Six Real Life Slides. Which Ones Show Prostate Cancer? Can YOU Make the Diagnosis?

A friend and I were reminiscing the other night about our high school biology class at Sullivan High with Mr. Dubin. That course was the first time I ever used a microscope. Believe me, I had no idea that staring at magnified pieces of tissue would be the basis of my future career.

What crosses my desk, or more literally my microscope stage, on a daily basis? Looking at five or eight or twelve sets of prostate biopsies, with multiple parts to each set, I may be examining over 200 slides in a day. There is plenty to see. But since the goal of 99.9% of prostate biopsies is to try to either confirm or rule out the presence of cancer, most of what is on the slide is background music, or sometimes just noise. Just as you tune out much of what you hear every day, I have to tune out the other “stuff.” It is on the slide, but like an Evelyn Wood trained speed reader, I try to hone in on the important and try to ignore the rest.

Remember that study a few years ago claiming pigeons could identify cancer on a slide? That was a lot of pigeon poop. But how about you? Could you think back to your own high school biology class and separate the benign from the malignant? Give it a try. Take a look at pictures A through F at the beginning of the post, make a diagnosis, and see how accurate you are. You can click on the picture to get an enlargement. Leave your number correct in the Comment field on the blog site or on Facebook. All the pictures are from cases I saw in the last day. A shout out to the great Anatomic Pathology Team at UroPartners Lab that keeps the slides coming.

Answers are below.

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A) You might have thought this picture looked very busy. Lots of cells here, but most of them are inflammatory cells. This patient probably has prostatitis, an inflammation of the gland. No fun to have, but not cancer. I am sure the patient was relieved to get his benign diagnosis.

B) Did you recognize this as normal prostate? Benign, with nothing to indicate the glands are at any risk to become cancerous. That’s all we identify in about half of our patients. It’s good to see.

C) Yes, those are cancerous glands. This is what we would consider a low grade (less aggressive) prostate cancer. Some men with this type of lesion may not need any treatment, just careful follow-up and a good relationship with their urologist.

D) No, these glands are in the biopsy, but not part of the prostate. They are colon glands. How did they get into the sample? To take the biopsy, the urologist passes the needle through the patient’s rectum, the end part of the colon. Little fragments of colon tissue frequently become incorporated into the biopsy. Nothing to worry about for the patient, and usually pretty easy to recognize on the slide.

E) See all those small dark cells? This is an aggressive prostate cancer. Tumors like this have a propensity to spread, so most men with a tumor formed by cells like this will get some form of therapy. Fortunately, there are some great new treatments, some even involving the bodies own immune system to fight the cancer.

F) This can be a tricky one. The cell nuclei look dark and irregular, often a hallmark of cancer. But see all that golden brown pigment? That’s called lipofuscin, and that easily identifies the glands as being part of the seminal vesicles, benign structures that sit on top of the prostate. I have often felt there must be some higher being that put that lipofuscin there to save me from making a bad diagnostic mistake.

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So how did you do? Could you separate the good from the bad? I’ll bet you could do better than a pigeon, but maybe not better than me!

Don’t forget to give your score in the Comment field of either the blog page or Facebook.

The opinions expressed above are the opinions of the authors, not UroPartners LLC.

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Our Biggest Fan Is Moving On, But Because Of Him We Will All Keep Blogging

The ChicagoNow Blogger Community has a little monthly ritual. On the last Wednesday of the month, Jimmy Greenfield, the Community Manager — the guy who keeps ChicagoNow clicking — announces a topic and gives all the participants one hour to write and publish a blog. He calls it Blogapalooza, because nothing is really big unless it is a palooza; I guess it could have been called Blognado, but maybe that name was already taken.

Many of the ChicagoNow bloggers palooz on the given topic. I have never been one of them. When it comes to what I choose to write, I am a bit persnickety. I wait for a great topic, or a nifty headline, or an ear-catching phrase to enter my right cerebral cortex. The idea either ferments nicely and I sit and write, or it turns to vinegar and winds up in our toxic waste barrel here in the lab for appropriate disposal. It was the same in the years I gave the annual Board of Education High School Commencement Address. I would be stymied for days or weeks until the right inspiration hit the right synapses. So even though I always get the Blogapalooza announcements, I have never participated. It just isn’t my bag.

Nonetheless, I was aware the topic for last weeks ‘Palooza was (spoiler alert) “write about goodbyes.” A topic you can sink your keyboard into in many ways. I have penned a few goodbye blogs myself–to a missed mentor, to a marvelous mutt, to Thursday Tennis. But I now suspect Jimmy had a deeper motivation when he chose this topic.

This morning Jimmy notified the ChicagoNow blogger community that he was leaving his position and the blog site he had midwifed and nurtured to life. He is not leaving the Tribune, but moving over to the digital sports page. He is choosing a moment where Chicago sports is at a low point, so I know he isn’t doing it for fame and glory, but perhaps he is seeking a local journalism area that needs his expert touch.

Jimmy, thanks for the insight and guidance. Thanks for the technical know-how you shared. Thanks for being the champion for all of us, with our varied backgrounds, our different careers, and so many novel reasons for writing. Go do your digital sports thing. I know your love is for the Cubs, but don’t forget we are a two baseball team town.

So grab a cold one and remember, this blog’s for you!

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“The Marvelous Mrs. Maisel”–“Mad Men” For Jews, and for Gentiles Too.

After reading some great reviews and hearing Laury tell us how wonderful it was, Barb and I sat down last night and watched the first two episodes of Amazon Prime’s new streaming series The Marvelous Mrs. Maisel.

Oy vey, did it feel good.

Mad Men set the bar for recreating the mood and atmosphere of the early ’60s. With Mrs. Maisel, we are back in 1960* New York City, but this time the setting ranges from the doorman managed co-ops on the Upper West Side to the shmatte factories and clubs of Lower Manhattan, all with a decidedly Jewish spin. Don Draper may have had a Jewish mistress in Mad Men, but with Mrs. Maisel, we take center stage, literally.

In the first two episodes, we see young marrieds Miriam and Joel Maisel each try their luck as stand up comedians. One of them steals material from Bob Newhart, the other finds humor in the catastrophes of everyday life, forges a relationship with Lenny Bruce, and learns to get a receipt for bail money. Want to guess which is which?

We care about the characters and their faltering (think not-too-bright secretary) relationship, but it is the atmospherics and little details that steal the show: Snaring the Rabbi for the Yom Kippur Break the Fast meal. Making up your face and getting the curlers out of your hair before your husband can see you in the morning. Bribing the club manager with a brisket and latkes. Meddling mother and father-in-laws. And the panic when someone dares to admit out loud there is shrimp in the eggrolls (something we all must surely know.) Universal touches for Jewish America early in the Age of Camelot.

With This is Us on December hiatus, Barb and I should have plenty of time to savor the remaining episodes of Season 1 of Mrs. Maisel. And word is that a second season has already been approved for production. So we will have the fun of seeing whether Miriam can make it on comedy club circuit and whether Joel gets over his secretary. And with every episode we can ask the primordial question, “but is it good for the Jews?”

*I know, some reviews say 1958. But the Bob Newhart never appeared on the Ed Sullivan Show before 1960. That is also when “The Button-Down Mind of Bob Newhart” album was released. So it is 1960 for me!

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Volvo Pledges No Fatalities. Ten Other Pledges for 2020 I Would Like to See.

Recently Volvo, the safety-first Swedish car manufacturer, has been advertising its safety pledge; by 2020, no one will die in a new Volvo automobile. Quite a bold promise to make! I applaud the manufacturer’s gumption, but question the likelihood of success. Especially since I despised the one Volvo I owned — one electrical failure after another. Let’s hope the company has made tremendous strides in quality control!

I don’t know if Volvo can pull it off, but I do know that there are lots of other promises, pledges, and guarantees I would like to see by 2020. Who is bold enough to make these commitments?

PLEDGES I WANT FOR 2020: NON-TRUMP DIVISION

The airline industry will promise to utilize artificial intelligence to devise a system in which no passenger traveling from Chicago, Illinois to Fairbanks, Alaska gets routed through Miami, Florida.
The recording industry will pledge that I recognize at least one song nominated for the Record of the Year Grammy.
The Sox, Cubs, Bears, Bulls, and Blackhawks will each pledge not to be in Year 1 of a 5 Year rebuilding plan.
While the airlines are making pledges, how about a guarantee that there are no bumped passengers hauled off a plane by air marshalls, or better yet, no bumped passengers at all?
The Democratic Party will pledge to have a viable Presidential Candidate. (I know this one is a b-i-g stretch!)
Progressive Insurance and Toyota will pledge to swap Flo and Jan for a month. Just because it would be fun.
Brian Urlacher will promise to readopt the shaved head look so we can get rid off all the awful hair growth billboards along I-294.
NBC will pledge that “Chicago Streets and Sanitation” will be the last show in it’s “Chicago” pantheon, and will return the streets of Chicago to the residents of Chicago.
Wisconsin will pledge no new shootings by 8-year-olds legally licensed to carry a weapon.
Chip and Joanna, Jonathan and Drew, and all those House Hunters will promise to take a year-long sabbatical so my TV sets can take an HGTV sabbatical too!

What pledge would you like for 2020? Leave your comment on Facebook, or email me at les.raff@post.com. And check out our new Facebook FanPage!

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I Give People Cancer, Part 2

(In Part 1 I discussed being the man who “gives people cancer.” I promised that Part 2 would be a little background as to how I got here.)

July, 1977

A hot day during what will be a steamy summer. The elevators in the University of Illinois Hospital are always too slow and too crowded. So I take the stairs up to the 13th floor, catching glimpses of the West Side Medical Center through the stairwell windows as I climb. It’s a long way up, but likely to be the only exercise I will see on this day.

It is the fifth day of my medical student rotation in Internal Medicine. There are three others on my team: Jerry, a second-year resident, Madelyn, a newly-minted intern, and my classmate Paul. We are E-Service, one of five trainee groups responsible for the diagnosis and management of all patients admitted to the UIH. Most patients are indigent or close to it; the paying patients in the area are down the block at Rush-Presbyterian-St. Lukes Hospital. We have an attending physician, a “real” doc, as part of the service, but she dips in and out of the ward, eager to get to her Infectious Disease consults at one of the other local hospitals.

The day is a mirror of the last four and presages the rest of my two-month rotation. We care for a young man who has lost an eye to a muscle tumor and is in for his monthly chemotherapy. A woman with Behçet’s Syndrome, suffering from ulcers from her mouth to her colon, gargles viscous lidocaine, without much relief. It is all that we have to offer to her.

In contrast to our Behçet patient, we are having much better luck treating Mr. George, an older fellow with stomach ulcers. We are using an experimental drug named cimetidine, the first of a new class of drugs called H2 antagonists. It is working wonders. By the end of the summer, Mr. George will be pain-free, and cimetidine will be released as the blockbuster ulcer drug, Tagamet.

I sweat throughout the summer. I examine patients. I take medical histories. I draw blood, do EKGs, and hold emesis basins. And I come to a realization. I don’t want to be doing this. I am good at book learning, but patient care is “not my forte and not for me.”

Following those long, hot, months, I investigated the non-patient care fields; pathology and radiology. Glass slides seemed more tangible than shadowy images on a piece of film, and I became a pathologist. It was the right choice for me.

I recently queried physicians throughout the US, Canada, and the UK about what led them to pathology. There was a unanimous consensus that a student didn’t enter medical school aspiring to be a pathologist, though one respondent had fond memories of a childhood microscope. Analogous to me, some became disenchanted with treating patients during medical school or internship. One felt that if he had to see one more patient he would wind up “in the stairwell with a straitjacket.” Some admired pathology professors and decided to emulate them. Others discovered they wanted to be detectives and learn the truth, and that truth was in the tissue.

All of us admit to liking the lifestyle, with the minimal call and only rare midnight hours. And a good friend tells me she feels like “an angel behind the scenes.” Who wouldn’t want that?

No, I don’t give people cancer, and neither do any of my hard-working pathologist colleagues. We search for the truth, and if at times we help vanquish cancer and other diseases, we can be happy with our lot.

The opinions above are the opinions of the author and not the opinions of Uropartners LLC.

Link to Part 1

Link to Some Thanksgiving Thoughts

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I Give People Cancer. Part 1

benign-and-malignant-prostate-glands — Benign (left) and malignant (right) prostate glands

I had the following conversation with a new acquaintance at a recent dinner party:

“I do merger and acquisitions, it was slow for a while, but now it is heating up again. I do OK. How about you, what do you do.”

“I guess I do OK too. I’m a pathologist. I run a medical diagnostic lab for a big group of urologists.”

“What does that mean. You run blood tests?”

“Oh, we do some blood testing, but I spend most of my time looking at biopsies. As a urology group, we get mostly prostate biopsies to decide if they are benign or malignant.”

“So you give people cancer.”

It is not quite accurate of course. I don’t pass out diseases from a punch bowl. I am not Typhoid Mary reincarnate. No need to quarantine me. But a few dozen times a week, yes, I am the first to say “Mr. Kranz has prostate cancer, Mr. Ferrick has prostate cancer, Mr. Blaine does not.”

I have the best staff and equipment to assist me, I have my valuable colleagues to verify my work. But in the end, it is my electronic signature on a report that is going to set into motion life-changing events. In that way, I DO “give people cancer.”

About half of the patient biopsies I see I will diagnose with prostate cancer. It is “flip-a-coin” likelihood, and like a coin flip, it sometimes feels very random. An eighty-year-old retiree with a firm prostate on the urologist’s exam may have a negative biopsy, while the 50-year-old executive with a slightly increased blood PSA level may have an aggressive tumor filling each core of the biopsy.

As with a coin flip or with the spin of a roulette wheel, things sometimes get “streaky.” There are days when I am merciless, with case after case receiving a malignant diagnosis. I feel as if I am a curse or have developed an evil eye. At other times, each biopsy I look at is bland and harmless.

After a few negative diagnoses in a row, I begin to wonder if I have suddenly forgotten what prostate cancer looks like under a microscope. I begin to worry about each minor aberration, each slightly enlarged nucleus or shrunken gland. I take a deep breath and regain my balance, knowing that over the course of a few weeks, the numbers will even out. The statistics I calculate every month tell me so.

Of course, the urologists have a harder role to play than I do. They must tell the patients with cancer the news, apprise them of the risks and benefits of the various therapies, hold their hands and dry their tears. But they also get to pass our the good news when a biopsy is benign or when treatment is a success.

So why would I go into pathology, and deal with cold glass slides instead of warm-blooded patients? In Part 2, I look at what brought me, and other pathologists around the country, to this field. We didn’t all start out this way…

In the meantime, read up about PSA.
Rather read a shaggy dog story? Here’s the link to our previous post: It’s A Dog’s Life

I Give People Cancer, Part 2

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The opinions expressed above are those of the author. They are not those of UroPartners LLC.

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Dog Days are Here Again-And We Couldn’t Be Happier

A Catholic Priest, a Protestant Minister, and a Jewish Rabbi are all asked the same question on a TV talk show. When does life begin? The Priest quickly answers “at conception.” The Minister wrinkles his forehead and says “when the Lord blows a soul into the tiny fetus.” The Rabbi grins and replies “When the kids leave for college and the dog dies!”

It’s an old joke, but it has been on my mind a lot recently. As you all know, our faithful companion and gentle giant Max passed away in April. Our sadness was profound, but there was a degree of freedom that we gained that we have not had in the last 33 years of child and/or dog parenting. Weekend days and nights out became more long and leisurely instead of “Oh, we have to get home for the dog.” But there was an emptiness when we did make it home…

I am not the “dog person” that Barb is. When we lost Max, she said she never wanted to again face the trauma of putting a loving pet down. And for the first 6 months, she held to that. But I could see her resolve was weakening and that she was beginning to ache for a wagging tail and a cool, wet nose when she returned home from work or from a day of babysitting. The kitten tried to impersonate a dog as best she could, but for Barb, it just wasn’t the same. I knew the tide had turned when Barb began reading out loud the dog histories from rescue center postings that popped up incessantly on her Facebook stream. I didn’t try to fight the urge, I just stipulated that anything under 10 pounds didn’t meet my criteria for a good dog pet.

When a free Saturday afternoon rolled around on Thanksgiving weekend, it felt like all the planets were aligned. With one of our granddaughters, we checked out an adoption “event” at a local Petsmart but saw no dogs that interested us. On our own later in the afternoon, Barb said: “Let’s check out Kay’s.” Meaning Kay’s Animal Shelter in Arlington Heights, the shelters from which both Max and our first dog Murphy had found us. It was pretty clear our dogless days were coming to an end.

It wasn’t without a bit of a battle. There was only one dog that moved us. He was 18 months old, not a puppy (good,) and he weighed more than ten pounds (even better,) but we had competition. A young couple had seen the pooch a few minutes before we had, and seemed infatuated with him. They were only concerned that there might be a “situation” between this pup and Gimlet, their beloved Irish Terrier. The wife went home and brought Gimlet back with her. The two dogs played together well at first in the fenced-in yard at Kay’s but after a few minutes, some teeth were bared and the dogs decided they didn’t care for each other all that much. Barb and I looked at each other, knowing what the other couple would decide, and that the little four-legged fellow would be spending his life in our home.

The shelter called him a Pomeranian mix. With his curly tail, Barb has him pegged as a Shiba Inu. On a call from her Thanksgiving break in Palm Springs, Laury named him Milo, adding to the litany of “M” names for our dogs. He has been a prince since Saturday, readily adapting to our house and yard. Yes, we had to do some schedule rearranging, and quickly hire a dog walker for those days when we both work. And carry out dinners replaced restaurants over the weekend. But the smile on Barb’s face when Milo cuddles up in her lap proves that life begins when it begins in your heart.
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What I Hope to Give Thanks For on Next Year’s Thanksgiving. It’s a Different THC.

My vision for Thanksgiving 2018.

The Oval Office, Monday, November 26, 2018, the first workday after Thanksgiving. President Donald Trump (R), meets incoming House Majority Leader Nancy Pelosi (D-CA), and incoming Senate Majority Leader Charles (Chuck) Schumer (D-NY.)

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Schumer: Now that all the disputed districts have been finalized, I think it is pretty clear Democrats are going to have a majority in both Houses, Mr. President. That doesn’t mean we won’t work with you. We aren’t veto-proof, we know that.

Pelosi: It’s been two years Mr. President, and we now agree it is time to Make America Great Again.

Schumer: And we know where to start Mr. President. We are ready to reach across the aisle and with our Republican partners, we will fulfill your greatest election promise. We, the Democrats of Congress, with your help, are ready to repeal and replace Obamacare.

Trump: You’re only ready to take this step because I am the master negotiator. I’m the one with the biggest balls. I stared down that little punk Kim Jong-Il. I stared down that little punk Al Franken. I stared down that little punk Paul Ryan. I’ve got no problem staring down the Democratic Party. So what is your timeline?

Pelosi: First we repeal the Affordable Care Act. And then we replace with a plan that includes great features.

Schumer: We’ll include portability.

Pelosi: We’ll cover all pre-existing conditions.

Schumer: Kids until age 26, no problem.

Pelosi: Medicaid expansion, millions of additional people covered. And a government option across all states.

Schumer: Nancy, don’t forget to tell the President about the individual mandate, we talked about the mandate.

Pelosi: Yes, the mandate. We’ve got to have the mandate. And we pay for it all with a 2% increase in the inheritance tax.

Trump: This is a disaster, this is worse than Obamacare. If you ever pass this I’ll veto it and kick your asses out of Congress.

Schumer: But wait for the best part.

Trump: Best part? There is no best part, this is all terrible. You’re all insane. You’re all fired.

Pelosi: The best part is…

Schumer: …we name it THCAmerica.

Trump: THC?

Pelosi and Schumer: TrumpHealthCare

Trump: I love it. It will be HUGE. Where do I sign?

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Well, I can dream, can’t I?
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Some Non-Sporting Observations from Yesterday’s Bear Game. Number Eight Was a Surprise!

It was a cold afternoon at Soldier Field on Sunday. Not brutal, but cold nonetheless. The November sun did what it could to provide a hint of warmth, but long johns, two down jackets, a wool hat and fiberfill gloves did a better job.

Michael and I knew we wanted to take in a game this weekend, and using weather as our guide, going to the Bears-Lions game Sunday made a far better choice than the Northwestern football game in Evanston on Saturday, when rain and snow emptied the stands long before the Wildcats finished their 39-0 decimation of the visiting Minnesota Golden Gophers.

Michael found tickets for pretty good seats on Ticketmaster, I worked Spot Hero for some decent parking just a mile walk from the field and bundled up for a polar expedition we took in the game, my first pro game in about ten years. As we all know, the Bears, unlike the NU ‘Cats, were losers, but it was a close and exciting game, coming down to the last few seconds. Some observations from the 30-yard line:

There were no unlicensed vendors outside the stadium selling knock-off Bears gear. The McCaskey family must have quite a bit of clout with the Mayor, the Park District, and the Police Department.
Maybe they could use some of that clout to improve the pedestrian route to get from the north end of the stadium to past the Museum Campus. The crush wasn’t as bad as after the U2 concert last July, but who needs hairpin turns for 60,000 fans?
The Bears sideline looked a little flat. Maybe they need a picker-upper like the Northwestern Strength Coach Alex Spanos, whose tee-shirted escapades on the NU sideline in the rain showed about three times as much effort as the Minnesota defense.
Grilled Vienna Hot Dogs, nice touch. Men’s Rooms without urinals, odd touch.
The injury to Leonard Floyd was a chiller. The parade of Bears walking over to give him words of encouragement or a high five as he was carted off the field conveyed a lot of warmth.
The sprinkling of Lions fans in the stands had a good time and didn’t seem to be hassled, at least in my section. I have seen far worse treatment of visiting fans at college events where the true fanatics live.
With the game being played in “Bear Weather,” why did I pack a blanket, and then leave it in the trunk of the car?
During the first 50 minutes of the game, the Bear fan behind me issued more F-Bombs then the casts of “The Wolf of Wallstreet” and “Casino” combined. They were directed at the Bears, the Lions, the coaching staffs and the refs. I have never sat near a more passionate fan. So what did he have to say during the crucial last five minutes of the game? I don’t know, he left. I guess he wanted to beat traffic.
Promo tee shirts getting flung into the crowd don’t fare any better in the wind than a last ditch field goal effort.
The Bears will be better. But it will be a few more years before they end a season with more wins than my NU Wildcats. Unless Cat’s Coach Pat Fitzgerald decides to move a few miles south. And takes Alex Spanos with him!

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Tricks for U2 Tix. What Works for You When You Want Tickets to a Show?

Do I want to go to a concert? First, a few questions to answer. Am I a fan club member? Do I have a credit card from the bank sponsoring the tour? Will I have a chance to take a break from looking at slides in my office at exactly 9:00 am (9:01 will be too late) to log in? Do I want to go to see the show enough to make this all worthwhile? Or have my U2 days passed me by?

It used to be fun and exciting to get tickets for a show or concert or game. You could go to the box office and lay down cash. You could send a check to the stadium with a self-addressed stamped envelope (remember those?) and check your mailbox every few days in anticipation. For immediate gratification, you could call an 800 number, and armed with a BankAmeriCard or MasterCharge, order your tickets. Or if you were lucky, you knew an insider who had gotten a hold of a stack of tickets and would sell you a pair of great seats for face plus a bottle of Seven Crown. Ah yes, the Good Old Days. Barb and I saw a lot of Neil Diamond in those simpler times.

Then came the Internet, and Ticketmaster online, and automated bots getting all the front row center seats. The common consumer was left to find their way to the secondary market, the Stubhubs and Craig’s Lists of the world. You paid your money and you took your chance, as our son learned after getting ripped off on a pair of Final Four tickets.

But now the artists and the venues are creating new party games, trying to make sure those valuable tickets find their way to the “real” fans. They are doing their best to get the bots and the brokers out of business. How? It’s Pre-registration, baby!

For the last 3 weeks, I have been barraged by emails about the U2 concert at the United Center next May. Bono and the boys want ME to get insider access. Just a few things they want to know:

Am I a fan club member? Well, I probably am, but I sure don’t remember my username or password. And I really don’t want to be on another mailing list.
How about credit cards. Do I have the “preferred” one to gain pre-public access? Here I might be in luck, as my wallet contains enough plastic to build a tower to the newly discovered habitable planet 6 light years away. Citibank is the sponsor this time around and voila, I have a never used Citibank card that came with my now defunct Costco membership. So hallelujah, I am preferred. All I have to do is make the necessary preparations:

I have filled out and sent in my pre-registration form.
I have checked my phone and received my secret access code.
I have a timer set on my phone, set to go off at 8:59.
I have my Citibank card out on my desk.

My goal–tickets for 2, not too far back, not behind a pair of seven footers, and with a view of the Jumbotron. That’s what I call preferred. I’ll let you know if I succeed. In the meantime, what are your tricks to get the best seat in the house?

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Some popular recent posts:
Trump at Gettysburg
What Hillary Clinton Should Have Done

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