who wrote the wagner matinee

"A Wagner Matineeby Willa Cather I received one morning a letter, written in pale ink on glassy, blue-lined notepaper, and bearing the postmark of a little Nebraska village.

A Wagner Matinee

This communication, worn and rubbed, looking as though it had been carried for some days in a coat pocket that was none too clean, was from my Uncle Howard and informed me that his wife had been left a small legacy by a bachelor relative who had recently died, and that it would be necessary for her to go to Boston to attend to the settling of the estate. He requested me to meet her at the station and render her whatever services might be necessary. On examining the date indicated as that of her arrival I found it no later than tomorrow. He had characteristically delayed writing until, had I been away from home for a day, I must have missed the good woman altogether. The name of my Aunt Georgiana called up not alone her own figure, at once pathetic and grotesque, but opened before my feet a gulf of recollection so wide and deep that, as the letter dropped from my hand, I felt suddenly a stranger to all the present conditions of my existence, wholly ill at ease and out of place amid the familiar surroundings of my study. I became, in short, the gangling farm boy my aunt had known, scourged with chilblains and bashfulness, my hands cracked and sore from the corn husking. I felt the knuckles of my thumb tentatively, as though they were raw again. I sat again before her parlor organ, fumbling the scales with my stiff, red hands, while she, beside me, made canvas mittens for the huskers. The next morning, after preparing my landlady somewhat, I set out for the station. When the train arrived I had some difficulty in finding my aunt. She was the last of the passengers to alight, and it was not until I got her into the carriage that she seemed really to recognize me. She had come all the way in a day coach; her linen duster had become black with soot, and her black bonnet gray with dust, during the journey. When we arrived at my boardinghouse the landlady put her to bed at once and I did not see her again until the next morning. Whatever shock Mrs. Springer experienced at my aunt's appearance she considerately concealed. As for myself, I saw my aunt's misshapen figure with that feeling of awe and respect with which we behold explorers who have left their ears and fingers north of Franz Josef Land, or their health somewhere along the Upper Congo. My Aunt Georgiana had been a music teacher at the Boston Conservatory, somewhere back in the latter sixties. One summer, while visiting in the little village among the Green Mountains where her ancestors had dwelt for generations, she had kindled the callow fancy of the most idle and shiftless of all the village lads, and had conceived for this Howard Carpenter one of those extravagant passions which a handsome country boy of twenty-one sometimes inspires in an angular, spectacled woman of thirty. When she returned to her duties in Boston, Howard followed her, and the upshot of this inexplicable infatuation was that she eloped with him, eluding the reproaches of her family and the criticisms of her friends by going with him to the Nebraska frontier. Carpenter, who, of course, had no money, had taken a homestead in Red Willow County, fifty miles from the railroad. There they had measured off their quarter section themselves by driving across the prairie in a wagon, to the wheel of which they had tied a red cotton handkerchief, and counting off its revolutions. They built a dugout in the red hillside, one of those cave dwellings whose inmates so often reverted to primitive conditions. Their water they got from the lagoons where the buffalo drank, and their slender stock of provisions was always at the mercy of bands of roving Indians. For thirty years my aunt had not been further than fifty miles from the homestead. But Mrs. Springer knew nothing of all this, and must have been considerably shocked at what was left of my kinswoman. Beneath the soiled linen duster which, on her arrival, was the most conspicuous feature of her costume, she wore a black stuff dress, whose ornamentation showed that she had surrendered herself unquestioningly into the hands of a country dressmaker. My poor aunt's figure, however, would have presented astonishing difficulties to any dressmaker. Originally stooped, her shoulders were now almost bent together over her sunken chest. She wore no stays, and her gown, which trailed unevenly behind, rose in a sort of peak over her abdomen. She wore ill-fitting false teeth, and her skin was as yellow as a Mongolian's from constant exposure to a pitiless wind and to the alkaline water which hardens the most transparent cuticle into a sort of flexible leather. I owed to this woman most of the good that ever came my way in my boyhood, and had a reverential affection for her. During the years when I was riding herd for my uncle, my aunt, after cooking the three meals--the first of which was ready at six o'clock in the morning-and putting the six children to bed, would often stand until midnight at her ironing board, with me at the kitchen table beside her, hearing me recite Latin declensions and conjugations, gently shaking me when my drowsy head sank down over a page of irregular verbs. It was to her, at her ironing or mending, that I read my first Shakespeare', and her old textbook on mythology was the first that ever came into my empty hands. She taught me my scales and exercises, too--on the little parlor organ, which her husband had bought her after fifteen years, during which she had not so much as seen any instrument, but an accordion that belonged to one of the Norwegian farmhands. She would sit beside me by the hour, darning and counting while I struggled with the ""Joyous Farmer,"" but she seldom talked to me about music, and I understood why. She was a pious woman; she had the consolations of religion and, to her at least, her martyrdom was not wholly sordid. Once when I had been doggedly beating out some easy passages from an old score of Euryanthe I had found among her music books, she came up to me and, putting her hands over my eyes, gently drew my head back upon her shoulder, saying tremulously, ""Don't love it so well, Clark, or it may be taken from you. Oh, dear boy, pray that whatever your sacrifice may be, it be not that. ""When my aunt appeared on the morning after her arrival she was still in a semi-somnambulant state. She seemed not to realize that she was in the city where she had spent her youth, the place longed for hungrily half a lifetime. She had been so wretchedly train-sick throughout the journey that she bad no recollection of anything but her discomfort, and, to all intents and purposes, there were but a few hours of nightmare between the farm in Red Willow County and my study on Newbury Street. I had planned a little pleasure for her that afternoon, to repay her for some of the glorious moments she had given me when we used to milk together in the straw-thatched cowshed and she, because I was more than usually tired, or because her husband had spoken sharply to me, would tell me of the splendid performance of the Huguenots she had seen in Paris, in her youth. At two o'clock the Symphony Orchestra was to give a Wagner program, and I intended to take my aunt; though, as I conversed with her I grew doubtful about her enjoyment of it. Indeed, for her own sake, I could only wish her taste for such things quite dead, and the long struggle mercifully ended at last. I suggested our visiting the Conservatory and the Common before lunch, but she seemed altogether too timid to wish to venture out. She questioned me absently about various changes in the city, but she was chiefly concerned that she had forgotten to leave instructions about feeding half-skimmed milk to a certain weakling calf, ""old Maggie's calf, you know, Clark,"" she explained, evidently having forgotten how long I had been away. She was further troubled because she had neglected to tell her daughter about the freshly opened kit of mackerel in the cellar, which would spoil if it were not used directly. I asked her whether she had ever heard any of the Wagnerian operas and found that she had not, though she was perfectly familiar with their respective situations, and had once possessed the piano score of The Flying Dutchman. I began to think it would have been best to get her back to Red Willow County without waking her, and regretted having suggested the concert. From the time we entered the concert hall, however, she was a trifle less passive and inert, and for the first time seemed to perceive her surroundings. I had felt some trepidation lest she might become aware of the absurdities of her attire, or might experience some painful embarrassment at stepping suddenly into the world to which she had been dead for a quarter of a century. But, again, I found how superficially I had judged her. She sat looking about her with eyes as impersonal, almost as stony, as those with which the granite Rameses in a museum watches the froth and fret that ebbs and flows about his pedestal-separated from it by the lonely stretch of centuries. I have seen this same aloofness in old miners who drift into the Brown Hotel at Denver, their pockets full of bullion, their linen soiled, their haggard faces unshaven; standing in the thronged corridors as solitary as though they were still in a frozen camp on the Yukon, conscious that certain experiences have isolated them from their fellows by a gulf no haberdasher could bridge. We sat at the extreme left of the first balcony, facing the arc of our own and the balcony above us, veritable hanging gardens, brilliant as tulip beds. The matinee audience was made up chiefly of women. One lost the contour of faces and figures-- indeed, any effect of line whatever-and there was only the color of bodices past counting, the shimmer of fabrics soft and firm, silky and sheer: red, mauve, pink, blue, lilac, purple, ecru, rose, yellow, cream, and white, all the colors that an impressionist finds in a sunlit landscape, with here and there the dead shadow of a frock coat. My Aunt Georgiana regarded them as though they had been so many daubs of tube-paint on a palette. When the musicians came out and took their places, she gave a little stir of anticipation and looked with quickening interest down over the rail at that invariable grouping, perhaps the first wholly familiar thing that had greeted her eye since she had left old Maggie and her weakling calf. I could feel how all those details sank into her soul, for I had not forgotten how they had sunk into mine when. I came fresh from plowing forever and forever between green aisles of corn, where, as in a treadmill, one might walk from daybreak to dusk without perceiving a shadow of change. The clean profiles of the musicians, the gloss of their linen, the dull black of their coats, the beloved shapes of the instruments, the patches of yellow light thrown by the green- shaded lamps on the smooth, varnished bellies of the cellos and the bass viols in the rear, the restless, wind-tossed forest of fiddle necks and bows-I recalled how, in the first orchestra I had ever heard, those long bow strokes seemed to draw the heart out of me, as a conjurer's stick reels out yards of paper ribbon from a hat. The first number was the Tannhauser overture. When the horns drew out the first strain of the Pilgrim's chorus my Aunt Georgiana clutched my coat sleeve. Then it was I first realized that for her this broke a silence of thirty years; the inconceivable silence of the plains. With the battle between the two motives, with the frenzy of the Venusberg theme and its ripping of strings, there came to me an overwhelming sense of the waste and wear we are so powerless to combat; and I saw again the tall, naked house on the prairie, black and grim as a wooden fortress; the black pond where I had learned to swim, its margin pitted with sun-dried cattle tracks; the rain-gullied clay banks about the naked house, the four dwarf ash seedlings where the dishcloths were always hung to dry before the kitchen door. The world there was the flat world of the ancients; to the east, a cornfield that stretched to daybreak; to the west, a corral that reached to sunset; between, the conquests of peace, dearer bought than those of war. The overture closed; my aunt released my coat sleeve, but she said nothing. She sat staring at the orchestra through a dullness of thirty years, through the films made little by little by each of the three hundred and sixty-five days in every one of them. What, I wondered, did she get from it? She had been a good pianist in her day I knew, and her musical education had been broader than that of most music teachers of a quarter of a century ago. She had often told me of Mozart's operas and Meyerbeer's, and I could remember hearing her sing, years ago, certain melodies of Verdi's. When I had fallen ill with a fever in her house she used to sit by my cot in the evening--when the cool, night wind blew in through the faded mosquito netting tacked over the window, and I lay watching a certain bright star that burned red above the cornfield--and sing ""Home to our mountains, O, let us return!"" in a way fit to break the heart of a Vermont boy near dead of homesickness already. I watched her closely through the prelude to Tristan and Isolde, trying vainly to conjecture what that seething turmoil of strings and winds might mean to her, but she sat mutely staring at the violin bows that drove obliquely downward, like the pelting streaks of rain in a summer shower. Had this music any message for her? Had she enough left to at all comprehend this power which had kindled the world since she had left it? I was in a fever of curiosity, but Aunt Georgiana sat silent upon her peak in Darien. She preserved this utter immobility throughout the number from The Flying Dutchman, though her fingers worked mechanically upon her black dress, as though, of themselves, they were recalling the piano score they had once played. Poor old hands! They had been stretched and twisted into mere tentacles to hold and lift and knead with; the palms unduly swollen, the fingers bent and knotted--on one of them a thin, worn band that had once been a wedding ring. As I pressed and gently quieted one of those groping hands I remembered with quivering eyelids their services for me in other days. Soon after the tenor began the ""Prize Song,"" I heard a quick drawn breath and turned to my aunt. Her eyes were closed, but the tears were glistening on her cheeks, and I think, in a moment more, they were in my eyes as well. It never really died, then-- the soul that can suffer so excruciatingly and so interminably; it withers to the outward eye only; like that strange moss which can lie on a dusty shelf half a century and yet, if placed in water, grows green again. She wept so throughout the development and elaboration of the melody. During the intermission before the second half of the concert, I questioned my aunt and found that the ""Prize Song"" was not new to her. Some years before there had drifted to the farm in Red Willow County a young German, a tramp cowpuncher, who had sung the chorus at Bayreuth, when he was a boy, along with the other peasant boys and girls. Of a Sunday morning he used to sit on his gingham-sheeted bed in the hands' bedroom which opened off the kitchen, cleaning the leather of his boots and saddle, singing the ""Prize Song,"" while my aunt went about her work in the kitchen. She had hovered about him until she had prevailed upon him to join the country church, though his sole fitness for this step, insofar as I could gather, lay in his boyish face and his possession of this divine melody. Shortly afterward he had gone to town on the Fourth of July, been drunk for several days, lost his money at a faro table, ridden a saddled Texan steer on a bet, and disappeared with a fractured collarbone. All this my aunt told me huskily, wanderingly, as though she were talking in the weak lapses of illness. ""Well, we have come to better things than the old Trovatore at any rate, Aunt Georgie?"" I queried, with a well-meant effort at jocularity. Her lip quivered and she hastily put her handkerchief up to her mouth. From behind it she murmured, ""And you have been hearing this ever since you left me, Clark?"" Her question was the gentlest and saddest of reproaches. The second half of the program consisted of four numbers from the Ring, and closed with Siegfried's funeral march. My aunt wept quietly, but almost continuously, as a shallow vessel overflows in a rainstorm. From time to time her dim eyes looked up at the lights which studded the ceiling, burning softly under their dull glass globes; doubtless they were stars in truth to her. I was still perplexed as to what measure of musical comprehension was left to her, she who had heard nothing but the singing of gospel hymns at Methodist services in the square frame schoolhouse on Section Thirteen for so many years. I was wholly unable to gauge how much of it had been dissolved in soapsuds, or worked into bread, or milked into the bottom of a pail. The deluge of sound poured on and on; I never knew what she found in the shining current of it; I never knew how far it bore her, or past what happy islands. From the trembling of her face I could well believe that before the last numbers she had been carried out where the myriad graves are, into the gray, nameless burying grounds of the sea; or into some world of death vaster yet, where, from the beginning of the world, hope has lain down with hope and dream with dream and, renouncing, slept. The concert was over; the people filed out of the hall chattering and laughing, glad to relax and find the living level again, but my kinswoman made no effort to rise. The harpist slipped its green felt cover over his instrument; the flute players shook the water from their mouthpieces; the men of the orchestra went out one by one, leaving the stage to the chairs and music stands, empty as a winter cornfield. I spoke to my aunt. She burst into tears and sobbed pleadingly. ""I don't want to go, Clark, I don't want to go! ""I understood. For her, just outside the door of the concert hall, lay the black pond with the cattle-tracked bluffs; the tall, unpainted house, with weather-curled boards; naked as a tower, the crook-backed ash seedlings where the dishcloths hung to dry; the gaunt, molting turkeys picking up refuse about the kitchen door. A Wagner Matinee was featured as The Short Story of the Day on Thu, Sep 19, 20135.8Create a library and add your favorite stories. Get started by clicking the ""Add"" button. Add A Wagner Matinee to your own personal library. Return to the Willa Cather Home Page, or . . . Read the next short story; On the Divide "


what does doctype mean

ion:doctype (Noun)A directive that associates an SGML or XML document (such as a webpage) with a Document Type Definition, potentially affecting how it is parsed and rendered. Origin: From document type.

Definitions &Translations

"Vocabulary What does doctype mean? Definitions for doctype Here are all the possible meanings and translations of the word doctype. Wiktionary (0.00 / 0 votes)Rate this definit

Numerology Chaldean Numerology The numerical value of doctype in Chaldean Numerology is: 5Pythagorean Numerology The numerical value of doctype in Pythagorean Numerology is: 7Images & Illustrations of doctype Translations for doctype From our Multilingual Translation Dictionarydoctype Ukrainian Get even more translations for doctype »Translation Find a translation for the doctype definition in other languages: Select another language: Discuss these doctype definitions with the community: Word of the Day Would you like us to send you a FREE new word definition delivered to your inbox daily? Please enter your email address: Subscribe Citation Use the citation below to add this definition to your bibliography: Style: MLA Chicago APA""doctype."" Definitions.net. STANDS4 LLC, 2018. Web. 2 Apr. 2018. < https://www.definitions.net/definition/doctype >. Are we missing a good definition for doctype? Don't keep it to yourself... Submit Definition "


does home health nurse need hospital experience

If you are looking for a job in healthcare that isn’t necessarily 9-to-5 with lots of independence, home health nursing just might be for you. Now, before you can embrace a career in home health you do need a couple of years experience in med/surg or ICU nursing or even the emergency room. You need to cement your day-to-day nursing skills. But once that is done, you are probably ready to get out and meet the public.

Get Out of the Hospital and Into Home Health Nursing July 31st, 2012By Jennifer Olin, BSN, RNBeing a registered nurse (RN) is the best! And apparently it’s going to stay that way according to the folks at to U. S. News & World Report. In their annual rankings of the best career choices in 2012, nursing topped the magazine’s list. Using measures such as projected job growth, average salary, and predicted job prospects, healthcare-related occupations filled five of the top ten picks. Number one, of course, was nursing with pharmacist, medical assistant, physical therapist, and occupational therapist filling other high- ranking spots. If you are a student trying to decide on a career path, clearly nursing could be a good choice. If you are looking for a career that offers many opportunities for growth and advancement, nursing is a good choice. And if you worry about getting bored, nursing is a great choice because there are so many different fields in nursing. Home Health Nursing Some areas of nursing are wide open as soon as you pass your licensing exam. Other areas require some experience before you can move into that specialty.

The focus of home healthcare nursing is individuals and their families. According to the American Nurses Association (ANA) home health nursing is a “synthesis of community health nursing and selected technical skills from other nursing specialties,” including medical/surgical nursing, psychiatric/mental health nursing, gerontology, parent/child nursing, and community heal

th. History of Home Health Nursing Home care has been an organized system of nursing in the United States for over 100 years. It developed in response to the needs and preferences of families to care for family members at home and because of the limitations and costs associated with institutional care.

Lillian Wald is widely regarded as the founder of visiting nursing or home healthcare in the U. S. and Canada. She is described as a nurse, social worker, public health official, teacher, author, editor, publisher, women's rights activist, and the founder of American community nursing. In 1893 she started teaching home classes on nursing for women living in the tenements on the Lower East Side of New York City. Not long after that she began to provide care for the ill and infirm residents of the same area. Along with another nurse, Mary Brewster, she was the founder of the Henry Street Settlement, dedicated to bringing nursing care, and eventually education to the immigrant poor on Manhattan’s Lower East Side. By 1906 she had expanded her services so much she had 27 nurses working by her side. The Henry Street Settlement is still in business tod

ay. Home Health Care Today Home health nurses will tell you there are significant advantages to caring for individuals and families in their own homes. The home setting is intimate. It helps foster familiarity, sharing, connections, and caring between clients, families, and their nurses.

Behavior in the home setting is more natural, cultural beliefs and practices are more visible and there is often exposure to multiple generations of family. When working in the home environment all the rules of the nursing process apply but some of the processes are a little different or expanded. For example, you don’t just assess the client, you assess their living space. The home health nurse obtains a health history for the client, reviews documentation, examines the client, observes the interaction between the client and the caregivers and assesses the environment. Parameters can include client and caregiver mobility, client’s ability to perform self-care, the cleanliness of the environment, the availability of caregiver support, safety, food preparation, financial supports, and the emotional status of both the client and the caregivers. Now you see why you need a wide range of experience before stepping into a home health career.

The home healthcare nurse is not just a care provider but also a teacher and an advocate for the client and their family. The nurse may have to intervene to mobilize resources of the community or a hospital to provide patient appropriate care. Home health nurses have first-hand knowledge of the burdens of caregiving.

There are many costs involved. Sometimes the caregiving demands can go on for months or years, placing the caregivers themselves at risk. Facing reality too, home health nurses must often enter homes where the living conditions and support systems are inadequate. When additional support or improved care cannot be obtained the home health nurse faces difficult decisions. Doing the Job There are some great benefits to working in home health. If you are tired of literally punching a time clock and being inside a hospital or clinic all the home health gives you frequent changes of setting. Want to be more your own boss? Home health offers lots of autonomy and less office or desk time than many jobs. You have the opportunity to create your own schedule when you are a home health nurse and working part-time is always an option. There are literally dozens of agencies in every city that provide home health care nurses. Of course, you have to keep in mind that home health care is not usually a quick visit, patients and families take more time, and you should probably enjoy driving and working out of your car. The most common patient base in home health is the elderly or the disabled young. You will look at a lot of decubitus ulcers, check a lot of urinary catheters and you should have good blood draw skills. According to the home health nurses I know you need to have a good sense of humor, be open minded, and be flexible. Your day will never go the way you plan, whether it’s traffic slowing you down or the need to jury-rig an IV pole out of a broomstick and vacuum cleaner for a rolling base, it’s probably not what you had planned when you first got in the car. Home health is a big industry, and it is unlikely to get smaller since shorter hospitalizations are the rule of the day and people are becoming more demanding about their healthcare options. If you truly like your patients and their families and often get talked to at work for spending too much time talking to your clients home health nursing just might be for you. Related Posts: Registered Nurse (RN)Kaplan University Online About Us Grand Canyon University Online University of Cincinnati Online Facebook Comments


what is the goal for the child with a cognitive impairment?

nt? Promoting optimum development The goal for children with cognitive impairment is the promotion of optimum social, physical, cognitive, and adaptive development as individuals within a family and community. Vocational skills are only one part of that goal. The focus must also be on the family and other aspects of development.

NURS 355 Chapter 21

"50 terms irishsulli7NURS 355 Chapter 21Learn Flashcards Write Spell Test Match Gravity Advertisement Upgrade to remove ads Like this study set? Create a free account to save it. Create a free account Maybe later Sort The American Association on Intellectual and Developmental Disabilities (AAIDD), formerly the American Association on Cognitive Impairment, classifies cognitive impairment based on what parameter? Adaptive skill domains The AAIDD has categorized cognitive impairment into adaptive skill domains. The child must demonstrate functional impairment in at least two of the following adaptive skill domains: communication, self-care, home living, social skills, use of community resources, self-direction, health and safety, functional academics, leisure, and work. Age of onset before 18 years is part of the former criteria. Low intelligence quotient (IQ) alone is not the sole criterion for cognitive impairment. Etiology is not part of the classification. Secondary prevention for cognitive impairment includes what activity? Newborn screening for treatable inborn errors of metabolism Secondary prevention involves activities that are designed to identify the condition early and initiate treatment to avert cerebral damage. Inborn errors of metabolism such as hypothyroidism, phenylketonuria, and galactosemia can cause cognitive impairment. Genetic counseling and avoidance of prenatal rubella infections are examples of primary prevention strategies to preclude the occurrence of disorders that can cause cognitive impairment. Preschool education and counseling services are examples of tertiary prevention. These are designed to include early identification of conditions and provision of appropriate therapies and rehabilitation services. What is a primary goal in caring for a child with cognitive impairme

Out-of-home care is considered part of the child's development. Optimum development includes adjustment for both the family and child. One of the techniques that has been especially useful for learners having cognitive impairment is called fading. What description best explains this technique? Gradually reduces the assistance given to the child so the child becomes more independent Fading is physically taking the child through each sequence of the desired activity and gradually fading out the physical assistance so the child becomes more independent. Positive reinforcement when tasks or behaviors are mastered is part of behavior modification. An essential component is ignoring undesirable behaviors. Verbal explanations are not as effective as demonstration and physical guidance. Consistent negative reinforcement is helpful, but positive reinforcement that focuses on skill attainment should be incorporated. The parents of a child with cognitive impairment ask the nurse for guidance with discipline. What should the nurse's recommendation be based on? Behavior modification is an excellent form of discipline Discipline must begin early. Limit-setting measures must be clear, simple, consistent, and appropriate for the child's mental age. Behavior modification, especially reinforcement of desired behavior and use of time-out procedures, is an appropriate form of behavior control. Aversive strategies should be avoided in disciplining the child. What intervention is most appropriate to facilitate social development of a child with a cognitive impairment? Provide peer experiences, such as infant stimulation and preschool programs. The acquisition of social skills is a complex task. Initially, an infant stimulation program should be used. Children of all ages need peer relationships. Parents should enroll the child in preschool. When older, they should have peer experiences similar to those of other children such as group outings, Boy and Girl Scouts, and Special Olympics. Providing age-appropriate toys and play activities is important, but peer interactions facilitate social development. Parents should expose the child to individuals who do not know the child. This enables the child to practice social skills. Verbal skills are delayed more often than physical skills. The nurse is discussing sexuality with the parents of an adolescent girl who has a moderate cognitive impairment. What factor should the nurse consider when dealing with this issue? Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. Adolescents with moderate cognitive impairment may be easily persuaded and lack judgment. A well-defined, concrete code of conduct with specific instructions for handling certain situations should be defined for the adolescent. Permanent contraception by sterilization presents moral and ethical issues and may have psychologic effects on the adolescent. It may be prohibited in some states. The adolescent needs to have practical sexual information regarding physical development and contraception. Cognitively impaired individuals may desire to marry and have families. The adolescent needs to be protected from individuals who may make intimate advances. The mother of a young child with cognitive impairment asks for suggestions about how to teach her child to use a spoon for eating. The nurse should make which recommendation? Do a task analysis first Successful teaching begins with a task analysis. The endpoint (self-feeding, toilet training, and so on) is broken down into the component steps. The child is then guided to master the individual steps in sequence. Depending on the child's functional level, using a spoon for eating should be an achievable goal. The child requires demonstration and then guided training for each component of the self-feeding. Feeding finger foods so spoon feeding is unnecessary eliminates some of the intermediate steps that are necessary to using a fork and spoon. For socialization purposes, it is desirable that a child use feeding implements. A newborn assessment shows a separated sagittal suture, oblique palpebral fissures, a depressed nasal bridge, a protruding tongue, and transverse palmar creases. These findings are most suggestive of which condition? Down syndrome These are characteristics associated with Down syndrome. An infant with microcephaly has a small head. Cerebral palsy is a diagnosis not usually made at birth; no characteristic physical signs are present. The infant with fragile X syndrome has increased head circumference; long, wide, or protruding ears; a long, narrow face with a prominent jaw; hypotonia; and a high-arched palate. A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the nurse that he is difficult to hold, that ""he's like a rag doll. He doesn't cuddle up to me like my other babies did."" What is the nurse's best interpretation of this lack of clinging or molding? A physical characteristic of Down syndrome Infants with Down syndrome have hypotonicity of muscles and hyperextensibility of joints, which complicate positioning. The limp, flaccid extremities resemble the posture of a rag doll. Holding the infant is difficult and cumbersome, and parents may feel that they are inadequate. A lack of clinging or molding is characteristic of Down syndrome, not detachment. There is no evidence of maternal deprivation. Autism is not associated with Down syndrome, and it would not be evident at 2 weeks of age. Many of the clinical features of Down syndrome present challenges to caregivers. Based on these features, what intervention should be included in the child's care? Use a cool-mist vaporizer to keep the mucous membranes moist and secretions liquefied. The constant stuffy nose forces the child to breathe by mouth, drying the mucous membranes and increasing the susceptibility to upper respiratory tract infections. A cool-mist vaporizer will keep the mucous membranes moist and liquefy secretions. Respiratory tract infections combined with cardiac anomalies are the primary cause of death in the first years. The child has a protruding tongue, which makes feeding difficult. The parents must persist with feeding while the child continues the physiologic response of the tongue thrust. The child is predisposed to constipation. Calories should be appropriate to the child's weight and growth needs, not mental age. What description applies to fragile X syndrome? Second most common genetic cause of cognitive impairment Fragile X syndrome is the most common inherited cause of cognitive impairment and the second most common genetic cause of cognitive impairment after Down syndrome. Fragile X primarily affects males and follows the pattern of X-linked dominant inheritance with reduced penetrance. The nurse should suspect a hearing impairment in an infant who fails to demonstrate which behavior? Babbling by age 12 months The absence of babbling or inflections in voice by at least age 7 months is an indication of hearing difficulties. Lack of eye contact is not indicative of a hearing loss. An infant with a hearing impairment might react to a loud noise but not respond to the spoken word. The child with hearing impairment uses gestures rather than vocalizations to express desires at this age. The nurse is talking with a 10-year-old boy who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. What intervention is the most appropriate nursing action? Suggest he reinsert the hearing aid The whistling sound is acoustic feedback. The nurse should have the child remove the hearing aid and reinsert it, making sure no hair is caught between the ear mold and the ear canal. Ignoring the sound or suggesting he raise the volume of the hearing aid would be annoying to others. The hearing aids are molded specifically for each ear. What technique facilitates lip reading by a hearing-impaired child? Speak at an even rate Help the child learn and understand how to read lips by speaking at an even rate. Avoiding using facial expressions, exaggerating pronunciation of words, and repeating in exactly the same way if the child does not understand interfere with the child's understanding of the spoken word. What condition is defined as reduced visual acuity in one eye despite appropriate optical correction? Amblyopia Amblyopia, or lazy eye, is reduced visual acuity in one eye. Amblyopia is usually caused by one eye not receiving sufficient stimulation. The resulting poor vision in the affected eye can be avoided with the treatment of the primary visual defect such as strabismus. Myopia, or nearsightedness, refers to the ability to see objects clearly at close range but not a distance. Hyperopia, or farsightedness, is the ability to see objects at a distance but not at close range. Astigmatism is unequal curvatures in refractive apparatus. The school nurse is caring for a child with a penetrating eye injury. Emergency treatment includes what intervention? Apply a Fox shield to the affected eye and any type of patch to the other eye. The nurse's role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if available) should be applied to the injured eye and a regular eye patch to the other eye to prevent bilateral movement. Placing cool compress on the eye during transport to emergency department, irrigating eye copiously with a sterile saline solution, or removing object with a lightly moistened gauze pad may cause more damage to the eye. A father calls the emergency department nurse saying that his daughter's eyes burn after getting some dishwasher detergent in them. The nurse recommends that the child be seen in the emergency department or by an ophthalmologist. The nurse also should recommend which action before the child is transported? Irrigate the eyes copiously with tap water for 20 minutes. The first action is to flush the eyes with clean tap water. This will rinse the detergent from the eyes. Keeping the eyes closed and applying cold compresses may allow the detergent to do further harm to the eyes during transport. Normal saline is not necessary. The delay can allow the detergent to cause continued injury to the eyes. A 5-year-old child has bilateral eye patches in place after surgery yesterday morning. Today he can be out of bed. What nursing intervention is most important at this time? Orient him to his immediate surroundings Safety is the priority concern. Because he can now be out of bed, it is imperative that he knows about his physical surroundings. Speaking to the child is a component of nursing care that is expected with all clients unless contraindicated. Unless additional impairments are present, his meal tray should be set up, and he should be able to feed himself. Reassuring him and allowing his parents to stay with him are essential parts of nursing care for all children. Autism is a complex developmental disorder. The diagnostic criteria for autism include delayed or abnormal functioning in which area with onset before age 3 years? Ability to maintain eye contact One hallmark of autism spectrum disorders is the child's inability to maintain eye contact with another person. Parallel play is play typical of toddlers and is usually not affected. Social, not gross motor, development is affected by autism. Physical growth and development are not usually affected. What intervention should be included in the nursing care of a child with autism spectrum disorder (ASD)? Communicate with the child at his or her developmental level. Children with ASD require individualized care. The nurse needs to communicate with the child at the child's developmental level. Consistent caregivers are essential for children with ASD. The same staff members should care for the child as much as possible. Children with ASD do not adapt to changing situations. The same foods should be provided to allow the child to adjust. A private room is desirable for children with ASD. Stimulation is minimized. What suggestion by the nurse for parents regarding stuttering in children is most helpful? Give the child plenty of time and the impression that you are not in a hurry. Hesitancy and dysfluency should be considered a normal part of speech development. An important approach is to allow the child plenty of time to speak. Promising rewards for proper speech places additional pressure on the child. Encouraging the child to take it easy and go slow when stuttering draws attention to the dysfluency. The child needs to complete a sentence and thought without being interrupted. What observation in a child should indicate the need for a referral to a specialist regarding a communication impairment? At 2 years of age, the child fails to respond consistently to sounds. If a 2-year-old child fails to respond consistently to sounds, it is an indication for referral to a specialist regarding communication impairment. At age 3 years, the child failing to use sentences of three words would be an indication for referral; impaired sentence structure would be seen in a 5-year-old child and poor voice quality in an older child who has a communication impairment. The nurse is performing a physical assessment on a 3-year-old child. The parents state that the child excessively rubs the eyes and often tilts the head to one side. What visual impairment should the nurse suspect? Myopia, or nearsightedness Clinical manifestations of myopia include excessive eye rubbing, head tilting, difficulty reading, headaches, and dizziness. Strabismus, astigmatism, and hyperopia have other clinical manifestations. The community nurse is planning prevention measures designed to avoid conditions that can cause cognitive impairment. Taking folic acid supplements during pregnancy to prevent neural tube defects is which type of prevention strategy? Primary Primary prevention strategies are those designed to avoid conditions that cause cognitive impairment. Use of folic acid supplements during pregnancy to prevent neural tube defects is a primary prevention strategy. Secondary prevention activities are those designed to identify the condition early and initiate treatment to avert cerebral damage. Tertiary prevention strategies are those concerned with treatment to minimize long-term consequences. Rehabilitation services is an example of tertiary prevention. The nurse is teaching a preschool child with a cognitive impairment how to throw a ball overhand. What teaching strategy should the nurse use for this child? Demonstrate how to throw a ball overhand Children with cognitive impairment have a deficit in discrimination, which means that concrete ideas are much easier to learn effectively than abstract ideas. Therefore, demonstration is preferable to verbal explanation, and the nurse should direct learning toward mastering a skill rather than understanding the scientific principles underlying a procedure. Demonstrating how to throw the ball is the best teaching strategy. The camp nurse is choosing a toy for a child with cognitive impairment to play with during swimming time. What toy should the nurse choose to encourage improvement of developmental skills? A large beach ball Toys are selected for their recreational and educational value. For example, a large inflatable beach ball is a good water toy; encourages interactive play; and can be used to learn motor skills such as balance, rocking, kicking, and throwing. Dive rings, an inner tube, and floating ducks are not interactive toys. The nurse is teaching feeding strategies to a parent of a 12-month-old infant with Down syndrome. What statement made by the parent indicates a need for further teaching? I will place the food on the top of the tongue Parents of a child with Down syndrome need to know that the tongue thrust does not indicate refusal to feed but is a physiologic response. Parents are advised to use a small but long, straight-handled spoon to push the food toward the back and side of the mouth. If food is thrust out, it should be refed. If the parent indicates placing the food on the tongue, further teaching is needed. The nurse is counseling a pregnant 35-year-old woman about estimated risk of Down syndrome. What is the estimated risk for a woman who is 35 years of age?c 1 in 350 The estimated risk of Down syndrome for a 35-year-old woman is one in 350. One in 1200 is the risk for a 25-year-old woman, one in 900 is the risk for a 30-year-old woman, and one in 100 is the risk for a 40-year-old woman. The nurse is teaching parents of a child with cataracts about the upcoming treatment. The nurse should give the parents what information about the treatment of cataracts? ""Cataracts require surgery to remove the cloudy lens and replace it."" Treatment for cataracts requires surgery to remove the cloudy lens and replace it (with an intraocular lens implant, removable contact lens, or prescription glasses). Treatment for glaucoma may require more than one surgery. Anisometropia is treated with corrective lenses. Myopia is corrected with biconcave lenses that focus rays on the retina. What action should the school nurse take for a child who has a hematoma (black eye) with no hemorrhage into the anterior chamber? Apply ice for the first 24 hours The care for a hematoma eye injury with no hemorrhage into the anterior chamber is to apply ice for the first 24 hours. A warm moist pack should not be applied, and the child should keep the eyes closed. Referral to an ophthalmologist is recommended if hyphema (hemorrhage into the anterior chamber) is present. The nurse is preparing an education program on hearing impairment for a group of new staff nurses. What concepts should be included? (Select all that apply.) A child with a slight hearing loss is usually unaware of a hearing difficulty. A clinical manifestation of a hearing impairment in children is avoidance of social interaction. A child with a severe hearing loss may hear a loud voice if nearby. A clinical manifestation of hearing impairment in an infant is lack of the startle reflex. When discussing hearing impairment in children, the nurse should include information about differences in hearing losses, such as with a slight hearing loss, the child is usually unaware of a hearing difficulty, and with a severe loss, the child may hear a loud noise if it is nearby. An infant with a hearing loss may lack the startle response, and a hearing impaired child may avoid social interaction. Children with a sensorineural hearing loss would not benefit from a hearing aid. Identification of a hearing loss is imperative in the first 3 to 6 months to facilitate language and educational development for children. The nurse understands that which gestational disorders can cause a cognitive impairment in the newborn? (Select all that apply.) Prematurity Postmaturity Low birth weight Prematurity, postmaturity, and low birth weight can be causes of cognitive impairment in newborns. Physiological jaundice and large for gestational age are not associated causes of cognitive impairment in newborns. The clinic nurse is assessing an infant. What are early signs of cognitive impairment the nurse should discuss with the health care provider? (Select all that apply.) Head lag at 11 months of age Unable to speak two to three words at 24 months of age Unresponsiveness to the environment at 12 months of age Early signs of cognitive impairment include gross motor delay (head lag should be established by 6 months, and head lag still present at 11 months is a delay), language delay (normal language development is speaking two to three words by age 12 months; if unable to speak two to three words at 24 months, that is a delay), and unresponsiveness to the environment at 12 months. No pincer grasp at 4 months of age is normal (palmar grasp is the expected finding), and colicky incidents at 3 months of age is a normal finding. The nurse is teaching parents of a child with a cognitive impairment signs that indicate the child is developmentally ready for dressing training. What signs should the nurse include that indicate the child is developmentally ready for dressing training? (Select all that apply.) Can follow verbal commands Can follow physical gestures or cues Can relate clothing to the appropriate body part Children are considered developmentally ready for dressing training if they can sit quietly for 3 to 5 minutes (not 1 to 2) while working on a task; can follow physical gestures or cues; can follow verbal commands; and can relate clothing to the appropriate body part, such as socks to feet. As with other self-help skills, the child may not be able to master every task but should be evaluated for evidence of willingness to participate at his or her level of readiness. The nurse is assessing a child with Down syndrome. The nurse recognizes that which are possible comorbidities that can occur with Down syndrome? (Select all that apply.) Congenital heart defects Respiratory tract infections Acute megakaryoblastic leukemia Children with Down syndrome often have multiple comorbidities, contributing to numerous other conditions. Respiratory tract infections are prevalent; when combined with cardiac anomalies, they are the chief cause of death, particularly during the first year. The incidence of leukemia is several times more frequent than expected in the general population, and in about half of the cases, the type is acute megakaryoblastic leukemia. A child has a slight (26-40 d B) degree of hearing loss. The nurse recognizes this amount of hearing loss can have what effect? (Select all that apply.) No speech defects Difficulty hearing faint speech Usually is unaware of the hearing difficulty A child with a slight degree of hearing loss has no speech defects, may have difficulty hearing faint speech, and is usually unaware of the hearing difficulty. The ability to distinguish vowels but not consonants is an effect of severe hearing loss and being unable to understand conversational speech is an effect of moderately severe hearing loss. What risk factors can cause a sensorineural hearing impairment in an infant? (Select all that apply.) Bacterial meningitis Childhood case of measles Administration of amino glycosides for more than 5 days Risk criteria for sensorineural hearing impairment in infants include bacterial meningitis; a case of measles; and administration of ototoxic medications (e.g., gentamicin, tobramycin, kanamycin, streptomycin), including but not limited to the aminoglycosides, for more than 5 days. Cat scratch disease and a childhood case of chicken pox are not risk factors that can cause a sensorineural hearing impairment. The nurse is teaching parents the signs of a hearing impairment in infants. What should the nurse include as signs? (Select all that apply.) Lack of a startle reflex to a loud sound Failure to localize a sound by 6 months of age Response to loud noise as opposed to the voice The fencing reflex is elicited when the infant is placed on his or her back; it does not indicate a hearing impairment. Awakening by a loud environmental noise is a normal response. The nurse is teaching parents the signs of a hearing impairment in a child. What should the nurse include as signs? (Select all that apply.) Yelling to express pleasure Asking to have statements repeated Foot stamping for vibratory sensation Failure to develop intelligible speech by 24 months of age Signs of a hearing impairment in a child include yelling to express pleasure, asking to have statements repeated, foot stamping for vibratory sensation, and failure to develop intelligible speech by age 24 months. The child's behavior is shy, not outgoing. The nurse should plan which actions to assist the stuttering child? (Select all that apply.) Set a good example by speaking clearly Give the child plenty of time to finish sentences Look directly at the child while he or she is speaking Actions to be encouraged to help the stuttering child include setting a good example by speaking clearly, giving the child plenty of time to finish sentences, and looking directly at the child while he or she is speaking. Asking the child to stop and start over and promising a reward for proper speech are actions to be avoided with stuttering children. The nurse should plan which actions to facilitate lipreading for a child with a hearing impairment? (Select all that apply.) Face the child directly Speak at eye level Keep sentences short Establish eye contact and show interest To facilitate lipreading, the nurse should plan to face the child directly, speak at eye level, keep sentences short, and establish eye contact and show interest. The nurse should plan to speak at a slow rate, not a fast one. What are indications for a referral regarding a communication impairment in a school-age child? (Select all that apply.) Barely audible voice quality Vocal pitch inappropriate for age Distortion of sounds after age 7 years Barely audible voice quality, vocal pitch inappropriate for age, and distortion of sounds after age 7 years are indications for a referral regarding a communication impairment. Intonation noted while speaking and maintaining a rhythm while speaking are normal characteristics of speech. Myopia Ability to see objects clearly at close range but not at a distance Hyperopia Ability to see objects at a distance but not at a close range Myopia Nearsighted Hyperopia Farsighted Astigmatism Unequal curvatures in refractive apparatus Anisometropia Different refractive strength in each eye Amblyopia Reduced visual acuity in one eye "


tobira stock price

We are reiterating a Buy rating on the common stock of Tobira Therapeutics with an updated price target (intrinsic value) of $34.88 using sum-of-the parts, enterprise DCF method. Tobira Therapeutics (NASDAQ: TBRA) announced the one-year results of a Phase 2 (CENTAUR) clinical trial in patients with non-alcoholic steato-hepatitis (NASH) on July 25.

"Why We Are Buying Tobira Therapeutics After A 'Failed' Phase 2 NASH Trial? Jul.26.16 | About: Tobira Therapeutics, (TBRA)Bob Sharma Registered investment advisor, portfolio strategy, biotech, contrarian Marketplace Vasuda Healthcare Analytics ( 4,492 followers)Summary Tobira Therapeutics announced the one-year results of a Phase 2 (CENTAUR) clinical trial in patients with non-alcoholic steato-hepatitis (NASH) on July 25. The clinical trial missed its primary end-point of at least a 2-point improvement in non-alcoholic fatty liver disease (NAFLD) score without worsening of liver fibrosis. On closer analysis, the study showed significant improvement in liver fibrosis (which is a more advanced stage in NASH and a harder end-point to achieve).

The clinical trial missed its primary end-point of at least a 2-point improvement in non-alcoholic fatty liver disease (NAFLD) score without worsening of liver fibrosis. On closer analysis, the study showed significant improvement in liver fibrosis (which is a more advanced stage in NASH and a harder end-point to achieve). We have earlier published a detailed research report on Tobira ( Link ), initiating coverage with a Buy rating and first price target (intrinsic value based on enterprise DCF method) = $15. The stock reached a price of $14.34 on June 27 before retracing on the results of the trial. The purpose of this article is to analyze the results of this trial and present an updated bullish investment thesis for Tobira Therapeutics. We are reiterating a Buy rating on the common stock of Tobira Therapeutics with an updated price target (intrinsic value) of $34.88. Figure 1: Tobira Therapeutics, common stock price chart (from Bloomberg.com). Discussion of one-year results of phase 2b (CENTAUR) trial (source): This clinical trial tested Cenicriviroc (CVC), an inhibitor of CCR2 and CCR5, vs. placebo in NASH patients with high-risk NASH population and liver fibrosis. A total of 289 subjects were enrolled in the study in various clinical centers in the U. S., Europe, Australia and Hong Kong. Sixty-seven of enrolled subjects had advanced liver fibrosis (stages F2 and F3). The primary end-point of the trial was at least a 2-point reduction in NAFLD activity score (NAS), which was not achieved in this study. The FDA has provided two revised study end-points for NASH studies, and at least one of these end-points should be met to consider a drug for approval in treatment of NASH. One of these two end-points is at least a one-stage improvement in liver fibrosis without worsening of NASH. This is a secondary end-point in the CENTAUR study and was achieved. The proportion of study subjects who achieved this end-point was 20% in the CVC arm compared to 10% in the placebo arm (p=0.02). The results were statistically significant. An improvement was seen across all 3 stages of liver fibrosis (F 1-3). The drug also was safe in this trial after 52 weeks of continuous treatment. The most common adverse events were fatigue (2.8%) and diarrhea (2.4%). These adverse events were similar in the CVC and the placebo treatment arms. The incidence of these adverse events was similar to earlier conducted studies. More detailed analysis of this trial will be presented at an upcoming scientific meeting (likely at the annual meeting of the American Association for Study in Liver Diseases, AASLD in November 2016). It also appears that CVC has predominant action on liver fibrosis, rather than the earlier NASH stages that may be correlated with metabolic abnormalities like glucose intolerance and dyslipidemia. CCR3 (chemokine receptor 3) has been shown in some other studies to play a role in fibrotic diseases like scleroderma-associated lung fibrosis and bleomycin-induced lung fibrosis ( source ). Tobira is also developing a DPP4 inhibitor, Evogliptin in type 2 diabetes. A combination of Evogliptin and CVC may help to target the metabolic abnormalities in NASH as well as liver fibrosis. A Phase 1 combination trial of these two drugs is likely to start in late 2016. It is notable that liver fibrosis is a more advanced stage in the spectrum of NAFLD (see figure 2). Liver fibrosis is the only histological feature in NAFLD that has been shown to have an independent correlation with poor clinical outcome and increased mortality. CENTAUR is the first prospective, randomized clinical trial that has shown success in meeting this study end-point. Before this trial, Intercept's (OCA) also showed a 35% rate of reversal in liver fibrosis in the Phase 2 (FLINT) trial. Non-invasive techniques like NAFLD-fibrosis score, FIB-4 index and transient elastography may help in early diagnosis of liver fibrosis without invasive liver biopsy. Figure 2: 'Multiple-hit' pathogenesis of NAFLD showing the spectrum of NAFLD ( source ). Paris-traded Genfit ( OTCPK: GNFTF) conducted a post-hoc analysis of a Phase 2 trial of Elafibranor, a dual agonist of PPAR-alpha and delta receptors (GOLDEN-505 study) in NASH patients (without cirrhosis) and showed success in meeting the second revised NASH end-point of NASH resolution without worsening of liver fibrosis. Elafibranor is thus targeting an earlier stage of NAFLD without advanced liver fibrosis. We have earlier published a detailed research report on Genfit, which can be accessed here. Tobira's management held an investor conference call on July 25, 2016 to discuss these study results. The management showed optimism towards clinical efficacy of CVC to reverse liver fibrosis and plan to advance CVC to a Phase 3 pivotal trial in NASH in the first half of 2017. Our opinion: We consider these results to be remarkable since Tobira is now the second NASH company to show a reversal in liver fibrosis, which is a harder end-point to achieve. The clinical significance of these study results is also very high since patients with liver fibrosis in NAFLD are at the highest risk to advance to liver cirrhosis and liver cancer, thus requiring liver transplant. These patients are also at the highest risk of death. A recent theory called 'Distinct Hit hypothesis' (figure 3) has postulated that rather than a progression along the spectrum from fatty change to steatohepatitis, fibrosis and cirrhosis (multiple hit hypothesis), there might be two distinct types of NAFLD: fatty changes in liver (steatosis) and NASH (steatohepatitis). NASH represents a higher risk type of NAFLD since these patients are at risk of progression to cirrhosis and liver cancer. Figure 3: 'Distinct-Hit hypothesis' of NAFLD ( source ). While these results so far show that CVC may not be an ideal drug for earlier stages of NASH (which together constitute about 95 to 123 million patients in the U. S. alone), the drug could still target about 6-10 million NASH patients in the U. S. alone, who have high-risk NASH with advanced liver fibrosis. The stock also has several upcoming catalysts over next 12 months. Results of Phase 2 study of CVC in pre-diabetes and diabetes (24-weeks data) are expected later this year. Phase 2 results of CVC in Primary Sclerosing Cholangitis (PSC) are expected to be announced in the first half of 2017. PSC represents another significant future revenue driver for Tobira. Updated valuation of the common stock: We updated our DCF valuation for the future forecasted revenue from CVC in NASH with liver fibrosis in the U. S. only. The target market size for CVC was about 10 million patients in the U. S. alone and about 10,000 new patients every year. We input annual drug price for CVC per patient = $10,000. This price is still very conservative compared to Intercept's OCA, which has been priced at about $70k per year to treat primary biliary cirrhosis (PBC). Conservatively, we modeled peak 2% market share for CVC in this target market segment. Adjusting the revenue with 60% probability (average probability of reaching the market for drugs in Phase 3 after passing Phase 2 is 67%, according to the data from Milken Institute), we modeled risk-adjusted, peak $1.2 billion revenue in 2030 at patent expiry in the U. S. alone. Using net income = 17.5% of revenue, depreciation and amortization = 7.3% after launch of the drug in 2019, 90% reinvestment rate, discount rate (cost of capital) of 15% initially (then decreasing to 12% and then 10% with time), and diluted common share count of 22.1 million (including warrants and stock options), we calculated the contribution to intrinsic value per common share from this indication = $32.32. The spreadsheet for this calculation can be accessed here. Our estimates are very conservative, and we increased our price target from the previous article, since the probability of success of reaching the market was increased to 60% after the results of this Phase 2 trial announced today. The potential competitor to Tobira in this NASH market segment is Intercept's OCA. Intercept is trading at an enterprise value of $3.3 billion compared to $174 million for Tobira, even after considering the metabolic adverse effects of OCA like worsening of glucose control and lipid profile. We believe that this represents a significant value gap and significant upside in stock price for Tobira. The contribution to non-cash assets minus liabilities for Tobira was calculated as $2.56/share after adjusting for deferred tax assets (including operating loss carry-forwards). Diluted share count was used. The spreadsheet for this calculation can be accessed here. Using the sum-of-the-parts valuation method, we calculated the intrinsic value for each common share of Tobira Therapeutics = $34.88. This represents significant upside from the current stock price. We did not include the contribution of future revenue from other indications like PSC or diabetes in this valuation, which could add to more upside. We will update the valuation as we get more data from these indications later this year. Risks in the investment: This is a high-risk, speculative investment and the risks are similar to those for any emerging biotechnology company with no significant revenue. Various product candidates mentioned above might fail to succeed in clinical trials, side effects might limit their use, regulatory agencies might not approve them and healthcare insurers might not reimburse them. While the cash is enough to last until early 2017 at present, a future capital raise may dilute existing shareholders and put downward pressure on the stock price. Conclusion: In conclusion, we are reiterating a Buy rating on Tobira Therapeutics with a price target (intrinsic value) per common share = $34.88 using the sum-of-the parts DCF method of valuation. The stock also has upcoming near-term catalysts that could propel the stock higher. Note: To get more investment ideas like this as soon as they are published, click on my profile and hit the ""Follow"" button and choose the real-time alerts option. Supporting Documents TOBIRA_SHEET_1_JULY_25.xlsx TBRA_JULY_25_CASH_MINUS_LIAB.xlsx Disclosure: I am/we are long TBRA, GNFTF. 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. Additional disclosure: This article represents my own opinion and is not a substitute for professional investment advice. It does not represent solicitation to buy or sell any security. Investors should do their own research and consult their financial advisor before making any investment. Editor's Note: This article covers one or more stocks trading at less than $1 per share and/or with less than a $100 million market cap. Please be aware of the risks associated with these stocks. Like this article "


who played fiddle for boxcar willie

gs. Born Lecil Martin in Sterrett, Texas, in 1931, Box Car Willie was the son of a railroad man who used to play his fiddle on the porch while his son played guitar. By his teens he was performing in jamborees all over the state, but he gave up show business to enlist in the Air Force, where he spent 22 years.

"Tuesday, April 13, 1999 - Page updated at 12:00 AME-mail article Print Singer Boxcar Willie Dies Of Leukemia At 67By John Rogers APBRANSON, Mo. - Box Car Willie, whose gentle country voice and songs of life on the road evoked memories of a time when hobos watched America pass by from the door of a freight car, died yesterday of leukemia. He was 67. The singer died at home, surrounded by his family and close friends, family spokeswoman Chisai Childs said. Box Car Willie was diagnosed with leukemia three years ago. After a brief remission, the disease returned last year. Family friend Dick Ringler said Box Car Willie knew he was losing the battle since being hospitalized for two weeks in February, but never mentioned it. ""He told me how tired he was, and I had to help him get out of his chair, which embarrassed him,"" Ringler said. Until his health began to fail, he had performed as many as six shows a week at the Box Car Willie Theatre in this Ozark mountain town, which is home to dozens of music theaters and scores of performers. He was more than one of Branson's most famous performers; he was also one of its most beloved. As a member of the Taney County Child Welfare Board, he raised thousands of dollars for needy children, Childs said, as well as $40,000 a year for police programs to fight crime and dru

After retiring from the service he returned to performing, and by the 1970s had developed the singing-hobo persona, complete with overalls, a battered old hat, worn suit jacket and two days growth of beard. He said he took the Box Car Willie look and name after seeing a freight train pass him by one day in Lincoln, Neb., as he was stuck in traffic. ""And there was an old boy sitting on a boxcar, dressed the way I dress today, and he looked just like a buddy of mine named Willie Wilson,"" he told The Associated Press in 1997. ""I said, `There's Willie in a boxcar,' and that's where it came from. ""He was devoted to singing and promoting old-fashioned country music, including the sorrowful train songs for which he was best known. He never had a hit single, but his albums sold well and he built a loyal following that made him one of the most popular performers in Branson, where he operated a motel and train museum as well as his theater. Although Roy Clark became the first nationally known entertainer to put his name on a Branson theater in 1983, Box Car Willie, who arrived three years later, liked to boast that he was the first big name to live and work there year-round. He counseled newly arrived performers on what worked and what didn't in a conservative, heartland town visited by millions of tourists each year. He fumed from time to time about performers who left Branson, saying it wouldn't last. Mayor Lou Schaefer has ordered flags throughout Branson to be flown at half-staff until the funeral, which Childs said would be Saturday or Sunday. Copyright (c) 1999 Seattle Times Company, All Rights Reserved. Get home delivery today! "


what company was skittles made by?

Skittles are small chewy candies in a package of original fruit flavors which are grape, green apple, lemon, orange and strawberry. ""Taste the rainbow of fruit flavors! ""Skittles History Skittles were first made commercially in 1974 by a British company. They were then introduced in North America in 1979 as an import confectionery. Finally in 1982, domestic production of Skittles began in the United States. Today they are made by Wrigley.

Skittles

"Skittles

Results: 1 – 10 of 10 Show: per page Sort By: ↓Skittles Fun-Size - Bulk Starting at: $0.39Add to Bag Skittles Fun-Size 0.65 oz - 1 pkg$0.39Add to Bag Skittles Original - 2.17 oz pkg$1.29Add to Bag Skittles Original - 2.17 oz pkg - box of 36$37.99Add to Bag Skittles Original 3.5 oz theater box$2.29Add to Bag Skittles Original 3.5 oz theater box - case of 12$22.99Add to Bag Skittles Sour - 1.8 oz pkg$1.29Add to Bag Skittles Sour - 1.8 oz pkg - box of 24$26.99Add to Bag Skittles Tropical - 2.17 oz pkg$1.29Add to Bag Skittles Tropical - 2.17 oz pkg - box of 36$37.99Add to Bag Filter Results Decade1980s (10)Flavors Tropical Flavors (2)Candy Type Chewy Candy (10)Sour Candy (2)Skittles Memories Skittles are my absolute favorite and have been since I was a little girl living in Hawaii. My big brother use to try to take my Skittles all the time. I would hide my bag in my room and my brother always found it. When he found it he would pour half of my bag in to his to make it seem that he had been saving his Skittles even though he finished his bag seconds after he got it. But, I became wise to him and began counting my Skittles, taping the bag shut and then writing the number of Skittles on the tape. After that if he tried to take my Skittles I would have evidence that he took them and he would get in trouble. To this day Skittles are still my favorite and now I send them to my brother every time he is stationed overseas. His most recent package went to Afghanistan and now he shares his Skittles with the men in his unit. ~ Kim from Colorado "


what is njstart

NJSTART is as self-service online platform that allows vendors to manage forms, certifications, submit proposals, access training manuals, reference guides and receive email alerts on upcoming procurement opportunities. There are several key advantages to the new system, but increased visibility is certainly a big one.

NJSTART â The State of New Jersey New eProcurement System

« All Events This event has passed. NJSTART – The State of New Jersey New e Procurement System Date: November 6, 2014 @ 8:30 am - 1:00 pm Location: Price: Free Register Now!

When your business is included in this new online directory, buyers in state and local agencies can easily see what you have to offer. And it will be easier for you to find other small businesses that may be interested in joining forces on larger proposals. Join us at this FREE seminar to learn more about this new system. The Essentials of Government Contracting Monitoring and responding to solicitations, processing paperwork, writing proposals, pricing your services/products – government contracting can be overwhelming, no matter the agency. This highly interactive session will help you make sense of what’s really important and how to keep on track. Bring your questions and share your experiences – you’ll come away better prepared. Learn From the Experts Elizabeth Mackay Assistant Director, Division of Purchase & Property, Department of the Treasury, State of New Jersey Elizabeth served for four years as Senior Policy Advisor in the Department of State, with specific responsibility for the Red Tape Review Commission and Small Business Advocacy in the Business Action Center. She was part of the Red Tape transition team and helped Lieutenant Governor Guadagno craft her position. Prior to that, Elizabeth worked as a Deputy Director at the Division of Consumer Affairs, as the Deputy Bureau Chief at the Bureau of Securities, and as a federal prosecutor for the U. S. Attorney’s Office in the Eastern District of New York. Before entering public service, Elizabeth enjoyed a lengthy investment career and is a Chartered Financial Analyst (CFA). She left Bear, Stearns in July 2001 as a Senior Managing Director/ Chief Investment Strategist for a second career in law. In 2004, she graduated from the Columbia University School of Law, honored as the Student with the Greatest Potential for Distinguished Trial Advocacy. Elizabeth is admitted to practice law in New York and New Jersey. Maryann Williams Director, UCEDC PTACMaryann brings over 30 years of government contracting experience to her position as director of UCEDC’s PTAC program. She brings a unique perspective to the job as she’s held positions on both sides of the table – helping businesses to obtain government contracts as well as overseeing the government contract process for a manufacturing concern in New Jersey. Following an 18-year tenure as a senior contracting official for Greenbrier Industries in Englewood Cliffs, Maryann served as director of the Rockland County PTAC for 13 years. She joined UCEDC in 2007, and under her direction, the PTAC program was awarded the 2010 “Outstanding Center Award” by the Association of Procurement Technical Assistance Centers (APTAC). Refreshments made possible through the support of Date: November 6, 2014Time:8:30 am - 1:00 pm Cost: Free Event Category: Free PTAC Seminars Website:https://ucedc.ecenterdirect.com/Conference Detail.action? ID=6358+ Google Calendar + i Cal Export« Financing Your Business Intellectual Property Basics for Small Businesses and Start-ups »


difference between coating and laminating

Lamination and UV coating are both used to add scuff resistance and shine to labels. UV coating is a liquid plastic applied to the surface of the label and cured under ultra violet (UV) light. Most playing cards are coated with a UV coating for protection and durability. Lamination is a layer of actual plastic film that is glued to the surface of the label. This is used in many restaurant menus.

What is the difference between lamination and UV coating?

Lamination adds water resistance in addition to shine and durability. It costs slightly more than UV coating, but offers more superior protection.0 Comments Add a Comment


definition neurogenic claudication

Neurogenic claudication Neurogenic claudication is a common symptom of lumbar spinal stenosis, or inflammation of the nerves emanating from the spinal cord. Neurogenic means that the problem originates with a problem at a nerve, and claudication, from the Latin for limp, because the patient feels a painful cramping or weakness in the legs.

Translations for Neurogenic claudication

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NC should therefore be distinguished from vascular claudication, which is when the claudication stems from a circulatory problem, not a neural problem. Neurogenic claudication can be bilateral or unilateral calf, buttock, or thigh discomfort, pain or weakness. In some patients, it is precipitated by walking and prolonged standing. The pain is classically relieved by a change in position or flexion of the waist and not simply relieved by rest, as in vascular claudication. Therefore, patients with neurogenic intermittent claudication have less disability in climbing steps, pushing carts and cycling. In some patients with severe compression of the nerve roots, the NC is not intermittent but painfully persistent. The pathophysiology is thought to be ischemia of the lumbosacral nerve roots secondary to compression from surrounding structures, hypertrophied facets, ligamentum flavum, bone spurs, scar tissue, and bulging or herniated discs. Numerology Chaldean Numerology The numerical value of Neurogenic claudication in Chaldean Numerology is: 9Pythagorean Numerology The numerical value of Neurogenic claudication in Pythagorean Numerology is: 7Images & Illustrations of Neurogenic claudication