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M. Snorre, M.B. B.CH. B.A.O., Ph.D.

Clinical Director, Roseman University of Health Sciences

This was previously fully recognized within operating income as a functional expense. In addition, the portion of the lease payments that represents the reduction of the lease liability is recognized in the cash flow statement as an outflow from financing activities. Given the leases involved, these Non-current assets held for sale or held for distribution to owners Non-current assets are classified as assets held for sale or related to discontinued operations when their carrying amount is to be recovered principally through a sale transaction or distribution to owners, and a sale or distribution to owners is considered highly probable. Assets related to discontinued operations and assets of disposal group held for sale are not depreciated or amortized. For more details on the assets and liabilities of disposal group classified as held for sale in the 2019 and 2018 balance sheets, see "Item 18. The shareholder approval to spin off the Alcon business also required the recognition of a distribution liability at the fair value of the Alcon business. The distribution liability was recognized through a reduction in retained earnings. Any resulting impairment of the business assets to be distributed would have been recognized in the consolidated income statements in "Other expense" of discontinued operations, at the date of initial recognition of the distribution liability or at subsequent dates resulting from changes of the distribution liability valuation. At the April 8, 2019 distribution settlement date, the resulting gain, which was measured as the excess amount of the distribution liability over the then-carrying value of the net assets of the business distributed, was recognized on the line "Gain on distribution of Alcon Inc. These fair value measurements were classified as "Level 3" in the fair value hierarchy. Impairment of goodwill and intangible assets" provides additional information on key assumptions that are highly sensitive in the estimation of fair values using valuation techniques. Transaction costs that were directly attributable to the distribution (spin-off) of Alcon to the Novartis shareholders, and that would otherwise have been avoided, were recorded as a deduction from equity. These deductions represent estimates of the related obligations, requiring the use of judgment when estimating the effect of these sales deductions on gross sales for a reporting period. The following summarizes the nature of some of these deductions and how the deduction is estimated. After recording these, net sales represent our best estimate of the cash that we expect to ultimately collect. United States-specific healthcare plans and program rebates the United States Medicaid Drug Rebate Program is administered by state governments, using state and federal funds to provide assistance to certain vulnerable and needy individuals and families. Calculating the rebates to be paid related to this program involves interpreting relevant regulations, which are subject to challenge or change in interpretative guidance by government authorities. Provisions for estimating Medicaid rebates are calculated using a combination of historical experience, product and population growth, product pricing, and the mix of contracts and specific terms in the individual state agreements. The United States Federal Medicare Program, which funds healthcare benefits to individuals aged 65 and older, and to people with certain disabilities, provides prescription drug benefits under the Part D section of the program. This benefit is provided and administered through private prescription drug plans. Provisions for estimating Medicare Part D rebates are calculated based on the terms of individual plan agreements, product sales and population growth, product pricing, and the mix of contracts. We offer rebates to key managed healthcare and private plans in an effort to sustain and increase the market share of our products, and to ensure patient access to our products. These programs provide a rebate after the plans have demonstrated they have met all terms and conditions set forth in their contract with us. These rebates are estimated based on the terms of individual agreements, historical experience, product pricing and projected product growth rates, and are recorded as a deduction from revenue at the time the related revenues are recorded. These provisions are adjusted based on established processes and experiences from filing data with individual states and plans. In several countries, we enter into innovative pay-for-performance arrangements. Under these agreements, we may be required to make refunds to the healthcare providers or to provide additional medicines free of charge if anticipated treatment outcomes do not meet predefined targets. The impact of potential refunds or the delivery of additional medicines at no cost is estimated and recorded as a deduction from revenue at the time the related revenues are recorded.

The organism does not learn something new but rather begins to perform in an existing behavior in the presence of a new signal. Operant conditioning, on the other hand, is learning that occurs based on the consequences of behavior and can involve the learning of new actions. In operant conditioning the organism learns from the consequences of its own actions. How Reinforcement and Punishment Influence Behavior: the Research of Thorndike and Skinner Psychologist Edward L. Thorndike (1874­1949) was the first scientist to systematically study operant conditioning. At first the cats scratched, bit, and swatted haphazardly, without any idea of how to get out. But eventually, and accidentally, they pressed the lever that opened the door and exited to their prize, a scrap of fish. The next time the cat was constrained within the box it attempted fewer of the ineffective responses before carrying out the successful escape, and after several trials the cat learned to almost immediately make the correct response. Unsuccessful responses, which produce unpleasant experiences, are "stamped out" and subsequently occur less frequently. Thorndike described the learning that follows reinforcement in terms of the law of effect. Skinner created specially designed environments known as operant chambers (usually called Skinner boxes) to systemically study learning. A Skinner box (operant chamber) is a structure that is big enough to fit a rodent or bird and that contains a bar or key that the organism can press or peck to release food or water. A rat placed in the chamber reacted as one might expect, scurrying about the box and sniffing and clawing at the floor and walls. Eventually the rat chanced upon a lever, which it pressed to release pellets of food. Soon the rat was pressing the lever as fast as it could eat the food that appeared. As predicted by the law of effect, the rat had learned to repeat the action that brought about the food and cease the actions that did not. Skinner studied, in detail, how animals changed their behavior through reinforcement and punishment, and he developed terms that explained the processes of operant learning (Table 7. Skinner used the termreinforcer to refer to any event that strengthens or increases the likelihood of a behavior and the term punisher to refer to any event that weakens or decreases the likelihood of a behavior. And he used the terms positive andnegative to refer to whether a reinforcement was presented or removed, respectively. Thus positive reinforcement strengthens a response by presenting something pleasant after the response andnegative reinforcement strengthens a response by reducing or removing something unpleasant. For example, giving a child praise for completing his homework represents positive reinforcement, whereas taking aspirin to reduced the pain of a headache represents negative reinforcement. In both cases, the reinforcement makes it more likely that behavior will occur again in the future. Positive punishment weakens a response by presenting something unpleasant after the response, whereasnegative punishment weakens a response by reducing or removing something pleasant. A child who is grounded after fighting with a sibling (positive punishment) or who loses out on the opportunity to go to recess after getting a poor grade (negative punishment) is less likely to repeat these behaviors. Although the distinction between reinforcement (which increases behavior) and punishment (which decreases it) is usually clear, in some cases it is difficult to determine whether a reinforcer is positive or negative. On a hot day a cool breeze could be seen as a positive reinforcer (because it brings in cool air) or a negative reinforcer (because it removes hot air). One may smoke a cigarette both because it brings pleasure (positive reinforcement) and because it eliminates the craving for nicotine (negative reinforcement). It is also important to note that reinforcement and punishment are not simply opposites. The use of positive reinforcement in changing behavior is almost always more effective than using punishment. This is because positive reinforcement makes the person or animal feel better, helping create a positive relationship with the person providing the reinforcement.

For more information on how these transactions affect our consolidated financial statements and on how foreign exchange rate exposure is managed, see "Item 18. Operating and Financial Review and Prospects Free cash flow Novartis defines free cash flow as net cash flows from operating activities and cash flows associated with the purchase or sale of property, plant and equipment, as well as intangible, other non-current and financial assets, excluding marketable securities. The December 31, 2019, consolidated balance sheet excludes the assets and liabilities of the Alcon business, due to the derecognition of the Alcon business at the date of the spin-off. The consolidated balance sheet discussion and analysis that follows excludes the impacts of the derecognition of the Alcon business at the date of the spin-off. For details on the net assets derecognized at April 9, 2019, the completion date of the spin-off, see "Item 18. Goodwill and other non-current assets were broadly in line compared to December 31, 2018. Operating and Financial Review and Prospects nition of the Alcon business current assets as a result of the spin-off. Income tax receivable and assets of disposal group held for sale remained broadly in line compared to December 31, 2018. We continue to monitor the level of trade receivables, particularly in Argentina, Brazil, Greece, Italy, Portugal, Russia, Saudi Arabia, Spain and Turkey. Should there be a substantial deterioration in our economic exposure with respect to those countries, we may change the terms of trade on which we operate. At December 31, 2019, amounts past due for more than one year are not significant in any of these countries on a standalone basis. The majority of the outstanding trade receivables from Portugal, Saudi Arabia and Spain (in 2018, in addition Greece) are due directly from local governments or government-funded entities. Currency exposures are described in more detail in "-Effects of currency fluctuations" above. Novartis believes that its total provisions are adequate based upon currently available information. In our key countries, Switzerland and the United States, assessments have been agreed by the tax authorities up to 2015 in Switzerland and 2014 in the United States, respectively, with the exception of one open United States position related to the 2007 tax filing. This decrease was mainly due to the dividend in kind to effect the spinoff of Alcon Inc. This revaluation resulted from the Swiss federal tax reform enacted in May 2019 (see "Item 18. Operating and Financial Review and Prospects to them under the respective programs. Treasury shares At December 31, 2019, our holding of treasury shares amounted to 262. Approximately 118 million treasury shares were held in entities that limit their availability for use. Approximately 122 million treasury shares were held in entities that limit their availability for use. Approximately 131 million treasury shares were held in entities that limit their availability for use. This involves modeling cash flow maturity profiles based on both historical experiences and contractual expectations to project our liquidity requirements. We are not aware of any significant demands to change the level of liquidity needed to support our normal business activities. We make use of various borrowing facilities provided by several financial institutions. We also successfully issued various bonds in previous years (including 2017 and 2018), and raised funds through our commercial paper programs. For further information on these policies and these products in development, see "Item 4. Due to the risks and uncertainties involved in progressing through preclinical development and clinical trials, and the time and cost involved in obtaining regulatory approvals, among other factors, we cannot reasonably estimate the timing, completion dates and costs, or range of costs, of our drug development program, or of the development of any particular development compound (see "Item 3. In addition, for a description of the research and development process for the development of new drugs and our other products, and the regulatory process for their approval, see "Item 4. E Off-balance sheet arrangements We have no unconsolidated special purpose financing or partnership entities or other off-balance sheet arrangements that have or are reasonably likely to have a current or future effect on our financial condition, changes in financial condition, revenues or expenses, results of operations, liquidity, capital expenditures or capital resources, that is material to investors.

Physical Examination the physical breast examination is a step by step process that should be carried out by an experienced practitioner, examining each breast, nipple and regional nodes through observation and palpation in both the erect and supine position. Skin oedema of the breast erythema (skin reddening) or a palpable breast mass, nipple retraction, asymmetry or changes of the character of the skin and regional node presence, size and character should all be noted. Other causes of breast masses Presentation Cystic Mass Firm/rubbery, Diagnosis Direct Ultrasound/ Aspiration Treatment Aspiration, Follow-Up in 6-8 weeks, Excisional Biopsy (if aspiration bloody) Observation/follow-up studies, complete surgical excision Fibroadenomas (Common in women under 40 years) Non-tender, round, macrolobulated masses that are firm/ rubbery. Triple Test Evaluation (Physical Exam, Mammography and Fine Needle Aspiration) Breast Imagingmammography Hematoma Ecchymosis (blood below subcutaneous tissue) painful tender mass. Supportive garments, analgesics and needle biopsy (if malignancy suspected) Fat Necrosis Small, firm, painless, ill defined breast masses usually post penetrating trauma (lumpectomy/breast reconstruction) Soft- differ only slightly to surrounding breast parenchyma Difficult to distinguish from Observation of mass. During a mammography each breast is placed between two plates and compressed so that a clear image is obtained. During a screening mammography 2 X-Rays are taken of each breast of asymptomatic women to detect change at a preclinical stage, this is the primary role of mammography. After analyzing mammographic images, radiologists classify findings into five categories (see table). American Cancer Society and American College of Radiology guidelines for screening for breast cancer and appropriate use of mammography state: Asymptomatic Women Women of 20 years of age or older should perform Breast Screening Examination monthly. Women 40 years and older should have a mammogram and physical breast exam every year. Symptomatic Women Any women experiencing signs or symptoms of breast cancer or unusual changes to the breasts should have a thorough breast examination including mammography and ultrasound despite age, to determine whether cancer is present. Its sensitivity is 65-98% and specificity is 34-100% in diagnosing breast lesions (Irish Cancer Society, 2011). The palpable breast mass is trapped and a fine needle is slowly inserted into the mass. After several advances within the mass along multiple planes the needle is withdrawn and the specimen is placed on a slide for investigation. Excisional Biopsy Excisional Biopsy is the complete surgical removal of a palpable breast lesion and is indicated if Needle biopsy is not feasible or if it is non-diagnostic or discordant with imaging results. Depending on the likelihood of malignancy, a rim of surrounding normal breast tissue can be removed. The patient is usually under local anaesthetic and 21 sedation with placement of the incision determined by both oncologic and cosmetic considerations. The breast lesion is removed and the biopsy cavity is examined for further abnormality or suspect lesions. Non-invasive or invasive breast cancer Non-invasive breast cancers stay within the ducts/lobules. Cell Grade A 1-3 Grade Scale with Gr 1 cells slightly different to normal cells and Gr 3 cells appearing very different to normal cells and growing in a rapid and disorganised pattern. Tumour Necrosis (Cell death) this is often a sign of a rapidly growing aggressive form of breast cancer. Surgical Margins the surgeon examines the rim of the tissue removed (surgical margin). If there are no cancerous cells on the outer rim of the removed tissue it is described as clear, it there is cancerous cells present it is called positive and if there is cancerous cells close to the edge it is called close. Vascular or Lymphatic Invasion Describes whether the cancerous cells have infiltrated the vascular/lymphatic system supplying the breast. Ploidy Diploid cancers cells have the same amount of chromosomes as normal cells and tend to be slower growing, less aggressive cells. Aneuploid cancer cells have too many/too little amount of chromosomes and tend to be rapid growing aggressive cells. Hormone Receptor Status Hormone receptor status determines if hormone therapy would be appropriate. Or may have spread to lymph nodes behind the breastbone but not spread to underarm lymph nodes. Tumour can be any size and has grown into the chest wall or the skin of T4 N0 M0 the breast.

For a number of years before that date, the National Socialists in Germany had been cooperating with the National Socialists of Austria with the ultimate object of incorporating Austria into the German Reich. The Putsch of 25 July 1934, which resulted in the assassination of Chancellor Dollfuss, had the seizure of Austria as its object; but the Putsch failed, with the consequence that the National Socialist Party was outlawed in Austria. On 11 July 1336 a n agreement was entered into between the two countries, Article 1. The resulting "incidents" were seized upon by the German National Socialists as a n excuse for interfering in Austrian affairs. The relationship between the two-countries steadily worsened, and finally the Austrian Chancellor Schuschnigg was persuaded by the Defendant Von Papen and others to seek a conference w i t h - ~ i t l e r which, took place a t Berchtesgaden on 12 February 1938. Schuschnigg finally agreed to grant a political amnesty to various Nazis convicted of crime, and t o appoint the Nazi Seyss-Inquart as Minister of the Interior and Security with control of the Police. Schuschnigg decided to hold a plebiscite on the question of Austrian independence, which was fixed for 13 March 1938. Hitler, two days later, sent a n ultimatum to Schuschnigg that the plebiscite must be withdrawn. I n the afternoon and evening of 11 March 1938 the Defendant Goring made a series of demands upon the Austrian Government, each backed up by the threat of invasion. After Schuschnigg had agreed to the cancellation of the plebiscite, another demand was put forward that Schuschnigg must resign, and. In conset quence, Schuschnigg resigned, and President Miklas, after a t first refusing to appoint Seyss-Inquart as Chancellor, gave way and appointed him. Meanwhile Hitler had given the final order for the German troops to cross the border at dawn on 12 March and instructed Seyss-Inquart to use formations of Austrian National Socialists t o depose Miklas and to seize control of the Austrian Government. After the order to march had been given to the German troops, Goring telephoned the German Embassy in Vienna and dictated a telegram which he wished Seyss-Inquart to send to Hitler to justify the military action which had already been ordered. It was: "The provisional Austrian Government, which, after the dis- missal of the Schuschnigg Government, considers its task to establish peace and order in Austria, sends to the German Governm. For this purpose i t asks the German Government 40 send German troops as soon as possible. This action outraged the Defendant Goring, because "it would disturb the rest of the Fiihrer, who wanted to go to Austria the next day". At daybreak on 12 March 1938 German troops marched into Austria, and met with no resistance. It was announced in the German press that Seyss-Inquart had been appointed the successor to Schuschnigg, and the telegram which Goring had suggested, but which was never sent, was quoted to show that Seyss-Inquart had requested the presence of German troops to prevent disorder. Seyss-Inquart demanded that President Miklas should sign this law, but he refused to do so, and resigned his office. This law was then adopted as a law of the Reich by a Reich Cabinet decree issued the same day, and signed by Hitler and the Defendants Goring, Frick, Von Ribbentrop, and Hess. It was contended before the Tribunal that the annexation of Austria was justified by the strong desire expressed in many quarters for the union of Austria and Germany; that there were many matters in common between the two peoples that made this union desirable; and that in the result the object was achieved without bloodshed. These matters, even if true, are really immaterial, for the facts plainly prove that the methods employed to achieve the object were those of an aggressor. The ultimate factor was the armed might of Germany ready to be used if any resistance was encountered; Moreover, none of these considerations appear from the Hossbach account of the meetings of 5 November 1937 to have been the motives which actuated Hitler; on the contrary, all the emphasis is there laid on the advantage to be gained by Germany in her military strength by the annexation of Austria. The Seizure of Czechoslovakia the conference of 5 November 1937 made it quite plain that the seizure of Czechoslovakia by Germany had been definitely decided upon. On 4 March 1938 the Defendant Von Ribbentrop wrote to the Defendant Keitel with regard to a suggestion made to Von Ribbentrop by the Hungarian Ambassador in Berlin, that possible war aims against Czechoslovakia should be discussed between the Gerlnan and Hungarian Armies. In the course of this letter Von Ribbentrop said: "I have many doubts about such negotiations. In case we should discuss with Hungary possible war aims against Czechoslovakia, the danger exists that other parties as well would be informed about this. Mastny, the Czechoslovak Minister in Berlin, assuring him that the developments then taking place in Austria would in no way have any detrimental influence on the relations between the German Reich and Czechoslovakia, and emphasized the continued earnest endeavor on the part of the Germans to improve those mutual relations. This design to keep Czechoslovakia quiet whilst Austria was absorbed was a typical maneuver on the part of the Defendant Goring, which he was to repeat later in the case of Poland, when he made the most strenuous efforts to isolate Poland in the impending struggle. Mastny, and assured him on behalf of Hitler that Germany still considered herself bound by the German-Czechoslovak Arbitration Convention concluded a t Locarno in October 1925. The evidence shows that after the occupation of Austria by the German Army on 12 March and the annexation of Austria on 13 March, Conrad Henlein, who was the leader of the Sudeten German Party in Czechoslovakia, saw Hitler in Berlin on 28 March.