Palestinian --
MR. FLEISCHER: Let me reiterate, Terry, that the President, at this meeting with Foreign Minister Peres is going to urge Israel to withdraw from Palestinian areas.
Q How are you going to brief us on this? What's the --
MR. FLEISCHER: I'll try to get a readout. Either I'll do it or somebody else from the meeting will do it. Allow the meeting to take place and then we'll figure out the next step.
Q Two things real quick. First of all, the situation that Helen was talking about, going back to the discrimination issue, the Brentwood thing, there is a little bit of concern in the public about that because these people were not on Capitol Hill, did not have the prestigious jobs, what have you, that their situation was somewhat sloughed to the side and let go for a couple of a days. Could you expound upon that?
And, also, the fact that you said that Brentwood was different; was it different because of the potency of the anthrax in that letter going to Daschle's office?
MR. FLEISCHER: Again, back on the premise of the question, what was done for employees in Senator Daschle's office was the same thing done for employees at NBC News, the same thing that was done for The Globe and for The National Enquirer and the employees at AMI. The treatment protocol was the same in all cases.
The places where the letter is received, the workers who work closest to the letter received nasal swabs to test whether they were positive or negative. And those who worked closest to the receipt of that mail were given Cipro as an antibiotic treatment in case that they did come down with any illnesses.
But, again, as a result of what happened at the post offices in Boca Raton and in New York, there was not an anticipated need to take additional action upstream, the way the -- how it was developed at Brentwood. The cause of what is happening at that facility is still under review. It's being investigated as we speak by law enforcement personnel, and so I don't have an answer for you on that yet.
Q Okay, a follow-up again. Many of those people -- what do you say to the workers there who said when the situation was going on Capitol Hill, in Daschle's office, when they closed it down and investigated and took the swabs and tested people, they were told to stay and keep working, to stay. And that mail actually came through that Brentwood facility.
What do you say to those workers who are upset about the fact that they were told to stay and continue to work and a week or so later, now they're being tested?
MR. FLEISCHER: April, the President's message to them is the same as the President's message has been to everybody who has been affected by this. It's a real cause for concern that anybody would be mailing anthrax to people in the United States; that it could do harm to people at the Postal Service; that it can do harm to people who receive the mail; that it can do harm to the security personnel who rush to the scene to help people who have received the mail.
That is the source of the President's concern. And what he is doing is putting all the resources of the federal government to work collaboratively with the local officials to prevent anybody from getting anthrax, to immediately respond wherever the anthrax is received.
What happened in Washington was different from what happened in Boca Raton, different from what happened in New York City. But that's the reason that the treatment, or the speed at which the treatment was done in Brentwood followed the course that it did -- because of the precedence that were established in Florida and New York.
And as I indicated at the very beginning of the briefing, the government is going to continue to take a look each time something like this comes up and adjust to do whatever is necessary to as quickly as possible get help to anybody who needs it.
So for the people at the Postal Service, the President is, of course, deeply concerned about what's happened at the postal facilities here in Washington, D.C., and the fact that two people have died, two others have been diagnosed with inhalation anthrax and that others may be exposed.
So, of course, he's concerned about it, and he is responding to it.
Q -- you're writing your own script, still? You're writing your own script of this, but you're getting guidelines with the CDC? I mean, in response?
MR. FLEISCHER: The CDC will play a prominent role in this, of course.
Q The Washington Post reports, and this is a quote, Yasser Arafat's Palestinian Authority rejected an ultimatum by Israel to hand over the assassins of an Israeli Cabinet minister, and they also quoted Sharon's promise, if not, we'll go to war against him. And my question, the first of two: Since we are at war with the terrorists in Afghanistan, how can we, with any fairness, oppose Israel's war on the terrorists in the West Bank?
MR. FLEISCHER: Lester, the two situations really are not the same.
Q No terrorists in the West Bank?
MR. FLEISCHER: In the case of what's happening between the Palestinian Authority and Israel, both parties have committed to a peace process. Both parties have signed onto the Mitchell Agreement. And the Mitchell Agreement provides a political solution, not a military solution, to the problems in the Middle East. Both parties have endorsed that.
So the President believes what's important is to hold both parties accountable for the promises they made to follow a political process toward peace; that is not at all the case in what's happened in Afghanistan.
Q The New York Times reports Mr. Arafat has repeatedly promised to jail Palestinian militants, and he has repeatedly failed to do so. How could any Palestinian state possibly be expected to respect Israel's peace and national security if Arafat heads it?
MR. FLEISCHER: Well, the President has made it very clear to the Palestinian Authority, and Secretary Powell has done so as well, about the need for the Palestinian Authority to immediately arrest those who are responsible for the assassination of Israeli Cabinet member Zeevi, and also he has called on the Palestinian Authority to act more decisively against all of those who are planning or conducting acts of terrorism and violence. That's the President's message to both parties.
Q Thank you.
MR. FLEISCHER: David, did you have one?
Q I wanted to follow up to Ron's question, whether there has been any testing of suspicious packages here that have later turned out to be negative for anthrax. But you said there was no health issue. Have there been suspicious substances that have presented themselves?
MR. FLEISCHER: Again, I'm not going to discuss what steps are in place at the White House. But if anything were to come about that would be a positive result, a positive test, we will fully inform the public. And there is nothing to report.
Q I just want to follow on a related point, which is, in all of the cases that you've mentioned prior to now where there have been anthrax letters, there has been this sort of tangible evidence, there's been this powdery substance.
And now, we have at the Brentwood facility, the real horrible circumstance where it is invisible and it's airborne and it's lethal. As a result of that, wouldn't it make sense, and is it currently under review, to do precautionary environmental testing at postal centers around the country, lest you act too late?
MR. FLEISCHER: That has not been ruled out. There are a series of steps that are under review, and as those steps are determined, that information will be provided.
Q Ari, last week, there was a lot of fear and confusion generated when there were conflicting statements on the Hill about the potency of the letter that went up there.
Now, we have Gephardt coming out this morning and talking about that same issue; and yet, the White House maintaining that it's still indistinguishable. Are you telling us today that Gephardt was wrong this morning and that there is nothing at all different, whether it's the strain or the way it was milled, or anything? That he was wrong and there was nothing --
MR. FLEISCHER: Actually, if you take a look at Leader Gephardt's statements in their entirety, I saw at the end of his statements out on the driveway, he said something that was a little bit different from what he said at the beginning, where he said that he doesn't mean to draw attention to any one specific word, the meaning of any one word, or to parse any word in a literal sense.
He added, just as I did this morning, that the issue here is whatever is being mailed is being mailed as a weapon. Obviously, it's been mailed in a way that has led to fatalities in Florida and now in Washington, D.C. So however it's scientifically characterized, which is an open question, it is being used as a weapon and that's why Congressman Gephardt said what he said.
Q But -- question about the character and nature of this stuff, that's an open question, it's not --
MR. FLEISCHER: That's a scientific matter. And this is where the Governor's statement, as I indicated a little while ago, stands, that it's indistinguishable.
Q -- the tests prove it's indistinguishable, which doesn't lead us to believe it's an open question, that leads us to believe it's a closed question.
MR. FLEISCHER: It's indistinguishable.
Q Ari, the death of at least one of these postal workers, does it not represent a hole in the public health system? This gentleman went to the emergency room, to a hospital, at 2:00 a.m. in the morning Sunday, was told to go home with a diagnosis of the flu. He did not offer up the information that he was a postal worker, but he wasn't asked, either.
MR. FLEISCHER: Right. Well, as has been explained by D.C. medical personnel, when somebody goes into a hospital, to an emergency room, they're asked treatment questions about what it is that they have that is an ailment, whether they have allergies, if they're aware of where they may have gotten this from, and then they prescribe remedies. It is not a standard question to ask somebody, where do you work.
Q Should it not be in a case like this?
MR. FLEISCHER: I think that may be something that evolves. I think that's going to be a decision, again, though, that is going to be made by the appropriate medical authorities. That's not going to be a decision that the White House, for example, makes. But that's something that medical authorities -- the Centers for Disease Control and others -- will review and make determinations about. But people go into emergency rooms hundreds, thousands of times across the United States every day. Whether that's a question that needs to be asked everywhere will be a medical determination.
Q Security Council Thompson was testifying this morning, and he said if any postal facility is found with an anthrax-tainted letter coming through, that facility will be immediately checked, workers there will be immediately tested and treated. It sounded like a new policy in light of lessons learned over the past couple of days. Is that a new administration policy?
MR. FLEISCHER: Well, again, as I indicated at the top of this, there's no change from what I said just a little while ago -- those determinations will be made collaboratively by the various officials involved. And Secretary Thompson, through the Centers for Disease Control, is certainly one of them. So there will be a series of officials -- local law enforcement, health officials -- who will make the determinations about where the tests need to be done as quickly as possible.
For example, again, there can be cases where a letter is couriered in, a letter is brought in individually by somebody, it doesn't go through the Postal Service. So, clearly, if that's the case, then there would not be a need to test at a postal facility. Those determinations are being driven by the facts on the ground.
Q Are we to expect Governor Ridge to come out today and brief us again?
MR. FLEISCHER: There's no plans at this moment for Governor Ridge to come out today. He'll be coming out regularly; it may not be daily, though.
THE PRESS: Thank you.


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At this point we have no idea how many people will become newly insured under ObamaCare. For the first year out, the number of people with insurance may actually go down! But the administrations goal is to insure an additional 30 million people and eventually a lot of those people will acquire health plans. When they do, the economic studies predict that they will try to double their use of the health care system.
Adding to this increased demand will be new mandated benefits. The administration never seems to tire of reminding seniors that they are entitled to a free annual checkup. Then there are new benefits for women, including free contraceptives. And all of us will be entitled to a long list of preventive serviceswith no deductible or copayment.
But the health care system cant possibly deliver on all these promises. The original ObamaCare bill actually had a line item for increased doctor training. But this provision was zeroed out before passage, probably to keep down the cost of health reform. The result will be increased rationing by waiting.
Take preventive care. The health reform law says that health insurance must cover the tests and procedures recommended by the U.S. Preventive Services Task Force. What would that involve? In the American Journal of Public Health, scholars at Duke University calculated that arranging for and counseling patients about all those screenings would require 1,773 hours of the average primary care physicians time each year, or 7.4 hours per working day.
And all of this time is time spent searching for problems and talking about the search. If the screenings turn up a real problem, there will have to be more testing and more counseling. Bottom line: To meet the promise of free preventive care nationwide, every family doctor in America would have to work full-time delivering it, leaving no time for all the other things they need to do.
When demand exceeds supply in a normal market, the price rises until it reaches a market-clearing level. But in this country, as in other developed nations, Americans do not primarily pay for care with their own money. They pay with time.
How long does it take you on the phone to make an appointment to see a doctor? How many days do you have to wait before she can see you? How long does it take to get to the doctors office? Once there, how long do you have to wait before being seen? These are all non-price barriers to care, and there is substantial evidence that they are more important in deterring care than the fee the doctor charges, even for low-income patients.
For example, the average wait to see a new family doctor in this country is just under three weeks. But in Boston, with ObamaCare-type reform, the wait is about two months.
When people cannot find a primary care physician who will see them in a reasonable length of time, all too often they go to hospital emergency rooms. Yet one study found up to 20% of the patients who enter an emergency room leave without ever seeing a doctor, because they get tired of waiting. Be prepared for that situation to get worse.
When demand exceeds supply, doctors have a great deal of flexibility about who they see and when they see them. Not surprisingly, they tend to see those patients first who pay the highest fees. A New York Times survey of dermatologists in 2008, for example, found an extensive two-tiered system. For patients in need of services covered by Medicare, the typical wait to see a doctor was two or three weeks, and the appointments were made by answering machine.
However, for Botox and other treatments not covered by Medicare (and for which patients pay the market price out of pocket), appointments to see those same doctors were often available on the same day, and they were made by live receptionists.
As physicians increasingly have to allocate their time, patients in plans that pay below-market prices will likely wait longest. Those patients will be the elderly and the disabled on Medicare, low-income families on Medicaid, and (if the Massachusetts model is followed) people with subsidized insurance acquired in ObamaCares newly created health insurance exchanges.
Their wait will only become longer as more and more Americans turn to concierge medicine for their care. Although the model differs from region to region and doctor to doctor, concierge medicine basically means that patients pay doctors to be their agents, rather than the agents of third-party payers such as insurance companies or government bureaucracies.
For a fee of roughly $1,500 to $2,000, for example, a Medicare patient can form a new relationship with a doctor. This usually includes same day or next-day appointments. It also usually means that patients can talk with their physicians by telephone and email. The physician helps the patient obtain tests, make appointments with specialists and in other ways negotiate an increasingly bureaucratic health care system.
Here is the problem. A typical primary care physician has about 2,500 patients (according to a 2009 study by the Centers for Disease Control and Prevention), but when he opens a concierge practice, hell typically take about 500 patients with him (according to MDVIP, the largest organization of concierge doctors). Thats about all he can handle, given the extra time and attention those patients are going to expect. But the 2,000 patients left behind now must find another physician. So in general, as concierge care grows, the strain on the rest of the system will become greater.
I predict that in the next several years concierge medicine will grow rapidly, and every senior who can afford one will have a concierge doctor. A lot of non-seniors will as well. We will quickly evolve into a two-tiered health care system, with those who can afford it getting more care and better care.
In the meantime, the most vulnerable populations may have less access to care than they had before ObamaCare became law.

subset: commoncrawl


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These pages describe a generalised data model and source format for genealogy, family history, and micro-history: STEMMA®. This serves several different purposes, including:
See FAQ page for specific questions.
This R&D project came about because I didn't want my family history data locked in to any single commercial product. Plus I didn't believe that existing data models were able to represent the depth and variety of my data completely and accurately because of its micro-history approach. STEMMA incorporates biological lineage (as in family trees), structured events, geography, source assimilation & analysis, and rich-text narrative to go beyond family history to address the micro-history of arbitrary people, places, animals, groups, and events.
Genealogy and family history — irrespective of whether you consider them to be the same or different — are part of the bigger circle of micro-history, alongside One-Name Studies, One-Place Studies, personal historians (as in APH), military history, house histories, etc. (see What is Genealogy?) Trying to compartmentalise these pursuits can be artificial when we're looking at real history, so why shouldn't there be a single, consistent approach to their data representation?
The STEMMA data model may be a source of inspiration to other people or groups with the same goals, primarily because it was developed independently and with minimal influence from other models and products.
This documentation constitutes V4.1 of STEMMA, and supersedes previous specifications.
This site is now located via https://parallaxview.co/stemma.
For compatibility, the site is also located via http://www.familyhistorydata.parallaxview.co.
Content created: 2 January 2012. Last updated 4 December 2020.
Tony Proctor is currently an independent researcher and writer working from rural Ireland.
Blog: http://parallax-viewpoint.blogspot.com/.
Copyright © 2012–2022. STEMMA is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
® STEMMA is a registered trademark of Tony Proctor.


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Day 27: Win a Cooler Master gaming upgrade
The HEXUS Epic Giveaway is back and bigger than ever! In partnership with Stormforce, we are giving all our fabulous readers the chance to win fantastic prizes every day throughout the holiday season!
Our awesome giveaways will feature goodies from all your favourite tech manufacturers, including AMD, Asus, Corsair, iiyama, Nvidia and Razer. It's going to get hectic, so be certain to bookmark our dedicated Epic Giveaway homepage to keep tabs on each new competition as it arrives.
On day 27, our prize is an excellent gaming bundle from Cooler Master. One lucky winner will walk away with a Masterkeys MK750 keyboard, MasterPulse White Edition headset, and MasterMouse MM520 mouse.
Want to be in with a chance of winning? Answer the following question, and don't forget, you can also claim a free second entry via Facebook. Good luck and check back soon for more prizes in the 2017 Epic Giveaway!
Terms and conditions
- There is no entry fee and no purchase necessary to enter this competition.
- The prize draw is open to HEXUS readers aged 12 years or over.
- The competition winner will be picked at random from all eligible entries that arrive by 09:00 London time on the closing date, January 13, 2018.
- Only one entry is permitted per household per HEXUS entry form; second Facebook entries, if applicable, are permitted. Duplicate entries on either form will result in disqualification and no entrant may win more than one prize.
- The winners will be notified via email by January 15, 2018. The winner must claim their prize within 7 days of the promoter sending notification. If the prize is unclaimed after this time, HEXUS reserves the right to offer the unclaimed prize to a substitute winner selected in accordance with these rules.
- The prize is a Cooler Master bundle comprising a Masterkeys MK750 keyboard, MasterPulse White Edition headset, and MasterMouse MM520 mouse.
- In the event that the prize offered is unavailable due to circumstances beyond our control, we reserve the right to offer an alternative prize of equal or greater specification.
- Prizes will ship to winners within 45 days of the draw, though we aim for sooner.
- HEXUS and its partners are responsible for shipping within the criteria laid out and the winner is responsible for local taxes if applicable.
- Prize draws are not open to employees of HEXUS and their affiliates, agencies, suppliers, sponsors and immediate families.
- Entry into the competition will be deemed as acceptance of these terms and conditions.
- A list of previous competition winners is available at HEXUS.net/Competition_Winners.


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This is Max the dog and his human mom Maureen. An amazing BBC Earth report tells their story: Max became depressed when he started to smell the cancer that Maureen was developing inside her breast. It's a really incredible tale.
According to BBC Earth's Secret Life of Dogs, "dogs watch us all the time and read our body language like a sixth sense. They also smell our bodies for changes. Max smelt cancer in Maureen before any medical scans could pick it up. Dogs do this naturally and can be trained to pick up on tiny volatile chemicals given off by cancerous tumors. They can even be taught to alert diabetics to low blood sugar levels."
Meet Microsoft's New Surface Laptops
Thanks for the tip, Anna Jane (help our friend AJ rebuild her home and school for dogs here)


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2017 Average Costs For Sink Installation
Completed Projects
If your sink is slow to drain or if your hot or cold water is not running how it's supposed to be, then you need the help of professionals. Furthur is the leading service provider in all of Van Buren and they are the ones you should turn to when it comes to problems with your sink. Whether it is cleaning or cooking, your kitchen sink acts as the central backdrop to numerous activities in your home. Furthur can replace your broken and beaten up kitchen sink with their excellent and reliable sink installation Van Buren services. They will make sure your sink is well-prepared for all the tasks that you're planning to do.
Sink Installation in Van Buren, AR
Brand New Sink Installation in Van Buren AR
Total plumbing service
Arkansas quotes on sinks
Once your faulty sink becomes a nuisance, remember that Furthur is the company to call. They have had years of experience in dealing with all types of sinks. Their technicians will recommend only the latest and best type of sinks that can fit the layout of your bathroom or kitchen perfectly.
When you call Furthur's experts for a Van Buren sink installation service, you can expect that their specialists will arrive wearing the proper uniform and carrying the necessary equipment. They'll also leave your property looking all great with a new and professionally-mounted sink.
What zipcode
do YOU NEED
Sink Installation Companies in?
2016 Average Costs For Sink Installation
FAQ for Sink Installation in Van Buren
What types of sinks do sink installation in Van Buren contractors offer?
There lies a variety of sinks that you can install in your house. These may include either drop in, undermount, integral, single bowl, double bowl, steel sinks and so on. To ensure that you get the correct sinks for your house you need to hire sink installation in Van Buren professionals. The type of sink that you will install will depend on the design of your house. A lot goes into the installation of a sink; therefore you should get information on what is more convenient for your home.
What factors affect costs of sink installation in Van Buren?
Van Buren sink installation costs depend on many different factors. The price range may start from as low $40 to as high as $3500. These factors include the type, quality, and material of the sink. Sinks that are of higher quality and have more capacity; for example, a double sink instead of a single are more costly. Other factors include the time required for the installation, skills required and also sink model.
When do I need to get sink installation in Van Buren done?
You should get your sink installation in Van Buren replacement when you notice that your sink is broken, deteriorated, discolored or it's worn out. A damaged sink left uncared for may cost you a lot of trouble. As a homeowner, you would love to have a desirable, attractive sink; it talks a lot about you and makes your home more beautiful. Another factor that may influence the replacement of the sink would be total remodel of your home. You may want to upgrade from your normal sink to a sink of higher quality, different material, and color when you have your bathroom or kitchen a total makeover.
Tn State Plumbing & HeatingFort Smith, AR 72901
Ft. Smith Plumbing School7200 Mahogany Av Fort Smith, AR 72903
Borengasser Plumbing, Inc4017 South S Street Fort Smith, AR 72903
WILSON & WILSON CONSTRUCTIONPO Box 15 Van Buren, AR 72956
Rick Parker Construction, Inc.-R2921 Melody Ln Alma, AR 72921
Payless Plumbing Contractors Inc1418 Fayetteville Rd Van Buren, AR 72956


text:
Red Dead Redemption 2: Ultimate Edition Content
|Bundle Count
|Retail Price
|check SteamDB, ITAD
Barter.vg tracks your digital game libraries, wishlists and tradables from different stores. You can find users with the games you want and if they've wishlisted your tradable games.
Sign in through Steam to view the users' collections and trades.
⇄ Tradable 0
★ Wishlist 1
📚 Library 41 (2%)
⚯ Related 1
🏷 Tags 1
💻 Sites
- IsThereAnyDeal current and historic deals
- SteamDB Profile the technical details
- Steam Trades find trades [Want] or [Have]
- Lestrades Profile instant game matching
- Powered by Steam store page


text:
Twists Hair Curl Sponge Brush Coil Magic Wave for Natural Hair
SKU: 456a83db1943 Category: Hair Curlers
Material: Sponge+Eva
Holes: 32 Holes
Hole Diameter: About 8MM
Size: About 150* 115* 60MM
Color: Black and Red
Package Included:
1 X Hair Curl Sponge Brush
How To Use:
1. This tool works best on hair that is only slightly damp.
2. Apply a twist and lock gel or your regular styling gel to your slightly damp hair.
3. You may also apply some of your styling product to the sponge.
4. Use sponge and go in a circular motion across your head.
5. Do not press heavily on the hair.Spin in one direction only.
6. Within minutes, you will have a head of perfectly formed twists.
Related products


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Burkitt Lymphoma is a rapidly progressive lymphoid malignancy requiring a prompt diagnosis and institution of therapy. Often, therapy needs to be instituted prior to the results of molecular studies which typically confirm the diagnosis. A goal of initiating therapy within 48 hours of presentation has been proposed as optimal treatment for Burkitt lymphoma. Therefore, a high degree of suspicion is required along with surgical colleagues who can rapidly obtain tissue for review by an expert hematopathologist.
The endemic variant of Burkitt lymphoma observed in equatorial Africa – a rapidly progressive jaw or orbital tumor – is the most common presentation, occurring more frequently in young children. In western countries where sporadic Burkitt lymphoma occurs more commonly, this presentation is relatively rare. Nodal disease accounts for most presentations, commonly occurring in the abdomen.
Abdominal disease can present with a variety of symptoms ranging from nausea, vomiting and a change in bowel habits to gastrointestinal bleeding and intestinal perforation. When involved lymph nodes are palpable, such as those in the cervical regions, involved sites can progress rapidly over hours to days, potentially leading to airway compromise. Extranodal disease is not uncommon, with numerous reports describing organ invasion, pleural effusions and ascites, as well as pharyngeal and sinus involvement.
Continue Reading
Bone marrow involvement is documented in roughly 20% of cases of sporadic Burkitt lymphoma and may be much less common in the endemic variant. Central nervous system involvement has been reported in up to one-third of patients, is typically associated with other sites of extranodal involvement, and appears more frequently in endemic Burkitt lymphoma.
Other non-Hodgkin lymphoma (NHL) histologies need to be differentiated from Burkitt lymphoma. Diffuse large B-cell lymphoma (DLBCL) is the most common NHL and may have a MYC rearrangement in 5% of cases. Given the relative incidence of DLBCL, Burkitt lymphoma occurs less commonly in developed countries than MYC+ DLBCL.
Cases with morphologic features intermediate between DLBCL and Burkitt lymphoma are termed "B-cell lymphoma, unclassifiable, with features intermediate between DLBCL and Burkitt lymphoma" as per the current World Health Organization classification. Differentiating these entities via expert hematopathologic review and appropriate molecular testing is critical given the major differences in treatment.
Other lymphoma histologies, including lymphoblastic lymphoma and blastic mantle cell lymphoma, present in a similar fashion to sporadic Burkitt lymphoma in adults. In younger patients, Wilms' tumor, neuroblastoma and soft tissue sarcomas should be considered in the differential.
Burkitt lymphoma can be divided into sporadic, endemic and immunodeficiency-related variants.
In developed countries where sporadic cases are most commonly encountered, Burkitt lymphoma can occur at any age, although the peak incidence is in the first decade of life. Roughly equal numbers of children and adults are affected. As such, Burkitt lymphoma accounts for 30% of pediatric lymphomas and less than 1% of lymphoma cases in adults. The disease incidence is 2-3 times higher in equatorial Africa. Termed endemic Burkitt lymphoma, the majority of cases are Epstein-Barr virus (EBV)-related. The immunodeficiency related variant is most commonly associated with human immunodeficiency virus (HIV) infection, where 1/3 of cases are also EBV-related.
The diagnosis is most readily made by an excisional lymph node biopsy. In cases where an excisional biopsy is difficult, multiple core needle biopsies may be adequate. Expert hematopathologic review is essential.
The distinct starry-sky pattern of classic Burkitt lymphoma, (Figure 1) in the setting of a histologic proliferative fraction approaching 100%, may quickly suggest the diagnosis while more unusual variants may be harder to distinguish. The most commonly used measure of proliferation is the Ki-67. In Burkitt lymphoma, nearly 100% of the cells stain positive for Ki-67.
A translocation involving the MYC oncogene is identified in the majority of patients. Classic Burkitt lymphoma demonstrates the t(8;14)(q24;q32) reciprocal translocation involving the immunoglobulin heavy chain locus in 80% of cases. Variants involving the light chain loci, t(8;22)(q24;q11) and t(2;8)(p12;q24), are less common.
Fluorescence in situ hybridization (FISH) to identify the MYC break-apart is routinely used along with routine karyotype analysis. Due to the molecular heterogeneity of chromosomal translocations causing MYC overexpression, polymerase chain reaction (PCR)-based testing to confirm their presence is not available. While diffuse large B-cell lymphoma can also demonstrate a t(8;14) translocation or MYC overexpression, this typically occurs in the context of other cytogenetic abnormalities.
Routine staging studies, including computed tomography of the neck, chest, abdomen, and pelvis +/- position emission tomography (PET), and bone marrow aspiration / biopsy, are indicated in the initial evaluation and ideally should be expedited so as not to delay therapy.
The Ann Arbor staging system continues to be used in adult patients. However, some individual treatment regimens have been developed with individualized risk-adapted therapeutic plans. In addition, a serum lactate dehydrogenase is used in treatment planning. Routine laboratory testing should include an evaluation of renal and hepatic function as well as testing for HIV. A study of cardiac ejection fraction is necessary for patients who will receive anthracyclines as part of their treatment. A lumbar puncture is indicated to exclude involvement of the cerebral spinal fluid. Despite the presence or absence of neurologic symptoms, this is frequently performed in conjunction with intrathecal chemotherapy as systemic treatment is initiated.
The rapid institution of chemotherapy, ideally within 48 hours of presentation, is of utmost importance in Burkitt lymphoma. Aggressive hydration and recombinant urate oxidase (rasburicase) for hyperuricemia are currently recommended as prophylaxis against tumor lysis syndrome.
Therapy in general consists of dose-intense multi-agent chemotherapy regimens. Some protocols employ a single less intense pre-phase chemotherapy regimen to provide additional time in completing the initial work-up as well as to further protect against tumor lysis syndrome and improve the patient's performance status.
Based on experiences in pediatric patients, the most effective therapies for adult Burkitt Lymphoma include chemotherapeutic agents administered in dose-intensive fashion as part of short duration regimens. In addition, they include agents such as methotrexate and cytarabine which penetrate the central nervous system when administered in high doses as well as intrathecal prophylaxis or treatment. Several regimens using similar agents have been reported. Based on the data available, a few may be preferable in adults. However, as demonstrated by a retrospective analysis of 470 adult patients treated on prospective trials, inferior outcomes have been demonstrated in older patients (defined as >40 years in this series). Standard first-line regimens include:
Developed at the National Cancer Institute (NCI), this regimen uses the strategies described above and employs a 2 group risk-stratification scheme based on Ann Arbor stage and lactate acid dehydrogenase (LDH). Patients with a normal LDH, a performance status of 0-1 and stage 1-2 disease are defined as having low-risk disease and receive 3 cycles of CODOX-M. All others are defined as having high risk disease and are treated with 4 alternating cycles of CODOX-M. (Table I) (Table II)
The regimen has been refined over several investigations for adult patients leading to reductions in neurologic toxicity, myelosuppression, and mucositis. In turn, a two-year progression free survival of 64% has been reported in the 3 most recent investigations, albeit with the majority of patients studied being less than 40 years of age. Preliminary results demonstrate that incorporating the anti-CD 20 antibody rituximab does not increase toxicity. Regimens developed by LMB and BFM groups are similar in the chemotherapeutics used, dose-intensity and risk adapted design. However, limited data in adults is available.
Data using the CODOX-M/IVAC regimen in HIV positive adults with Burkitt lymphoma suggests its feasibility in these patients. The Aids Malignancy Consortium reported on 34 patients treated with CODOX-M/IVAC plus rituximab. With a median age of 42 years and a CD4 count of 195/uL, 20 patients had severe myelosuppression and 14 had severe infections complicating therapy. With 1 treatment-related death, the 1-year progression-free survival was 69% and overall survival was 72%.
Utilizing infusional etoposide, vincristine and doxorubicin, the dose-adjusted EPOCH regimen combined with rituximab appears to provide excellent results in a less intensive manner. A prospective trial reported on 19 patients treated with DA-EPOCH-R and 11 patients with HIV-related Burkitt lymphoma treated with a short course of EPOCH with dose intensive rituximab. After more than 6 years of f/u in both groups, the rate of freedom from disease progression were 95% and 100% in the HIV negative and HIV positive cohorts respectively. While designed to achieve an absolute neutrophil count of <500 cells per cubic millilitre, only 22% of DA-EPOCH-R cycles were complicated by febrile neutropenia. Further, severe gastrointestinal events were rare and grade 3 or 4 sensory neuropathy occurred in 17% of patients.
(See Table III)
This Cancer and Leukemia Group B developed regimen is a dose-intensive short-duration treatment plan lasting 18 weeks in duration. Following a seven-day cycle of cyclophosphamide and prednisone, patients receive alternating cycles of ifosfamide, methotrexate, vincristine, cytarabine, etoposide, dexamethasone with cyclophosphamide, methotrexate, vincristine, doxorubicin, and dexamethasone. The inclusion of prophylactic cranial radiation to high-risk individuals and the initially observed neurologic side effects may partially account for its limited use.
Largely studied in children and adolescents, this dose-intense regimen divides patients into 4 different risk categories, allocating the most intense and toxic treatment to patients with higher risk disease. The prognostic groups are based on whether the disease has been surgically resected, stage, LDH, leukemic presentation, and central nervous system (CNS)
Based on risk group, patients received 2-6 cycles of chemotherapy. For all patients except those with completely resected disease, treatment was preceded by a less intense prephase cycle intended to improve the patient's performance status. More than 500 patients were investigated on this protocol, demonstrating excellent event-free survival rates. Further, they demonstrated that for patients with limited stage disease, the high-dose methotrexate dose and infusion could be reduced without compromising outcomes.
Similar to the BFM protocol, LMB 96 was developed in children and adolescents. It is a dose-intense regimen where patients are stratified into therapy groups based on surgical resection of disease, CNS involvement, and degree of bone marrow involvement. This regimen also demonstrated excellent results in these younger patients and the ability to achieve comparable outcomes across risk groups by using prephase treatment, tailoring the therapy intensity based on the above factors and aggressively prophylaxing / treating patients for CNS disease.
(See Table IV)
The hyper-CVAD regimen was initially developed for patients with acute lymphoblastic leukemia but has been evaluated in Burkitt lymphoma. Hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone is alternated with high dose methotrexate and cytarabine for 8 cycles. Results with and without rituximab have been encouraging, albeit in a more heterogeneous population than CODOX-M/IVAC was evaluated in.
Regarding the optimal up front treatment regimen, comparative studies are not available. We have historically treated younger patients using the CODOX-M/IVAC protocol. Of the published variations on this regimen, all are reasonable options with comparable efficacy and toxicity. Additionally, we included rituximab with first-line treatment. Patients with HIV-associated disease have been typically treated in a similar manner. The NCI-generated results using DA-EPOCH-R suggest that excellent outcomes may be obtained with less intensive infusional therapy. However, this regimen requires treating physicians to adjust the doxorubicin, etoposide and cyclophosphamide doses based on neutrophil and platelet nadirs with each cycle. For older patients or those unable to tolerate a short-course, dose-intensive regimen, the dose-adjusted EPOCH-R regimen may provide the best risk to benefit ratio for this population. Standard RCHOP should be considered as being palliative in this population.
Autologous stem cell transplantation has been evaluated as a consolidative strategy after patients have received initial therapy. While data are limited, results suggest comparable outcomes to those obtained with the short -course regimens listed above.
Few options exist for patients who relapse after initial therapy. Typical salvage regimens used in diffuse large B-cell lymphoma such as ICE (ifosfamide, carboplatin, etoposide) or DHAP (dexamethasone, cytarabine, cisplatin) can at times be used to bridge patients to either autologous or allogeneic stem cell transplantation.
Post-chemotherapy supportive care is critical given the dose intensity and subsequent side effects associated with standard treatment regimens. As such, close outpatient follow-up to monitor side effects and transfusion requirements is needed. Patients require appropriate inpatient resources and staff experienced in chemotherapy administration and their respective side effects. Most notably is the sophistication involved in the use of IV high-dose methotrexate. Patients require pre-treatment hydration and alkalinization, monitoring of urine pH, renal and hepatic function, rapid turnaround in methotrexate levels, attention to leucovorin rescue, and availability of carboxypeptidase in rare circumstances.
Prevention and management of tumor lysis syndrome typically includes aggressive intravenous hydration and the urate oxidase, rasburicase. In the event of renal failure from uric acid nephropathy, management may include hemodialysis. Additionally, granulocyte colony-stimulating factor support as well as antibacterial, antiviral and antifungal prophylaxis are routinely administered.
Burkitt Lymphoma is rapidly progressive and universally fatal in the absence of therapy. In patients able to tolerate a dose-intensive chemotherapy program, timely initiation and completion of therapy can result in long-term survival. While most patients will initially respond to treatment, progression-free and overall survival rates in adults have not matched outcomes in younger patients. Using the CODOX-M/IVAC regimen, investigators have reported two-year overall survival ranging from 67-92%. At five years, CALGB 9251 resulted in 52% of patients being alive and in complete remission. Three-year overall survival for hyper-CVAD has ranged from 49-89%. Six-year overall survival for DA-EPOCH-R has been reported to be 100%, albeit in 19 patients having a median age of 33 years. For patients who relapse after initial therapy, salvage options should be considered palliative given few patients achieving long-term survival.
"The patient is too sick to receive chemotherapy".
Due to the rapidly progressive nature of Burkitt lymphoma, patients may present with evidence of end-organ dysfunction or a poor performance status secondary to lymphoma. Based on experiences with other malignancies, medical professionals and intensive care unit staff may assume that the patient isn't able to tolerate chemotherapy. Patients with Burkitt lymphoma may experience a rapid improvement in function with appropriate treatment. Clinical trial experiences have demonstrated that temporizing measures such as fractionated cyclophosphamide or a single cycle of CHOP chemotherapy can allow for time to confirm the diagnosis and improve a patients performance status without compromising the patients change of cure. Measures such as these may also be used in the critically ill patient to optimize organ function prior to starting a dose-intensive regimen.
"Lack of referral to a tertiary care center".
Given the need for close monitoring of patients during therapy, the use of high-dose methotrexate, and aggressive tumor lysis prophylaxis, most patients should be treated by staff experienced in managing Burkitt lymphoma. As such, clinical intuition and a prompt diagnosis are important to allow for transfer of the patient's care.
Normally functioning as a transcription regulator, constitutive overexpression of the MYC oncogene plays a primary role in the pathogenesis of Burkitt lymphoma. While c-MYC expression is not uncommon in other malignancies, this typically represents a secondary alternation occurring in the setting of clonal evolution. In Burkitt lymphoma, c-MYC overexpression typically results from a chromosomal translocation between the c-MYC oncogene on the long arm of chromosome 8 and either the Ig heavy chain gene on chromosome 14, the kappa light chain gene on chromosome 2, or the lambda light chain gene on chromosome 22. As a result of the MYC oncogene juxtaposing with one of the immunoglobulin gene loci, the c-MYC allele is expressed constitutively and cell cycle control is lost.
Next-generation sequencing has revealed a number of diverse genetic abnormalities contributing to the pathogenesis of Burkitt lymphoma. Among the most common include recurrent silencing mutations in the tumor suppressor gene ID3 leading to constitutive activation of the transcription factor TCF-3. This promotes tonic B-cell receptor signalling, engaging the PI3K signalling pathway in addition to promoting cell-cycle progression through CCND3.
Additional, more poorly understood genetic lesions simultaneously inhibit apoptosis. One such mechanism includes the Epstein-Barr virus (EBV), the genome of which is contained in tumor cell nuclei in some cases, mostly commonly in endemic and HIV related disease. This accounts for the majority of endemic African Burkitt lymphomas where it is hypothesized that malaria causes B-cell hyperplasia facilitating disease genesis in the setting of widespread EBV. This explanation does not account for the majority of cases in developed countries where10-20% of cases are EBV-related.
The rapid nature of disease presentation and progression is the most salient feature obtained in the patient's history. Insidious non-specific symptoms over a prolonged time course is uncommon. Inquiring about risk factors for HIV may be helpful in identifying immunodeficiency-related disease. Patients may have systemic complaints or B symptoms defined as fever of more than 38°C, weight loss of more than 10% of body weight, or the presence of drenching night sweats.
Enlarged lymphadenopathy, abdominal masses, or organomegaly may be palpable on physical exam. In conjunction, a rapidly declining performance status may be evident.
Analysis to identify overexpression of BCL-2, most commonly due to the t(14;18) translocation, is identified in a small number of cases by routine karyotype analysis or FISH. More rarely, a translocation involving the BCL-6 gene on chromosome 3q27 may be identified. These so-called "double hit" lymphomas have an extremely poor prognosis with a median overall survival reported at 2.5 months in one series.
Mead, GM,, Sydes, MR,, Walewski, J. "An international evaluation of CODOX-M and CODOX-M alternating with IVAC in adult Burkitt's lymphoma: results of United Kingdom Lymphoma Group LY06 study.". . vol. 13. 2002. pp. 1264-1274. [This international effort documents patient outcomes after the CODOX-M/IVAC regimen, including older adults.]
Noy, A,, Lee, JY,, Cesarman, E. "AMC 048: modified CODOX-M/IVAC-rituximab is safe an effective for HIV-associated Burkitt lymphoma.". Blood. vol. 126. 2015. pp. 160-6. [This trial reports on the largest group of HIV patients treated with CODOX-M/IVAC.]
Kieron, Dunleavy,, Stefania, Pittaluga,, Margaret, Shovlin. "Low-Intensity Therapy in Adults with Burkitt's Lymphoma". N Engl J Med. vol. 369. 2013. pp. 1915-25. [This uncontrolled, single-center case series suggests excellent long-term outcomes for the DA-EPOCH-R regimen.]
Rizzieri, DA,, Johnson, JL,, Niedzwiecki, D. "Intensive chemotherapy with and without cranial radiation for Burkitt leukemia and lymphoma: final results of Cancer and Leukemia Group B Study 9251.". Cancer. vol. 100. 2004. pp. 1438-1448. [The CALGB 9251 study documents cooperative outcomes for the intensive, short-duration chemotherapy regimen in Burkitt lymphoma. Less intensive CNS prophylaxis provided curable therapy without prohibitive neurotoxicity.]
Dave, SS,, Fu, K,, Wright, GW. "Molecular diagnosis of Burkitt's lymphoma.". N Engl J Med. vol. 354. 2006. pp. 2431-2442.
Hummel, M,, Bentink, S,, Berger, H. "A biologic definition of Burkitt's lymphoma from transcriptional and genomic profiling.". N Engl J Med. vol. 354. 2006. pp. 2419-2430. [The above two studies demonstrate the unique molecular signature associated with Burkitt lymphoma. Gene expression appears to more specifically define Burkitt lymphoma compared to routine histologic classification, differentiating patients with diffuse large B-cell lymphoma having a chromosomal breakpoint at the MYC locus.]
Thomas, DA,, Faderl, S,, O'Brien, S. "Chemoimmunotherapy with hyper-CVAD plus rituximab for the treatment of adult Burkitt and Burkitt-type lymphoma or acute lymphoblastic leukemia.". Cancer. vol. 106. 2006. pp. 1569-1580. [This publication documents the results of the hyper-CVAD regimen combined with rituximab for a heterogeneous group of Burkitt and Burkitt like lymphoma.]
Mead, GM,, Barrans, SL,, Qian, W. "A prospective clinicopathologic study of dose-modified CODOX-M/IVAC in patients with sporadic Burkitt lymphoma defined using cytogenetic and immunophenotypic criteria (MRC/NCRI LY10 trial).". Blood. vol. 112. 2008. pp. 2248-2260. [The LY10 study is the most recent modification of the CODOX-M/IVAC regimen. Therapy was tailored for high group. The study demonstrates comparable outcomes and reduced toxicity with a dose reduction in high dose systemic methotrexate.]
Kelly, JL,, Toothaker, SR,, Ciminello, L. "Outcomes of patients with Burkitt lymphoma older than age 40 treated with intensive chemotherapeutic regimens.". Clin Lymphoma Myeloma. vol. 9. 2009. pp. 307-310. [This publication retrospectively analyses data from 14 treatment series documenting outcomes for older patients affected by Burkitt lymphoma. It suggests that intensive chemotherapy regimens are appropriate for selected older patients. Outcomes may be favorable for these patients but future studies should formally analyze older patients to better define who will benefit from aggressive therapy.]
Evens, AM,, Carson, KR,, Kolesar, J. "A multicentre phase II study incorporating high-dose rituximab and liposomal doxorubicin into CODOX-M/IVAC regimen for untreated Burkitt's lymphoma.". Annals of Oncology. vol. 24. 2013. pp. 3076-81. [This trial demonstrates the tolerability and preserved efficacy of CODOX-M/IVAC combined with rituximab.]
Lacasce, A,, Howard, O,, Lib, S. "Modified magrath regimens for adults with Burkitt and Burkitt like lymphomas: preserved efficacy with decreased toxicity.". Leuk Lymphoma. vol. 45. 2003. pp. 761-7. [This publication details results of the CODOX-M / IVAC regimen in adults with a median age of 47 years. Results demonstrated similar outcomes in this cohort as compared to previous publications including younger patients.]
Magrath, I,, Adde, M,, Shad, A. "Adults and children with small non-cleaved-cell lymphoma have a similar excellent outcome when treated with the same chemotherapy regimen.". JCO. vol. 14. 1996. pp. 925-34. [Initial results combining CODOX-M / IVAC in 39 adults and 33 children demonstrating an excellent event free survival of 92% at 2 years.]
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USA: Jindal Calls for Swift Release of RESTORE Act Funds
Governor Bobby Jindal addressed a gathering of the Gulf Coast Ecosystem's Restoration Council in New Orleans, where he highlighted the importance of Louisiana to the Gulf's Ecosystem and called for a swift flow of RESTORE Act funds to Gulf States, counties and parishes affected by the BP oil spill.
The Governor also highlighted his commitment to coastal restoration and the state's historic Master Plan for a Sustainable Coast, which will protect and preserve Louisiana's coastal wetlands and communities. A day before the anniversary of Katrina and a year after Isaac's landfall, the Governor's address also focused on Louisiana's unprecedented recovery from Hurricane Katrina, one of the nation's worst disasters.
The Gulf Coast Ecosystem's Restoration Council is comprised of Gulf State governors and designees and cabinet or sub-cabinet level representatives from the U.S. Departments of Agriculture, Army, Commerce, Homeland Security, Interior and the Environmental Protection Agency. The mission of the state-federal council is to administer oil spill restoration programs associated with Clean Water Act civil penalties resulting from BP's Deepwater Horizon Disaster.
Governor Jindal said: "In Louisiana, we've seen our share of disasters. Hurricane Katrina battered our state nearly eight years ago, followed by Hurricanes Rita, Gustav, Ike and Isaac. In 2010, Louisiana was ground zero for the Deepwater Horizon oil spill and the damage is still occurring today. But we are resilient. We have worked tirelessly to protect our coast, committing billions of dollars to community resilience in Louisiana and the progress has been impressive. We've dedicated these dollars because Louisiana's coastal resources play a key role in putting wild, healthy, domestic seafood on dinner tables across America, powering our nation's economy and expanding global trade – including doing our part to meet America's export goals.
"Our coastal area is also the top source of offshore energy in the United States and abundant reserves remain. In addition, we have seen strong growth in shale plays onshore – further increasing Louisiana's role in our national energy security. Louisiana also serves as the gateway to America's Commerce Superhighway – the Mississippi River system. All of this must be protected and sustainable for the future. Our coastal efforts underway in Louisiana today represent the largest effort in the nation to protect and restore a coastal landscape. All of this progress and all of these recovery efforts are going to be wasted if our coast is not sustainable. That's why I've directed state officials to commit 100 percent of RESTORE Act funding to ecosystem restoration and community resilience projects associated with our Master Plan. We must see a swift flow of RESTORE Act funds without red tape so we can continue responding to the compounding damages caused by the BP oil spill here in Louisiana and across the entire Gulf Coast."
The Governor said prior to the BP oil spill, Louisiana was on track to have the lowest rates of land loss in over a decade due to billions of dollars in investments in coastal restoration and hurricane protection. However, he said Louisiana marshes have become more vulnerable to erosion in areas where oil injured coastal vegetation, continuing to impede coastal progress. Researchers continue to report accelerated erosion in areas where vegetation has died due to oil build up. The Governor called on BP to stop spending hundreds of millions of dollars on their public relations campaign and instead address their Clean Water Act and Natural Resources Damage liabilities now.
Since 2008, the Jindal Administration has dedicated more than $2.5 billion to coastal projects. The state's Coastal Protection and Restoration Authority (CPRA) acts as the single state authority that integrates coastal restoration and hurricane protection by marshaling the expertise and resources of the all state agencies, speaking with one clear voice for the future of Louisiana's coast. In 2012, using the best available science and an unprecedented amount of outreach to coastal stakeholders, the CPRA developed the Master Plan for a Sustainable Coast – a 50 year, $50 billion plan to preserve and protect Louisiana's coast now and for the future.
Press Release, August 29, 2013


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A Budget Spreadsheet Isn't Exciting -- Until It Saves You Thousands
It sure might seem like there can't be many things more boring than budgeting and spreadsheets -- so a budget spreadsheet sounds extra-deadly, no? But hold on -- don't be too hasty. Just as taxes can be slightly interesting, an excellent spreadsheet can actually keep your attention for a bit, too. Especially if it's all about some of your favorite subjects: You! And money!
The thought of budgeting may have you wanting to run for the hills, but it doesn't have to mean keeping detailed records of every penny you ever spend for the rest of your life. It can take many forms, including perhaps just spending a few hours once a year or so, tracking all your sources of income and all the ways you spent it.
But why?
Understanding why you should budget can help you get yourself to do it. The main benefit of budgeting is that it will give you a relatively clear picture of your financial habits and situation. You might know that you need to rein in your spending and might be wincing at the thought of losing your cable TV or stopping your tennis lessons or having to pass up your daily Venti coffee with two pumps hazelnut, two pumps vanilla, two pumps caramel, five Equals, and extra cream.
By figuring out exactly how much money is going where, you can more clearly see where you can make some changes, and you can weigh your options against each other more rationally. (And let's face it, a budget spreadsheet can be quite helpful with this -- though a simple notebook can work, as well. And there are handy websites, too.)
Your efforts might reveal that a $4 coffee every weekday is costing you about $1,000 per year, and that your weekly $40 tennis lesson costs $2,080. That pack-a-day smoking habit, when cigarettes cost $6 per pack: nearly $2,200. An extra $40 on your cable bill for lots of premium and movie channels? $480. When you see these numbers, you might realize that you can keep your cable channels, and that quitting smoking can save your tennis lessons, too. (Cut out all these items, though, and you can save more than $5,500 -- which will add up to close to $30,000 in just five years. See what budgeting can do?)
Categorically speaking...
If you want to set up a budget spreadsheet, or even just start keeping track of your money management in a notebook, you'll need to list categories. Everyone's expenses and inflows are a bit different -- for example, Internet costs might be an entertainment expense for some, a work expense for others, and nonexistent for still others. Here are some key categories to consider as you set up your list:
Salary/main job income
Dividend income
Income from side jobs
Proceeds from sales
Capital gains reaped from investments
Rent or mortgage
Groceries and household necessities (toilet paper, detergent, etc.)
Eating out
Utilities (water, gas, electricity, garbage, sewer, etc.)
Transportation (car, maintenance, repairs, gas, public transportation costs, parking, etc.)
Taxes (property, income, etc.)
Telephone and communication
Debt repayments
Travel (airfare, hotels, etc.)
Insurance (home, health, car, disability, life, etc.)
Entertainment and recreation (cable TV, Internet, season tickets, etc.)
Medical and health (doctor visits, glasses, gym memberships, etc.)
Charitable donations
Child-related expenses
Pet care
Once you've set up your list, spend a month (ideally, spend three) tracking where your dollars go. The more specific you can be, the more useful the whole exercise will be for you.
Using a budget spreadsheet instead of a notebook can be extra handy, as you can set it up to automatically convert monthly expenses into annual costs, and to automatically total expenses and inflows. A budget spreadsheet is also great if you want to tweak numbers. Turn those five expensive coffees each week into two and the spreadsheet will automatically adjust everything for you to show you how much you'd save.
You don't have to spend the rest of your life budgeting, but spending a little time on it for a very limited period can greatly improve your financial future.
Making the right financial decisions today makes a world of difference in your golden years, but with most people chronically under-saving for retirement, it's clear not enough is being done. Don't make the same mistakes as the masses. Learn about The Shocking Can't-Miss Truth About Your Retirement. It won't cost you a thing, but don't wait, because your free report won't be available forever.
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