text:
- TanzaniaFoodFunding via Tujijenge Tanzania Ltd
Karume GroupTanzaniaClothingFunding via Tujijenge Tanzania Ltd
Five Brothe...TanzaniaRetailFunding via Tujijenge Tanzania Ltd
Reebok Group
This is his fourth loan from Tujijenge Tanzania. He used the previous loans all of which has paid in full to open his TV show room business. He earned a profit which he used to buy a sofa set, home TV, fridge and paid for school fees and home food expenses. In the coming years, Hussein would like to be a successfully man managing a company. He will use this new loan to buy a projector for his TV show room to attract more people.
Hussein will share this loan with his loan group" Reebok" which totals ten nine members. The members of the group will hold each other accountable for paying back the loan.
Additional Information
About Tujijenge TanzaniaThis loan is administered by Tujijenge Tanzania, which was founded in 2006. It has operations in Dar es Salaam, the coastal region, and the Lake Victoria region. The organization aims to reach out to micro entrepreneurs and provide them with financial and social intermediation services because capital is one of the major barriers to development and success for micro-enterprise initiatives in Tanzania.
For more information on Tujijenge Tanzania, please visit its partner page, or join its lending team.
This is a Group Loan
In a group loan, each member of the group receives an individual loan but is part of a larger group of individuals. The group is there to provide support to the members and to provide a system of peer pressure, but groups may or may not be formally bound by a group guarantee. In cases where there is a group guarantee, members of the group are responsible for paying back the loans of their fellow group members in the case of delinquency or default.
Kiva's Field Partners typically feature one borrower from a group. The loan description, sector, and other attributes for a group loan profile are determined by the featured borrower's loan. The other members of the group are not required to use their loans for the same purpose.
Loan tags help lenders find loans that match certain areas of interest. You can add up to 5 tags for this loan.
About Tanzania
19View loans »
Success!! The loan was 100% repaid
- Repayment Term
- 8 months (Additional Information)
- Repayment Schedule
- Monthly
- Pre-Disbursed:
- Mar 19, 2014
- Listed
- Mar 31, 2014
- Currency Exchange Loss:
- Possible
- Ended:
- Sep 17, 2014


text:
I once had a friend.
That was made of pretend,
Who's only friend was me.
We played all alone,
Just all on our own.
Down on the hills,
And the trees.
We ran through the woods,
Jumped in the hills,
And played in the dark,
Because we lived for the thrills.
We went on our journeys,
And time would stand still.
The world would change,
Because it bowed to our will.
Then came the days
My friend started to fade.
We no longer spoke,
We just sat in the shade.
And as we sat silent
We looked at the sky .
My friend left for the last time,
Without a goodbye.
I guess the fact is.
They were no longer shy.
I once had a friend,
I thought was made of pretend.
Who supposedly no one could see.
So I sit and I wait,
Pretending their late.
Alone with no guarantee.
Hoping and saying ,
Undoubtedly praying.
The friend,
Of pretend.
Wasn't me.
Beautiful. Simply beautiful
Still moving... no matter how many times I read it... love this...
That is very... thought provoking! Wow! I love it! XD
love it!!!
I love the theme! It reminds me of a story I started writing a year or two ago... Great work
STRAIGHT TO FAVS! So much emotion!!!! Awesome poem!
beautiful very beautiful
great rhythm to this and interesting concept!
I think the idea is brilliant, and I do love the rhythm of it. It makes for such a great little read and the end stanza makes the entire thing
I will admit, I'm not usually into the repetition style you used, but the theme and conclusion of this poem completely turned me around. Well done!
I love your poem! It is made of Awesome!
hey if I was an imaginary friend I would take full advatage of it
I can't decide if the poem or the concept itself is more amazing. Wonderful!
i'm more in favor of the concept.
Amazing poem really well thought out and very clever.
I didn't quite get it until I read your artist's comment. Once I got it, it was really cool.
This is one of the most wonderful things I've ever read. And I've read a lot. Truly beautiful, and touches deep. You, my friend, are gifted.
Broke my heart..Wonderful writing, you pass the feelings exactly as you wish to.
Proud to be your watcher
Proud to be your watcher
This is a beautiful poem. I'm crying!

subset: commoncrawl


text:
There are healthy cannabis-infused treats, for those who want them. And then there are delicious gobs of ganja goodness like the Coco Crispy Treats from Nikki's Canna Kitchen.
I practically got arm strain, I got my wallet out so fast.
While attending Sonshine Organics' Washington Farmers Market 4/20 event in Olympia (by the way, a great social event for patients; kudos to organizer Sarena Haskins), I spotted the Coco Crispy Treats on Nikki's vendor table.
Being a follower of sugar, butter and ganja, I was naturally unable to resist trying one of the little free sample bites Nikki had wisely placed on the table. One bite and I was a goner; this stuff tastes delicious, and how could it not?
I practically got arm strain, I got my wallet out so fast. (Five bucks and worth it.)
Unless you're particularly sensitive to the effects of marijuana, you can go ahead and consume the entire Coco Crispy Treat at one sitting. Potency-wise, these treats fall about midway on the continuum between "underpowered" and "knock you on your ass;" in other words, most people are going to get medicated when they eat one.
You can find Nikki's Canna Kitchen's table at Washington Farmers Market, where they're planning another social event -- a Mexican Fiesta -- for Cinco de Mayo. Check 'em out from 10:30 a.m. to 5:30 p.m., Saturday, May 5, at 3211-A Yelm Highway, Olympia.
You'll need your medical marijuana authorization and your Washington ID for admittance. Tell 'em Incredible Medibles sent you!


text:
Oklahoma students learn about careers in health care
Whitney Harris stood at a table with friends, holding a blood-red animal lung in her gloved hands.
The John Marshall High School senior listened to a respiratory therapist explain how the heart and lungs work.
Harris looked less grossed-out than her friends, a good thing since she is interested in possibly pursuing a career in health care.
"It interests me how the body works and how everything goes along with the body and how it functions and what types of technologies are used to care for certain things in the body," Harris said.
Harris was one of about 600 students from the Oklahoma City metro area who attended a high school health care career fair Friday at Mercy Hospital Oklahoma City.
For most of the afternoon, students mingled around the room, looking at several booths, including an animal heart and lungs at an exhibit about respiratory care, a model of the stomach and digestive tract and a booth about nutrition scattered with fruits and vegetables.
Teresa Featherly, one of the fair's organizers, said events like this help introduce students to fields of medicine and give them a behind-the-scenes look at health care.
"Sometimes it's a very sterile environment, sometimes it's a scary environment, but there's a very human aspect to it, and I think this gives them a different comfort level," said Featherly, a nurse recruiter at Mercy.
When most people think of jobs in health care, they think of doctors or nurses, she said.
However, there are several opportunities in health care, and presently, the state faces a shortage in some of those job categories, she said.
Oklahoma faces not only a shortage of primary care doctors but also has a lack of occupational therapists and physical therapists, said Jim Durbin, executive director of the Oklahoma Health Care Workforce Center.
One of the issues Oklahoma faces is that colleges that train these types of medical professionals don't have enough space or resources to meet the demand, he said.
And there currently isn't any movement to do anything about it, he said.
"They've been cutting their budgets, not adding to them, because of the state budget issues as well, and so we're trying to keep people aware that these problems exist, but until there's some more resources at the state level to expand that education pipeline, there isn't a whole lot that is going to be done," he said.
Durbin said students should consider getting a bachelor's degree instead of an associate degree if they can.
More and more hospitals are looking for people with bachelor's degree level training, he said.
"With the Affordable Care Act expanding access to care to tens of thousands more Oklahomans and with the baby boomer group aging, we know that the demand for nurses is going to increase," he said. "We're just not there yet for a variety of reasons."
Sometimes it's a very sterile environment, sometimes it's a scary environment, but there's a very human aspect to it, and I think this gives them a different comfort level."
Teresa Featherly,
nurse recruiter at Mercy Hospital


text:
Tartini: Violin Concertos (8) / Giuliano Fontanella, Enrico Casazza, Paolo Ciociola, violins; Interpreti Veneziani
2 CD / Newton Classics / 2012-09-25Works: Giuseppe Tartini: Concerto for Violin in A minor, D. 113; Concerto for Violin in A minor, D. 115; Concerto for Violin in G major, D. 80; Concerto in A, D96; Concerto for Violin in D minor, D. 45; Con...
Performers: Casazza, Enrico; Ciociola, Paolo; Fontanella, Giuliano; Rossi, Cristiano; Vianello, Sebastiano Maria
Ensemble: Interpreti Veneziani
Tartini, (b.1692) is regarded as one of the most important composers of his generation. The Italian wrote over 130 concertos, six of which form the...continue...
Recording information: Scuola Grande di S. Giovanni Evangelista, Venice, Italy....continue...
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Tartini: The Violin Concertos, Vol. 13
2 CD / Dynamic / 2007-09-25Works: Giuseppe Tartini: Concerto for Violin in G major, D. 84; Concerto for Violin in A major, D. 105; Concerto for Violin in E major, D. 50; Concerto for Violin in A major, D. 101; Concerto for Violin in ...
Performers: Guglielmo, Federico; Guglielmo, Giovanni; Lazari, Carlo
Ensemble: L'Arte dell'Arco
The ensemble L'Arte dell'Arco continue in their patient rediscovery of Tartini's Violin Concertos. The eight concertos on our two CDs can all be assigned, according...continue...
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text:
magg0214's Mom Answers Activity
I'm fantasizing about another man. Is this normal?
Most recent answer (04/12/2015):
This is no longer a friendship , this is a distraction from your new baby and the affection for your husband . Avoid avoid avoid !!!!posted by Lavictor25
How can I handle my fears that I won't love my children equally?
Most recent answer (08/04/2014):
I'm the same way! I'm so close to my daughter. I don't see how I can have another bond as strong... I'm pregnant with my ...posted by MarysasMom
Most recent answer (09/03/2010):
i was due for a period yesterday. and my breast isnt tender to the point i cant touch them . but when i enter somewhere cold . or the fa...posted by almorion


text: DBHPS Chennai Results of Trichy Jan 2016-2017 is on dbhpsabha.org. Dakshina Bharat Hindi Prachar Sabha (DBHPS), Chennai has published notification for your Result of Entrance Examination held upon Janaury month. As every the notification, DBHPS took the prepared test for Hindi throughout Chennai and Trichy Centers in month of Jan for just a day for few a huge number of students.


text:
=The Daemonic Legion Army list=__________________
(Reference:Storm of Chaos)
-A couple of quick questions-
-Has anyone seen it at any tournaments?
-is there any reason why I can't play it?
It can looks like this...
Daemonic Legion:
-Army wide +1 Ld and true ward saves
Be'Lakor 650-ish points Daemon Prince
1Lord and 1Hero slots
Special Rules:,Chaos undivided,Whispers in the Darkness,Night Wards,Eternal Terror,Shadow-shroud,Insurmountable Rage,Daemonic,Large-target,Fly.
Master of the Shadows
Level 4 wizard,Spells:Bolt of Dark-light,Nightmare,Curse of the Dark Master,Fog of Death,Coils of the Serpent.
10-30 Chaos Furies (0-1 Unit choice for as many undivided characters)
1 Bloodthirster
15 Bloodletters,Unholy Icon(+1ward save),Banner of the Gods(Hatred) (True core unit)
15 Plague Bearers,standard (True core unit)
1 Daemon Chariot of Nurgle,one additional plague beast,poisoned attacks.(Rare unit)
15 Daemonettes (True core units)
5 Mounted Daemonettes (fast cav)poisoned attacks
15 Horrors of Tzeench,Daemonic Herald of Tzeench(Lvl,2?),Standard,it had a bound spell lightning attack,Blasted Standard? Very Magically Shooty unit,3x shooting,unit,herald,banner
5 Screamers of Tzeench
I can't remember what it came to but probably 3000-3500,pts
I still own this and its sitting in storage,its awesome at refused flank(4x flying units) and flank-marching,high in magic offence/defence, good close combat,generally fast,Week Armour and vulnerable to shooting but alleviated by Shadow-Shroud -1 Bs when shooting at this army.
Be'Lakor,The Dark Master
Warriors of Chaos Army Lists
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text:
Dr DRE by maddrawingsWatch
©2007-2016 maddrawings
made on coloured paper.
ink, charcoal, and acrylic.
ink, charcoal, and acrylic.
very nice
he looks like a cheese
Wow. Nice Job.
I like the expression on DRE's face it is very real. GREAT ART
AWSOME, great pic, luv it. Dr. Dre makes legends, he made Snoop dogg, 2pac(a lil), Eminem, 50 cent, ect.. Dre is the stuff legends are made of. Dre is the legend of legends. He one of the greatest rapperz EVA!!!
This is tight.
He still got this rap like a mummy!
That is tha bomb man! One of the best Dr DRE potraits I've seen! It's also one of the best mixed media pieces on DA! Respect! Keep up the good work!
its motherfucking dre day bitches.
I like the touch of bling...
love it!
im not a big fan of his, but that is amazing piece of work


text:
Number: 0493
Kidney Transplantation
Aetna considers kidney transplantation medically necessary when all of the following criteria below are met:
Absence of symptomatic HIV infection, as defined by all of the following:
** Note: Given waiting periods for cadaveric donors averaging 1 to 4 years, kidney transplantation is considered medically necessary for persons with severe chronic renal failure with anticipated progression to end stage renal disease. Severe chronic renal failure is defined as a creatinine clearance of less than 30 ml/min.
Kidney transplant is not considered medically necessary for persons who do not meet the transplanting institution's protocol selection criteria, or in the absence of a protocol, for persons who have any of the following (not an all-inclusive list):
Combined Kidney/Pancreas Transplantation
For persons undergoing kidney transplantation due to diabetic nephropathy, a combined kidney/pancreas transplantation may be considered medically necessary under some circumstances (see CPB 0587 - Pancreas Kidney Transplantation). Other multi-organ transplants (e.g., kidney/heart, liver/kidney) should be referred to Aetna's National Medical Excellence Program for review.
Renal Autotransplantation and Ex-Vivo Bench Surgery
Aetna considers autotransplantation and ex-vivo repair medically necessary where repair of the kidney, renal artery or its branches are not amenable to in-situ reconstruction.
Gene Microarrays for Diagnosis of Rejection
Aetna considers the use of gene microarrays in diagnosis of rejection of kidney transplantation experimental and investigational because of insufficient evidence of their effectiveness.
Evaluation of Urine Immunocytology
Aetna considers evaluation of urine immunocytology for T cells experimental and investigational for the diagnosis of acute kidney rejection because of insufficient evidence of its effectiveness.
Belatacept (Nulojix)
Aetna considers the use of belatacept (Nulojix) medically necessary for the prevention of acute rejection in kidney transplant recipients who are sero-positive for the Epstein Barr virus (EBV).
Aetna considers belatacept experimental and investigational for the prophylaxis of organ rejection in other transplanted organs because its effectiveness for the prevention of acute rejection in organ transplant other than kidney has not been established.
Aetna considers measurement of pre-transplantation soluble CD30 level as a predictor of acute rejection in kidney transplantation experimental and investigational because its clinical value has not been established.
Aetna considers measurement of cytokines (e.g., cytokine-14, interleukin-1 beta (IL-1β), IL-2, IL-4, IL-6, granulocyte-macrophage colony-stimulating factor (GM-CSF), monocyte chemoattractant protein-1 (MCP-1), and tumor necrosis factor-alpha (TNF-α); not an all-inclusive list) for the diagnosis of acute renal allograft rejection experimental and investigational because the effectiveness of this approach has not been established.
Aetna considers equine anti-thymocyte immune globulin (Atgam) medically necessary for the following indications: 1) prophylaxis or management of allograft rejection episodes in renal transplantation; and 2) moderate to severe aplastic anemia. Equine antithymocyte immune globulin is considered experimental and investigational for all other indications.
Aetna considers human leukocyte antigen-G-14-base-pair-insertion/deletion polymorphism for evaluating the risk of developing kidney graft rejection experimental and investigational because the effectiveness of this approach has not been established.
Chronic renal failure (CRF) occurs in approximately 2 out of 10,000 people. It results in the accumulation of fluid and waste products in the body, causing azotemia and uremia. Azotemia is the build-up of nitrogen waste products in the blood. It may occur without symptoms. Uremia is the state of ill health resulting from renal failure since most body systems are affected by CRF. Treatment of the underlying disorders may help prevent or delay development of CRF.
Chronic renal failure is slowly progressive over a number of years and most often results from any disease that causes gradual destruction of the internal structures of the kidneys. It can range from mild dysfunction to severe kidney failure, termed end stage renal disease (ESRD). In the early stages, there may be no symptoms. In fact, progression may be so gradual that symptoms do not occur until kidney function is less than 1/10 of normal. Because of the reversible nature of acute renal failure, all patients with this diagnosis should be supported with dialysis, at least for some period of time, to allow return of renal function.
The 3 diseases most commonly leading to CRF and treated by kidney transplantation are (i) type 1 diabetes mellitus, (ii) glomerulonephritis, and (iii) hypertensive nephrosclerosis, accounting for about 75 % of the total candidate population. Numerous subsets of patients in several study populations have shown that patients have a better survival if they receive a renal transplant than if they remain on dialysis therapy.
Patients with ESRD have 3 options for renal replacement therapy: (i) hemodialysis; (ii) chronic ambulatory peritoneal dialysis; or (iii) transplantation. The choice should be based on the relative risks and benefits. With the increasing appreciation that transplantation results are superior to those of chronic dialysis, the indications for transplantation have been broadened. Improvements in peri-operative care and immunosuppression have allowed many patients who would previously have been denied transplantation consideration as acceptable candidates. The best recipients for transplantation are young individuals whose renal failure is not due to a systemic disease that will damage the transplanted kidney or cause death from extra-renal causes.
The time a patient has spent on dialysis is an independent predictor of a poorer outcome from renal transplantation. Pre-emptive renal transplantation generally leads to better outcomes than transplantation after dialysis is initiated, and should be pursued in most cases for live donor transplants. The current shortage of cadaveric kidneys makes it unlikely that pre-emptive transplants will be a practical option for recipients of cadaveric kidney transplants.
No specific cause of intrinsic and irreversible renal failure is considered a contraindication to kidney transplantation. Nonetheless, all patients still should have reversible causes of renal dysfunction excluded before considering renal replacement therapy e.g., obstructive nephropathy has to be removed, chronic pyelonephritis secondary to recurrent infection has to be adequately treated, and reflux has to be fixed.
The evaluation of all transplant candidates, in addition to a standard medical work-up, should include cytomegalovirus (CMV) antibody titer; creatinine clearance; serology for syphilis, and hepatitis B (HBV) and C (HCV) viruses; evaluation of parathyroid status; coagulation profile; Pap smear; ABO and histocompatibility typing; urologic evaluation (including a voiding cystourethrogram in selected patients to assess outlet obstruction and reflux); gastro-intestinal evaluation (as warranted by history of ulcer, diverticulitis, or other symptoms); and psychosocial evaluation.
Patients with renal failure induced by diabetes (Kimmelstiel-Wilson disease) make up the greatest population of patients currently referred for transplantation. Actually, this has become the treatment of choice because persons with diabetes clearly do better with transplantation than with dialysis. In fact, both graft and patient survival for 1 to 2 years are reported to be as good in persons with diabetes as in other patients, whereas on chronic dialysis, less than 20 % of persons with diabetes survive 5 years. If diabetic patients can undergo transplantation before extensive damage occurs in other organs, such as the eye and heart, rehabilitation will be more satisfactory. Even patients with diseases in which the transplanted kidney may eventually be damaged by recurrent disease (e.g., lupus erythematosus, cystinosis, and amyloidosis) are often better palliated by transplantation than by dialysis. Indeed, the current results of transplantation mandate serious consideration of this therapy in virtually any patient with terminal renal disease. Not only is the quality of life far better with transplantation than with dialysis, but because the mortality of patients in the first year after transplantation is now less than 5 %, survival is also superior.
Careful attention must be given to eradication of all infections including those of the urinary tract, lungs, teeth, and skin. Since cardiovascular complications are as common as infection as a cause of post-transplantation mortality, the patient's cardiovascular status should be carefully evaluated and optimized. In older patients and diabetic patients, this might require stress testing, cardiac catheterization, or even pre-transplant coronary artery bypass. Age is never an absolute contraindication for kidney transplantation. Although infants have had successful transplantations, most centers maintain infants on dialysis until body size is increased to 10 to 20 kg. Older patients are becoming more numerous in transplant clinics. Older age (greater than 65 years) never precludes transplantation, but it increases the risk of complications. Transplant centers usually encourage older patients who have multiple medical problems (rather than isolated kidney failure) to remain on dialysis. On both ends of the age spectrum, however, transplantation is becoming more common. Malignancy is considered a contraindication for kidney transplantation, as is severe atherosclerotic or pulmonary disease. Patients with active liver disease are also usually excluded. Both hepatitis B and C can result in eventual liver failure in some patients after transplantation.
The proper timing of transplantation is a delicate decision because the progression of renal dysfunction is variable and premature imposition of the risks of transplantation is not justified. However, dialysis or transplantation should not be withheld until advanced uremic symptoms, such as pericarditis, cardiac failure, severe anemia, osteodystrophy and neuropathy, ensure because these complications may become irreversible.
There are 3 sources of donor kidneys for kidney transplantation: (i) living related donors; (ii) cadaver donors; and (iii) living unrelated donors. A donor left kidney is usually transplanted to the right iliac fossa, with the renal artery anastomosed end-to-end to the hypogastric artery, and the renal vein end-to-end to the common iliac vein. The ureter is implanted into the bladder and under special conditions a uretero-ureteral anastomosis or uretero-pyelostomy may be performed. Autotransplantation has developed as an outgrowth of the technique used in renal transplantation. The simultaneous development of an apparatus that could preserve kidneys extracorporeally for long periods of time and of preservation solutions led to extracorporeal renal repair (work-bench surgery) and subsequent autotransplantation for conditions mentioned above.
On rare occasions, kidneys with lesions of the renal artery or its branches are not amenable to in-situ reconstruction. In these circumstances, temporary removal of the kidney, ex-vivo preservation, microvascular repair (work-bench surgery), and autotransplantation may permit salvage.
Some examples of clinical conditions where the renal artery or its branches are not amenable to in-situ reconstruction such that a person might benefit from autotransplantation and/or ex-vivo repair include but are not limited to:
Patients with chronic kidney disease have significant abnormalities of bone remodeling and mineral homeostasis and are at increased risk of fracture. The fracture risk for kidney transplant recipients is 4 times that of the general population and higher than for patients on dialysis. Ebeling (2007) noted that organ transplant candidates should be assessed and pre-transplantation bone disease should be treated. Preventive therapy initiated in the immediate post-transplantation period is indicated in patients with osteopenia or osteoporosis, as further bone loss will occur in the first several months following transplantation. Long-term organ transplant recipients should also have bone mass measurement and treatment of osteoporosis. Bisphosphonates are the most promising approach for the management of transplantation osteoporosis. Active vitamin D metabolites may have additional benefits in reducing hyper-parathyroidism, particularly after kidney transplantation. The author stated that large, multi-center treatment trials with oral or parenteral bisphosphonates and calcitriol are recommended.
In a Cochrane review, Palmer et al (2007) assessed the use of interventions for treating bone disease following kidney transplantation. Randomized controlled trials (RCTs) and quasi-RCTs comparing different treatments for kidney transplant recipients of any age were selected. All other transplant recipients, including kidney-pancreas transplant recipients were excluded. Two authors independently evaluated trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) with 95 % confidence intervals (CI) for dichotomous variables and mean difference (MD) for continuous outcomes. A total of 24 trials (n = 1,299) were included. No individual intervention (bisphosphonates, vitamin D sterol or calcitonin) was associated with a reduction in fracture risk compared with placebo. Combining results for all active interventions against placebo demonstrated any treatment of bone disease was associated with a reduction in the RR of fracture (RR 0.51, 95 % CI: 0.27 to 0.99). Bisphosphonates (any route), vitamin D sterol, and calcitonin all had a beneficial effect on the bone mineral density (BMD) at the lumbar spine. Bisphosphonates and vitamin D sterol also had a beneficial effect on the BMD at the femoral neck. Bisphosphonates were more effective in preventing BMD loss when compared head-to-head with vitamin D sterols. Few or no data were available for combined hormone replacement, testosterone, selective estrogen receptor modulators, fluoride or anabolic steroids. Other outcomes including all-cause mortality and drug-related toxicity were reported infrequently. The authors concluded that treatment with bisphosphonates, vitamin D sterol or calcitonin after kidney transplantation may protect against immunosuppression-induced reductions in BMD and prevent fracture. However, they state that adequately powered clinical studies are needed to ascertain if bisphosphonates are better than vitamin D sterols for fracture prevention in this population. Moreover, the optimal route, timing, and duration of administration of these interventions remains unknown.
Acute rejection is an immune process that begins with the recognition of the allograft as non-self and ends in graft destruction. Histological features of the allograft biopsy are currently used for the differential diagnosis of allograft dysfunction. In view of the safety and the opportunity for repetitive sampling, development of non-invasive biomarkers of allograft status is an important objective in transplantation. Khatri and Sarwal (2009) stated that in the past 10 years, microarray technology has revolutionized biological research by allowing the screening of tens of thousands of genes simultaneously. These investigators reviewed recent studies in organ transplantation using microarrays and highlighted the issues that should be addressed in order to use microarrays in the diagnosis of rejection. Microarrays have been useful in identifying potential biomarkers for chronic rejection in peripheral blood mononuclear cells, novel pathways for induction of tolerance, and genes involved in protecting the graft from the host immune system. Microarray analysis of peripheral blood mononuclear cells from chronic antibody-mediated rejection has identified potential non-invasive biomarkers. In a recent study, correlation of pathogenesis-based transcripts with histopathological lesions is a promising step towards inclusion of microarrays in clinics for organ transplants. The authors concluded that despite promising results in diagnosis of histopathological lesions using microarrays, the low dynamic range of microarrays and large measured expression changes within the probes for the same gene continue to cast doubts on their readiness for diagnosis of rejection. They stated that more studies are needed to resolve these issues. Dominating expression of globin genes in whole blood poses another challenge for identification of non-invasive biomarkers. In addition, studies are also needed to demonstrate effects of different immunosuppression therapies and their outcomes.
Hartono et al (2010) noted that urinary cell and peripheral blood cell mRNA profiles have been associated with acute rejection of human renal allografts. Emerging data support the idea that development of non-invasive biomarkers predictive of antibody-mediated rejection is feasible. The demonstration that intra-graft microRNA expression predicts renal allograft status suggests that non-invasively ascertained microRNA profiles may be of value. These researchers stated that they are pleased with the progress to date, and anticipate clinical trials investigating the hypotheses that non-invasively ascertained mRNA profiles will minimize the need for invasive biopsy procedures, predict the development of acute rejection and chronic allograft nephropathy, facilitate preemptive therapy capable of preserving graft function, and facilitate personalization of immunosuppressive therapy for the allograft recipient.
Mihovilovic and colleagues (2010) evaluated urine immunocytology for T cells as a method for non-invasive identification of patients with acute renal allograft rejection in comparison to renal biopsy. In this prospective study, a cohort of 56 kidney, or kidney-pancreas transplant recipients was included. Patients either received their transplant at the University Hospital "Merkur", or have been followed at the "Merkur" Hospital. Patients were subject to either protocol or indication kidney biopsy (a total of 70 biopsies), with simultaneous urine immunocytology (determination of CD3-positive cells in the urine sediment). Acute rejection was diagnosed in 24 biopsies; 23 episodes were T-cell mediated (6 grade IA, 5 grade IB, 1 grade IIA, 1 grade III and 10 borderline), while in 1 case acute humoral rejection was diagnosed. A total of 46 biopsies did not demonstrate acute rejection. CD3-positive cells were found in 21 % of cases with acute rejection and in 13 % of cases without rejection (non-significant). A finding of CD3-positive cells in urine had a sensitivity of 21 % and specificity of 87 % for acute rejection (including borderline), with positive predictive value of 45 % and negative predictive value of 68 %. The authors concluded that although tubulitis is a hallmark of acute T cell-mediated rejection, detection of T cells in urine sediment was insufficiently sensitive and insufficiently specific for diagnosing acute rejection in this cohort of kidney transplant recipients.
Belatacept, a selective T-cell co-stimulation blocker, is a cytotoxic T-lymphocyte-associated antigen 4-immunoglobulin. It is designed to block CD28, a critical activating receptor on T cells, by binding and saturating its ligands B7-1 and B7-2. In phase II and III clinical trials, belatacept was compared with cyclosporine (in combination with basiliximab, mycophenolate mofetil, and steroids). Advantages observed with belatacept include superior graft function, preservation of renal structure and improved cardiovascular risk profile. Concerns associated with belatacept are a higher frequency of cellular rejection episodes and more post-transplant lymphoproliferative disorder (PTLD) cases especially in Epstein-Barr virus (EBV) sero-negative patients, who should be excluded from belatacept-based regimens (Wekerle and Grinyo, 2012).
On June 15, 2011, the Food and Drug Administration approved belatacept (Nulojix) for the prevention of acute rejection in adult kidney transplant recipient. Nulojix is approved for use with other immunosuppressants, specifically basiliximab, corticosteroids, and mycophenolate mofetil. The approval of Nulojix was base on 2 open-label, randomized, multi-center, controlled phase III clinical trials that enrolled more than 1,200 patients and compared 2 dose regimens of Nulojix with another immunosuppressant, cyclosporine. These trials demonstrated that the recommended Nulojix regimen is safe and effective for the prevention of acute organ rejection.
Nulojix carries a Boxed Warning for an increased risk of developing PTLD. The risk of PTLD is higher for transplant patients who have never been exposed to EBV. Transplant patients who have not been exposed to EBV have more difficulty mounting an effective immune response to the virus if they get infected after transplant; typically they get exposed to the virus at time of transplant, as it is carried in around 80 % of donated organs. Patients should be tested for EBV and should only receive Nulojix if the test shows they have already been exposed to EBV. Another Boxed Warning on the Nulojix label, as well as labels of other immunosuppressants, warns of an increased risk of serious infections and other cancers. Common adverse reactions observed in transplant patients in the trials included anemia, constipation, kidney or bladder infection, and swollen legs, ankles, or feet. Any transplant patients, including those receiving Nulojix, should limit the amount of time spent in sunlight because of the risk of skin cancer and should not get live vaccines because of the risk of infection.
Chen and colleagues (2012) stated that the question of whether high pre-transplantation soluble CD30 (sCD30) level can be a predictor of kidney transplant acute rejection (AR) is under debate. These investigators performed a meta-analysis on the predictive efficacy of sCD30 for AR in renal transplantation. PubMed (1966 to 2012), EMBASE (1988 to 2012), and Web of Science (1986 to 2012) databases were searched for studies concerning the predictive efficacy of sCD30 for AR after kidney transplantation. After a careful review of eligible studies, sensitivity, specificity, and other measures of the accuracy of sCD30 were pooled. A summary receiver operating characteristic curve was used to represent the overall test performance. A total of 12 studies enrolling 2,507 patients met the inclusion criteria. The pooled estimates for pre-transplantation sCD30 in prediction of allograft rejection risk were poor, with a sensitivity of 0.70 (95 % CI: 0.66 to 0.74), a specificity of 0.48 (95 % CI: 0.46 to 0.50), a positive likelihood ratio of 1.35 (95 % CI: 1.20 to 1.53), a negative likelihood ratio of 0.68 (95 % CI: 0.55 to 0.84), and a diagnostic odds ratio of 2.07 (95 % CI: 1.54 to 2.80). The area under curve of the summary receiver operating characteristic curve was 0.60, indicating poor overall accuracy of the serum sCD30 level in the prediction of patients at risk for AR. The authors concluded that the results of the meta-analysis showed that the accuracy of pre-transplantation sCD30 for predicting post-transplantation AR was poor. They stated that prospective studies are needed to clarify the usefulness of this test for identifying risks of AR in transplant recipients.
Lv and colleagues (2012) noted that results from published studies on the association of donor or recipient IL-6 -174G/C (rs1800795) polymorphism with AR of renal allograft are conflicting. These investigators performed a meta-analysis to estimate the possible association. Studies were identified by searching PUBMED and EMBASE until July 1, 2011. Meta-analysis was performed in a fixed/random effects model using Revman 5.0.25 and STATA10.0. A total of 7 studies addressing the association between donor high producer genotype (G/G and G/C) of IL-6 -174G/C polymorphism and AR of renal allograft were identified. Pooled odds ratio (OR) based on 341 cases (whose recipient developed AR) and 702 controls (whose recipient did not develop AR) was 0.59 (95 % CI: 0.26 to 1.33; p = 0.20), with a strong between-study heterogeneity. No association was observed in the subgroup analysis based on ethnicity. A total of 13 studies evaluating the association between recipient IL-6 -174G/C polymorphism and AR were identified. Pooled OR based on 451 cases (patients did not develop AR) and 848 controls was 1.00 (95 % CI: 0.72 to 1.37; p = 0.98), with a weak between-study heterogeneity. The authors concluded that donor high producer genotype (G/G and G/C) of IL-6 -174G/C polymorphism had a tendency of decreased risk for AR, although it was not statistically significant. Recipient high producer genotype was not associated with AR of renal allograft. Moreover, they stated that additional well-designed studies with larger sample size are needed to support these findings, especially for the association between donor high producer genotype (G/G and G/C) of IL-6 -174G/C polymorphism and acute renal allograft rejection.
In an observational cross-sectional study, De Serres et al (2012) determined the utility of a non-invasive cytokine assay in screening of AR. A total of 64 patients from 2 centers were recruited upon admission for allograft biopsy to investigate acute graft dysfunction. Blood was collected before biopsy and assayed for a panel of 21 cytokines secreted by peripheral blood mononucleated cells (PBMCs). Patients were classified as acute rejectors or non-rejectors according to a classification rule derived from an initial set of 32 patients (training cohort) and subsequently validated in the remaining patients (validation cohort). Although 6 cytokines (interleukin-1 beta [IL-1β], IL-6, tumor necrosis factor-alpha [TNF-α], IL-4, granulocyte-macrophage colony-stimulating factor [GM-CSF], and monocyte chemoattractant protein-1 [MCP-1]) distinguished acute rejectors in the training cohort, logistic regression modeling identified a single cytokine, IL-6, as the best predictor. In the validation cohort, IL-6 was consistently the most accurate cytokine (area under the receiver-operating characteristic curve, 0.85; p = 0.006), whereas the application of a pre-specified cut-off level, as determined from the training cohort, resulted in a sensitivity and specificity of 92 % and 63 %, respectively. Secondary analyses revealed a strong association between IL-6 levels and AR after multi-variate adjustment for clinical characteristics (p < 0.001). The authors concluded that in this pilot study, the measurement of a single cytokine can exclude AR with a sensitivity of 92 % in renal transplant recipients presenting with acute graft dysfunction. Moreover, they stated that prospective studies are needed to determine the utility of this simple assay, particularly for low-risk or remote patients.
Wu and associates (2013) stated that cytokines have been implicated in the AR of solid organ transplantation. Many studies have investigated the association between recipient or donor IL-4 polymorphism and AR, with different studies reporting inconclusive results. These investigators searched PUBMED and EMBASE until June 2012 to identify eligible studies investigating the association between IL-4 polymorphism with AR after solid organ transplantation. Statistical analysis was performed using STATA10.0. A total of 12 studies were included. Pooled ORs suggested (i) no significant association was detected between recipient or donor IL-4 -590C/T polymorphism and acute rejection of solid allograft; (ii) no significant association was detected between recipient IL-4 -33C/T polymorphism and AR of solid allograft; (iii) when stratified by transplantation type, IL-4 -590C/T polymorphism was associated with AR of liver transplantation (T/T+C/T versus C/C: OR = 0.36, 95 % CI: 0.14 to 0.90); and (iv) significantly decreased risk of AR was detected in recipient IL-4 -590*T-negative/donor T-positive genotype pairs than all other recipient-donor IL-4 -590T/C pairs (OR = 0.14, 95 % CI: 0.03 to 0.66). The authors concluded that the findings of this meta-analysis suggested that recipient IL-4 -590C/T polymorphism was associated with AR of liver transplantation, but nor renal or heart transplantation. It was also suggested that combined recipient IL-4 -590*T-negative/donor T-positive genotype may suffer decreased risk of AR of solid allograft. Moreover, they stated that further well-designed studies with larger sample size were needed to verify these findings, with focus on the association of IL-4 polymorphism with AR in patients with liver transplantation and studies investigating combined recipient-donor genotype.
An UpToDate review on "Clinical manifestations and diagnosis of acute renal allograft rejection" (Chon and Brenna, 2014a) does not mention measurement of cytokines as a management tool.
Furthermore, an UpToDate review on "Investigational methods in the diagnosis of acute renal allograft rejection" (Chon and Brenna, 2014b) states that "The introduction of potent immunosuppressive drugs in the past three decades has led to a dramatic reduction in the incidence of acute rejection in kidney transplant recipients. At the present time, renal allograft biopsy with conventional histologic evaluation remains the gold standard for diagnosing acute rejection among patients with a deterioration in kidney function as detected by measuring serum creatinine levels. However, the lack of additional markers of rejection makes it difficult to optimize anti-rejection therapy for transplant recipients. The evaluation of methods other than conventional renal biopsy and/or measurement of the serum creatinine to help diagnosis acute kidney rejection has been the focus of a large number of investigators. This topic review will discuss some of the methods undergoing investigation for the diagnosis of acute rejection …. Measuring the levels of urinary or circulating proteins and cytokines, circulating soluble interleukin-2 (IL-2) receptor, the urinary concentration of soluble adhesion molecules, or cellular activation with urinary flow cytometry may be helpful in diagnosing acute allograft rejection …. Interleukin-6 (IL-6) may be a potential biomarker for acute rejection. In an observational study of 32 patients who presented with acute graft dysfunction, of six tested cytokines (including IL-1beta, IL-6, TNF-alpha, IL-4, GM-CSF, and MCP-1), IL-6 best predicted acute rejection. Among a validation cohort of 32 additional patients, using a prespecified IL-6 cutoff level of 85 pg/ml, IL-6 assay had a sensitivity of 92 and specificity of 63 percent for the diagnosis of acute rejection. These results need to be confirmed in a larger prospective trial".
Kim et al (2014) stated that antibody-mediated rejection (AMR), also known as B-cell-mediated or humoral rejection, is a significant complication after kidney transplantation that carries a poor prognosis. Although fewer than 10 % of kidney transplant patients experience AMR, as many as 30 % of these patients experience graft loss as a consequence. Although AMR is mediated by antibodies against an allograft and results in histologic changes in allograft vasculature that differ from cellular rejection, it has not been recognized as a separate disease process until recently. With an improved understanding about the importance of the development of antibodies against allografts as well as complement activation, significant advances have occurred in the treatment of AMR. The standard of care for AMR includes plasmapheresis and intravenous immunoglobulin that remove and neutralize antibodies, respectively. Agents targeting B cells (rituximab and alemtuzumab), plasma cells (bortezomib), and the complement system (eculizumab) have also been used successfully to treat AMR in kidney transplant recipients. However, the high cost of these medications, their use for unlabeled indications, and a lack of prospective studies evaluating their safety and effectiveness limit the routine use of these agents in the treatment of AMR in kidney transplant recipients.
Gupta et al (2014) stated that although several strategies for treating early AMR in kidney transplants have been investigated, evidence on treatment of late AMR manifesting after 6 months is sparse. In this single-center series, these researchers presented data on 23 consecutive patients treated for late AMR. Late AMR was diagnosed using Banff 2007 criteria along with presence of donor-specific antibodies (DSA) and acute rise in serum creatinine (SCr). Response to therapy was assessed by improvement in SCr, histologic improvement, and decline in DSA strength. Overall, 17 % (4/23) had documented non-adherence while 69 % (16/23) had physician-recommended reduction in immunosuppression before AMR. Eighteen patients (78 %) were treated with plasmapheresis or low-dose IVIG + rituximab; 11 (49 %) with refractory AMR also received 1 to 3 cycles of bortezomib. While there was an improvement (p = 0.02) in mean SCr (2.4 mg/dL) at the end of therapy compared with SCr at the time of diagnosis (2.9 mg/dL), this improvement was not sustained at most recent follow-up. Eleven (48 %) patients had no histologic resolution on follow-up biopsy. Lack of histologic response was associated with older patients (OR = 3.17; p = 0.04), presence of cytotoxic DSA at time of diagnosis (OR = 200; p = 0.04), and severe chronic vasculopathy (cv greater than or equal to 2) on index biopsy (OR = 50; p = 0.06). The authors concluded that a major setting in which late AMR occurred in this cohort was reduction or change in immunosuppression. They stated that these data demonstrated an inadequate response of late AMR to current and novel (bortezomib) therapies. They stated that the benefits of therapy need to be counter-weighed with potential adverse effects especially in older patients, large antibody loads, and chronic allograft vasculopathy.
Eskandary et al (2014) noted that despite major advances in transplant medicine, improvements in long-term kidney allograft survival have not been commensurate with those observed shortly after transplantation. The formation of DSA and ongoing AMR processes may critically contribute to late graft loss. However, appropriate treatment for late AMR has not yet been defined. There is accumulating evidence that bortezomib may substantially affect the function and integrity of alloantibody-secreting plasma cells. The impact of this agent on the course of late AMR has not so far been systematically investigated. The BORTEJECT Study is a RCT designed to clarify the impact of intravenous bortezomib on the course of late AMR. In this single-center study (nephrological outpatient service, Medical University Vienna) these researchers plan an initial cross-sectional DSA screening of 1,000 kidney transplant recipients (functioning graft at greater than or equal to 180 days; estimated glomerular filtration rate (eGFR) greater than 20 ml/min/1.73 m2). DSA-positive recipients will be subjected to kidney allograft biopsy to detect morphological features consistent with AMR. Forty-four patients with biopsy-proven AMR will then be included in a double-blind placebo-controlled intervention trial (1:1 randomization stratified for eGFR and the presence of T-cell-mediated rejection). Patients in the active group will receive 2 cycles of bortezomib (4 × 1.3 mg/m2 over 2 weeks; 3-month interval between cycles). The primary end-point will be the course of eGFR over 24 months (intention-to-treat analysis). The sample size was calculated according to the assumption of a 5 ml/min/1.73 m2 difference in eGFR slope (per year) between the 2 groups (alpha: 0.05; power: 0.8). Secondary end-points will be DSA levels, protein excretion, measured glomerular filtration rate, transplant and patient survival, and the development of acute and chronic morphological lesions in 24-month protocol biopsies. The authors concluded that the impact of anti-humoral treatment on the course of late AMR has not yet been systematically investigated. Based on the hypothesis that proteasome inhibition improves the outcome of DSA-positive late AMR, these investigators suggested that their trial has the potential to provide solid evidence towards the treatment of this type of rejection.
Hou et al (2014) noted that the human leukocyte antigen-G may have a positive role in graft acceptance in human organ transplant. Several studies have reported an association between the human leukocyte antigen-G-14-base-pair-insertion/deletion polymorphism and risk of developing kidney graft rejection, but the results are inconclusive. These researchers performed a meta-analysis to evaluate this association. They included 5 case-control studies that evaluated the association between human leukocyte antigen-G-14-base-pair-insertion/deletion polymorphism and risk of developing kidney transplant rejection, including a total 907 patients (rejection, 271 patients; no rejection, 636 patients). There was no significant association between the human leukocyte antigen-G-14-basepair-insertion/deletion polymorphism and risk of developing kidney transplant rejection in the allele contrast, homozygous, heterozygous, recessive, or dominant genetic models for all rejection or acute rejection. In 2 studies, there was a significant association between human leukocyte antigen-G-14-base-pair-insertion/deletion polymorphism and chronic graft rejection in the allele contrast model (+14 versus -14: OR, 0.68; 95 % CI: 0.48 to 0.96; p = 0.618), heterozygous model (+14/-14 versus -14/-14: OR, 0.44; 95 % CI: 0.23 to 0.83; p = 0.248), and dominant genetic model ([+14/+14 and +14/-14] versus -14/-14: OR, 0.48; 95 % CI: 0.30 to 0.78; p = 0.355). The authors concluded that there may be no association between 14-base-pair polymorphisms and risk of developing kidney allograft rejection. They stated that additional studies with larger sample size and better study design are justified.
A Medicare National Coverage Determination states that the FDA has approved lymphocyte immune globulin, anti-thymocyte globulin (equine), for the management of allograft rejection episodes in renal transplantation. The Centers for Medicare and Medicaid Services has stated that these biologics are viewed as adjunctive to traditional immunosuppressive products such as steroids and anti metabolic drugs. At present, lymphocyte immune globulin preparations are not recommended to replace conventional immunosuppressive drugs, but to supplement them and to be used as alternatives to elevated or accelerated dosing with conventional immunosuppressive agents.
|CPT Codes / HCPCS Codes / ICD-10 Codes
|Information in the [brackets] below has been added for clarification purposes.  Codes requiring a 7th character are represented by "+":
|ICD-10 codes will become effective as of October 1, 2015:
|CPT codes covered if selection criteria are met:
|Donor nephrectomy, (including cold preservation); from cadaver donor, unilateral or bilateral
|Donor nephrectomy, (including cold preservation); open from living donor
|Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection of allograft and removal or perinephric fat, diaphragmatic and retroperitoneal attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary
|Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary
|Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; venous anastamosis, each
|arterial anastamosis, each
|ureteral anastamosis, each
|Recipient nephrectomy (separate procedure)
|Renal allotransplantation, implantation of graft; without recipient nephrectomy
|Renal allotransplantation, implantation of graft; with recipient nephrectomy
|Removal of transplanted renal allograft
|Renal autotransplantation, reimplantation of kidney
|Laparoscopy, surgical; donor nephrectomy (including cold preservation); from living donor
|Other CPT codes related to the CPB:
|77051 - 77057
|Breast Mammography[female candidates should have a negative result within the past two years]
|88141 - 88175
|Cytopathology [female candidates should have a negative result within the past three years]
|90918 - 90940
|End stage renal disease services and hemodialysis
|Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour
|Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (List separately in addition to code for primary procedure)
|Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (List separately in addition to code for primary procedure)
|Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure)
|Home visit for hemodialysis
|Other HCPCS codes related to the CPB:
|Cervical or vaginal cancer screening; pelvic and clinical breast examination[female candidates should have a negative result within the past three years]
|Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; screening by cytotechnologist under physician supervision[female candidates should have a negative result within the past three years]
|requiring interpretation by physician [female candidates should have a negative result within the past three years]
|Screening, cytopathology, other
|End stage renal disease services
|Home therapy, hemodialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing services coded separately), per diem
|Home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately
|ICD-10 codes covered if selection criteria are met:
|Chronic kidney disease, Stage V
|End stage renal disease
|ICD-10 codes contraindicated for this CPB:
|Coagulation defects [untreated]
|Disorders of sphingolipid metabolism and other lipid storage disorders [severe neurological or mental impairment]
|Mental and behavioral disorders due to psychoactive substance [ongoing alcohol or drug abuse]
|Rett's syndrome [severe neurological or mental impairment]
|Hereditary and degenerative diseases of the central nervous system [severe neurological or mental impairment]
|Arteritis, unspecified [active vasculitis]
|Congenital anomalies [extrarenal congenital abnormalities]
|Belatacept (Nulojix):
|HCPCS codes covered if selection criteria are met:
|Injection, belatacept, 1 mg
|ICD-10 codes covered if selection criteria are met:
|Complications of kidney transplant [for the prevention of acute rejection in kidney transplant recipients who are sero-positive for the Epstein Barr virus (EBV)] [not covered for the prophylaxis of organ rejection in other transplanted organs]
|Kidney transplant status [for the prevention of acute rejection in kidney transplant recipients who are sero-positive for the Epstein Barr virus (EBV)] [not covered for the prophylaxis of organ rejection in other transplanted organs]
|ICD-10 codes not covered for indications listed in the CPB:
|Complications of transplanted organs and tissue [excludes kidney]
|Soluble CD30:
|Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified [not covered for measurement of pre-transplantation soluble CD30 level as a predictor of acute rejection in kidney transplantation]
|Anti-thymocyte globulin:
|HCPCS code covered if selection criteria are met:
|Lymphocyte immune globulin, antithymocyte globulin, equine, parenteral, 250 mg
|Lymphocyte immune globulin, antithymocyte globulin, rabbit, parenteral, 25mg
|ICD-10 codes covered if selection criteria are met::
|Other aplastic anemias and other bone marrow failure syndromes [moderate to severe]
|Complications of kidney transplant [prophylaxis of allograft rejection episodes]
|Kidney transplant status
|Measurement of cytokines:
|Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified [(e.g., cytokine-14, interleukin-1 beta [IL-1β], IL-2, IL-4, IL-6, granulocyte-macrophage colony-stimulating factor [GM-CSF], monocyte chemoattractant protein-1 [MCP-1], and tumor necrosis factor-alpha [TNF-α]; not an all-inclusive list) for the diagnosis of acute renal allograft rejection]
|ICD-10 codes not covered for indications listed in the CPB:
|Complications of transplanted kidney [not covered for the diagnosis of acute renal allograft rejection]
|Kidney transplant status [not covered for the diagnosis of acute renal allograft rejection]


text:
i'd have married every bedside witch from here to east dallas
i'd have glistened like a worm to their mescaline psalms
i'd have mired in sinuous wineskin, repentant spectra
i'd Om along in cooing groups, babble with freethinkers
all my endeavors would be gas station derelicts
all of my wrongs would be quasi-continuous
even the over-sought moon would protest
and i wouldn't recognize one half of the universe
if i hadn't had the drunk luck to meet you by spoemsWatch
©2014-2016 spoems
Daily DeviationGiven 2014-06-23
if i hadn't had the drunk luck to meet you by thetaoofchaos is a "beautifully woven, unrelenting piece" (suggester's words). ( Suggested by UnspecifiedUnknown and Featured by neurotype )
I remember why I liked your work. It makes my soul happy.
Belatedly enjoying your genius, Shane. Every line is about a million miles from being a gas station derelict.
Ah. Who needs love poetry after this.
I hope lots of people do, especially since I hope I'm not done writing it. Thanks for stopping in, An.
wonderful. truly wonderful.
Probably the best first line I have read this year...
This piece is like, Ginsberg meets Bukowski.
No matter how many times I read it, it never looses it's magic. Great work.
Brilliant metaphors!!
this is the kinda thing i'd want to be able to say once I find a woman I can love and who would love me back.
I really appreciate that. Finding such a companion has proven to be an endeavor worthy of my art and my dreams. I hope the same happens for you.
And back yet again to do what I had forgotten to do 19 hours ago: to fave your piece, which holds such lucid moments for me with a cornucopia of artistic grit.
The last line got me. I love this.
Congratulations on your DD! Very interesting piece.
Hey, congratulations on the DD!! I'm so pleased to see your wonderful work recognized.
Congratulations on the DD, Shane.
This is great.
congrats on the DD, one of my favorites of yours. well deserved.
I love this so much! It's beautiful!
I love it! i know what poem I'm giving to my significant other next valentines day
Flagged as Spam
Flagged as Spam
most romantic thing ive read in a while....
This works so well, each line strong enough on its own and so much more as a whole piece. Thanks for sharing.


text:
Politically Correct Arts Opens Door to Socialism
Markowitz, Jack, Tribune-Review/Pittsburgh Tribune-Review
This is about the music market, but see if you agree on some disturbing overtones here.
Have we come to a time, for example, when businesses have to pledge "public service" as a condition for making profits? Will accountants, engineers, nurses and plumbers be expected to "reach out" to the needy to show they're worthy to work?
The questions arise from an article by the music critic of the New York Times. "Ten Years of Opening the Tent" was Anthony Tomassini's take on how the classical performing arts are trying to recruit younger audiences against the trashy allure of pop culture.
But the Times man posed a most dubious "principle," his word.
"It is not enough today to be a terrific performer. A musician must be able to connect with people," he wrote. Rather than recruiting the "best" violinist for a job opening, a symphony orchestra might pick an "exceptional violinist with proven skills at engaging the public and the young."
But whoa. How does a job applicant "prove" such skills? Obviously, by showy demonstrations of community activism.
If you're a music student, you might tutor poor kids. Or form choruses in housing projects. Show the world how "involved" you are.
But it happens that mastering the violin, trumpet or whatever takes plenty enough time, toil, tuition and tears. No way to shortcut it. Ah, but you'll beat out the "best" applicant for an orchestra chair if you're "exceptional" enough, and politically correct.
What piles of potential mischief here. First, performance standards must decline. But so will the perceived fairness of the selection process itself. …


text:
North Central College will celebrate Free Speech Week, observed nationwide and on campus Oct. 20-26, with an exhibit in the College's Oesterle Library Gallery, 320 E. School St.
North Central College's 2014 Homecoming Celebration is nearly here! It happens Oct. 16-19 and features many fun events—some traditional and some new.
In a tradition we began with the Sesquicentennial in 2011, the all-class Homecoming Reunion Celebration brings together current students, alumni and friends for dinner and dancing in the spacious Res/Rec Center Saturday evening, Oct. 18. This year's popular event features a new element. The Alumni Awards and Recognition Ceremony has been moved from a convocation on Friday to Saturday night as part of the Reunion Celebration.
Globalization is "complex, ambiguous, dynamic, gray, complicated, divisive, exciting," explained North Central College faculty at a recent panel discussion.
It's a new world, they said, as they shared how globalization has impacted their different academic disciplines and how they teach.
North Central College will present a panel discussion, featuring four North Central faculty members from different areas of study who will discuss the effects of globalization on their academic disciplines. The issue of globalization is a yearlong, campus-wide area of focus.
Free and open to the public, the panel begins at 7:30 p.m. Tuesday, Oct. 7, in the College's Harold and Eva White Activities Center, 325 E. Benton Ave.
North Central College presents William Shakespeare's "A Midsummer Night's Dream," featuring student actors with direction by guest director Kathryn Walsh.
This fall, North Central College welcomes to campus several noted authors—some are also recognized actors and a musician—as part of the College's partnership with Anderson's Bookshops in Naperville. The authors will discuss and sign copies of their latest books.
Here's the lineup:
North Central College supports and encourages sustainability practices in all aspects of campus life throughout the year. Recent news include recognition for the College's food composting efforts, addition of another electric vehicle charging station and paperless efforts in the Office of Admission.
Students in North Central College's Digital Media Club will host a group art exhibit, titled "The Movement Exhibition," Oct. 2-Nov. 2.
The free exhibit will showcase a variety of media, including digital illustrations, animations, paintings, drawings, photography and more. Open to the public, the exhibit will be on display Oct. 2 through Nov. 2 in the College's Meiley-Swallow Hall Gallery, 31 S. Ellsworth St. Meet the artists during a reception from 6 to 8 p.m. Sunday, Oct. 5, in the gallery; light refreshments will be served.
Student broadcasters representing WONC-FM 89.1, North Central College's student-run radio station, have earned nominations in state and national competitions.
In a state competition, four students earned two nominations in two different categories in the annual Student Silver Dome Awards presented each fall by the Illinois Broadcasters Association (IBA) to the top college and university radio and TV programs in the state.
G.I. Jobs magazine rates North Central College a 2015 Military Friendly School.
The 2015 Military Friendly Schools list honors the top colleges, universities and trade schools that are doing the most to embrace America's military service members and veterans as students. This is the third consecutive year North Central College has earned the recognition.
North Central College prepares students to be informed,
involved, principled and productive citizens and leaders over their lifetime.


text:
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|This article or section contains insufficient information and is considered as a Stub. You can help GTA Wiki by expanding it as much as you can.
- Casey redirects here. For the character in GTA London 1969 & 1961, see Mick Casey.
Casey is worker for Gruppe 6, he is forced to help with the heist in the mission "The Big Score".
- Casey was first uncovered on his voice actor's IMDb page on March 31, 2013. Jeff Wincott later confirmed it on his Facebook page on April 9. Wincott refused to reveal his character's role.[1]


text:
The nurses' unions focus on health gives them a unique perspective on climate change among organized labor.
The movement to persuade schools to divest from fossil fuels has taken off around the country. Meet a few people who helped get Stanford's money out of coal.
Key national unions are stepping up to support the People's Climate March on September 21. But some green radicals say unions need to create their own climate protection strategy that democratizes the energy sector.
Gas stations aren't great for the climate, but the move is a step toward local control over economic decisions—a model that holds great potential for developing renewable energy in the long term.
Incubator farms help seasonal workers start their own businesses, where they get better pay and the support of a community.
More than 400 workers and supporters were arrested on Thursday amid a nationwide wave of walkouts and demonstrations.
A new bill provides two years of tuition at a community college for participating high school grads who might otherwise face a 7.5 percent unemployment rate—and other states are already following suit.
Utah, Minnesota, and Washington have seen traffic fatalities decline by 40 percent. Here's how they did it.
47 million Americans live beneath the official poverty line, under a daily judgment of failure. The question today is: Whose failure?
For low-wage workers, Seattle's minimum wage increase means a chance to go to college, pay the rent, and visit the dentist.
In Germany, auto workers get paid well and their companies still profit. Author Thom Hartmann on why living wages and corporate success don't have to be mutually exclusive.


text:
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Sen. Schumer tells Clinton to pressure Saudi Arabia to pump more oil
Sen. Chuck Schumer (D-N.Y.) wants Secretary of State Hillary Rodham Clinton to press Saudi Arabia, OPEC's dominant oil producer, to boost output as rising prices are hitting consumers at the gasoline pump.
A letter to Clinton on Sunday from Schumer, a top political strategist for Senate Democrats, comes as Democrats are trying to blunt constant GOP […]
Gov. Daniels: Obama administration 'wanted higher gas prices'
Indiana Gov. Mitch Daniels (R) blamed President Obama for the spike in oil prices, saying the administration had pushed for consumers to pay higher prices at the pump.
"Let's give the president credit for one domestic policy that works. He wanted higher gas prices and he got them," said Daniels on Fox News Sunday.
"Secretary Chu said […]
Hotels Suggested for ThEC11
We are pleased to suggest a number of hotels in New York, the site for this year's conference. Hotels are conveniently located close to the A train that takes you from JFK International Airport through Manhattan. Attendees who would like to stay at any of these should contact the hotels. Please […]
A Matter of Politics for Washington and Thorium
George William "Bill" Foster (born October 7, 1955) is a physicist and businessman, and the former U.S. Representative for Illinois's 14th congressional district, serving from 2008 until 2011. In May 2011, Foster announced plans to run for Congress in Illinois' proposed new 11th District.
At ThEC11 he will present on the important […]
Speakers at ThEC11
The following individuals and others will contribute to ThEC11, covering a wide range of important subjects to move Thorium Energy to the market.
Registration is still open at ThEC11, see you in New York!
Speakers are:
"Report from the DOE ADS Working Group" by Stuart Henderson – FNAL
"Science Doesn't Speak for Itself" by Parker […]


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October 3rd, 2012 (12:42 AM).
Ice Car
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I used to use Firefox a lot since it was faster than Chrome and... *cough* Internet Explorer *cough* as is every other browser, but on my new computer it was slower for some reason so I switched to Chrome which was just about as fast as Firefox so stuck with it. Now I'm too used to it to switch back to Firefox.
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Golden Sun- Felix and Piers by Shin-WolfWatch
©2010-2016 Shin-Wolf
Were they just kissing? O.o ~<3
Felix and Piers... Cute^^
I like it! Especially the colours! Eeeeek!
I'm trying to figure out what's happening in this picture...my yaoi senses are tingling.
OMG!!! is...is very cute.....
OMG!!! is...is very cute.....
Great work!!
They're both so adorable.
Very nice coloring style and facial expression.
Nicely done! I must say I'm fond of your colors and how they interact.
Blushing Piers FTW! I loved the Golden Sun games. I still have them. XD. Can't wait for the new one I've heard about for the DS. Great job on the pic!
Lovely! You capture their essence really well.
This is so adorable. >:
Wah! This picture makes me so happy! Very cute. I do enjoy these two.
This is so adorable!
I love their facial expressions lots!
I love their facial expressions lots!
Your coloring is really nice! I love it.
Teeheee. Why is it that I'm seeing gaysubtext in this picture? X333
awesome *_____*
I love the colors <333
they both look so cute
I love the colors <333
they both look so cute
I like your drawingstyle and the coloration is awesome!
I have to this
I have to this
I can't wait for GSDS! I'm geeking out.
Awesome work! I love how Piers is blushing. Great colors!
Whaa it's fantastic!
I love seeing these two next each or togheter in a pic x3
btw well drawn love the coloring
btw well drawn love the coloring


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There's finally a place to sing in Fremont on Wednesday nights. For years, the only steady option for karaoke there has been Mondays and Tuesdays at the Dubliner, but last month the White Rabbit brought in Absolute Karaoke to host, and it's been a big hit.
Simple Minds: not simple to sing.
I figured it would get busy, but I was not prepared for how crazy it was the night I checked things out. I got there right when karaoke started at 9 p.m., and it was close to packed. Everyone already had half a bag on, and the rotation was over 10 singers deep.
The place is the perfect size for karaoke, featuring one big room with all the attention focused on the stage. The lighting is nice and dim, and they had a big projector screen for lyrics on the wall behind the singers. The KJ's name is Rachelle. I'm pretty sure this is her first hosting gig, but she's a natural. I met her at another karaoke spot in Kirkland a few months back. She's got a really quick wit and an awesome country-style voice. I talked to her a bit about the Rabbit's scene, and she said the nights have been solid ever since they started.The crowd on the night I was there was relatively young, good-looking, and cool. People were partying, and I was very annoyed that I had to play catch-up. There is nothing worse than being sober when things are in full swing. On top of that, I had no idea what I wanted to sing. Early on, the performances were average, but they picked a lot of good classic rock and '80s pop. That's my wheelhouse. I could (and should) have just gone with one of my showstoppers and dominated, but for some reason I wanted to challenge myself with a suicide--a song out of my comfort zone that I've never tried before. It took me forever to settle on "Everlong" by the Foo Fighters. By the time I turned it in, the rotation had cracked the 20-singer mark.
I was happy to wait because I needed to allow time for a buzz to set me free, but the performances got better and better as the night went on. At around 11 the place got taken over by a kickball team that had just completed a game. They were all hammered. Still not drunk enough, I got self-conscious and changed my pick to "Alive and Kicking" by Simple Minds. As soon as I turned it in, I regretted that one as well.
When I finally got called up, my performance was very shaky. Luckily, a bunch of people throughout the bar knew the song and sang along and danced to it. I had a very off night, but this crowd totally bailed me out.
The White Rabbit, 513 N. 36th St., Suite E, 588-0155, FREMONT


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Medic Versus Dr.Zed! From 2 of my favorite games (Team Fortress two and Borderlands). The similarities are amazing, they are both doctors who lost their medical licenses, they both fiddle with medicine, they both have the going grey hair, and they are both the only doctors in their respective games. Can you imagine them fighting ?
Who needs a medical licence when you got style?
Yes. This is good.
ha, thanks
i can only imagine that shit would go down in this case
although i think the medic would beat zed because the medic has more battlefield practice
although i think the medic would beat zed because the medic has more battlefield practice
uber charge? Heavy?
To be honest, I strongly doubt one can count Heavy as part of Medic's weaponry
And seeing how there's no mention of Medic and Heavy vs Dr. Zed in the description, I think it's safe to assume I'm on the safe side.
As for the ÜberCharge, well, that only lasts a buncha seconds, whereas a good shield will keep a whole lotta rounds of bullets from perforating your entrails before finally dying down.
Medic's got some bone saws, a crossbow, and things to shoot syringes with.Zed, on the other hand, has access to Insta-Health, assault rifles, and the most exquisite shields imaginable.
Probably, it would be a fun battle to watch though
But Zed would come back undead Zed.


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Roman Park, Noon
(Continued from Page 1)
A babysitter is asleep,
angled in a corner of the sharp
iron bench. The baby is quiet,
asleep in the direct sunlight.
How shall we find our way in-
to this moment which stands between
us and a remembered future?
It is speaking, the water,
telling over each detail
with a retreating chuckle of gravel.
Loneliness is not appeased,
but the water is speaking, at least.
We will follow the glance of the water.


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Archaeologists say they have turned up about 150 skulls of human sacrifice victims in a field in central Mexico, one of the first times that such a large accumulation of severed heads has been found outside of a major pyramid or temple complex in Mexico.
Experts are puzzled by the unexpected find of such a large number of skulls at what appears to have been a small, unremarkable shrine.
The heads were carefully deposited in rows or in small mounds, mostly facing east toward the rising sun, sometime between 660 and 860AD, a period when the nearby city-state of Teotihuacan had already declined, but the Aztec empire, founded in 1325, was still centuries in the future.
Georgia State University archaeologist Christopher Morehart, who found the skulls last year in Xaltocan, a farming village just north of Mexico City, said that between 150 and 200 adult skulls or their equivalent in bone parts have been excavated so far from fields that stand on a former lake bed.
Experts weren't expecting to find anything of this kind in the flat, undistinguished pasture land and corn fields.
The site is near, but not immediately adjacent to, Teotihuacan, one of the biggest pre-Hispanic cities.
It reached its height between 100BC and 750AD and was abandoned by the time the Aztecs arrived in the area in the 1300s.
Morehart was conducting a study of ancient agricultural patterns and human landscape uses in the northern part of the Mexico Valley in 2007, when during a walking survey of the site he started noticing looters' pits that had turned up human bones.
A subsequent season of excavations in 2012 turned up dozens more skulls. The results of the 2007 dig were just published in the academic journal Latin American Antiquity.
While the Teotihuacan culture and the Aztecs were known to practise human sacrifice, and remains of hundreds of victims have been found in their pyramids or other large structures, the Xaltocan mound "is like a bump in the landscape that you could really easily walk over and not know you're standing on it," Morehart said.
"The interesting question is, why are we seeing this kind of sacrificial act that we often associate with something like Teotihuacan or a big centre. Why do we see this... in a place that's not associated with these cities?"
Physical anthropologist Abigail Meza Penaloza of the Institute of Anthropology at Mexico's National University said her team was still cleaning and assembling the skulls, but have a confirmed count of about 130 skulls so far, all of which appear to be of adult males.
Meza Penaloza said it was the first find of its kind, both because of the location - a small, artificial mound built in the middle of an agricultural field - and the kind of decapitations carried out there. She said mass sacrifices had been documented at temple inaugurations of temple closings, but not in the middle of fields.
She said it was also unusual in that the skulls appear to come from a varied population, including people who practiced cranial deformation and others who did not, as opposed to more homogenous groups of sacrifice victims found in the past.
The skulls were also found with a shorter length of vertebrae attached to the skulls than is the case of other such finds, suggesting the decapitation cut was made closer to the base of the skull.
Still, other strange details emerged: Morehart said some of the skulls were found with finger bones inserted into the eye sockets.
"It was common enough that it was intentionally placed there in the eye socket," Morehart said, though the ritual significance of that remains unclear.
Arizona State University Dr. Michael E. Smith, who was not involved in the project, said "this is certainly an impressive and very puzzling find," adding: "I am not aware of any other finds of mass burials or mass sacrifices outside of major settlements."
The key to the placement might be the natural springs that provided fresh, clean water in an area dominated by shallow, brackish lakes.
The springs existed for centuries until they were covered and tapped by pipes around the 1950s.
The ancient inhabitants of Xaltocan apparently used those springs to water lakebed farm plots.
Carvings associated with the water-god Tlaloc and corn and chile plants were found at the excavation site, suggesting it may have been an agricultural shrine.
There were also indications that the site remained a ceremonial spot for centuries after the human sacrifices ended, and perhaps is still used for that purpose.
Morehart said researchers found a plastic bag containing a black candle, an egg, and paper streamers wrapped around photographs of people at the site, what one local worker suggested was a form of witchcraft.
"They were attracted to this spot for some reason, and even in the colonial period people came back and did rituals there, even after the Spanish came," Morehart noted.
"The spot has been integrated into something religiously significant across several centuries. It's amazing."
Smith said it is possible that, as archaeologists start excavating more ancient farm sites, they might discover more evidence of large-scale rural sacrifices.
"Very few rural areas or rural shrines have ever been located, so it is hard to say that this site represents an unusual find. It certainly is unusual for being the first such feature excavated by archaeologists, but it is possible that such shrines were more common in ancient times; we simply have no idea."
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Anyone who needs further convincing that it's impossible to take the politics out of politics>"/>
Krist Novoselic's column runs every Tuesday on the Daily Weekly.
Anyone who needs further convincing that it's impossible to take the politics out of politics should look no further than King County, Washington.
Like the Florida butterfly ballot that wrecked the 2000 presidential election for Democrats, or Chicago ward politics where residents of cemeteries can still vote, as the center of the disputed 2004 governor's race, King County elections administration has gained a certain infamy in Washington state. And this distinction was made apparent during the 2008 election with GOP political signage that read, "Don't Let Seattle Steal This Election!".
This is the first time voters will pick the King County elections director, a task formerly handled by local lawmakers. And it's not a bad idea. Why not let the voters decide who counts the ballots? But the irony isn't lost that the current appointed elections director is a favorite to win. (If you live in King County, please be sure to postmark your ballot today.)
And what a great idea it was to make the office nonpartisan--this way party politics promises to stay out of the ethical obligation of counting ballots with fairness. Here's the lure of nonpartisan elections: By removing the party affiliation next to a candidate's name on the ballot, POOF--partisanship simply vanishes!
Yeah, right!!!!!!
With six names on the ballot, the two leading candidates are each endorsed by the Republican or Democratic party. This only shows what a charade nonpartisan elections really are.
Party affiliation on the ballot is a cue to voters about the candidate running for office. It is a simple convenience for voters. Voters are often well-informed about, for example, the presidential candidates at the top of ballots, but may never have heard the names on down-ballot races of state legislators or public administration officials. That's when the cue or party affiliation comes in, to help voters choose--or not choose--a candidate.
But there's still the impression that taking partisan cues off the public ballot will remove partisanship from politics. You might as well hope or dream that passing out cake and candy will calm the kids down! And that's what nonpartisan elections attempt to do--take the politics out of politics!
Party politics have already entered the appointment for Ron Sims' soon-vacant county executive seat. Democratic State Chairman Dwight Pelz was quoted in the Seattle P-I: "We're hoping that a strong Democrat can emerge from the process as our next county executive."
But how can that be? King County now has its brand-new nonpartisan system! It doesn't matter, because there is no law that stops a party from promoting a candidate. Perhaps major and minor parties could start nominating candidates for local city council races that also have nonpartisan ballots? So what! It's up do the individual voter to determine the value of an association with a party. Voters can either love a party candidate or leave 'em in this regard.
This is a reason why state and local elections should be partisan on the ballot: because they're partisan in real life. In their quest for state office, many lawmakers have emerged from local nonpartisan offices to declare themselves Democrats or Republicans. It's not as though a sudden revelation came over these ambitious public servants which made them discover their political ideology--they already hold views that usually place them to the left or right of the center. The partisan ballot gives voters a signal as to which party caucus in Olympia a candidate hopes to join. And if the voter agrees with the party caucus, they will choose this candidate.
Some states have partisan elections for their judiciary. Washington is nonpartisan, but look at how politicized our state Supreme Court races have become. Federal judicial appointees and U.S. attorneys serve at the pleasure of the President--a partisan office. Also, the Washington Attorney General, the top law enforcer in the state, is a partisan position.
I believe voters are attracted to nonpartisan elections because they hold the Republican and Democratic parties in low esteem. At the same time, voters usually don't give independents and third-party candidates the time of day!
Nonpartisan elections seek to sanitize the democratic process. Party politics can be messy, but at least people are participating. And for better or worse, a party nomination acts as a winnowing process.
In the end, it's up to voters to decide who will best represent them in government. There's no reason we can't make the process easier with a little piece of information regarding a candidate's party affiliation on the ballot.


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Goodguys 11th Nashville Nationals
May 13-15,2016
Nissan Stadium
Goodguys Rod & Custom Association returns to Music City for three big days of Southern-style hot rodding at the 11th Nashville Nationals Giant Automotive Festival the weekend of May 13-15 at Nissan Stadium in downtown Nashville.
Grab your family and all your friends and come on out to see over 2,500 of the finest 1972 & older hot rods, customs, muscle cars, trucks & classics in the country. Plus, you don't want to miss the ultra-intense Goodguys AutoCross timed racing competition, Nitro Thunderfest Dragster Exhibition, over 150 vendor exhibits, a Swap Meet & Cars 4 Sale Corral, Live Music Entertainment featuring some of Nashville's best local acts, a FREE Kids Zone, Builder's Choice Awards by Bobby Alloway, and new for 2016, the crowning of the Goodguys 2016 Tanks Hot Rod of the Year. And, late model American made or powered muscle cars, customs and trucks are welcome on May 15th for K & N Filters All American Sunday.
For complete details and to register your vehicle or purchase tickets, visit www.good-guys.com. Goodguys… Cool Cars, Cool People, Good Times!
Friday, May 13: 8am-5pm
Saturday, May 14: 8am-5pm
Sunday, May 15: 8am-3pm
If purchased online by May 12th:
General Admission (ages 13+): $17 / Kids (ages 7-12): $6 / Kids (ages 6 & under): N/A
At the Gate:
General Admission (ages 13+): $20 / Kids (ages 7-12): $6 / Kids (ages 6 & under): Free
Parking: $5
Military Personnel: Show your active or retired military ID for $5 off your General Admission ticket when purchased at the gate.
Register your vehicle, see the weekend schedule, and get more event details at Good-Guys.com.


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Black And White Skull With Cross On Forehead Vector ArtCelebration,Day Of The Dead,Dead,Death,Decoration,Digitally Generated Image,Dressing Up,Halloween,Human Body Part,Human Representation,Human Skull,Illustration,Illustration Technique,Mask - Disguise,No People,Symbol,Traditional Festival,Vector,VerticalPhotographer BettyCollection: Imagezoo


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|Phillip J.
Hi, my name is Phillip. I have been watching Monk since the first episode, and have been hooked ever since. I just can't get enough. I watch it every week, and there are times when I can relate to the stuff Monk is afraid of.
I own all five seasons on DVD and I always watch an episode before I go to bed. I also own all four of the Monk books that are out. I am also always connecting things in conversations I have with friends and family to Monk.
My favorite Monk phobia is his fear of heights, because I am also afraid of heights. It was so funny in "Mr. Monk Goes to the Carnival" when he trys to save Sharona from the killer, so he climbs up the ferris wheel and then it turns on. My Favorite episode of Monk so far would be "Mr. Monk Goes to a Rock Concert", because I go to many rock concerts and it was funny to see Monk go to one.
The picture I included is of me with some of my Monk stuff.
Think you deserve the honor of "Monk Fan of the Week"?
Email email@example.com your credentials and tell us which Monk phobia or mystery is your favorite. Include your name and a photo of yourself, and we may feature you right here on the official site!


text:
English and Modern Languages Department
Auerbach Hall 212J
PhD Oxford University | BA Williams College
Charles Ross earned a BA from Williams College and a DPhil from Oxford University. He has been a Fulbright Scholar and a Guggenheim Fellow.
His scholarship includes books and editions on D. H. Lawrence, the English writer, and articles and presentations on hypertext literature and theory.


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