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Dermatology Research and Practice
Volume 2012 (2012), Article ID 952186, 8 pages
[http://dx.doi.org/10.1155/2012/952186]
## Melanonychia
Oregon Health and Science University, Portland, OR, USA
Received 3 December 2011; Revised 3 April 2012; Accepted 3 April 2012
Academic Editor: Eckart Haneke
Copyright © 2012 Julie Jefferson and Phoebe Rich. This is an open access article distributed under the
[Creative Commons Attribution License](http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
#### Abstract
Melanonychia, or melanin-derived brown-to-black nail pigmentation, is a diagnostic challenge for clinicians. The most serious disease of the nail unit, melanoma, primarily presents with melanonychia. However, melanonychia most often occurs as a result of benign etiologies such as nail matrix melanocytic activation, nail matrix melanocytic hyperplasia, and nail invasion by melanin-producing pathogens. Regrettably, patients with nail apparatus melanoma are often initially misdiagnosed, and due to diagnostic delays of an average of 2 years, melanoma of the nail unit carries a poor prognosis. Having a thorough knowledge of the various causes of melanonychia and using a systematic approach when evaluating brown-to-black nail pigmentation may help prevent misdiagnosis and thereby improve prognosis.
#### 1. Introduction
Roughly two-thirds of cases of nail apparatus melanoma (NAM) are characterized by melanin-derived brown-to-black nail pigmentation, or melanonychia [
[1](#B1)]. However, melanonychia is an ambiguous clinical finding that most commonly occurs as a result of benign etiologies such as nail matrix melanocytic activation, nail matrix melanocytic hyperplasia, and nail invasion by melanin-producing pathogens. Additionally, other nail pathogens, exogenous substances, and subungual hemorrhage can cause non-melanic brown-to-black nail pigmentation [ [1](#B1)– [3](#B3)]. Unfortunately, patients with NAM are often initially misdiagnosed [ [2](#B2)]. Due to diagnostic delays of an average of 2 years, NAM carries a poor prognosis with reported 5-year and 10-year survival rates of 30% and 13%, respectively [ [4](#B4), [5](#B5)]. Having a thorough knowledge of the various causes of brown-to-black nail pigmentation and using a systematic approach when evaluating clinical cases may help prevent misdiagnosis and ultimately save a life.
#### 2. Melanonychia
Melanin within the nail plate is usually produced by nail matrix melanocytes [
[2](#B2), [6](#B6)]. Active melanocytes transfer melanin-rich melanosomes by way of dendrites to differentiating nail matrix-derived onychocytes [ [2](#B2), [6](#B6)]. This process most commonly results in a longitudinal band of melanonychia, but total or transverse melanonychia may also occur, although rarely [ [2](#B2), [6](#B6), [7](#B7)]. Melanonychia usually originates in the distal nail matrix [ [2](#B2), [6](#B6)]. Most melanocytes in the proximal nail matrix lie dormant in the lower 2–4 germinative cell layers while active (as well as dormant) melanocytes exist in the 1st and 2nd germinative layers of the distal nail matrix [ [2](#B2), [6](#B6)]. The etiologies of melanonychia may be divided into 2 broad categories: melanocytic activation and melanocytic hyperplasia (Table [1](tab1/)) [ [1](#B1)– [3](#B3)]. **Table 1:**Classification of conditions associated with longitudinal melanonychia. Table adapted from J. Andre, N. Lateur. Pigmented nail disorders [ [2](#B2)].
##### 2.1. Melanocytic Activation
Melanocytic activation (also termed melanocytic stimulation or functional melanonychia) describes the process by which melanonychia results from increased melanic pigmentation of the nail matrix epithelium and nail plate without a concurrent increase in the number of melanocytes [
[2](#B2)]. Seventy-three percent of adult cases of single digit longitudinal melanonychia (LM) occur as a result of melanocytic activation [ [2](#B2), [8](#B8)]. Several physiologic, local and regional, dermatologic, systemic, iatrogenic, and syndromic factors may lead to melanocytic activation [ [2](#B2), [9](#B9)]. *Physiologic Causes*
Physiologic causes of LM include racial melanonychia and pregnancy (Figure
[1](fig1/)) [ [2](#B2)]. Darkly pigmented individuals such as blacks, Asians, Hispanics, and Middle Easterners frequently have benign longitudinal pigmented bands [ [2](#B2), [4](#B4)]. The number and width of the bands increases with age [ [2](#B2), [10](#B10)]. In fact, nearly 100% of blacks develop 1 or more pigmented bands by the age of 50 years [ [2](#B2)]. Pigmented bands are most often located in the digits used for grasping such as the thumb, index finger, and middle finger, or in those digits prone to trauma such as the great toe [ [2](#B2)]. Additionally, the nail plates of patients with darker phototypes may exhibit LM more easily with other causes of melanocytic activation [ [2](#B2)]. *Local and Regional Causes*
If melanonychia is associated with abnormalities of the nail plate or the periungual tissues, the possibilities of onychotillomania, nail biting, frictional trauma, and even carpal tunnel syndrome should be explored (Figure
[2](fig2/)) [ [2](#B2), [11](#B11)]. If melanonychia is symmetric and affects the lateral and external part of the 4th or 5th toenail and great toe, repeated trauma from ill-fitting shoes or overriding toes is a likely cause [ [2](#B2), [12](#B12)]. *Dermatologic Causes*
Inflammation due to dermatologicconditions such as onychomycosis, paronychia, psoriasis, lichen planus, amyloidosis, and chronic radiodermatitis may lead to the activation of melanocytes and subsequently the appearance of a light-brown band [
[2](#B2)]. Oftentimes melanonychia occurs following the resolution of the inflammatory process [ [2](#B2)]. Nonmelanocytic tumors including onychomatricoma [ [13](#B13)], Bowen’s disease [ [14](#B14)], myxoid pseudocyst [ [10](#B10)], basal cell carcinoma [ [10](#B10)], subungual fibrous histiocytoma [ [10](#B10)], verruca vulgaris [ [10](#B10)], and very rarely subungual linear keratosis [ [7](#B7), [15](#B15)] have also been documented to cause melanocytic activation resulting in LM [ [2](#B2)]. *Systemic Causes*
Melanonychia due to systemic causes often manifests as multiple bands involving both fingernails and toenails. Interestingly, melanonychia associated with Addison’s disease, nutritional disorders, and AIDS is commonly accompanied by cutaneous and mucosal pigmentation [
[2](#B2), [16](#B16)]. Melanonychia has been reported to be due to alcaptonuria, hemosiderosis, hyperbilirubinemia, and porphyria [ [2](#B2), [10](#B10)]. *Iatrogenic Causes*
Iatrogenic causes of melanocytic activation include medications (especially chemotherapeutic agents) [
[17](#B18)– [19](#B20)], phototherapy, X-ray exposure, and electron beam therapy [ [20](#B17)] (Figure [3](fig3/), Table [2](tab2/)) [ [2](#B2)]. Presentations of iatrogenically-induced melanonychia may vary significantly depending on the exposure, but are usually associated with melanonychia of several fingernails and toenails [ [2](#B2)]. Fortunately when melanonychia is drug-related, it typically fades slowly following drug withdrawal [ [2](#B2)]. Transverse melanonychia, while uncommon, is most commonly reported as a result of iatrogenic causes. Transverse melanonychia has occurred in conjunction with use of the following: electron beam therapy [ [20](#B17)], conventional radiographic therapy to treat hand dermatitis (used in the 1950s and 1960s) [ [21](#B21), [22](#B22)], psoralen with ultraviolet A (PUVA) [ [23](#B23)– [26](#B26)], infliximab [ [27](#B27)], zidovudine [ [28](#B28)], prolonged antimalarial therapy with amodiaquine, chloroquine, mepacrine, or quinacrine [ [2](#B2), [26](#B26), [28](#B28)], and chemotherapy with agents such as doxorubicin, bleomycin, cyclophosphamide, daunorubicin, dacarbazine, 5-fluorouracil, methotrexate [ [20](#B17)], and hydroxyurea [ [26](#B26), [29](#B29), [30](#B30)]. Transverse melanonychia associated with electron beam therapy and PUVA is benign and typically resolves with the cessation of treatment [ [20](#B17), [23](#B23), [26](#B26)]. Interestingly, for antimalarials amodiaquine, chloroquine, and mepacrine, transverse melanonychia may be attributable to either melanin production or more commonly ferric dyschromia [ [2](#B2)]. **Table 2:**Drugs associated with melanocytic activation and subsequent longitudinal melanonychia. Table adapted from J. Andre, N. Lateur. Pigmented nail disorders [ [2](#B2)]. *Syndrome-Associated Melanonychia*
Syndrome-associated melanonychia, which occurs in conjunction with Laugier-Hunziker, Peutz-Jeghers, and Touraine syndromes, typically involves multiple digits, and all of these syndromes are also characterized by mucosal pigmented macules involving the lips and oral cavity [
[2](#B2)]. Laugier-Hunziker syndrome is a chronic benign mucocutaneous syndrome that generally arises spontaneously in 20–40-year-old Caucasian adults, while Peutz-Jeghers and Touraine syndromes are autosomal dominantly inherited disorders that typically manifest during childhood and are associated with intestinal polyposis and an increased risk for gastrointestinal and pancreatic malignancies [ [2](#B2)].
##### 2.2. Melanocytic Hyperplasia
The 2nd broad category of melanonychia, melanocytic hyperplasia, is characterized by an increase in the number of matrix melanocytes [
[2](#B2)]. Both benign and malignant forms exist [ [2](#B2)]. Benign melanocytic hyperplasia is subdivided into 2 categories, lentigines, when nests of melanocytes are absent, and nevi, when at least 1 melanocytic nest is present [ [2](#B2)]. While lentigines are observed more often than nevi in adults, nevi are found far more often than lentigines in children (Figures [4](fig4/) and [5](fig5/)). NAM occurs rarely in children, and benign melanocytic hyperplasia constitutes 77.5% of cases of childhood melanonychia [ [2](#B2), [31](#B31)].
Nail apparatus nevi primarily involve the fingernails, with the thumbnail being most commonly affected. Nevi can be congenital or acquired, and the majority are junctional [
[1](#B1), [2](#B2), [8](#B8), [31](#B31), [32](#B32)]. One half of cases of nevi are characterized by a bandwidth of over 3 mm, two-thirds by melanic brown-black pigmentation, and one-third by melanic periungual pigmentation [ [2](#B2)]. Nevertheless, nail matrix nevi may also present as scarcely pigmented bands [ [2](#B2), [8](#B8), [9](#B9), [31](#B31), [32](#B32)].
Malignant melanocytic hyperplasia includes both
*in situ* and invasive melanoma of the nail apparatus (Figure [6](fig6/)) [ [2](#B2)]. Melanoma is most commonly observed in the thumbs, index fingers, and great toes in patients mean age 60–70 years [ [2](#B2)]. Roughly, 1–3% of melanomas in Caucasians [ [1](#B1), [33](#B33)– [35](#B35)], 15–20% in blacks [ [1](#B1)], 16% in Mexicans [ [1](#B1), [36](#B36)], 10–30% in Japanese [ [1](#B1), [37](#B37), [38](#B38)], 17% in Chinese [ [1](#B1), [39](#B39)], and 33% in Native Americans [ [1](#B1), [40](#B40)] occur within the nail unit [ [4](#B4), [10](#B10)]. Because other forms of melanoma occur less often in people with darker phototypes compared to Caucasians, the absolute incidence of nail-associated melanoma is similar among the various racial groups [ [1](#B1), [2](#B2), [41](#B41)].
##### 2.3. Pathogen-Induced Melanonychia
As previously highlighted, certain pathogens involved in onychomycosis or paronychia can trigger an inflammatory response that induces melanocytic activation resulting in melanonychia. In addition, some Gram-negative bacterial pathogens such as
*Proteus mirabilis* [ [42](#B42)], and some dermatophyte strains, such *as trichophyton rubrum. * *Var nigricans,* can produce melanin and infrequently present as a linear streak [ [1](#B1)]. Several other organisms can present with linear brown-to-black nail dyschromia by producing a pigment other than melanin.
#### 3. Clinical Evaluation of Melanonychia
##### 3.1. History
A thorough history with particular attention to the onset, progression, and possible triggers of melanonychia should be obtained. Providing patients with a nail questionnaire with inquiries concerning their occupation, hobbies, exposure to topical substances, history of digital trauma, drug history, medical history, and family history prior to the visit allows them ample time to prepare thoughtful answers, and also allows the physician more time during the appointment to focus on key portions of the history. Nail apparatus melanoma should be suspected in any patient with unexplained melanonychia who provides a history containing any of the following features: (i)involvement of a single digit (especially the thumb, index finger, or great toe);(ii)development during the fourth decade of life or later;(iii)development in the setting of a history of digital trauma; (iv)development in the setting of a personal/family history of melanoma or dysplastic nevus syndrome; (v)development in the setting of nail dystrophy;(vi)abrupt development or change (darkening or widening proximally) [
[1](#B1), [4](#B4)].
##### 3.2. Physical Examination
Initial physical examination should include evaluation of all twenty nails, skin, and mucous membranes while keeping in mind all potential causes of brown-to-black nail pigmentation. Questions to help guide the initial examination of the nails include the following:(i)Are one or more nails involved? (ii)If multiple nails are involved, is one particular nail changing or different from the rest? (iii)Is the discoloration located on top of, within, or beneath the nail plate? (iv)Is the discoloration linear in orientation? (v)Is the band wider or darker proximally? (vi)Is the discoloration associated with nail plate dystrophy?
*Exogenous Substances*
The possibility of linear nail pigmentation due to an exogenous substance on top of or beneath the nail plate should be ruled out. Notably, a linear band secondary to pigment production by a nail pathogen is typically wider distally than proximally indicating a distal rather than proximal (or matrix) origin [
[1](#B1)]. Infection can be confirmed by histopathologic examination, and/or culture [ [1](#B1)].
Exogenous substances such as dirt, tar, tobacco, and potassium permanganate are usually located on top of the nail plate and follow the shape of the proximal nail fold rather than the lunula [
[1](#B1), [2](#B2)]. Exogenous substances grow-out with the nail plate, and can sometimes be simply scraped off [ [1](#B1), [2](#B2)]. In cases of suspected potassium permanganate staining, one component, manganese dioxide, can be reduced to a colorless compound with the application of 5–10% ascorbic acid [ [1](#B1)].
Occasionally, subungual hematomas can present in linear fashion [
[1](#B1)]. In such instances, dermoscopy may be used to help distinguish blood from melanin and is discussed later. Direct visualization of the underlying nail bed by punching a hole in the nail plate in the area of dyschromia can be performed to confirm its presence [ [2](#B2), [43](#B43)]. Additionally, blood is also characterized by a positive pseudoperoxidase reaction (Hemostix test) [ [1](#B1)]. *Hutchinson’s Sign*
The surrounding skin should be carefully examined for discoloration similar to that seen in the nail plate. Hutchinson’s sign, or the extension of pigment from the matrix to the perionychium in association with NAM is sometimes helpful in confirming the clinical diagnosis but is an inconsistent feature (Figure
[7](fig7/)) [ [4](#B4)]. Melanoma can occur without Hutchinson’s sign. Moreover, pseudo-Hutchinson’s sign, or the presence or illusion of pigment in the perionychium, is associated with both benign and malignant conditions in the absence of melanoma (Figure [8](fig8/)) [ [2](#B2), [4](#B4), [44](#B44)]. *Dermoscopy*
Dermoscopy may provide clues when deciding whether biopsy is necessary [
[3](#B3), [43](#B43)]. However, the topic of dermoscopic findings associated with NAM versus benign etiologies is currently controversial among experts and further studies are needed. Blood spots are usually purple to brown in color, and are characterized by well-limited, rounded proximal edges [ [2](#B2), [43](#B43)]. A study by Ronger et al. found that cases of NAM were significantly associated with a brown coloration of the background, and the presence of irregular longitudinal lines (per color, spacing, thickness, and parallelism) (Figure [9](fig9/)) [ [3](#B3), [43](#B43)]. The study also observed the micro-Hutchinson’s sign (a Hutchinson’s sign that is too small to be seen with the human eye) only in cases of melanoma [ [3](#B3), [43](#B43)]. However, the micro-Hutchinson’s sign rarely occurs, and the study was unable to statistically evaluate for specificity [ [3](#B3), [43](#B43)]. Nail apparatus nevi were significantly associated with a brown coloration of the background and the presence of regular lines, while nail apparatus lentigines, ethnic-type pigmentation, and drug-induced pigmentation were significantly associated with homogeneous longitudinal thin gray lines and gray coloration of the background [ [3](#B3), [43](#B43)].
Additionally, dermoscopy of the free edge of the nail plate may facilitate preoperative mapping by helping to identify the origin of the pigmented band in the matrix [
[3](#B3), [45](#B45)]. A pigmented band in the ventral nail plate originates from the distal matrix, whereas a band in the dorsal nail plate originates in the proximal matrix [ [3](#B3), [45](#B45)]. If despite dermoscopic evaluation, doubt remains as to the location of the pigmented band in the matrix, a distal nail clipping stained with Fontana Masson will demonstrate the matrix band origin [ [3](#B3)]. **Figure 9:**Dermoscopy of the nail apparatus melanoma *in situ*seen in Figure [7](fig7/). Notice the brown coloration of the background and the presence of irregular longitudinal lines per color, spacing, thickness, and parallelism. *ABC Rule for Clinical Detection of NAM*
An ABCDEF mnemonic was created to help both clinicians recall certain key clinical features that should raise suspicion for the possibility of subungual melanoma [
[46](#B46)]. “” stands for the *age* of the patient at presentation [ [46](#B46)]. Subungual melanoma occurs most commonly within the 5th–7th decades, although it has been reported to occur in patients as young as 1 year old and as old as 90 years [ [46](#B46)]. “” represents the most common clinical presentation of a subungual melanoma with a pigmented band composed of variegated shades of *brown-to-black* with a *breadth* of over 3 mm and irregular or *blurred borders [ 46]*. “” is for *change*—a sudden, recent, or rapid increase in the size of the pigmented band is considered comparable to the radial growth phase [ [46](#B46)]. A change in nail plate morphology is also concerning for melanoma [ [46](#B46)]. “” signifies single *digit*involvement with the thumb, then great toe or index finger being most commonly involved [ [46](#B46)]. “” denotes the *extension*of pigment into the perionychium in association with melanoma, or Hutchinson’s sign [ [46](#B46)]. “” stands for *family*or personal history of melanoma and/or dysplastic nevus syndrome [ [46](#B46)].
#### 4. Biopsy of Melanonychia
As the clinical diagnosis of melanonychia is frequently difficult, a biopsy is oftentimes necessary to rule out melanoma [
[3](#B3)]. In fact, a study by Di Chiacchio et al. found that the overall accuracy of dermatologists in the preoperative diagnosis of NAM *in situ* was low ranging from 46–55% [ [47](#B47)]. Interestingly, the study also found that a dermatologist’s level of expertise in nail disease did not statistically influence the correct diagnosis [ [47](#B47)].
While no formally adopted algorithm with guidelines for when to perform a diagnostic biopsy exists, there are several suggested clinical practices that help guide clinical decision making [
[4](#B4)]. The threshold for biopsy should be low in a white patient with unexplained melanonychia of a single digit [ [2](#B2), [46](#B46)]. For cases of unexplained melanonychia of a single digit in a nonwhite patient, or of multiple digits in a patient with any phototype, melanonychia should be closely monitored and biopsied if any suspicious features arise [ [2](#B2), [46](#B46)]. Because unexplained melanonychia in children is rarely due to an underlying melanoma, their management is more conservative [ [2](#B2), [47](#B47)].
When performing a biopsy, the origin of the pigment, which most often lies in the nail matrix, should be sampled in its entirety. The nail matrix biopsy, while a relatively safe and simple procedure when basic principles are followed, is associated with the greatest risk in terms of scarring when compared to other biopsy locations within the nail unit [
[48](#B50)]. With regards to the anatomy and physiology of the nail unit, the distal matrix forms the ventral nail plate, and the proximal matrix forms the dorsal nail plate [ [4](#B4), [48](#B50)– [51](#B53)]. Thus a biopsy of the distal matrix is almost always preferred over a proximal matrix biopsy as any resultant scar, which clinically manifests as a thinned ridge, would lie on the undersurface of the nail plate [ [4](#B4), [48](#B50)– [51](#B53)]. Thinned ridges on the dorsal surface of the nail plate are easily traumatized as they catch on items such as clothing and are much more troublesome for the patient [ [4](#B4)].
In order to minimize any potential scarring, nail matrix excisional biopsies can be oriented transversely [
[3](#B3), [4](#B4), [48](#B50)]. Moreover, full thickness nail matrix biopsies larger than 3 mm can be sutured in order to achieve an optimal cosmetic result [ [1](#B1), [52](#B54)].
The punch biopsy is generally reserved for longitudinal melanonychia less than 2.5–3 mm in width originating in the distal matrix [
[1](#B1), [3](#B3)]. A punch biopsy should be taken at the origin of the pigmented band and should extend to depth of the periosteum [ [3](#B3), [48](#B50)]. Punch biopsies are generally not recommended for evaluating pigmented lesions 3 mm or more in width (even if multiple punch biopsies are taken) because peripheral pigmentation may not be adequately sampled to rule out malignancy. Additionally, taking serial punch biopsies is associated with an increased risk of permanent nail dystrophy [ [3](#B3)].
The lateral longitudinal excision is best suited for biopsying suspicious lesions located in the lateral one-third of the nail as this technique samples all components of the nail unit including the nail matrix, nail bed, nail fold, and hyponychium [
[1](#B1), [3](#B3)]. The tangential (shave) excision is ideal for sampling a longitudinal pigmented band with a lower preoperative suspicion of melanoma that is greater than 3 mm in width in the midnail plate or of any width originating in the proximal matrix [ [1](#B1), [3](#B3), [53](#B55)]. The tangential technique, first described by Eckart Haneke in 1999, is less invasive than a transversely-oriented matrix excision, and it is associated with minimal long-term dystrophy despite the increased width commonly associated with its use [ [1](#B1), [3](#B3), [53](#B55)]. However, for any case with a high preoperative likelihood of invasive melanoma, a full-thickness nail matrix biopsy is necessary for prognosis determination as a tangential biopsy may not provide an accurate Breslow depth [ [3](#B3)].
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*Journal of the American Academy of Dermatology*, vol. 34, no. 1, pp. 87–90, 1996. [View at Publisher](http://dx.doi.org/10.1016/S0190-9622(96)90839-7)· [View at Google Scholar](http://scholar.google.com/scholar_lookup?title=Hutchinson%27s+sign%3a+a+reappraisal&author=R.+Baran&author=P.+Kechijian&publication_year=1996)· [View at Scopus](http://www.scopus.com/scopus/inward/record.url?eid=2-s2.0-0030023182&partnerID=K84CvKBR&rel=3.0.0&md5=0c7e9a043997ac6eb1e8c8a33850208d)
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FOR IMMEDIATE RELEASE
PR- 156-07
May 22, 2007
MAYOR BLOOMBERG ANNOUNCES TAXI FLEET TO BE FULLY HYBRID BY 2012
PlaNYC Goal for Greener Taxis Will Reduce Emissions from Cabs By 50% in the Next Decade
Yahoo! Donates 10 Hybrid Taxis Which Will Replace Existing Gas-only Powered Cabs
Mayor Michael R. Bloomberg today announced that as part of PlaNYC, the Taxi and Limousine Commission (
"In PlaNYC, we set aggressive goals for the taxicab industry and today we're going to begin meeting those goals," said Mayor Bloomberg. "Implementing tougher standards for the more than 13,000 taxis in this City will provide the same clean air benefits as removing 32,000 privately owned cars from our streets, which will significantly reduce the air pollution that causes childhood asthma. This will also decrease the fuel costs for taxi drivers, making this a win for the public and operators alike. I'd like to thank Yahoo! for their commitment to the environment and for recognizing our efforts in addressing global warming by donating these cabs."
On Earth Day, Mayor Bloomberg outlined PlaNYC, a series of 127 proposals aimed at helping New York meet the challenges of adding nearly one million people to the City's population between now and 2030, while at the same time reducing the City's greenhouse gas emissions by 30%. The Ford Crown Victoria, the current workhorse of the taxicab fleet, achieves only 14 miles per gallon (mpg). After October 2008, all new vehicles entering the fleet must achieve a minimum of 25 mpg (based on EPA city surface street ratings), and after October 2009, all new vehicles must achieve a minimum of 30 mpg. When fully implemented, the new standards are expected to reduce carbon emissions by more than 215,000 tons. Currently there are only 375 hybrid vehicles in the City's taxi fleet. By October 2008, the number of hybrids in the fleet will triple. The phase-in for the City fleet to become completely hybrid is as follows:
"We expect these new standards will save 22 million gallons of fuel in the first year, and that is only the beginning of what we will be able to accomplish," said TLC Commissioner Daus. "Thanks to Mayor Bloomberg's bold vision laid out in PlaNYC, the New York City taxi fleet's carbon footprint will be lighter than at any point in its 100-year history. The environmental meter is running, and our efforts are paying the fare for a healthier tomorrow. We appreciate Yahoo!'s support and their gift of ten clean, green taxicabs."
It is estimated that increasing fuel efficiency from 14 mpg to 30 mpg will save the average taxi operator more than $10,000 per year. The new fuel efficiency standards will be accompanied by clear guidelines for evaluating the vehicles emissions performance, and for new vehicle specifications that will ensure both passenger comfort and driver safety. Wheelchair accessible taxicabs being brought into service will be exempt from the new fuel economy requirements.
"In the face of climate change, the old ways of doing things are no longer good enough. Mayor Bloomberg's PlaNYC is an absolutely essential step toward reversing course on climate change and air quality, and I will work as hard as I can to help turn the Mayor's plan into reality," said Councilmember David Yassky. "I applaud Mayor Bloomberg for acting now to turn New York City taxi cabs from part of the problem into part of the solution. New York City's 13,000 taxi cabs will still be yellow on the outside, but soon they will be green on the inside."
As part of its "Be a Better Planet" program, Yahoo! donated ten hybrid Ford Escape taxicabs to operator Team Systems. The cabs will be used to replace gasoline-only powered Ford Crown Victoria vehicles, saving tens of thousands of gallons of fuel over a taxicab's service lifetime, and reducing carbon emissions by more than 16 tons per vehicle each year. The vehicles being donated today get approximately 36 mpg (city streets). Yahoo! kicked off the "Be a Better Planet Challenge" in Times Square last week.
"Yahoo! applauds Mayor Bloomberg's aggressive PlaNYC initiative to build a greener, greater New York City," said Patrick Crane, vice president of marketing, Yahoo! Network Division. "As a company focused on protecting the environment, we found it only fitting to award New York with a fleet of hybrid taxis as part of our 'Be a Better Planet' campaign, which gives people across the country specific ways to take green actions in their hometowns. We challenge other cities across America to follow New York's example as Yahoo! searches for the greenest city in America."
"Putting more clean cabs on New York City streets is an important step in our fight to improve air quality, especially for the one million asthmatics in our city," said Louise Vetter, President and CEO of the American Lung Association of the City of New York. "By turning our yellow cabs green, we can put New York City miles ahead on the road to clean air."
In addition to the PlaNYC speech on Earth Day, New York City hosted the historic C-40 Large Cities Summit last week. During a keynote address to the Summit on Tuesday, Mayor Bloomberg announced that New York is joining the Climate Group, and on Wednesday he announced that New York City would participate in an initiative sponsored by the Clinton Foundation to reduce carbon emissions from buildings.
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MEDIA CONTACT:
Stu Loeser/John Gallagher (212) 788-2958
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**Theo các tài liệu Hán Nôm lưu giữ tại chùa và các bậc cao niên có am hiểu về lịch sử tại xã Chí Công cho biết: vào giữa thế kỷ XVIII, có 3 vị thiền sư quê ở Thanh Hóa do chán ghét sự tiếm quyền của chúa Trịnh đối với triều Lê đã rời bỏ quê hương vào Nam, dừng chân trên mảnh đất Duồng và dựng tạm một ngôi tiểu am bằng mái tranh vách đất tại Đá Bồ - Gành Son để làm nơi tu hành lấy tên là Phước An tự. **
Một thời gian sau, nhà sư Nguyễn Phước Sanh - một trong 3 vị sư sáng lập chùa đã dời chùa đến vị trí cách Đá Bồ 300 m về phía tây. Đến năm Kỷ Dậu 1849, chùa được di dời đến vị trí hiện nay và được xây dựng lại quy mô và bề thế hơn theo lối kiến trúc dân gian truyền thống đương thời.
Ngược dòng lịch sử, cuối thế kỷ XIX, đầu thế kỷ XX, chùa Phước An là nơi gặp gỡ, bàn bạc và trao đổi thời cuộc của các sĩ phu yêu nước đương thời. Đặc biệt là vào tháng 8/1910, Chủ tịch Hồ Chí Minh - khi đó còn là anh thanh niên Nguyễn Tất Thành trên đường từ Quy Nhơn vào Sài Gòn đã ghé Duồng để tìm gặp cụ Trương Gia Mô - vốn là bằng hữu của ông Nguyễn Sinh Sắc - thân sinh Nguyễn Tất Thành - khi hai ông còn làm quan tại triều đình Huế.
Cụ Mô đã tiếp đón Nguyễn Tất Thành với một tình cảm đặc biệt ưu ái. Để tránh sự nhòm ngó của bọn mật thám Pháp, ban ngày cụ gửi anh Thành tá túc ở chùa Phước An, đêm đến mới đưa anh Thành về lại nhà an nghỉ. Đêm đêm, bên ngọn đèn hai bác cháu hàn huyên, trao đổi thời cuộc, cả hai cùng có chung một chí hướng là làm sao tìm ra con đường cứu nước, cứu dân phù hợp để đánh đuổi bọn thực dân, phong kiến.
Những ngày dừng chân và sinh sống ở Duồng, được tiếp xúc với cảnh sống cơ cực của người dân lao động biển đã giúp cho Nguyễn Tất Thành hiểu sâu hơn về cuộc sống và nỗi khốn khổ của nhân dân ta trước ách thống trị của bọn thực dân phong kiến.
Chùa Phước An tọa lạc trên sườn đồi có cao độ 52m so với mực nước biển trung bình. Dưới thời Pháp thuộc, để khống chế và đàn áp phong trào đấu tranh cách mạng của quân và dân ta, giặc đã cho xây dựng đồn bót kiên cố ngay phía sau lưng chùa Phước An. Liên tục từ năm 1949 - 1954, quân ta đã nhiều lần tiến công đánh đồn, nhiều trận đánh ác liệt đã diễn ra, chùa Phước An do ở sát cạnh đồn nên phải gánh chịu hậu quả nặng nề của bom đạn chiến tranh.
Trải qua những biến cố của lịch sử, đến nay chùa Phước An đã được trùng tu, tôn tạo lại khá trang nghiêm và bề thế, với nhiều hạng mục như: chính điện, giảng đường, hậu tổ, cổng chính, bảo tháp, pho tượng Thích Ca nhập niết bàn, lầu chuông, lầu trống…Kiểu dáng, kết cấu kiến trúc và các họa tiết trang trí nghệ thuật ở ngoại và nội thất của các hạng mục đều mang đậm dấu ấn Phật giáo truyền thống của dân tộc.
Tại chùa còn bảo lưu một bộ ván gỗ khá nguyên vẹn, trong thời gian ẩn dật tại chùa trước đây, Nguyễn Tất Thành đã sử dụng chính bộ ván này để nghỉ ngơi. Đến nay, bộ ván gỗ này vẫn được nhà chùa và nhân dân địa phương trân trọng bảo quản và đặt ở nơi trang nghiêm trong chùa để thể hiện tấm lòng thành kính đối với Bác.
Từ khi tạo lập đến nay, chùa Phước An là nơi sinh hoạt tôn giáo, tín ngưỡng tâm linh quan trọng của người dân địa phương và giới tín đồ phật tử gần xa. Ngoài những giá trị về mặt văn hóa tâm linh như những ngôi chùa khác, chùa Phước An còn được người dân địa phương tôn vinh với thái độ thành kính và trân trọng. Dù đã hơn 100 năm trôi qua, nhưng hình bóng thời trai trẻ của Bác như vẫn còn nơi đây.
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1. Prices are calculated with shipping in the US. Ask for outside US shipping pricing. 2. Paypal only. No exceptions. 3. Item will ship either same day of order or the next business day [via USPS] 4. ASK for more pictures if you would like to see more before you buy. Louis Vuitton Denim Coin Pouch Limited Edition Color: Blue Condition: 9.9/10 Measurements: 4.7" x 2.8" Retail: $??? Price: SOLD
[post #1](#post_4524726)of 1
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## [UPDATE] angelas ashes the online book download fiel [ypk2] free
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04/06/2015 12:37:13
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## Bình luận
Cái này chỉnh sửa được những gì vậy?
Cấu hình máy thế nào? Máy t yếu quá k0 cài mấy phần mềm dựng phim nổi. Mà nhu cầu cũng chỉ cần cắt, ghép video àh.
Movie maker chỉnh sửa được video sao??
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* XP: RAM 512 MB(tiến cử 1 GB hoặc cao hơn). Vista: 1 GB (tốt nhất 2GB).
* Card đồ hoạ hỗ trợ DirectX 9 (hoặc cao hơn)64 MB (tốt nhất từ 128 MB trở nên).
* Card âm thanh hỗ trợ DirectX 9 (hoặc cao hơn).
* 150 MB bộ nhớ trống để cài đặt chương trình.
Chỉnh sửa được cái gì md dùng md biết hìhì, chắc đủ khả năng để cắt ghép video đấy hìhì.
## công nghệ
phần mềm này có ghép được audio không bạn oi?

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# Làm gì khi núm vú bị tụt vào trong
08:40
Núm vú không thò ra ngoài phải chăng cũng là khiếm khuyết nhỏ của tạo hoá. Vấn đề này quả là điều khó chịu và khó khăn với các bà mẹ mới sinh con, theo thống kê thì có khoảng 10% các bà mẹ bị núm vú thụt vào trong. Các bạn chịu khó vất vả chút làm theo 1 số phương pháp sau :
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– Giải pháp cuối cùng là mua núm ti giả khi cho con bú thì lắp vào, tuy bé hơi khó khăn chút nhưng cũng có thể giúp bé bú được và cũng có tác dụng kéo đầu ti ra.
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Các bài viết khác
Cho con hỏi năm nay con 15 tuổi, con cao 1m67 nặng 54 kg. Cái bầu của con nó to nhưng không to lắm, mà cái núm vú hình như không có, nó thụt vào trong mất tiêu. Mà con bị từ chỏ tới giờ, mẹ con nói vú đỉa ? Có cáhc nào giúp con có núm vú không, con thấy bất tiện lám khi nói đến vòng một của con. Mong sẽ có câu trả lời cho con để con chữa trị. Trần thành cảm ơn các cô chú !
Cũng có nhiều bạn trẻ, thậm chí là các bà mẹ có con nhỏ cũng gặp phải việc núm vú thụt vào trong. Bạn đang ở trong giai đoạn phát triển. Bạn đã thử cách nào để kéo núm vú ra ngoài chưa? Nếu núm vú của bạn hơi tụt vào trong, hàng ngày bạn có thể thử cách làm sau để kéo núm vú ra ngoài: Bạn mân mê quầng vú và núm vú cho núm vú cứng lên, rồi lấy hai ngón tay cái và trỏ ấn hai bên sát cạnh núm vú, núm vú sẽ dần nổi lên. Dùng tay kia kéo nhẹ núm vú ra ngoài. Luyện tập nhiều lần như vậy, núm vú sẽ không còn thụt vào trong nữa.
Cháu năm nay 16 t mà chàu không thấy núm vú cháu lồi lên gì cả.co lúc nó lên mà chỉ lên có một xíu àk.không biét có sao không bác sĩ
Điều này cũng có thể là do ống tuýen sữa ngắn nên núm vú bị tụt vào trong. Sau này khi có gia đình và có con, khi bé bú sẽ có tác động kéo núm vú ra. Bây giờ bạn ăn uống đầy đủ dinh dưỡng, thể dục chân tay đều đặn, mỗi khi tắm hay lúc nào thuận tiện bạn có thể dùng 2 ngón tay kẹp nhẹ và kéo ra từ từ, xoa bóp nẹh nhàng 2 bên bầu vú.

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UMass Medical School's Center for Health Care Financing has secured a five-year, $3.75 million contract to help Washington state increase federal reimbursements for health services.
**Newswise**
Commentary on the history of psychiatry by Jeffrey Geller, MD, professor of psychiatry.
[Foster's daily Democrat](http://www.google.com/url?sa=X&q=http://www.fosters.com/apps/pbcs.dll/article?AID=/20110829/GJBUSINESS_01/708299987/-1/FOSBUSINESS&ct=ga&cad=CAEQAhgAIAAoATAAOABA3szv8gRIAVgBYgJlbg&cd=davlxxtL-ns&usg=AFQjCNFVxGH8d6S9VUw3YO0YXwteYUwWOQ)News story on co-generation plant control technology being used in the Power Plant expansion. [Reuters ](http://www.reuters.com/article/2011/08/23/us-diet-bad-cholesterol-idUSTRE77M7PM20110823)coverage of scientific study on cholesterol and diet quotes UMMS faculty expert **Yunsheng Ma**, PhD. **Dan Meisels**, director of the UMass Memorial EMS program, talks about the new LifeFlight helicopter that is equipped with the latest technology in emergency medicine.
In an “As I See It” column, Chancellor Michael F. Collins reflects on how technology is affecting how medical schools teach, and how medical students learn.
[Worcester Telegram & Gazette](http://www.telegram.com/article/20110824/NEWS/108249977/1020/OPINION)
Assistant Professor
**Sean Collins**, PhD, talks about his work as senior researcher for the Joint Combat Casualty Research Team in Afghanistan. [U.S. Air Force](http://www.af.mil/news/story.asp?id=123268963)
UMMS alum
**Thomas H. Dohlman**, MD, talks about the work of his grandfather Claes Dohlman, MD, the creator of the Boston Keratoprosthesis, an artificial cornea that’s helped some 3,000 blind people see again. [Boston Herald](http://news.bostonherald.com/news/regional/view/2011_0822specialist_still_focused_on_refining_eye_implant/) **Adel Bozorgzadeh**, MD, professor of surgery and chief of organ transplantation services, talked to columnist Dianne Williamson about the live donor liver transplant program at UMass Memorial Medical Center. The column describes a recent live donor liver transplant performed by Dr. Bozorgzadeh and the transplant team.
Shrewsbury teen Liz Bradley is one of several patients to be featured in a photo gallery in the Diabetes Center of Excellence Hall of Fame.
**David M. Harlan**, MD, the William and Doris Krupp Professor in Medicine and direct of the Center, is quoted in the story. [Daily Shrewsbury](http://www.thedailyshrewsbury.com/Articles-c-2011-08-15-80168.113122-Shrewsbury-teen-featured-at-UMass-in-Diabetes-Hall-of-Honor.html)
Research by
**Robin E. Clark**, PhD, associate professor of family medicine & community health, points to buprenorphine being a less expensive and no less safe form of opioid addiction treatment than methadone. [MedScape](http://www.medscape.com/viewarticle/748340)
A story about the potential local impact of cuts to the federal budget for medical research includes comments from
**John L. Sullivan**, MD, vice provost for research and professor of pediatrics and molecular medicine. [Worcester Telegram and Gazette](http://www.telegram.com/article/20110819/NEWS/108199804/-1/NEWS06)
An op-ed by Lt. Gov. Timothy Murray and Worcester City Manager Michael O’Brien about current economic development projects in Worcester and the need to market the city references the Sherman Center.
A study by
**Robin E. Clark**, PhD, associate professor of family medicine & community health, argues that buprenorphine treatment offers several advantages over other opioid addiction therapies, such as methadone.
Two studies about novel techniques that directly assess “off-target effects” of gene-cutting zinc finger nucleases (ZFNs) includes comments from
**Scot Wolfe**, PhD, associate professor of biochemistry & molecular pharmacology and molecular medicine. [Chemical and Engineering News](http://pubs.acs.org/cen/news/89/i33/8933notw8.html)
UMass Memorial Medical Center was named to U.S. News & World Report’s list of best hospitals
**Christopher Rosenbaum**, MD, assistant professor in emergency medicine, talks to RadioBoston’s hosts about a new type of designer drug containing amphetamines and stimulants which is marketed and sold as bath salts. **Darshak M. Sanghavi**, MD, assistant professor of pediatrics, writes about recent changes that curb the number of consecutive hours residents can work.
A story about improving the system companies and hospitals use to identify early signs of troubled medical devices references UMass Medical School’s $12 million grant from the Agency for Healthcare Research and Quality to establish a national registry to gather data related to knee and hip replacements.
[Modern Health Care](http://www.modernhealthcare.com/article/20110808/MAGAZINE/110809994)
A new study looks at the demand for care at safety-net hospitals and community health centers following health care reform enactment in Massachusetts.
**Bob Seifert**, principal associate at the Center for Health Law and Economics, comments on the study findings, which he said were not unexpected. [WBUR CommonHealth](http://commonhealth.wbur.org/2011/08/safety-net-hospital-demand/)
A study by
**Katherine A. Fitzgerald**, PhD, associate professor of medicine and Douglas T. Golenbock, MD, chief of the Division of Infectious Diseases and Immunology, describes a novel DNA-sensing pathway important to the triggering of an innate immune response for malaria.
An obituary for
** Elliott M. Marcus**, MD, professor emeritus of neurology, includes comments from David Chad, MD, professor of neurology, and former UMMS resident Cynthia Brown, MD.
A feature story about former Worcester School Superintendent John Durkin’s battle with a rare blood condition similar to hemophilia includes comments from the physician who diagnosed the disorder, hematology and oncology fellow
**Bradley Switzer**, MD. [Worcester Telegram and Gazette](http://www.telegram.com/article/20110803/NEWS/108039956/0/FRONTPAGE)
A story about enrolling non-English speaking Hispanics in health insurance includes comments from
** Bob Seifert**, principal associate at the Center for Health Law and Economics, about how local organizations have increased efforts over the last two years to bridge this gap. [Boston Globe](http://www.boston.com/news/local/massachusetts/articles/2011/08/04/more_latinos_insured_in_massachusetts_but_health_coverage_still_lags/)
A story about the safety of barbiturate pentobarbital use in capital punishment cases includes comments from
**Mark Dershwitz**, MD, PhD, professor of anesthesiology and biochemistry & molecular pharmacology.
UMass Medical School graduate
** Stephanie Ruest**, MD, talks about her decision to become a pediatrician. [New Bedford Standard-Times](http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20110726/EDU/107260302/-1/NEWS01)
A story looking at cost disparities between area hospitals references the cost of delivering a baby at UMass Memorial Medical Center.
[Worcester Business Journal](http://www.wbjournal.com/news49493.html)
A feature about long-distance commuters in Worcester County references UMass Medical School and its efforts to promote alternative modes of transportation, including its partnership with MassRides.


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Công ty Cổ phần Vật Giá Việt Nam. Số GCNDT: 011032001615, cấp ngày 21/06/2012, nơi cấp: UBND thành phố Hà Nội
Trụ sở chính: Số 102, phố Thái Thịnh, phường Trung Liệt, quận Đống Đa, Hà Nội - Chi nhánh Hồ Chí Minh: Đường Lữ Gia, Phường 15, Quận 11, Hồ Chí Minh

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Công ty Cổ phần Vật Giá Việt Nam. Số GCNDT: 011032001615, cấp ngày 21/06/2012, nơi cấp: UBND thành phố Hà Nội
Trụ sở chính: Số 102, phố Thái Thịnh, phường Trung Liệt, quận Đống Đa, Hà Nội - Chi nhánh Hồ Chí Minh: Đường Lữ Gia, Phường 15, Quận 11, Hồ Chí Minh
phamphuthu 23/09/2008 - 20:06

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Công ty Cổ phần Vật Giá Việt Nam. Số GCNDT: 011032001615, cấp ngày 21/06/2012, nơi cấp: UBND thành phố Hà Nội
Trụ sở chính: Số 102, phố Thái Thịnh, phường Trung Liệt, quận Đống Đa, Hà Nội - Chi nhánh Hồ Chí Minh: Đường Lữ Gia, Phường 15, Quận 11, Hồ Chí Minh
####
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[ Xem thêm tại mục ](/529/may-photocopy-khong-dung.html) **Máy photocopy(không dùng)** **Máy photocopy(không dùng)**

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Công ty Cổ phần Vật Giá Việt Nam. Số GCNDT: 011032001615, cấp ngày 21/06/2012, nơi cấp: UBND thành phố Hà Nội
Trụ sở chính: Số 102, phố Thái Thịnh, phường Trung Liệt, quận Đống Đa, Hà Nội - Chi nhánh Hồ Chí Minh: Đường Lữ Gia, Phường 15, Quận 11, Hồ Chí Minh
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[ Xem thêm tại mục ](/2858/san-pham-danh-cho-da-lao-hoa.html) **Sản phẩm dành cho da lão hóa** **Sản phẩm dành cho da lão hóa**

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