text:
China bird flu crisis
The H7N9 flu has infected 108 people in China since it was first detected in March, according to the World Health Organization. The new strain of avian flu has killed 22 people among confirmed cases.
Michael: My question to those who support Donald Trump is: IF this were Donald Trump that was the subject of all these wiki-leaks leaks, how many of you would be calling foul and complaining it was the media being biased against Mr. Trump. And if it were proven by 17 security companies that it was Russia behind these leaks in a blatant attempt to push the vote against him (Donald Trump) how many of you would be quick to condemn Russia for trying to interfere with American politics?


text:
|News & Politics
Insight, analysis and expert debate as key policy makers are challenged on the latest news stories. From BBC Radio 4's Today programme
June 5th, 2015
Episode 401 of 1270 episodes
Featuring Friday boss Taavet Hinrikus, co-founder of TransferWise.
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subset: commoncrawl


text:
Lake Saint Louis Bakeries
Shari's Berries
Serving the Lake Saint Louis area.
- (888) 396-1892
1. Baker Boys Plus
8653 Highway NLake Saint Louis, MO 63367
2. Schnucks
101 Civic Center DrLake Saint Louis, MO 63367
3. Heaven Scent Bakery
I love their donuts! They are HUGE and my favorite is the the heavenly cream filled donuts. Custard used to be my favorite until I had their heavenl…
4. Bakery Case
7987 Dockside DrO Fallon, MO 63368
5. Sweet Start Bakery
7224 Ofallon Lake DrO Fallon, MO 63366
6. The Divine Cake
Great experience, delicious cake and amazing artist. Thanks so much!
7. Sinfully Sweet Cupcakes
O Fallon, MO 63368
9. Sweet Art Cake Designs
Serving the Lake Saint Louis Area.
10. Susie G's Specialty CakesMenu
Bought a cake for a baby shower here. It was absolutely gorgeous and the guests raved about how moist and delicious it was!
11. Shari's Berries
There are several cake shops near town but this one is the one we usually go to. If you happen to visit them, ask for their bestsellers and you won'…
12. Cupcake Amore
2443 Hwy KO Fallon, MO 63368
From Business: O'Fallon, Missouri's premier cupcake caf.
13. Baby Cakes Bakery
107 Ofallon PlzO Fallon, MO 63366
14. French Gourmet Bakery
2439 Highway KO Fallon, MO 63368
15. Interstate Brands Corp
222O Fallon PkwyO Fallon, MO 63368
16. Bakers Whip Service
1456 Hepperman RdWentzville, MO 63385
17. SweetCakes by Lindsay
Troy, MO 63379
18. Laulie Cakes
Great Cake and Great Service. We ordered our son's 9th birthday cake and I brought pictures of what we wanted it to look like. Instead of getting …
19. Valenti Bakery & Deli
Excellent cuts of meat & prices! Occasionally you have to stand in line awhile when it's really busy.
20. Sinfully Sweet Cupcakes
406 S Church StSaint Peters, MO 63376
21. Saint Louis Bread Co
290 Mid Rivers CtrSaint Peters, MO 63376
22. J Noto Bakery
5105 Westwood DrSaint Charles, MO 63304
23. Great America Cookie
1600 Mid Rivers MallSaint Peters, MO 63376
24. Bakery Case
48 Dugan CtSaint Charles, MO 63304
25. Rosciglione Bakery
26. Bake My Day St. Louis!
3301 Domain StSaint Charles, MO 63301
From Business: A family owned bakery dedicated to delivering excellence to make any gathering a party!
27. Sweets To RememberMenu
255 Cap Au Gris StTroy, MO 63379
28. Bridge Bread Bakery
419 S Main StSaint Charles, MO 63301
From Business: Bridge Bread is a social enterprise that provides supportive employment for people without safe and stable housing. We offer a variety of artisan breads, gourmet ci…
29. Sucrose
700 S 5th StSaint Charles, MO 63301


text:
To avoid criticism, do nothing, say nothing, be nothing.
~ Elbert Hubbard
Music provides one of the clearest examples of a much deeper relation between mathematics and human experience.
I'd like to think that her husband and/or children would not have a 70% chance of being full of shit, for starters. I tend to think if her husband was full of it 70% of the time, she'd have given him the boot a long time ago. I could be wrong, but since I absolutely 100% resonate to every word she said, I'm gonna take a chance on that.
Well said, Cafe, well said!
Preamble for Fi or Ne types ... I woke from a dream in the middle of the night last night and I saw with a clarity the differences between our outer and inner worlds. Like many of my middle of the night revelations, it was clear as a bell when I thought the thoughts in the moment. This morning, it's more like a remembered symphony but still I want to try to share it. And @Z Buck McFate & @cascadeco have said some stuff like this in the past, but something really struck me last night ...
Now, I've got a deadline here in terms of writing this. So, it will be narrative, might be less structured and I request tolerance of that, apologizing in advance.
Before I went to bed, I had written out the following post but not posted it:
The best metaphor I can come up with is the sense that I am always getting my head dunked under water in the outer world.
Someone says, "Did you do that errand?" The sense I get from that for a second is total confusion, being startled. Not unlike that feeling you get when you suddenly find your head dunked under water. So I splash back up to the surface, manage to collect my thoughts enough to ask "Did I do what?" "You know, you said you would do X this week."
Someone else asks says, "Why did you do that?" Again ... for a few seconds it's *splash* a head dunk, I splutter back up and say, "What do you mean, what was wrong about it?" It's hard to sort out what the real question is ... and Fi doms can be very bad at hearing criticism where it's not intended.
It's a vantage point, it's a position, and I take total ownership of my reaction, and I know I'm the only person who can depersonalize from those questions. But for the first few seconds ... the reaction is so ingrained, it's a challenge to not get the head-dunk feeling ...
I just wish I wouldn't get head-dunked in the first place! No matter how much I ask not to be, it's especially hard for a Je dom or aux to not do it, it's like it just busts out of you guys! You don't realize the kind of impact it has.
And it feels dangerous too sometimes, like I'm getting my head held under water just a little longer than is tolerable ...
Maybe INFJ's feel like they're getting head-dunked in the inner world, when INFP's focus on wanting the information we find pertinent ...
And perhaps you feel the same way about the inner world as I do about the outer world.
Another metaphor:
I'm not a tidy person. I am comfortable with piles of paper on my desk, messiness in general. Oh sure, I will clean it up, for a few reasons: 1.) because messiness in the outer world stresses my husband 2.) things run more smoothly when everything is in place or 3.) sometimes outer messiness adds to inner messiness and symbolically, cleaning the outer messiness helps tidy the inner world.
Where I can't tolerate messiness is in my inner world. My inner work, with all of the emotions I feel, all of that processing every day, is tantamount to cleaning house every single day. I know that the majority of folks do not keep a tidy inner house, far from it. Some people VERY far from it. So when I work so hard to keep the inner house clean so my inner messiness does not spill out into the outer world (like most people's do) I can feel frustrated when everyone else is far more interested in keeping the outer world tidy, just a veneer of structure with chaos underneath. But I feel that's what the INFJ's are more tolerable of - that the inner world can be messy as long as the outer world is in order. To me, when the inner world is tidy, so is the outer world, at least more so, since it is messy, chaotic - uncontrollable. I can tolerate a lot of outer world messiness since I have no expectation it should be a certain way. But messing with my inner world - throwing a pile of my well-organized papers in the air, not so nice.
So, for INFJ's protocols are important, social graces are important, because they keep the outer world managed ... chaos can't just pop up wherever.
I manage my inner world like you manage the outer. The reliability & continuity of the outer world brings you security, minimizes your mixed messages, brings order to your inner world I think. I was noting how @Tiltyred looked at each of my posts, looking for what each one was saying, trying to manage that outer world info ... assign a motivation to it all, add a message to it all.
Z Buck talked about throwing furniture around the room. That happens for me when intention is misread, when motivation is misread, when grand stories to explain something are created, when inferences are made ... I look to how I feel about all the inner world stuff, what emotions I sense from each person, contemplate word choices, assess sincerity of expression ... all that stuff. The outer world stuff is just messy and I can deal with the fractal nature of it not seeming to make sense.
Eh, like most dreams trying to express it all here in the morning, in this post is difficult. Pick out any stuff that jumps out as relevant or resonant.
"Remember always that you not only have the right to be an individual, you have an obligation to be one."
― Eleanor Roosevelt
"When people see some things as beautiful,
other things become ugly.
When people see some things as good,
other things become bad."
― Lao Tzu, Tao Te Ching
At the great risk of your feeling like you're being dunked again, my first reaction to your post is great curiosity at how you would feel more comfortable being approached if someone wants to know whether or not you did indeed do the errand you had mentioned last week you intended to do.
Sure - if someone said, "You know that errand we talked about last week, going to the XYZstore? Did you get a chance to do it?" then I wouldn't be lost.
eta: it's about mentioning the topic before the action ... it's like the filing system in my mind is set up by topics, and yours by tasks ??
"Remember always that you not only have the right to be an individual, you have an obligation to be one."
― Eleanor Roosevelt
"When people see some things as beautiful,
other things become ugly.
When people see some things as good,
other things become bad."
― Lao Tzu, Tao Te Ching
Honestly, not even that -- your reaction to it is the same as mine, but having that reaction doesn't disturb me. And my having that reaction will sometimes cause the other person to smile, but it doesn't seem to hurt me going forward. It happens at work with my ISTJ. "Did you do X?" and because X is just at the moment the furthest thing from my mind, my first reaction is often "Huh?" or similar, and I have to hear the question again to give me a second to focus. This seems fairly normal to me and goes across types. If you ask anyone a direct question out of the blue, it might take them a second to redirect their attention to where it's being pointed.
And p.s. (sorry, I'm so bad with the afterthoughts) -- a "normal" actual response would be "Yes," "No," "It's next on my To Do list," or "It slipped my mind! Thanks for the reminder."
I may be overstepping and I apologize in advance if so, but this concern seems to indicate a desire on your part to appear in control to an extent that might not be possible for mere humans. That's my impression. I mean, I could see a reasonableness on the part of the questioner that at least some of the time you would know right off hand what they were referring to, but expecting you to always know what they're talking about immediately, especially if you are otherwise occupied when they ask you, seems like a lot to ask.
And if somebody's giving you shit for it, they need to stop. IMO. Unless you have never done the thing you said you would, and you never know what they are talking about. But even then, there are ways to help yourself and it's not disastrous.
Also, and I say this with the hugest respect, your inner world seems to have a lot of hot spots, some of which are maybe created by unrealistic expectations of yourself or perhaps by having been treated harshly for being human, I don't know, but I just put it out there fwiw. (And I know it's true of myself as well)
@PeaceBaby, Yes, my inner world is rather an unclear imprecise morphing mess, at times, until I have clarity and things come together. It's why as I mentioned earlier, I'm much more susceptible and distrustful of any nudgings or what I perceive as being forced to make my inner world more concrete/being 'rushed' to cement things. I don't work that way. And as for externals, I don't care so much about being prodded about schedules or external decision-points, because I naturally like the externals to be 'concluded' or organized, anyway.
"...On and on and on and on he strode, far out over the sands, singing wildly to the sea, crying to greet the advent of the life that had cried to him." - James Joyce
My Photography and Watercolor Fine Art Prints!!! Cascade Colors Fine Art Prints
Also, to "why did you do that?" I see "I don't know" as a perfectly valid answer. "I don't know. Why do you ask?" is particularly effective because it makes the other person answer so you have something to react to while you organize your mind to respond. At the very least, you can hear them and say No, it wasn't because of that. and then you can choose to elaborate or remain mysterious and drive them nuts wondering.
This makes me think of my ESTJ husband asking me "Why did you buy that?" - when we were first married, I thought he was looking for a list of tangibles, why it was a good value or why we needed it.
I learned years and years ago all I had to say was, "I liked it" and that was usually a good enough answer for him!
Now, if it was something potentially expensive, the next question might be, "How much did it cost?" THAT's a whole 'nuther discussion!
"Remember always that you not only have the right to be an individual, you have an obligation to be one."
― Eleanor Roosevelt
"When people see some things as beautiful,
other things become ugly.
When people see some things as good,
other things become bad."
― Lao Tzu, Tao Te Ching


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HCMN 415 Review for Exam 1
HCMN 415 Review for Exam 1 HCMN 415
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This 4 page Study Guide was uploaded by Amend on Wednesday August 24, 2016. The Study Guide belongs to HCMN 415 at Towson University taught by Chuck Zorn in Fall 2015. Since its upload, it has received 14 views. For similar materials see Financing & Organization of Healthcare Services in the U.S. in Health services at Towson University.
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Accounting measurement, in financial terms, of events that reflect resources, operations, & financing of an org. Financial management provides the theory, concepts, & tools to help managers make better financial decisions Role of Finance: health services need to plan for, acquire, & utilize resources to maximize the efficiency (value) of an org Activities include: Plan & budget Financial reporting Financial risk management Manage financial operations Financial & operational analysis Capital investment decisions Contract management o Four Cs to Monitor Costs : 1. Costs monitored to ensure no excess amount of services provided 3. Capital ($) raised by businesses to buy facilities & equip. to offer services 2. Cash on hand and sufficient for businesses to meet payments 4. Control present for businesses' resources to ensure they are used wisely 5. Health Service Setting: Hospital (inpatient), Ambulatory (outpatient), Longterm, & Integrated Delivery Systems 6. Regulatory Issues: Regulated by Licensure, Certificate of Need (CON), Cost containment & rate review 7. Legal Issues: Primarily: Professional liability, General liability, Antitrust, Right to die 8. Current Financial Challenges: Level of reimbursement, Bad debt losses, Revenue cycle, Capital acquisitions 9. Charity: Hospitals write off all/part of costs of treatment services & covered by governmentassistance programs (Medicaid, Medicare, etc.) 10. Business raises $ in capital markets, invests funds in assets, uses assets to create product/service, & sells product/service for sustainment 11. Legal Forms of Business (4): 12. Proprietorship (sole) & Partnership 13. Advantages of Both: No corporate income taxes Difficult to transfer ownership Ease of formation 14. Disadvantages of Both: Unlimited liability Subject to few regulations Limited life 15. Difficult to raise capital 16. Corporation a. Advantages: Limited liability c. Disadvantages: Unlimited life Ease of raising capital Cost of formation & reporting Easy transfer of ownership b. Double (or triple) taxation for investorowned corporations d. Hybrid forms Limited Partnership (LP) Limited Liability Company (LLC) o General partners have control o Members taxed like partners o Limited partners liable only for initial contribution o Liability like stockholders o Not commonly used by healthcare providers Professional Corporation (PC)/Professional Association (PA) Limited Liability Partnership (LLP) o Owners have benefits of incorporation o Partners share general business liability o Liable for malpractice o Partners are liable only for own malpractice actions o Often used by individual clinics e. Alternate Forms of Ownership: Zero forprofit hospitals in MD A. Investorowned (forprofit): Goal Shareholder wealth (stock price) maximization: Must satisfy all stakeholders a. Primary market transactions: Initial public offerings (IPOs) & New common stock sales b. Secondary: On exchanges & In the overthecounter market c. Stockholders have: Right of control and claim on residual earnings & residual liquidation proceeds B. NotforProfit: Large # of hospitals, meet requirements, Goal Mission statement: ensure viability, satisfy owners a. Generally NO shareholders c. Being owned by "the community" b. Receive tax exemptions Form 990: provides corp. governance info. & execudti.ve Required to attach Schedule H provides charity care info, community benefit compensation e. activities, & collection practices f. Tax Laws Influence: Finance decisions, operating $ flows to an investorowned business, ability to raise contribution $ 1. Federal vs. State vs. Local 2. Personal vs. Corporate g. Personal pay federal (state) taxes on salaries, interest, & income that approach 50% a. Capital gains & dividends (in some years) taxed at lower rates b. Lower the amount of useable income (AT = BT x (1T)) h. Corporate 1. Investorowned: pay federal & state taxes on corp. income at rates 2. Notforprofit: most part not subject to taxation & benefits: issue taxexempt i. that can exceed 40% j. (municipal) bonds & receive taxexempt contributions 3. Ordinary Income vs. Capital Gains k. Part A Hospital insurance: helps cover inpatient care in hospitals, skilled o. Part C Medicare Advan. Plans (HMO or PPO) offered by private co.& cover l. nursing facilities, hospice & home health care Part A & B/may m. Part B Medical insurance: helps cover medical necessary servicesdoctors' cover services such as vision, dental, & drug plans n. services & outpatient care q. Part D Medicare Prescription Plan r. Taxable vs. Muni Bonds: Notforprofit businesses generally are exempt from local property taxes and state and federal income taxes s. Assume FP Healthcare must offer a 10% interest rate on its new bonds. z. Assume NFP Healthcare can issue similarrisk municipal bonds with an 8% interest t.Jane Green, an individual investor with a 28% tax rate, buys one $1,000 bond. rate. u. What is the effective (aftertax) annual interest? aa. Should Jane buy the NFP bond rather than the FP bond? v. AT$ = (0.10 × $1,000) x (1 0.28) ab. At what rate on the FP bond would Jane be indifferent between the two bonds? w. = $100 × 0.72 = $72. ac. AT% = BT% × (1 T) x. AT% = 10% × (1 0.28)= 10% × 0.72 ad. 8% = BT% × (1 0.28) = BT% × 0.72 y. = 7.2%. ae. BT% = 8% / 0.72 = 11.1% af. Hospital Reimbursement: Except for MD Fee for service Federal Programs % of bill Bill Payers using UB04 Other insurers negotiate: diem, case rates, DRG, No one pays 100% of bill Part B Physician Billing: Bill Payers by using form HCFA 1500 services from a medical practitioner) Most providers bill electronically using clearinghouses Use ICD9CM (International Classification of Disease, Clinical Modification Assigned Use CPT codes (Current Procedural Terminology Assigned tasks/ to diagnoses associated w/ inpatient/outpatient/physician office utilization) System Complexity: 16% of all U.S. Personal Consumption MANY different healthcare providers: for profit, not for profit, government, service providers physicians, suppliers medical equipment etc. No standardization for bills or payments Payment System: Third party payers (insurance Government sets rates (Feds PPS, States) Medicaid Could be HUGE differences between charges & payments companies/government) Insurers negotiate discounts & payment methods (contractual allowance, charity care, bed debt) Variety of Insurance Products: HMO, PPO, High deductible, etc. Deductibles: amount paid by insurer before insurance kicks in Copays: amount insurer pays for service Health Savings Accounts: used to pay deductibles Health Care Reform: June 28, 2012; Goals: Decrease individuals without health insurance; improve coverage for those with preexisting conditions; improve prescription drug coverage for Medicare beneficiaries Major Components of Patient Protection and Affordable Care Act (PPACA) 1. Eliminates annual & lifetime coverage caps for patients 5. State exchanges established= customers compare premiums & plans 2. Eliminates copays for essential services 6. Creates ACOs to be accountable for members' health care 3. Must have insurance or pay penalty 7. Shifts some Medicare payment from feeforservices to payment for bundled service 4. Eliminates preexisting condition exclusions ICD10 Compliance: Providers: Hospitals, Physicians Federal & State Agencies: State Medicaid Health Plans & Payers: Third Party facilities, Home Health Agencies, Home Medical (going to have most problems), Center for Disease Administrators Equipment, Reference Labs Control Maryland System: HSCRC Ensure equity/fairness/stability, maximize access to care, contain hospital costs/total costs are reasonable, & provide accountability PreHSCRC (Late 60s Early 70s)= Over utilization, length of stay exceeded national avg., excess capacity Weak financial performance for MD Inconsistent access to hospital care for the Cost per case in MD exceeded national average by 25% Hospitals poor & uninsured Formation of HSCRC: Law enacted by general assembly regulates inpatient/ outpatient services at the hospital 1977: MD became Allpayer state Waiver test: cumulative rate of growth in Medicare payments to hospitals is no > the cumulative rate of growth in Medicare payments to nation over the same time period Unit Rates: HSCRC establish & approve rates for each unit of service (Room & Board, imaging, lab, etc.) Reasonably related to underlying costs (including social costs of uncompensated care bad debt/ charity) Payers required to pay hospitals based on each hospitals approved unit rates New Waiver: New Model includes Provisions Annual allpayer, per capita, total $ growth limited to 3.58% Reduce 30day Medicare readmission rate to national avg. in 5 yrs. Medicare per beneficiary total $ growth must be below national avg. Annual Potentially Preventable Compliance (PPC) 30% reduction 80% of hospital rev. shifted into global payment models by yr. 5 Propose a model extension at the start of year 4 Cannot exceed national avg. by >1% pt. & must break even w/ national Waives Sec. 1814(b)(3) of the SSA: Waiver Test avg. by yr. 4 Not extended/terminated, transition national Medicare payment systems Insurance "to work" Characteristics: 3. Risk transfer Problems that Arise: 1. Pooling of losses 4. Indemnification 1. Adverse Selection 2. Payment only for random losses 2. Moral Hazard Insurance co. use underwriting provisions for minimization Adverse Selection those w/> risk are more likely to buy insurance Problem exists due to asymmetric information Crosssubsidies may exist among different group Underwriting Provisions Opposing Positions of Insurers: Community & Experience rating HIPAA & ACA set national standards: Preexisting condition clauses banned by Rights to purchase insurance 2014 Consumer protection Moral hazard the overuse of health services/forgoing of prevention because individuals do not bear the full $ of the consequences Insurers Protected by: Policy restrictions (ACA placed limits on ability of insurers to include unreasonable restrictions), Deductibles, Copayment, Coinsurance Reimbursement Approaches: Regardless of the payer only limited # of approaches (payment for services) Feeforservice (FFS): payment is tied to the amount of services provided Cost based: Payer pays all allowable $ incurred in providing services & Medicare used for hospital payment in early yrs. Charge based: Payer pays billed charges for services rendered to covered patients & thirdparty paid for services on the basis of charges (chargemaster prices) Prospective payment: Fixed amount determined beforehand unrelated to either costs/charges o May be: per procedure, diagnosis (DRG), diem (per day), or global pricing (bundling, episode of care) Capitation: payment is tied to the patient population (# of enrollees) Managed Care system of healthcare delivery that tries to control the $ of services & regulating access to services & maintain/improve their quality Achieved through contracts w/ selected providers to furnish comprehensive set of services Managed Care Organizations (MCOs): Combine insurance & provider functions Why Need for Change: Cost shifting government programs to Unrealistic public expectations Inefficient use by providers & consumers privately insured Defensive medicine Proliferation of new, expensive technology Fraud & waste Building Blocks: (Base to Top) Hospitals, PCPs, Specialty Physicians Home Health, TCUs & SNFs, Ambulatory Facilities PCP Gatekeepers, Utilization controls, Fin.controls Lab & Image + Rehab Providers, Allied Health Pro. DME & Ambulance, Orthotics & Prosthetics Third Party Payer Models PPOs/POS/EPOs Consumer Health Saving Accounts/ Driven HMO Government Programs Healthcare Exchanges (new to the marke Self Funded Insurers MCO in MD: Aetna CIGNA United HealthCare: MAMSI: MDIPA/ Optimum CareFirst Kaiser Choice Financial accounting creation of financial statements (used by managers & outsiders) that report the financial status of the overall business Managerial accounting creation of subunit information used internally for managerial decisionmaking Cost measurement is a critical part Costs are classified by relationship to volume & to subunit being analyzed Underlying cost structure relationship between costs & the volume of services provided if known, managers can forecast costs at diff. levels Fixed Cost= independent of volume & Variable Cost= dependent on volume Costs classified by relationship to unit of activity: DIRECT unique & exclusive to subunit; INDIRECT (overhead) assoc. w/ shared resources used by entire org. Purpose of Cost Allocation: assign all overhead costs to departments that create need for such costs (Patient service Rev. producing depart.) Cost pool overhead amount to be allocated, consists of direct costs of one support depart. & multiple are used if $ of single support differs majorly Cost driver basis on which the cost pool is allocated/ might be amount of space used by each patient service department (depreciation, utilities) o Critical to cost allocation process o Create an allocation highly correlated w/ actual amout of Good cost driver attributes: perceived as fair & overhead services consumed o promotion of org. cost reduction o Traditional Allocation Process: 1) Identify Cost Pool: $ of overhead activity to be allocated (ex. Direct cost of Housekeeping Department $100,000) 2) Determine Cost Driver (ex. Department occupy 200,000 sq. ft. of space) 3) Calculate Allocation Rate: # value used to make allocation $ in cost pool/ total volume of cost driver ($100,000/ 200,000= $.50) 4) Determine the Allocation Amount: Each user department allocates some portion (ex. Critical Care occupies 10,000 sq. ft. .50 x 10,000= $5,000) 5) Allocation Methods: 1. Direct: costs of each support department are allocated directly to, & only to, the patient services departments (example above) 2. Stepdown: some (not all) of the intrasupport department relationships are recognized; more complex, but manageable 3. Reciprocal: recognizes all support department interrelationships, but requires system of simultaneous equations/ complex set of iterative calc. 4. Unlike traditional cost allocation= topdown system, Activitybased Costing (ABC): begins w/ individual activities that comprise the services provided 5. 6. T 8. 9. 10.
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Attic Fan in Trumbull, CT
Attic fan installation in Trumbull, CT comes with a number of benefits, including lowering energy bills each month. If you want to begin saving a noticeable amount of money on your utilities in the long term, an attic fan in Trumbull, CT is definitely a good decision. These fans can lower the temperature in your house by as much as five degrees, making it more comfortable and less likely for you to have to use your air conditioning when it's hot outside.
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If you are tired of paying way too much for your monthly energy bill, it is important that you take the time to look into Trumbull attic fan installation services. One of these fans can make a very big difference when it comes to just how comfortable you are in your home throughout the summer months. A lot of homeowners choose to get these fans installed because of the massive benefits that are associated with them. One of the primary reasons for high energy bills is using the air conditioning too much, but with an attic fan in Trumbull, CT you will be able to rely less on your AC unit. You will definitely be glad you decided to get an attic fan in Trumbull, CT.
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|Name: _________________________
|Period: ___________________
This quiz consists of 5 multiple choice and 5 short answer questions through Chapter 8.
Multiple Choice Questions
1. What does Alberto personally offer in exchange for Maruja's freedom?
(a) To support Escobar's family when he goes to prison.
(b) A personal prison in Itagüí.
(c) Himself.
(d) A personal talk with President Gaviria.
2. When Escobar first begins his business with the drug cartel, how do the people of Medellín view them?
(a) They look at him as their Robin Hood.
(b) With curiosity but complacency.
(c) They are afraid to say anything.
(d) They are angry at the rise in crime.
3. Who is allowed to visit Marina and Beatriz in January?
(a) Guido Parra.
(b) A doctor.
(c) Rafael Pardo.
(d) Alberto Villamizar.
4. Why does Escobar reject the law that gives him immunity from his most feared punishment?
(a) He wants non-extradition offered no matter the situation.
(b) He wants to lower maximum imprisonment despite the number of cases.
(c) He wants to rid of the death penalty altogether.
(d) He believes a drug trafficker should only be imprisoned for one sentence.
5. Which hostage is no longer worth a bargain?
(a) Beatriz.
(b) Marina Montoya.
(c) Diana Turbay.
(d) Francisco Santos.
Short Answer Questions
1. Who begins a personal campaign to contact Escobar?
2. Who is the first person freed?
3. How do the kidnappers abduct the first set of people?
4. How many men are directly involved with the kidnappings of Maruja and Beatriz?
5. What is most surprising about Santos' kidnapping?
This section contains 303 words
(approx. 2 pages at 300 words per page)


text:
CS Bhagwati charanpractising company secretary at bhagwati charan & associates Delhi, India | Top Management
- practising company secretary at bhagwati charan & associates
- CA/CS/CPA, Top Management - Finance, Top Management - Legal
Profile Synopsis
Summary: total 7 year work exp. in the field of account ,legal and secretarial deptt..
CS Bhagwati charan's Profile Overview
Current Company
practising company secretary at
bhagwati charan & associates
Department: Top Management, from Jan 2009 till now
Job Description : incorporation of company,compliance report,maintaining register & records under corporate law,connsultancy on corporate law taxation etc,Internal audit,book keeping,Autorised representative role under various judicial authority,Trade mark related work..
Educational Information
MBA/PGDM at
Indira Gandhi National Open University ( IGNOU )
from Jul 2003 till Jun 2007
CS at The Institute of Company Secretaries of India ( ICSI )
from Jan 2002 till Jan 2006
BGL at Annamalai University
from Jul 1998 till Jun 2000
CS Bhagwati charan's Additional information
Reason to be on PeerPower : Career Enhancement
Web Profile : http://www.peerpower.com/pub/bhagwaticharan
CS Bhagwati charan's Personal Details
Interest:making friend
PeerPower.com is a networking site for top professionals enabling them to profit from networking and connect with thought leaders.
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CS Bhagwati charan's Connection
Anku KhannaPartner - Corporate Practice at BSK Legal amita goladeputy manager at the times of india group Bhuvana RamanNo Current Company Mentioned Pardeep MannGroup Leader- Legal & Secretarial at Minda Management Services Limited ashok purohitComoany Secretary & Manager-Legal at Pan Emami Cosmed Limited View All
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The Daily Dope


text:
"I will oversee media relations. I will also continue to work with Coach Croom as far as his media needs. But the day to day football operations, from a media standpoint will fall to Joe Galbraith. He'll handle press conferences and teleconferences, player interviews, assistant coach interviews. And he'll be at the practices. He'll also handle some new duties such as practice releases and several other things."
What are some other duties you'll have?
"I'll also oversee marketing/promotions. That includes all the advertising for ticket sales, season and gameday tickets. We'll also have all the gameday activities and events, the atmosphere. Chad Thomas is actually the guy who runs it, but I'm overseeing what he does. But he does the day-to-day duties. He's done a great job and will continue doing that.
"What I'm really going to do in that area, as well as in media relations, is really craft the approach that we are going to take - as far as what is important to the department, what is important as far as the job is concerned. In other words, what is most important to us from a media relations standpoint, what are we going to stress, what we are going to work on. It will be the same with marketing. Ultimately, our primary responsibility is to sell tickets and encourage Bulldog Club membership. Those are our two primary goals in virtually everything we do."
Will you be doing more speaking engagements?
"I know I'm in more meetings that Greg (Byrne) has included me in or has gotten me to go in his place. But I think that's going to be the case for several of us.
"Even though Scott Stricklin won't have the title of Senior Associate Athletic Director, he'll be out there trying to raise funds. He'll be on the road more than I will."
That's two things. Any others?
"I'm also a liaison between Jim Ellis, who is the General Manager for the Learfield Property at Mississippi State, and Mississippi State. Jim will be the guy who will run the Learfield operation for us on campus. He's going out and selling sponsorship in our arenas and stadiums. The money he raises won't necessarily be tied to tickets and donations. That would include things like scoreboard sponsorships, and things we sell advertising for such as gameday score cards and other things like that. But the revenue he generates will be more for Learfield, but Learfield pays us a rights fee, so we are getting money from Learfield."
That's a big job for Jim. Will he have help?
"Jim has Taylor Harris working for him and I think Learfield may hire another person pretty soon. And maybe even an intern to help them in the office."
In addition to those three things you also will work with baseball won't you?
"Yes, I'm the administrator for baseball. What that means is I'm the guy who will be working with our baseball staff to make sure they have what they need from an administrative standpoint."
What will most of your day-to-day duties be?
"I think media relations will be most of what I do day-to-day, but I'm trying to give Joe as much of that as I can. The reason is, first of all, he wants it and I want him to have that (responsibility). But at least in the short-term, I will still handle any major announcements, such as a schedule, a new assistant coach, maybe something Coach Croom is doing.
"And in addition to that, up to this point, Greg has had me doing some things that don't really have a direct line to my job responsibilities. So, I assume I will continue doing those things as needed.
"But I really think day-to-day it will be a mix of everything."
Really, it seems like Greg is giving those of you who are now Senior Associate Athletic Directors more duties and experiences so that it allows you to be prepared to be an athletic director if you want to work toward that goal.
"I think that is probably true. But it's not only giving us experience, it's also giving us more opportunities to do more things. And it's also freeing him to do things that are strengths of his such as allowing him to stay out on the road and raise money.
"Greg, who cut his teeth in this business as a fundraiser, has spent a lot of time going out and meeting the Mississippi State people. For him to continue that, it will require a lot of other people to pick up a lot of slack because he'll be out of the office so much."
Greg mentioned that you are on a university committee which is looking into the MSU logo. Where does that stand right now?
"I'm on a university committee that is in charge of reviewing the university logos to see if there is anything we want to look at it. I think we are still fairly far away from anything happening."
Based on everything you've said, it appears he's going to allow the head of the departments, especially those of you who are Senior Associate Athletic Directors, a lot of leeway when it comes to making decisions.
"I really think the people that we have working at Mississippi State - from Greg all the way down - are quite capable. So, it wasn't a problem when more things started falling into our laps. Everybody in our department is a professional who wants to be the best and wants Mississippi State to be the best. When I say professional, I mean we want to do the best possible job that we can do. And then when we do that, we want to look for ways so that we can do it even better. And in order for that to happen, we have to work a little harder than the next guy. But that's not a problem for us."
Gene Swindoll is the publisher of the GenesPage.com website, the source for Mississippi State sports on the Scout.com sports network. You can contact him by emailing email@example.com.


text:
Armani Clothing Hong Kong
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MSI 8600GTS Diamond Plus with HDMI
HDMI is an acronym getting thrown around a lot more these days. We have to wonder though if it's one of those features that people are actually using. It's a bit like VIVO, everyone seemed to want a VIVO card a few years ago, but from what I have seen and heard rarely did people actually make use of the video input feature.
HDMI has been on TVs for quite a while now, but until the release of the Playstation 3 there wasn't really many devices which used it so the port would go to waste on the back of your brand spanking new digital TV.
Digital TV users might currently find themselves with a Home Theater PC which utilizes a standard VGA cable, the other popular choice is a DVI-to-HDMI cable. The good news is that if you're using the former but think it's time to go digital connectivity between your HTPC and TV, we might have just the card for you.
MSI had a Diamond Plus version of the 7600GT which seemed like a bit of an instruction to HDMI on video cards, though this time around it looks a whole lot more professional on the 8600GTS Diamond Plus.
Let's check it out.
PRICING: You can find products similar to this one for sale below.
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text:
The food was fantastic, we've enjoyed two different types of menu's and both were very delicious. The atmosphere and the service was excellent.
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The food was fantastic, we've enjoyed two different types of menu's and both were very delicious. The atmosphere and the service was excellent.
Good atmosphere restaurant. I told cock he has worked for a long time. I have not yet had like this "Teppan-Yaki" restaurant ever in Japan . Cock cooks in front of you. And set menu is nice. Perhaps 3-4sets. Each food is So good. And healthy. Again I wanna. Much guest come here.
A wonderful evening with new friends at this restaurant and the food was fabulous. Fresh fish and excellent meat. We had a set menu of 5 courses and it was all really good. Good wine / beverage list. You must book a table!
This is my favourite restaurant in Nuremberg, I love their menus and how they cook in front of you. I am not usually a big dessert fan, but their crepe with ice creame is delicious!
Very nice tepanyaki and other authentic japanese food! They have set menus fron 23€ to 45€ and a la carte, too. Good service
Excellent Japanese food, the real experience. The food is high quality and cooked in front of you in the most healthy ways. The ambiance is very pleasant and service is excellent.
I'd never been to a Japanese restaurant, as I don't like sushi and wasn't sure I'd like it. This teppanyaki... 更多
Okay yes this place was a lot different than any other Japanese restaurant we have been. It was nice that... 更多
Very good Japanese restaurant in Nuremberg !!! The food is really good, the atmosphere is unique and the cooks in... 更多
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text:
Ukrainian Parliament with a constitutional majority has adopted a statement calling Crimea inseparable from Ukraine and urged Russian President Vladimir Putin not to send troops, Ukrinform reported.
MPs have passed this decision at a meeting behind closed doors on Sunday.
"The Autonomous Republic of Crimea is an inseparable part of Ukraine, the territory is covered by the Constitution and laws of Ukraine," reads the statement.
It also notes that the movement of foreign military should only be in agreement with the Ukrainian authorities of Ukraine.
MPs, among other, have called on to resolve conflicts by peaceful means.
To recall, Russian President Vladimir Putin received permission from Russia's upper house of parliament Saturday to send troops to Ukraine, responding to what he called a threat to Russian lives.
RF Cabinet of Ministers 'snips' Black Sea
Court considered case of Mejlis member Zeynur Yakubov in Cr
Putin's sinister image
Road map plan to ensure security in Donbas
Prosecutor of ATO forces charged with illicit enrichment
Crimea-SOS announces rally in support of kidnapped in Crimea
Scary and amazing, leading to the world of the unconscious: exhibition of masks
Italy hinders introduction of new sanctions against Russia
Incidence of tuberculosis in Crimea is higher than in Russia
Umerov received 2 examination results from FSB
Putin feared to see NATO ships in Sevastopol
Russia refused to return control of Debaltsevo to Ukraine
Ships of Russian Navy are heading to Scotland
Collection of unique documents on Crimea presented in Kiev
Anti-terrorist exercises launched in Krasnogvardeiskoe
Sanctions against RF for annexation of Crimea may increase
What threatens Sevastopol with new public vehicles on routes
Poroshenko reminds Putin about Ukrainian hostages
Kiev bridges across the Dnipro
Coach Myron Markevich came under fire in Maryinka
AGROPORT starts its work in Kharkiv
Family of human rights defender Emir Usein Kuku persecuted
Yesterday, RF violated Ukrainian airspace 40 times
"Crimean Word" - a source of truth in occupied Crimea
ISIL leaders are leaving Mosul


text:
Trend Topics 2016
Searching for medical clues
Knowledge helps to help
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Data for health care - perfectly safe!
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Everywhere - medical technology for the world
Industry News
Topic of the Month
Topics of the Month 2016
October 2016: Networked healthcare
September 2016: Intraoperative Imaging
August 2016: Medical Industry Worldwide
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June 2016: Hospital hygiene
May 2016: The heart
March 2016: Paediatrics and neonatology
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Topics of the Month 2015
December 2015: The brain
November 2015: MEDICA
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August 2015: Nuclear medicine
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Topics of the Month 2014
December 2014: Ethics
November 2014: MEDICA 2014
October 2014: Orthopedics and physical therapy
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MEDICA Magazine
New Gene that Regulates Body Weight
New Gene that Regulates Body Weight
While studying these side effects, which are called dyskinesia, Kovoor discovered that RGS9 2 also plays a role in regulating body weight. Kovoor and his collaborators found that humans with a gene variation that could reduce RGS9 2 levels had a significantly higher body mass index.
Because RGS9-2 is normally expressed in the brain's striatum, a section of the brain involved in both motor control and reward responses, Kovoor and his fellow researchers thought that the weight gain could be a result of an increased reward response triggered during eating.
"Our research shows that the striatum, through RGS9-2, has a role in regulating body weight that is independent of the motivation, movement and reward responses," Kovoor said. "We have identified a new gene that likely regulates weight gain through metabolism."
Surprised by the discovery, Kovoor said he and his team have been studying RGS9-2 and its role in the movement side effects of drug therapy for Parkinson's disease and schizophrenia for almost a decade.
"We treated RGS9-2 knockout mice (those without the RGS9-2 gene) with anti-psychotic drugs or with L-DOPA, a drug used to treat Parkinson's disease, and the mice all rapidly developed dyskinetic movement disorders when being treated.
In fact, prompted by Kovoor's discovery, one of his collaborators, Stephen Gold, and his colleagues at the University of Texas, were able to show that gene therapy with RGS9-2 could suppress drug-induced dyskinesias in monkeys.
"Separately, we were looking to see if we could predict the risk susceptibility for these (movement) disorders by searching for variations in the RGS9-2 gene in humans."
Kovoor and his fellow researchers at the University of California in San Francisco also monitored the body mass index of patients in their study. "We noticed that study subjects with a variation in the RGS9-2 gene, which could weaken expression of the gene, had a higher body mass index."
MEDICA.de; Source:
University of Rhode Island


text:
The important industrial center of Kharkov was captured by the Germans on the 24th October. The Soviets were now dismantling whole factories and shipping them east to resume production far away from the front line. It was a close run thing in Kharkov where the evacuation of a tank factory was completed with only a few days to spare. There was fierce fighting to protect the rail lines as the Germans came within seven miles of the railhead where the industrial equipment was loading.
{ 0 comments }


text:
After the Storm
Hilla Medalia
Director: Hilla Medalia
|List Price:
|You Save:
|$2.50 (10% Off)
Out of Print: Future availability is unknown
Format: DVD
sku: 98QK
Brand New
DVD Features:
- Rated: Not Rated
- Run Time: 1 hours, 29 minutes
- Video: Color
- Released: April 5, 2011
- Originally Released: 2009
- Label: Passion River
- Encoding: Region 1 (USA & Canada)
- Note: Trailer
- Deleted Scenes
- Photo Gallery
- Audio:
- Dolby Digital 2.0 Stereo - English
Performers, Cast and Crew:
|Directed by
|Hilla Medalia
|Screenwriting by
|Hilla Medalia & Bob Eisenhardt
|Composition by
|Stephen Flaherty
|Director of Photography:
|Ran Shetreet, William Sabourin OReilly & Guy Jackson
|Hosted by
|Gerry McIntyre, Randy Redd, Deshawn Dabney, Hannah Guillory, Desiree Stevenson, Annie Britton, Taylor Marrs, Ashley Rose Richard, April Stewart, James Lecesne, Eric Calhoun, Griffin III Collins, Joel C. Dyson, Jasmin Simmons, Rayan Arnold, Grant Hunter & Gabrielle Porter
Product Description:
After Hurricane Katrina tore through the American South in 2005, people from all across the United States were eager to help, especially those in the creative community, who felt a special kinship to New Orleans, long regarded as a home to musicians and artists. Three veteran artists of the Broadway stage -- actor and writer James Lecesne, choreographer and actor Gerry McIntyre and musical director Randy Redd -- came up with a novel idea to generate both money and support for hurricane relief in New Orleans. They came to Louisiana to stage a new production of the musical Once On This Island, which they would cast with local talent. Thirteen high school students, most of whom had lost homes and family members in the hurricane, were selected to appear in the play, and filmmaker Hilla Medalia captured the auditions, rehearsals and final show on film for the documentary AFTER THE STORM, which focuses on both the practical and the spiritual side of the long process of recovery from Katrina's impact. AFTER THE STORM received its world premiere at the 2009 Los Angeles Film Festival.
Plot Keywords:
Art / Artists | Behind The Scenes | Disaster | Documentary
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- International Shipping: 1 item


text:
Vintage Pair Christmas Hard Plastic Rosbro Snowman Snowmen Rosen Holiday Decor
This item has been shown 0 times.
Vintage Pair Christmas Hard Plastic Rosbro Snowman Snowmen Rosen Holiday Decor:
VINTAGE PAIRROSBRO ROSENPLASTIC SNOWMAN SNOWMENChristmas HOLIDAYDECORATIONS
For your consideration, I am offering this old vintage pair of Christmas holiday snowmen. These are plastic and I believe they were made by Rosbro ~ Rosen however they are not marked. The tallest guy stands approximately 7 1/2" tall and the shorter fella stands approximately 5" tall. The larger snowman would have held a light at one time. The smaller snowman would have possibly held a bottle brush tree?
They both show wear consistent with age and use. They have the normal yellowing of the glue joints, and the smaller one has a knick on his left foot and some very minor yellowing to the front. The smaller one also looks as if maybe he should have a pipe but it is now just a white stick in his mouth. The larger snowman appears to have a stubby cigar in his mouth.
These will make a fantastic addition to any vintage plastic figure or Christmas holiday collection!
These fellas are a recent estate find and are looking for a good home! Please feel free to ask any questions! Thanks for taking a look! Non Smoking ~ Pet Free Home
Vintage Pair Christmas Hard Plastic Rosbro Snowman Snowmen Rosen Holiday Decor:
Vintage Double Glo Honeycomb Snoman Snowman 13" Tall Christmas Decoration
Vintage Handcrafted Wood Bowling Pins Christmas Snowman & Penguin
Vintage Cmi/henton Snowman Figurine Hand Painted Christmas Letter S Holiday Fun
Beautiful Arthur Court Grape & Leaves Buffet Plate / Pie Caddy Stand Holder
Curtis Cd Player Clock Radio Space Saver Undercounter Kcr2609


text:
Greenwich Heights median real estate price is $156,459, which is more expensive than 70.8% of the neighborhoods in Kansas and 39.7% of the neighborhoods in the U.S.
The average rental price in Greenwich Heights is currently $1,389, based on NeighborhoodScout's exclusive analysis. The average rental cost in this neighborhood is higher than 91.0% of the neighborhoods in Kansas.
Greenwich Heights is a suburban neighborhood (based on population density) located in Wichita, Kansas.
Greenwich Heights real estate is primarily made up of medium sized (three or four bedroom) to large (four, five or more bedroom) single-family homes and townhomes. Most of the residential real estate is owner occupied. Many of the residences in the Greenwich Heights neighborhood are newer, built in 2000 or more recently. A number of residences were also built between 1970 and 1999.
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Ikomi, Fumitaka, James Hunt, Gayda Hanna, and Geert W. Schmid-Schönbein. Interstitial fluid, plasma protein, colloid, and leukocyte uptake into initial lymphatics.J. Appl. Physiol. 81(5): 2060–2067, 1996.—Lymphatics serve to remove from the interstitium a range of materials, including plasma proteins, colloid materials, and cells. Lymph flow rates can be enhanced by periodic tissue compression or venous pressure elevation, but little is known to what degree enhancement of lymph flow affects material transport. The objective was to examine the uptake of plasma proteins, a colloidal perflubron emulsion (LA-11063, mean particle diameter = 0.34 μm), and leukocytes into lymphatics. Prenodal collecting lymphatics in the lower hindlimb of rabbits were cannulated with and without foot massage and after elevation of venous pressure (40 mmHg). The average lymph flow rates were elevated ∼22-fold by the skin massage but only about threefold by venous pressure elevation. Lymph-to-plasma protein concentration ratio remained unchanged by the massage but decreased significantly after venous pressure elevation. Lymph colloid concentration and leukocyte counts were elevated on average 47 and 8.5 times, respectively, by foot massage, but both decreased after venous pressure elevation. These results suggest that skin movement by massage and elevation of the venous pressure lead to opposite lymph transport kinetics of protein, colloids, and cells. Massage is more effective to enhance material transport out of the interstitium into the initial lymphatics.
- rabbit skin
- skin massage
- lymph formation
- collecting lymphatics
- perfluorocarbon
- lymph fluid
the lymphatic system carries tissue fluid, proteins, and leukocytes from the interstitial space to the intravascular compartment and takes up exogenous particles from peripheral tissue spaces. For example, chylomicra absorbed in the intestinal wall enter the intestinal lymphatics (4) and tattoo dye, carbon particles, or colloidal gold from subcutaneous tissue are carried in lymphatics and deposited in lymph nodes (18, 26, 28). Even larger liposomes are trapped in regional lymph nodes after subcutaneous injection (8).
An understanding of material and cell uptake by the lymphatics is important for analysis of immunological control and diagnosis as well as treatment of lymph node abnormalities (25, 30). However, little is known about the uptake kinetics of the initial lymphatics from the interstitial space. In this report, we study lymphatic transport from the interstitium of the skin on the rabbit hind leg.
In the skin, the arterial pulse pressure serves as a basic lymph transport mechanism (16). The level of lymph flow generated by the arterial pulse pressure can be enhanced by either tissue massage or by elevation of the venous pressure (2, 11). However, there are currently few studies that provide a quantitative picture of lymph colloidal or cellular constituents after enhancement of lymph flow by either massage or after venous pressure elevation (17). In skeletal muscle, elevation of the lymph flow rate by venous pressure elevation is accompanied by reduced lymph protein concentrations (6). However, there are no reports about lymph transport after controlled tissue massage.
Accordingly, the present study was designed to examine the protein transport, transport of a colloid suspension (LA-11063, a brominated fluorochemical suspension of known particle dimensions), and transport of leukocytes in prenodal lymph vessels in the skin with and without massage and venous pressure elevation. A comparison is made under similar circumstances in a region of the skin where the microanatomy of the lymphatic network has previously been delineated (9, 11, 12).
Experimental preparation.
All animal procedures were previously reviewed and approved by the University of California, San Diego, Animal Subjects Committee. Studies were carried out on male New Zealand White rabbits (2.0–3.0 kg) anesthetized with pentobarbital sodium (30 mg/kg iv). Intermittent boluses of pentobarbital sodium were injected as needed during the experiment. The trachea was cannulated to ensure a patent airway. A catheter was inserted into the right external jugular vein for administration of drugs and into the carotid artery for systemic pressure measurement and blood collections. The catheters were filled with 10 U/ml heparinized (original solution of heparin = 1,000 U/ml) saline (Baxter Healthcare, Deerfield, IL). Oral temperature was monitored and maintained at 38–39°C by using a heating pad.
Lymph fluid was collected by cannulating one of the lymphatics (300–500 μm in diameter) in the lower left leg before it enters the popliteal node, as described previously (10). Briefly, cannulations were made under a stereomicroscope. The free tip of the lymph drainage cannula was positioned 5 cm below the cannulation site to create a constant negative hydrostatic pressure. To promote lymph flow, the toe portion of the foot was rotated passively in a sagittal plane with an electric motor on a circle with a diameter of 6 cm. The rotational velocity was constant at a rate of 0.1 Hz.
Formation of hind leg edema.
To increase left hind leg venous pressure and generate a mild edema, a blood pressure cuff was placed on the upper left leg above the knee at a position that was proximal to the popliteal node and the cannulation site. The cuff was inflated to 40 mmHg. The venous pressure was continuously monitored in the lower left leg via a polyethylene cannula (PE-50 tubing) placed into a small vein parallel to the tendo calcaneus on the lateral side of the lower left hind leg (11).
Lymph and blood measurements.
Lymph flow rates were measured by timed collection into 50-μl microsyringes. The leukocyte count in each lymph sample was determined with a hemocytometer. Colloid osmotic pressure and protein concentration of plasma and lymph were measured with an osmometer with PM10 Diaflo ultrafiltration membrane (10,000 mol wt cutoff; Amicon, Danvers, MA) (13, 31). This osmometer has a perforated stainless steel membrane support. Normal saline was used to fill the solvent compartment of the osmometer. About 0.1 ml of sample is required for each measurement, and equilibrium was obtained after 3 min. The osmometer membrane was washed three times with normal saline between readings. All measurements were performed at room temperature (22–23°C).
The lymph-to-plasma protein concentration ratio was determined from simultaneously collected aliquots of plasma and lymph. Blood samples were collected from the arterial catheter into heparinized syringes (final heparin concentration = 10 U/ml) and spun for 10 min at 2,500 revolutions/min. The supernatant plasma was used in the osmometer measurements. Lymph samples were measured without any treatment. To construct a calibration curve, the oncotic pressure of bovine serum albumin (Sigma Chemical, St. Louis, MO) solution in saline was obtained (at 0.3, 1.0, 3.0, 10.0 g/100 ml). Protein concentration in each lymph sample was determined by means of this calibration curve. At the same protein concentrations, rabbit plasma and human albumin exhibited similar oncotic pressure (13, 31).
LA-11063 was used to investigate the colloidal particle uptake from interstitial space into the lymphatic system. LA-11063 is a brominated perfluorochemical emulsion (60% wt/vol perflubron, perfluorooctyl bromide, and 4% wt/vol egg yolk phospholipid; Alliance Pharmaceutical, San Diego, CA). The egg yolk phospholipid surfactant ensures a stable suspension in which each perflubron particle is covered by a phospholipid layer. Particle diameter of LA-11063 was 0.34 ± 0.24 (SD) μm (Alliance Pharmaceutical). To determine LA-11063 concentration, the number of particles of LA-11063 were counted under a microscope with ×100 oil-immersion objective (numerical aperture 1.25, E. Leitz, Wetzlar, Germany) in a hemocytometer under a glass coverslip. The number of particles in a 200 × 200-μm-square field were counted four times for each sample. Before injection of LA-11063, no particles or only a negligible number could be seen in the lymph sample. Lymph samples with foot massage were diluted 1:10–1:100 because the original lymph contained too many particles to be recognized individually. To construct a calibration curve, the counting procedure with the hemocytometer was repeated with dilutions of the original LA-11063 emulsion in 0.5% bovine serum albumin in saline (10−3, 10−4, 10−5 dilutions). The concentration of LA-11063 in each lymph sample was determined by using this calibration curve.
Local tissue massage.
Gentle hand massage was performed on the rabbit's skin over the injection site of LA-11063. For this purpose, the forefinger and middle and third fingers were placed on the skin with slight pressure and rotated horizontally in a circular direction with diameter of ∼3 cm at a frequency of ∼3 Hz. Massage was applied for 15 min at the end of each experimental protocol. This procedure was carried out by a single operator and gave reproducible lymph flow rates (9).
Experimental protocol.
Lymph was collected 1 h before and during the first, second, and third hours after LA-11063 injection (0.1 ml) into the dorsal skin of the rabbit's foot. After lymph sample collections, the foot was gently massaged for 15 min and then the lymph collection was repeated. The samples served to determine lymph flow rate, leukocyte count, LA-11063 concentration, colloid osmotic pressure, and protein concentration. After this procedure, Evans blue dye and an albumin solution were injected at the same location of the previous LA-11063 injection. This served to visually identify the drainage area feeding into the cannulated lymphatic vessel.
All results are expressed as means ± SE. Two-tailed Student'st-test for paired or unpaired data or a one-way analysis of variance was used to test for significant differences between groups. Differences between groups were considered significant at P < 0.05.
In both the control saline-injection group and the LA-11063 group, the lymph flow rates without massage remained constant in time throughout the experiment (Fig. 1). There was no significant difference between the saline and LA-11063 groups at any time point. Application of local skin massage led to a significant elevation of the lymph flow rates, on average from 0.10 ± 0.01 to 1.27 ± 0.11 (SE) ml/h in the saline-injection group (P < 0.01) and from 0.10 ± 0.02 to 1.61 ± 0.50 ml/h in the LA-11063-injection group (P < 0.01) (Fig.1). The effect of massage on lymph flow rate was virtually instantaneous and could be maintained for several hours.
The lymph-to-plasma protein ratio remained below one and was unaffected by the saline/LA-11063 injections and had a tendency to reach, on average, slightly higher levels after local tissue massage (Fig.2 A, not significant). No significant changes were observed in plasma or lymph plasma oncotic pressure over a period of 3 h after saline/LA-11063 injection (Table 1). The lymph plasma protein clearance (lymph-to-plasma protein concentration ratio × lymph flow rate) was significantly elevated after massage, mostly due to the increased lymph flow rates (Fig.2 B). Massage of the rabbit's skin at the injection site, however, increased the average LA-11063 concentration 47 times (Fig.3 A) and average lymph flow rates ∼22 times (Fig.3 B).
Massage also increased lymph leukocyte count significantly in both the saline control and the LA-11063 groups (Fig.4 A). During the control period without massage, the lymph leukocyte counts were on the order of 100 cells/mm3. After massage, the lymph leukocyte counts increased from 107 ± 20 to 1,414 ± 465 cells/mm3 in the saline-injection group and from 121 ± 31 to 1,264 ± 278 cells/mm3 in the LA-11063-injection group (P < 0.01) (Fig.5 A). No significant differences were observed between the saline and the LA-11063 groups, with and without massage. As product of lymph leukocyte count and lymph flow rate, the average lymph leukocyte flux was elevated by massage some 183–194 times in the saline and LA-11063 group, respectively, compared with without massage (Fig.5 B).
In contrast to the situation during application of skin massage, which instantaneously raised lymph transport, a slower time-dependent increase in lymph flow rate was encountered after elevation of the venous pressure with the cuff (Fig. 5). Therefore, all measurements of lymph transport with venous pressure elevation by the cuff will be presented in form of a time course.
The elevated venous pressure increased lymph flow rate from 0.12 ± 0.03 ml/h in the control period to 0.35 ± 0.08 (0–1 h) and 0.56 ± 0.14 ml/h (1–2 h) in the saline-injection group and from 0.10 ± 0.03 to 0.40 ± 0.03 (0–1 h) and 0.58 ± 0.06 ml/h (1–2 h) in the LA-11063-injection group. The colloid osmotic pressure in lymph decreased after application of the cuff (Table 2). The lymph-to-plasma protein ratios decreased during pressure elevation (Fig.6 A), which led to only about a threefold increase in lymph plasma protein clearance (Fig. 6 B). During swelling of the hind leg, the lymph LA-11063 concentration tends to fall (Fig.7 A), therefore resulting, despite the elevated flow rate, in only a mild increase in LA-11063 transport rate (Fig.7 B). The lymph leukocyte concentration also undergoes a decrease after swelling (Fig.8 A) without a significant shift in lymph leukocyte flux (Fig.8 B). There were no significant differences between the saline and LA-11063 groups.
These results suggest that tissue swelling by hind leg venous occlusion with a cuff and tissue movement by deformation of initial lymphatics lead to opposite lymphatic uptake kinetics of plasma proteins, colloidal particles, and leukocytes, despite the fact that both serve to enhance lymph flow rates. Repeated tissue deformation leads to instantaneous enhancement of the lymph flow rate (Fig. 1), in line with the frequency and tissue area that is subject to massage (11). The enhancement of lymph flow by tissue massage can be maintained over several hours, even after reduction of the central blood pressure by arrest of the heart (11). In contrast, enhancement of lymph flow after application of an inflated cuff requires time (Fig. 5) and is accompanied by reduced transport of materials with a wide range of dimensions, from plasma proteins to the size of leukocytes (Figs.6, 7, 8).
The elevation of the lymph flow rates by raising venous pressure to 40 mmHg (Fig. 5) is close to the maximum effect that can be achieved in this preparation by cuff occlusion without significantly shifting vascular permeability (6). Lower pressure elevations lead to lower lymph flow enhancement, whereas elevation of the pressure >40 mmHg toward arterial pressure levels may lead to enhanced lymph flow rates. Lymph flow enhancement by tissue massage is significantly more effective and has not necessarily reached peak values because lymph flow rates are frequency dependent (11) and the current massage frequency of ∼3 Hz was selected only as a practical limit. Higher frequencies of massage may lead to further enhancement of lymph flow rates. Periodic tissue motion is also a more effective mechanism for removal of macromolecular and cellular materials from the interstitium.
Inflation of a cuff over the upper hind leg is accompanied not only by venous and capillary pressure elevations in the lower hind leg but also by edema formation and possible reduction of blood flow in the hind leg. Interstitial and lymphatic edema formation serve to dilute interstitial material, which may, in part, be the reason for the dilution observed under these conditions. Thus inflation of the cuff may affect the entire chain of interstitial fluid transport and lymph formation, but it has less influence on the rhythmic expansion and compression of the initial lymphatics in this preparation.
The lymphatics in the skin of rabbit hindlimb are of the initial type, deeply embedded in connective tissue at the base of hair follicles and in the adventitia of subdermal arterioles (12). These initial lymphatics start as blind channels, form a meshlike network structure, and possess intraluminal valves. Initial lymphatics have a single attenuated endothelial lining and no smooth muscle (15). Their luminal cross section is irregular and may be collapsed. To pump lymph fluid, the initial lymphatics need to be cyclically compressed and expanded by either a pulse pressure, vasomotion, or external tissue compression in the form of massage. Initial lymphatic endothelial cells have discontinuous tight junctions and show an overlap between adjacent endothelial cells. Lymph and interstitial fluid communicate through gaps between two adjacent tight junctions of the endothelium. Also, flaps of initial lymphatic endothelial cells are attached by anchoring filaments to adjacent collagen fibers (3, 15). The characteristic overlap between adjacent lymphatic endothelial cells may provide a valvelike configuration (endothelial microvalves) that facilitates unidirectional movement of interstitial fluid from interstitium into the lymphatics (23, 24). Whereas it is possible that the lymphatic interendothelial junctions can be separated (with openings in the range of micrometers) by a mechanical pulling on the endothelial cells (5), the present results suggest that these junctions allow the entry not only of colloid-sized particles from the interstitium but even of leukocytes (∼6 μm in diameter).
The initial lymphatics drain into collecting lymphatics that can pump actively by using lymphatic smooth muscle (7, 32). At the cannulation point, the collecting lymphatics have valves and a single layer of loosely arranged smooth muscle cells surrounding the endothelium. Some smaller initial lymphatics are positioned in the adventitia of the collecting lymphatics. Lymph from specific areas in the dermis of the foot are relatively isolated and not significantly contaminated by connections from surrounding lymphatics (1). For this reason, lymph dilution from tissue adjacent to the injection site may not significantly affect the colloid concentration in the cannulated afferent lymphatic. This contention is supported by the observation that lymph from cannulated lymphatics becomes blue after injection of Evans blue albumin at the same sites as the LA-11063 colloid suspension or saline injections. Few, if any, other prenodal lymphatic channels away from the collection site contain Evans blue under these conditions.
Lymph protein flux was increased >10 times by massage (Fig. 2). This may be due, in part, to the fact that massage may serve to increase uptake of protein from the interstitium as well as leakage from blood vessels. Vibration of the canine hindlimb also increased lymph protein flux (19). In contrast, elevation of the venous pressure tends to reduce lymph protein concentration (6, 20) (Fig.6 A) so that, despite elevated lymph flow rates, the actual transport of proteins by the lymphatics in the skin is only slightly enhanced (Fig.6 B).
Many colloidal materials injected subcutaneously can be absorbed and transported by lymphatics, including colloidal gold (0.05–0.25 μm in diameter) (26), colloidal carbon (18), or fluorocarbon suspensions (10). The particles accumulate in regional lymph nodes. The transport is associated, however, with considerable dilution of the suspension. For example, the lymphatic colloidal concentration 1 h after subcutaneous injection was 0.05 mg/ml, which is much lower than that of the original density of 600 mg/ml. Local skin massage over the injection site served to increase the LA-11063 concentration in lymph by about two orders of magnitude, and LA-11063 flux increased by about three orders of magnitude (Fig. 3). Convective transport of LA-11063 through the large interendothelial gaps of initial lymphatics may increase with increased flow caused by massage. Clearance of radiolabeled colloids from pigskin can be increased by massage (17), in agreement with the present observations.
Colloidal particles may also be transported via an intracellular pathway after phagocytosis by tissue macrophages. The magnitude of intracellular transport after subcutaneous injection is smaller (3–4 orders of magnitude lower) than extracellular convective transport in the form of free particles. Several days after the injection, however, the extracellular transport becomes progressively less significant, and the intracellular removal of interstitial colloidal particle deposits becomes the dominating mode of removal by the lymphatics. The intracellular transport can also be enhanced by tissue massage (10).
LA-11063 emulsion is predominantly made up of perflubron-containing particles. Each particle is composed of perflubron and encapsulated by a phospholipid layer. Perflubron is radiopaque, has the ability to carry oxygen, and has been used as an magnetic-resonance-image contrast medium (21). Perflubron is also being developed as an artificial blood (Alliance Pharmaceutical) because of its high oxygen solubility. Furthermore, because of its radiopacity and echogenicity, emulsified perflubron has been used widely in preclinical radiological analysis (22). Emulsified perflubron can be used for lymph node imaging (30) and as an adjuvant for tumor radiotherapy (29). Analysis of particle uptake by lymphatics may contribute to further understanding of diagnostic procedures and treatment of lymphatic cancer metastasis by drug targeting.
Typical values of leukocyte counts in prenodal lymphatics of the extremities are 200–400 cells/μl in rabbits (14) or sheep (27). A surprising result of the present experiments was the large enhancement of lymphatic leukocyte flux during skin massage (Fig. 4) in contrast to the low counts of leukocytes after venous pressure elevation (Fig. 8). This may be important for immunological control functions and intracellular transport by lymphocytes (9). The lymph leukocyte count without skin massage was, on average, 200 cells/μl in the prenodal lymphatics, which increased with massage to ∼1,500 cells/μl. A previous study in the dog hindlimb suggests that after 2 min at 60 Hz mechanical vibration, the lymph leukocyte count increased from ∼250 to 500 cells/μl (19). Because the mechanical massage leads to almost instantaneous increase in leukocyte counts in the lymphatics, some of the leukocytes may have resided in the interstitium before mechanical stimulation. The elevated leukocyte counts in the lymphatics can be maintained for several hours by massage, suggesting that eventually the leukocyte trafficking from the vasculature may be enhanced as well. Morphologically, the majority of leukocytes in prenodal lymphatics resemble blood lymphocytes. Their exact phenotype remains to be identified. Compared with leukocyte migration from blood vessel to interstitium, the mechanism of leukocyte transport in the interstitial space toward and into the initial prenodal lymphatics has not been well defined.
The authors thank Dr. B. W. Zweifach for his many valuable suggestions.
Address for reprint requests: G. W. Schmid-Schönbein, Dept. of Bioengineering, Institute for Biomedical Engineering, Univ. of California, San Diego, La Jolla, CA 92093-0412.
This work was supported in part by National Heart, Lung, and Blood Institute Grant HL-10881 and Program Project Grant HL-43026 (Dr. Shu Chien, Director).
- Copyright © 1996 the American Physiological Society


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Elevating Table, Slit Lamp Table, Phoroptor Table, Vision Tester Table
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CORRECTIONAL Services describes parole as an integrated part of the penal system, granted when an offender has demonstrated during incarceration that he or she has been rehabilitated.
The offender must show that he or she is unlikely to be a danger to society and that there is a full awareness of and contrition for the crime committed.
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