So great has been the demand for these books hair loss in men 39 generic propecia 1mg on-line, following their recommendation in a very excellent text-book hair loss cure yoga order 1 mg propecia mastercard, that many editions have been published hair loss gastric sleeve buy propecia 5 mg with visa. We hope the reaction will lead the practitioners to adopt some instrument requiring less guess-work hair loss in men burning propecia 1mg on line. From the records of 176 medical students hair loss guinea pigs purchase propecia 1mg without a prescription, all normal men during the third decade of life hair loss wigs order 1mg propecia with visa, the readings made with great care, the Fleischl instruments in lOi cases read from 65 to no per cent. Here the direct readings of the instruments not corrected with the Miescher are given. Oliver, or Fleischl is good enough, it provided incorrect, be a standardized instrument, for so with time. This method, proposed as the most accurate way of determining the amount of h;emoglobin, determines the absolute amount of iron We shall merely outline the method. The fluid from this latter tube is allowed to escape through a stopcock, drop by drop, until the tint of the two solutions is the same. The incineration is done in a platinum crucible, the blood being first dried, then incinerated, the potassium sulphate, o. With the apparatus is a table giving the values in haemoglobin for the various readings. In the first place, the haemoglobinometers are more accurate than they were at the time when this was In the second place, it was found that the results with this did not agree used. Even this was named of these arguments are rather lame, since hscmoglobin is a rather constant body, and in the very small amount of blood used the amount of iron in other forms would hardly produce an appreciable error. Perhaps it is the method itself which the method has been severely criticised by Pekar," who describes 2 is at fault. Careful estimations of the haemoglobin at the various ages have shown a regular age curve, quite parallel to that of the red blood-cells, but with variations a little more pronounced. By oUgochromccmia is meant a relative diminution in the amount of haemoglobin per unit volume of blood. It therefore is seen to have this table of Leichtenstern at From it tion) is merely a relative and not an absolute value. By color index is meant the percentage of haemoglobin divided by the percentage of the red blood-cells. For estimating the denominator, 5,000,000 red blood-corpuscles are considered 100 per cent. The color index is leSs than i in all cases in which the blood after anaemia is regenerating, hence in all secondary anaemias, and especially in chlorosis, in which the average is about In pernicious anaemia, on the 0. The high color index is of especial value in differentiating pernicious anaemia from certain cases of cancer of the stomach, a diagnosis clinically hard to make. Yet we often see cases with the above indexes reported as " mild chlorotic ansemia. If in each case the number of grammes of haemoglobin per 1,000,000 cells be reckoned, the mean of these figures should be an approximately normal color-index. These quotients fell within surprisingly close limits, 42 of the 53 varying from 2. Using this figure as the standard of haemoglobin content, we hope in the future to be more accurate in our use of the color index. Students seem to consider that the mechanism regulating the blood-count is almost as delicate as that controlling the body heat, and that the count of the blood of normal men should vary almost as little as does the temperature, although that varies somewhat. The same is true of the Hence, in total amount of haemoglobin per 100 cc, and also for that per cell. A length of the column of corpuscles of 50 per cent, he accepts as normal, hence the 100 per cent, of the calculation (see page 449)The most important result he obtained is that in pernicious anjemia that is. From them can per- micron in diameter, spherical or slightly oval, quite and color, are very refractive and so in the fresh specimen appear black. These granules have been found in the blood of every animal whose blood has been examined, from the frog to man. They are of albuminous nature and not fatty as their appearBarker has found that they contain iron. These granules are said to vary in size, coarse, about i uniform in size - some to be as large as a granules, others considerably smaller. They stain like eosinophilic granules, except that in a mixture of eosin and indulin They they will take the latter; they also take certain basic stains. They are found in some leucocytes of the bone-marrow of man and various animals (rabbit and guinea-pig), and in the peripheral blood in certain anaemias. These may explain, in leukaemia for instance, the variations in the size and tint of the granules in some of the eosinophil cells. In the connective tissue and blood of all animals and man are cells which contain large basophile granules. Those of the tissues stain best with dahlia,* taking - a metachromatic tone rather than strictly basophilic, resembling that of mucin, of which, indeed, some claim that they are composed. This tone is best seen if polychrome methylene blue be used, and is explained the granules are spherical or oval in shape, and vary considerably in size in the sarne cell. Considerable doubt exists, and is admitted even by Ehrlich, concerning a relationship between the basophil cells of the blood and of the tissues, the latter the true Mastzellen. In fact, their only resemblance seems to be that both have basophile granules, yet which do not stain What is more, considerable doubt exists whether the y granules in cells of abnormal blood are exactly the same as those present in the normal blood and bone-marrow, since even between these certain variations in the staining qualities exist, and those in leukicmic blood are more soluble in aqueous solutions than those of normal blood. It is, therefore, at least possible that we have here to do not with one specific granulation, but with three or more different granuexactly alike. These granules were originally described by Ehrlich as occurring in the mononuclear cells, especially the lymphocytes as not staining by dahlia, and hence differed from y granules and occurring especially in the cells of bone-marrow. Ehrlich, while he has not publicly repudiated these, leads one to suppose;; - that he now considers them to be not true granules, but nodes of the reticulum of the protoplasm. They are extremely fine, dust-like, and occur in the mononuclear cells of the bone-marrow, a few in transitional cells, and fill the feld), neutrophile granules of this size, arrangement, in found only ordinary finely granular cells of the blood. With the Ehrlich triple only specific stain for them, but they also will take an acid stain: hence others name them the " fine oxyphilic granulation. In certain leucocytes, mononuclears especially, and polymorphonuclears, but in some specimens stained with Ehrlich triple stain in any of the leucocytes, are sometimes seen blackish-green gfranules, which always appear attached to the nucleus. Their size varies much, and they have often a glistening or refractile appearance. The Granulation fine violet of Lymphocytes, - In well-spread specimens Romanowski stain are seen c; stained by the various modifications of the granules in about one-third of the lymphocytes, especially those with a fairly wide protoplasmic margin. By this discovery Michaelis and Wolff ^^ consider that they have broken down the sharp line of demarcation drawai by Ehrlich between the granular and the nongranular cells. They are not found in cells from smears of lymphEhrlich replied that while it cannot be denied glands, or of marrow. In eosinophile cells there may be a and P granules from this possibility, all a granules are not of the same size, but some larger ones are mixed in, especially in the cells of bone-marrow, sometimes a few in one these may resemble myelin or other degenerations eosinophile, sometimes many. The view is to be mentioned that all eosinophile granules are the results of phagocytosis of fragments of red cells, or of platelets. Cells with various sizes of e granules occur, and artists employed to illustrate articles on blood absolutely refuse to picture them all of the same size. It may be an individual peculiarity, but in the blood of some patients occurs a large group of cells with acidophilic granules, which one hesitates to classify as neutrophile cells, since they are so large, or as eosinophiles. This is true in fresh preparations as well as in the stained specimens, and has been admitted by several observers, especially^ in cases of trichinosis, hence some consider them transitionals (Brown, McCrae, Anderson). And, lastly, especially in smears of the bone-marrow and leukaemic blood, the line between the granular and non-granular cells is exceedingly difficult to draw, since there are so many mononuclear cells with a protoplasm suggesting a faint granulation. Of a set of smears the same patient at tlic same time, but heated and stained with different technic, the granules will and of markedly different color-tone. It is appear of somewhat different size with due allowance made for this that Leucocytes. They may be deeply notched, especially and even suggest a polymorphonuclear cell, but are never just like it. The protoi)lasm forms a narrow rim around the nucleus, is sometimes acidophilic (older cells The larger cells of group have an irregularly staining nucleus with a chromatin network and a faintly granular margin of protoplasm. These latter forms may be exceedingly large in lymphatic leukiemia and in the blood of normal infants. These cells, if stained with the polychrome methylene blue-eosin stains, show a distinct granulation in about one-half their number. The lymphocytes constitute from 22 to 25 per cent, of the leucocytes in the normal adult blood, and from 40 to 60 per cent, in the stain. These cells are two or three times as large as red blood-cells, have a large, oval, vesicular, eccentrically placed, faintly staining nucleus, which indeed may be overlooked, and abundant weakly basophilic protoplasm withNodal thickenings are present, and by out granules (Ehrlich stain). These cells constitute alx)ut While in I per cent, of the leucocytes of the normal adult blood. The small forms it is easy to distinguish from lymphoc^ies, but they occur very seldom in normal blood. Polymorphonuclear Neutrophiles - When spherical they are about 10 microns out upon the glass, they a well-spread smear, in which they have flattened may seem about twice this size. The amount which they have flattened explains their varying size, so often decepThe nucleus is characterized by tive in smears of unequal thickness. It is be a strand variously bent, or small fragments, two the protoplasm takes well filled with the neutrophile granules which may cells. The may have the same shape, yet less pycnotic, fainter staining ones are the rule. The nucleus is polymorphous, very faintly the protoplasm contains a variable number staining, of gran- ules of different sizes, yet for the most part as large as a granules, which form a band around the nucleus. These granules are not stained by the triple stain, hence one sees only the spaces occupied by them. They have every appearance of old cells are small, do not spread well, but: look shrivelled, with acidophilic protoplasm and polymorphous nucleus. In this case tlie cells were almost achromatophilic, with the protoplasm slightly acidophilic. The characteristic point is the shape of the nucleus, which is either perfectly round, oval, indented or kidney-shaped, but never polymorphous or pycnotic; if it were, the cell would count as an ordinary leucocyte. It is impossible to draw a sharp line between a myelocyte and polymorphonuclear cell (Plate I. As myelocytes we count all cells with round, oval, or kidney-shaped nuclei, providing the nucleus occupies at least one-half of the cell. A cell with nucleus more compact, more distorted, or the specificadiffusely stained than this ranks as a leucocyte. But in leucocytes they are (occupying only about a quarter of the diameter of One is tempted to believe that could the cell) and stain diffusely. They are found especially in splenomyelogenous leukaemia and in anaemia pseudolymphatica infantum. These cells have a round, inSmall Neutrophiles tensely staining nucleus and a narrow margin of protoplasm full of neutrophile They are rare, occurring Their size is about that of a lymphocyte. This writer has given a classification of leucocytes based on specimens stained with the triple stain, more objective than that of Ehrlich, and although not in common use, yet valuable to bear in mind when using any classification. Cells with a round nucleus, narrow ring-like rim of protoplasm separated from the nucleus by a clear sharp circle, the nucleus and proto- - - plasm staining intensely. Characterized by the quantity of protoplasm which with the triple stain remains colorless. The nucleus is homogeneous, round, oval, or bean-shaped, usually eccentric and stains a feeble pinkish shade. They are rich in a protoplasm which is sometimes slightly granular and always takes a good stain, but less intensely than that of lymphocytes. The nucleus stains more deeply than the protoplasm and usually has no clear ring around it. As young forms, he considered the small and large lymphocytes and the small transparents; the ripe elements were all the transitionals and the large and the lobulated transparents, while the over-ripe forms have polymorphous nuclei. It is, however objective, and gives a much better description of the cells actually found than does the Ehrlich. Since we know so little of the relationship between the various leucocytes, of their age, their changes, their origin, and of their function, the only classification possible would be a purely morphological one. Ehrlich separates in the normal blood, small mononuclears, large mononuclears, transitionals, polymorphonuclear neutrophiles, eosinophiles, and Mastzellen. S 509 lymphocytes and the small transitionals and transparents of As large mononuclears are classified any non-granular cells larger than a polymorphonuclear neutrophile. This is best seen in typhoid fever and malaria, in which diseases the group of the transparent cells of Uskow is increased as a whole, both the large and small forms and in the so-called lymphatic leuksemia, in many cases of which the mononuclear cells are certainly not lymphocytes. Neither is it just to separate groups on the basis of an indentation of the nucleus. It is now generally agreed that these large cells with indented nuclei are only older (senile) forms of those with oval nuclei, and need no longer be counted as separate. One group of cells does confuse us, especially in heated specimens, cells which are represented merely by a faintly staining nucleus, and that this is a nucleus especially if one control his count by one on the fresh one is often in doubt Such cells should not be passed blood, then he is sure all are not leucocytes. We believe that most observers do not pay much attention to a point formerly emphasized, the characteristic lilac line in the can exist;; that they do not believe that true eosinophile of the neutrophile granules may be as fine as neutrophiles and distinguished by their color-tone alone, To most of us neutrophile as do some who have written concerning eosinophilia. Of the latter the lymphocytes might be counted alone, and other mononuclear non-granulars in one group, unless they be increased, when one could separate transparents and transitionals (Uskow) on the basis of the protoplasmic stain, or large mononuclears and transitionals (Ehrlich) on the basis of the shape of the nucleus.
Some idea of the intensity of the infection may be gathered from the number in the of colonies per cubic centimetre of blood; Typhoid bacilli have been demonstrated blood in upward of 75 per cent hair loss cure dec 2013 cheap propecia 5mg otc, of a series of cases by Cole hair loss in men zoot proven propecia 1mg, Buxton hair loss cure cotsarelis generic 1 mg propecia with amex, Schatmiiller hair loss every 7 years order propecia 1mg with mastercard, Hewlett hair loss 12776 dixie highway discount propecia 5mg free shipping, and others hair loss 22 order 1 mg propecia amex, often days or even weeks before the Widal test is positive. In the paracolon infections the isolation of the organism from the blood or stools forms the only definite means of differentiation. In pneumococcus infections the percentage of positive cultures is less but still large, the organism being found principally less in the graver cases. The nature of the interaction between the bacteria and the agglutinating serum is unknown. This is the agglutination phenomenon ap- these have the property of organism whose activias agglutinins. The being gradually and thoroughly rubbed into the solution with a small spatula, allow to stand five or six days before using. Living fluid cultures may give rise to confusion from the presence of clumps due to the growth of the organism. This is very readily accomplished by means of a rather stifif loop, a loopful of the salt growth being rubbed against the side of the tube of fluid. Glass tubes two inches in length by one-quarter inch in diameter are drawn out into a capillary at either end and kept on hand for the - purpose. If a centrifuge is available, the process of separation may be hastened and the yield of serum increased by sealing the tip of tube which is free from blood in a flame and centrifugalizing a few minutes, when the clot and corpuscles will be condensed in the lower end and the serum left as a clear layer above. Serum with clotting amounts of blood are with the syringe as required, a vein should be aspirated spontaneously, the clot now retracting Ji, procedure for blood-culture. To obtain the dilution of serum used in the reaction a number of methods are employed. From serum is dropped into the tubes or dishes in which the dilutions are to be made. If greater accuracy or very high dilutions be required, special mixing pipettes similar to the Zeiss melangeur for blood counting may be employed. Again, dilutions may be made directly from the whole blood with such a melangeur, using salt solution as diluting fluid and counting each two volumes. The mixture is allowed to settle With the diluted serum we now proceed to the macroscopic or microscopic tests. This method depends on the agglutination of the organisms into clumps visible to the naked eye and the eventual precipitation of the clumps, leaving a clear supernatant the serum is diluted in a test-tube of small calibre, and the fluid. The tube is then examined by strong transmitted light to see that its contents are homogeneous and free from accidental clumps. A narrow band of light from a lamp enclosed by a screen aids in detecting the early appearance of clumping. A positive test is reckoned if there be general clumping at a dilution of 1/50 or higher in one hour with complete precipitation, leaving a clear supernatant fluid after twenty-four hours. The diluted serum may be mixed with the requisite volume of the typhoid suspension by the use of pipettes, as above noted, and a drop of the mixture taken for observation on a hanging" drop slide. The loop is flamed off and dipped into the typhoid suspension in the same way, and the two drops thoroughly mixed on Approximately equal volumes are readily obtained the cover-slip. The hanging drop is observed with a moderately high dry lens (Zeiss D, or Leitz i/6 the Argand burner in. The macroscopic method has rapidly gained favor in the best laboratories, and is probably less open to error than I in 50 or higher Hence tests and dilution (one hour 50 or higher) are observed. There is so much variation in the determination of microscopic clumping by different observers that it is often difficult to compare their results. This method is based on the use of blood dried on glass, tin-foil, or glazed paper, and is only accurate where the blood is carefully weighed and the dilution based on weight instead of volume. Its sole recommendation is the convenience with which the blood so dried may be transported. Still, it remains our most certain confirmatory test and is indispensable in abortive, doubtful, and obscure cases. The persistence of the agglutinative reaction is variable, the limits being from a few weeks to many years. Some cases of long persistent Widal have been attributed to the presence of typhoid bacilli in the gall-bladder, in gall-stones, or in the urinary bladder. The agglutination reactions have been applied to many different organisms with more or less definite results, but in most cases they have not reached any considerable diagnostic value and are often very difficult of application. The opinion of Weidenreich and Lewis, this that in the circulation these cells are not flat but are cap-shaped, is borne out clinically in it is many specimens, especially those from the bone-marrow; a point of no importance. When they are not round, or are of very abnormal size, the term " poikilocyte" is applied to them (Plate I, 25-28). Ehrlich considers that heat is the best fixative, because it gives a homogeneous cell without structure. This argument seems weak, for heat renders difficult of observation the structure of many other cells of similar nature, including the protoplasm, but not the granules, of leucoessential part of the cell tates;; cytes, and hence may be the very worst method for the study of red also their coarse structure in dispute. Not only is their fine, but membrane formerly believed to; the cell then doubted, is again claimed by Deetjen, who describes it as elastic, gelatinous, glassy, and stained best in underheated specimens while others claim merely a haemoglobin-free concentration of the; stroma at the surface. The question of the nucleoid is in dispute, some considering it to be related to the nucleus and others to be totally independent. It means among others the " differentiated inner body of Lowit;" that is, a nucleus-like structure in the centre of the red blood-cell which in certain specimens is very apparent, it taking a basic stain; it has a fibrillar structure, and a central clear space in its centre again is a differentiated inner body, which " may be extruded as a " the nucleoid develops after the extrusion of the nucleus (Maxiplatelet. Against these as parts of the cell is to be urged that constant technique is necessary to give constant results; that their size varies from very small to that two-thirds of the corpuscle their periphery is indistinct often, and radially striated that is, they do not look " genuine. They enter it as almost perfect, and they leave it before marked signs of age are apparent (see page 479). Evidence is given that the red blood-cells of various nationalities differ somewhat, the size diminishing as one in from 8 to 9 microns diameter. In the fresh blood occur physiological rhythmical changes, the cells being somewhat larger in the venous than in the arterial blood where they are charged with oxygen (Hamburger). They are found rarely in the healthy adult, but are common in all anaemias, especially the primary and severe secondary anaemias. In chlorosis they are often very pale, hence the term " chlorotic " or " dropsical " cells. They are also very common in cases with choliemia, which is of interest since cases of pernicious anaemia are so often. Whether the chief difference between the small dark cells and the large pale cells is the amount of water, each having approximately the same amount of haemoglobin, is the question. In pernicious anaemia the largest cells are sometimes the darkest, and some of the microcytes are exceedingly pale, while in secondary anaemia the reverse is true. Red blood-cells like all other cells while alive are achromatophilic, and take a stain only in proportion to their death changes. If the red cell is killed by a good fixative which prevents post-mortem changes, all normal cells are monochromatophilic, and - since they take only acid stains from a mixture, are acidophilic. With and and most dyes changes Cells it is the haemoglobin especially that takes the stain, in this will show themselves to a certain degree by the tint the tone which the cells take. By this term (a synonym of which is "anaemic degeneration") we do not now include the basophilic granules to be described later. Eosin stains the basophilic cells more faintly than the normal, and if followed by a basic stain, such as haematoxylin, will be supplanted by it. With haematoxylin and eosin such cells take a violet tint; with the Ehrlich, a fainter tone than normal, or a grayish color; with polychrome methylene blue stains a bluish violet in all cases, basophilic. In favor of this are, that other signs of degeneration are also present; that it can be produced in animals by inanition that these cells are present within twenty-four hours after a haemorrhagej that is, before any to;; nucleated cells or other signs of active regeneration have appeared; the other view is Others say that the granules are evidence of incomplete intracellular oxidation. Basophilic cells occur in pernicious anaemia in the grave secondary anaemias, especially those* due to cancer; in the eruptive fevers, malaria, the purpuras; and after various blood poisons. Other cells are " fuchsinophilic " (Plate I, 35); that is, stained and that it affects especially the megaloblasts. While the middle ground is usually unsatisfactory, yet there is, we think, the best of evidence that young red cells in general are and good evidence that a degenerating cell will usually the same may be said for microcytes, macrocytes, and the basophilic granules it is hard to say whether they are signs basophilic, take Such stains. They are not signs simply of anaemia, for anaemia all abnormal corpuscles abnormal in size, shape, amount of pigment, nucleation, with protoplasm having abnormal staining affinities, etc. To us basophilia as evidence of youth is interesting, since it was Theobald Smith who first suggested it in a case of purpura and later emphasized it in his studies on Texas fever. In normal marrow the basophilia is in inverse proportion to the amount of haemoglobin that the cells contain, judging by the fresh specimen before staining, hence the term " anaemic degeneration;" but this lack of haemoglobin could be primary or result from the loss of some from the cell. Germani also emphasizes them as an important feature of the blood picture in severe anaemias, their number being since easy in direct proportion to the severity of the case, and, to stain, suggests them as a valuable hint in diagnosis and cells prognosis. These degenerations certainly led to many mistaken diagnoses before resembling platelets. In heated specimens, if this be done too quickly, or if they be exposed to moisture, around the periphery of the cell may sometimes be seen a row of large dots, which are neither true granules nor do they resemble the granules in malaria. We are sure these are not artefacts, and that they are not the same as the granules of lead poisoning which also may be present in the cells. The " methylene blue degeneration of Ehrlich" is the name given to a beautiful picture seen in specimens of fresh blood stained by this dye, the cell containing a mesh-work of fibres. A cover-glass is blood-staining was used by lightly spread with the saturated alcoholic vital solution of methylazur or of toluidin blue, which is then allowed to dry. Over this stained surface a blood smear is made, and the surface at once inverted over a hollow slide with vaselined rim. They are not seen in fresh unstained specimens they are not increased by allowing the blood to stand. While any methylene blue-eosin mixture will do, the most beautiful specimens are prepared as follows. The bloodsmear fixed by heat (not alcohol) is stained for a few seconds with the filtrate. Stain In a severe case one finds as many as five or six of these " stippled cells " in a field, but, as a rule, several fields must be searched There may be but one or a few granules in a in order to find one. They occur anywhere in the cell, but are distributed quite regularly as Many think they are situated in the external layers of the a rule. They occur in the severest anaemias, especially the primary pernicious, in ** which they are large and conspicuous; f. They also occur nephritis, small contracted parenchymatous In gout they are many in rheumatism with even severe blood changes they are very rare. In gout it is of interest that especially large numbers are found in those cases with haematoporphyrinuria Guyot found them regularly in the haemoglobinuria due to cold; in tuberculosis Grawitz says they occur only after the secondary infection of a cavity. On the other hand they are normal in embryonic blood, never, some say, in adult blood nucleated reds often contain them, good evidence against their relation to a degenerating nucleus. They are often present in the degenerated reds, but also occur independently of other degenerations, as polychromatophilia, poikilocytosis, etc. Their relation to malaria and to polychromatophilic degeneration is now generally abandoned. Others say that they are in some way or other related to new formation of cells, while now and again recurs the view now; that they are related to the nucleus. Cadwalader distinguishes three groups of granulated corpuscles those with the granules in fine and coarse thread-like strands those with fine dot-like granulations; and those with dense coarse masses. The first type is found in small numbers in normal blood the second, the most common form, in lead poisoning and pernicious anaemia the last in those cases of lead poisoning in which nucleated reds are plentiful. These last granules, in position and size, suggest a;;;; breaking-down normoblast nucleus. Others deny that transitional stages between fragmenting nuclei and these occur, and point out that they are least in the bone-marrow where karyorrhexis is most common. Again, it is claimed that they do not occur until definite signs of regeneration have also occurred (but the hydraemia is also at its maximum then), well seen in post-hemorrhagic anaemia, hence the opinion of some that they are related to regeneration. In favor of this is the difficulty of producing them by the direct influence of lead salts. Cadwalader** finds them always associated with nucleated reds in lead poisoning, and thinks them the result of a fragmentation of the nucleus of the red cell. In favor of this is the fact that the increase in nucleated reds precedes that of the granulated cells, and he thinks the forms of granules suggest steps in the process. Compare them side by side with the Grawitz granules, and they do not seem to belong to the same class of structures. It is impossible to say they are not related, but they do not look as if they were. Perjiaps their greatest importance is in lead poisoning, since here they may be the only abnormal blood-feature. In other diseases in which they occur, as the anaemias, they form but a minor part of the blood picture, although they occur in large numbers. They are very fine in size Some claim that they can be found in the blood of all lead-workers. This may be the case, but it depends on the length of time that the specimen is studied, and we do find cases of lead poisoning, particularly the peripheral neuritis cases, the one condition in which it would be most important to find them, in which they have not been found, or only one cell, in the time at the disposal of the ordinary clinical worker. In the diagnosis of intestinal colic they may be of importance, but in the cases of peripheral neuritis we have failed to find them so. Other references to this subject arc, Naegeli," who considers them related to blood regeneration Boellke," who denies that they bear any relation to the; nucleus. The average count for the normal man is usually given as 5,ooo,cxk) cells per cubic millimetre of for the it is - blood; ever, woman. It is evident that this number is simply relative, that variations may be due either to actual variations in the number of red blood-cells in the body, or to the amount of plasma, which may by diluting the blood cause an oligocythaemia, and when it is reduced in amount, a polycythiemia. By polycyth<rmia millimetre than this present; the blood-count may var' in different parts of the body. Oliver ^* found that anything which increases the blood-pressure even locally as, for instance, in a limb will cause a rise in the count at that point in a dependent position, active or passive motion, that, has been hanging; * Miinch. Excessive exercise, Willebrand found, would raise the count of red cells from 3 to 23 per cent, (average 12. This variation occurs only during the menstrual period of life, since for girls until their fifteenth year the count averages 5,444,000, while for boys of the same age 5,102,000; between the ages of forty and sixty, again the count of women averages 5,000,000. The maximum is at birth, in which case it may be even 7,000,000, but, as a rule, is lower.
Entergy intends to shut down the Palisades plant permanently no later than May 31 hair loss zomig order propecia 5mg visa, 2022 hair loss medication purchase propecia 1 mg with visa. As a result of the change in expected operating life of the Palisades plant hair loss cure quinlan buy cheap propecia 1mg, the expected probability-weighted undiscounted net cash flows as of September 30 hair loss breakthrough 2016 order propecia 1mg with amex, 2017 exceeded the carrying value of the plant and related assets hair loss genetics propecia 1mg low price. Accordingly hair loss hypothyroidism buy 5mg propecia free shipping, nuclear fuel spending, nuclear refueling 201 Table of Contents Entergy Corporation and Subsidiaries Notes to Financial Statements outage spending, and expenditures for capital assets incurred at Palisades after September 30, 2017 are no longer charged to expense as incurred, but recorded as assets and depreciated or amortized, subject to the typical periodic impairment reviews prescribed in the accounting rules. In addition to the impairments and other related charges, Entergy expects to incur additional charges through mid-2022 associated with these strategic transactions. See Note 13 to the financial statements for further discussion of these additional charges. As discussed above in Dispositions, on August 26, 2019, Entergy sold the Pilgrim plant to a Holtec International subsidiary. Entergy accordingly evaluated the Vermont Yankee asset retirement obligation in light of the terms of the sale transaction, and evaluated the remaining values of the Vermont Yankee assets. These evaluations resulted in $173 million of asset impairment and related charges in the fourth quarter 2018. See Note 9 to the financial statements for additional discussion of the revision of the asset retirement obligation. Market risk is the potential loss that Entergy may incur as a result of changes in the market or fair value of a particular commodity or instrument. The Utility has limited exposure to the effects of market risk because it operates primarily under cost-based rate regulation. In addition to its forward physical power and gas contracts, Entergy Wholesale Commodities may also use a combination of financial contracts, including swaps, collars, and options, to mitigate commodity price risk. When the market price falls, the combination of instruments 202 Table of Contents Entergy Corporation and Subsidiaries Notes to Financial Statements is expected to settle in gains that offset lower revenue from generation, which results in a more predictable cash flow. A significant factor influencing the overall level of market risk to which Entergy is exposed is its use of hedging techniques to mitigate such risk. Hedging instruments and volumes are chosen based on ability to mitigate risk associated with future energy and capacity prices; however, other considerations are factored into hedge product and volume decisions including corporate liquidity, corporate credit ratings, counterparty credit risk, hedging costs, firm settlement risk, and product availability in the marketplace. Derivatives Some derivative instruments are classified as cash flow hedges due to their financial settlement provisions while others are classified as normal purchase/normal sale transactions due to their physical settlement provisions. Entergy may enter into financially-settled swap and option contracts to manage market risk that may or may not be designated as hedging instruments. Electricity over-thecounter instruments and futures contracts that financially settle against day-ahead power pool prices are used to manage price exposure for Entergy Wholesale Commodities generation. The maximum length of time over which Entergy Wholesale Commodities is currently hedging the variability in future cash flows with derivatives for forecasted power transactions at December 31, 2020 is approximately 3 months. Planned generation currently under contract from Entergy Wholesale Commodities nuclear power plants is 98% for 2021, of which approximately 29% is sold under financial derivatives and the remainder under normal purchase/normal sale contracts. These master agreements facilitate the netting of cash flows associated with a single counterparty and may include collateral requirements. Cash, letters of credit, and parental/affiliate guarantees may be obtained as security from counterparties in order to mitigate credit risk. The collateral agreements require a counterparty to post cash or letters of credit in the event an exposure exceeds an established threshold. In addition, collateral agreements allow for termination and liquidation of all positions in the event of a failure or inability to post collateral. Certain of the agreements to sell the power produced by Entergy Wholesale Commodities power plants contain provisions that require an Entergy subsidiary to provide credit support to secure its obligations depending on the mark-to-market values of the contracts. As of December 31, 2020, there were no derivative contracts with counterparties in a liability position. In addition to the corporate guarantee, $5 million in cash collateral was required to be posted by the Entergy subsidiary to its counterparties and $39 million in letters of credit were required to be posted by its counterparties to the Entergy subsidiary. As of December 31, 2019, there were no derivative contracts with counterparties in a liability position. In addition to the corporate guarantee, $11 million in cash collateral was 203 Table of Contents Entergy Corporation and Subsidiaries Notes to Financial Statements required to be posted by the Entergy subsidiary to its counterparties and $1 million in cash collateral and $98 million in letters of credit were required to be posted by its counterparties to the Entergy subsidiary. If the Entergy Corporation credit rating falls below investment grade, Entergy would have to post collateral equal to the estimated outstanding liability under the contract at the applicable date. The notional volumes of these swaps are based on a portion of projected annual exposure to gas price volatility for electric generation at Entergy Louisiana and Entergy Mississippi and projected winter purchases for gas distribution at Entergy New Orleans. The maximum length of time over which Entergy had executed natural gas swaps and options as of December 31, 2020 is 3. Entergy initially records financial transmission rights at their estimated fair value and subsequently adjusts the carrying value to their estimated fair value at the end of each accounting period prior to settlement. Unrealized gains or losses on financial transmission rights held by Entergy Wholesale Commodities are included in operating revenues. Credit support for financial transmission rights held by Entergy Wholesale Commodities is covered by cash. No cash or letters of credit were required to be posted for financial transmission rights exposure for Entergy Wholesale Commodities as of December 31, 2020 and December 31, 2019. Certain investments, including those not designated as hedging instruments, are subject to master netting agreements and are presented in the balance sheet on a net basis in accordance with accounting guidance for derivatives and hedging. Also excludes letters of credit in the amount of $1 million posted and $39 million held as of December 31, 2020 and $98 million held as of December 31, 2019. The ineffective portion of cash flow hedges was recorded in competitive businesses operating revenues. Based on market prices as of December 31, 2020, unrealized gains recorded in accumulated other comprehensive income on cash flow hedges relating to power sales totaled $38 million of net unrealized losses. Approximately $38 million is expected to be reclassified from accumulated other comprehensive income to operating revenues in the next twelve months. Entergy may effectively liquidate a cash flow hedge instrument by entering into a contract offsetting the original hedge, and then dedesignating the original hedge in this situation. Net Fair Gross Fair Offsetting Value (c) Instrument Balance Sheet Location Value (a) Position (b) (d) Registrant (In Millions) 2020 Assets: Natural gas swaps and options Prepayments and other $0. Due to regulatory treatment, the changes in the estimated fair value of financial transmission rights for the Utility operating companies are recorded through purchased power expense and then such amounts are simultaneously reversed and recorded as an offsetting regulatory asset or liability. Therefore, estimates are not necessarily indicative of the amounts that Entergy could realize in a current market exchange. Accounting standards define fair value as an exit price, or the price that would be received to sell an asset or the amount that would be paid to transfer a liability in an orderly transaction between knowledgeable market participants at the date of measurement. Entergy and the Registrant Subsidiaries endeavor to use the best available information to determine fair value. Accounting standards establish a fair value hierarchy that prioritizes the inputs used to measure fair value. The hierarchy establishes the highest priority for unadjusted market quotes in an active market for the identical asset or liability and the lowest priority for unobservable inputs. Level 2 - Level 2 inputs are inputs other than quoted prices included in Level 1 that are, either directly or indirectly, observable for the asset or liability at the measurement date. Prices are reviewed and can be challenged with the independent parties and/or overridden by Entergy if it is believed such would be more reflective of fair value. Level 2 consists primarily of individually-owned debt instruments and gas swaps and options valued using observable inputs. Level 3 consists primarily of financial transmission rights and derivative power contracts used as cash flow hedges of power sales at merchant power plants. The values for power contract assets or liabilities are based on both observable inputs including public market prices and interest rates, and unobservable inputs such as implied volatilities, unit contingent discounts, expected basis differences, and credit adjusted counterparty interest rates. The valuations of these assets and liabilities are performed by the Office of Corporate Risk Oversight and the Entergy Wholesale Commodities Accounting group. The Office of Corporate Risk Oversight is also responsible for managing the energy trading and risk management system, forecasting revenues, forward positions and analysis. The Entergy Wholesale Commodities Accounting group performs functions related to market and counterparty settlements, revenue reporting and analysis, and financial accounting. The Office of Corporate Risk Oversight reports to the Vice President and Treasurer while the Entergy Wholesale Commodities Accounting group reports to the Chief Accounting Officer. The amounts reflected as the fair value of electricity swaps are based on the estimated amount that the contracts are in-the-money at the balance sheet date (treated as an asset) or out-of-the-money at the balance sheet date (treated as a liability) and would equal the estimated amount receivable to or payable by Entergy if the contracts were settled at that date. These derivative contracts include cash flow hedges that swap fixed for floating cash flows for sales of the output from the Entergy Wholesale Commodities business. The fair values are based on the mark-to-market comparison between the fixed contract prices and the floating prices determined each period from quoted forward power market prices. The amounts reflected as the fair values of electricity options are valued based on a Black Scholes model, and are calculated at the end of each month for accounting purposes. As described further below, prices and implied volatilities are reviewed and can be adjusted if it is determined that there is a better representation of fair value. On a daily basis, the Office of Corporate Risk Oversight calculates the mark-to-market for electricity swaps and options. The Office of Corporate Risk Oversight also validates forward market prices by comparing them to other sources of forward market prices or to settlement prices of actual market transactions. Implied volatilities used to value options are also validated using actual counterparty quotes for Entergy Wholesale Commodities transactions when available and compared with other sources of market 213 Table of Contents Entergy Corporation and Subsidiaries Notes to Financial Statements implied volatilities. Moreover, on a quarterly basis, the Office of Corporate Risk Oversight confirms the mark-to-market calculations and prepares price scenarios and credit downgrade scenario analysis. The scenario analysis is communicated to senior management within Entergy and within Entergy Wholesale Commodities. The valuations of these assets and liabilities are performed by the Office of Corporate Risk Oversight. The Office of Corporate Risk Oversight reports to the Vice President and Treasurer. The Entergy Wholesale Commodities Accounting group reports to the Chief Accounting Officer. The assessment of the significance of a particular input to a fair value measurement requires judgment and may affect their placement within the fair value hierarchy levels. Fixed income securities are held in various governmental and corporate securities. The decommissioning trust funds fair value presented herein does not include the recognition of a credit loss valuation allowance of $0. See Note 16 to the financial statements herein for additional information on the allowance for expected credit losses. The following table sets forth a reconciliation of changes in the net assets (liabilities) for the fair value of derivatives classified as Level 3 in the fair value hierarchy for the years ended December 31, 2020, 2019, and 2018: 2020 2019 2018 Financial Financial Financial Power transmission Power transmission Power transmission Contracts rights Contracts rights Contracts rights (In Millions) Balance as of January 1, $118 $10 ($31) $15 ($65) $21 Total gains (losses) for the period (a) Included in earnings 1 1 12 - 2 (1) Included in other comprehensive income 77 - 232 - (40) - Included as a regulatory liability/asset - 67 - 54 - 80 Issuances of financial transmission rights - 23 - 35 - 46 Settlements (158) (92) (95) (94) 72 (131) $38 $9 $118 $10 ($31) $15 Balance as of December 31, 215 Table of Contents Entergy Corporation and Subsidiaries Notes to Financial Statements (a) Change in unrealized gains or losses for the period included in earnings for derivatives held at the end of the reporting period is ($0. The following table sets forth a description of the types of transactions classified as Level 3 in the fair value hierarchy and significant unobservable inputs to each which cause that classification, as of December 31, 2020: Fair Value as of Significant Unobservable Range from Effect on Fair Transaction Type December 31, 2020 Inputs Average % Value (In Millions) (In Millions) Power contracts - electricity swaps $38 Unit contingent discount 4. The assessment of the significance of a particular input to a fair value measurement requires judgment and may affect its placement within the fair value hierarchy levels. Equity securities are invested to approximate the returns of major market indices. See Note 16 to the financial statements herein for additional information on the investment portfolios. The following table sets forth a reconciliation of changes in the net assets for the fair value of derivatives classified as Level 3 in the fair value hierarchy for the year ended December 31, 2020. Entergy Entergy Entergy Entergy New Entergy Arkansas Louisiana Mississippi Orleans Texas (In Millions) Balance as of January 1, 2020 Issuances of financial transmission rights Gains (losses) included as a regulatory liability/asset Settlements Balance as of December 31, 2020 $3. Entergy Entergy Entergy Entergy New Entergy Arkansas Louisiana Mississippi Orleans Texas (In Millions) Balance as of January 1, 2019 Issuances of financial transmission rights Gains (losses) included as a regulatory liability/asset Settlements Balance as of December 31, 2019 $3. Entergy records decommissioning trust funds on the balance sheet at their fair value. Because of the ability of the Registrant Subsidiaries to recover decommissioning costs in rates and in accordance with the regulatory treatment for decommissioning trust funds, the Registrant Subsidiaries have recorded an offsetting amount of unrealized gains/(losses) on investment securities in other regulatory liabilities/assets. Decommissioning trust funds for the Entergy Wholesale Commodities nuclear plants do not meet the criteria for regulatory accounting treatment. In December 2020, Entergy liquidated its interest in the registered investment company. Generally, Entergy records gains and losses on its debt and equity securities using the specific identification method to determine the cost basis of its securities. The unrealized gains/(losses) recognized during the year ended December 31, 2020 on equity securities still held as of December 31, 2020 were $531 million. A relatively small percentage of the equity securities are held in funds intended to replicate the return of the Wilshire 4500 index or the Russell 3000 Index. The unrealized gains/(losses) above are reported before deferred taxes of $31 million as of December 31, 2020 and $13 million as of December 31, 2019 for debt securities. The amortized cost of available-for-sale debt securities was $2,423 million as of December 31, 2020 and $2,366 million as of December 31, 2019. As of December 31, 2020, available-for-sale debt securities have an average coupon rate of approximately 3. The fair value and gross unrealized losses of available-for-sale debt securities, summarized by length of time that the securities have been in a continuous loss position, are as follows as of December 31, 2020: Gross Unrealized Fair Value Losses (In Millions) Less than 12 months $187 $3 More than 12 months 2 - $189 $3 Total the fair value and gross unrealized losses of available-for-sale debt securities, summarized by length of time that the securities have been in a continuous loss position, are as follows as of December 31, 2019: Gross Unrealized Fair Value Losses (In Millions) Less than 12 months $404 $5 More than 12 months 38 1 $442 $6 Total 222 Table of Contents Entergy Corporation and Subsidiaries Notes to Financial Statements the fair value of available-for-sale debt securities, summarized by contractual maturities, as of December 31, 2020 and 2019 are as follows: 2020 2019 (In Millions) Less than 1 year ($4) $128 1 year - 5 years 672 807 5 years - 10 years 852 666 10 years - 15 years 377 125 15 years - 20 years 144 126 20 years+ 576 604 Total $2,617 $2,456 During the years ended December 31, 2020, 2019, and 2018, proceeds from the dispositions of available-for-sale securities amounted to $1,024 million, $1,427 million, and $2,406 million, respectively. During the years ended December 31, 2020, 2019, and 2018, gross gains of $47 million, $25 million, and $7 million, respectively, and gross losses of $4 million, $4 million, and $47 million, respectively, related to available-for-sale securities were reclassified out of other comprehensive income or other regulatory liabilities/assets into earnings. The fair values of the decommissioning trust funds related to the Entergy Wholesale Commodities nuclear plants as of December 31, 2020 are $631 million for Indian Point 1, $794 million for Indian Point 2, $991 million for Indian Point 3, and $554 million for Palisades.
To the extent that operating cash flows are insufficient to support planned investments hair loss from medications order propecia 1 mg without prescription, Entergy Arkansas may issue incremental debt or reduce distributions hair loss cure when generic propecia 1mg with visa, or both hair loss cure natural way propecia 5mg low cost, to maintain its capital structure hair loss in men 14k order 1 mg propecia amex. In addition hair loss 6 mp generic 5 mg propecia with amex, in certain infrequent circumstances hair loss in women proven 5mg propecia, such as financing of large transactions that would materially alter the capital structure if financed entirely with debt and reducing distributions, Entergy Arkansas may receive equity contributions to maintain its capital structure. For Entergy Arkansas, almost all of the total consists of unconditional fuel and purchased power obligations, including its obligations under the Unit Power Sales Agreement, which are discussed in Note 8 to the financial statements. In addition to the contractual obligations given above, Entergy Arkansas currently expects to contribute approximately $66. Also in addition to the contractual obligations, Entergy Arkansas has $252 million of unrecognized tax benefits and interest net of unused tax attributes for which the timing of payments beyond 12 months cannot be reasonably estimated due to uncertainties in the timing of effective settlement of tax positions. Management provides more information on long-term debt maturities in Note 5 to the financial statements. Entergy Arkansas will purchase the facility upon mechanical completion and after the other purchase contingencies have been met. Entergy Arkansas may refinance, redeem, or otherwise retire debt prior to maturity, to the extent market conditions and interest rates are favorable. Entergy Arkansas has sufficient capacity under these tests to meet its foreseeable capital needs. Entergy Arkansas has a credit facility in the amount of $150 million scheduled to expire in September 2024. Entergy Arkansas also has a $25 million credit facility scheduled to expire in April 2021. As of December 31, 2020, there were no cash borrowings and no letters of credit outstanding under the credit facilities. See Note 4 to the financial statements for further discussion of the credit facilities. See Note 4 to the financial statements for further discussion of the nuclear fuel company variable interest entity credit facility. Entergy Arkansas filed its response addressing the requested adjustments in October 2019. In its July 2019 formula rate plan filing, Entergy Arkansas proposed to recover an $11. The total proposed revenue change for the 2021 projected year and 2019 historical year netting adjustment was $88. As part of the formula rate plan tariff the calculation for the revenue constraint was updated based on actual revenues which had the effect of reducing the initially-proposed $74. The remaining issue litigated concerned the methodology used to calculate the netting adjustment within the formula rate plan. Also with the formula rate plan filing, Entergy Arkansas is requesting an extension of the formula rate plan rider for a second five-year term. The transaction was accounted for as a transaction between entities under common control. The rider utilizes the prior calendar-year energy costs and projected energy sales for the twelve-month period commencing on April 1 of each year to develop an energy cost rate, which is redetermined annually and includes a true-up adjustment reflecting the over- or underrecovery, including carrying charges, of the energy costs for the prior calendar year. In March 2017, Entergy Arkansas filed its annual redetermination of its energy cost rate pursuant to the energy cost recovery rider, which reflected an increase in the rate from $0. In March 2018, Entergy Arkansas filed its annual redetermination of its energy cost rate pursuant to the energy cost recovery rider, which reflected an increase in the rate from $0. The redetermined rate became effective with the first billing cycle of April 2018. In March 2019, Entergy Arkansas filed its annual redetermination of its energy cost rate pursuant to the energy cost recovery rider, which reflected a decrease from $0. In July 2009 the Utility operating companies filed a response to the complaint arguing among other things that the System Agreement contemplates that the Utility operating companies may make sales to third parties for their own account, subject to the requirement that those sales be included in the load (or load shape) for the applicable Utility operating company. Refunds and interest in the following amounts were paid by Entergy Arkansas to the other operating companies in December 2018: Total refunds including interest Payment/(Receipt) (In Millions) Principal Interest Total Entergy Arkansas $68 $67 $135 Entergy Louisiana ($30) ($29) ($59) Entergy Mississippi ($18) ($18) ($36) Entergy New Orleans ($3) ($4) ($7) Entergy Texas ($17) ($16) ($33) Entergy Arkansas previously recognized a regulatory asset with a balance of $116 million as of December 31, 2018 for a portion of the payments due as a result of this proceeding. Briefing was completed in September 2020 and oral argument was heard in December 2020. In March 2019, Entergy Services filed an answer and motion to dismiss the new complaint. Circuit issued an order establishing that briefing will occur in January 2021 through April 2021. Net Metering Legislation An Arkansas law was enacted effective July 2019 that, among other things, expands the definition of a "net metering customer" to include two additional types of customers: (1) customers that lease net metering facilities, subject to certain leasing arrangements, and (2) government entities or other entities exempt from state and federal income taxes that enter into a service contract for a net metering facility. The latter provision would allow eligible entities, many of whom are small and large general service customers, to purchase renewable energy directly from third party providers and receive bill credits for these purchases. Because of the size and number of customers eligible under this new law, there is a risk of loss of load and the shifting of costs to customers. A hearing was held in December 2019, with utilities, cooperatives, the Arkansas Attorney General, industrial customers, and Entergy Arkansas advocating the need for establishment of a reasonable rate structure that takes into account impacts to non-net metering customers; an additional hearing was conducted in February 2020 for purposes of public comment only. Nevertheless, reserving its rights, Entergy Arkansas has complied with the directive to amend its tariffs. Entergy Arkansas is, therefore, subject to the risks related to owning and operating nuclear plants. Costs and Sensitivities the following chart reflects the sensitivity of qualified pension cost and qualified projected benefit obligation to changes in certain actuarial assumptions (dollars in thousands). Impact on 2021 Qualified Impact on 2020 Qualified Actuarial Assumption Change in Assumption Pension Cost Projected Benefit Obligation Increase/(Decrease) Discount rate (0. Impact on 2020 Impact on 2021 Accumulated Postretirement Actuarial Assumption Change in Assumption Postretirement Benefit Cost Benefit Obligation Increase/(Decrease) Discount rate (0. Costs and Employer Contributions Total qualified pension cost for Entergy Arkansas in 2020 was $81. Entergy Arkansas contributed $60 million to its qualified pension plans in 2020 and estimates pension contributions will be approximately $66. Total other postretirement health care and life insurance benefit income for Entergy Arkansas in 2020 was $10. Entergy Arkansas expects 2021 postretirement health care and life insurance benefit income of approximately $11. The Company is not required to have, nor were we engaged to perform, an audit of its internal control over financial reporting. Critical Audit Matter the critical audit matter communicated below is a matter arising from the current period audit of the financial statements that was communicated or required to be communicated to the audit committee and that: (1) relates to accounts or disclosures that are material to the financial statements and (2) involved our especially challenging, subjective, or complex judgments. Accounting for the economics of rate regulation impacts multiple financial statement line items and disclosures, such as property, plant, and equipment; 330 Table of Contents regulatory assets and liabilities; income taxes; operating revenues; operation and maintenance expense; and depreciation and amortization expense. We identified the impact of rate regulation as a critical audit matter due to the significant judgments made by management to support its assertions about impacted account balances and disclosures and the high degree of subjectivity involved in assessing the impact of future regulatory orders on the financial statements. Management judgments include assessing the likelihood of recovery in future rates of incurred costs, including costs related to the Opportunity Sales Proceeding and refunds to customers. The storms resulted in widespread outages, significant damage to distribution and transmission infrastructure, and the loss of sales during the outages. This estimate includes all costs to restore power and repair or replace the damages from the hurricanes, except for the cost to repair or replace damage incurred to an Entergy Louisiana transmission line in southeast Louisiana, and the amount of that cost could be significant. The restoration plan for this transmission line and the related cost estimate is still being evaluated. Entergy Louisiana is considering all reasonable avenues to recover storm-related costs from Hurricane Laura, Hurricane Delta, and Hurricane Zeta, including securitization. Entergy Louisiana recorded accounts payable and corresponding construction work in progress and regulatory assets for the estimated costs incurred that were necessary to return customers to service. Entergy Louisiana recorded the regulatory assets in accordance with its accounting policies and based on the historic treatment of such costs in its service area because management believes that recovery through some form of regulatory mechanism is probable. There are well established mechanisms and precedent for addressing these catastrophic events and providing for recovery of prudently incurred storm costs in accordance with applicable regulatory and legal principles. Because Entergy Louisiana has not gone through the regulatory process regarding these storm costs, there is an element of risk, and Entergy is unable to predict with certainty the degree of success it may have in its recovery initiatives, the amount of restoration costs that it may ultimately recover, or the timing of such recovery. Natural gas purchases for Entergy Louisiana for February 1st through 25th, 2021 are approximately $190 million compared to natural gas purchases for February 2020 of $39 million. Also contributing to the increase were higher retail electric price, lower other operation and maintenance expenses, and a lower effective income tax rate. The increase was partially offset by higher depreciation and amortization expenses, lower volume/weather, lower other income, higher interest expense, and higher taxes other than income taxes. See Note 3 to the financial statements for further discussion of the tax audit resolution and the tax settlement. Operating Revenues Following is an analysis of the change in operating revenues comparing 2020 to 2019: Amount (In Millions) $4,285. See "Hurricane Laura, Hurricane Delta, and Hurricane Zeta" above for discussion of the storms. The return of unprotected excess accumulated deferred income taxes to customers resulted from the return of unprotected excess accumulated deferred income taxes through changes in the formula rate plan effective May 2018. There was no effect on net income as the reduction in operating revenues was offset by a reduction in income tax expense. See Note 2 to the financial statements for further discussion of regulatory activity regarding the Tax Cuts and Jobs Act. The retail electric price variance is primarily due to an increase in formula rate plan revenues effective June 2019 due to the inclusion of the first-year revenue requirement for the J. Charles Power Station) and effective April 2020 due to the inclusion of the first-year revenue requirement for the Lake Charles Power Station and increases in formula rate plan revenues effective September 2019 and September 2020. See Note 2 to the financial statements for further discussion of the formula rate plan proceedings. Charles Power Station) and the Lake Charles Power Station being placed in service. See "Critical Accounting Estimates" below and Note 11 to the financial statements for further discussion of pension and other postretirement benefit costs; and several individually insignificant items. Taxes other than income taxes increased primarily due to increases in ad valorem taxes resulting from higher property assessments. Depreciation and amortization expenses increased primarily due to additions to plant in service, including the J. Charles Power Station), which was placed into service in May 2019 and the Lake Charles Power Station, which was placed in service in March 2020. See Note 3 to the financial statements for further discussion of the settlements and savings obligations. Charles Power Station) and the Lake Charles Power Station projects; and changes in decommissioning trust fund activity. The difference in the effective income tax rate versus the federal statutory rate of 21% for 2019 was primarily due to the amortization of excess accumulated deferred income taxes. Entergy Louisiana had income tax refunds in 2020 and income tax payments in 2019 in accordance with an intercompany tax allocation agreement. Entergy Louisiana had income tax refunds in 2020 as a result of a refund of an overpayment on a prior year state income tax return. See Note 14 to the financial statements for further discussion of the Washington Parish Energy Center purchase; an increase of $16. Financing Activities Net cash flow provided by financing activities increased $1,221. The increase in the debt to capital ratio for Entergy Louisiana is primarily due to the net issuances of long-term debt in 2020. Entergy Louisiana seeks to optimize its capital structure in accordance with its regulatory requirements and to control its cost of capital while also maintaining equity capitalization at a level consistent with investment-grade debt ratings. To the extent that operating cash flows are insufficient to support planned investments, Entergy Louisiana may issue incremental debt or reduce distributions, or both, to maintain its capital structure. In addition, in certain infrequent circumstances, such as financing of large transactions that would materially alter the capital structure if financed entirely with debt and reducing distributions, Entergy Louisiana may receive equity contributions to maintain its capital structure. For Entergy Louisiana, almost all of the total consists of unconditional fuel and purchased power obligations, including its obligations under the Vidalia purchased power agreement and the Unit Power Sales Agreement, both of which are discussed in Note 8 to the financial statements. In addition to the contractual obligations given above, Entergy Louisiana currently expects to contribute approximately $59. In addition to routine capital spending to maintain operations, the planned capital investment estimate for Entergy Louisiana includes specific investments such as transmission projects to enhance reliability, reduce congestion, and enable economic growth; distribution spending to maintain reliability and improve service to customers, including advanced meters and related investments; resource planning, including potential generation and renewables projects; system improvements; investments in River Bend and Waterford 3; software and security; and other investments. Estimated capital expenditures are subject to periodic review and modification and may vary based on the ongoing effects of regulatory constraints and requirements, environmental compliance, business opportunities, market volatility, economic trends, business restructuring, changes in project plans, and the ability to access capital. Entergy Louisiana may refinance, redeem, or otherwise retire debt prior to maturity, to the extent market conditions and interest rates are favorable. Entergy Louisiana has sufficient capacity under these tests to meet its foreseeable capital needs. As of December 31, 2020, there were no cash borrowings and no letters of credit outstanding under the credit facility.
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