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Military Prehospital Use of Low Titer Group O Whole Blood
Benefit of Critical Care Flight Paramedic-Trained Search and Rescue Corpsmen in Treatment of Severely Injured Aviators
Challenges of Transport and Resuscitation of a Patient With Severe Acidosis and Hypothermia in Afghanistan
The Shrail: A Comparison of a Novel Attachable Rail System With the Current Deployment Operating Table
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Introduction
Bringing Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Closer to the Point of Injury
Feasibility and Proposed Training Pathway for Austere Application of Resuscitative Balloon Occlusion of the Aorta
Laboratory Model of a Collapsible Tube to Develop Bleeding Control Interventions
The Myth of Hyperresilience Evolutionary Concept Analysis of Resilience in Special Operations Forces
Intramuscular Tranexamic Acid in Tactical and Combat Settings
Successful Use of Ketamine as a Prehospital Analgesic by Pararescuemen During Operation Enduring Freedom
Blood Lead Toxicity Analysis of Multipurpose Canines and Military Working Dogs
Ocular Injuries and Cultural Influences in Afghanistan During 5 Months of Operation Enduring Freedom
Lead Exposure in the Special Operations Shooter How to Prevent Cognitive Decline and Permanent Disability
Routine Screening Laboratory Studies for Nonheat Stroke Field Heat Injuries Are Unnecessary: A Retrospective Review
Prehospital Care of Canine Gastric Dilatation and Volvulus
Spiritual Fitness: An Essential Component of Human Performance Optimization
Epidemiological Evidence and Possible Mechanisms for the Association Between Cigarette Smoking and Injuries (Part 1)
Diagnosis and Treatment of Anaphylaxis During Law Enforcement Operations
Integrating Chemical Biological, Radiologic, and Nuclear (CBRN) Protocols Into TCCC Introduction of a Conceptual Model - TCCC + CBRN = (MARCHE)2
Documentation in Prolonged Field Care
Prehospital Medicine and the Future Will ECMO Ever Play a Role?
Editorial Response
Patella Fracture in US Servicemember in an Austere Location
I Can't Breathe-A SIPe of Water
You Never Know, Until You Know, and Then You Know: An Interview With COL (Ret) John F. Kragh Jr, MD
Medicine on the Edge of Darkness
The Death of The Golden Hour and the Return of the Future Guerrilla Hospital
The Quiet Soldier: On Selection With 21 SAS
Proceedings from the 2017 Mid-Year Meeting of the Committee for Tactical Emergency Casualty Care (C-TECC) and Committee Updates
Committee on Tactical Combat Casualty Care: Meeting Minutes. 6-7 September, 2017; San Antonio, TX
Warner N, Zheng J, Nix G, Fisher AD, Johnson JC, Williams JE, Northern DM, Hellums JS. 18(1). 15 - 18. (Case Reports)
The military's use of whole-blood transfusions is not new but has recently received new emphasis by the Tactical Combat Casualty Care Committee. US Army units are implementing a systematic approach to obtain and use whole blood on the battlefield. This case report reviews the care of the first patient to receive low titer group O whole blood (LTOWB) transfusion, using a new protocol.
Keywords: blood transfusion; group O whole blood; Tactical Combat Casualty Care
Snow RW, Papalski W, Siedler J, Drew B, Walrath B. 18(1). 19 - 22. (Case Reports)
During routine aircraft start-up procedures at a US Naval Air Station, an aviation mishap occurred, resulting in the pilot suffering a traumatic brain injury and the copilot acquiring bilateral hemopneumothoraces, a ruptured diaphragm, and hepatic and splenic contusions. The care of both patients, including at point of injury and en route to the closest trauma center, is presented. This case demonstrates a benefit from advanced life-saving interventions and critical care skills beyond the required scope of practice of search and rescue medical technicians as dictated by relevant instructions.
Keywords: en route care; MEDEVAC; military; traumatic brain injury; pneumothorax; critical care
Brazeau MJ, Bolduc CA, Delmonaco BL, Syed AS. 18(1). 23 - 28. (Case Reports)
We present the case of a patient with new-onset diabetes, severe acidosis, hypothermia, and shock who presented to a Role 1 Battalion Aid Station (BAS) in Afghanistan. The case is unique because the patient made a rapid and full recovery without needing hemodialysis. We review the literature to explain how such a rapid recovery is possible and propose that hypothermia in the setting of his severe acidosis was protective.
Keywords: new-onset diabetes; severe acidosis; hypothermia; hemodialysis
Dilday J, Sirkin MR, Wertin T, Bradley F, Hiles J. 18(1). 29 - 31. (Case Reports)
The current forward surgical team (FST) operating table is heavy and burdensome and hinders essential movement flexibility. A novel attachable rail system, the Shrail, has been developed to overcome these obstacles. The Shrail turns a North Atlantic Treaty Organization litter into a functional operating table. A local FST compared the assembly of the FST operating table with assembling the Shrail. Device weight, storage space, and assembly space were directly measured and compared. The mean assembly time required for the Shrail was significantly less compared with the operating table (23.36 versus 151.6 seconds; p ≤ .01). The Shrail weighs less (6.80kg versus 73.03kg) and requires less storage space (0.019m3 versus 0.323m3) compared with the current FST operating table. The Shrail provides an FST with a faster, lighter surgical table assembly. For these reasons, it is better suited for the demands of an FST and the implementation of prolonged field care.
Keywords: Shrail; litter; operating table; prolonged field care; austere, military
King DR. 18(1). 32 - 32. (Case Reports)
Pasley JD, Teeter WA, Gamble WB, Wasick P, Romagnoli AN, Pasley AM, Scalea TM, Brenner ML. 18(1). 33 - 36. (Case Reports)
Background: The management of noncompressible torso hemorrhage remains a significant issue at the point of injury. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used in the hospital to control bleeding and bridge patients to definitive surgery. Smaller delivery systems and wirefree devices may be used more easily at the point of injury by nonphysician providers. We investigated whether independent duty military medical technicians (IDMTs) could learn and perform REBOA correctly and rapidly as assessed by simulation. Methods: US Air Force IDMTs without prior endovascular experience were included. All participants received didactic instruction and evaluation of technical skills. Procedural times and pretest/posttest examinations were administered after completion of all trials. The Likert scale was used to subjectively assess confidence before and after instruction. Results: Eleven IDMTs were enrolled. There was a significant decrease in procedural times from trials 1 to 6. Overall procedural time (± standard deviation) decreased from 147.7 ± 27.4 seconds to 64 ± 8.9 seconds (ρ < .001). There was a mean improvement of 83.7 ± 24.6 seconds from the first to sixth trial (ρ < .001). All participants demonstrated correct placement of the sheath, measurement and placement of the catheter, and inflation of the balloon throughout all trials (100%). There was significant improvement in comprehension and knowledge between the pretest and posttest; average performance improved significantly from 36.4.6% ± 12.3% to 71.1% ± 8.5% (ρ < .001). Subjectively, all 11 participants noted significant improvement in confidence from 1.2 to 4.1 out of 5 on the Likert scale (ρ < .001). Conclusion: Technology for aortic occlusion has advanced to provide smaller, wirefree devices, making field deployment more feasible. IDMTs can learn the steps required for REBOA and perform the procedure accurately and rapidly, as assessed by simulation. Arterial access is a challenge in the ability to perform REBOA and should be a focus of further training to promote this procedure closer to the point of injury. Keywords: hemorrhage control; independent duty medical technician; resuscitative endovascular balloon occlusion of the aorta; REBOA
Ross EM, Redman TT. 18(1). 37 - 43. (Case Reports)
Background: Noncompressible junctional and truncal hemorrhage remains a significant cause of combat casualty death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective treatment for many junctional and noncompressible hemorrhages. The current hospital standard for time of placement of REBOA is approximately 6 minutes. This study examined the training process and the ability of nonsurgical physicians to apply REBOA therapy in an austere field environment. Methods: This was a skill acquisition and feasibility study. The participants for this experiment were two board-certified military emergency medicine physicians with no prior endovascular surgery exposure. Both providers attended two nationally recognized REBOA courses for training. A perfused cadaver model was developed for the study. Each provider then performed REBOA during different phases of prehospital care. Time points were recorded for each procedure. Results: There were 28 REBOA catheter placement attempts in 14 perfused cadaver models in the nonhospital setting: eight placements in a field setting, eight placements in a static ambulance, four placements in a moving ambulance, and eight placements inflight on a UH-60 aircraft. No statistically significant differences with regard to balloon inflation time were found between the two providers, the side where the catheter was placed, or individual cadaver models. Successful placement was accomplished in 85.7% of the models. Percutaneous access was successful 53.6% of the time. The overall average time for REBOA placement was 543 seconds (i.e., approximately 9 minutes; median, 439 seconds; 95% confidence interval [CI], 429-657) and the average placement time for percutaneous catheters was 376 seconds (i.e., 6.3 minutes; 95% CI, 311-44 seconds) versus those requiring vascular cutdown (821 seconds; 95% CI, 655-986). Importantly, the time from the decision to convert to open cutdown until REBOA placement was 455 seconds (95% CI, 285-625). Conclusion: This study demonstrated that, with proper training, nonsurgical providers can properly place REBOA catheters in austere prehospital settings at speeds
Keywords: austere environments; noncompressable hemorrhage; resuscitative endovascular balloon occlusion of the aorta; battlefield REBOA; combat resuscitation team; prehospital REBOA; damage control resuscitation; helicopter REBOA; en route care REBOA
Griffin LV, Kragh JF, Dubick MA. 18(1). 47 - 52. (Journal Article)
Background: To develop knowledge of mechanical control of bleeding in first aid, a laboratory model was set up to simulate flow through a blood vessel. A collapsible tube was used to mimic an artery in two experiments to determine (1) the extent of volumetric flow reduction caused by increases in the degree of compression of the vessel and (2) the extent of flow reduction caused by increases in the length of compression. Methods: Water was used in vertical tubing. Gravity applied a pressure gradient of about 100mmHg to cause flow. A silicone tube (10mm-diameter lumen [the inner opening], 1mm-thick wall, 150mm length) was used. Tests of no compression of the external wall constituted the control group for both experiments. For all groups, flow volume was sampled over a period of time, and six samples were averaged. In both experiments, the study group consisted of tests with compression that was measured as the reduced area of the luminal cross section. In the first experiment, six groups with luminal area reductions of 0% (control), 74%, 81%, 91%, 94%, and 97% were tested. In the second experiment at 74% luminal area reduction, the three lengths of compression were 5mm, 20mm, and 70mm. The measured data were compared with calculated data by applying established mathematical equations. Results: In the first experiment, flow decreased with decreasing area due to luminal compression, but the association was a parabolic curve such that 94% or greater reduction in luminal area was required to reduce flow by greater than 50%. A reduction in luminal area of 97% reduced flow by 95%. In the second experiment, mean flow rates were not significantly different among the three lengths of compression. Measured data and calculated data were in good agreement. Conclusions: Compared with an uncompressed vessel, volumetric flow of water through a single, unsupported collapsible tube in steady, nonpulsatile conditions with compression applied to its external wall to produce a reduction in luminal area of 97% reduced flow by 95%. Flow was affected by the degree of compression but not by the length of compression.
Keywords: first aid/therapy, tourniquet; hemorrhage, prevention and control, bleeding control; biomechanics, collapsible tubes, steady flow, rheology, pres; models, theoretical
Rocklein Kemplin K, Paun O, Sons N, Brandon JW. 18(1). 54 - 60. (Journal Article)
Despite many resilience studies and resilience-building initiatives in the military, resilience as a concept remains granularly unexamined, vague, and inconsistently interpreted throughout military-specific research literature. Specifically, studies of military suicide and related mental health constructs assert that Servicemembers in Special Operations Forces (SOF) possess higher levels of resilience without providing an empirical basis for these statements. To provide rigorous evidence for future studies of resilience in SOF, a concept analysis was performed via Rodgers' evolutionary method to contextualize resilience in the SOF community and provide accurate redefinitions on which theoretical and methodological frameworks can be constructed reliably.
Keywords: resilience; military; concept analysis; Special Operations Forces; suicide
Vu EN, Wan WC, Yeung TC, Callaway DW. 18(1). 62 - 68. (Journal Article)
Background: Uncontrolled hemorrhage remains a leading cause of preventable death in tactical and combat settings. Alternate routes of delivery of tranexamic acid (TXA), an adjunct in the management of hemorrhagic shock, are being studied. A working group for the Committee for Tactical Emergency Casualty Care reviewed the available evidence on the potential role for intramuscular (IM) administration of TXA in nonhospital settings as soon as possible from the point of injury. Methods: EMBASE and MEDLINE/PubMed databases were sequentially searched by medical librarians for evidence of TXA use in the following contexts and/or using the following keywords: prehospital, trauma, hemorrhagic shock, optimal timing, optimal dose, safe volume, incidence of venous thromboembolism (VTE), IM bioavailability. Results: A total of 183 studies were reviewed. The strength of the available data was variable, generally weak in quality, and included laboratory research, case reports, retrospective observational reviews, and few prospective studies. Current volume and concentrations of available formulations of TXA make it, in theory, amenable to IM injection. Current bestpractice guidelines for large-volume injection (i.e., 5mL) support IM administration in four locations in the adult human body. One case series suggests complete bioavailability of IM TXA in healthy patients. Data are lacking on the efficacy and safety of IM TXA in hemorrhagic shock. Conclusion: There is currently insufficient evidence to support a strong recommendation for or against IM administration of TXA in the combat setting; however, there is an abundance of literature demonstrating efficacy and safety of TXA use in a broad range of patient populations. Balancing the available data and risk- benefit ratio, IM TXA should be considered a viable treatment option for tactical and combat applications. Additional studies should focus on the optimal dose and bioavailability of IM dosing of patients in hemorrhagic shock, with assessment of potential downstream sequelae.
Keywords: intramuscular; tranexamic acid; hemorrhagic shock; Tactical Combat Casualty Care; Tactical Emergency Casualty Care
Lyon RF, Schwan C, Zeal J, Kharod C, Staak BP, Petersen CD, Rush SC. 18(1). 70 - 73. (Journal Article)
Effective analgesia is a crucial part of the care and resuscitation of a traumatically injured patient. These secondary effects of pain may increase morbidity and mortality in the acutely injured patient. When ketamine is administered appropriately in the clinical setting, it can provide analgesia, anxiolysis, and amnesia for patients with less respiratory depression and hypotension than equivalent doses of opioid analgesics.
Keywords: ketamine; analgesia; pain; opioids; prehospital analgesic; Pararescuemen; Operation Enduring Freedom
Reid P, George C, Byrd CM, Miller L, Lee SJ, Motsinger-Reif A, Breen M, Hayduk DW. 18(1). 74 - 76. (Journal Article)
Special Operations Forces and their accompanying tactical multipurpose canines (MPCs) who are involved in repeated live-fire exercises and military operations have the potential for increased blood lead levels and toxicity due to aerosolized and environmental lead debris. Clinical lead-toxicity symptoms can mimic other medical disorders, rendering accurate diagnosis more challenging. The objective of this study was to examine baseline lead levels of MPCs exposed to indoor firing ranges compared with those of nontactical military working dogs (MWDs) with limited or no exposure to the same environment. In the second part of the study, results of a commercially available, human-blood lead testing system were compared with those of a benchtop inductively coupled plasma-mass spectrometry (ICP-MS) analysis technique. Blood samples from 18 MPCs were tested during routine clinical blood draws, and six samples from a canine group with limited exposure to environmental lead (nontactical MWDs) were tested for comparison. There was a high correlation between results of the commercial blood-testing system compared with ICP-MS when blood lead levels were higher than 4.0µg/dL. Both testing methods recorded higher blood lead levels in the MPC blood samples than in those of the nontactical MWDs, although none of the MPC samples tested contained lead levels approaching those at which symptoms of lead toxicity have previously been reported in animals (i.e., 35µg/dL).
Keywords: heavy metal toxicity; aerosolization; lead, blook toxicity analysis; canines, multipurpose; dogs, military working
Paz DA, Thomas KE, Primakov DG. 18(1). 77 - 80. (Journal Article)
In support of Operation Enduring Freedom, American, North American Treaty Organization (NATO) Coalition, and Afghan forces worked together in training exercises and counterinsurgency operations. While serving at the NATO Role 3 Multinational Medical Unit, Kandahar, Afghanistan, numerous patients with explosive blast injuries (Coalition and Afghan security forces, and insurgents) were treated. A disparity was noted between the ocular injury patterns of US and Coalition forces in comparison with their Afghan counterparts, which were overwhelmingly influenced by the use, or lack thereof, of eye protection. Computed tomography imaging coupled, with a correlative clinical examination, demonstrated the spectrum of ocular injuries that can result from an explosive blast. Patient examination was performed by Navy radiologists and an ophthalmologist. A cultural analysis by was performed to understand why eye protection was not used, even if available to Afghan forces, by the injured patients in hope of bridging the gap between Afghan cultural differences and proper operational risk management of combat forces.
Keywords: ocular injury; culture; explosive blast injury
Brandon JW, Solarczyk JK, Durrani TS. 18(1). 81 - 87. (Journal Article)
Lead toxicity is an important environmental disease and its effects on the human body can be devastating. Unique exposures to Special Operations Forces personnel may include use of firing ranges, use of automotive fuels, production of ammunition, and bodily retention of bullets. Toxicity may degrade physical and psychological fitness, and cause long-term negative health outcomes. Specific effects on fine motor movements, reaction times, and global function could negatively affect shooting skills and decision-making. Biologic monitoring and chelation treatment are poor solutions for protecting this population. Through primary prevention, Special Operations Forces personnel can be protected, in any environment, from the devastating effects of lead exposure. This article offers tools to physicians, environmental service officers, and Special Operations Medics for primary prevention of lead poisoning in the conventional and the austere or forward deployed environments.
Keywords: lead toxicity; lead poisioning; environmental health; primary prevention
Schauer SG, Pfaff JA. 18(1). 88 - 90. (Journal Article)
Background: Heat injuries are common in the military training environment. Base policies often mandate that heat causalities require evaluation at a higher level of care, which comes at significant use of resources. Laboratory studies are often ordered routinely, but their utility is unclear at this time. Methods: This project evaluated the use of screening laboratory studies for heat casualties brought to Bayne-Jones Army Community Hospital, Fort Polk, Louisiana. Casualties brought from the field directly to the emergency department (ED) were included. Abnormalities in laboratory study findings, admission/discharge rates, and length of stay were documented. Results: From May through September 2014, 104 casualties were seen in the ED because of heat injury. Laboratory tests were ordered for 101 patients. Of these, 11 patients were admitted to the hospital because of laboratory, history, and/or physical examination abnormalities. Nine were discharged in less than 24 hours. The remaining two were discharged within 48 hours; both had documented altered mental status on arrival to the ED. Laboratory test abnormalities were seen in most of the patients and appeared to have no impact on the decision to admit. Conclusion: Routine laboratory studies appeared to have low clinical utility in this patient population. A more targeted approach based on the history and physical examination may reduce military resource use.
Keywords: heat injury; heat exhaustion; heat stroke; climate; rhabdomyolysis; heat
Palmer LE. 18(1). 91 - 98. (Journal Article)
The intent of the Operational K9 (OpK9) ongoing series is to provide the Special Operations Medical Association community with clinical concepts and scientific information on preventive and prehospital emergency care relevant to the OpK9. Often the only medical support immediately available for an injured or ill OpK9 in the field is their handler or the human Special Operations Combat Medic or civilian tactical medic attached to the team (e.g., Pararescueman, 18D, SWAT medic). The information is applicable to personnel operating within the US Special Operations Command as well as civilian Tactical Emergency Medical Services communities that may have the responsibility of supporting an OpK9.
Keywords: Operational K9s; gastic dilation and volvulus; bloat; gastric decompression; trocarization; dogs
Worthington D, Deuster PA. 18(1). 100 - 105. (Journal Article)
Spirituality is a key interweaving and interacting domain, and an integral component for maintaining Special Operations Forces readiness; however, it remains an under-researched and likely one of the most poorly understood domains of Preservation of the Force and Family and Total Force Fitness initiatives. Although there are numerous factors that contribute to spiritual performance or spiritual fitness, core values and value-directed living are essential. An initial step toward spiritual performance or fitness is developing core values and identity, followed by a second step toward spiritual performance or fitness, which is developing an increased awareness and deeper understanding of those values. This process of developing core values and identity, and building awareness can be enhanced through cognitive flexibility and agility (psychological performance domain). This article explains the importance of "spirituality" as a component of Special Operations Forces performance and describes approaches to enhancing performance through various spiritual activities, including mindfulness, meditation, and prayer. These three practices can be adapted and modified to be more vertical or more horizontal in their application.
Keywords: spirituality; human performance optimization; Special Operations Forces
Burnett MW. 18(1). 106 - 107. (Journal Article)
Keywords: infectious disease; Giardiasis; intestinal parasite; gastroenteritis
Knapik JJ, Bedno SA. 18(1). 108 - 112. (Journal Article)
Surveys indicated that 24% of military personnel are current cigarette smokers. Smoking is well known to increase the risk of cancers, cardiovascular and respiratory diseases, reproductive problems, and other medical maladies, but one of the little known effects of smoking is that on injuries. There is considerable evidence from a variety of sources that (1) smoking increases overall injury risk, (2) the greater the amount of smoking, the higher is the injury risk, and (3) smoking is an independent injury risk factor. Smoking not only affects the overall injury risk but also impairs healing processes following fractures (e.g., longer healing times, more nonunions, more complications), ligament injury (e.g., lower subjective function scores, greater joint laxity, lower subsequent physical activity, more infections), and wounding (e.g., delayed healing, more complications, less satisfying cosmetic results). Smoking may elicit effects on fractures through low bone mineral density (BMD), lower dietary intake of calcium and vitamin D, altered calcium metabolism, and effects on osteogenesis and sex hormones. Effects on wound healing may be mediated through altered neutrophils and monocytes functions resulting in reduced ability to fight infections and remove damaged tissue, reduced gene expression of cytokines important for tissue healing, and altered fibroblast function leading to lower density and amount of new tissue formation. Limited data suggest smoking cessation has favorable effects on various aspects of bone health over periods of 1 to 30 years. Favorable effects on neutrophil and monocyte functions may occur as early as 4 weeks, but fibroblast function and collagen metabolism (important for wound remodeling) appear to take considerably longer and may be dependent on the amount of prior smoking. Part 2 of this series will use this information to explore the possibility of a causal relationship between smoking and injuries.
Keywords: smoking; injury; cigarettes; tobacco
Gerold KB. 18(1). 113 - 117. (Case Reports)
DeFeo DR, Givens ML. 18(1). 118 - 123. (Journal Article)
The authors would like to introduce TCCC [Tactical Combat Casualty Care] + CBRN [chemical, biological, radiological, and nuclear] = (MARCHE)2 as a conceptual model to frame the response to CBRN events. This model is not intended to replace existing and well-established literature on CBRNE events but rather to serve as a response tool that is an adjunct to agent specific resources.
Keywords: MARCHE; (MARCHE)2; CBRN; CBRNE; triage; casualties
Loos PE, Glassman E, Doerr D, Dail R, Pamplin JC, Powell D, Riesberg JC, Keenan S, Shackelford S. 18(1). 126 - 132. (Journal Article)
Macku D, Hedvicak P, Quinn JM, Bencko V. 18(1). 133 - 138. (Journal Article)
Due to the hybrid warfare currently experienced by multiple NATO coalition and NATO partner nations, the tactical combat casualty care (TCCC) paradigm is greatly challenged. One of the major challenges to TCCC is the ad hoc extension phase in resource-poor environments, referred to as prolonged field care (PFC) and forward resuscitative care (FRC). The nuanced clinical skills with limited resources required by warfighters and auxiliary health care professionals to mitigate death on the battlefield and prevent morbidity and mortality in the PFC phase represent a balance that is still under review. The aim of our article is to describe the connection between extracorporeal membrane oxygenation (ECMO) or the extracorporeal life support (ECLS) treatment and its possible improvement in prehospital trauma care, at a Role 1 or 2 facility and, more provocatively, in the PFC phase of care in the future through innovative technology and how it connects with FRC. We report and describe here the primary components of ECMO/ECLS and present the main concept of a human extracorporeal circulation cocoon as a transitional living form for the cardiopulmonary stabilization of wounded combatants on the battlefield and their transportation to higher echelons of care and treatment facilities (to include damage control resuscitation [DCR] and damage control surgery [DCS]). As clinical governance, these matters would fall within the remit of the Committee on Surgical Combat Casualty Care (CoSCCC) and the Committee on Enroute Combat Casualty Care (CoERCCC), and it is within this framework that we propose this concept piece of ECMO in the prehospital space. We caution that this report is a proposed innovation to TCCC but also serves to push the envelope of the PFC and FRC paradigm. What we propose will not change the practice this year, but as ECMO technology progresses, it may change our practice within the next decade. We conclude with proposed novel future research to save life on the battlefield with ECMO as a major challenge and one worth the focus of further research. Medicine is controversial and constantly changing; for those who work in prehospital and battlefield medicine, change is the only constant on which we rely, and without provocative discussion that makes our systems and practice more robust, we will fail.
Keywords: NATO; TCCC; prolonged field care; forward resuscitative care; extracorporeal membrane oxygenation; extracorporeal life support
Keenan S. 18(1). 139 - 140. (Editorial)
Schermerhorn SM, Auchincloss PJ, Kraft K, Nelson KJ, Pamplin JC. 18(1). 142 - 144. (Journal Article)
Objective: Review the management of a patient with acute patella fracture supported by telemedical consultation. Clinical Context: Regionally Aligned Forces (RAF) supporting US Army Africa/Southern European Task Force (USARAF/ SETAF) in Africa Command area of responsibility. Care was provided by a Role I facility on the compound. Organic Expertise: Three 68W combat medics; one Special Operations Combat Medic (SOCM). Closest Medical Support: Organic battalion physician assistant (PA) located in the United States; USARAF PA located in a European country; French Role II located in nearby West African country; telemedical consults via e-mail, phone, or videoteleconsultation. Earliest Evacuation: Estimated at 12 to 24 hours with appropriate clearances.
Keywords: critical care; telemedicine; military personnel; emergency treatment; patient transfer; prolonged field care
Urbaniak MK, Hampton K. 18(1). 145 - 145. (Journal Article)
Pennardt A. 18(1). 147 - 148. (Interview)
Christensen PA. 18(1). 150 - 154. (Journal Article)
Austere care of the wounded is challenging for all Western medical professionals-nurse, medic, or physician. There can be no doubt that working for the first time, either for a nongovernment organization or in the Special Forces, you will be taking care of wounded patients outside your training and experience. You must have the ability to adapt to and overcome lack of resources and equipment, and accept standards of treatment often very different and lower than that common in western hospitals. The International Committee of the Red Cross (ICRC) was asked to provide relief for the Pakistan Red Crescent in 1982 and set up the ICRC Hospital for Afghan War Wounded in Peshawar on the border to Afghanistan. This article relates how a western-trained young anesthetist on a ICRC surgical team experienced this, at the time, austere environment.
Keywords: austere; ICRC; Pakistan; Afghanistan; nongovernment organization
Neal CA. 18(1). 155 - 156. (Book Review)
Farr, Warner D. "Rocky." The Death of The Golden Hour and the Return of the Future Guerrilla Hospital. MacDill Air Force Base, FL: Joint Special Operation University (JSOU) Press; 2017. 72 pp. Dr Farr's monograph is available from JSOU Press Publications: http://jsou.libguides.com/ld.php?content_id=37706446
Farr WD. 18(1). 157 - 157. (Book Review)
Ballinger, Adam. The Quiet Soldier: On Selection With 21 SAS. Orion Books, Ltd.: London, United Kingdom, 1992. Paperback, 240 pages. ISBN 1-85797-158-2.
Hartford B, Shapiro G, Marino MJ, Smith R, Tang N. 18(1). 160 - 161. (Classical Conference)
Butler FK, Giebner S. 18(1). 164 - 171. (Classical Conference)
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Stoke on Trent has many hidden treasures, but none quite as magical as what I experienced at the World of Wedgwood in Barlaston recently. Tucked away, near the Trentham Estate, you can simply skip up a street or two and uncover the magic of the Wedgwood Museum; alongside a plethora of other amazing treats to see and do in the same place.
For those not familiar with Wedgwood, it is one of (if not, the) most treasured parts of the The Potteries rich history. Founded by Josiah Wedgwood in 1759, this independent potter from the small town of Burslem, developed three of the most famous ceramic bodies in the world. Renowned over the globe Queen's Ware, Black Basalt and Jasper were all created by Josiah Wedgwood and all maintain their desirability to this day. The most iconic of the collections is Jasper ware, which is where the iconic Wedgwood Blue colour shade hails from. You'll often find the base of the blue ceramic holding an intricate design in a contrasting white.
Having recently taken on a team of industry renowned specialists, including Ulrik Garde Due, who has a background with both Burberry and Celine(!), Wedgwood has been re-launched to truly tell the story of the brand. Bringing in the extensive history and intertwining it in to the modern day, the experience, which has been specially developed for Christmas, takes you through the story of Mr Chisholm and some pesky cats.
We all know I love cats, but that's not what made it exciting. It was the amazing way that the story had been though through from start to finish. Every detail has been thought about, from the story itself providing reading material on the way around; through to the festive dining table which even has a name card for Walter the Cat.
As you walk around the factory, gift shop, tea rooms and museum, you can spot the Christmas tale in action. Spot the cats as you walk around through the seasonal displays, to find yourself ending up the in the absolutely astonishing tea rooms.
Honestly, I still cannot get over how beautiful the tea room actually is. It's like something you'd find in an infamous London restaurant for Afternoon Tea. All complete with the Wedgwood crockery to eat the delicious selection of sandwiches,scones and cakes off. The seasonal selection also included possibly the greatest mind pie I have ever tasted. With a pastry case, tea soaked mince filling and delicious cream on the top, we also enjoyed pairing it with the speciality Wedgwood teas.
The Afternoon Tea also remains true to the original style, where you can enjoy refills of both drinks and food whenever you run out of the goodness.
After enjoying our food, this acted as a great refuel for the next element of our trip – throwing our own pot! A skill I never managed to master when I was at uni doing a degree in 3D Design (which involved a lot of ceramics, whoops). This usually costs between £5 and £10 and you are aided throughout the process to create a pot in whatever shape you like.
During the Christmas period, there's also the opportunity to make your own decorations in the mini workshop. Perfect for customising as a gift!
All in all, the entire Wedgwood Visitor Centre is an experience which was completely unexpected for me. I've lived in this city my entire life and never been, just expecting it to be like all the other factory shops and pottery workshops we have strewn throughout the city. It turns out I was completely wrong though.
The Wedgwood Christmas Tale is on until the 23rd of December and I would thoroughly recommend going, especially with kids. You can go around, reading the story and spotting all of Mr Chisholms cats! There's also a factory shop to finish off your Christmas shopping on the sly.
Afternoon Tea costs £25 per head, which is an average price for such a treat. You can actually grab a gift voucher on the Wedgwood website where you can enjoy Afternoon Tea for Two alongside free annual entry to the museum, a factory tour and a tea tasting session for £49. You can find more information about that here.


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Q: Const-qualification of parameters in function declaration I have the following function declaration in a header file:
extern void flash(const char *message, const enum msg_type type);

Basically, it takes two parameters and pushes a corresponding message into a global message queue. Since it doesn't need to modify the parameters, I const-qualified them. However, CLion's static code analyzer emitted a warning about it:

Clang-Tidy: Parameter 'type' is const-qualified in the function declaration; const-qualification of parameters only has an effect on function definitions

Here is my questions:

*

*I const-qualified both parameters, why does only the latter trigger a warning?

*Is it really bad? I know it has no effect, but technically specking const qualifiers have no effect too.

*Can I get rid of this warning?

A:
I const-qualified both parameter, why does only the latter trigger a warning?

As your warning says, it does not affect a prototype. It only affects the implementation.

Is it really bad?

It is noise in the meaning that it does not affect anything, but other than that, no.

Can I get rid of this warning?

You can safely remove the const qualifier since it is not needed.
However, it seems a bit messy to suppress warnings in general with clang-tidy. This link might help:
clang-tidy: How to suppress warnings?
But these warnings can actually be a blessing. It's not very uncommon to accidentally write int foo(const char *) instead of int foo(char * const). The latter would not trigger this warning, so if you get this warning it's a sign that you have mixed something up.

A: The first parameter is of type const char *, or pointer to constant character. This means that you can pass into the function a pointer to a string which you can't modify, for example:
const char* msg = "Hello, world!";
flash(msg, SOME_MESSAGE_TYPE);

You can't change the characters in msg; it's a pointer to const char. Passing it to a function with parameter type char* would indicate the function might change them, which would be illegal. This const in the parameter type is relevant to the caller, so is kept.
On the other hand, enum msg_type is just an enum, and will be copied into the function. When calling the function, I don't care what happens in the body of the function with type; it won't affect anything outside the function. Saying that this is const doesn't make a difference, hence the warning.
If you change the first parameter to const char *const message, then it'll warn about that too. That would indicate that you can't change what the pointer message points to, which again the caller doesn't care about because whatever pointer it passes in won't change.

This isn't really bad; it's telling you that you might be confused, but in this case it doesn't hurt anything. You should still get rid of the warning, though, because warnings indicate potential problems and clogging them with non-problematic noise just makes it less likely you'll read the important ones.

Change the header file, but not wherever flash is implemented, to not have const on the second parameter. Where it's implemented, keep the const so you don't actually change type inside the function body, but it's not needed in the declaration.

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The OPS Manager plans, organizes and controls the V.Mueller UDI marking activities in close alignment with the sourcing and quality team within corporate, BU as well as local functional team members.
You will be responsible to develop and organize in-house production flow as well as capacity planning and production schedules. Furthermore, you will drive the e valuation of operational SQDC metrics, especially bottle-neck process optimization, and work with cross-functional team to ensure site readiness for any new processes (i.e. fixtures, laser programs, storage locations, BOMs/routers).
You have a university degree in Business Economics, Finance or Industrial Engineering as well as appropriate professional experience in manufacturing of surgical instrumentation or similar technical products in a regulated, medical device environment.
Collaboration in a highly motivated global environment. A familiar work climate in an innovative environment where your input counts. A safe workplace with long term perspectives. We endeavor a long term collaboration – hence corporate career planning throughout diverse phases of life conveys a high importance and value for us.


In 2012, we saw several large data breaches occurring to website-based companies such as LinkedIn, eHarmony, and Last.fm. These breaches exposed millions of passwords and led us to ask the question, are emails and passwords personally identifiable information (PII)? Because people tend to use email addresses and passwords across multiple website accounts that might contain information such as first and last names, physical addresses, and credit card information, we suspect that if email addresses and passwords aren't considered PII by everyone today, they soon will be.
(Aug. 8th, 2012) "A significant number of states just lifted verbatim what other states had written into law. A rough guess is that about one third of the states had almost identical data privacy laws.
But the remaining two thirds of the regulations varied greatly, even in defining what PII is. It was common to consider the First Name and Last Name in combination with a Social Security number, bank account number, or driver's license number as information that constituted PII that needed to be protected. But after reading and collating all 45 states, I found 41 data items that were considered PII! In addition to the standard data items, I found passport numbers, military IDs, medical numbers, email addresses, and much else. I even found definitions of PII that went something like this: 'Any information in aggregate that can identify an individual must be protected.' It was a lot of ground to cover.
This is something I believe not only still holds true, but will become even more important in the future. Using encryption to protect log-in information and passwords is the best way any one company can protect that information. Of course, using good encryption key management is also a critical part of that process. Even if a hacker gets hold of encrypted data, they cannot get access to that data unless they also find the encryption keys.
For more information, download our white paper "AES Encryption and Related Concepts" and learn about how proper encryption and encryption key management work together to secure your data.
Draft versions of a Federal data privacy and breach notification law have been in existence for over a year. The House of Representatives passed a version some months ago, and two versions have been working their way through the US Senate. This week saw a significant advance in the US Senate as the judiciary committee under Senator Patrick Leahy's leadership passed a version out of committee with a vote along party lines. I think Senate Bill 1151 represents a significant step forward towards a federal law that will replace all of the approximately 45 state laws on breach notification. The law still has to be reconciled with the House version, and a lot can change in the process, but there is general agreement in the business community that one Federal law is preferable to a lot of different state laws. So I think there is a good chance that a Federal privacy law can pass.
You will need to have a written security policy.
You will need to perform periodic vulnerability assessments.
You will need to protect data using industry standard practices such as encryption.
The legal penalties include fines and imprisonment.
If you share sensitive data with service providers, you must ensure that they protect the data.
You are responsible for notifying people affected by the data loss.
There is an expanded definition of "Sensitive Personally Identifiable Information".
You will need to maintain audit trails of who accessed sensitive information.
In many ways, the new federal law goes further than most state laws in defining what companies must do to protect sensitive data. The law tries to strike a balance between prescriptive measures, and the evolving nature of threats. In many respects the law comes close to adopting many of the principles of the Payment Card Industry Data Security Standards (PCI DSS), and companies who meet PCI DSS standards will find a lot that is familiar in the law.
The definition of Personally Identifiable Information (PII) has expanded pretty dramatically and now includes telephone numbers and mobile device IDs, email addresses, and other information. I will talk about this a bit more in future blogs. I think there are some substantial procedural and technology issues in this area that will affect your approach to protecting data.
As I expected, the Federal law makes reference to industry standards for encryption and key management, and points directly to existing laws such as Gramm-Leach-Bliley (GLBA), the Health Insurance Accountability and Portability Act (HIPAA), and others. The Federal Trade Commission is charged with developing guidelines in this area. I think there is a well-worn template for this type of work that will point directly to the NIST standards and best practices. I believe that companies would do well to be sure that their data protection strategies line up with NIST standards. FIPS-140-2 certification is already required of some private enterprises, and this is probably the direction we are going.


Prince William and Kate Middleton arrived on the red carpet at the Royal Albert Hall in London to huge cheers, with all eyes firmly on Kate and her outfit. It wasn't just the gorgeous gown and classic updo.
Kate wore a show-stopping white one shoulder gown by Alexander McQueen with Jimmy Choo glittery pumps and Princess Diana's diamond and south sea pearl earrings.
Her date for the night was of course, Prince William, who cut a stylish figure in a black tuxedo and slick loafers. Princess Diana wore the same earrings in 1995 when she accepted the Humanitarian of the Year Award from the United Cerebral Palsy Foundation.
Why were Prince William and Kate Middleton at the BAFTAs? The charming couple looked picture flawless, with the Prince opting for a simple black tuxedo. Yorgos Lanthimos, I can't think of the words to thank you enough for letting me do this.
The Favourite, which looks at Queen Anne's relationship with two cousins, took home seven awards, with lead Olivia Coleman picking up the gong for Best Actress.
Princess Kate shared some quality time with Dermont O'Leary. With her hair pulled up, Middleton's earrings were on full display.
Both the Duchess of Cambridge and the Duchess of Sussex, Meghan Markle, will likely wear more of their late mother-in-law's jewelry at events, with Markle spotted wearing Diana's aquamarine ring to her wedding reception.
John Stillwell - WPA Pool/Getty Images.
When Prince William and Kate Middleton's engagement was announced, the Duke of Cambridge noted: "It's my mother's engagement ring, and it's very special to me, as Kate is very special to me now as well".
The delicate earrings also come with a removable clasp, which allows for the pearls to be removed.
A stunned Colman shook as she gave her acceptance speech.


Born and raised in Gary, Indiana (WEST SIDE COUGARS BABY!), I believe issues of race in the US cannot be ignored and left to a "I wish it would just go away" state of mind.
In spite of all that occurs/has occurred in this country for minorities, I believe this country is the best place for a black person, to date. My parents and their parents parents have been TAX PAYING citizens (THEY HAVE ALWAYS HAD JOBS) of this country and has bled and slaved for this country.
This is my country as much as it is any other persons (and I mean this with every ounce of my being). I care for it. My daughters deserve the opportunity to prosper in it. I will not stand idly by and allow special interest entities (oil companies, pharmaceutical companies, big corporate businesses, stock investors/speculators) destroy what MY fore-fathers, the decendents of slaves, literally bled for – the right to live free.
Imagine if the US was operating on all cylinders of equality. The types of prosperity that can be had for all those who work hard for it.
I'm not for giving anyone anything. If the playing field was level, I believe many issues that affect the black community in a negative manner would be lessened to an extent to which it's levels would mirror those of the white community.
This blog serves as my take on these concerns as well as issues that show/displays that life's water under the bridge comes from the same source, no matter whose bridge it flows under.
Yo, Brotha. I wrote a blog post on Obama, and I was given a link to your domain here. I really like what you are throwing down in here.
What kind of sites do you link to? What community issues do you discuss?
Oh, and did you pledge?
At any rate. The handle is HiScrivener.
Faireastside, you might be interested in my comments on "That One." You can find it here.
Brotha … kudos to you for this blog.
these blogs are fake. you are not black. youre just another jew trying to steer public opinion to your zionist worldview. this blog only proves how racist you jews really are.
All I got to say to that is "wow".
I am an Indiana native myself. I'm from Richmond, but my mom was born in East Chicago, IN and had relatives from Gary. So I feel some sort of connection to the region, even if its just by sheer relation.
A lot of hard work and passionate thought have obviously gone into your writing, and I commend you for it. I wonder if you'd kindly indulge me. I imagine we would disagree on a number of issues while finding ourselves with many of the sames values and dreams, based on your bio.
A) You establish clearly that your family before you has been hardworking and has sought to make a way for itself, and that you deserve the rights, respect, and benefits of being a United States citizen. Have you often encountered open challenges, say, in the last 30 years or so, to the reality of your family's work ethic, or your right to enjoy natural born citizenship? It would seem to me that for one born in the United States, of parents born in the United States, the legitimacy of your citizenship would be unassailable. What threat creates the need for you to reinforce what, on the surface, seems obvious to me? Again, let me emphasize: I am not saying your need is not legitimate. I'm just wondering what sustains it.
Personally, when you state your birthplace, your rights as a citizen would be assumed in my mind. In fact, unless you explicitly said you held foreign citizenship somewhere else, my assumption would be that a black man in Raleigh would be a United States citizen. Has someone suggested to you that this is not your country, or that you don't have a right to be here? That would be sad indeed.
C) What specific actions or practices are being committed by the industries you list above as "special interest entities" to destroy the right to live free? I'm white. Do you believe they are destroying my right to live free as well?
D) If you could affect immediate and irrevocable changes to the United States of any scope or fashion, what would you do to level the playing field?
E) Lastly, I find your life metaphor of water under the bridge interesting. But I'm not sure I understand it completely. I believe you mean the bridge to represent our individual life perspectives, depending upon our background, age, upbringing, education, etc. What is the water, and what is the source from which it all flows?
Thanks for considering my inquiries. It would be my pleasure and honor to hear your responses and begin this dialogue of understanding. I expect to be a better and more informed person for it.
I appreciate your interest in my having dialogue with you, but I'm far past the point of allowing someone to interact with me as though I was some type of specimen or third world country person of whom you are trying to study.
IF your interested in what a guy like me has to say, continue reading my blog from time to time. In fact, that is precisely what I have to say to someone like you.
This blog is about "What's on a brotha's mind". Something that is not displayed in the media/press that assumes it's core audience is not interested in what guy like me has to say. I'm sure you could find quite a bit if not all of the answers to the questions you asked above in my previously posted blogs.
I, just like the world, am OVER INDULGED (assuming your white) daily about "What's on the white guys mind".
Stop trying to take a short cut. It's one of two things, either your trying to trip me up on something (which you simply just can't do) or your genuinely interested in what's on a brotha's mind. IF the later is your interest, I suggest you not only read my blog, but other blogs written by blacks to get a real feel of how WE see things, because you'll never really find out by interacting with ANY other type of multi-media media source.
Other then books, blogs are the only real uncontrolled source of info on how WE see things.
on December 16, 2010 at 12:07 pm | Reply Just saying..
It kind of pisses me off that you throw around the term, "Third world country person" as if your life is comparable at all. The media does occasionally talk about the perspective of african americans (albeit not often). However, how many times have you heard the media discuss the life of as you call it, a "third world country person?" I'd say extremely rarely, if at all. My life is most definetely not the easiest nor most represented on media either (also last time I checked, not every white or black man has the same opinion or perspective so stop acting like everything is so concrete). But what I getting at is that I can't imagine sitting back and complaining about the woes and hardships of my life when millions in other parts of the world live in absolute destitution and utter poverty. Your an american. No matter how you look at it, your standard of living is exponentially better than millions around the world so quick moaning about the hardships of being an american and realize how fortunate you are. Aka….think outside the box. One last thing, before you respond (assuming you respond) please look up information on the following: Darfur, Northern Uganda, and the Democratic Republic of Congo.
Having served in the military, my perspective on Darfur, Uganda and other places as compared to my/your life here in the U.S. is that we in this country give people, the oppressed in places such as Darfur, hope. We the U.S. of A. are the model for those in other countries who wish to one day experience freedom. In fact, after visiting poor provinces in Korea and the Phillipines, I came back to the U.S. definitely more thankful of what this land allows me… freedom.
But what definitely came into focus after my return is how desperately some people in this country would love for the U.S. to return to the behavior of oppression that essentially this country was built on. This desire mimics the current regimes and policies that exist in places such as Darfur, Uganda and the Congo that causes such oppression. Don't act like the U.S. has always had the model of equality at the current level during its history… it hasn't.
You are essentially telling me to shut up and be glad I'm here and not in Darfur. I say to you step off. I pay my taxes like anyone else and I have a right to participate and ensure that the US embrace its role to those in the world who look to us for hope. When they see the U.S. back sliding on civil rights and prosperity, where do they have to turn too….China? India? Russia? France? Britian? Mexico?
The fact is that these countries themselves look to the US as a model for democracy. I will continue to express my viewpoint on backsliding mindsets such as Sarah Palin placing congresswoman Gabrielle Giffords district in the cross hairs of a scope insinuating violence via gun is needed to silence this Democrat representative. I'm sure Jared Lee Loughner was a fan of Palin, Beck, Fox News and the Tea Party as well as the Libertarian Party. All advocate gun violence through use of innuendo and scare tactics as a course of change in this country.
Haha rather than conceding or arguing your point, you simply delete the entire post. Nice.


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Lone Conservative
Kamala Harris Lies About Abraham Lincoln
by Samantha Kamman
During the historic vice presidential debate, Harris once again evaded a question about Joe Biden's alleged plans to expand the Supreme Court should the Trump administration move forward with confirming Amy Coney Barrett to the bench. Harris did this by completely misrepresenting history.
"In 1864…Abraham Lincoln was up for reelection," Harris said. "And it was 27 days before the election, and a seat became open on the United States Supreme Court. Abraham Lincoln's party was in charge not only of the White House, but the Senate.
But Honest Abe said, 'It's not the right thing to do. The American people deserve to make the decision about who will be the next president of the United States, and then that person can select who will serve for a lifetime on the highest court of our land'. And so Joe and I are very clear; the American people are voting right now. And it should be their decision about who will serve on this most important body for a lifetime."
It's true the passing of Chief Justice Roger Taney in October 1864 left an opening on the Supreme Court during an election year, a time when the Republicans controlled the Senate and the White House. But Lincoln never said the things Harris claimed he did.
For sake of adding a more historical perspective to the situation, it should be noted that Taney had been the author of the final majority opinion in the Dred Scott v. Sanford decision. This Supreme Court case ruled all people of African descent could not be considered United States citizens, and it deprived them of their right to sue in federal court. It also declared that the Fifth Amendment protected the rights of slaveholders to own slaves, as slaves were the legal property of their owners.
Lincoln and Taney were not exactly on the best of terms. Lincoln publicly criticized the Dred Scott decision when debating Stephen Douglas, and Lincoln made the Supreme Court ruling a major theme of his 1860 presidential campaign. Though Lincoln did not mention Taney by name, Lincoln again rebuked the ruling in his inaugural address.
Now, Harris is correct that Lincoln did not fill Taney's seat before the November 1864 election. But was it because Lincoln believed filling the vacancy during an election year was "not the right thing to do?" No; much like the 1619 Project, this factoid from Harris is nothing more than a historical invention.
Lincoln did not send a nominee to the Senate in October of 1864 because the Senate was out of session until December 5. However, Lincoln submitted his nomination for a Supreme Court Chief Justice on December 6—his former Treasury Secretary Salmon P. Chase. Chase was confirmed that very same day.
The supposed standard Harris is pointing to that prevented Lincoln from nominating a Supreme Court Justice does not exist. Truth be told, there have been 29 such vacancies during an election year. In most of these cases, presidents have promptly made nominations to fill the open seat.
Harris also does not have much room to stand on principle here. It seems unlikely that Lincoln or any previous president would support packing the Supreme Court. The fact that Harris and Biden have repeatedly refused to answer such a basic question should make anyone who values the balance of power in our governmental institutions rather nervous.
Samantha Kamman
Samantha Kamman is a conservative and a graduate of North Central College. Having pursued a degree in theatre and English studies, she has a lot to write about and is looking for ways to get published. Samantha is incredibly grateful to the staff of The Lone Conservative for considering her work.
The views expressed in this article are the opinion of the author and do not necessarily reflect those of Lone Conservative staff.
About Samantha Kamman
@KammanSamantha
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text:
When everyone hates an asset class, it's usually a good time to buy
People often write off an entire asset class as "dead", when it is merely in the gutter. And if it's in the gutter, it's cheap. John Stepek explains why it often makes sense to buy the things people hate.
Everyone hates emerging markets right now © Getty
Trader at the Hanoi Securities Trading Centre © Jeff Holt/Bloomberg via Getty Images
I'm a sucker for contrarian indicators. The market has an entertaining, if infuriating, habit of proving everyone wrong at exactly the point at which it will cost the most people the most money.
Keeping an eye out for potential turning points can be a useful layer to add to your asset allocation decisions.
So I've just been enjoying reading an interesting new paper from Research Affiliates which points out that when an asset class is declared "broken", it's often a good sign that it's about to pull a Lazarus.
People are very quick to turn against a losing asset class
Emerging market stocks: buy the "Asian Century"
John West and Amie Ko of asset manager Research Affiliates have put out a paper looking at the historical performance of a selection of asset classes which have, at one point or another, been declared "dead" or "broken" by popular decree.
As with most such studies, it's based on anecdotal examples. There aren't many easy scientific ways to work out just how empirically "dead" an asset class is deemed to be.
But even with the caveat that the data is anecdotal and limited, it's a useful reminder that the people who make these sweeping declarations are usually ignorant of history. It's also a useful reminder that when you hear these declarations being made, it often suggests that the hard times are close to an end for said asset class.
Among other examples, the pair cite Business Week's infamous cover story "The death of equities", which was published in 1979, three years before one of the best and longest bull markets ever seen in US equities kicked off.
They also look at the late 1990s dismissal of real-estate investment trusts by US financial paper Barron's, and the even more infamous 1999 claim by The Economist that dirt cheap oil was "likely to remain so" (that particular cover story marked a low for oil, pretty much to the day).
So what did they find? Long story short, the asset classes being condemned had all endured notably weak performance for at least three years, prior to being declared "broken". They also tended to have strikingly underperformed the US S&P 500, which is arguably the most pertinent benchmark (ie, the one that everyone watches).
And yet, in the five years subsequent to being considered "uninvestable", each asset class "roared back in a strong, and for many, swift rebound". And the reality is, the periods of underperformance that led to the asset being condemned in the first place, were not unprecedented – they'd all seen similarly poor periods before.
West and Ko confirmed this pattern by looking to previous periods when the asset classes in question had endured particularly bad three-year underperformance and they found the same thing. In the vast majority of cases (nearly 90%) a terrible three-year period was followed by a strong five-year period.
Here's a cheap and hated asset class for you
Asian income stocks: where to find the continent's top money machines
What does this mean for investors? It's really just a reiteration of our regular advice – if you're a long-term investor, it's better to buy stuff when it's cheap and own less of it when it's expensive. And try not to chase winners – it often ends badly.
Of course, the exasperating thing about all of this is that none of us knows for sure when struggling assets will turn around, and that makes them hard to hold on to. And there are always occasional exceptions. Entire asset classes have been destroyed, though it's pretty much always due to war (property destruction) or revolution (property confiscation).
I've regularly highlighted indicators that can be helpful on the sentiment front. I wrote about the global fund manager survey earlier this week, and I've talked about magazine and newspaper covers frequently in the past.
I've found the latter to be particularly helpful in terms of getting a sense of when the mood might be close to over-reacting. (Indeed, as I flagged up on Twitter at the time, The Times newspaper carried a strikingly stark front cover on 17 March this year, less than a week ahead of the market bottoming out on 23 March).
But nothing is infallible, and you can't plan your entire portfolio around trying to time the market based on sentiment indicators.
For example, while I'm not convinced that the value versus growth distinction is a terribly helpful one (it's somewhat vague), it's certainly true that value as it's currently widely defined has underperformed growth for a long time, despite endless predictions of a comeback.
The point is more this: when someone says that an entire asset class is "dead", that's quite an extravagant statement. It's almost certainly wrong. What it tells you instead is that this asset class is in the gutter.
If it's in the gutter, it's cheap. If it's not going to die, then at some point it's likely to revert to the mean. And if you buy it when it's cheap, that means that you will get better-than-expected returns – if and when it does return to the mean.
These days, a notably disliked asset class is emerging markets. As I've just pointed out, the fact that it's cheap and hated doesn't mean you should put your entire portfolio into it. You should always be sensibly diversified, the nature of which is mostly dictated by your investment time horizon. But you should certainly have a bit of exposure.
My colleague Cris Sholto Heaton looked at some of the best ways to do so in a recent issue of MoneyWeek magazine. If you're not already a subscriber, then don't miss our future articles on the topic – you can get your first six issues free here.
(By the way, if you're interested in contrarian investing and indicators, I think you'll enjoy my book, The Sceptical Investor.)
MoneyWeek magazine
Money Morning


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Modern Healthcare Names NYC Health + Hospitals' CEO Mitchell Katz, MD, One of the 50 Most Influential Clinical Executives
Targeted News Service (Press Releases)
NEW YORK, June 18 -- The New York Health and Hospitals issued the following news release:
- Katz is recognized for his work to expand access to primary care services while driving down costs.
Dr. Mitchell Katz, President and CEO of NYC Health + Hospitals has been named in Modern Healthcare's "50 Most Influential Clinical Executives" list for his work in expanding access to primary care services while driving down costs. Dr. Katz's most successful initiatives during his time as President and CEO of the country's largest public healthcare system are driven by the organizations overall goals of strategic investment to aid in transforming care and increasing access. Modern Healthcare's "50 Most Influential Clinical Executives" program honors physicians working in the healthcare industry who are deemed by their peers and an expert panel to be the most influential in terms of demonstrating leadership and impact. Dr. Katz was also recently recognized by the Heritage Foundation for Organizational Leadership for fundamentally changing how healthcare is delivered at an institution.
"The '50 Most Influential Clinical Executives' recognition is a reflection of the amazing NYC Health + Hospitals system I'm lucky enough to be a part of," said Mitchell Katz, MD, President and CEO of NYC Health + Hospitals. "I am pleased that more people around the country are as impressed as I am by the tremendous work our doctors, nurses, pharmacists, social workers and staff do every day."
Dr. Katz was appointed as President and CEO of NYC Health + Hospitals in January 2018. During this time, Dr. Katz has focused on advancing the transformation of the public health care system with numerous new initiatives to expand access to primary care services, reduce administrative costs, invest in more front-line clinical staff, and build financial stability. Previously, Dr. Katz was the Director of the Los Angeles County Health Agency, an agency that combines the Departments of Health Services, Public Health, and Mental Health into a single entity so as to provide more integrated care and programming within Los Angeles.
Before he came to Los Angeles Dr. Katz was the Director and Health Officer of the San Francisco Department of Health for 13 years. He is well known for funding needle exchange, creating Healthy San Francisco, outlawing the sale of tobacco at pharmacies, and winning ballot measures for rebuilding Laguna Honda Hospital and San Francisco General Hospital. He is a graduate of Yale College and Harvard Medical School. He completed an internal medicine residency at UCSF Medical School and was an RWJ Clinical Scholar.
Dr. Katz is the Deputy Editor of JAMA Internal Medicine, an elected member of the National Academy of Sciences (previously the Institute of Medicine) and the recipient of the Los Angeles County Medical Association 2015 Healthcare Champion of the year.
About NYC Health + Hospitals
NYC Health + Hospitals is the largest public health care system in the nation serving more than a million New Yorkers annually in more than 70 patient care locations across the city's five boroughs. A robust network of outpatient, neighborhood-based primary and specialty care centers anchors care coordination with the system's trauma centers, nursing homes, post-acute care centers, home care agency, and MetroPlus health plan--all supported by 11 essential hospitals. Its diverse workforce of more than 42,000 employees is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible. For more information, visit www.nychealthandhospitals.org and stay connected on Facebook at https://www.facebook.com/NYCHealthSystem or Twitter at @NYCHealthSystem.
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ASH Agenda
ASH Agenda for Hematology Research
Genome Editing and Gene Therapy: New Opportunities to Correct Inherited Blood Disorders
Inherited genetic alterations are responsible for a range of devastating hematologic diseases, including sickle cell anemia and other hemoglobinopathies, as well as bleeding disorders due to abnormalities of coagulation and platelet function. Correction of the genetic defects that cause these disorders would allow for cure, rather than life-long palliation. Clinically valuable curative methods not only must be efficacious, but should also be durable, safe, cost-effective, and, ideally, widely available.
Previous therapeutic approaches for these disorders have included transplantation to replace hematopoietic stem cells or gene therapy using viral vectors to express normal copies of the affected gene in hematopoietic cells. Early efforts were met with challenges including transient gene expression, transplant-related toxicities, and leukemia induced by the integration of viral vectors into the host genome. However, great progress has been made in addressing these issues, and current gene transfer methods have demonstrated improved safety and long-term efficacy in correcting a number of monogenic diseases. In parallel, modification of transplant conditioning regimens has significantly reduced transplant-related toxicities.
In recent years, transformative advances have emerged in the use of genome editing approaches to precisely manipulate cellular genomes and correct mutations. These techniques include a range of nuclease systems that can target, cleave, and repair specific genomic sequences at sites of inherited disease-generating mutations, such as zinc finger nucleases (ZFNs), transcription activator-like effector nucleases (TALENs), and the Clustered Regularly Interspaced Short Palindrome Repeats and their associated Cas proteins (CRISPR/Cas9) system. Each of these systems can generate breaks at specific DNA sites that are corrected by the cell's own DNA repair machinery.
The CRISPR/Cas9 system potentially offers the greatest flexibility for genome editing because of its striking efficiency. As an experimental tool, this system has tremendous power to help researchers develop and manipulate experimental models of benign and malignant hematologic disorders. Emerging data attest to the ability of the CRISPR/Cas9 system to correct hematologic disorders, with proof-of-principle data for correcting β-thalassemia in stem cells. Ideal targets for these gene correction strategies are hematologic disorders such as hemoglobinopathies and coagulation disorders such as hemophilia, since existing treatment approaches have shown that only partial restoration of gene function is required to ameliorate the disease, and hematopoietic progenitors that are corrected can be easily re-transfused into the patient. The gene correction strategies developed for inherited disorders will likely also be attractive for other hematologic diseases, including autoimmune disorders (e.g., lupus, rheumatoid arthritis, type I diabetes), as well as for transplant rejection (either hematopoietic stem cell or solid organ transplants).
Raising the Potential for Cure: Priorities to Advance Genome Editing Technologies
While genome editing technology represents a highly promising area to advance the future of therapy for hematologic disorders, critical questions must be addressed to effectively translate this approach into clinical use.
1. RESEARCH PRIORITY: Establish strategies for determining the efficacy, safety, and toxicity of genome editing techniques
Widely used CRISPR/Cas9 and TALEN genome editing approaches have shown great promise in proof-of-principle preclinical studies and have attracted great interest as potential therapeutic approaches, particularly for therapeutic correction of monogenic disease. Two important areas for future research include the development of proper clinical trial infrastructure and basic research to further advance understanding of the biology of genome editing. Efforts to test the potential for gene therapy in clinical trials have been hindered by contraction of federal funding budgets and the fragmented nature of funding and regulatory mechanisms needed to develop clinical trials. These issues were previously highlighted by the American Society of Gene and Cell Therapy in relation to gene transfer technology,1 and their recommendations are relevant to clinical trials of genome editing. A unified federal grant review process is needed that encompasses all phases of research from bench to bedside.
1.1 Development of an National Institutes of Health (NIH)-funded clinical trial infrastructure is essential to advance research on this important emerging technology. Once preclinical efficacy is established, support is needed for clinical vector production, toxicity testing of the vectors/reagents used to manipulate the genome, and the conduct and monitoring of the clinical trial. A modified version of the NIH funding and review process can encompass each of these areas in a single review and funding process.
1.2 With this infrastructure, basic and preclinical research in genome editing technology is critical to identify the optimal genome editing approach to maximize efficacy and minimize toxicity. Areas for investigation include:
1.2.1 The potential utility of other CRISPR/Cas9 systems, full elucidation of the mechanism of action, and optimization of both target specificity and methods of delivery in order to maximize efficacy and flexibility while minimizing undesired off-target effects.
1.2.2 Optimization of the accuracy, safety and efficiency of targeting vectors to minimize off-target mutations and chromosomal rearrangements and identify strategies to reduce the toxicity of gene modification.
1.2.3 Studies on potential advantages to in utero genome editing versus childhood or adult genome editing, and strategies to implement this type of editing infrastructure, particularly when considering the treatment of under-resourced patient populations.
1.2.4 Evaluation of the potential application of existing monitoring strategies for toxicity from traditional approaches for gene modification trials.
1.3 Because genome editing currently requires culturing hematopoietic stem cells (HSCs) for extended periods (days) and selection of gene-corrected cells, optimized protocols for ex vivo propagation are needed; these need to be paired with rigorous methods to monitor genetic alterations in the modified and expanded cells and determine the functional/safety consequences of these alterations.
1.4 The introduction of nonsense codons into the genes encoding minor and major histocompatibility antigens that are immune targets would reduce transplant rejection and have broad applicability.
2. RESEARCH PRIORITY: Apply genome editing technology to correct HSCs derived from patients with congenital hematologic disorders
Recent research findings indicate broad therapeutic potential for genome editing technologies across a variety of hematologic disorders. The promise of genome editing to correct HSCs was recently demonstrated by targeting a corrective complementary DNA into the interleukin-2 receptor subunit gamma (IL2RG) gene of a subject with X-linked severe combined immunodeficiency (SCID).2 The edited HSCs sustained normal hematopoiesis and gave rise to functional lymphoid cells that possessed a selective growth advantage over those carrying the IL2RG mutations.
Advancement of these techniques within hematologic disorders would build the foundation for translation of genome editing to a wide range of human diseases, including genetic alterations of other organs (e.g., alpha-1 antitrypsin deficiency) as well as non-genetic disorders.
2.1 Studies must determine which disorders are amenable to genome editing correction (e.g., immune deficiencies, including SCID), whether certain disorders can be characterized by more complex mutations, and which gene alterations should be targeted. Further, evaluations are needed to determine if this approach can circumvent the risks associated with HSC gene therapy, including insertional mutagenesis and unregulated transgene expression.
2.2 Single nucleotide variants that result in hemoglobinopathies or immunodeficiencies (e.g., thalassemias, SCID) may be the most amenable to correction by gene editing, and therefore are ideal platforms for initial research programs. Assessments must address specific concerns, including the potential off-target activity of these nucleases.
NIH Funding of Gene Therapy Trials. Position Statement. American Society of Gene & Cell Therapy. September 29, 2006
Genovese P et al. Targeted genome editing in human repopulating haematopoietic stem cells. Nature. 2014 Jun 12;401(7504);235-240.


Okay, a bit of a theme going on with my recent post titles linking to some of my favourite songs, but would you think I was weird if I told you I often think in music lyrics and associate images with lyrics or song titles?...thought so!
Anyway this one felt apt after spending a long weekend in London town. I ♥ London (I don't need a t-shirt to declare it). I love everything about it. I lived there for just over a year and had the best time and one of the best summers I've ever had. Most of my friends still live there and I will forever associate it with sunshine and good times and this weekend didn't fail to disappoint!
I was in London to be a bridesmaid and a photographer at my best friend Emma's wedding. Paul and I spent the weekend catching up with friends, wandering around Soho, eating (mostly asian) food and enjoying the sunshine...and there was a lot of sunshine!
This photo was taken whilst we were on a boat trip to Greenwich (a great way to see the city from a different perspective). The young girl was a tourist who I assume was still caught up with Royal Wedding fever... surely there is no other reason you would wear a union-jack shirt?!


In 2011, Jose Goyos founded GreenRock Property Partners. This private placement fund was able to purchase residential and commercial mortgage-backed securities in excess of $100 million during the initial stages of operation. As GreenRock Property Partners continues to grow, Mr. Goyos has taken on varying roles within the company. Currently, he is serving as the Director of Marketing and working to implement branding initiatives that will allow the company to attract new investors. Prior to forming GreenRock Property Partners, Jose Goyos served as the Senior Vice President at Clear Choice Financial Services, LLC from January 2008 to October 2011. His responsibilities in this position included creating growth metrics for all departments, developing cash flow models to help make sure that the company remained on target to hit the quarterly projections provided to investors, and obtaining all state-required licensing. Mr. Goyos also managed a $25 million warehouse line of credit and developed new products that were able to substantially increase company revenue. The fight to obtain affordable housing for low-income people is especially significant to Jose Goyos due to his experience in the real estate industry. For Mr. Goyos, charitable involvement is in sync with his professional skills, and he supports the Fern House's efforts to find affordable and safe housing for men in the West Palm Beach area who are struggling with homelessness due to substance abuse problems. Jose Goyos has a current mortgage broker's license and an Associate's degree in Business Management from Palm Beach State. He is presently taking classes to earn his Bachelor's degree in Economics from Florida Atlantic University.


I love YouTube.It is the single best thing that has happened to the Net in the past several years.没有人会说服我,否则,no matter how hard they try..Calacanis won't..古巴不会..Doug Morris won't..
What all these YouTube haters don't see is that it isn't the"盗版内容"这让我每天都去YouTube。我可以在网上找到很多其他的地方(BitTorrent)石灰线,pando).It isn't the"免费托管这让我每天都去YouTube。I can get that at plenty of other places on the Net (revver,vimeo,BLIPTV运动框)。.
It's the experience.工具。球员。The comments.社区。这就是YouTube的精髓。These guys invented the embeddable flash player.迄今为止,在线视频游戏中最好的一个动作。我爱他们和他们建造的服务以及那里存在的社区。.
更新:Saul Hansellhas a story in today's NY Times 亚博体育app下载苹果版 YouTube在其中他涵盖了一些相同的问题,并有许多好的引文来自Chad Hurley,YouTube创始人兼首席执行官。.
前几天,我参加了一个数字和媒体类型的聚会,与一位知名而成功的企业家和一位知名而成功的技术记者交谈。Somehow the subject ofADD我说,"I am surely ADD although I've never been diagnosed as such".他们都笑了,并承认他们也是肯定加起来的。.
Growing up I never was able to study for long periods of time,不能长时间看电视,我会继续做一些新的事情。I can't do repetitve work for more than 15-20 minutes without going crazy.我不喜欢开车,如果我不必因为我的思想而徘徊。I am curious to a fault and am terrible at organizing things.I just pile stuff up,and move on to new piles.它驱动哥谭加尔疯子。.
但是如果你看看大多数成功的企业家,they exhibit many of these characteristics too.他们不能长期专注于任何事情,但他们会以贪婪的胃口闯入新的事物来解决问题。.
I don't know 亚博体育app下载苹果版 the clinical side of this disorder.我相信,有很多情况下,这种疾病是非常禁用。但我真的想知道适量的添加是否是一件坏事。我认为这可能是一件好事。这当然是我在企业家中认识和热爱的一个特点。.
When I started this blog,I looked for regular things to post on a set day each week.这使我进入了一个常规,而且效果很好。.
But it's not working for me anymore.我觉得被迫在一个固定的时间发表这些想法,变成了一件苦差事。所以我还是把MP3贴到我的博客上,但不仅仅是星期一早上。I'll do it whenever I am hit with the urge to do it.我会用一周的VC标题来写陈词滥调,但每当我有一个帖子的冲动时,它们就会来。我会用同样的方式来做我的掘金柱——当我感觉到的时候。.
我要感谢所有对跳过鲨鱼哨所发表评论的人。They were helpful in getting me to do this..
I've felt this way 亚博体育app下载苹果版饲料燃烧器long before we invested in the 亚博体育下载app,并且喜欢美味的,在苹果软件FeedBurner从我们的投资组合中消失很久之后(希望不会很快消失),我会有这种感觉。所以请不要把这个当成"弗莱德又在胡乱交易了。..
This post is 亚博体育app下载苹果版 FeedBurner doing something great for me,再一次。.
昨天,我放了喂炉"智能铸造"on all my feeds and now the flash videos I post are available in Bloglines,MyYahoo,and several other popular web-based feedreaders..
This is a huge deal for me.做得好的加料机(这是他们在芝加哥的办公室工作人员)。.
当我谈到饲料燃烧器的时候,不要错过我的帖子我怎么看饲料广告播放and what I think FeedBurner's role will be in that ecosystem..
On Monday there wasa lot of discussion亚博体育app下载苹果版 TechMeme's use of feeds to power their new sponsored posts section..Jeff Jarvis likes itI.也是.
第二天Digg和Techdirt开始运行由赛门铁克提供的饲料广告在垂涎的页面右上方部分。.联邦媒体的Chas在这些交易上有很好的职位。I assume he was involved in the deals but am not sure..
Yes,供电广告很酷。But they are hardly new.CNET已经做了一段时间,我可以从字面上考虑几十种情况下,饲料已经被用来为一个广告单元供电。.
这里是为什么饲料动力广告是如此之大。广告单元只是一个微型阅读器。The advertiser retains real time control of what goes into the ad.他们只是更新他们的饲料和广告的变化。它使广告和内容更紧密地联系在一起。.
最好的例子就是TeaMeMe。The"赞助职位"事实上就是这样——来自ObLogo的帖子社会文本博客and Wink blog.当然,这是他们各自博客的广告,but they also contain content that is relevant to the reader of the ad..
我真的很喜欢TeaMeMe实现这一点的方式,因为它从谷歌的线索。left is organic,"有偿"metaphor.The posts on the left side of Techmeme get there from the heat they are generating.TeMMETE右边的帖子是因为他们付费。.
But feed powered advertising is screaming out for a full blown platform to support this model.因为广告实际上是饲料,you should be able to subscribe to them and have them go right into your feed reader.广告应该是旋转的,所以当你浏览网页(cookie供电的频率上限)时,你不会看到同样的提要或帖子被提升。AD单元应该是闪光灯,以便馈送可以是播客或视频馈送。当然,还需要分析广告是如何表现的,以及它们生成了多少新的子程序。.
理想情况下,整个生态系统应由网络服务。There are many feeds out there that are in fact advertisements or offers.iTunes最佳专辑和顶级歌曲feeds have been around for several years.Feeds that are ads or offers should be available to any and all publishers who wish to run them and get paid for doing that (with the typical controls so your feed powered ad doesn't end up in a place you don't want it)..
平台和网络都很快从我们的投资组合饲料燃烧器.They have a large network of publishers,252,000 at last count,越来越多的营销人员通过广告或要约来经营饲料。So the ecosystem for feed powered ads is there and the platform and the network are just around the corner.I am really excited 亚博体育app下载苹果版 the possibilities..
I see feed powered ads as a natural evolution in thedisaggregation of media.出版商不会控制他们的内容在哪里消费,广告商也不会。Both will put the content (and ads are content) into the ether and it will go where it will go.只要两者都可以追踪,measured,货币化,对每个人来说都会更好。.
The Killers'声名大噪是我们2005年初选择房子的记录。We listened to it all the time andI posted on it好几次。We saw themlive at Summerstage last summer这是我们家2005的音乐会亮点之一。.
The Killers are back with Sam's Town which was released in the UK this week and will be released on Oct 3rd in the US.You can亚马逊预购现在。我们昨天拿到唱片,听了好几次。.
单身,当你年轻的时候,has been all over the radio and the internet for months.我在七月中旬.The word is that the new record is Hot Fuss meets Born To Run and certainly When You Were Young sounds like it.唱片的很多其他部分也都是这样的。.
That said,I don't think Sam's Town is quite as strong as Hot Fuss.它缺少单身人士对它的热闹。But I like it better in some ways.它更有趣。.
Sorry 亚博体育app下载苹果版 the crappy formatting.这是一封电子邮件的剪切和粘贴。.
Whereby YouTube provided those streams..