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Rooms 101, for the Top Florida Cities for a Vacation



top Florida cities

There’s no American state the more solidly embodies the idea of a vacation than Florida. That’s no exaggeration – it’s a fact. With its perpetually sunny weather, gorgeous beaches, lush vegetation and laid back, friendly atmosphere, there’s a reason people call it The Sunshine State.

But with an entire state to choose from, where should you book your next vacation to get the best experience?

We’re happy you asked. Join us today, as we bring you the top Florida cities for a vacation. Then, get ready for the trip of a lifetime.


Orlando is two things to any list of vacation destinations in Florida: an obvious choice, and an unavoidable one. You’ve got to include it, because, frankly, there’s too much to do to leave it out.

It’s the family-friendly, sunshine heart of the Sunshine State, with something for everyone. From theme parks to museums, shopping malls, beaches, fishing, and boardwalks, there’s no boredom during an Orlando trip.

St Augustine

If Orlando is the most impressive option for a vacation in Florida, St Augustine is by far the most charming. A small college town decked out impressively in Spanish architecture, this is a city with something to see on every corner.

Take in the St James Roman Catholic Cathedral, go for a haunted tour of the surrounding city by night, or soak in some culture at one of the many local museums. However you spend your visit, St Augustine is a city with more than enough to keep you plugged in.

Daytona Beach

Florida’s original party city, the energy in Daytona Beach is almost tangible, no matter what time of year you visit. Get in the stands for high-performance racing action at the Daytona International Speedway, or take the party down to the beach for a sundown session.

From tours to concerts, dolphin spotting to amazing fishing, you’ll find it all here. Whether you’re out in the streets for the biannual bike week or taking in the city’s amazing restaurants literally any other time of the year, this is one beach town with a lot of heart.

Rooms 101: Discover Florida With Us

Florida is a treasure trove for vacationing. With some of the most gorgeous scenery, scenic locations, and flat-out fun cities in the country to choose from, you can’t go wrong in the Sunshine State.

Hopefully today you’ve discovered your next vacation destination in our list of top Florida cities.

Looking for the vacation of a lifetime? Rooms 101 leads the promotional vacations industry, and we’re excited to put you in a shared ownership venue for your next big trip. Visit us and get the vacation you deserve, today!

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How CBD Oil Products Work: A Closer Look



cbd oil

If you’re alive and have read the news in recent years, chances are you’ve heard about CBD oil at some point. It’s a multipurpose extract made from cannabidiol (CBD), a non-psychoactive chemical derived from marijuana. Patients are using it as a treatment for everything from pain to anxiety and depression.

With more and more research coming out on the topic every day, it’s a product that is quickly changing the medical landscape for patients and medical practitioners alike.

CBD oil

CBD oil has taken the medical world by storm in recent years.

To be honest, though, the concept of using cannabis as a treatment can be discouraging to people. They imagine it’s something illicit, and no matter how much research they read, they worry it might be psychoactive.

But with the explosion CBD’s popularity in recent years, there are new opportunities to evaluate the way we feel about this product. Join us today, as we take a closer look at CBD benefits and how it could be an extremely effective solution for people suffering from pain, anxiety and more.

An Average User’s Experience with CBD Oil

While our test subject had never tried CBD products before, they actually had two family members using CBD oil treatment for anxiety. The reports they got back from them were remarkably similar: both confirmed the treatment was fast acting and relieved their stress almost instantly.

Both also confirmed this occurred without any of the side effects of marijuana.

In another case, a colleague of theirs from work used CBD oil to treat her undiagnosed nausea. She claimed the product helped for long periods of the day, before eventually wearing out.

She also learned you can use CBD oil to treat your pets, safely and effectively. A client used a CBD salve on his dog, who had been suffering from an aggressive form of cancer. The results were remarkable: the dog was happier, more active, and more responsive than he’s been in years, all immediately following from his veterinarian-recommended CBD treatment!

The end result was our subject learned a valuable lesson about what CBD is actually used for: easing nausea, managing muscular pain, and soothing anxiety. As a person who’d never tried CBD treatment, herself, the versatility of this came as a big surprise.

CBD Oil: What It Is

As we’ve mentioned, CBD is a non-psychoactive ingredient extracted from hemp and marijuana plants. Without the psychotoxic effects that are associated with hallucinogens like marijuana, it is remarkably safe for use in a variety of everyday scenarios.

Strains of CBD Oil with little to no THC help to treat various medical problems. The oil itself comes in a host of different forms, from syringes to tinctures and topicals, capsules, edibles, vapes, and dabs. Each form, in turn, brings with it its own selection of benefits and issues.

Studies suggest that CBD oil may be beneficial for a host of problems, including:

  • Aches and Pains
  • Anxiety
  • Arthritis
  • Auto-Immune Diseases
  • Chronic Pain
  • Diabetes
  • Epilepsy
  • Headaches and Migraines
  • Insomnia
  • Mood Disorders
  • Multiple Sclerosis
  • Neurological Disorders

While the FDA has not confirmed these, there is a wealth of informal research and thousands of inspiring reviews, online.

Is It Legal in America?

CBD is different to medical cannabis, which as we all know is still not legal everywhere in the United States. Instead, oil products can be found in retailers across the country, as well as many online CBD stores.

Your only job when dealing with any of these outlets is to read the fine print. Always do your research when buying CBD products online. Go with a reputable retailer, with good reviews and a lot of insightful information to read up on ahead of time. Remember: if there’s little to nothing on them, there’s probably a reason why.

Always look for quality rather than the cheapest prices.

cbd oil

There are numerous physical and mental benefits of CBD oil products.

CBD Dose

Interested in high-quality CBD oil products from a reputable online retailer? CBD Dose is one of the most exciting brands currently operating online. Check out our awesome digital catalog and find CBD products that fit your lifestyle today!

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Port Orange Grill To Refocus and Reopen Under New Name



coastal grill raw bar

The Stonewood Grill & Tavern, a staple in the Port Orange restaurant scene, is closing its doors after fifteen years in the business. The move is a shakeup for such a well-known location. Management assures its fans, however, that they’re pursuing something new and “outside the box”. Namely, a new venture: The Coastal Grill Raw Bar.

In the month of August, Ormond’s well-known Dunlawton Avenue restaurant will close for business. Then, in October, it will be reopening as a brand new eatery called Coastal Grill & Raw Bar.

But, before you run off swearing your loyalties to a new Port Orange eatery, we should make one thing clear. This is a new restaurant with the same team you know and love behind it.

Coastal Grill Raw Bar: Breaking New Ground

The changeover is the result of Stonewood Holdings retargeting the local market and trying to do something new. It’s a reopening with a fresh image and a different focus while maintaining the good faith the Stonewood Grill & Tavern has established over the last fifteen years.

And just because they’re revamping the menu doesn’t mean they’re dropping your favorite foods. The new restaurant will focus more on fresh seafood than the grilled fare of years before, but with signature dishes actually remaining on the menu. The steaks you love aren’t going anywhere – they’re just sharing a menu with some exceptional seasonal chowders, po’ boys, and shrimp cocktails.

“You’ve got to think outside the box and try something new,” Stonewood Holdings chairman, L. Gale Lemerand, said, describing the switch. “We’ll offer oysters, conch chowder, fresh conch, conch salad and fresh seafood, more fish than we normally would have. We also have a new way of preparing shrimp.”

The new restaurant will also feature a raw bar.

Familiar Faces

What so often happens when restaurants reopen after a refocusing like this is that they very quickly drop all of their old staff members during the reshuffle. It’s a sad part of the industry and one that spoils reopenings like this for local community members and visitors from out of town who visit with certain expectations.

In another stroke of good news, Steve Papero, Stonewood Holdings president, and CEO confirmed Coastal Grill & Raw Bar will retain the management and most of the Port Orange Stonewood’s more-than 60 employees while the eatery is closed for construction. These staffers will be given temporary assignments at other nearby Stonewood Grills, Peach Valley Cafes, and Houligan’s Spirited Sports Grille. Open reopening, the Coastal Grill & Raw Bar is likely to bring on 40 full- and part-time employees to meet its new hours of operation.

Coastal Grill & Raw Bar: Welcome Home To Port Orange

Local residents and visitors from out of state won’t have to wait long before to experience this incredible new seafood location. Dunlawton Avenue’s Stonewood Grill & Tavern will close later this month before commencing renovations.

The target opening date for the new Coastal Grill is in late October.

And looking ahead to the future? Papero is on record as saying he feels Coastal Grill could become a new chain entirely on its own.

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CBD Oil Where To Buy It?



CBD oil where to buy

CBD Oil Where To Buy

So you’ve gone over to your favorite search engine and typed “CBD oil where to buy?”

Everybody’s got to start somewhere.

CBD Dose is a premium cannabidiol (CBD) website, offering a range of high-end products for CBD lovers of all walks of life. And, while we’re proud of that fact, we also recognize that not all of you may know exactly what this product is, where to find it, and what the potential benefits are for you.

Join us today, for more on CBD Oil Where To Buy, and get to make a change.

CBD oil where to buy

Trying to find out about CBD oil where to buy? You’ve come to the right place!

What It Is

If you’ve paid attention to the news recently, there’s a good chance you’ve heard more and more about CBD oil. You’ve probably also heard debates over its legalization and various battles to have it recognized as a medicine. “CBD Oil Where To Buy” seems to be the question on everybody’s lips, and seemingly with good reason.

But what is it?

In as simple a manner as possible: CBD oil is a hemp oil, derived from the non-psychoactive plant cannabis sativa. It’s been applauded by the people who’ve used it for its various positive health effects.

It comes in three forms, usually: green (unfiltered), blue (filtered, but not “cooked down”), and gold (filtered, carboxilated or cooked down). The benefits of each form may vary from producer to producer, but it’s shown promising results in the treatment of some of the following:

  • Pain management
  • Anxiety
  • Inflammation
  • Skin care
  • Heart health

As we’ve mentioned, when considering CBD oil as a health and wellness treatment, keep in mind that it is non-psychoactive. This means that, though it is derived from a cannabis plant, using it will not in any way leave you in an altered state. You may find it relaxes you, but you can put concerns about hallucinations, rambling, or embarrassing behavior out of your mind. 

So, your next question after “What is CBD oil?” should be “CBD Oil Where To Buy?”

CBD oil where to buy

Learn more about CBD Oil Where To Buy with us, today!

CBD Oil Where To Buy It

Depending on which state you live in, “CBD Oil Where To Buy?” is a question that could have a lot of answers. Your safest bet is to research retailers in your area, or further out if needs be. Then, check out reviews online to make sure that what they offer is safe, effective, and not overpriced.

CBD Dose is a supplier of high-end CBD products, sourced from reliable suppliers and sold at a fraction of the normal costs. With our extensive experience in the industry and a product line including some of the highest-quality products available anywhere, we are proud of our product and its efficacy.

For more on CBD oil where to buy, get in touch with us or check out the CBD Dose online store, today!

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How to Cut Down a Tree In 12 Easy Steps (Tree Removeal Guide)



tree removeal

Deciding to cut down your own tree is a big step. It’s a job with a lot of work and a fair share of danger involved, and certainly not one to just start doing without proper planning beforehand.

You need to know what you’re doing, what you shouldn’t be doing, and everything to do when what you should be doing turns sour unexpectedly.

That’s why we’ve assembled this, our professional 12-step guide to tree removeal for taking care of your own tree problem quickly and efficiently.

Ready to get cutting? Good – because so are we!

Tree Removeal Guide

Web Stark Media and Tree Worx Florida bring you this 12 Step Tree Removeal Guide

1. Safety First

Getting the right safety gear in place before you start can save you time and potential injuries, down the line. These should include (but certainly won’t be limited to):

  • Logger’s helmets help to protect your head, specifically, from falling wood and debris.
  • Earmuffs and face screens to safeguard your ears and eyes.
  • Safety glasses to stop dust getting into your eyes.
  • Kevlar chaps to stop a chain if you happen to drop the bar against your leg.

2. Bring A Lookout

As with all things in life, tree-felling is better with friends. And much, much safer. Bring an assistant to watch out for falling branches or, in a worst-case scenario, unexpectedly falling trees while you’re busy with the chore of sawing. And listen when they give you the tap – if it’s early into the cut and your partner lets you know something is happening, drop your saw and leave.

3. Felling Wedges

A set of plastic felling wedges will prevent your saw from becoming pinched in the crease of a heavy tree trunk during a cut.

4. Felling Zones

Being able to accurately estimate a felling zone is crucial to the tree felling process. The ax trick is a method that is roughly adequate for this job. Hold an ax handle out from yourself at arm’s length and eye level. Close one eye and back away from the tree until the top of the ax handle is level with the tree top and the bottom is in line with the base. This should be roughly far enough away to have the tree land safely at your feet, though remember it is just an estimate, and it’s always good to give it just a little more room.

5. Clearing Cutting Zones

Cutting down a tree can teach you quickly how little you’re ever really sure of in life. Even with lots of time to prep, a felled tree could fall in a direction that takes you completely by surprise. Clear three different escape routes through the brush around the tree, in roughly 45 degrees from each other, so you can easily choose a new one if you have to in a pinch.

6. Figure Out Your Tree

Any tree removeal tutorial worth its salt will tell you to look out for treacherous trees before anything else. Check your tree for the following, and don’t cut it down if you see them:

  • dead branches, either kept up by other branches or by partial connections to the tree
  • it is clearly leaning heavily in a specific direction
  • important buildings or structures nearby that would be damaged in a fall

7. Knowing A Notch

Make sure your notch has a depth of one-fifth of the tree trunk’s diameter. You’ll want to create a wedge shape in the side of the tree, measuring around 30° down from and 60° up from that line. Then, from the other side of the tree, use a saw and wedge to create a cut into the tree that meets the tip of the notch you started with. As you push the wedge further into this cut, you’ll create a hinge, from where the tree will tip over.

You can plan where this notch will start by scoring the tree trunk with a piece of chalk, making sure it’s at a comfortable height.

8. A Note On Making The Notch

Use a chainsaw to cut into the tree from the top, then from the bottom, creating your triangular notch. If you do this perfectly, a wedge of wood will fall out. If (like most people) you don’t do this perfectly the first time, you’ll have to cut further into the wood either from above or below to have the two cuts meet and the notch of wood fall out.

9. Big Trees Need Wedges

The bigger the tree, the more chance you have of getting your chainsaw caught in the space you’ve cut when the trunk of the tree leans back on it. Stop cutting with the saw when you’ve penetrated far enough into the tree to pound a wedge in behind it. Keep the right there in the cut with the saw running and the chain brake locked, and tap in the wedge to loosen up the gap. Then simply finish the cut.

10. Fell That Tree!

Use your chalk to score a line from the opposite side of the tree to the apex of your notch, and cut into it with a saw along that line. This is the felling cut. Once the tree starts leaning, pull your saw out of the cut and walk away along one of your escape routes, depending on the way the tree is falling. And remember to keep your eye on the fall at all times. This is an especially important moment for your lookout to be prepared.

11. Cut Low, Progress High

One the tree is safely on the ground, begin sawing off branches starting at the bottom of the trunk and moving upwards towards the top.

12. Time To Make Firewood

Lastly, cut the log into 16″ lengths of firewood. Cut three-quarters of the way into the log, then roll it over and complete the cut from the other side.

Tree Worx Tree Removeal: Now You’re Ready

Ultimately, tree removeal is a long, tedious, and dangerous process. If you do decide to handle it yourself, however, at least now you’ll know the twelve most important steps to keep in mind as you work.

If you decide to let a professional handle it, however, get in touch with Tree Worx for tree removal service in Volusia County.

For those of you considering tree removeal in an area with houses, power lines, or other structures nearby, check out the following video for an alternative to the method described above:

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What Are The Benefits of CBD Oil?





One of the popular remedy used for common ailment is the cannabidiol oil commonly referred to as CBD which is one of the 104 chemicals found in the cannabis and marijuana plant.

Unlike THC (Tetrabydrocannabinol) that makes people get high, cannabidiol is not psychoactive. Its quality is what makes it appealing to relief pain, suppress and cure other symptoms.

To make CBD oil, CBD is extracted from cannabis plant and is diluted with any carrier oil like hemp seed oil or coconut oil.
Since research and studies have shown that it has various health benefits and plays a vital role in treating variety of ailment, the unique oil has gained momentum.

How does CBD work?

Cannabinoids are known to always produce effects in the body by attaching to certain receptors because the human body is known to produce certain receptors called CB1 and CB2.

CB1 deals with pain, appetite, mood, memories and coordination, they are found in the body but higher concentrations are found in the brain while the CB2 receptors deal with inflammation and pain and they are found in the immune system.

Initially, researchers believed that the CB2 receptors are what CBD attaches to but it doesn’t work that way. CBD directs the body to make use of more of its own cannabinoids.

The health impact of CBD in the body cannot be overemphasized but here are some of the beneficial effects;

It helps in relieving pain

The anti-inflammatory and natural pain relief properties made CBD oil useful in relieving pains and stiffness. It can also be used for the treatment of chronic pain.

Helps reduce anxiety disorders

THC have been known to amplify the feeling of anxiousness but research on Neurotherapeutics showed that CBD is beneficial in reducing anxiety in people with certain disorders like general anxiety disorder, social anxiety disorder, panic disorder, post-traumatic stress disorder and obsessive-compulsive disorder.

Treatment of Acne

This is one of the promising uses of CBD oil, because of its anti-inflammatory effect it helps in lowers the production of sebum. Sebum is the oily substance produced by the body and when it is over produced, it causes acne.

It is useful in the treatment of Type I diabetes

Type 1 diabetes is a result of inflammation that occurs when the cells in the pancreas are attacked by the immune system. The anti-inflammatory effect of the chemical makes it useful in the treatment of the disease.

Useful in fighting cancer

Researchers have made it known that using CBD oil will help reduce and combat cancer by suppressing the growth and promoting the destruction of cancer cells.

Beneficial for heart health

Another benefit this great product provides is that it lowers high blood pressure which is linked to numerous health conditions like metabolic syndrome, stroke and heart attack.

In a recent study, CBD oil was used in treating ten men with high blood pressure. The result of the treatment showed that their blood pressure was lowered after they took 600mg of CBD oil.

Other benefits of CBD include;

  • Anti-tumor effect
  • Treatment of substance abuse
  • Treatment of Alzheimer disease and
  • Epilepsy treatment

Holistically, the benefits of CBD cannot be overemphasized.


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Gold’s Gym Raises $2,300 For Local Jewish Federation



Ormond Beach Gold's Gym

Gold’s Gym Ormond Beach hosted a charity event with a lot of heart over the weekend of August 4. Members participated in specialty classes designed specifically for this event and made donations while having fun.

Ormond Beach Gold's Gym

Ormond Beach Gold’s Gym Back to School Charity Event

And the results were better than anybody could have hoped for. On the following Friday, Gold’s Gym informed their Facebook followers they had raised more than $2,300 for the Jewish Federation. This is money used to buy backpacks and school supplies for Volusia County children.

“This is a cause that is very close to our hearts. It brought us a lot of joy to play a part in this donation,” said the official announcement.

Community and gym members alike were invited, over the course of the weekend, to participate in a series of fun spin and fitness classes. The end goal: to encourage attendees to donate generously.

Ormond Beach Gold's Gym

Ormond Beach Gold’s Gym Giving A Check To The Jewish Federation

Handing over a check for $2,308 to representatives from the Jewish Federation on Thursday, smiles, and gratitude filled the room. Gold’s Gym had made the impact they’d set out to make. More importantly, though they’d made a difference.

The Jewish Federation of Volusia and Flagler Counties

The Jewish Federation of Volusia and Flagler Counties is an organization which works hand-in-hand with local Jewish communities. Part of their mission statement is strengthening the Jewish identity on a local level,  and meeting their unique needs.

For more information on how you can help support the Federation and the work they do, call 396-672-0294 or visit them, online.

And to those of you interested in fitness in the Ormond Beach area, why not stop in at your local Gold’s Gym and break a sweat, today?

And, to Daytona community members, read our recent article on Gold’s Gym’s exciting new move to the Shoppes at One Daytona.


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Gold’s Gym Brings Exceptional Fitness To The Daytona Beach Community



Tyler Ward Golds Gym

Fitness enthusiasts in Daytona Beach have a lot to look forward to this December, as Gold’s Gym makes its way to the Shoppes at One Daytona. With an exciting rollout, a massive new store, and an innovative pre-sale event planned, Gold’s is set to make an explosive entrance into the world’s most famous beach.

And it’s in good hands, too!

Gold’s Gym and the Ward Family

Ormond Beach Gold’s Gym franchise owners, the Ward family, will be taking over the lease at the Daytona location. Co-owner, Tyler Ward, spoke about the family’s experience owning the store since 2001, what prompted the expansion, and his hopes for the future.

“We’ve been looking to expand for quite some time, now,” Ward said. “Branch out, and, with a few folks we had worked with before, we started a discussion about leasing out this space.”

What To Expect

The location in question clocks in at an impressive 29,300 sq ft, surpassing the available work area at the Ward family’s current location. It’s also the largest available space at the Shoppes at One Daytona. Management is predicting staff members at the new location will number around 50 workers, with a full complement of gym equipment. It’s a strong introduction into the community from one of the leading fitness brands in the country, and translates into increased job opportunities within the city itself.

“One thing that will be unique to the new location is going to be more of a studio style or boutique style of classes. We’ll have five different class spaces with five different offerings going on at any time of the day. We’re bringing a host of classes under one roof and allowing our guests to pick. So, where once you may have had to go from one location to another, do this but not that because of time, now you can take any combination of classes you want.”

The gym will feature a team training center, as well as facilities for yoga, cycling, and exercise. Guests can also look forward to hydrotherapy massage facilities, and there’s even an onsite Kids Club for busy parents.

Classes will be half-hour slots, so guests can combine classes without becoming exhausted. “We want people to be able to fit their workouts in before work, during lunch, and after work.”

Another bit of innovation behind the launch is an interactive pre-sale area, going up in Shoppes at One Daytona in mid-September. “We will have a small pre-sale space opening right there in the shopping center while the new gym is still under construction. And that pre-sale area, what it’s going to offer is a sneak peak view into the look and feel of the facility.”

The area will feature massive picture frames, showing off 3D renderings of each the gym area, long before it’s finished being built. Future guests can walk in, look around, and get an almost exact idea of what they will be experiencing when the gym has its grand opening, later this year.

And to top it all off: “We’ll have actual gym equipment set up in the pre-sale room as well, for people to get a full-on tactile experience of what we’ll be offering.”

A Note On Service

Ormond members understand the Ward family’s involvement with their location. This is something Tyler and Ward co-owners, his father, grandfather, and aunt are all proud of. “We’ve grown with Ormond beach, as a family as well as a company. The reciprocation of the members – their love of the facility is the foundation of what Gold’s Gym is, here in Ormond.”

“We were at about 10,000 sq ft and 1200 members back in 2001 and we’ve grown this into over a 5,000 member base and 27,000 sq ft of space. It’s been amazing over the years to see how many members have joined with us and continue to stick with us because, when they come in every day, they get a ‘Hello’. We work in that way to brighten their day, give them a good start to their day.”

Ward spoke about his hopes to bring that same personable model over to operations at the Shoppes at One Daytona. “Our tagline within this facility has always been ‘Friendliness, cleanliness, and professionalism’. And in the time that we’ve been operational, we’ve created programs to duplicate that work ethic and carry that with us, over and over again, wherever we go.”

“We put the value to the customer long before anything else,” Ward said. “Within both facilities, you’re part of our Gold’s Gym family – you’re not a number to us. When you join us, you’re joining a family.”

Gold’s Gym, Daytona

Memberships are priced per month, for individuals and families, but Ward says to look out for special offers in the following months. “Pre-sale rates, grand opening offers – guests can look forward to that. Keep your eyes open.”

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Evaluation and Diagnosis of Wrist Pain: A Case-Based Approach



Patients with wrist pain commonly present with an acute injury or spontaneous onset of pain without a definite traumatic event. A fall onto an outstretched hand can lead to a scaphoid fracture, which is the most commonly fractured carpal bone. Conventional radiography alone can miss up to 30 percent of scaphoid fractures. Specialized views (e.g., posteroanterior in ulnar deviation, pronated oblique) and repeat radiography in 10 to 14 days can improve sensitivity for scaphoid fractures. If a suspected scaphoid fracture cannot be confirmed with plain radiography, a bone scan or magnetic resonance imaging can be used. Subacute or chronic wrist pain usually develops gradually with or without a prior traumatic event. In these cases, the differential diagnosis is wide and includes tendinopathy and nerve entrapment. Overuse of the muscles of the forearm and wrist may lead to tendinopathy. Radial pain involving mostly the first extensor compartment is commonly de Quervain tenosynovitis. The diagnosis is based on history and examination findings of a positive Finkelstein test and a negative grind test. Nerve entrapment at the wrist presents with pain and also with sensory and sometimes motor symptoms. In ulnar neuropathies of the wrist, the typical presentation is wrist discomfort with sensory changes in the fourth and fifth digits. Activities that involve repetitive or prolonged wrist extension, such as cycling, karate, and baseball (specifically catchers), may increase the risk of ulnar neuropathy. Electrodiagnostic tests identify the area of nerve entrapment and the extent of the pathology.

Also Read: Orthopedic Doctor: Types Of Fractures

Musculoskeletal problems are responsible for up to 20 percent of all visits to primary care offices in the United States. 1  Family physicians are often the first to evaluate and treat wrist pain. Wrist pain is traditionally classified as acute pain caused by a specific injury or as subacute/chronic pain not caused by a traumatic event (Tables 1 and 2). Injuries that cause acute pain may result in contusions, fractures, ligament sprains or tears, and instability. Subacute or chronic pain may result from overuse, have neurologic or systemic causes, or be a sequela from an old injury. Patients with these injuries may have a history of repetitive wrist movement, either occupationally or recreationally. The addition of sensory disturbances, such as numbness or tingling, points to nerve involvement.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to

History and physical examination lead to the correct diagnosis in most cases. The location, nature, timing, and quality of the pain are important clues for narrowing the differential diagnosis. In acute wrist injuries, plain radiography should be obtained with anteroposterior, lateral, and oblique views. When the diagnosis remains unclear, further imaging, such as bone scan, ultrasonography, computed tomography, or magnetic resonance imaging (MRI), may help identify the cause. Because nontraumatic wrist pain has a wide differential diagnosis, the patient history should include a review of systems with neurologic or constitutional symptoms, as well as a social history of vocational and recreational activities. The following case studies discuss the background and presentation of three causes of wrist pain, as well as diagnostic tests and strategies.

Case 1. Scaphoid Fracture

A 21-year-old man presents with dorsal left wrist pain after falling onto his outstretched hand while inline skating. He noted immediate swelling and painful wrist extension. Physical examination reveals soft tissue swelling with limited motion, mostly in extension, secondary to pain. There is bony tenderness along the distal radius as well as the anatomic snuff box. His sensory and vascular examination results are unremarkable.


The wrist comprises eight carpal bones (Figure 12), but only the lunate and scaphoid articulate with the radius and absorb significant impact during a fall onto an outstretched hand. The scaphoid is the most commonly fractured carpal bone. The primary vascular supply to the scaphoid originates distally from retrograde branches of the distal radial artery, making the proximal pole of the scaphoid relatively avascular and at higher risk of nonunion and avascular necrosis. Fractures of the proximal and distal portions of the scaphoid each account for 20 percent of scaphoid fractures, and the middle portion accounts for the remaining 60 percent.


Figure 1.

The bones of the wrist.

Reprinted with permission from Daniels JM II, Zook EG, Lynch JM. Hand and wrist injuries: part I. Nonemergent evaluation. Am Fam Physician. 2004;69(8):1941.

The peak incidence of scaphoid fractures occurs at about 15 years of age. Because of the weakness of the distal radius compared with the scaphoid, scaphoid fractures are not common in older persons. In young children, the supportive cartilage surrounding the ossific nucleus of the immature scaphoid creates protection, making physeal injuries of the radius more common.

Also Read: Orthopedic Doctors In Florida: Facts About A Proximal Humerus Fracture


The typical history of a patient with a scaphoid fracture is a fall onto an outstretched hand with the wrist dorsiflexed and radially deviated. Most patients with scaphoid fractures present shortly after a fall, but in some cases, the initial pain improves, causing a delayed presentation.

Physical examination may reveal a swollen wrist. Tenderness is usually located dorsally around the distal radius. Patients may have painful wrist extension and loss of grip strength if they present a few days after the injury.

There are no reliable clinical tests to rule out a scaphoid fracture. Swelling of the anatomic snuff box (Figure 2) increases the likelihood of a scaphoid facture. The combination of snuff box swelling, scaphoid tubercle tenderness, and pain with axial pressure on the first metacarpal bone has a sensitivity of approximately 100 percent. However, the specificity of each test is 9, 30, and 48 percent, respectively. Diminished grip strength compared with the contralateral side increases the positive predictive value for a scaphoid fracture. The differential diagnosis of a suspected scaphoid fracture is listed in Table 3.

Figure 2.

Anatomic snuffbox. The scaphoid is located below the snuffbox.

Reprinted with permission from Phillips TG, Reibach AM, Slomiany WP. Diagnosis and management of scaphoid fractures. Am Fam Physician. 2004;70(5):880.


Conventional radiography (anteroposterior, lateral, and oblique views) alone can miss up to 30 percent of scaphoid fractures. Based on retrospective studies, sensitivity improves if additional views are added (i.e., posteroanterior in ulnar deviation, pronated oblique, and supinated oblique). In many cases, repeat radiography is needed in 10 to 14 days to observe sclerosis, which indicates a healing fracture.

If the diagnosis cannot be confirmed with plain radiography, a bone scan or MRI can be performed. Bone scan has a sensitivity near 100 percent but produces false-positive results up to 25 percent of the time. MRI within one day after trauma has a sensitivity of 80 percent, but late examination (more than 10 days after injury) has a sensitivity and specificity comparable to bone scan.


If a scaphoid fracture is suspected based on history and physical examination, plain radiography should be performed, including specialized views such as a posteroanterior in ulnar deviation and a pronated oblique. If radiography is negative for fracture but clinical suspicion is high, the wrist should be protected in a thumb spica cast with the option of repeat plain radiography in 10 to 14 days or a bone scan one to two days after injury. If repeat plain radiography is negative but wrist pain persists, MRI should be performed to clarify the diagnosis.

Case 2. Ulnar Neuropathy

A 39-year-old right-handed woman presents with a four-week history of wrist pain and numbness and tingling in her right hand. There is no history of trauma or injury to the neck, elbow, or wrist. She works mostly at a desk job but has not had any changes in her work schedule. Physical examination of the wrist reveals no soft tissue swelling, muscle atrophy, or skin changes. She has painful wrist extension, as well as reproduction of the tingling in her fifth finger with tapping over the pisiform. Grip strength is normal and no other bony tenderness is appreciated.


The ulnar nerve originates from the C8 and T1 nerve roots (Figure 3), and extends from the medial cord of the brachial plexus through the axilla, innervating the muscles of the forearm and the hand. Proximal to the wrist, dorsal and palmar cutaneous branches split off, whereas the rest of the nerve courses through the Guyon canal (Figure 4) to the palmar surface of the hand. This triangular canal is bordered medially by the pisiform, laterally by the hamate, anteriorly by the tendon of the flexor carpi ulnaris, and posteriorly by the transverse carpal ligament. In the canal, the ulnar nerve splits to a superficial sensory branch, which supplies sensation to the hypothenar eminence, and to a deep motor branch that innervates the hypothenar muscles, adductor pollicis, and flexor pollicis brevis. The ulnar nerve may be compressed anywhere in the Guyon canal, causing motor, sensory, or mixed deficits. Compression is usually caused by ganglion cysts or repetitive trauma.

Ulnar nerve entrapment is the second most common neuropathy of the upper extremity, surpassed only by median nerve entrapment (i.e., carpal tunnel syndrome). Although the true incidence of ulnar neuropathy at the wrist is not well documented, it is accepted to be the second most common site after compression at the elbow. Ulnar neuropathies are slightly more common in men than in women. Peak incidence is in men older than 35 years.


The typical presentation in ulnar neuropathy is wrist discomfort with sensory changes in the fourth and fifth digits. Grip weakness may be present in chronic cases. History usually reveals no specific injury. Activities that involve repetitive or prolonged wrist extension, such as cycling, karate, and baseball (specifically catchers) may increase the risk of ulnar neuropathy.

Physical examination of a patient presenting with these neurologic symptoms should include cervical spine, shoulder, and elbow examinations to rule out a proximal lesion. Reproduction of pain on neck movement could indicate cervical disk disease; pain with shoulder motion could indicate a brachial plexus problem; and reproduction of symptoms with compression of the nerve at the ulnar groove could indicate compression at the elbow. Compression of the ulnar nerve at the Guyon canal should cause weakness of the hypothenar muscles innervated by the deep motor branch and sensory disturbances of the fifth digit innervated by the superficial sensory branch.

Clinical tests include a positive Tinel sign on percussion of the ulnar nerve over the Guyon canal, as well as a positive Phalen sign (maximum passive flexion of the wrist for more than one minute) with paresthesias in the fourth and fifth fingers. Unlike in carpal tunnel syndrome, sensitivity and specificity of these tests for ulnar neuropathy at the wrist are not known. The differential diagnosis of suspected ulnar neuropathy at the wrist is listed in Table 4.


Plain radiography evaluates wrist anatomy well, and can identify fractures, dislocations, or soft tissue masses that may have led to nerve compression.

Ultrasonography of peripheral nerves is helpful in identifying compressive etiologies of nerve injury and in visualizing structural nerve changes. It is noninvasive, relatively inexpensive, and well tolerated by patients.

Electromyography and nerve conduction studies can be helpful in identifying the area of entrapment and documenting the extent of the pathology. Motor and sensory conduction velocities are more useful in acute entrapments, whereas electromyography is a better choice for chronic neuropathies because it shows axonal degeneration more clearly. The sensitivity and specificity of these electrodiagnostic tests in the primary care setting are unknown because existing studies are limited to a small number of patients with known neuropathy.

MRI can detect abnormalities of the ulnar nerve, flexor tendons, vascular structures, and the transverse carpal ligament around the Guyon canal. Neurogenic edema can be seen as early as 24 to 48 hours after denervation compared with electromyography, in which changes after denervation are not seen for one to three weeks. Imaging criteria for neuropathy on MRI are not well defined, and several studies have found MRI abnormalities in healthy, asymptomatic patients.


If ulnar neuropathy is suspected, plain radiography should be ordered first. If no obvious mass or lesion is found, electrodiagnostic tests should be ordered to localize the lesion, measure its severity, and aid in the prognosis. In the setting of inconclusive or nonlocalizing electrodiagnostic test results, ultrasonography or MRI may be useful.

Case 3. De Quervain Tenosynovitis

A 31-year-old woman presents with several months of worsening radial left wrist pain that started insidiously. She denies any specific trauma. She has no numbness or tingling in the wrist, hand, or fingers. Her pain worsens with gripping and grasping, and with picking up her nine-month-old daughter. Physical examination reveals no discoloration and minimal soft tissue swelling along the radial styloid and anatomic snuff box. There is soft tissue tenderness about the anatomic snuff box and radial styloid. She has limited motion of the thumb, with pain mostly in extension and abduction. Her sensory and vascular examinations are unremarkable.


Two major dorsal tendons of the thumb are involved: the extensor pollicis brevis and the abductor pollicis longus (Figure 5). [ corrected] These tendons comprise the lateral border of the anatomic snuffbox, with the extensor pollicis longus medially and the scaphoid bone at the bottom. The two tendons have similar function in bringing the thumb into radial abduction. These tendons run in a synovial sheath in the first extensor compartment of the hand. Inflammatory changes in the sheath and tendons result in a tenosynovitis. Recurrent or persistent inflammation may result in stenosing tenosynovitis.


The typical presentation includes subacute radial wrist pain at the thumb base and into the distal radius. In retrospect, patients may identify a new or repetitive hand-based activity as the cause, but the etiology often is idiopathic. De Quervain tenosynovitis is more common in women, particularly those 30 to 50 years of age. New mothers are especially noted to have this problem from picking up a child.

Physical examination may reveal a minimally swollen wrist. Tenderness is usually located over the radial tubercle and sometimes around the soft tissues of the anatomic snuff box. Thumb motion is invariably painful. Neurovascular examination should be unremarkable. The Finkelstein test is confirmatory because it has good sensitivity and specificity. It is performed by making a fist over the thumb and then moving the hand into ulnar deviation, which passively stretches the thumb tendons over the radial styloid A grind test of the thumb, which is performed by axial compression and slight rotation of the metacarpophalangeal joint, should be negative in those with de Quervain tenosynovitis but positive in those with first carpometacarpal osteoarthritis. The differential diagnosis of suspected de Quervain tenosynovitis is listed in Table 5.


The diagnosis is clinical based on history and examination. In cases where osteoarthritis of the carpometacarpal joint is considered, pain relief with diagnostic lidocaine (Xylocaine) injection of the first extensor compartment excludes arthritic cause. Radiography, electromyography/nerve conduction studies, blood tests, and MRI or ultrasonography may be used to evaluate for alternative diagnoses.


If the history and examination are consistent, no further diagnostic testing is needed. For suspicion of fracture or arthritis, radiography is an appropriate first step. If suspected, radial nerve abnormalities may be ruled out with electromyography or nerve conduction studies. If there is concern for infectious tenosynovitis, a complete blood count and measurement of inflammatory markers, such as erythrocyte sedimentation rate and C-reactive protein levels, are appropriate. If the patient does not respond to treatment or if the diagnosis is in question, an MRI or musculoskeletal ultrasonography may be ordered to further evaluate the first extensor compartment.

Data Sources: A PubMed search was completed in Clinical Queries using the key terms scaphoid fracture, ulnar neuropathy, and de Quervain’s. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were Essential Evidence Plus, the Cochrane database, the National Guideline Clearinghouse, and UpToDate. Search date: August 2011.

Also Read: Long Bone Fractures and Complications

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Pope Declares Death Penalty Unacceptable in All Cases



abolition of the death penalty

ROME — Pope Francis has declared that the death penalty is wrong in all cases, a definitive change in church teaching that is likely to challenge faithful Catholic politicians, judges and officials in the United States and other countries who have argued that their church was not entirely opposed to capital punishment.

Francis added the change to the Catechism of the Roman Catholic Church, the book of doctrine that is taught to Catholic children worldwide and studied by adults in a church with 1.2 billion members.

Francis said executions were unacceptable in all cases because they are “an attack on the inviolability and dignity of the person,” the Vatican announced on Thursday.

The church also says it will work “with determination” for the abolition of capital punishment worldwide.

Francis’ decision is likely to put many American Catholic politicians in a difficult position, especially Catholic governors, like Greg Abbott of Texas and Pete Ricketts of Nebraska, who have presided over executions.

And it could set off a backlash among American Catholic traditionalists who have already cast Francis as being dangerously inclined to change or compromise church teaching on other issues, like permitting communion for Catholics who have divorced and remarried without getting a church annulment.

It could also complicate the lives of judges who are practicing Catholics.

In a 2002 article, Justice Antonin Scalia, who died in 2016, said, “I do not find the death penalty immoral,” and added that he was confident that Catholic doctrine allowed for it to be used in some cases.

He wrote that it would be a bad idea if Catholic judges had to recuse themselves in death penalty cases or if Catholic governors had to promise commutations of death sentences, and commented, “Most of them would never reach the governor’s mansion.”

The new teaching appears to make the conflict much sharper, if not definitive.

President Trump’s nominee to the Supreme Court, Judge Brett M. Kavanaugh, is Catholic, as are Chief Justice John G. Roberts Jr. and Justices Clarence Thomas, Samuel A. Alito Jr. and Sonia Sotomayor. One of the other finalists for the vacancy created by the retirement of Justice Anthony M. Kennedy was Judge Amy Coney Barrett, who is also Catholic.

She wrote a 1998 law review article suggesting that Catholic judges should consider recusing themselves in some death penalty cases that might conflict with their religious beliefs.

Abolishing the death penalty has been one of Francis’ top priorities for many years, along with saving the environment and caring for immigrants and refugees. He mentioned it in his address to the United States Congress on his trip to America in 2015, saying that “from the beginning of my ministry” he had been led “to advocate at different levels for the global abolition of the death penalty.”

He added, “I am convinced that this way is the best, since every life is sacred, every human person is endowed with an inalienable dignity, and society can only benefit from the rehabilitation of those convicted of crimes.”

The new teaching builds on the instructions of Francis’ two immediate predecessors.

“This didn’t come out of nowhere,” said John Thavis, a Vatican expert and author. “John Paul II and Benedict laid the ground work; he’s taking the next logical step.”

“I think this will be a big deal for the future of the death penalty in the world,” he added. “People who work with prisoners on death row will be thrilled, and I think this will become a banner social justice issue for the church.”

Sergio D’Elia, the secretary of Hands Off Cain, an association that works to abolish capital punishment worldwide, said, “Now even the most far-flung parish priest will teach this to young children.”

The Vatican announced the change on Thursday, publishing a letter to bishops approved by the pope in mid-June.

The letter says that Francis made the death penalty shift “ to better reflect” the clearer awareness of the church “for the respect due to every human life.”

On social media, some Catholics asked whether the Vatican had timed the announcement to deflect attention from a scandal over revelations that former cardinal Theodore McCarrick had been allowed to climb the hierarchy despite accusations made to senior church officials that he was sexually abusing his seminary students.

In the catechism promoted by St. John Paul II, in 1992, the death penalty was allowed if it was “the only practicable way to defend the lives of human beings effectively against the aggressor.”

The change on the issue has been developing for years. In 2015, four Catholic media outlets in the United States published a joint editorial calling for the abolition of the death penalty. They included the liberal-leaning National Catholic Reporter and the conservative-leaning National Catholic Register.

Many Catholics in the United States have rallied around calls to abolish the penalty.

When Francis visited the United States in 2015, he went to a prison in Pennsylvania and met with a few prisoners and their families. He also wrote a detailed letter that year to the International Commission against the Death Penalty, arguing that capital punishment “does not render justice to the victims, but rather fosters vengeance.”

In it, he made two arguments that specifically spoke to the American context: The death penalty is illegitimate because many convictions have later been found to be in error and have been overturned, and because executions of prisoners in some states have been badly botched.

Still, support for the death penalty persists in the United States among some conservative Catholics. The Rev. C. John McCloskey III, an influential teacher and confidant of countless American politicians and civic leaders, has written that the church’s doctrine “does not and never has advocated unqualified abolition of the death penalty.”

In his argument, he cited Saints John Paul II, Augustine and Thomas Aquinas. He even cited Cardinal Joseph Bernardin, who served as archbishop of Chicago, and who frequently used the term “seamless garment” to express that the church was for life, from conception to death.

Father McCloskey argued that for any human being, “it is a great grace to know the time of one’s death, as it gives us the opportunity to get right with the Lord who will judge us at our death. Perhaps many people have been saved in this way by the death penalty.”

Elisabetta Povoledo reported from Rome, and Laurie Goodstein from New York. Adam Liptak contributed reporting from Washington.

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Wages Are Rising in Europe. But Economists Are Puzzled.



wage growth

Workers may finally be getting a bigger piece of the economic pie — at least in Europe. Just don’t ask why, or whether it will last.

In the decade since the financial crisis, much of the global economy has recovered and is back on stable footing. Companies are reporting record profits, unemployment levels are plummeting and overall global growth is back on track.

Wages in most developed countries, however, have barely budged.

The economic puzzle has ramifications for global political as well as financial stability. Resentment among middle- and lower-class workers, and the feeling they were not getting a fair share of economic growth, helped elect Donald J. Trump and contributed to the rise of right-wing parties in parts of Europe.

“This is one of the big economic questions of our time,” said Ángel Talavera, lead eurozone economist at Oxford Economics in London.

Europe may offer an exception to that trend. Wages in the eurozone are rising again after years of stagnation, a welcome development not only for working people but also for Mario Draghi, the president of the European Central Bank, who will hold a news conference on Thursday after a meeting of the bank’s Governing Council.

The central bank has been pulling out all the stops to push inflation back toward a level considered healthy for growth. But wage increases are effectively a prerequisite for sustained inflation, and, until recently, the bank had been frustrated by the failure of eurozone citizens’ paychecks to rise along with strong economic growth.

When official data last month showed that hourly wages in the eurozone rose 2 percent in the first three months of 2018 — finally — the central bank got the signal it was looking for. It announced it would end its main stimulus measure at the end of the year. At its meeting on Thursday, the Governing Council is expected to reaffirm that plan.

Yet a mystery remains. Economists have not been able to agree on why pay for most people in the United States, Europe, Japan and other wealthy countries had long been stagnant even as unemployment plummeted. In Europe, experts attribute the spike to an acute shortage of workers in countries like Germany, but there are many other theories.

And because officials don’t know for sure why wage growth recovered in the region, they can’t be sure it’s sustainable. Japan has already seen surges in wage growth that quickly sputtered.

Back in simpler days, falling unemployment usually led to higher wages. Employers had to compete harder for workers, and paychecks rose across the board. Inflation also went up, at least temporarily, as businesses passed on the higher cost of labor to customers.

The Phillips Curve, a graph plotting the inverse relationship between falling joblessness and rising inflation, named for its originator, the New Zealand-born economist William Phillips, was for decades a staple both of introductory economics courses and of monetary policy.

But in recent years the relationship between growth, wages and inflation has become much harder to understand. Economists have devoted enormous energy trying to explain why inflation and wages remained stuck in neutral even as unemployment in countries like Germany fell to record lows.

In a measure of the issue’s importance, the European Central Bank made the interplay of those factors the focus of its annual gathering last month of leading economists in Sintra, Portugal.

Economists there offered numerous theories to explain the phenomenon. The decline of unions has taken away employees’ bargaining power, some said. Globalization, outsourcing, and the easy flow of money and information across borders have also forced workers in wealthy countries to compete with those in poorer ones.

Another suggestion is that the rise of companies like Apple, Google and Amazon as industry behemoths has concentrated power in fewer companies and squelched competition. And the so-called sharing economy, exemplified by Uber or Airbnb, has made many people into freelancers with few benefits.

In one much-discussed paper presented at Sintra, Uta Schönberg, a professor at University College London, compared data from Germany and France and came to the conclusion that low wage growth and rising inequality were a result of diminished bargaining power by workers.

Flat wage growth in Germany during the last two decades coincided with reforms that allowed companies to opt out of collective bargaining agreements, weakening union power. In France, where union agreements applied to whole industries and were binding for companies, wages continued to climb and inequality was less pronounced.

But France paid a price. While unemployment fell below 4 percent in Germany, it remains above 9 percent in France. The implication is that companies may not hire as much if they are locked into union wage contracts.

Professor Schönberg pointed out that pay in Germany has begun rising again, suggesting that the effect of reforms was temporary. At a certain point, low unemployment does still seem to lead to higher wages. It just may take longer than it used to.

That is no doubt what the European Central Bank is counting on. Wages are a key issue for the bank because, by law, its job is to keep inflation at or close to 2 percent. It would be hard to believe that inflation is on an upward trend without an accompanying rise in pay.

Even after five years of steady economic growth, until recently inflation in the 19-nation euro area remained stubbornly below the official target. Consumer prices rose at an annual rate of 1.9 percent in May and 2 percent in June, but the numbers were not very convincing. The increases were due almost exclusively to a steep rise in energy prices, which fluctuate often.

Wage growth “was the key variable we would look at for convergence of inflation,” Mr. Draghi said at a news conference in June after a meeting of the European Central Bank’s Governing Council.

Still, economists are far away from any consensus on why wages have taken so long to rise even when companies gripe they can’t find the people they need.

Mr. Talavera of Oxford Economics argues that unemployment data does not measure large numbers of workers who have given up looking for jobs. When demand for labor recovers, these people join the work force again, acting as a buffer and preventing labor shortages.

This hidden reserve of workers is bigger than economists thought, Mr. Talavera said. But in Europe it appears to have finally been exhausted. “That is one of the reasons you haven’t seen wage growth picking up substantially,” he said.

If he’s right, that should mean that wages will continue to rise.

The fact that low wage growth has afflicted virtually every wealthy country, though, suggests that there are deeper forces at work that are not yet fully understood.

Aviv Nevo, a professor of economics at the University of Pennsylvania, summed up the mood of uncertainty about the dynamics of wages and prices by referring to the idea of the streetlight effect, where researchers look for information only where it is easiest to find, rather than probing further.

During a discussion in Sintra, Professor Nevo said, “We’re all drunks looking under the lamppost.”

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