Subject: News from Dr. Kevin Fickenscher
From: "The Fickenscher Files" <[email-masked]>
To: <[email-masked]>
Date: Mon, 21 Aug 2017 11:54:31 -0400 (EDT)

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The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAaH4L6_CwDtRjTA5bEWXk6blUkVjDh7kzlQuFvuat8lqW_hBHI-rDNn_Ae68gPF5OVZZPl9YEkuCPRqW6G5zW9uPJrgWgpum0njWItoluhf8Uwz2KQA_WnZIR6EzlAo1qvYzMQiZEEuu&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
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The Fickenscher Files, Vol. 5, Issue 7
Kevin M. Fickenscher [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAdvoarqDaMCYXz7wOCmk7C7fuQ1QBYY0ltRaSt8f38iCB8g2JWMuHqm2fl30EUs_DQGyJ-6dHmtfJNqCNsR-RK3okEW7x9Lo5L2IxxTA2eIlXXS8vsECcHck9-3dwJAc93mGnt8limsxS-paZqYWpRlhn2gq1mc_uA==&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==],
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
"I told her this last night [that] it's easy to stand up to your opponents. It's
 very hard to stand up to your friends."
Senator Angus King (I-ME) in comments at the Portland (Maine) Airport upon arrival
back home following the decisively slim margin vote where Senator Susan Collins 
led a small coalition in opposition to the Republican led effort to undo the Affordable
Care Act.
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Readings To Consider
Books and Articles worth a Review...
Of all the places to be reminded of the tenors of the times, the most unanticipated
source of a very pertinent reading recently came to me via National Parks Magazine.
 In addition to a wonderful article on the work of William Watkins - a bioacoustics
expert who developed the largest library of oceanographic sounds in the world - 
there was this letter to the editor from William Rukeyser on the internment of the
Japanese during World War II.  The internment was one of the saddest historical 
misadventures of the United States in the last century.  It is one of those reminders
of a period gone by that should never have occurred.
In particular, the Rukeyser letter quotes the decision of Supreme Court Justice 
Frank Murphy who offered a strong dissent in the Korematsu vs. U.S. who as an internee
took his case to the Court and lost in a 1944 split decision at the height of the
war.  In his opinion, Murphy offers a resolute and commanding minority decision 
that should be read by every one of us as we dialogue, debate, and discuss the recent
happenings in Charlottesville.  He offered these thoughts:
"...This exclusion of 'all persons of Japanese ancestry, both alien and non-alien,'
from the Pacific Coast area on a plea of military necessity in the absence of martial
law ought not be approved.  Such exclusion goes over 'the very brink of constitutional
power,' and falls into the ugly abyss of racism...Racial discrimination in any form
and in any degree has no justifiable part whatever in our democratic way of life.
 It is unattractive in any setting, but it is utterly revolting among a free people
who have embraced the principles set forth in the Constitution of the United States.
 All residents of this nation are kin in some way by blood or culture to a foreign
land.  Yet they are primarily and necessarily a part of the new and distinct civilization
of the United States.  They must, accordingly, be treated at all times as the heirs
of the American experiment, and as entitled to all the rights and freedoms guaranteed
by the Constitution."
While health care continues to be my focus, none of us must forget our responsibility
as citizens to stand up for what this country is all about.  I am the stock of third
generation German-American homesteaders. One set of cousins are second generation
Japanese-Americans whose Japanese grandfather was interned during World War II. 
 Many of my friends are first generation Whatever-Americans.  But, the common thread
among all of us - is that we are all "Americans".  Murphy said it well.  We should
not forget his words as we debate the future of our nation.
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Consulo Indicium
Information for your Consideration...
Susan Collins: Finding The Right Path - When Senator Susan Collins (R-ME) made the
comment that the Democrats were wrong in ramming the Affordable Care Act through
 the U.S. Senate without a single Republican vote seven years ago, she was right.
And, she was right again, when Senator Collins stood up to the pressure [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsf-b-z_J3yRsF05-TGWNSSwZzmSc2Cbrwljs7h_RuVjLeZb5hPiB97S9IIP8aVPADMxbRcP8b56ucxuRcAD8toq3reRnqBnIB37SuHE-Ce-fBAlzg8Tq2CPahnOQDCbCGumfy9MoqkS00IMb-wUSZ5wxgKLweEUSxLPWl67o_eeH_e7M-DIXKDBd3q_n7jWRcmDS_SLA7AflzI2kzyo7rhpA==&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
from her Republican colleagues that when the shoe was on the other foot, it was 
still not right.  It takes courage to take that kind of position and, as my Senator
from Maine, I was proud of her!!  Through her efforts along with the support of 
Senators Murkowski (R-AK), Capito (R-WV) and McCain (R-AZ) - a decisive vote ended
the seemingly endless dispute - at least temporarily - over the ongoing implementation
of the Affordable Care Act.
From my perspective, this does not mean that the debate is over!  In fact, perhaps
we'll actually get down to solving some of the problems with the ACA.  But, solving
those problems - as I have said so many times before - will not occur on the fringes
but "in the middle".  Virtually every big piece of legislation passed by Congress
over the last two centuries involved support from both sides of the aisles.  The
 give and take, the debate, the dialogue, the reaching of mutual understanding (and
benefit) has created the necessary compromises that have built our society.  It 
could be Social Security.  It could be civil rights.  It could be any number of 
issues facing society that required both sides to come together and solve the problem.
 That's exactly what's needed in health care.
In the wake of the vote, Senator Lamar Alexander (R-TN), Chairman of the Senate 
Health, Education, Labor and Pensions Committee indicated that a panel of Senators
has begun work to bring forward legislation in September to "stabilize and strengthen
the individual health insurance market for 2018."  His group of Senators has not
 yet unveiled any specific plans but following the summer recess many observers 
will be turning to his commitment.  Not to be outdone, the Democratic Senators are
also fast at work on their efforts to develop a new bipartisan effort for stabilizing
the ACA.  The more temperate tone from both sides is reassuring.A Spoon Full Of 
Goodness - Remember the song from Mary Poppins, where Julie Andrews sings about 
a "spoon full of sugar makes the medicine go down"?  Well, if we modify the song
 and change "sugar" to "goodness" the essence of a new report in Lancet [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsfCeJ-Idhr40AUZFLEpEg9F-67zpb7WlxO0ANNTnK0Ljhm2dJ_umHZ1liySr59pmFeH5b435IgmSrvZjpGw3N-GPRie7C7KwleGOcf5OBo_wnq7hXbYC0uAVI3CrVbkNnxPRQa0M1nm-jIct0GJWmJTg==&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
becomes clear.  The study estimates that one-third of the nearly 50 million people
with Alzheimer's disease could have prevented onset of the disease with the application
of some simple, healthy habits and a change towards a healthy lifestyle.  This is
a particularly crucial issue for the world where the estimated number of cases will
triple by 2050. The Lancet study was a macro-analytics review of available data.
The types of interventions [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsfHOYp0aggVLcd5ISQsx58xFYMhnUNuFmPc9Xj8YStmgKMcWuIhiZniynbz3Fnq20khvoQUhR53F2_nJjutDIgsaI2qGMNj9ytONAQuUsP5Kokbn7bmP4pEL7xltuXq-zcTMw7R-TCChNDvxHpVTxB1FwgfrrFiEj45HL7wJWrvFw=&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
included avoiding smoking (duh!), maintaining a normal blood pressure, managing 
obesity and getting an education, maintaining strong social connections, engaging
in stimulating brain activities, exercise and maintaining a healthy diet - which
 goes along with not being obese.  In particular, the researchers noted that these
interventions are not "Johnny-come-lately" types of activities.  They need to be
 started in childhood and maintained throughout one's life. The long and short of
it all means that there is something all of us can do now to reduce the potential
risk and impact of Alzheimer's on family and society - maintain a healthy lifestyle.
For example, the MIND diet [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsfXypWnatPV_0cNX5frasB9Ef_yvN-1PTUDmyUhGHjslFU7iiF7onIHOvWUTcHrBvyGzn4z9ZQxnpHw7MKZtQjlF2LLalk5vpC8TaE8Sk4W-RRn_fmv-SCHQv2XcT7DoHr49_y7yx_4LmBetzsQDODxFMzlmfYRR1md40WB7I6GyjGNSnfaKgeTFnHoSDARzz56JKEycy1a7o=&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
developed at Rush University Medical Center in Chicago and Harvard T.H. Chan School
of Public Health combines elements of the Mediterranean diet and the DASH diet (Dietary
Approaches to Stop Hypertension) has been shown to lower the risk of Alzheimer's
 [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsflR8Ad85oPu1dLlYHXDi-GQRH3cIyDe3ZS6RxMKkHpH39YfjAlSr3pq-43sIy8KtxI42g4gQLu7RrF5iMSukPdkALT1KBLMynN6PxBmX0-7TBv1PpsOzOhy5CRsmCySTVj--eg19YpT8=&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
by a whopping 53%!!  But, if that is not your cup of tea, the Canadian version of
which has been adapted to Western eating habits (is there any bacon?) has been shown
to decrease the risk of Alzheimer's by 36% [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsfPgFVONVi3a58FYSrV_knqV9fFAH0y5edmjy5oLTwalIrpN6vIMtj4nsaNMS6tUSVg2zlP_alREjEnOCFn7nw0iXsQC9mMij0ezoEOfrqs9HsqkDJvN0BAoqha19A8YBzq_uHpvNMvVc=&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==].
Either way, adopters of the diets are way ahead...
The Increasing Virtuality Of Care - In the last month there have been a spate of
 surveys reported on the acceptance of virtual visits by patients as an alternative
to the more traditional brick and mortar health care experience.  While almost all
of these studies show an increasing acceptance of telemedicine and telecare experiences,
the results of the Health Industry Distributors Association caught my eye.  Not 
only did it show that users of telemedicine intended to increase their remote visits
in the coming year (59%), it also found that the majority (54%) indicated that telemedicine
was "better" than an in-person visit.  Other findings included the fact that 41%
 equated a telemedicine visit to an office visit while only 5% felt that it was 
worse than the usual experience with 3% indicating they intended to reduce their
 use of telemedicine in the coming year.  And, as one would expect, the top reasons
for using telemedicine over the usual office visit were cost, convenience and the
feeling that their problem was not "serious".  These results point in the direction
of a booming utilization of the telemedicine and telecare modalities as the technology
continues to improve in the coming years.
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Future Health
Delivering care in the new virtual world...
The High Hope And High Cost of Gene Therapy - If there is one area of medicine that
has changed our whole of notion related to the who-what&when of care delivery, it
is the anticipation of gene therapy.  For those with rare genetic diseases, it offers
a ray of hope that goes far beyond traditional therapeutic models and interventions.
 The approach is relatively straightforward.  In essence, the DNA with a functional
gene that resolves the lack of functioning by a deficient gene enters a cell through
an intentional viral "infection" designed to implant the gene with the correcting
capability in the patient. This approach has been discussed for decades and was 
conceptual when I was a medical student.  Now, it's a reality!
There are now nearly 1,000 gene therapy trials in process for rare diseases ranging
from the more commonplace hemophilia to the much rarer Leber's congenital amaurosis.
 But, these drugs and treatments come at a cost.  For example, when Glybera became
available for the treatment of Lipoprotein lipase deficiency by restoring the enzyme's
activity, the price tag came in at a whopping $1.4 million dollars. The Leber's 
congenital amaurosis mentioned above has a new treatment which is becoming available
from Spark Therapeutics at a cost of around $500,000 per eye. Why are the costs 
so high? [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsfL5CWQ72d_QIR68J_5HdwgXc2zRaLaQtEdOwkfYS-akC77Qwf67FIbfI0yzSUwbzSKjSJpyDFHSMB54S1FyPMRYeuOyV68uo7y_cPCb-T7kS6Lv2ZAFqq3iHGeB2KIa6kk8w3iMhoEE3PGk0d2IvWaA==&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
It represents the combination of repaying the original investment, providing an 
ongoing dividend to the stockholders; and, reinvestment in further research and 
other promising new therapeutic options.
The old pricing model used by the pharmaceutical industry was to invest in drug 
development, create a pill and then recapture the investment over time as the medication
was used by consumers.  The approach doesn't work well with the new gene therapy
 solutions because the treatment is most often a "one-and-done" model that offers
an injection - which solves the problem. With such a short treatment period, the
 costs are all compacted into a very short period of time.  As a result, the old
 business model is disproportionately skewed by the new medications. So, the question
facing the pharmaceutical companies is what is the business model when a medication
is used only once?
This is but one example of the volume-based reimbursement models we have used over
the last ¾ of a century in paying for health care.  The question in front of us 
- as leaders in health care - is how to accommodate these new "wonder drugs" in 
a value-based reimbursement model.  Value is the key parameter that needs to be 
ferreted out...but, the current approaches to payment in these models still do not
effectively manage the costs of these whopper drugs.
More importantly, the economics of this new approach to treatment is only one dimension
of the problem.  There are the ethical and societal considerations that need to 
be weighed as well.  Who should be eligible for treatment?  What is the government's
responsibility (in the USA J) for those without insurance coverage?  Are any of 
these treatments part of an essential package of benefits? Who will serve as the
 arbiters of coverage?  How will "value" be calculated? And, the questions go on...
 The debate needs to start now.  As usual, the technology is outpacing the use!
The Cyber"Fly" In The Healthcare Ointment - The digitalization of healthcare has
 had its fits and starts. We can argue about the pace, the focus, the results - 
but, the direction is unarguable.  We are clearly moving into a new world just like
every other industry before us.  It's just that healthcare is one of the latecomers
to the digital makeover along with education and a few other stragglers.  But, now
that the transition has begun in earnest a new threat is looming on the horizon 
or, cybersecurity.
Healthcare cybersecurity has been likened to the "digital trifecta" because healthcare
collects personal information, financial information and health care information
 - all of which can be used individually and collectively in nefarious ways by intruders
into the system.  According to a study [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsfmaLvAsBV_eDX9H2sGMXqDVbAnFGajc4WGgFbyNI6cXNqCnc8nIL0fYIn-9nH8MqMs3wOKxyHMCrgEUgZGLTBunLAUvPo7bETC-pPjYVs3_a1I5Mk1WuVuPsnEptzqMCApliNxTPfB1EccYZYH8UR-CwdyalWNLKQ8FNU53U9twBAFAJ-rkxLj23CEg9e-soCu57c6e_BCNQ=&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
sponsored by IBM and conducted by the Ponemon Institute most (yes, I used the word
"most") health care organizations that were surveyed earlier this year have experienced
a major breach.  These incidents are not cheap either.  The average cost is running
about $4 million per incident.
However, increasingly the cost is no longer associated with loss of data.  We are
now seeing the disruption of service.  One of the issues that got my attention several
months ago was a discussion with several academic researchers who are working on
 the cybersecurity of devices - or, how to maintain integrity of devices that control
heart rates, glucose administration or any number of other, increasingly technical,
areas of management.  Such intrusive disruptions have the potential for causing 
a loss of life just as loss of vehicular control can result in a similar loss of
 life.  Our lives are increasingly tied to devices for any number of support activities.
 Healthcare is not immune from the problem and needs to prepare much more aggressively
[http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAdvoarqDaMCYLxmIPb9hKIizQpIUgm4C8deZO9ldlNg_rLJVB57EA860trFm_wTHrlaHLQPg4n_mQnhcvDkiImkvJ08EhtewmanLw7lQ_vGu5T2TYWYqtlAVND_cjTf7OBDNGOhWOKDRJLLeUlQeI9GRO92WR6BqNl65FMQbWqeNYr0lfZXGLRPCBjsinMbC5i9hnNWwXOt5wBDCi2q9z_A=&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
for the new world.
It's clear that the intensity of cybersecurity in healthcare needs to increase. 
 Vulnerability management, cyber-hygiene, cyber-testing and ongoing platform evaluation
- among other cyber considerations - are moving to the forefront of health information
technology.  And, it will not just be malware management that fosters good preventive
measures.  The members of the health care community - starting with the frontline
users of the systems - must be a priority for cybersecurity education.  Such education
has been woefully deficient in most healthcare organizations.
Those of us in the healthcare field frequently talk about the shortage of personnel
to fill vacancies that seem to be growing by leaps and bounds.  However, there is
an insufficient amount of attention paid to the over one million cybersecurity personnel
[http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsfq4oBWNZAr57zC356B00GcfknQgwV0WkRhCouPfN9-etXJDsitZ7END6PjowDaGQco8S6TL8JV280lIQgZgt3M1QTuaA_DnJ4zd8eZe_nLUTbcThDFKMUB-qD9KpOP4bHV9gWevqpaT4UKv-bdzQwt_O-QHykoR4bjhW2-16_czi4UhI-aa5JEaYapJX5xvP3VBa4rIHBT_A=&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
positions which are presently unfilled and, expected to grow to more than 1.5 million
by 2019. As the movie mantra says, "Uh, Houston.  We've got a problem."  The leaders
of healthcare need to step up to the plate and position the cybersecurity issues
 on a much higher plane than it currently holds.  Meanwhile, the hackers are hard
at work...
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The Weekly Whisk
Musings from a foodie...
I will no doubt wax poetic on my experience at iLatina [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAeBB9Rm9njsfpU_bUzIPRu__XHX2TC1RacVB4M-ESoukua1YOjG0y8fjeHJrYsaVEm7f3mqRTR3vG64hncm1ypAOPhIj6xpP353c2W1T_m7tE15xlQSWCsA-MawvdJMf3zYcLcFLF1J2&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
[* * * * * *] but, it's one of the best restaurants of the last year - perhaps even
exceeding the experience at Steirereck's in October, 2016 during our visit to Vienna,
Austria.  As the first to arrive at iLatina, I thought at first that perhaps I had
gone in the wrong direction.  As is typical of Americans, we arrived at our normal
dinner hour.  The remainder of the guests at iLatina arrived on South American time
J.  But, after the seating and the first serving - my fears melted away.  I don't
even know where to start.  The entire dinner was outrageously wonderful.  In fact,
it was so good that I want to plan a trip to Argentina simply to have another opportunity
to eat at iLatina.  The rest of the country - while wonderful - can wait for supper...
One of the highlights for me was the Papelon con Limon - or, lemonade with lime 
and cane sugar.  What an accompaniment for a fantastic dinner experience.  We started
off on the right track with "carimandas" - or shredded lamb with coconut and cilantro.
 Oh la la!  That was quickly followed by Nikkei ceviche with spicy soy, vinegar,
 cilantro and corn consisting of a variety of shrimp plus octopus.  Next came the
catch of the day - a white fish indigenous to Argentinian rivers - fried in a coriander,
peanut, coconut and salt mixture.  Wow!!  They then served a non-alcoholic mojito
sorbet to cleanse the palate before bringing on the quail with mole sauce and pork
shoulder with a coffee and sugar cane sauce.  It came to a finale with the cacao
 truffle with sea salt.  The coffee following dinner helped us to say awake...
If you get even a bit close to Argentina, make a visit to iLatina a priority - Murillo
725 (Capital - Federal) - Buenos Aires, Argentina - +54 (11) 4857 9095 - [email-masked]
[mailto:[email-masked]]
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The Good, The Bad, And The Ugly
The ongoing saga...
The Great - Check out the Tweet @Schwarzenegger for Arnold's clear repudiation of
Nazi flags, white supremacists and other similar garbage.
The Really Good - The entire membership of the Arts and Humanities Council and the
Cultural Council resigned en masse this past week along with some members of the
 Evangelical Advisory Board.  Clarity by ALL OF US on the issue of white supremacy,
the confederacy and the dignity of being an American is crucial.
The Good - The growing recognition among Members of Congress that any "fixes" of
 the Accountable Care Act will require a bi-partisan approach of actually working
together.
The Bad - The lack of moral leadership...enough said!
The Ugly - The pain the vast majority of Americans are feeling for Americans!
The statements in The Fickenscher Files [http://r20.rs6.net/tn.jsp?f=001U51L8_v4pZdid1ggYxpCZTMMAIoZFQ2xbHc7ZEWbkpHGr7l2VLGiAaH4L6_CwDtRjTA5bEWXk6blUkVjDh7kzlQuFvuat8lqW_hBHI-rDNn_Ae68gPF5OVZZPl9YEkuCPRqW6G5zW9uPJrgWgpum0njWItoluhf8Uwz2KQA_WnZIR6EzlAo1qvYzMQiZEEuu&c=4v6KAft4Jx6CPpRIF1NMyA-gadWynWvJLiZchMy3VZ___WMPKg-QNA==&ch=W2J44RnezOcc3FnJAUNk-96qFBsR45nBccgAKcieDdYIgHF9KJUJ4w==]
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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