Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Thu, 27 Apr 2017 08:58:28 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEhxs5-8XFWio_YTbETBF0ObReoSUvkdvonx7nHs6V6-_M8aEqdkGBBmDoLlh_XWAvyQ1llnkFt6OnSQ6MgoNyfxqwPWK03PtwfZZpeAv7ezZrrI0K0e-yFPb9gzh7CktD_lgrpeb-zGH&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==]
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The Fickenscher Files, Vol. 5, Issue 4
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEjXsO6Rx2WZs0AlLqaown_GxpO32ZHytk9kM3RFSW_-l9y5m8DLC5LqSEIARdUC7OV3YYx0mPT91GqgcXeCr_u3oJb0tSyVpHk_VfFm6ap_ij5MI2hsSUfxNnKw_bRz-_B-LFMJ_lcXaUp97HRd0GFOTkOIn7Se-NBm8w_DzDkT5o5_1vSodxumFg5QUVmNlhtOdqt_7T_2ljfX8YRfGiFU=&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==],
MD, CPE, FACPE, FAAFP
@MDKev
A compilation of information, thoughts, and perspectives on the issues of the day
related to healthcare, technology, and beyond - including the latest culinary explorations.
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Quote(s) Of The Week
"On average, the CDC team estimated, 65 percent of flu-related deaths could be prevented
if all US [children received a] yearly flu shot."
The Centers for Disease Control and Prevention, in a new research repor [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEszD4bImaBMqS2w4MdOWdwaMRmE5g-famNf0Zlo58H0JE5nAu7flglYTZ0XFuE5DTZTslwLEx5Mko9UTE9pprLKx8Nr-dz0XYswXhvsaVEHKXpvlAfWgmdcGwtN2V40vRmJT5vUFola5VKntU28wpX9RWbMbz-tReQBIYOlnOikOmedpzCFONDs=&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==]t
[http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEszD4bImaBMqS2w4MdOWdwaMRmE5g-famNf0Zlo58H0JE5nAu7flglYTZ0XFuE5DTZTslwLEx5Mko9UTE9pprLKx8Nr-dz0XYswXhvsaVEHKXpvlAfWgmdcGwtN2V40vRmJT5vUFola5VKntU28wpX9RWbMbz-tReQBIYOlnOikOmedpzCFONDs=&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==]
on the need for improvement in vaccination of children.
"Everybody knows somebody. This state is a laboratory for the future of Alzheimer's
in America."
Kendra Binger, a program manager with the Alzheimer's Association of Minnesota and
North Dakota, in comments on the large number of cases of Alzheimer's in the State
of North Dakota.
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Readings To Consider
Books and Articles worth a Review...
As a consumer of many periodicals (in fact, far too many to keep up) and a member
of the ultra-buyer list for Amazon books (many of which are lying piled up in my
 home office awaiting a read), I've started sharing the best of those reads for 
your consideration.  I started a couple of weeks ago with Thanks for Being Late 
by Thomas Friedman - which is a fabulous read.  This week, I'm offering up a book
that I should have read some time ago but only recently discovered.  It's Neal Postman'sTechnology
- published originally in 1993.  For someone who prides himself on keeping up with
the latest in technology, I found the very apt descriptions on the impact of technology
on society quite enlightening.  As he describes it, technology is "...about the 
technologies that alter our interests, the things we think about...the character
 of our symbols, the things we think with...the nature of our community, the arena
in which thoughts develop."  While originally published in 1993, the book still 
carries considerable wisdom and perspective on how technology impacts our lives,
 our presence the world and the way we lead our lives.  It's definitely worth a 
read for all of us - technophile or not...
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Consulo Indicium
Information for your Consideration...
GAO Joins The Push For Greater Telecare - The General Accounting Office (GAO) recently
published its latest assessment on the use of telehealth and remote patient monitoring
for enhancing the ability to deliver health care.  The assessment chided Medicare
for hampering the further development of the capability through the program's payment
and coverage restrictions which create obstacles to the use of these technologies.
I'm an ardent supporter for telecare technologies so the GAO report [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEszD4bImaBMq5NcIqKa1H6b8HlWW1pbq036w3P1pJ66q0DzU6lNrwUNYFERsp3ErCWScdAPWU6Ktj4QYcjs631zRMXNKq8xELqZk3ODr7Wm5bDmCC3_bVSOyZoAwi9PJzsLjC1XN1zYyAQXt8mlR9SA=&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==]
came as a welcome support for fostering development of the field.  One of the core
obstacles has been payment for services under Medicare and the GAO called out the
finding as part of its new audit. And, as we all know - so goes Medicare, so goes
the rest of the insurance industry
GAO did the assessment as part of the Medicare Access and CHIP Reauthorization Act
of 2015.  The Act included a provision requiring GAO to study "telehealth and remote
patient monitoring". As part of their study, they interviewed various provider organizations.
 The uniform response was that the payment policies are getting in the way of moving
forward with a technology that improves outcomes and provides better service.  One
of my mantras for the health care community is: "It's not the money.  It's the money!"
 Or, money drives the behavior of the industry!  How we pay for services determines
how services are organized and delivered.  It took more than a few years for the
 health care community to pick up Laennec's great invention - the stethoscope.  
So, it is likely that with persistence those of us who believe in the use of telecare
services will eventually see success in the adoption of the "next stethoscope" -
 telecare services.  It will dramatically alter our capabilities - in ways that 
we are only beginning to understand.  It's clearly time to develop a more progressive
approach toward support of the telecare field.
Another area that was highlighted in the report was the need for improvement in 
infrastructure.  I couldn't agree more!  Specifically, the report notes that the
 lack or insufficient availability of broadband capability is hampering the use 
of both telehealth and remote patient monitoring. However, that problem will not
 be solved by Medicare.  So, it will be incumbent upon the health care community
 to go outside the usual boundaries of advocacy and look to other groups or agencies
like the Federal Communications Commission (FCC) and the telecos for assistance 
in solving the problem.  Perhaps Congress should consider an "American Broadband
 Equity Act of 2017" to solve the problem of availability and reliability of broadband
systems throughout the nation (NOTE: Are there any Congressional staffers reading
this?).  There is a bipartisan group of Senators who are seeking to solve the problem.
 They have re-introduced a bill that seeks to improve health outcomes through the
use of telecare services for Medicare beneficiaries living with chronic diseases.
The so-called Creating High-Quality Results and Outcomes Necessary to Improve Chronic
(CHRONIC [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEszD4bImaBMqr2OlzmPoQk43iWpeirrJpPbBpuK7bW3V0kXosaqlax2IAfwUvKQMD8LMOha2zmbqcvPZ07y4NkqQGW88rY91RZCbKUtqv8TVIzrC0zCOZAYSGXAeNQS31ySbIKzfaW0NEqtNWKbf83gDWnDYqtRgnbXIphDctuDJ3UcsQXvHbJ3CIi2muh2FOD6L3dZQjna_qNZlAky9o4yIHeYre1ZqLQ==&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==])
Care Act of 2017 contains a number of telecare provisions targeted at patients with
chronic conditions such as home dialysis and other chronic care problems.
The GAO report is a bit at odds with the Congressional Budget Office (CBO) which
 has expressed concerns related to the use of telecare technologies.  Specifically,
CBO is concerned that changing reimbursement policy for Medicare could result in
 a dramatic increase in overall health care spending.  So, it is likely that there
will need to be a resolution of the GAO-CBO perspectives if changes are to be forthcoming
more quickly.
There is a tsunami wave of technology on the horizon that will make the use of telecare
technologies even more compelling.  Not only will these technologies offer alternative
ways for delivery and supporting care, I believe at the end of the day the health
improvements experienced by patients treated with telecare technologies over our
 traditional models of care delivery will be substantialandcompelling.  The debate
is not over...but, get ready for a dramatic change of course.  Telecare is here 
to stay...
The Non-News, News - Earlier this month, the Centers for Disease Control and Prevention
released a report citing the fact that, "A new study...says getting young children
vaccinated against the flu could save their lives."  The researchers found that 
"most children who have died of flu in recent years were not vaccinated against 
the virus." Duh!  In fact, the researchers went on to note that "...at least three-quarters
of kids who died from influenza between 2010 and 2014 had not been vaccinated in
 the months before they got sick." Double Duh!!
It's Not Just My Mom: The Leading Edge of Alzheimer's Is North Dakota - One of the
issues that I have become keenly aware of over the last couple of years is the Alzheimer's
crisis that exists in America.  It's in part because I am witnessing this is in 
my own family.  Mom is slowly - but, surely - moving into the darkening tunnel of
Alzheimer's.  If she were fully aware, I know that she would approve of me sharing
this information if it would help everyone to understand the magnitude of the crisis.
 From my perspective, we have a lot to thank President Ronald Reagan for in this
 regard.  He brought the problems of Alzheimer's to the forefront with his public
acknowledgement that he had the disease.  It helped to shed light on a growing problem
- but, the light is not quite bright enough...
My home state of North Dakota is a leader in the nation - for Alzheimer's L.  While
the number of cases is climbing dramatically [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEszD4bImaBMqto9LLovWKpu5kaLa87oMcDjjrVYm4tukh73VLeaGnk8zeRTB_1bnu_zetR05hAamcpM_h8D4FcfGqlbRoGJvzWXBolVowAjW4jrKpEiZKERdZzkINOjdhihfukwAD6eZCwtYv6iGdrutWZzNM0Tqpd8kywMPFpTJ0i26ZtzPxvaMBh5cvghpew==&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==]
across the USA there are certain pockets - like North Dakota - where the incidence
exceeds the average by an appreciable number.  In fact, the State of North Dakota
has the USA's second highest death rate [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEszD4bImaBMq3SQa4FbkO6n-G_DCqjf0LNzZ4cHfBzOW0VgP1yA20Q_ZNHoKn_bdsLzsLQu6iqvqpixmMv-CWB5XKdKWENJiG4CPbVN9GbnvuBH-hF1S0COVRM2tvY9hLaVf4AnscUrDAwr9LmhHRbdZTN75Ju3ydGJ4ujTLkekn&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==]
from the Alzheimer - where, among all causes, it is the third ranking cause of death
in the state versus the sixth across the nation.  So, in essence, North Dakota is
a laboratory for the future...
The state is investing in programs that primarily focus on help for family caregivers.
 These are the spouses, daughters and sons along with other family caregivers that
provide the lion's share of service in support of the Alzheimer's victims. The statewide
program has trainers that travel throughout the state to evaluate families' need,
train caregivers, connect them to services, and offer advice. It's a remarkable 
program and one that should be replicated.  In fact - as a family - we're in the
 midst of all these issues.  Just this past week, we were having a family discussion
on whether or not Mom can stay in her apartment or does she need to move to an assisted
care facility in the same complex and, eventually, a nursing home [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEszD4bImaBMqOyGQ6oOJUTnufWb7M_FDIvKX_k-rrQaGrzXelzqi4SuLzHGV_WMNpEuGOKeMJF4Y_euYBVTg3p9IzhnbmmVbjOwpuqBi4CLtK_8QWEjyg49NSU9Etz97RotNyePbE9gds92FvylRaek7Nx-KSNNAUVOMMpAMk93HaoPRVN83rgI=&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==].
 These are options that not only cost a lot of money BUT, are equally dissatisfying
to the victim of Alzheimer's.
As a nation, it's clear that we need to do a far better job of integrating "family
care" into the overall spectrum of services provided to Alzheimer's patients and
 their families.  Simply paying for institutionalization and other more traditional
"medical model" services is NOT the way to go.  Challenging the traditional approaches
will pave the way toward a new model of care delivery.  It's akin to the "value-based
reimbursement" models we are seeing for acute care.  The same concept of "value-based"
support services to be implemented for longitudinal problems like Alzheimer's.
Furthermore, this is not a problem only in the rural areas like North Dakota.  It's
a massive problem in the cities as well.  But, the incidence as a percent of the
 populace is not as high.  Why?  For example, Rhode Island has the highest percentage
of elderly over the age of 85 but, the incidence of Alzheimer's is not nearly as
 high as North Dakota.  What gives?  The answer will no doubt be found by carefully
examining the laboratory = North Dakota.  In fact, redoubling our efforts on research
and remodeling our approach toward care is the way forward.  Consider the alternatives.
 Without a new approach, the few problems that are chronic and menacing - like Alzheimer's
- will bankrupt the nation.  It's incumbent upon us to push the problem forward 
since it's not just a problem.  It's a crisis!!
Another Trump Explosion On The Horizon - It seems that President Trump has signaled
another option to the "repeal and replace" model that failed to pass the House. 
 Instead of offering up another solution, he might wait for the Affordable Care 
Act (ACA) to simply "explode" before offering up an alternative replacement plan.
It's an interesting ("sad", to use the common vernacular J) strategy. While most
 experts and the CBO have expressed doubts about the possibility of a catastrophic
failure with the ACA, it's clear that the adoption of certain policies could clearly
hamper the ongoing progress we've made over the last few years toward increasing
 the number of individuals in the USA who are fully insured.
The supposed explosion or implosion or whatever kind of "...osion" is to be expected
can only occur at this point if there is no funding forthcoming.  What that means
is that the brinkmanship that is on the horizon with the budget is the predicator.
 If funding is provided, the explosion will not occur.  If funding is diverted to
other options (e.g. "the Wall"), then I predict more of a dissolution rather than
an explosion.  Such an approach would undermine the health exchanges but it would
not suddenly undo them.  Essentially, what would happen is that the cost-sharing
 payments to insurers for participating in the ACA for roughly six million exchange
customers who are currently insured with lower deductibles, coinsurance and copayments
would disappear. The end result of that action would most likely be that insurers
would pull out of the exchange program.
Many are predicting that short of an explosion, the Trump Administration will move
the ACA's state innovation waivers in the direction of greater flexibility for the
states.  That is - in essence - what the Republicans were proposing with the American
Health Care Act, which went down to defeat a couple of weeks ago.  In fact, Secretary
Tom Price has sent clear signals to the state Governors that DHHS is willing to 
actively consider such ideas as high-risk pools and state-operated reinsurance programs.
 Such moves clearly push the notion of a state-directed option rather than a federally-mandated
model.  Also, Medicaid alterations are in the wings as well.
Long story short, the story changes every day.  I've been overseas for the last 
week and it has been incredibly hard to keep up given the seemingly minute-to-minute
debates.  The upcoming showdown over the budget will be a telltale sign of how far
the Trump Administration and the Republican colleagues in Congress are willing to
go in pushing the agenda.  We shall see.
Meanwhile, some members of the Democratic Party still prefer the universal coverage
model embodied in a single payer system. In fact, rumor has it that Senator Bernie
Sanders (D-VT) intends to submit a version of the single payer approach [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEszD4bImaBMqRtFksPnzz66Q6prSVmEo-DaUG0GvvRCGdGnkGHI06qrVXQ3mmPDXUGKNR3wETi2VvdWOiaFDF27uI61lB0zRg6acHSlQOeZrxY51yoMzFTTYNQkbed91LjyzETOi3edk9GNdOT2DNZSKTMLWxekUX8uy2DB59GTJ3W99OKs-ZaOkhwaL75WfHCM4XQhbtODILDHgzRaaMRzVFTxk5K-JCQ==&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==]
sometime over the next couple of weeks.  Such an approach goes to the other extreme.
 So, at the end of the day, we still have ideology against ideology rather than 
solution eyeing solution - which tends to be in the middle ground.  Such is the 
state of American politics - impasse rather than resolution.
It seems to me that we could easily agree on a couple of perspectives. First, the
health care system is heading in the direction of bankrupting the nation if we don't
change course.  The continuing escalation of costs under the current model of "pass-a-tube-get-a-payment"
doesn't work given our demographics or flattening economy.  Second, simply passing
the costs on to the consumer in the form of higher deductibles and copayments does
little to resolve the underlying problem.  In fact, it creates a pile of dirt under
the carpet.  Third, the Accountable Care Act has flaws that need to be fixed.  As
a person who supported the Act, I can see that and have been advocating a "fix" 
for those problems for some time.  In fact, just as Republicans can be faulted for
their lack of clarity on what exactly do they mean by "repeal and replace", the 
Democrats can be faulted for not putting forward a single, serious piece of legislation
over the last bunch of years designed to "Fix-ACA-Flaws" (or, FAF).  Fourth, a continuation
of an uncharted course for the industry due to the uncertainties of national policy
will result in continuation of the "wait and see" phenomenon.  Health care leaders
are not going to take risks which require hefty investments and development initiatives
if the directions of the health care industry are unclear.  And, fifth, we need 
more real conversation rather than real confrontation.  Like an increasing number
of Americans, I'm moving past frustration.  So, what's next?  Stay tuned.  It will
likely change tomorrow morning...
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The Weekly Whisk
Musings from a foodie...
For those who travel, this review is for you!  I had the opportunity to visit one
of our southern neighbors in the past couple of weeks - down in Argentina.  First,
I fell in love with Argentina.  What a great place.  Buenos Aires reminded me of
 Paris although I still rank Paris as First Among Many Great Cities of the World.
 But, I digress as usual...
In traveling to Argentina, you need to learn only one thing = grilled meat is a 
prime consideration at every evening meal.  Among those I tested, Cabana Las Lilas[*
* * *] did a great job.  Located in the renovated port area, we had seating along
the water on a wonderful, crisp autumn evening.  For starters, they served up eggplant
(grilled) with a sage tomato salsa sauce that served as the initiation.  Then came
the cheese bread served as little puff balls with various jams and marinades followed
by a fabulous local burrata mozzarella cheese with tomatoes.  But, the piece de 
resistance for the starters was a grilled provolone.  Served at just the right temperature,
it was a wonderful send off to the main course - which, of course - consisted of
 grilled meats.  Basically, our table had either filet or ribeye.  There were other
options like chicken and pork but, we were a crowd of Midwestern origins so beef
 was the dominate desire.  And, besides - all of the travel books suggest beef as
your first choice.  We were not disappointed.  I'm not a fan of ribeye primarily
 because in the states it is so variable.  The ribeye was served as a single steak
sliced down the middle in a filet fashion, which was able to serve two with one.
  The filet was delicate and magnificent on the tongue.  As you can tell, I loved
the place.  If you're in Buenos Aires - enjoy the walk around the city and plan 
a visit to Cabana Las Lilas - Av. Alicia Moreau de Justo, 516 - C1107AAL - Buenos
Aires, Argentina - +54 (11) 4313 1335 - +54 (11) 4098 2470 - [email-masked]
[mailto:[email-masked]].
But, the little crème de la crème that I discovered was
iLatina [
*
* * * * *
], which started as a puerta cerrada - or, a semi-secret dining room - inside a 
private home where Colombian siblings Santiago, Camilo, and Laura Macías served 
up Latin American dishes. They had incredible success which eventually became iLatina.
 I'm told it is one of the most difficult reservations to get in town, although 
I went online several weeks before traveling and found an evening time that suited
my fancy. There is no menu.  Rather, there is a seven-course offering created by
 Chef Santiago. It is a culinary tour de force of Latin America with a strong Colombian
influence.
I don't know where to start except to say that in the last decade, I've only given
out a handful of six star designations - among them The French Laundry (Napa Valley,
California), Steirereck im Stadtpark (Vienna, Austria) and a couple of other places.
 Needless-to-say, I was quite taken by iLatina.  Santiago - the Chef - was not available
as he was off in Sao Paulo for "business" but I enjoyed the offerings nonetheless.
 I started dinner with my usual question of "What types of juices do you offer?"
  There were the usual orange and pineapple but, sadly, no blueberry J.  They suggested
I try Papelon con limon [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEszD4bImaBMqoJC9LvIpAHokMABRsr1fp0-0SQ8G3cfe9P8E_UzBLwuwIao52JKdfnDkLre2jZ7oOIg8aEki5cl2L_X-n8OJZvQXIHq60uEH-NdT5EGYWBEaOLIjgVUe5VhHh8tqmcGQ-CuwOX_zzrrI7aATYZmueXofsVq8mIcXObYA_IcKoEkT3hAxLzLsgA==&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==].
Oh la la!!!  It's a Venezuelan refreshment that more than refreshes.  While I can't
vouch for the recipe in the hyperlink, it is definitely worth a try (NOTE: I've 
become a "Papelon" fan).
The tastings started with a shredded lamb on a small dried tortilla with a coconut-cilantro
dressing.  What a way to start!!!  From there, it went to - literally - the best
 ceviche I've ever had using shrimp, octopus and assorted white fish along with 
small pumpkin squares, a soy-vinegar or "milk of the tiger" and roasted corn.  From
there, we had the catch of the day which was a delicate "silver-sided white fish"
from the local rivers dusted with coriander, peanuts, coconut and salt.  Amazing.
 To prepare for the next entree, they then offered up a Mojito sorbet for cleansing
the palate.  And, we were not to be disappointed at the next offering when they 
served up delicate quail breasts in a mole of chocolate, peppers and coffee - again,
one of the best moles I've had in a very long, long time.  And, if that weren't 
enough, a pork shoulder with a coffee rub and coffee-sugarcane sauce was then served.
 The closer was a truffle with a cacao sail drizzled in a spiced olive oil with 
sea salt.  What a way to go...  It you ever get close to Buenos Aires, I more than
recommend you expend the effort to join the team at iLatina - Murillo 725 (Capital
Federal) - Buenos Aires, Argentina - +54 (11) 4857 9095.  Prepare yourself for a
 gastronomic delight of unassailable perfection.
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - My faith in the American system of governance to eventually work things
out...
The Good - A week away from the continental United States without access to CNN!!
The Bad - The continuing discord between Democrats and Republicans in Congress and
the brinksmanship that will resolve nothing...
The Ugly - And, we thought we had problems here in the USA.  Donald Tusk, European
Council President made the following declarative statement when asked about the 
EU and Britain having "parallel" talks on exiting and engaging with the rest of 
Europe: "Starting parallel talks on all issues at the same time as suggested by 
some in the UK will not happen." Hmmm - guess the discussions will not be as easy
as UK Prime Minister Theresa May thought...
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001F8p5eDkoXC_5xMSK2LsMZzEoL53pnoA0qq2-RHAPYftfdh6etwvGEhxs5-8XFWio_YTbETBF0ObReoSUvkdvonx7nHs6V6-_M8aEqdkGBBmDoLlh_XWAvyQ1llnkFt6OnSQ6MgoNyfxqwPWK03PtwfZZpeAv7ezZrrI0K0e-yFPb9gzh7CktD_lgrpeb-zGH&c=851fr33Y6eWxtOclyw3CA-KTLGF4gW4fqqeitnwGk904199MP-l3oQ==&ch=KOaBkegDpWU41HMnH0MvKpxlH6cek1jsR6_CtnZ4h6t4sMpQ7cLGew==]
are the personal views of Kevin Fickenscher, MD and do not reflect the views or 
policies of any organization with which he is affiliated.
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