text:
Household Edition (1873). 10.5 cm high by 13.8 cm wide (4 ⅛ by 5 ⅜ inches), framed, p. 237. Chapter 34. Running head: "Taken in Hand by Mr. Tulkinghorn" (243). [Click on the image to enlarge it.]— thirty-sixth illustration by Fred Barnard in the
"Sergeant," the lawyer proceeds in his dry passionless manner, far more hopeless in the dealing with than any amount of vehemence, "make up your mind while I speak to you, for this is final. After I have finished speaking I have closed the subject, and I won't re-open it. Understand that. You can leave here, for a few days, what you say you have brought here if you choose; you can take it away at once if you choose. In case you choose to leave it here, I can do this for you—I can replace this matter on its old footing, and I can go so far besides as to give you a written undertaking that this man Bagnet shall never be troubled in any way until you have been proceeded against to the utmost, that your means shall be exhausted before the creditor looks to his. This is in fact all but freeing him. Have you decided?"
The trooper puts his hand into his breast and answers with a long breath, "I must do it, sir."
So Mr. Tulkinghorn, putting on his spectacles, sits down and writes the undertaking, which he slowly reads and explains to Bagnet, who has all this time been staring at the ceiling and who puts his hand on his bald head again, under this new verbal shower-bath, and seems exceedingly in need of the old girl through whom to express his sentiments. The trooper then takes from his breast-pocket a folded paper, which he lays with an unwilling hand at the lawyer's elbow. "'Tis only a letter of instructions, sir. The last I ever had from him." [Chapter XXXIV, "A Turn of the Screw," 243]
Matthew Bagnet and George Rouncewell meet with Mr. Tulkinghorn in his offices at Lincoln's Inn Fields after Joshua Smallweed has turfed them out: he and then the lawyer turn the screw on the military men in order to extract Hawdon's handwritten documents. If George does not capitulate, Tulkinghorn will sue Bagnet for the principal and interest of George's loan.
The scene follows Mrs. Roucewell's leaving her consultation with the old attorney in his inner office. In departing through the outer office, the Dedlocks' housekeeper at Chesney Wold has failed to recognize her estranged son, who has kept his back to her, as if studying something mounted on the wall. Tulkinghorn reveals himself to be entirely without scruple or sympathy as he is quite prepared to sue the hapless Bagnet since he is the cosigner to George's loan and George cannot lay his hands on the funds necessary to pay Smallweed out. This is our first assessment of Tulkinghorn as merciless, predatory, and determined, and therefore conditions our response to his murder.
Related Material, including Other Illustrated Editions of Bleak House
- Bleak House (homepage)
- Phiz's Illustrations for Bleak House (March 1852 - September 1853)
- Sir John Gilbert's Frontispiece in the New York edition (Vol. 1, 1863)
- O. C. Darley's Frontispiece in the New York edition (Vol. 2, 1863)
- O. C. Darley's Frontispiece in the New York edition (Vol. 3, 1863)
- O. C. Darley's Frontispiece in the New York edition (Vol. 4, 1863)
- Sol Eytinge, Junior's 16 Diamond Edition Illustrations (1867)
- Harry Furniss's Illustrations for the Charles Dickens Library Edition (1910)
- Kyd's five Player's Cigarette Cards, 1910
Scanned image, colour correction, sizing, caption, and commentary by Philip V. Allingham. [You may use this image without prior permission for any scholarly or educational purpose, as long as you (1) credit the person who scanned the image, and (2) link your document to this URL in a web document or cite the Victorian Web in a print one.]
"Bleak House — Sixty-one Illustrations by Fred Barnard." Scenes and Characters from the Works of Charles Dickens, Being Eight Hundred and Sixty-six Drawings by Fred Barnard, Gordon Thomson, Hablot Knight Browne (Phiz), J. McL. Ralston, J. Mahoney, H. French, Charles Green, E. G. Dalziel, A. B. Frost, F. A. Fraser, and Sir Luke Fildes. London: Chapman and Hall, 1907.
Collins, Philip. Dickens and Crime. London: Macmillan, 1964.
Davis, Paul. Charles Dickens A to Z: The Essential Reference to His Life and Work. New York: Facts On File, 1998.
Dickens, Charles. Bleak House. Illustrated by F. O. C. Darley and John Gilbert. The Works of Charles Dickens. The Household Edition. New York: Sheldon and Company, 1863. Vols. 1-4.
_______. Bleak House. Illustrated by Sol Eytinge, Jr, and engraved by A. V. S. Anthony. 14 vols. Boston: Ticknor & Fields, 1867. VI.
_______. Bleak House, with 61 illustrations by Fred Barnard. Household Edition. London: Chapman and Hall, 1873. IV.
_______. Bleak House. Illustrated by Harry Furniss [28 original lithographs]. The Charles Dickens Library Edition. Vol. 11. London: Educational Book, 1910.
_______. Bleak House, ed. Norman Page. Harmondsworth: Penguin, 1971.
Hammerton, J. A. "Chapter 18: Bleak House." The Dickens Picture-Book. The Charles Dickens Library Edition. London: Educational Book, 1910. XVII, 366-97.
Vann, J. Don. "Bleak House, twenty parts in nineteen monthly instalments, October 1846—April 1848." Victorian Novels in Serial. New York: The Modern Language Association, 1985. 69-70.
Created 15 March 2021


The department may pay a local health department, as defined in s. 250.01 (4)
, that submits certified cost reports for services described under subd. 1.
a percentage of the federal funds claimed for those services, which percentage is established in the most recent biennial budget.
The department shall select a payment procedure under either par. (a)
and may change which procedure under par. (a)
is selected. The department shall notify each county department and local health department, as applicable, of the selected payment procedure before the date on which payment for services is made under that selected or newly selected procedure.
(53m) Coverage program for institutions for mental disease.
Subject to any necessary waiver approval of the federal department of health and human services, or as otherwise permitted under federal law, the department may, if federal funding participation is available, provide Medical Assistance coverage of services provided in an institution for mental disease to persons ages 21 to 64.
(54) Therapy for children participating in the birth to 3 program. 49.45(54)(a)(a)
Federal share for county expenditures.
If a county certifies to the department that the amount the county expended to provide services specified under s. 49.46 (2) (b) 6. b.
to children participating in the early intervention program under s. 51.44
exceeds the amount the county received as reimbursement under this section, based on reimbursement rates established by the department for those services, and the federal government pays the state the federal share of Medical Assistance for the amount by which the county expenditures exceed the reimbursement, the department may disburse the federal share to the county. A county that receives moneys under this paragraph shall expend the moneys for early intervention services under s. 51.44
or for services under the disabled children's long-term support program, as defined in s. 46.011 (1g)
From the appropriations under s. 20.435 (4) (b)
and (7) (bt)
, the department may pay the costs of services provided under the early intervention program under s. 51.44
that are included in program participant's individualized family service plan and that were not authorized for payment under the state Medicaid plan or a department policy before July 1, 2017, including any services under the early intervention program under s. 51.44
that are delivered by a type of provider that becomes certified to provide Medical Assistance service on July 1, 2017, or after.
(56) Disease management program.
Based on the health conditions identified by the physical health risk assessments, if performed under sub. (57)
, the department shall develop and implement, for Medical Assistance recipients, disease management programs. These programs shall have at least the following characteristics:
The use of information science to improve health care delivery by summarizing a patient's health status and providing reminders for preventive measures.
Educating health care providers on health care process improvement by developing best practice models.
The improvement and expansion of care management programs to assist in standardization of best practices, patient education, support systems, and information gathering.
Establishment of a system of provider compensation that is aligned with clinical quality, practice management, and cost of care.
Focus on patient care interventions for certain chronic conditions, to reduce hospital admissions.
(57) Physical health risk assessment.
The department shall encourage each individual who is determined on or after October 27, 2007, to be eligible for Medical Assistance to receive a physical health risk assessment as part of the first physical examination the individual receives under Medical Assistance.
(58) Program for all-inclusive care for the elderly.
The department may administer the program of all-inclusive care for the elderly under 42 USC 1396u-4
(59) Health maintenance organization payments to hospitals. 49.45(59)(a)(a)
The department shall, from the appropriation accounts under s. 20.435 (4) (xc)
, pay each health maintenance organization with which it contracts to provide medical assistance a monthly amount that the health maintenance organization shall use to make payments to hospitals under par. (b)
Health maintenance organizations shall pay all of the moneys they receive under par. (a)
to eligible hospitals, as defined in s. 50.38 (1)
, within 15 days after receiving the moneys. The department shall specify in contracts with health maintenance organizations to provide medical assistance a method that health maintenance organizations shall use to allocate the amounts received under par. (a)
among eligible hospitals based on the number of discharges from inpatient stays and the number of outpatient visits for which the health maintenance organization paid such a hospital in the previous month for enrollees who are recipients of medical assistance. Payments under this paragraph shall be in addition to any amount that a health maintenance organization is required by agreement between the health maintenance organization and a hospital to pay the hospital for providing services to the health maintenance organization's enrollees.
Each health maintenance organization that provides medical assistance shall report to the department each month the amount it paid each hospital under par. (b)
and the percentage of the total payments it made under par. (b)
that it paid to each hospital.
Each health maintenance organization that provides medical assistance shall report monthly to each hospital to which the health maintenance organization makes payments under par. (b)
such information regarding the payments that the department specifies in its contract with the health maintenance organization to provide medical assistance.
If the department determines that a health maintenance organization has not complied with a requirement under pars. (b)
, the department shall order the health maintenance organization to comply with the requirement within 15 days after the department's determination of noncompliance.
The department may terminate a contract with a health maintenance organization to provide medical assistance if the health maintenance organization fails to comply with a requirement under pars. (b)
The department may audit a health maintenance organization to determine whether the health maintenance organization has complied with the requirements under pars. (b)
The department shall specify in contracts with health maintenance organizations to provide medical assistance the method for adjusting payments under par. (b)
to correct a health maintenance organization's inaccurate counting of inpatient discharges or outpatient visits in calculating a monthly payment to a hospital under par. (b)
If a health maintenance organization and hospital do not agree on the amount of a monthly payment that the health maintenance organization is required to pay the hospital under par. (b)
, either the health maintenance organization or the hospital, within 6 months after the first day of the month in which the payment is due, may request that the department determine the amount of the payment. The department shall determine the amount of the payment within 60 days after the request for a determination is made. The health maintenance organization or hospital is, upon request, entitled to a contested case hearing under ch. 227
on the department's determination.
(60) Savings account program.
The department shall submit to the federal department of health and human services a request for a waiver of federal Medicaid law to establish and implement a savings account program that is similar in function and operation to health savings accounts in the Medical Assistance program under this subchapter. The department shall exclude from any requirement to have a Medical Assistance savings account under the waiver request under this subsection any individual who is elderly, blind, or disabled and any child.
(61) Services provided through telehealth and communications technology. 49.45(61)(a)1.
“Asynchronous telehealth service” is telehealth that is used to transmit medical data about a patient to a provider when the transmission is not a 2-way, real-time, interactive communication.
“Interactive telehealth” means telehealth delivered using multimedia communication technology that permits 2-way, real-time, interactive communications between a certified provider of Medical Assistance at a distant site and the Medical Assistance recipient or the recipient's provider.
“Remote patient monitoring” is telehealth in which a patient's medical data is transmitted to a provider for monitoring and response if necessary.
“Telehealth” means a practice of health care delivery, diagnosis, consultation, treatment, or transfer of medically relevant data by means of audio, video, or data communications that are used either during a patient visit or a consultation or are used to transfer medically relevant data about a patient. “Telehealth” does not include communications delivered solely by audio-only telephone, facsimile machine, or electronic mail unless the department specifies otherwise by rule.
Subject to par. (e)
, the department shall provide reimbursement under the Medical Assistance program for any benefit that is a covered benefit under s. 49.46 (2)
and that is delivered by a certified provider for Medical Assistance through interactive telehealth.
Subject to par. (e)
, the department shall provide reimbursement under the Medical Assistance program for all of the following:
Except as provided by the department by rule, a consultation pertaining to a Medical Assistance recipient conducted through interactive telehealth between a certified provider of Medical Assistance and the Medical Assistance recipient's treating provider that is certified under Medical Assistance.
Except as provided by the department by rule, remote patient monitoring of a Medical Assistance recipient and asynchronous telehealth service in which the medical data pertains to a Medical Assistance recipient.
Except as provided by the department by rule and subject to par. (e) 4.
, services that are covered under the Medicare program under 42 USC 1395
et seq. for which the federal department of health and human services provides Medical Assistance federal financial participation and that are any of the following:
Any other telehealth or communication technology-based services.
Any service that is not specified in subds. 1.
or par. (b)
that is provided through telehealth and that the department specifies by rule under par. (d)
is a covered and reimbursable service under the Medical Assistance program.
The department shall promulgate rules specifying any services under par. (c) 4.
that are reimbursable under Medical Assistance. The department may promulgate rules excluding services under par. (c) 1.
from reimbursement under Medical Assistance. The department may promulgate rules specifying any telehealth service under par. (b)
or (c) 1.
that is provided solely by audio-only telephone, facsimile machine, or electronic mail as reimbursable under Medical Assistance.
The department may not require a certified provider of Medical Assistance that provides a reimbursable service under par. (b)
to obtain an additional certification or meet additional requirements solely because the service was delivered through telehealth, except that the department may require, by rule, that the transmission of information through telehealth be of sufficient quality to be functionally equivalent to face-to-face contact. The department may apply any requirement that is applicable to a covered service that is not provided through telehealth to any service provided under par. (b)
The department may not limit coverage or reimbursement of a service provided under par. (b)
based on the location of the Medical Assistance recipient when the service is provided.
The department may not cover or provide reimbursement under Medical Assistance for a service described under par. (c) 3.
that is first covered under the Medicare program under 42 USC 1395
et seq. after July 1, 2019, until the date that is one year after the date the service is covered under the Medicare program or the date the secretary explicitly approves the service as a Medical Assistance covered service, whichever is earlier.
History: 1971 c. 40
; 1971 c. 42
; 1971 c. 213
; 1971 c. 215
; 1973 c. 62
; 1973 c. 333
; 1975 c. 39
; 1975 c. 223
; 1975 c. 224
; 1975 c. 383
; 1975 c. 411
; 1977 c. 29
; 1979 c. 34
, 2102 (20) (a)
; 1979 c. 102
; 1981 c. 20
, 2202 (20) (r)
; 1981 c. 93
; 1983 a. 27
, 2200 (42)
; 1983 a. 245
; 1985 a. 29
, 3200 (23)
, (56), 3202 (27)
; 1985 a. 120
; 1985 a. 332
, 251 (5)
; 1985 a. 340
; 1987 a. 27
, 3202 (24)
; 1987 a. 186
; 1987 a. 403
; 1987 a. 413
; 1989 a. 6
; 1989 a. 31
; 1989 a. 107
; 1991 a. 22
; 1993 a. 16
; 1993 a. 27
; 1995 a. 20
; 1995 a. 27
, 9126 (19)
, 9130 (4)
, 9145 (1)
; 1995 a. 191
; 1997 a. 3
; 1999 a. 9
; 2001 a. 13
; 2003 a. 33
; 2005 a. 22
; 2005 a. 25
; 2005 a. 107
; 2007 a. 20
, 9121 (6) (a)
; 2007 a. 90
; 2009 a. 2
; 2011 a. 10
; 2011 a. 260
; 2013 a. 20
; 2013 a. 116
; 2013 a. 117
; 2013 a. 130
; 2013 a. 165
; 2013 a. 226
; 2015 a. 55
; 2017 a. 34
; 2019 a. 8
; 2019 a. 9
; 2021 a. 22
; 2021 a. 23
; 2021 a. 58
; 2021 a. 238
; 2021 a. 239
; 2021 a. 240
; 2021 a. 248
; 2023 a. 12
; s. 13.92 (1) (bm) 2.; s. 13.92 (2) (i).
Wisconsin has no medical assistance plan independent of Medicaid. Non-residence under federal Medicaid regulations is determinative of medical assistance eligibility. Pope v. DHSS, 187 Wis. 2d 207
, 522 N.W.2d 22
(Ct. App. 1994).
Section 49.89, not sub. (19) (a) 2., specifically addresses assignment of actions and subrogation of rights by a public assistance recipient who is injured and has a tort claim against a 3rd party. Ellsworth v. Schelbrock, 2000 WI 63
, 235 Wis. 2d 678
, 611 N.W.2d 764
Sub. (7) (a) requires that a health care facility resident who is a recipient of certain funds apply those funds toward the cost of care in the health care facility. The agent who received funds from the Social Security Administration on behalf of the resident has an obligation to pay the funds to the health care facility and is subject to an action for conversion. Methodist Manor of Waukesha, Inc. v. Martin, 2002 WI App 130
, 255 Wis. 2d 707
, 647 N.W.2d 409
Medical assistance eligibility is not a default position that the department must rebut, but a privilege for which the applicant must prove eligibility. An initial determination of eligibility does not preclude a later redetermination of that status. The state has an ongoing duty to ensure that a MA recipient is eligible and the recipient bears the ongoing burden of proving eligibility. Estate of Gonwa v. DHFS, 2003 WI App 152
, 265 Wis. 2d 913
, 668 N.W.2d 122
Sub. (2) (a) 9. does not direct the department to promulgate rules regarding conditions of reimbursement, but instead to include those conditions in a contract with the provider. A department handbook provision requiring odometer readings was a condition of reimbursement, not an administrative rule requiring promulgation. Meda-Care Vans of Waukesha, Inc. v. Division of Hearings and Appeals, 2007 WI App 140
, 302 Wis. 2d 499
, 736 N.W.2d 147
Medicaid reimbursement is governed by the “Methods of Implementation for Wisconsin Medicaid Nursing Home Payment Rates" adopted by the department under sub. (6m). Sub. (6m) (e) requires the department to establish an appeals mechanism within the department to review petitions for modifications to any payment under sub. (6m). The “Methods" provides that the nursing home appeals board is available for redress in the event a facility has extraordinary fiscal circumstances. The department does not have the authority to grant an increased reimbursement rate absent appeals board approval. Park Manor, Ltd. v. DHFS, 2007 WI App 176
, 304 Wis. 2d 512
, 737 N.W.2d 88
Sub. (3) (f) gives the Department of Health Services (DHS) the authority to recoup payments made to a Medicaid provider when that provider failed to maintain records as required by DHS for verification of the provider's claims, regardless of whether other records possessed by the provider show that the provider actually rendered the services in question. In this case, the records were not required, so DHS could not recoup payments. Newcap, Inc. v. Department of Health Services, 2018 WI App 40
, 383 Wis. 2d 515
, 916 N.W.2d 173
When read together, sub. (3) (f) 1. and 2. make it clear that a provider has an obligation to make the required records available to the Department of Health Services (DHS) at the time of an audit in order to allow DHS to verify the provider's claims, and DHS may recoup payments already made if the provider fails to do so. Newcap, Inc. v. Department of Health Services, 2018 WI App 40
, 383 Wis. 2d 515
, 916 N.W.2d 173
The fact that this section does not address testamentary trusts is not an indication the legislature gave consideration to whether payments from testamentary trusts should be included as unearned income for medical assistance eligibility purposes and concluded to the contrary. Tarrant v. Department of Health Services, 2019 WI App 45
, 388 Wis. 2d 335
, 933 N.W.2d 145
Under sub. (3) (f) 1. and 2., the Department of Health Services (DHS) may recoup Medicaid payments from service providers only in cases where DHS cannot verify one of the following: 1) the actual provision of covered services; 2) that the reimbursement claim is appropriate for the service provided; or 3) that the reimbursement claim is accurate for the service provided. A record imperfection alone is not an independent basis for recouping payments. DHS's practice of seeking recoupment of payments simply because a post-payment audit found that records were not perfect exceeded DHS's recoupment authority. Papa v. Department of Health Services, 2020 WI 66
, 393 Wis. 2d 1
, 946 N.W.2d 17
A contract between the trustees of a nursing home and a medical clinic for exclusive medical services under the medical assistance act for residents of such home violates public policy of this state. 59 Atty. Gen. 68.
Poverty is not a constitutionally suspect classification. Encouraging childbirth except in the most urgent circumstances is rationally related to the legitimate governmental objective of protecting potential life. Medical assistance discussed. Harris v. McRae, 448 U.S. 297
Medical Assistance & Divestment. Canellos. Wis. Law. Aug. 1991.
Counting promissory notes as assets for certain Medical Assistance programs. 49.452(1)(1)
In this section, “promissory note" means a written, unconditional agreement, given in return for goods, money loaned, or services rendered, under which one party promises to pay another party a specified sum of money at a specified time or on demand.
If an individual's assets are counted when determining or redetermining the individual's financial eligibility for Medical Assistance, the department shall include a promissory note as a countable asset if all of the following apply:
The individual applying for or receiving benefits under Medical Assistance or his or her spouse provided the goods, money loaned, or services rendered for the promissory note.
The promissory note was entered into or purchased on or after July 14, 2015.
The promissory note is negotiable, assignable, and enforceable and does not contain any terms making it unmarketable.
A promissory note is presumed to be negotiable and its asset value is the outstanding principal balance at the time the individual applies for Medical Assistance or at the time the individual's eligibility for Medical Assistance is redetermined, unless the individual shows by credible evidence from a knowledgeable source that the note is nonnegotiable or has a different current market value, which will then be considered the asset value.
History: 2015 a. 55
Divestment of assets. 49.453(1)(am)
“Covered individual" means an individual who is an institutionalized individual or a noninstitutionalized individual.
“Community spouse" means the spouse of either the institutionalized person or the noninstitutionalized person.
“Expected value of the benefit" means the amount that an irrevocable annuity will pay to the annuitant during his or her expected lifetime as determined under sub. (4) (c)
“Look-back date" means either of the following:
For transfers made before February 8, 2006, the date that is 36 months before, or with respect to payments from a trust or portions of a trust that are treated as assets transferred by the covered individual under s. 49.454 (2) (c)
or (3) (b)
the date that is 60 months before:
For a covered individual who is an institutionalized individual, the first date on which the covered individual is both an institutionalized individual and has applied for medical assistance.
For a covered individual who is a noninstitutionalized individual, the date on which the covered individual applies for medical assistance or, if later, the date on which the covered individual, his or her spouse, or another person acting on behalf of the covered individual or his or her spouse, transferred assets for less than fair market value.
For all transfers made on or after February 8, 2006, the date that is 60 months before the dates specified in subd. 1m. a.
“Reasonable compensation" means the prevailing local market rate of compensation for the service or care provided.


text:
From Our Editors
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domain: food


A new report into the use of biological therapies to treat inflammatory bowel disease (IBD) has found that new biosimilar* medicines, which work in the same way as the more expensive existing treatments, are safe and effective for patients and if adopted could reduce the cost of treatment by half.
Biological therapies are drugs that are produced by a biological rather than chemical process and block the excessive inflammation that occurs in diseases such as IBD, a serious life-long condition causing inflammation to the bowel. This year’s national clinical audit of biological therapies for IBD, published by the Royal College of Physicians on behalf of the IBD audit programme today (September 22), is the latest report to assess the use of these therapies in treating the condition.
The audit is the first to include data on new Infliximab ‘biosimilar’ drugs Inflectra and Remsima, now being used on patients as alternatives to the original Remicade in the treatment of IBD. These drugs have been available in the UK from February 2015 and are designed to have active properties similar to the biological treatment already licensed.
The report finds that biological therapies, which have revolutionised the treatment of IBD, are safe and are increasingly used on patients in the UK. It recommends the adoption of Infliximab biosimilars, as the data indicates they work as well as the original therapies and are far more cost effective to provide. Their use can reduce the cost of treatment from approximately £10,000 per patient per year to less than £5,000.
The audit, which was focused only on patients starting treatment with biological therapies, found that a fifth of patients are currently receiving Infliximab biosimilars and if the therapy was extended to all patients in the audit it would equate to an annual saving to the NHS of £3 million. The potential overall saving to the NHS could be much higher if patients already established on these therapies also switched to biosimilar substitutes. Remicade is used in the UK to treat a number of serious health conditions including IBD and in 2014 providing the therapy to patients cost the NHS £142 million**.
The majority of hospitals in the UK treating patients with IBD took part in the RCP audit. It included 3,000 patients (adults, children and young people) who began biological therapy treatment in the 12 months to February 2016, the largest number entered in a single year since the audit started in 2011.
The report, commissioned by the Healthcare Quality Improvement Partnership as part of the National Clinical Audit Programme (NCA), highlights that patients continue to benefit from being on biological therapies. These are being adopted earlier in the treatment of patients with IBD and frequency of surgery prior to treatment has reduced (from 36% of adults in 2011 to 15% in 2016). Patients are also reporting improvement in their health and quality of life after starting treatment.
However it also notes with concern that not all patients are pre-screened for infections before undergoing biological therapy treatment. It recommends that full pre-screening in line with NICE guidelines*** takes place with all patients before treatment starts to reduce the chances of an adverse reaction. It also cautions against the over use of steroids in the treatment of IBD and stresses the importance of systematic patient monitoring afterwards to check and record outcomes.
Several areas for improvement and of note are contained in the report:
- A need for comprehensive pre-treatment infection screening – only 60% of adult and 47% of paediatric patients audited had complete pre-treatment screening for opportunistic infections
- Better post-treatment monitoring - only 31% of adult and 44% of paediatric patients audited in 2016 were recorded as having been followed up at 3 months
- Biological treatments are being used earlier in the disease course. The median time from diagnosis to treatment for adult patients has fallen from 4.5 years in 2012 to 3.8 years in 2016.
Key recommendations include:
- Clinicians should completely screen all patients for infections prior to treatment with biological therapies
- Clinicians should document follow-up in all patients within 3 months and at 1 year following initial treatment with biologics. A record of disease activity should also be captured at these time points using a disease activity index
- Steroid use in all patients should be kept to a minimum. Infliximab has a steroid sparing effect and steroids should be stopped at the first opportunity
- Clinicians must continue to audit all patients on biological therapies to ensure safe and appropriate use.
The 2016 national clinical audit of biological therapies for UK inflammatory bowel disease (IBD), hosted by the Royal College of Physicians (RCP), is the last IBD audit to be undertaken by the inflammatory bowel disease programme. In order to continue to monitor the effectiveness of biological therapies and the impact of treatments on outcomes, quality and patient care, reporting into the IBD registry, where possible, should remain a priority for IBD services.
Dr Ian Arnott, IBD programme clinical director and Consultant Gastroenterologist at Western General Hospital, Edinburgh said:
This report is the first from the UK IBD audit to include data on the safety and effectiveness of biosimilar Infliximab to treat inflammatory bowel disease. The analysis shows that biosimilars are as effective as originals during initial treatment, which is invaluable knowledge for doctors balancing budget contraints with providing the best care for their patients.
This will be the final report produced by the UK IBD audit at the Royal College of Physicians. We are currently in the process of transitioning the data collection to the UK IBD Registry. It is hoped this will further drive safe and effective use of these medicines.
Dr Richard K Russell, Consultant Paediatric Gastroenterologist at the Royal Hospital for Children, Glasgow said:
This report highlights the significant benefits of using biosimilar medicines in adults with IBD are equally applicable to children and young people. It is important that having established this we continue to audit the safety and effects of these medicines in the longer term. The significant cost savings that this represents will hopefully now be reinvested into local IBD services to continue to further improve patient care.
For further information or a copy of the report contact Jane McCormick by phone on 020 3075 1354 or email at firstname.lastname@example.org.
*Biosimilar refers to a biopharmaceutical drug designed to have active properties similar to one that has previously been licensed. Biosimilars are officially approved versions of original drugs. They can be manufactured when the original product's patent expires.
** NICE, 2011. Technology appraisal 187: Infliximab (review) and adalimumab for the treatment of Crohn’s disease.www.nice.org.uk/guidance/TA187
*** Health and Social Care Information Centre. Hospital Prescribing England 2013–2014. Health and Social Care Information Centre. 12 November 2014. http://www.hscic.gov.uk/catalogue/PUB15883/hosp-pres-eng-201314-rep.pdf
Inflammatory bowel disease (IBD) encompasses Crohn’s disease, ulcerative colitis and IBD unclassified
This round of audit is of particular interest due to the emerging availability of Infliximab biosimilars (Inflectra and Remsima) which became available in the UK from February 2015. This report is the first audited data in the UK comparing the original biological therapy Infliximab (Remicade) to its biosimilar versions (Inflectra and Remsima).
UK Inflammatory Bowel Disease (IBD) Programme
The national clinical audit of biological therapies is commissioned by Healthcare Quality Improvement Partnership (HQIP) as part of the National Clinical Audit Programme (NCA)*. The UK IBD audit programme is carried out by the Royal College of Physicians on behalf of the IBD audit programme steering group.
National Clinical Audit of Biological Therapies - UK Inflammatory Bowel Disease (IBD) Audit 2016
This is the fifth biological therapy report published from the UK IBD audit. This report publishes national and hospital-level findings on the efficacy, safety and appropriate use of biological therapies for patients newly started on biologics since its inception on 12 September 2011 until 29 February 2016. The report data is taken from completed submissions within the biological therapy audit web tool. A full and executive summary copy of this report is available in the public domain via the Royal College of Physicians (RCP) website.
About HQIP, the National Clinical Audit Programme and how it is funded
The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact that clinical audit has on healthcare quality in England and Wales. HQIP holds the contract to manage and develop the National Clinical Audit Programme, comprising more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual audits, also funded by the Health Department of the Scottish Government, DHSSPS Northern Ireland and the Channel Islands.
UK IBD Registry
Further information about the UK IBD Registry.


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The constructive kcalorie burning associated with human body as distinguished from catabolism
- the synthesis in residing organisms of more technical substances (age.g., living tissue) from simpler people alongside the storage space of power
- The useful metabolic rate of the human body, as distinguished from katabolism.
1886; see anabolic + -ism.
accumulating or building together; the building of cells in the human body. The term opposing to catabolism.
(letter.) The useful k-calorie burning regarding the body, as distinguished from katabolism.

domain: medical


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Senators power-up in 5-2 win over Ducks
Akron went 0-for-5 with runners in scoring position in Saturday's loss.
HARRISBURG, PA – Harrisburg’s Wilson Ramos slugged a three-run homer in the third inning Saturdaynight, one of three Senators home runs in a 5-2 victory over the Akron RubberDucks at Metro Bank Park.
Ramos, appearing with the Senators on a minor league rehab assignment from the Washington Nationals, jacked a threerunshot to right off Cody Anderson (2-6) to snap a 1-1 tie. Eight batters came to the plate in the inning, which proved tobe Anderson’s last. Rick Hague doubled and Jeff Kobernus walked prior to the Ramos’s rainmaker.
The series is now even at one-game apiece with the rubber game scheduled for Sunday at 2:00 p.m. The RubberDucks(44-31) saw their four-game win streak come to an end, while the Senators (29-43) snapped a five-game skid.
Akron’s Joe Wendle launched a solo homer to right with two outs in the first inning, giving the Ducks a 1-0 lead againstformer Akron star Paolo Espino. Harrisburg’s Kevin Keyes tied it with a solo shot on the first pitch he saw from Andersonin the second inning to tie it up, 1-1. It was Keyes’ 11th of the year.
The RubberDucks pulled to within 4-2, in the fifth when Ronny Rodriguez doubled and came home to score on a fieldingerror by Keyes. After that, the Senators bullpen rose to the occasion, stifling the RubberDucks on one hit over the last four innings. Derek Self worked three scoreless frames, and Robert Benincasa authored a perfect ninth for his first AA save.
Anderson left after three innings, and was saddled with his third straight loss. Jordan Cooper picked up the slack, hurling four innings of impressive relief. He retired the first seven batters he faced, firing 19 strikes among his first 20 pitches. Heallowed only a solo homer to Hague leading off the seventh to make it 5-2. Lefty Giovanni Soto worked the ninth, strikingout two.
Espino (3-3), Akron’s all-time strikeout leader during his tenure in the Indians organization, lasted five innings and allowedjust four hits to pick up the win. He struck out eight and did not walk a batter. He evened his record on the season overalland against the RubberDucks, who beat him at Canal Park on June 1st, 6-3.
Rodriguez and Anthony Gallas had two hits apiece for Akron. Alex Lavisky was 0-4, ending a six-game hitting streak.The RubberDucks and Senators will finish up the series on Sunday afternoon at 2:00. It will also conclude the road trip forAkron. RHP Duke von Schamann (3-1, 3.09) will oppose Harrisburg RHP A.J. Cole (6-3, 2.78). The game will bebroadcast on WARF 1350 AM and www.AkronRubberDucks.com.
The Akron RubberDucks are the Double-A affiliate of the Cleveland Indians. The 2014 season is the 18th since moving toCanal Park and the first as the RubberDucks. For more information, including official team merchandise, go towww.AkronRubberDucks.com or call 330-253-5151. Fans may also follow the team on Facebook atwww.facebook.com/AkronRubberDucks and Twitter at @AkronRubberDuck.

domain: sports


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Welcome to the inaugural issue of my Unusual Option Activity Briefing.
During the week, I look for unusual options activity and at the end of the week; I highlight the most compelling options activity that occurred. In addition, I will be looking at potential catalysts that could drive the stocks I cover upward or downward towards the strike prices that the unusual options activity occurred.
The way I determine the most compelling ideas is by using my ThinkorSwim platform to scan the market and to see which ideas have the most potential upside/downside. For example, if stock "XYZ" is trading at $25 and has a large call buy at the $26 strike, and then say stock "ABC" is also trading at $25 and has a large call buy at the $29 strike, I will cover "ABC" because of the higher potential upside.
Unusual Call Activity #1: Host Hotels & Resorts (NYSE:HST)
On Tuesday January 12th, there was a purchase of 10,000 April $16 calls. At closing that day, the stock was priced at $14.33, which implied a potential upside of 11.65%.
Action Since Trade: Since this trade was initiated, the share price has fallen from $14.33 to $13.10 at the time of writing this and with that drop, the potential upside has increased from 11.65% to 22.14% if the stock were to reach the $16 strike price by expiration.
Catalyst: HST reports earnings on February 17th and that is a potential catalyst that could send shares of HST to the $16 strike price of the options that were purchased. This seems to be a quality idea because as the table below shows, HST has beat earnings in each of the last four quarters.
[Image from HST Zacks page]
Unusual Call Activity #2: iStar (NYSE:STAR)
On Tuesday January 14th, there was a purchase of 2,450 July $12 calls. At closing that day, the stock was priced at $10.66, which implied a potential upside of 12.57%.
Action Since Trade: Since this trade was initiated, the share price has fallen from $10.66 to $10.24 at the time of writing this. With that drop, the potential upside has increased from 12.57% to 17.19% if the stock were to reach the $12 strike price by expiration.
Catalyst: With this call buyer purchasing calls in July, they are getting two potential catalysts the first of which is when STAR reports earnings on February 18th and the second is when the company reports its 1st quarter earnings this spring as well. While HST has seen small consistent earnings beats, STAR has a wide range of earnings quarter to quarter as the table below shows. As the table below shows, when STAR does beat earnings, they do so by a wide margin.
[Image from STAR Zacks page]
Unusual Put Activity #1: Newfield Exploration (NYSE:NFX)
On Tuesday January 12th, there was a purchase of 7,831 March $25 puts. At closing that day, the stock was priced at $29.31, which implied a potential downside of 14.70%.
Action Since Trade: Since this trade was initiated, the share price has fallen from $29.31 to $26.00 at the time of writing this. With that drop, the potential downside has decreased from 14.70% to 3.85% because the stock has fallen nearly 7% in today's massive sell-off.
Catalyst: This put buyer is getting one catalyst in the form of an earnings report on February 23rd as well as the continued long-term catalyst of oil market weakness. As the chart below shows, Newfield posted positive earnings in the fourth quarter of 2014, but since then, its earnings have been significantly negative. I expect with the continued drop in oil that when NFX reports earnings on February 23rd, they will once again post another quarter of record losses.
[Chart Data from Gurufocus]
Unusual Put Activity #2: Exelon (NYSE:EXC)
On Wednesday January 13th, there was a purchase of 12,400 April $25 puts. At closing that day, the stock was priced at $27.54, which implied a potential downside of 9.22%.
Action Since Trade: Since this trade was initiated, the share price has fallen from $27.54 to $27.25 at the time of writing this. With that drop, the potential downside has decreased from 9.22% to 8.26% if the stock were to reach the $25 strike price by expiration.
Catalyst: Since EXC is a utility, they don't usually have big jumps for earnings, so I looked at what potential catalysts there were that could occur by April and found that there is the possibility that their proposed merger with Pepco (NYSE:POM) could be thwarted. Just a couple weeks ago, there was a news story about how the GSA urged regulatory agencies to reject the deal. If this deal were to fall through, I would expect that EXC shares would decline.
As this is the inaugural issue, I would love to hear reader's thoughts on this new series. I hope the comments section can be a place to discuss unusual options activity that fellow readers see in the market.
Disclaimer: See here.
Disclosure: I/we have no positions in any stocks mentioned, and no plans to initiate any positions within the next 72 hours. I wrote this article myself, and it expresses my own opinions. I am not receiving compensation for it (other than from Seeking Alpha). I have no business relationship with any company whose stock is mentioned in this article.

domain: finance


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Select your stay dates to check availability at Euro Hotel
About the Hotel
When you stay at Euro Hotel in Pieve Santo Stefano, you'll be within the vicinity of Michelangelo Museum. This hotel is within the region of Podesteria di Michelangelo and The Rock of Adam.
Make yourself at home in one of the 50 air-conditioned rooms featuring minibars. Complimentary wireless Internet access keeps you connected, and satellite programming is available for your entertainment. Private bathrooms have complimentary toiletries and bidets. Conveniences include safes, and both irons/ironing boards and cribs/infant beds (surcharge) are available on request.
Take in the views from a rooftop terrace and make use of amenities such as complimentary wireless Internet access and gift shops/newsstands.
Take advantage of the hotel's room service (during limited hours). Quench your thirst with your favorite drink at a bar/lounge.
Business, Other Amenities
Featured amenities include express check-in, complimentary newspapers in the lobby, and a 24-hour front desk. Free self parking is available onsite.
- Free newspapers in lobby
- Free self parking
- Rooftop terrace
- Express check-in
- Accessible bathroom
- Roll-in shower
- In-room accessibility
- Number of buildings/towers - 1
- Number of floors - 4
- 24-hour front desk
- Gift shops or newsstand
- Laundry facilities
- Total number of rooms - 50
- Multilingual staff
- Shopping on site
- Television in common areas
- Free WiFi
- One meeting room
- Free breakfast
- Free toiletries
- In-room safe
- Satellite TV service
- Soundproofed rooms
- Room service (limited hours)
- Premium TV channels
- Rollaway/extra beds available
- In-room climate control (air conditioning)
- Connecting/adjoining rooms available
- Iron/ironing board (on request)
- Pay movies
- Cribs/infant beds (surcharge)
- Free WiFi
- Private bathroom
- Hair dryer
Know Before You Go
- All guests, including children, must be present at check-in and show their government-issued photo ID card or passport.
- Cash transactions at this property cannot exceed EUR 2999.99, due to national regulations. For further details, please contact the property using information in the booking confirmation.
- The property has connecting/adjoining rooms, which are subject to availability and can be requested by contacting the property using the number on the booking confirmation.
- Guests can arrange to bring pets by contacting the property directly, using the contact information on the booking confirmation.
- Crib (infant bed) fee: EUR 10.00 per night
- Rollaway bed fee: EUR 20.00 per night

domain: travel


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Log in if you have an account
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FINAL SALE. NO RETURNS. NO EXCHANGES.
A G-Star RAW graphic is placed at the upper chest. The Gsraw GR hooded sweater is designed with a kangaroo pocket, a 3-panel hood and a crossover front. Drawcords offer adjustability, while the ribbed edges along the cuffs and waist complete this comfortable fit.
- 3-panel hood with a crossover front- drawcords
- Long sleeves, straight inset
- Ribbed cuffs and waist
- Kangaroo pocket
- G-Star RAW graphic at chest
- G-Star RAW print at the lower sleeve
Model 5' 10 | Size

domain: design


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Posted on March 18, 2020
Bitcoin is Financial Detox
The term “crypto world” is still a highly ambiguous term. It includes developments that are, on the face of it, exactly opposite from each other and would actually have to be differentiated. One clear illustration of this would be the topic of DeFi. In recent months, crypto headlines have been dominated by Decentralized Finance. This new area of numerous financial applications on the Ethereum blockchain has grown rapidly and has been called the next big thing in crypto.
Ethereum proponents are visibly proud of all the DeFi achievements to date and are obtrusively rubbing them in Bitcoiners’ face. The former especially complain about Bitcoin’s rudimentary programmability, which does not allow for any financial innovation at the baselayer the same way we are seeing it with Ethereum, enabling the current money protocols in DeFi. Ultimately, the criticism by Ethereans revolves around the fact that Bitcoin has enabled decentralization in issuing and storing money, but not in matters of finance use cases. In the case of Bitcoin, finance still remains centralized and a world of finance evolving around Bitcoin would again be centralized, since it cannot be built by programming it into the Blockchain itself through sophisticated smart contracts. This makes Bitcoin users dependent on centralized entities such as exchanges all over again.
De-Financialization, not DeFi
What is considered a killer argument by some Ethereum bulls is, interestingly enough, interpreted by hardcore Bitcoiners as a sign that the critics have not understood what Bitcoin really is about. Thus, Decentralized Finance is not only a misconstruction due to recurring smart contract vulnerabilities, but also contradicts Bitcoin’s inner philosophy and objectives. The mother of all cryptoassets has set out to drive the de-financialization of this world; it is explicitly not about decentralizing the world of finance through shaky and buggy code. If Bitcoin has its way, the world needs healthy money, not another wave of new financialization.
Bitcoiners consider the ever-increasing financialization of our society to be the biggest problem of our time. According to the arguments by Bitcoiners, the distorting process of financialization has happened because our financial system is not tied to a scarce asset. The actual root of the problem Bitcoiners see in the closing of the gold window in 1971. Richard Nixon’s decision not to meet international demands for gold in exchange for dollars imposed a fiat money standard on the entire world.
The agony of fiat money
Bitcoiners are convinced that the world is affected by today’s fiat money standard in various ways, the sum of which is surely negative. Although prosperity has grown continuously over the past decades, the current fiat money standard has nevertheless put a golden yoke on us. Apart from the fact that the cost of living has risen (all things considered), much of our current prosperity should be correctly assessed as pseudo-prosperity. Because what nominally looks like prosperity and might be real prosperity for a certain period of life can only too quickly evaporate.
Thus, the financialization of today’s markets has led to an ever more delicate inflation of various assets in the economy. Today, a potential fall is enormous and it is difficult to estimate what would effectively turn out to be real and not pseudo-prosperity if the financial circumstances were to turn sour. Our financial world today operates on the principle of constant leverage, upon leverage, upon leverage. Credit is granted on the basis of loans that already serve as the basis for other credit operations. Different parties have valid claims to the same asset on their balance sheets. This is very the inflation of our economy is happening: several parties believe to actually own an asset, even though it exists only once. Such leverage can lead to a deflationary cascade in which pseudo-wealth (financial promises) vanishes in an instant. Financialization always means the indebtedness and fragility of the economy.
Old wine in new skins
In the eyes of Bitcoiners, the promotion and development of the DeFi world would once again create an unsustainable credit bubble, but based on the blockchain. Such financialization in a new dress could not be what “crypto” should really strive for. After all, any kind of financialization is inherently unstable. Sooner or later it would always turn out that the emperor is naked – no matter whether he presents himself in a new dress or not.
Bitcoin, on the other hand, sets out to break this financialization. But as reality shows, even Bitcoin itself is not immune to financialization. There are already countless Bitcoin derivatives and the cryptoasset is being integrated into the existing financial market structure by hedge funds and other financial players. An abstracted financial alchemy based on Bitcoin will be unavoidable. Paradoxically, given its structure as an absolutely scarce digital good, the derivatives and hedging market is therefore likely to assume even greater dimensions in relative terms when compared to the traditional world.
However, one essential difference, remains: Bitcoin (on-chain) cannot be manipulated or inflated on its base layer. The Bitcoin network knows neither a Fed nor a Plunge Protection Team that stands ready to intervene when push comes to shove. As a cryptographically secured asset, Bitcoin is also individually controllable. Anyone who wants to can control their Bitcoin independently of any financial alchemy. This gives each individual person unprecedented sovereignty in modern financial matters. As remarkable as that is, it should be exactly this way. For Bitcoin is probably the most abstract form of base money known to mankind to this day, the cryptoasset nevertheless has the best prerequisites to make the abstract financial alchemy of our days a little more bearable.
This article was made possible with the kind support of Bitalo, the first crypto exchange in Germany completely regulated by the BaFIN (https://bitalo.de).