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Americas hospital industry美国医疗行业Taking a scalpel to costs对医疗费用动动刀Hospital operators brace themselves for health-care reform医院负责人正为医保制度改革做准备EARLIER this month Americas hospital bosses gathered in Washington, DC, with vice-president Joseph Biden.本月早些时候,美国医院的领导者们和副总统Joseph Biden齐聚华盛顿。To the amazement of many, they vowed to accept a cut of 5 billion in their expected revenues over the next decade as part of a grand bargain on health-care reform.令人感到惊奇的是,他们郑重同意在接下来的十年将预期收益削减1550亿美元,作为医疗保健改革已取得的巨大成效中的一部分。How can they justify giving away such a vast sum?他们为什么会同意放弃这么大一笔收益?There are several explanations, not all of them altruistic.对此有很多种解释,他们的动机也不全出于利他。Taken together, they show that the industrys leaders are bracing themselves for a period of upheaval.总之,他们已经显示出整个行业的领导人正积极应对未来行业的大变动。For hospitals, the positive thing about health-care reform is that it is going to be good for business.对医院来说,医保改革带来的好处是它对商业有利。It will be welcome news to an industry that is hardly in rude health.改革对于一个不太健康的行业来说总是好事。Despite two decades of consolidation, hospitals finances remain anaemic; over a quarter of them regularly post negative operating margins.诚然,医保行业走过了二十年的稳固期,但是医院的财经状况仍旧不景气,超过四分之一的医院存在周期性亏损。The recession is making things worse.而且现在的经济危机更是加剧了形势恶化。Moodys, a credit-rating agency, notes that many patients are putting off non-essential treatments.信贷评级机构Moodys注意到很多患者正在推迟一些非必须的治疗。So any reforms that promise a flood of new demand for health services should be welcome.因此任何可以使得医疗务的需求大幅增长的改革承诺都应该是大受欢迎的。Rich Umbdenstock, the head of the American Hospital Association and one of the bosses who shared the stage with Mr Biden,作为美国医院协会会长的Rich Umbdenstock和与副总统Biden先生见面会谈的领导人之一,acknowledges that extending health insurance to most of Americas nearly 50m uninsured will benefit his industry in the long term.承认从长远看来,为没有享受医保的五千万美国人提供保险将会使整个行业受益。Those unfortunates still turn up at emergency rooms and often do not pay their bills.这些没有医保的人们经常出现在急诊室里而且无力付医药单。The government gives hospitals some money to compensate them for this, but the AHA says it does not cover the full cost,对此,政府会给医院发放一定数额的资金以作弥补,但是美国医院协会表示,这些金额不足以付资金缺口。which it put at billion in 2007, up from .9 billion in 1980.这些缺口已经从1980年的39亿上升到2007年的340亿,Paul Mango of McKinsey, a consultancy, estimates that the hospitals recover only 10-12% of this cost.大约占医院每年财政收入的5%。来自咨询公司麦肯锡公司的Paul Mango估计,医院大概只能收回这些资金的10-12%,But he says the problem would be greatly reduced under a system of universal health-insurance which included subsidies for the indigent, as the proposed health reforms envisage.但他也说,如果可以建立一个大部分人都享受医保并且贫困人口得到补助的体制,这些资金缺口就可以被大大减少,而这种体制正是当前的医疗改革尝试建立的。Herbert Pardes, chief executive of New York-Presbyterian, a research hospital, says the large numbers of underinsured patients, who frequently fail to pay their bills in full, cost hospitals still more.Herbert Parades是纽约一家研究型医院Presbyterian的总裁,他说,很多保额不足的病人不能全额付他们的医疗花费,这仍旧给医院带来越来越大的负担。The huge sums the hospitals stand to gain from reducing such losses make even 5 billion over ten years look like a reasonable amount of money to sacrifice to secure such a bonanza.如果医院在未来十年可以通过削减这种损失而获得1550亿的利润,那么这样的暂时性损失也是合理的。But there are less virtuous reasons why the hospitals offered such a generous-sounding deal.但是人们不知道医院愿意放弃这样一笔利润的背后仍有很多不太高尚的原因。As Mr Umbdenstock notes, it was less painful than the 5 billion or more in cuts that Barack Obama had been pressing for earlier in the year.正如Umbdenstock先生所说,相比奥巴马总统今年早些时候敦促的2250亿甚至更多的财政削减计划,现行的削方案就没有那么痛苦了。This is a tacit acknowledgment that hospital chiefs were seeking to avert the one thing that strikes fear into their hearts: the sp of price controls.医院负责人们早已心照不宣地承认,他们通过这样的变通,正在努力避免物价被控制,这正是会令他们惊恐不安的事情。Because of the creeping expansion of Medicare and Medicaid, the publicly funded health-care schemes for the elderly and the poor,在美国,为老年病人和残疾病人的国家医疗照顾体制正在慢慢向更多的公民扩展,the government aly pays over half the bills at the average American hospital.正因为如此,平均下来政府已经为每家医院付了超过半数的医疗费。But the political left is clamouring for a government-run insurance plan, to compete with private ones, as part of any reform effort.但是政治左派却在改革之中叫嚣一个政府操作的保险计划,以此来和私人运营计划相抗衡。The problem, argues Toby Cosgrove, chief executive of the Cleveland Clinic, a hospital group, is that the existing public schemes routinely underpay hospitals for care.Toby Gosgrove是,一个名为Cleveland Clinic的理疗团体总裁,他说,这样做的问题在于,现行的医保体制总是使得医院获得不足额的补助。Some economists question that claim.一些经济学家对此持怀疑态度。Even so, it is probably right to suggest,尽管如此,正如Cosgrove医生所建议的,as Dr Cosgrove does, that any public insurance plan based on Medicares pricing would squeeze hospitals hard and, as a result, require private insurers to cross-subsidise the bill.依照目前国家医疗照顾体制的集款方式所运营的任何公共保险计划都会使医院出现资金困难,结果仍旧需要投保个人来买单。In addition to a determination to head off any moves towards greater government control over prices,采取此项改革的一个重要原因是医院领导人们下定决心阻止政府对医药价格的进一步控制,another even less noble reason for offering the price cut was a desire to thwart a proposed change to the tax status of non-profit hospitals, which make up most of the national total of 5,700 or so.相比而言另一个不怎么高尚的原因则是领导者们试图通过减少削减开来抵制改变非营利性医院税收政策的提案,非营利性医院在全美有5700家之多。On the ground that they provide charitable care, many religious and community hospitals have been granted an exemption allowing them to issue tax-free bonds,由于很多宗教和社区医院提供慈善性的救助,他们都享有税收优惠的政策,可以发放免税券,免收财产和收入税收等等。avoid taxes on property and income, and so on. But investigations by the Internal Revenue Service and others have revealed that many in fact provide very little charitable care, while paying enormous salaries or going on acquisition sprees.但是美国国内收入署和其他一些机关的调查表明,有些医院提供很少的慈善性救助,他们所做的无非是领取高额工资,无节制地享受收益。On this proposal, the industry may carry the day.在这样的提案下,整个行业的反对可能会占上风。Although the tax break is hard to defend, closing the loophole would lead to many small, weak hospitals shutting down—something voters would be unlikely to tolerate.尽管人们很难为税务减免而辩护,结束这样的漏洞可能会导致很多小型医院的倒闭,这正是选民们不能容忍的事情。Even those hospitals that survived might spark a backlash.甚至那些得以幸存的医院也会引发人们强烈的反对。Dr Pardes argues that abolishing the tax advantages would mean higher running costs that would inevitably be passed through to those patients who have private insurance.Parades医生说废除税收优惠政策即意味着更高的运作成本,这无疑将给那些拥有个人医疗保险的病人施加经济负担。The other great fear of hospital bosses is being forced to accept greater competition.医院负责人们的另一个隐忧是被迫进入激烈的行业竞争。Although the industry is fragmented, Jon Scholl of the Boston Consulting Group points out that because pricing is done at city or regional level, there are local pockets of power.波士顿咨询集团的Jon Scholl指出,现在的医疗行业处于离破碎的状态,由于定价的过程是在某一城市或地区范围之内完成的,本地权利口袋影响定价的行为是存在的。Alain Enthoven, an economist at Stanford Universitys business school who helped inspire the managed health care movement of the 1990s, promoted an approach that succeeded in squeezing costs at the time,Alain Enthoven是来自斯坦福大学商学院的经济学家,他曾经在二十世纪90年代推动管理医保运动的开展。but ultimately failed as patients rebelled against the restrictions it placed on their choice of doctors and treatments.当时他推行的改革方案在削减成本方面颇有成效,但因为病患不满他们失去了选择医生和疗法的自由而抗议,这项改革以失败告终。Mr Enthoven argues that the consolidation that followed managed care has resulted in too little competition.Enthoven先生认为,改革失败后的相对稳固导致了今日几无竞争存在的行业格局。Antitrust action in the hospital field has been woefully weak, he says.他说:反垄断在医疗行业只是一句可悲的空话。There are some innovative competitors emerging to challenge hospitals.当然还是有一些富有创新精神愿意挑战垄断的竞争者出现。Paul Keckley of Deloitte, a consultancy, estimates that there are over 1,000 retail health clinics operating today at Wal-Mart stores,Deloitte咨询公司的Paul Keckley估计,在沃尔玛店铺,Walgreen药店还有其他的一些便利商店,总共有超过1000家药品零售诊所存在。Walgreens pharmacies and other convenient locations, and their numbers are expected to multiply in the next few years.在今后几年,这些零售诊所的数量有可能翻倍。Some of these cheap and cheerful outfits are staffed by nurse practitioners, which incenses doctors and hospital bosses.一些有医师资格的护士在这里工作,他们的工资水平比医师低很多,这让医生和医院负责人们很是恼怒。The nascent boom in medical tourism could also disrupt the hospital business,但医疗旅游近期的初步兴起还是困扰医疗行业的一个原因。even if every hip-replacement patient does not actually go to India to get it done.尽管不是每一个需要做髋关节置换手术的病人都选择去印度治疗,Mr Keckley points out that in several parts of the country the mere introduction of insurance plans offering cheap surgery abroad has forced local hospitals to respond by slashing their prices—something unheard of in this industry.Keckley先生指出,在美国的一些地方,出现了一些提供便宜海外手术的医疗保险计划,这就使得当地医院不得不采取减价策略,但事实上,减价在医疗行业是前所未闻的事情。Mr Enthoven argues that if reforms are done properly, they would force hospitals to get organised to compete and get more efficient.Enthoven先生说,如果改革可以成功实施,那么这将促使医院组织性更强的去参与行业竞争,而且将使整个行业提高效率。Alas, the omens are not good.但是,目前的预兆不太好。One of the explicit concessions wrung by the hospital bosses from the White House was a promise to crack down on clinics owned by doctors.医院负责人们与政府方面协商出的一个明确让步就是打击私人医生开设的诊所。These outfits are guilty of anti-competitive self-dealing, since the doctor has a financial motive to refer cases to his own firm,因为医生们出于经济动机可能会向自己的私人诊所推荐病例,这些小诊所违反了反竞争的自利交易原则,but what hospital bosses were really concerned about was that such clinics are competing hard with them, and siphoning off the most profitable patients.但事实上医院负责人们真正担心的问题是这些小诊所正与大医院激烈的竞争,大医院可能因此失掉那些可以让他们赚大钱的病例。As this back-room deal illustrates, the strongest motives behind the hospitals ostensibly generous price cut were self-serving ones: to reduce competition, not boost it,正如这个密室协议所明的,在医院表面慷慨削减开的背后,最真实的动机却是自我获利:and to head off any increase in government influence over their prices.非但不促进,反而减少竞争,并竭力避免任何可能出现的政府对价格的管制。As health-care reform forges ahead, reformers are desperate to find cost savings and the hospital industry is a juicy target.医保改革就在眼前,改革者们将会失望的发现医疗行业减少开的目标很难实现。So its bosses felt they had to cut a deal.所以行业负责人们觉得他们必须做笔交易。As Julius Hobson of Bryan Cave, a veteran health lobbyist, puts it: If youre not at the table, then youre on the .Julius Hobson,是Bryan Cave公司的一个老兵健康游说者,现在的情形正如他所说:如果你不愿意主动出击,那你就等着被人利用吧。 /201304/237221Can animals count?动物能数数吗?People count easily, from the time we are little kids and learn our one-two-threes.数数对人类而言易如反掌,孩提时代就开始数一二三了。But what about other species?但是其它物种如何呢?Careful observations in the wild support the idea that some can.通过对于自然环境中一些物种的仔细观察发现它们真的具有这项技能。The American coot is a duck-like North American bird.美洲骨顶是一种生活在北美而且长得像野鸭的鸟类。Sometimes a coot will try and sneak one of its eggs into a neighbors nest.有时骨顶会试着把自己的蛋偷偷放到邻居的巢中。Some coots recognize the deception, and roll the strangers egg out again.有的骨顶能识破诡计,剔除这个不明来路的蛋。Others dont catch on, and raise the strangers egg as their own.而有的则丈二和尚摸不着头脑,干脆当作自己的后代抚养长大。Researcher Bruce Lyon at the University of California, Santa Cruz, and his team observed a series of coot nests for four seasons, noting which birds could spot a strangers eggs and which couldnt.加利福利亚圣克鲁斯大学研究员的布鲁斯·里昂和他的团队四个季节以来一直致力于观察骨顶巢。他们记录下了哪些鸟能认出陌生的鸟蛋,哪些不能认出。Then they compared how many eggs each kind laid.然后他们比较了这些鸟各生了多少蛋。201312/268948

Science and technology科技报道Climate change in the Arctic北极气候变化Beating a retreat仓惶撤退Arctic sea ice is melting far faster than climate models predict. Why?北极海冰正在以比气候模型所预测的快得多的速度融化,为什么?ON SEPTEMBER 9th, at the height of its summertime shrinkage, ice covered 4.33m square km, or 1.67m square miles, of the Arctic Ocean, according to Americas National Snow and Ice Data Centre.据美国国家冰雪中心监测,今年的9月9日,处于夏季收缩极值的北极海冰仅仅覆盖了433万平方公里,或相当于167万平方英里的北冰洋洋面。That is not a record low—not quite.这虽未创下最低记录,但也已相去不远。But the actual record, 4.17m square km in 2007, was the product of an unusual combination of sunny days, cloudless skies and warm currents flowing up from mid-latitudes.2007年的417万平方公里的最低记录是受到当时艳阳高照,万里无云的天空以及从中纬度上来的暖流这种异常组合的影响的产物。This year has seen no such opposite of a perfect storm, yet the summer sea-ice minimum is a mere 4% bigger than that record.而尽管并没有观测到如此不利的情况,今年海冰的极小值也仅仅比那年的记录大了4%。Add in the fact that the thickness of the ice, which is much harder to measure, is estimated to have fallen by half since 1979, when satellite records began, and there is probably less ice floating on the Arctic Ocean now than at any time since a particularly warm period 8,000 years ago, soon after the last ice age.除此以外,较难测量的冰面厚度预计比首次有卫星观测记录的1979年降低了一半。现在,漂浮在北冰洋上面的冰块很可能是8000千年前最后一个冰河期结束后的那个极暖期以来最少的。That Arctic sea ice is disappearing has been known for decades.数十年前,人们已经认识到北极海冰正在消亡一事。The underlying cause is believed by all but a handful of climatologists to be global warming brought about by greenhouse-gas emissions.除了少数人以外,几乎所有气候学家都将其归咎于温室气体排放所带来的全球变暖。Yet the rate the ice is vanishing confounds these climatologists models.然而海冰消失的速率使这些气象学家建立的气候模型陷入混乱。These predict that if the level of carbon dioxide, methane and so on in the atmosphere continues to rise, then the Arctic Ocean will be free of floating summer ice by the end of the century.按照他们的预计,若大气中的二氧化碳、甲烷以及其他温室气体持续增加,到本世纪末夏季的北极海冰将完全消失。At current rates of shrinkage, by contrast, this looks likely to happen some time between 2020 and 2050.但是相较之下,依现在的消融速率,这一情况将可能在2020年到2050年之间发生。The reason is that Arctic air is warming twice as fast as the atmosphere as a whole.其原因是由于北极的空气正在以大气整体的两倍速度暖化。Some of the causes of this are understood, but some are not.其中部分根源已经被了解,但仍有一些未能解开。The darkness of land and water compared with the reflectiveness of snow and ice means that when the latter melt to reveal the former, the area exposed absorbs more heat from the sun and reflects less of it back into space.与强反射的冰雪表面相比,当其融化后露出下面深色的陆地或水体时,这部分区域将从太阳吸收到更多的热量而仅仅反射更少的部分到空中。The result is a feedback loop that accelerates local warming. Such feedback, though, does not completely explain what is happening.结果造成了一个局部暖化加速的恶性循环,尽管这种反馈机制未能完全解释当下正在发生的事情。Hence the search for other things that might assist the ices rapid disappearance.今后对其他事物的研究可能会对解释海冰的快速消失带来帮助。Forcing the issue解决问题One is physical change in the ice itself.另一个原因是海冰自身的物理结构发生了改变。Formerly a solid mass that melted and refroze at its edges, it is now thinner, more fractured, and so more liable to melt.以前融化和冻结仅发生在冰块的边缘,但是它现在变得更薄,更易破裂,并且更倾向融化。But that is a marginal effect. Filling the gap between model and reality may need something besides this.但这只是名副其实的边际效应。要弥合模型与现实的差距,还需要其他原因。The latest candidates are short-term climate forcings.最后一个候选者是所谓的短期气候强迫物质。These are pollutants, particularly ozone and soot, that do not hang around in the atmosphere as carbon dioxide does, but have to be renewed continually if they are to have a lasting effect.即是大气污染物,尤其是臭氧和煤烟。尽管它们不能像二氧化碳那样在大气中停留,以至于需要不断补充以持续发挥作用。If they are so renewed, though, their impact may be as big as CO2s.但是假如它们得到足够的补充,将对全球变暖带来不亚于二氧化碳的影响。At the moment, most eyes are on soot.当前,绝大多数眼球都注目于煤烟。In the Arctic, soot is a double whammy.煤烟给北极带来了双重打击。First, when released into the air as a result of incomplete combustion, soot particles absorb sunlight, and so warm up the atmosphere. Then, when snow or rain wash them onto an ice floe, they darken its surface and thus cause it to melt faster.首先,当作为非充分燃烧的产物被排放到空中后,煤烟颗粒吸收阳光,加热了大气。其次,当雨雪将煤烟带到冰面上后,使冰面颜色变深,并导致加速消融。Reducing soot would not stop the summer sea ice disappearing, but it might delay the process by a decade or two.尽管减少煤烟排放不能阻止夏季海冰的消失,但或许能减缓这一过程十到二十年。According to a recent report by the ed Nations Environment Programme,联合国环境规划署的一份最新报告显示,reducing black carbon and ozone in the lower part of the atmosphere, especially in the Arctic countries of America, Canada, Russia and Scandinavia, could cut warming in the Arctic by two-thirds over the next three decades.减少低层大气中的黑炭以及臭氧,尤其是北极圈国家,如美国,加拿大,俄罗斯,斯堪的纳维亚诸国,能够在未来三十年里降低北极地区的暖化速度达三分之二。Indeed, the report suggests, if such measures—preventing crop burning and forest fires, cleaning up diesel engines and wood stoves, and so on—were adopted everywhere they could halve the wider rate of warming by 2050.事实上,如果能如此份报告所说,到处都采取诸如防止焚烧作物和森林火灾,清理柴油发动机以及火炉等措施,到2050年止能将当下较大的暖化速率减半。Without corresponding measures to cut CO2 emissions, this would be but a temporary fix.如果没有相应的削减二氧化碳排放的措施,这将只是一个临时性解决方法。Nonetheless, it is an attractive idea because it would have other benefits and would not require the wholesale rejigging of energy production which reducing CO2 emissions implies.尽管如此,这仍是一个有足够吸引力的主意,因为它还能带来其他利益,也不会像削减二氧化碳排放那样需要大规模调整能源产业。Not everyone agrees it would work, though. Gunnar Myhre of the Centre for International Climate and Environmental Research in Oslo, for example, notes that the amount of black carbon in the Arctic is small and has been falling in recent decades. He does not believe it is the missing factor in the models.然而,不是每个人都认为它将很有效。例如位于奥斯陆的国际气候与环境研究中心的冈纳·迈尔表示,他注意到北极的黑炭的量微乎其微,并且已经在最近的数十年里沉降下来。他不相信这会是模型中确实的影响因子。Carbon dioxide, in his view, is the main culprit. Black carbon deposited on the Arctic snow and ice, he says, will have only a minimal effect on its reflectivity.在他眼中,二氧化碳才是罪魁祸首。他说,落到北极冰雪上面的黑炭,只会对其反射率带来微小的影响。The rapid melting of the Arctic sea ice, then, illuminates the difficulty of modelling the climate—but not in a way that brings much comfort to those who hope that fears about the future climate might prove exaggerated.北极海冰的快速消融揭示了建立气候模型的困难,只不过,与那些认为对未来气候的恐惧可能被过分夸大的人的想法背道而驰。When reality is changing faster than theory suggests it should, a certain amount of nervousness is a reasonable response.当事实上的变化快于纸面理论时,一定量的情绪不安是合理的反应。Its an ill wind一利百弊The direct consequences of changes in the Arctic are mixed.北极的变化将带来的各种后果。They should not bring much rise in the sea level, since floating ice obeys Archimedess principle and displaces its own mass of water.它并不会使海平面上升许多,因为浮冰遵循阿基米德原理排开了相当于它自身的水。A darker—and so more heat-absorbent—Arctic, though, will surely accelerate global warming and may thus encourage melting of the land-bound Greenland ice sheet.然而一个相对深色的—也会吸收更多热量—北极,毫无疑问会加速全球变暖,并且可能促使连接在陆地上的格陵兰岛冰盖加快融化。That certainly would raise sea levels.而这将一定导致海平面上升。Wildlife will also suffer.野生动物也将深受其害。Polar bears, which hunt for seals along the ices edge, and walruses, which fish there, will both be hard-hit.沿着浮冰边缘狩猎海豹的北极熊,以及在此的海象,都将受到沉重打击。The effects on the wider climate are tricky to assess.它给更广范围的气候所带来的影响难以评估。Some meteorologists suspect unseasonal snow storms off the east coast of America in 2010 were partly caused by Arctic warming shifting wind patterns.一些气象学家推测北极变暖造成的气流模式改变是造成2010年袭击美国东海岸的那场非季节性暴风雪的部分原因。One feedback loop that does seems certain, though, is that the melting Arctic will enable the extraction of more fossil fuel, with all that that implies for greenhouse-gas emissions.然而,有一个恶性循环似乎是真的—一个融化中的北极将会使得更多化石燃料被抽取,这与温室气体排放直接关联。The Arctic is reckoned to hold around 15% of the worlds undiscovered oil reserves and 30% of those of natural gas.北极被估计保有全球石油储量的15%以及天然气储量的30%。Hence a growing polar enthusiasm among energy companies—as witnessed last month in an Arctic tie-up between Exxon Mobil, of America, and Rosneft, Russias state-controlled oil giant.因此,在能源公司中掀起了一股极地热潮—上个月美国的埃克森美孚公司与俄罗斯国有石油巨头俄罗斯石油公司达成北极大陆架战略伙伴关系协议就是明。Recent plankton blooms suggest a warmer Arctic will provide a boost to fisheries there, too.而浮游生物的大量繁殖预示着一个较温暖的北极也将推动此处的渔业发展。And the vanishing ice has begun to allow a trickle of shipping across the Arctics generally frozen north-west and north-east passages, thus linking the Atlantic and Pacific oceans.消失的冰面也开始允许船只缓慢通过通常封冻的北极西北和东北通道,从而连接了大西洋和太平洋。In August a Russian supertanker, the Vladimir Tokohonov, aided by two nuclear icebreakers, became the first such vessel to cross the north-east route, hugging the Siberian coast.在今年八月,一艘俄罗斯籍超级油轮,弗拉基米尔·蒂克霍诺夫号在两艘核能破冰船的帮助下成为了第一艘通过东北路径的同类船只。So far, despite some posturing by Canada and Russia, there are few territorial disputes in the region and the Arctic Council, the club of Arctic nations, has functioned reasonably well.迄今为止,除了加拿大和俄罗斯所摆出的一些姿势外,在该地区鲜少有领土争端问题。Whether the interests of these countries coincide with those of the wider world, though, is moot.北极理事会—北极圈国家的俱乐部,也运行良好。A warming Arctic will bring local benefits to some.尽管有待讨论,无论这些国家的利益是否与其他国家重合,一个正在变暖的北极只会给当地带来利益,The rest of the world may pay the cost.而世界上其他地方将不得不为之埋单。 /201309/257508

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