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"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

In the context of Large Language Models(LLMs) like ChatGPT, how can ethical concerns be effectively integrated into their development and deployment? Also, explain the importance of applying multiple ethical perspectives.

The development of Large Language Models (LLMs) has been an incremental process, but particularly the public release of ChatGPT, an LLM-based conversational agent, in November 2022, sparked a worldwide hype and even speculation about impeding Artificial General Intelligence (AGI). Articles in both popular and academic publications have discussed diverse opportunities, challenges, and implications of conversational agents (e.g., Dwivedi et al. 2023). The field is developing so fast, that there is hardly time to properly assess what is going on. For many organizations, governments, companies, and citizens, key questions are: What can it do exactly? Is it hype or real? What are the various ethical issues? It is this last question that we aim to (partially) address in this paper. Below, we will discuss several ethical issues aspects of one LLM-based conversational agent: ChatGPT. The authors have worked in multiple applied research and innovation projects, with numerous clients and partners, on the development and evaluation of AI systems, and aiming to integrate concerns for ethical aspects in these projects. It is from this vantage point that we are interested in the ethical aspects of conversational agents. We have observed that ethical concerns often remain implicit; the people involved rarely explicitly discuss ethical perspectives and aspects. Conversely, we propose that making such perspectives and aspects more explicit, and organizing reflection and deliberation, is necessary, if we want to move ‘from principles to practices’ (Morley et al. 2020). Such ethical reflection and deliberation are urgent when AI systems are deployed in practice; especially if people’s safety and fundamental rights are at stake. In this article we discuss an approach to organize ethical reflection and deliberation, around the seven key requirements of the European Commission’s High-Level Expert Group on AI (HLEG) (2019). There are diverse approaches to integrate ethical aspects in the development and deployment of technologies; methods can be used at the start of development, during development, or after development (Reijers et al. 2018). We propose that integrating ethical aspects during development and deployment would be most useful, especially when this is part of an iterative development process, like CRISP-DM (Martínez-Plumed et al. 2021; Shearer 2000). Furthermore, we propose to use different ethical perspectives more explicitly. Notably, we propose to use consequentialism, duty ethics, relational ethics, and virtue ethics (Van de Poel and Royakkers 2011), and to use them in parallel, as complimentary perspectives. Moreover, we understand ethics as an iterative and participatory process of ethical reflection, inquiry, and deliberation (REF removed for review). The task for the people involved is then to make room for such a process and to facilitate relevant people to participate. Such a process can have three (iterative) steps: Identify issues that are (potentially) at play in the project and reflect on these. A handful of issues works best (if there are more, one can cluster; if there are less, one can explore more.) Organize dialogues with relevant people, both inside and outside the organization, for example, stakeholders, to inquire into these issues from diverse perspectives and to hear diverse voices. Make decisions, for example, between different design options and test these in experiments; this promotes transparency and accountability. The key is to steer the project more consciously, explicitly, and carefully. Our focus is on the first step (identify issues); below, we identify and discuss a range of ethical aspects of one specific LLM-based conversational agent: ChatGPT. The second step (organize dialogues) and the third step (make decisions) are outside the current article’s scope. Below, we will introduce the ingredients of our approach: a modest form of systems thinking; four complementary ethical perspectives; and the HLEG’s seven key requirements. Then we illustrate our approach with a case study of ChatGPT. This case study is also meant to explore how different ethical perspectives are relevant to different key requirements. We close the paper with a discussion of our approach. Human agency and oversight, including fundamental rights; the HLEG proposes the principle of respect for human autonomy (2019, p. 12), which they describe as follows: ‘Humans interacting with AI systems must be able to keep full and effective self-determination over themselves […]. AI systems […] should be designed to augment, complement and empower human cognitive, social and cultural skills.’ Human oversight refers to measures that help ‘ensuring that an AI system does not undermine human autonomy’ (HLEG, 2019, p. 16). Technical robustness and safety; this requirement refers to resilience to attacks and other security risks; to having effective fallback plans to promote safety; and to accuracy, reliability, and reproducibility. The evaluation of many of these aspects would require technical tests or experiments. In this article, however, we will only identify and discuss these aspects, and not actually conduct tests or experiments. Privacy and data governance; various concerns are at play, notably: that privacy sensitive information has probably been part of the training corpus many LLMs; and that users can submit privacy sensitive data through their prompts, thus submitting these data to the organizations that owns these LLMs and the conversational agents built on them. This information can also be used for subsequent finetuning of the model. Transparency; the HLEG argues (2019, p. 12) that ‘[e]xplicability is crucial for building and maintaining users’ trust in AI systems. This means that processes need to be transparent, the capabilities and purpose of AI systems openly communicated, and decisions—to the extent possible—explainable to those directly and indirectly affected. […] The degree to which explicability is needed is highly dependent on the context and the severity of the consequences if that output is erroneous or otherwise inaccurate.’ It also includes traceability, explainability, and communication. Moreover, it refers not only to the explicability of the AI system itself, but also to the processes in which this AI system is used, the capabilities and purposes of this system, and to communication about these processes, capabilities, and purposes. Diversity, non-discrimination and fairness; the HLEG (2019, p. 12) describes fairness as having ‘both a substantive and a procedural dimension. The substantive dimension implies a commitment to: ensuring equal and just distribution of both benefits and costs, and ensuring that individuals and groups are free from unfair bias, discrimination and stigmatisation. […] The procedural dimension […] entails the ability to contest and seek effective redress against decisions made by AI systems and by the humans operating them.’ Fairness not only refers narrowly to an application, but also to the processes and organizations in which this application is used (REF removed). Related aspects are: accessibility and universal design, and involving stakeholders in design and deployment. Societal and environmental well-being; the HLEG proposes the principle of prevention of harm (2019, p. 12): ‘AI systems should neither cause nor exacerbate harm or otherwise adversely affect human beings’; they draw attention to ‘situations where AI systems can cause or exacerbate adverse impacts due to asymmetries of power or information, such as between employers and employees, businesses and consumers or governments and citizens’ and to harms to ‘the natural environment and all living beings.’ Accountability; the HLEG describes this as ‘the assessment of algorithms, data and design processes’, through either internal or external audits; especially of applications that may affect fundamental rights or safety-critical applications (2019, pp. 19–20). It includes concerns for the auditability of systems and the ability to obtain redress for users; the HLEG recommends ‘accessible mechanisms… that ensure adequate redress’ (2019, p. 20).

"================ <TEXT PASSAGE> ======= The development of Large Language Models (LLMs) has been an incremental process, but particularly the public release of ChatGPT, an LLM-based conversational agent, in November 2022, sparked a worldwide hype and even speculation about impeding Artificial General Intelligence (AGI). Articles in both popular and academic publications have discussed diverse opportunities, challenges, and implications of conversational agents (e.g., Dwivedi et al. 2023). The field is developing so fast, that there is hardly time to properly assess what is going on. For many organizations, governments, companies, and citizens, key questions are: What can it do exactly? Is it hype or real? What are the various ethical issues? It is this last question that we aim to (partially) address in this paper. Below, we will discuss several ethical issues aspects of one LLM-based conversational agent: ChatGPT. The authors have worked in multiple applied research and innovation projects, with numerous clients and partners, on the development and evaluation of AI systems, and aiming to integrate concerns for ethical aspects in these projects. It is from this vantage point that we are interested in the ethical aspects of conversational agents. We have observed that ethical concerns often remain implicit; the people involved rarely explicitly discuss ethical perspectives and aspects. Conversely, we propose that making such perspectives and aspects more explicit, and organizing reflection and deliberation, is necessary, if we want to move ‘from principles to practices’ (Morley et al. 2020). Such ethical reflection and deliberation are urgent when AI systems are deployed in practice; especially if people’s safety and fundamental rights are at stake. In this article we discuss an approach to organize ethical reflection and deliberation, around the seven key requirements of the European Commission’s High-Level Expert Group on AI (HLEG) (2019). There are diverse approaches to integrate ethical aspects in the development and deployment of technologies; methods can be used at the start of development, during development, or after development (Reijers et al. 2018). We propose that integrating ethical aspects during development and deployment would be most useful, especially when this is part of an iterative development process, like CRISP-DM (Martínez-Plumed et al. 2021; Shearer 2000). Furthermore, we propose to use different ethical perspectives more explicitly. Notably, we propose to use consequentialism, duty ethics, relational ethics, and virtue ethics (Van de Poel and Royakkers 2011), and to use them in parallel, as complimentary perspectives. Moreover, we understand ethics as an iterative and participatory process of ethical reflection, inquiry, and deliberation (REF removed for review). The task for the people involved is then to make room for such a process and to facilitate relevant people to participate. Such a process can have three (iterative) steps: Identify issues that are (potentially) at play in the project and reflect on these. A handful of issues works best (if there are more, one can cluster; if there are less, one can explore more.) Organize dialogues with relevant people, both inside and outside the organization, for example, stakeholders, to inquire into these issues from diverse perspectives and to hear diverse voices. Make decisions, for example, between different design options and test these in experiments; this promotes transparency and accountability. The key is to steer the project more consciously, explicitly, and carefully. Our focus is on the first step (identify issues); below, we identify and discuss a range of ethical aspects of one specific LLM-based conversational agent: ChatGPT. The second step (organize dialogues) and the third step (make decisions) are outside the current article’s scope. Below, we will introduce the ingredients of our approach: a modest form of systems thinking; four complementary ethical perspectives; and the HLEG’s seven key requirements. Then we illustrate our approach with a case study of ChatGPT. This case study is also meant to explore how different ethical perspectives are relevant to different key requirements. We close the paper with a discussion of our approach. Human agency and oversight, including fundamental rights; the HLEG proposes the principle of respect for human autonomy (2019, p. 12), which they describe as follows: ‘Humans interacting with AI systems must be able to keep full and effective self-determination over themselves […]. AI systems […] should be designed to augment, complement and empower human cognitive, social and cultural skills.’ Human oversight refers to measures that help ‘ensuring that an AI system does not undermine human autonomy’ (HLEG, 2019, p. 16). Technical robustness and safety; this requirement refers to resilience to attacks and other security risks; to having effective fallback plans to promote safety; and to accuracy, reliability, and reproducibility. The evaluation of many of these aspects would require technical tests or experiments. In this article, however, we will only identify and discuss these aspects, and not actually conduct tests or experiments. Privacy and data governance; various concerns are at play, notably: that privacy sensitive information has probably been part of the training corpus many LLMs; and that users can submit privacy sensitive data through their prompts, thus submitting these data to the organizations that owns these LLMs and the conversational agents built on them. This information can also be used for subsequent finetuning of the model. Transparency; the HLEG argues (2019, p. 12) that ‘[e]xplicability is crucial for building and maintaining users’ trust in AI systems. This means that processes need to be transparent, the capabilities and purpose of AI systems openly communicated, and decisions—to the extent possible—explainable to those directly and indirectly affected. […] The degree to which explicability is needed is highly dependent on the context and the severity of the consequences if that output is erroneous or otherwise inaccurate.’ It also includes traceability, explainability, and communication. Moreover, it refers not only to the explicability of the AI system itself, but also to the processes in which this AI system is used, the capabilities and purposes of this system, and to communication about these processes, capabilities, and purposes. Diversity, non-discrimination and fairness; the HLEG (2019, p. 12) describes fairness as having ‘both a substantive and a procedural dimension. The substantive dimension implies a commitment to: ensuring equal and just distribution of both benefits and costs, and ensuring that individuals and groups are free from unfair bias, discrimination and stigmatisation. […] The procedural dimension […] entails the ability to contest and seek effective redress against decisions made by AI systems and by the humans operating them.’ Fairness not only refers narrowly to an application, but also to the processes and organizations in which this application is used (REF removed). Related aspects are: accessibility and universal design, and involving stakeholders in design and deployment. Societal and environmental well-being; the HLEG proposes the principle of prevention of harm (2019, p. 12): ‘AI systems should neither cause nor exacerbate harm or otherwise adversely affect human beings’; they draw attention to ‘situations where AI systems can cause or exacerbate adverse impacts due to asymmetries of power or information, such as between employers and employees, businesses and consumers or governments and citizens’ and to harms to ‘the natural environment and all living beings.’ Accountability; the HLEG describes this as ‘the assessment of algorithms, data and design processes’, through either internal or external audits; especially of applications that may affect fundamental rights or safety-critical applications (2019, pp. 19–20). It includes concerns for the auditability of systems and the ability to obtain redress for users; the HLEG recommends ‘accessible mechanisms… that ensure adequate redress’ (2019, p. 20). https://link.springer.com/article/10.1007/s43681-024-00571-x ================ <QUESTION> ======= In the context of Large Language Models(LLMs) like ChatGPT, how can ethical concerns be effectively integrated into their development and deployment? Also, explain the importance of applying multiple ethical perspectives. ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

[Use only the provided text to answer any questions. Do not include information from the internet or your data storage.]

How does production relate to the definition of a farm for tax purposes?

Meeting the qualifications of farming and being a farmer under the Internal Revenue Code (IRC) allows for special benefits; however, not all agricultural producers meet these qualifications even if they are producing agricultural products, which is why it is vitally important for operators of farms and their tax professionals to understand the IRS tax definitions of farm, farming, and farmer. For example, one of the benefits of being classified as a farmer is the exclusion of certain receipts from income as in the case of conservation payments as allowed under IRC Section 175. Brief examples of farmers/ranchers are: • Bob raises wheat and sells his wheat to the local elevator. • Rosa has a flock of milking goats and sells the milk to a local organic foods co-op. • Amal grows cut flowers which she sells weekly at the local farmer’s market. • Ricardo raises lettuce and cabbage which he sells to a salad processing company. • Louisa operates a cattle ranch; she sells weaned calves to a feedlot investor. These examples show a producer raising or growing a product and selling that product. They have not further processed or modified the product. These are farming activities and hence would all qualify as farm income. The following discussion looks at the definition of a farmer from an income tax perspective, including the definitions of farm, farming and farmers as found in the Internal Revenue Code (IRC) and Treasury Regulations. Defining “Farm” Farm is commonly defined in the tax code in numerous places with nearly the same words. One such definition is found in IRC Section 2032A(e)(4) relative to estate tax valuation; it reads as follows: The term “farm” includes stock, dairy, poultry, fruit, furbearing animal, and truck farms, plantations, ranches, nurseries, ranges, greenhouses or other similar structures used primarily for the raising of agricultural or horticultural commodities, and orchards and woodlands. Examples of other locations in the Internal Revenue Code (IRC) and Treasury Regulations (TR) where this language with minor variation is used to define farm are: • TR Section 1.61-4(d) (gross income of farmers) • TR Section 1.175-3 (soil and water conservation expenses) • TR Section 1.6073-1(b)(2) (estimated taxes) • IRC Section 6420(c)(2) (excise tax on gasoline) • TR Section 48.6420-4(c) (meaning of terms; excise tax on gasoline) In the definition above the word orchard is included, however, vineyard or grove is not. Yet, operators of a grape vineyard will fall under the definition of farm when using the inclusive wording “agricultural and horticultural commodities”. Grapes are the product of the vineyard and an agricultural commodity; therefore, the vineyard is a farm. Other rural operations producing products which can be defined as agricultural or horticultural, for example, a rural business producing goat’s milk will be defined for income tax purposes as a farm. A vineyard selling grapes is a farm. A winery that produces and sells wine would not be a farm. For operations with a combination, they would need to work with their tax preparer to separate the farming activities from non-farm business activity. The definition of a farm describes farming activities. These activities produce farm income which is recorded on a Form 1040 Schedule F: Profit or Loss From Farming. Someone may have a farm and produce farm income, but not qualify as a farmer under a specific tax provision. Estimated Tax Payments [IRC § 6654(i)(2)] If a taxpayer qualifies as a farmer by having more than two-thirds of his/her gross income being derived from farming; they may make a single estimated tax payment by the 15th of the month that follows the close of their tax year or make payment in full of their income tax liability by the first of the third month following the close of their tax year. (Calendar-year taxpayers: 15th of January or 1st of March). Example 1: Jose raises sheep full-time in the alpine meadows of Colorado. Jose sells market lambs and wool shorn from the flock. This is Jose’s primary source of income with over two-thirds of his income coming from this. He has a profit motive relative to his business activities. Wooly is a farmer for income tax purposes and would qualify for the estimated tax payments provisions. Example 2: Susie grows herbs for sale at her local farmer’s market on the weekends. Susie’s main source of income is her work as a computer engineer for a software company. Her herb sales are a small part of her total income. Even though she has a horticultural activity, less than 2/3s of her income is from farming. So, she would not qualify for the special benefits for estimated tax payments. If Susie can show she has a profit motive, her herb production would qualify as a farm activity and any income and expenses would be recorded on an IRS Form 1040 Schedule F. Installment Sale of Farm Products (IRC § 453) Cash-basis farmers are permitted to report income from the sale of farm products when the product is sold. They are not required to maintain inventories. If the farmer enters a forward sales contract to deliver the farm product in a subsequent year after production the income is reported in the year of payment not production. The contract must specify that the farmer can only receive the payment in the subsequent year to production, even if the delivery of the production occurred in the year of production. This is available for all farming income. The activities must fall within the definition of a farm in the previous section. Defining Agritourism as a Contrast to Farming Determining whether or not a business is a farming business is a confusing issue for operators of agritourism businesses using farmland and farm production as part of that business model which may be educational in nature or focuses on the sale of value-added products (Isn’t it really the “farming of people”?). In recent years agritourism businesses have a goal of connecting the non-farming population with production agriculture through experiences in a rural and farm setting. Agritourism is defined by Merriam-Webster as, “the practice of touring agricultural areas to see farms and often to participate in farm activities”. Merriam-Webster also indicates that the word agritourism entered the English language as a new word in 1979. Agritourism is also defined in other sources to include cooking cleaning and handicrafts or in contrast only when staying at the farm1. 1 The unabridged Dictionary.com (based on Random House Dictionary © 2009) defines agritourism as a noun with the following meaning: Tourism in which tourists take part in farm or village activities, as animal and crop care, cooking and cleaning, handicrafts, and entertainments. Agritourism is also defined by The American Heritage® Dictionary of the English Language, Fourth Edition © 2009 by Houghton Mifflin Company, with the following meaning: Tourism in which tourists board at farms or in rural villages and experience farming at close hand. Agritourism is not defined in the Internal Revenue Code or Treasury Regulations for income tax purposes. Definitions from dictionaries provide similarities within the meaning of agritourism ranging from simply touring agricultural areas to see farms to boarding on those farms and engaging in various activities for education or entertainment. When the definition of farming is contrasted with these definitions of agritourism it becomes clear that farming taxpayers who expand into agritourism activities and their practitioners should be diligent in determining extent of the non-farming business. Example 3: Friendly Farmer uses the six- bedroom antebellum farm house as a Bed & Breakfast. He has developed walking and horseback riding trails over the 600 acre farm that has been in his family for six generations. He is quite successful as a spinner of tall tales and is a gregarious host, so much so, that he now generates 70 percent of his gross income from guest services. Friendly is in the agritourism business even though he uses the family farm as the venue for these activities, he is more of an entertainer than farmer. While the income from the farm part of the operation would still be considered Farm Income and reported on IRS 1040 Schedule F, since less than two-thirds of his income is from farming, he would not be eligible for the estimated tax payments provisions.

[Use only the provided text to answer any questions. Do not include information from the internet or your data storage.] Meeting the qualifications of farming and being a farmer under the Internal Revenue Code (IRC) allows for special benefits; however, not all agricultural producers meet these qualifications even if they are producing agricultural products, which is why it is vitally important for operators of farms and their tax professionals to understand the IRS tax definitions of farm, farming, and farmer. For example, one of the benefits of being classified as a farmer is the exclusion of certain receipts from income as in the case of conservation payments as allowed under IRC Section 175. Brief examples of farmers/ranchers are: • Bob raises wheat and sells his wheat to the local elevator. • Rosa has a flock of milking goats and sells the milk to a local organic foods co-op. • Amal grows cut flowers which she sells weekly at the local farmer’s market. • Ricardo raises lettuce and cabbage which he sells to a salad processing company. • Louisa operates a cattle ranch; she sells weaned calves to a feedlot investor. These examples show a producer raising or growing a product and selling that product. They have not further processed or modified the product. These are farming activities and hence would all qualify as farm income. The following discussion looks at the definition of a farmer from an income tax perspective, including the definitions of farm, farming and farmers as found in the Internal Revenue Code (IRC) and Treasury Regulations. Defining “Farm” Farm is commonly defined in the tax code in numerous places with nearly the same words. One such definition is found in IRC Section 2032A(e)(4) relative to estate tax valuation; it reads as follows: The term “farm” includes stock, dairy, poultry, fruit, furbearing animal, and truck farms, plantations, ranches, nurseries, ranges, greenhouses or other similar structures used primarily for the raising of agricultural or horticultural commodities, and orchards and woodlands. Examples of other locations in the Internal Revenue Code (IRC) and Treasury Regulations (TR) where this language with minor variation is used to define farm are: • TR Section 1.61-4(d) (gross income of farmers) • TR Section 1.175-3 (soil and water conservation expenses) • TR Section 1.6073-1(b)(2) (estimated taxes) • IRC Section 6420(c)(2) (excise tax on gasoline) • TR Section 48.6420-4(c) (meaning of terms; excise tax on gasoline) In the definition above the word orchard is included, however, vineyard or grove is not. Yet, operators of a grape vineyard will fall under the definition of farm when using the inclusive wording “agricultural and horticultural commodities”. Grapes are the product of the vineyard and an agricultural commodity; therefore, the vineyard is a farm. Other rural operations producing products which can be defined as agricultural or horticultural, for example, a rural business producing goat’s milk will be defined for income tax purposes as a farm. A vineyard selling grapes is a farm. A winery that produces and sells wine would not be a farm. For operations with a combination, they would need to work with their tax preparer to separate the farming activities from non-farm business activity. The definition of a farm describes farming activities. These activities produce farm income which is recorded on a Form 1040 Schedule F: Profit or Loss From Farming. Someone may have a farm and produce farm income, but not qualify as a farmer under a specific tax provision. Estimated Tax Payments [IRC § 6654(i)(2)] If a taxpayer qualifies as a farmer by having more than two-thirds of his/her gross income being derived from farming; they may make a single estimated tax payment by the 15th of the month that follows the close of their tax year or make payment in full of their income tax liability by the first of the third month following the close of their tax year. (Calendar-year taxpayers: 15th of January or 1st of March). Example 1: Jose raises sheep full-time in the alpine meadows of Colorado. Jose sells market lambs and wool shorn from the flock. This is Jose’s primary source of income with over two-thirds of his income coming from this. He has a profit motive relative to his business activities. Wooly is a farmer for income tax purposes and would qualify for the estimated tax payments provisions. Example 2: Susie grows herbs for sale at her local farmer’s market on the weekends. Susie’s main source of income is her work as a computer engineer for a software company. Her herb sales are a small part of her total income. Even though she has a horticultural activity, less than 2/3s of her income is from farming. So, she would not qualify for the special benefits for estimated tax payments. If Susie can show she has a profit motive, her herb production would qualify as a farm activity and any income and expenses would be recorded on an IRS Form 1040 Schedule F. Installment Sale of Farm Products (IRC § 453) Cash-basis farmers are permitted to report income from the sale of farm products when the product is sold. They are not required to maintain inventories. If the farmer enters a forward sales contract to deliver the farm product in a subsequent year after production the income is reported in the year of payment not production. The contract must specify that the farmer can only receive the payment in the subsequent year to production, even if the delivery of the production occurred in the year of production. This is available for all farming income. The activities must fall within the definition of a farm in the previous section. Defining Agritourism as a Contrast to Farming Determining whether or not a business is a farming business is a confusing issue for operators of agritourism businesses using farmland and farm production as part of that business model which may be educational in nature or focuses on the sale of value-added products (Isn’t it really the “farming of people”?). In recent years agritourism businesses have a goal of connecting the non-farming population with production agriculture through experiences in a rural and farm setting. Agritourism is defined by Merriam-Webster as, “the practice of touring agricultural areas to see farms and often to participate in farm activities”. Merriam-Webster also indicates that the word agritourism entered the English language as a new word in 1979. Agritourism is also defined in other sources to include cooking cleaning and handicrafts or in contrast only when staying at the farm1. 1 The unabridged Dictionary.com (based on Random House Dictionary © 2009) defines agritourism as a noun with the following meaning: Tourism in which tourists take part in farm or village activities, as animal and crop care, cooking and cleaning, handicrafts, and entertainments. Agritourism is also defined by The American Heritage® Dictionary of the English Language, Fourth Edition © 2009 by Houghton Mifflin Company, with the following meaning: Tourism in which tourists board at farms or in rural villages and experience farming at close hand. Agritourism is not defined in the Internal Revenue Code or Treasury Regulations for income tax purposes. Definitions from dictionaries provide similarities within the meaning of agritourism ranging from simply touring agricultural areas to see farms to boarding on those farms and engaging in various activities for education or entertainment. When the definition of farming is contrasted with these definitions of agritourism it becomes clear that farming taxpayers who expand into agritourism activities and their practitioners should be diligent in determining extent of the non-farming business. Example 3: Friendly Farmer uses the six- bedroom antebellum farm house as a Bed & Breakfast. He has developed walking and horseback riding trails over the 600 acre farm that has been in his family for six generations. He is quite successful as a spinner of tall tales and is a gregarious host, so much so, that he now generates 70 percent of his gross income from guest services. Friendly is in the agritourism business even though he uses the family farm as the venue for these activities, he is more of an entertainer than farmer. While the income from the farm part of the operation would still be considered Farm Income and reported on IRS 1040 Schedule F, since less than two-thirds of his income is from farming, he would not be eligible for the estimated tax payments provisions. How does production relate to the definition of a farm for tax purposes?

Please answer from the text only and do not extrapolate from the source material.

What are the different ways to induce labor for an expectant mother?

Department of Obstetrics and Gynecology - 1 - Induction of Labor What is induction of labor? Induction of labor is a medical procedure that softens the cervix (the opening to the womb or uterus) and starts contractions (muscle movements that help push the baby out of the uterus). This procedure is a way to plan when your labor (childbirth) will start, instead of waiting until labor starts on its own. The goal of an induction is to have a safe vaginal birth within 24 hours. What happens during an induction procedure? We use standard medications and techniques to soften and dilate (widen) the cervix so it can reach 10 centimeters (cm) wide. A safe and effective induction procedure includes the following: Misoprostol (Cytotec®) • This is a small pill that your provider will place in the vagina every 3 hours at the start of your induction until the cervix is 3-4 cm dilated. • Misoprostol causes your cervix to soften and open and starts your contractions. Balloon • When your cervix is between 1-3 cm dilated, your provider will place a soft balloon at the top of the cervix. This causes your cervix to soften and dilate. • This balloon can also be placed in the OB Triage or in the clinic before your scheduled induction. Then you will be admitted to the hospital later in the day. Department of Obstetrics and Gynecology Induction of Labor - 2 - • Misoprostol is used in combination with the balloon. Amniotomy • When your cervix is around 3-4 cm dilated, your provider will remove the balloon. Then they will use a device to break the bag of water around your baby. This procedure is called an amniotomy. • The amniotomy causes more contractions to help labor progress. Oxytocin (Pitocin®) • Starting around when your cervix is 3-4 cm dilated, your provider will give you oxytocin through an IV (a needle inserted into your vein). • This medication causes contractions, and it can be easily increased or decreased to avoid having too many contractions. Sometimes oxytocin is also used instead of misoprostol earlier in the induction process. Other steps throughout your induction procedure: • We will do cervical exams every 2-4 hours to confirm that the induction process is going well. • We will do continuous fetal monitoring (medical checks on the baby) to make sure that the baby is doing well throughout the process. • We will place an IV at the start of your induction. Department of Obstetrics and Gynecology Induction of Labor - 3 - Timeline (by centimeters dilated) of the induction procedures and medications: What are the benefits of induction? Induction for a medical reason For some medical conditions, induction of labor is recommended to reduce the risk of complications (medical problems) for both the pregnant person and the baby. Timing your birth instead of waiting for spontaneous labor (whenever labor naturally starts on its own) decreases the chance that your medical conditions will get worse. It also decreases the risk of stillbirth (when a baby dies during pregnancy or birth). Some of these medical conditions include: • Pre-eclampsia and high blood pressure • Diabetes • Low amniotic fluid (oligohydramnios) • When the baby is much smaller than expected Ask your doctor, nurse, or midwife if you have a condition where early birth is recommended. Induction after 39 weeks of pregnancy Induction of labor can be done safely after 39 weeks for pregnant people who do not have a medical reason for early birth. Potential benefits include: • Reduced risk of developing high blood pressure or pre-eclampsia later in pregnancy Department of Obstetrics and Gynecology Induction of Labor - 4 - • Decreased risk of stillbirth (if induced before 42 weeks) • Possibly making it less likely that you will need a Cesarean birth (a surgery to deliver a baby through a cut made through the belly, also called a C-section) What are the risks of induction? • We monitor the baby’s heartbeat continuously because sometimes labor can be harmful to babies. If this is the case, you might need urgent or emergency interventions (including Cesarean birth). • An induction of labor can fail if your cervix does not dilate to 10 cm, despite all efforts to help labor progress. If this happens, you will need a Cesarean birth. Your doctor, midwife and nurse will regularly keep you updated on next steps for care. • If an induction takes too long (more than 24 hours), there is a higher risk of bleeding, infection, and Cesarean birth. • Patients who are induced have a longer hospital stay before birth compared to patients who have spontaneous labor. • It may be harder for you to rest during the early parts of your labor. What are alternatives to induction? • Waiting for spontaneous labor • Cesarean birth How can I help my induction go well? • During the early part of the induction, try to rest as much as possible, drink fluids, and snack lightly. • When your contractions get stronger, rock on a birth ball or use the shower to make yourself more comfortable. Being upright (instead of lying down) and active helps your labor move forward. Department of Obstetrics and Gynecology Induction of Labor - 5 - Disclaimer: This document contains information and/or instructional materials developed by University of Michigan (U-M) Health for the typical patient with your condition. It may include links to online content that was not created by U-M Health and for which U-M Health does not assume responsibility. It does not replace medical advice from your health care provider because your experience may differ from that of the typical patient. Talk to your health care provider if you have any questions about this document, your condition, or your treatment plan. Authors: Joanne Bailey, CNM PhD, Jourdan Triebwasser, MD Edited by: Brittany Batell, MPH MSW Patient Education by U-M Health is licensed under a Creative Commons AttributionNonCommercial-ShareAlike 4.0 International Public License. Last revised 02/2024 • Change positions often, especially if you have an epidural (an injection of medication that blocks pain during labor). • Plan to have a support team (your partner, family member, doula, friend) with you. Having ongoing labor support after your contractions get stronger decreases the possibility of a Cesarean birth and improves your labor and birth experience. • Before you come to the hospital for your induction, learn about ways to push effectively after the cervix is 10 cm dilated. What can I eat and drink during an induction? During an induction, you can eat food without animal protein or fat. Once you get an epidural or once you’re in active labor, you can have clear liquids (like water, apple or grape juice, gelatin, popsicles). What does a scheduled induction look like? On the day that your induction is scheduled, you should arrive at the Birth Center at the time you are scheduled (unless you are contacted that day with different instructions). Please note that we may have to delay your induction 1 day or more, depending on how busy it is in the Birth Center. We try to give you as much advance notice as possible about delays.

Please answer from the text only and do not extrapolate from the source material. What are the different ways to induce labor for an expectant mother? Department of Obstetrics and Gynecology - 1 - Induction of Labor What is induction of labor? Induction of labor is a medical procedure that softens the cervix (the opening to the womb or uterus) and starts contractions (muscle movements that help push the baby out of the uterus). This procedure is a way to plan when your labor (childbirth) will start, instead of waiting until labor starts on its own. The goal of an induction is to have a safe vaginal birth within 24 hours. What happens during an induction procedure? We use standard medications and techniques to soften and dilate (widen) the cervix so it can reach 10 centimeters (cm) wide. A safe and effective induction procedure includes the following: Misoprostol (Cytotec®) • This is a small pill that your provider will place in the vagina every 3 hours at the start of your induction until the cervix is 3-4 cm dilated. • Misoprostol causes your cervix to soften and open and starts your contractions. Balloon • When your cervix is between 1-3 cm dilated, your provider will place a soft balloon at the top of the cervix. This causes your cervix to soften and dilate. • This balloon can also be placed in the OB Triage or in the clinic before your scheduled induction. Then you will be admitted to the hospital later in the day. Department of Obstetrics and Gynecology Induction of Labor - 2 - • Misoprostol is used in combination with the balloon. Amniotomy • When your cervix is around 3-4 cm dilated, your provider will remove the balloon. Then they will use a device to break the bag of water around your baby. This procedure is called an amniotomy. • The amniotomy causes more contractions to help labor progress. Oxytocin (Pitocin®) • Starting around when your cervix is 3-4 cm dilated, your provider will give you oxytocin through an IV (a needle inserted into your vein). • This medication causes contractions, and it can be easily increased or decreased to avoid having too many contractions. Sometimes oxytocin is also used instead of misoprostol earlier in the induction process. Other steps throughout your induction procedure: • We will do cervical exams every 2-4 hours to confirm that the induction process is going well. • We will do continuous fetal monitoring (medical checks on the baby) to make sure that the baby is doing well throughout the process. • We will place an IV at the start of your induction. Department of Obstetrics and Gynecology Induction of Labor - 3 - Timeline (by centimeters dilated) of the induction procedures and medications: What are the benefits of induction? Induction for a medical reason For some medical conditions, induction of labor is recommended to reduce the risk of complications (medical problems) for both the pregnant person and the baby. Timing your birth instead of waiting for spontaneous labor (whenever labor naturally starts on its own) decreases the chance that your medical conditions will get worse. It also decreases the risk of stillbirth (when a baby dies during pregnancy or birth). Some of these medical conditions include: • Pre-eclampsia and high blood pressure • Diabetes • Low amniotic fluid (oligohydramnios) • When the baby is much smaller than expected Ask your doctor, nurse, or midwife if you have a condition where early birth is recommended. Induction after 39 weeks of pregnancy Induction of labor can be done safely after 39 weeks for pregnant people who do not have a medical reason for early birth. Potential benefits include: • Reduced risk of developing high blood pressure or pre-eclampsia later in pregnancy Department of Obstetrics and Gynecology Induction of Labor - 4 - • Decreased risk of stillbirth (if induced before 42 weeks) • Possibly making it less likely that you will need a Cesarean birth (a surgery to deliver a baby through a cut made through the belly, also called a C-section) What are the risks of induction? • We monitor the baby’s heartbeat continuously because sometimes labor can be harmful to babies. If this is the case, you might need urgent or emergency interventions (including Cesarean birth). • An induction of labor can fail if your cervix does not dilate to 10 cm, despite all efforts to help labor progress. If this happens, you will need a Cesarean birth. Your doctor, midwife and nurse will regularly keep you updated on next steps for care. • If an induction takes too long (more than 24 hours), there is a higher risk of bleeding, infection, and Cesarean birth. • Patients who are induced have a longer hospital stay before birth compared to patients who have spontaneous labor. • It may be harder for you to rest during the early parts of your labor. What are alternatives to induction? • Waiting for spontaneous labor • Cesarean birth How can I help my induction go well? • During the early part of the induction, try to rest as much as possible, drink fluids, and snack lightly. • When your contractions get stronger, rock on a birth ball or use the shower to make yourself more comfortable. Being upright (instead of lying down) and active helps your labor move forward. Department of Obstetrics and Gynecology Induction of Labor - 5 - Disclaimer: This document contains information and/or instructional materials developed by University of Michigan (U-M) Health for the typical patient with your condition. It may include links to online content that was not created by U-M Health and for which U-M Health does not assume responsibility. It does not replace medical advice from your health care provider because your experience may differ from that of the typical patient. Talk to your health care provider if you have any questions about this document, your condition, or your treatment plan. Authors: Joanne Bailey, CNM PhD, Jourdan Triebwasser, MD Edited by: Brittany Batell, MPH MSW Patient Education by U-M Health is licensed under a Creative Commons AttributionNonCommercial-ShareAlike 4.0 International Public License. Last revised 02/2024 • Change positions often, especially if you have an epidural (an injection of medication that blocks pain during labor). • Plan to have a support team (your partner, family member, doula, friend) with you. Having ongoing labor support after your contractions get stronger decreases the possibility of a Cesarean birth and improves your labor and birth experience. • Before you come to the hospital for your induction, learn about ways to push effectively after the cervix is 10 cm dilated. What can I eat and drink during an induction? During an induction, you can eat food without animal protein or fat. Once you get an epidural or once you’re in active labor, you can have clear liquids (like water, apple or grape juice, gelatin, popsicles). What does a scheduled induction look like? On the day that your induction is scheduled, you should arrive at the Birth Center at the time you are scheduled (unless you are contacted that day with different instructions). Please note that we may have to delay your induction 1 day or more, depending on how busy it is in the Birth Center. We try to give you as much advance notice as possible about delays.

Only use the information provided in the document to give your answer. Keep it to less than 50 words.

In the context of the provided document, what is the definition of "nonexpendable equipment"?

**Creating a budget for a grant** Although the degree of specificity of any budget will vary depending on the nature of the project and OJP agency requirements, a complete, well-thought-out budget serves to reinforce your credibility and increase the likelihood of your proposal being funded. Keep in mind the following— A well-prepared budget should be reasonable and demonstrate that the funds being asked for will be used wisely. The budget should be as concrete and specific as possible in its estimates. Make every effort to be realistic, to estimate costs accurately. The budget format should be as clear as possible. It should begin with a budget narrative, which you should write after the entire budget has been prepared. Each section of the budget should be in outline form, listing line items under major headings and subheadings. Each of the major components should be subtotaled with a grand total at the end. Your budget should justify all expenses and be consistent with the program narrative: Salaries should be comparable to those within the applicant organization. If new staff is being hired, additional space and equipment are considered, as necessary. If the budget lists an equipment purchase, it is the type allowed by the agency. If additional space is rented, the increase in insurance is supported. If an indirect cost rate applies to the proposal, the division between direct and indirect costs is not in conflict, and the aggregate budget totals refer directly to the approved formula. Indirect costs are costs that are not readily assignable to a particular project, but are necessary to the operation of the organization and the performance of the project (like the cost of operating and maintaining facilities, depreciation, and administrative salaries). If matching funds are required, the contributions to the matching fund are taken out of the budget unless otherwise specified in the application instructions. While budget adjustments are sometimes made after the grant award, this can be a lengthy process. It’s best to be certain that implementation, continuation, and phase-down costs can be met with the budget you submit with the proposal. Consider costs associated with leases, evaluation systems, hard/soft match requirements, audits, development, implementing and maintaining information and accounting systems, and other long-term financial commitments. Use OJP’s Budget Detail Worksheet as a guide when preparing your budget and budget narrative. You may submit this worksheet or your own version, but it must address all of the categories in the sample budget detail worksheet. (See a sample budget summary and narrative.) Whatever format you submit, however, must include all of the information asked for on the budget detail worksheet in the solicitation for your grant application, in addition to the budget narrative: Personnel—List each position by title and employee name, if available. Show the annual salary rate and the percentage of time to be devoted to the project. Compensation paid for employees engaged in grant activities must be consistent with that paid for similar work within your organization. List only the employees of the applicant organization; all other grant-funded positions should be listed under the consultants/contracts category. Fringe Benefits—Base fringe benefits on actual known costs or an established formula. Fringe benefits are for listed personnel and only for the percentage of time devoted to the project. Fringe benefits on overtime hours are limited to FICA, workers’ compensation, and unemployment compensation. Travel—Itemize travel expenses for project personnel by purpose (e.g., staff to training, field interviews, advisory group meetings). Show how you calculated these costs (e.g., six people to 3-day training at $X airfare, $X lodging, $X meals). In training projects, list travel and meals for trainees separately. Show the number of trainees and the unit costs involved. Identify the location of travel, if known. Indicate the source of any travel policies you have applied, and if applicant or federal travel regulations apply. The use of use federal grant funds to travel to non-DOJ-sponsored training events requires prior approval from the funding agency. Equipment—List nonexpendable items that are to be purchased. Nonexpendable equipment is tangible property having a useful life of more than 2 years and an acquisition cost of $5,000 or more per unit. (Note: An organization’s own capitalization policy may be used for items costing less than $5,000.) Include expendable items either in the "supplies" category or in the "other" category. Analyze the cost benefits of purchasing versus leasing equipment, particularly high-cost items and those subject to rapid technical advances. List rented or leased equipment costs in the "contractual" category. Explain why the equipment is needed for the project to succeed. Attach a narrative describing the method that will be used to procure the equipment. Supplies—List items by type (office supplies, postage, training materials, copying paper, and expendable equipment items costing less than $5,000, such as books and handheld tape recorders) and show how you calculated these costs. (Note: An organization’s own capitalization policy may be used for items costing less than $5,000.) Generally, supplies include any materials that are expendable or consumed during the course of the project. Construction—As a rule, construction costs are not allowable. In some cases, minor repairs or renovations may be allowable. Check the solicitation and with the program office before budgeting funds in this category. Consultants/Contracts—Indicate whether you will follow your organization’s formal, written procurement policy or the Federal Acquisition Regulations. Consultant Fees: For each consultant, enter the name, if known, service to be provided, hourly or daily fee (8-hour day), and estimated time on the project. Consultant fees in excess of $450 per day require additional justification and prior approval from OJP. Consultant Expenses: List all expenses to be paid from the grant to the individual consultants in addition to their fees (e.g., travel, meals, lodging). Contracts: Describe the product or service to be procured by contract and provide an estimate of the cost. Promote free and open competition in awarding contracts. You must provide a separate justification for sole-source contracts of $100,000 or more. Other Costs—List items (e.g., rent, reproduction, telephone, janitorial or security services, investigative or confidential funds) by major type and show how you calculated the costs. For example, for rent, provide the square footage and the cost per square foot or a monthly rental cost and how many months of rent are proposed. Indirect Costs—Indirect costs are allowed only if you have a federally approved indirect cost rate and you attach a copy of the rate approval (a fully executed, negotiated agreement). If you don’t have an approved rate, you can request one by contacting your cognizant federal agency, which will review all documentation and approve a rate. Or, if your accounting system permits, you may allocate costs in the direct costs categories. Remember to include computations that clearly show how the costs were derived, as well as documentation that explains the cost or line item. Sustaining the Project Do not anticipate that the grant income will be the sole support for your project. Consider this when developing your overall budget requirements and, in particular, when developing budget line items most subject to inflation. Exercise restraint when determining inflationary cost projections (avoid padding budget line items), but try to anticipate possible future increases. Federal funds must be used to supplement existing funds for program activities and must not replace (supplant) those funds that have been appropriated for the same purpose. SUPPLANTING IS PROHIBITED Definition: To deliberately reduce state or local funds because of the existence of federal funds. Prohibition: Federal funds must be used to supplement existing funds for program activities and must not replace those funds that have been appropriated for the same purpose. Example: When state funds are appropriated for a stated purpose and federal funds are awarded for that same purpose, the state replaces its state funds with federal funds, thereby reducing the total amount available for the stated purpose. Monitoring: Supplanting will be the subject of application review, preaward review, postaward monitoring, and audit. Most grant programs require applicants to include information that explains how they will fund and sustain the project once the grant funds have been expended. Describe a plan for continuing your project beyond the grant period, and outline all other fundraising efforts you are considering and any plans to apply for additional grants in the future. Please note that it is prohibited to use grant funds or grant-funded positions for your fundraising efforts. Also, provide projections for operating and maintaining facilities and equipment. Discuss maintenance and future program funding if program funds are for construction activity. Account for other needed expenditures if the program includes purchasing equipment.

<Text Passage> ========== **Creating a budget for a grant** Although the degree of specificity of any budget will vary depending on the nature of the project and OJP agency requirements, a complete, well-thought-out budget serves to reinforce your credibility and increase the likelihood of your proposal being funded. Keep in mind the following— A well-prepared budget should be reasonable and demonstrate that the funds being asked for will be used wisely. The budget should be as concrete and specific as possible in its estimates. Make every effort to be realistic, to estimate costs accurately. The budget format should be as clear as possible. It should begin with a budget narrative, which you should write after the entire budget has been prepared. Each section of the budget should be in outline form, listing line items under major headings and subheadings. Each of the major components should be subtotaled with a grand total at the end. Your budget should justify all expenses and be consistent with the program narrative: Salaries should be comparable to those within the applicant organization. If new staff is being hired, additional space and equipment are considered, as necessary. If the budget lists an equipment purchase, it is the type allowed by the agency. If additional space is rented, the increase in insurance is supported. If an indirect cost rate applies to the proposal, the division between direct and indirect costs is not in conflict, and the aggregate budget totals refer directly to the approved formula. Indirect costs are costs that are not readily assignable to a particular project, but are necessary to the operation of the organization and the performance of the project (like the cost of operating and maintaining facilities, depreciation, and administrative salaries). If matching funds are required, the contributions to the matching fund are taken out of the budget unless otherwise specified in the application instructions. While budget adjustments are sometimes made after the grant award, this can be a lengthy process. It’s best to be certain that implementation, continuation, and phase-down costs can be met with the budget you submit with the proposal. Consider costs associated with leases, evaluation systems, hard/soft match requirements, audits, development, implementing and maintaining information and accounting systems, and other long-term financial commitments. Use OJP’s Budget Detail Worksheet as a guide when preparing your budget and budget narrative. You may submit this worksheet or your own version, but it must address all of the categories in the sample budget detail worksheet. (See a sample budget summary and narrative.) Whatever format you submit, however, must include all of the information asked for on the budget detail worksheet in the solicitation for your grant application, in addition to the budget narrative: Personnel—List each position by title and employee name, if available. Show the annual salary rate and the percentage of time to be devoted to the project. Compensation paid for employees engaged in grant activities must be consistent with that paid for similar work within your organization. List only the employees of the applicant organization; all other grant-funded positions should be listed under the consultants/contracts category. Fringe Benefits—Base fringe benefits on actual known costs or an established formula. Fringe benefits are for listed personnel and only for the percentage of time devoted to the project. Fringe benefits on overtime hours are limited to FICA, workers’ compensation, and unemployment compensation. Travel—Itemize travel expenses for project personnel by purpose (e.g., staff to training, field interviews, advisory group meetings). Show how you calculated these costs (e.g., six people to 3-day training at $X airfare, $X lodging, $X meals). In training projects, list travel and meals for trainees separately. Show the number of trainees and the unit costs involved. Identify the location of travel, if known. Indicate the source of any travel policies you have applied, and if applicant or federal travel regulations apply. The use of use federal grant funds to travel to non-DOJ-sponsored training events requires prior approval from the funding agency. Equipment—List nonexpendable items that are to be purchased. Nonexpendable equipment is tangible property having a useful life of more than 2 years and an acquisition cost of $5,000 or more per unit. (Note: An organization’s own capitalization policy may be used for items costing less than $5,000.) Include expendable items either in the "supplies" category or in the "other" category. Analyze the cost benefits of purchasing versus leasing equipment, particularly high-cost items and those subject to rapid technical advances. List rented or leased equipment costs in the "contractual" category. Explain why the equipment is needed for the project to succeed. Attach a narrative describing the method that will be used to procure the equipment. Supplies—List items by type (office supplies, postage, training materials, copying paper, and expendable equipment items costing less than $5,000, such as books and handheld tape recorders) and show how you calculated these costs. (Note: An organization’s own capitalization policy may be used for items costing less than $5,000.) Generally, supplies include any materials that are expendable or consumed during the course of the project. Construction—As a rule, construction costs are not allowable. In some cases, minor repairs or renovations may be allowable. Check the solicitation and with the program office before budgeting funds in this category. Consultants/Contracts—Indicate whether you will follow your organization’s formal, written procurement policy or the Federal Acquisition Regulations. Consultant Fees: For each consultant, enter the name, if known, service to be provided, hourly or daily fee (8-hour day), and estimated time on the project. Consultant fees in excess of $450 per day require additional justification and prior approval from OJP. Consultant Expenses: List all expenses to be paid from the grant to the individual consultants in addition to their fees (e.g., travel, meals, lodging). Contracts: Describe the product or service to be procured by contract and provide an estimate of the cost. Promote free and open competition in awarding contracts. You must provide a separate justification for sole-source contracts of $100,000 or more. Other Costs—List items (e.g., rent, reproduction, telephone, janitorial or security services, investigative or confidential funds) by major type and show how you calculated the costs. For example, for rent, provide the square footage and the cost per square foot or a monthly rental cost and how many months of rent are proposed. Indirect Costs—Indirect costs are allowed only if you have a federally approved indirect cost rate and you attach a copy of the rate approval (a fully executed, negotiated agreement). If you don’t have an approved rate, you can request one by contacting your cognizant federal agency, which will review all documentation and approve a rate. Or, if your accounting system permits, you may allocate costs in the direct costs categories. Remember to include computations that clearly show how the costs were derived, as well as documentation that explains the cost or line item. Sustaining the Project Do not anticipate that the grant income will be the sole support for your project. Consider this when developing your overall budget requirements and, in particular, when developing budget line items most subject to inflation. Exercise restraint when determining inflationary cost projections (avoid padding budget line items), but try to anticipate possible future increases. Federal funds must be used to supplement existing funds for program activities and must not replace (supplant) those funds that have been appropriated for the same purpose. SUPPLANTING IS PROHIBITED Definition: To deliberately reduce state or local funds because of the existence of federal funds. Prohibition: Federal funds must be used to supplement existing funds for program activities and must not replace those funds that have been appropriated for the same purpose. Example: When state funds are appropriated for a stated purpose and federal funds are awarded for that same purpose, the state replaces its state funds with federal funds, thereby reducing the total amount available for the stated purpose. Monitoring: Supplanting will be the subject of application review, preaward review, postaward monitoring, and audit. Most grant programs require applicants to include information that explains how they will fund and sustain the project once the grant funds have been expended. Describe a plan for continuing your project beyond the grant period, and outline all other fundraising efforts you are considering and any plans to apply for additional grants in the future. Please note that it is prohibited to use grant funds or grant-funded positions for your fundraising efforts. Also, provide projections for operating and maintaining facilities and equipment. Discuss maintenance and future program funding if program funds are for construction activity. Account for other needed expenditures if the program includes purchasing equipment. <Query> ========== In the context of the provided document, what is the definition of "nonexpendable equipment"? <System Instruction> ========== Only use the information provided in the document to give your answer. Keep it to less than 50 words.

Only answer by using the information in the context block below. Do not use external sources for your answer.

How does 10% of calories from fat benefit us?

The rationale for the Nutrition Spectrum Reversal Program guidelines can be stated briefly: 10% OF TOTAL CALORIES FROM FAT. The guideline of 10% of calories from fat provides sufficient nutrition, supports heart disease regression, and weight loss. It can be accomplished by eating a wide range of satisfying and pleasurable foods. Limiting dietary fat to 10% of total calories reduces consumption of all fats, which decreases blood cholesterol levels. It also typically reduces total calorie intake, because fat contains 9 calories per gram compared to 4 calories per gram in carbohydrates and protein. Reducing body weight reduces risk because obesity adds to the risk of heart disease. A nutrition program without added fats and high-fat foods (i.e. meat, fish, poultry, milk fat, oils, and high-fat plant foods) still contains about 10% of calories from fat. This comes from the naturally occurring fat in grain products and some vegetables and beans. Excessive food restrictions would be required for the nutrition program to go lower than 10% fat. The human body needs about 5% of calories from fat to obtain the essential fats for good health. Plus, there are no research studies that have evaluated or supported a fat intake below 10% fat. Diets with higher amounts of fat (20-30% fat) have not been associated with heart disease reversal. In addition, high-fat diets have been associated with an increased risk of some cancers, such as breast, colon, and prostate. All fats and oils contain three kinds of fat: saturated fat, monounsaturated fat, and polyunsaturated fat. These kinds of fats are present in different proportions in fats and oils, and they affect blood cholesterol levels differently. Typically, foods that are very high in saturated fat are solid at room temperature, and foods that are very low in saturated fat are liquid at room temperature.

Only answer by using the information in the context block below. Do not use external sources for your answer. How does 10% of calories from fat benefit us? [The rationale for the Nutrition Spectrum Reversal Program guidelines can be stated briefly: 10% OF TOTAL CALORIES FROM FAT. The guideline of 10% of calories from fat provides sufficient nutrition, supports heart disease regression, and weight loss. It can be accomplished by eating a wide range of satisfying and pleasurable foods. Limiting dietary fat to 10% of total calories reduces consumption of all fats, which decreases blood cholesterol levels. It also typically reduces total calorie intake, because fat contains 9 calories per gram compared to 4 calories per gram in carbohydrates and protein. Reducing body weight reduces risk because obesity adds to the risk of heart disease. A nutrition program without added fats and high-fat foods (i.e. meat, fish, poultry, milk fat, oils, and high-fat plant foods) still contains about 10% of calories from fat. This comes from the naturally occurring fat in grain products and some vegetables and beans. Excessive food restrictions would be required for the nutrition program to go lower than 10% fat. The human body needs about 5% of calories from fat to obtain the essential fats for good health. Plus, there are no research studies that have evaluated or supported a fat intake below 10% fat. Diets with higher amounts of fat (20-30% fat) have not been associated with heart disease reversal. In addition, high-fat diets have been associated with an increased risk of some cancers, such as breast, colon, and prostate. All fats and oils contain three kinds of fat: saturated fat, monounsaturated fat, and polyunsaturated fat. These kinds of fats are present in different proportions in fats and oils, and they affect blood cholesterol levels differently. Typically, foods that are very high in saturated fat are solid at room temperature, and foods that are very low in saturated fat are liquid at room temperature.]

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

My doctor said he can't use Nexobrid to remove an eschar on my arm because of my papaya allergy. Can you explain why this allergy prevents me from using this treatment, even though papayas aren't an ingredient? Explain in 50 words or less.

2.2 Recommended Dosage Recommended Dosage in Adults Apply a 3 mm thick layer (approximate thickness of a tongue depressor) of NEXOBRID to a burn wound area of up to 15% body surface area (BSA) in one application in adult patients. Remove NEXOBRID after 4 hours [see Dosage and Administration (2.5)]. A second application of NEXOBRID may be applied 24 hours following the first application to either the same area previously treated with NEXOBRID or to a new area in adult patients. Apply a second application if: • The wound area is more than 15% BSA, or • Multiple wound areas on different body surfaces require two treatments for logistical reasons such as body position, or • The first application’s eschar removal was not complete. For both applications, the total treated area must not exceed 20% BSA. Recommended Dosage in Pediatric Patients Pediatric Patients 6 Years of Age and Older Apply a 3 mm thick layer (approximate thickness of a tongue depressor) of NEXOBRID to a burn wound area of up to 15% BSA in one application in pediatric patients 6 years of age and older. Remove NEXOBRID after 4 hours [see Dosage and Administration (2.5)]. A second application of NEXOBRID is not recommended. Pediatric Patients Less Than 6 Years of Age Apply a 3 mm thick layer (approximate thickness of a tongue depressor) of NEXOBRID to a burn wound area of up to 10% BSA in one application in pediatric patients less than 6 years of age. Remove NEXOBRID after 4 hours [see Dosage and Administration (2.5)]. A second application of NEXOBRID is not recommended. 2.3 Preparation of Patient and Burn Wound Treatment Area Prepare the wound area as follows: 1. Thoroughly clean the wound to remove any charred tissue, blisters, and any topical products. 2. Apply a dressing soaked with an antibacterial solution to the treatment area for at least 2 hours. 3. Ensure the wound bed is clear of any remnants of topical agents (e.g., silver sulfadiazine, povidone iodine). 4 4. Apply an ointment skin protectant (e.g., petrolatum) 2 to 3 cm outside of the treatment area to create an ointment barrier. Avoid applying the protectant ointment to the treatment area itself, as this would impede direct contact of NEXOBRID with the eschar. 5. Protect any other open wounds (e.g., laceration, abraded skin, escharotomy incision) with skin protectant ointments or ointment gauze to prevent possible exposure to NEXOBRID. 2.4 Preparation and Application of NEXOBRID Gather the following sterile supplies prior to NEXOBRID preparation and application: • Instrument for mixing (e.g., spatula or tongue depressor) • Tongue depressor for NEXOBRID application • 0.9% Sodium Chloride Irrigation • Occlusive film dressing • Loose, thick fluffy dressing and bandage Preparation Prepare NEXOBRID at the patient’s bedside within 15 minutes of the intended application. Using aseptic technique, mix NEXOBRID lyophilized powder and gel vehicle as follows: 1. Pour the NEXOBRID lyophilized powder into the gel vehicle jar. 2. Thoroughly mix the NEXOBRID lyophilized powder and gel vehicle using a sterile instrument (e.g., tongue depressor or spatula) until the mixture is uniform. The mixed lyophilized powder and gel vehicle produce NEXOBRID in a final concentration of 8.8% w/w. DISCARD NEXOBRID IF NOT USED WITHIN 15 MINUTES OF PREPARATION, as the enzymatic activity of NEXOBRID decreases progressively following mixing. Application Apply NEXOBRID within 15 minutes of preparation as follows: 1. Moisten the treatment area by sprinkling sterile 0.9% Sodium Chloride Irrigation onto the burn wound. 2. Using a sterile tongue depressor, completely cover the moistened burn wound treatment area with the mixed NEXOBRID in a 3 mm thick layer (approximate thickness of a tongue depressor). Ensure NEXOBRID covers the entire target treatment area. 3. Cover the treated wound with a sterile occlusive film dressing. 4. Gently press the occlusive film dressing at the area of contact with the ointment barrier to ensure adherence between the occlusive film dressing and the ointment barrier and to achieve complete containment of NEXOBRID on the treatment area. There should be no visible air under the occlusive film dressing. 5. Cover the occlusive film dressing with a sterile loose, thick, fluffy dressing and secure with a sterile bandage. 6. Discard any unused portions of NEXOBRID. 5 2.5 Removal of NEXOBRID Remove NEXOBRID after 4 hours. Gather the following sterile supplies prior to NEXOBRID removal: • Blunt-edged instruments (e.g., tongue depressor) • Large dry gauze • Gauze soaked with 0.9% Sodium Chloride Irrigation • Dressing soaked with an antibacterial solution 1. Remove the occlusive film dressing using aseptic technique. 2. Remove the ointment barrier using a sterile blunt-edged instrument. 3. Remove the dissolved eschar from the wound by scraping it away with a sterile blunt-edged instrument. 4. Wipe the wound thoroughly with a large sterile dry gauze, then wipe with a sterile gauze that has been soaked with sterile 0.9% Sodium Chloride Irrigation. Rub the treated area until the appearance of a clean dermis or subcutaneous tissues with pinpoint bleeding. 5. To remove remnants of dissolved eschar, apply a dressing soaked with an antibacterial solution for at least 2 hours. 5 WARNINGS AND PRECAUTIONS 5.1 Hypersensitivity Reactions NEXOBRID-Treated Patients Serious hypersensitivity reactions, including anaphylaxis, have been reported with postmarketing use of NEXOBRID. If a hypersensitivity reaction occurs, remove NEXOBRID (if applicable) and initiate appropriate therapy. NEXOBRID is contraindicated in patients with a known hypersensitivity to anacaulase- bcdb, bromelain, pineapples or to any other component of NEXOBRID. NEXOBRID is also contraindicated in patients with known hypersensitivity to papayas or papain because of the risk of cross-sensitivity. Healthcare Providers Preparing and Applying NEXOBRID Healthcare personnel should take appropriate precautions to avoid exposure when preparing and handling NEXOBRID (e.g., gloves, surgical masks, other protective coverings, as needed). In the event of inadvertent skin exposure, rinse NEXOBRID off with water to reduce the likelihood of skin sensitization. 5.2 Coagulopathy A reduction of platelet aggregation and plasma fibrinogen levels and a moderate increase in partial thromboplastin and prothrombin times have been reported in the literature as possible effects following oral administration of bromelain, a component of NEXOBRID. In vitro and animal data suggest that bromelain can also promote fibrinolysis. Avoid use of NEXOBRID in patients with uncontrolled disorders of coagulation. Use NEXOBRID with caution in patients on anticoagulant therapy or other drugs affecting coagulation, and in patients with low platelet counts and increased risk of bleeding from other causes (e.g., peptic ulcers and sepsis). Monitor patients for possible signs of coagulation abnormalities and signs of bleeding.

"================ <TEXT PASSAGE> ======= 2.2 Recommended Dosage Recommended Dosage in Adults Apply a 3 mm thick layer (approximate thickness of a tongue depressor) of NEXOBRID to a burn wound area of up to 15% body surface area (BSA) in one application in adult patients. Remove NEXOBRID after 4 hours [see Dosage and Administration (2.5)]. A second application of NEXOBRID may be applied 24 hours following the first application to either the same area previously treated with NEXOBRID or to a new area in adult patients. Apply a second application if: • The wound area is more than 15% BSA, or • Multiple wound areas on different body surfaces require two treatments for logistical reasons such as body position, or • The first application’s eschar removal was not complete. For both applications, the total treated area must not exceed 20% BSA. Recommended Dosage in Pediatric Patients Pediatric Patients 6 Years of Age and Older Apply a 3 mm thick layer (approximate thickness of a tongue depressor) of NEXOBRID to a burn wound area of up to 15% BSA in one application in pediatric patients 6 years of age and older. Remove NEXOBRID after 4 hours [see Dosage and Administration (2.5)]. A second application of NEXOBRID is not recommended. Pediatric Patients Less Than 6 Years of Age Apply a 3 mm thick layer (approximate thickness of a tongue depressor) of NEXOBRID to a burn wound area of up to 10% BSA in one application in pediatric patients less than 6 years of age. Remove NEXOBRID after 4 hours [see Dosage and Administration (2.5)]. A second application of NEXOBRID is not recommended. 2.3 Preparation of Patient and Burn Wound Treatment Area Prepare the wound area as follows: 1. Thoroughly clean the wound to remove any charred tissue, blisters, and any topical products. 2. Apply a dressing soaked with an antibacterial solution to the treatment area for at least 2 hours. 3. Ensure the wound bed is clear of any remnants of topical agents (e.g., silver sulfadiazine, povidone iodine). 4 4. Apply an ointment skin protectant (e.g., petrolatum) 2 to 3 cm outside of the treatment area to create an ointment barrier. Avoid applying the protectant ointment to the treatment area itself, as this would impede direct contact of NEXOBRID with the eschar. 5. Protect any other open wounds (e.g., laceration, abraded skin, escharotomy incision) with skin protectant ointments or ointment gauze to prevent possible exposure to NEXOBRID. 2.4 Preparation and Application of NEXOBRID Gather the following sterile supplies prior to NEXOBRID preparation and application: • Instrument for mixing (e.g., spatula or tongue depressor) • Tongue depressor for NEXOBRID application • 0.9% Sodium Chloride Irrigation • Occlusive film dressing • Loose, thick fluffy dressing and bandage Preparation Prepare NEXOBRID at the patient’s bedside within 15 minutes of the intended application. Using aseptic technique, mix NEXOBRID lyophilized powder and gel vehicle as follows: 1. Pour the NEXOBRID lyophilized powder into the gel vehicle jar. 2. Thoroughly mix the NEXOBRID lyophilized powder and gel vehicle using a sterile instrument (e.g., tongue depressor or spatula) until the mixture is uniform. The mixed lyophilized powder and gel vehicle produce NEXOBRID in a final concentration of 8.8% w/w. DISCARD NEXOBRID IF NOT USED WITHIN 15 MINUTES OF PREPARATION, as the enzymatic activity of NEXOBRID decreases progressively following mixing. Application Apply NEXOBRID within 15 minutes of preparation as follows: 1. Moisten the treatment area by sprinkling sterile 0.9% Sodium Chloride Irrigation onto the burn wound. 2. Using a sterile tongue depressor, completely cover the moistened burn wound treatment area with the mixed NEXOBRID in a 3 mm thick layer (approximate thickness of a tongue depressor). Ensure NEXOBRID covers the entire target treatment area. 3. Cover the treated wound with a sterile occlusive film dressing. 4. Gently press the occlusive film dressing at the area of contact with the ointment barrier to ensure adherence between the occlusive film dressing and the ointment barrier and to achieve complete containment of NEXOBRID on the treatment area. There should be no visible air under the occlusive film dressing. 5. Cover the occlusive film dressing with a sterile loose, thick, fluffy dressing and secure with a sterile bandage. 6. Discard any unused portions of NEXOBRID. 5 2.5 Removal of NEXOBRID Remove NEXOBRID after 4 hours. Gather the following sterile supplies prior to NEXOBRID removal: • Blunt-edged instruments (e.g., tongue depressor) • Large dry gauze • Gauze soaked with 0.9% Sodium Chloride Irrigation • Dressing soaked with an antibacterial solution 1. Remove the occlusive film dressing using aseptic technique. 2. Remove the ointment barrier using a sterile blunt-edged instrument. 3. Remove the dissolved eschar from the wound by scraping it away with a sterile blunt-edged instrument. 4. Wipe the wound thoroughly with a large sterile dry gauze, then wipe with a sterile gauze that has been soaked with sterile 0.9% Sodium Chloride Irrigation. Rub the treated area until the appearance of a clean dermis or subcutaneous tissues with pinpoint bleeding. 5. To remove remnants of dissolved eschar, apply a dressing soaked with an antibacterial solution for at least 2 hours. 5 WARNINGS AND PRECAUTIONS 5.1 Hypersensitivity Reactions NEXOBRID-Treated Patients Serious hypersensitivity reactions, including anaphylaxis, have been reported with postmarketing use of NEXOBRID. If a hypersensitivity reaction occurs, remove NEXOBRID (if applicable) and initiate appropriate therapy. NEXOBRID is contraindicated in patients with a known hypersensitivity to anacaulase- bcdb, bromelain, pineapples or to any other component of NEXOBRID. NEXOBRID is also contraindicated in patients with known hypersensitivity to papayas or papain because of the risk of cross-sensitivity. Healthcare Providers Preparing and Applying NEXOBRID Healthcare personnel should take appropriate precautions to avoid exposure when preparing and handling NEXOBRID (e.g., gloves, surgical masks, other protective coverings, as needed). In the event of inadvertent skin exposure, rinse NEXOBRID off with water to reduce the likelihood of skin sensitization. 5.2 Coagulopathy A reduction of platelet aggregation and plasma fibrinogen levels and a moderate increase in partial thromboplastin and prothrombin times have been reported in the literature as possible effects following oral administration of bromelain, a component of NEXOBRID. In vitro and animal data suggest that bromelain can also promote fibrinolysis. Avoid use of NEXOBRID in patients with uncontrolled disorders of coagulation. Use NEXOBRID with caution in patients on anticoagulant therapy or other drugs affecting coagulation, and in patients with low platelet counts and increased risk of bleeding from other causes (e.g., peptic ulcers and sepsis). Monitor patients for possible signs of coagulation abnormalities and signs of bleeding. https://www.nexobrid-us.com/pdf/nexobrid-full-prescribing-information.pdf ================ <QUESTION> ======= My doctor said he can't use Nexobrid to remove an eschar on my arm because of my papaya allergy. Can you explain why this allergy prevents me from using this treatment, even though papayas aren't an ingredient? Explain in 50 words or less. ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

Draw your answer only from the provided text. Give your answer in bullet points. If you cannot fully answer the question with only the provided information, say “I’m sorry, I cannot answer that question due to a lack of context”.

Find and summarize how nanotechnology is being used to treat cancer and influenza, highlighting the different methods, each in three to five sentences.

What Is Nanotechnology? Most current applications of nanotechnology are evolutionary in nature, offering incremental improvements to existing products and generally modest economic and societal benefits. For example, nanotechnology has been used in display screens to improve picture quality, color, and brightness, provide wider viewing angles, reduce power consumption and extend product lives; in automobile bumpers, cargo beds, and step-assists to reduce weight, increase resistance to dents and scratches, and eliminate rust; in clothes to increase resistance to staining, wrinkling, and bacterial growth and to provide lighter-weight body armor; and in sporting goods, such as baseball bats and golf clubs, to improve performance.4 Nanotechnology plays a central role in some current applications with substantial economic value. For example, nanotechnology is a fundamental enabling technology in nearly all microchips and is fundamental to improvements in chip speed, size, weight, and energy use. Similarly, nanotechnology has substantially increased the storage density of non-volatile flash memory and computer hard drives. In the longer term, proponents of nanotechnology believe it may deliver revolutionary advances with profound economic and societal implications. The applications they discuss involve various degrees of speculation and varying time-frames. The examples below suggest a few of the areas where revolutionary advances may emerge, and for which early R&D efforts may provide insights into how such advances might be achieved. Detection and treatment of diseases. A wide range of nanotechnology applications are being developed to detect and treat diseases: *Cancer. Current nanotechnology disease detection efforts include the development of sensors that can identify biomarkers—such as altered genes,5 receptor proteins that are indicative of newly-developing blood vessels associated with early tumor development, 6 and prostate specific antigens (PSA)7—that may provide an early indicator of cancer.8 Some of these approaches are currently in clinical trials or have been approved for use by the Food and Drug Administration.9 One approach uses carbon nanotubes and nanowires to identify the unique molecular signals of cancer biomarkers. Another approach uses nanoscale cantilevers—resembling a row of diving boards—treated with molecules that bind only with cancer biomarkers. When these molecules bind, the additional weight alters the resonant frequency of the cantilevers indicating the presence and concentration of these biomarkers. Nanotechnology also holds promise for showing the presence, location, and/or contours of cancer, cardiovascular disease, or neurological disease. Current R&D efforts employ metallic, magnetic, and polymeric nanoparticles with strong imaging characteristics attached to an antibody or other agent that binds selectively with targeted cells. The imaging results can be used to guide surgical procedures and to monitor the effectiveness of non-surgical therapies in killing the disease or slowing its growth. Nanotechnology may also offer new cancer treatment approaches. For example, researchers have developed a chemically engineered adenovirus nanoparticle to deliver a molecule that stimulates the immune system10 and a nanoparticle that safely shuts down a key enzyme in cancer cells. 11 Another approach employs nanoshells with a core of silica and an outer metallic shell that can be engineered to concentrate at cancer lesion sites. Once at the sites, a harmless energy source (such as near-infrared light) can be used to cause the nanoshells to heat, killing the cancer cells they are attached to.12 Yet another treatment uses a dual cancer-killing approach. A gold nanoshell containing a chemotherapy drug attaches itself to a cancer cell. The shell is then heated using a near-infrared light source, killing the cancer cells in the vicinity while also rupturing the shell, releasing the chemotherapy drug inside the tumor. 13 Another approach would employ a nanoparticle to carry three or more different drugs and release them “in response to three distinct triggering mechanisms.”14 * Ebola. In February 2015, amid the Ebola outbreak in West Africa that began in 2014, the Food and Drug Administration provided emergency authorization of a nanotechnology-enabled antigen test for the detection of Ebola viruses. * Influenza. Medical researchers at the National Institutes for Health are using nanotechnology in the development of a molecule they intend to serve as a universal influenza vaccine that “stimulates the production of antibodies to fight against the ever-changing flu virus.” 15 * Diabetes. Diabetes is the target of a nano-enabled skin patch that painlessly delivers insulin using an array of microneedles, each of which contains more than 100 million vesicles that release insulin in response to the detection of high glucose levels.1

Find and summarize how nanotechnology is being used to treat cancer and influenza, highlighting the different methods, each in three to five sentences. Draw your answer only from the provided text. Give your answer in bullet points. If you cannot fully answer the question with only the provided information, say “I’m sorry, I cannot answer that question due to a lack of context”. Context: What Is Nanotechnology? Most current applications of nanotechnology are evolutionary in nature, offering incremental improvements to existing products and generally modest economic and societal benefits. For example, nanotechnology has been used in display screens to improve picture quality, color, and brightness, provide wider viewing angles, reduce power consumption and extend product lives; in automobile bumpers, cargo beds, and step-assists to reduce weight, increase resistance to dents and scratches, and eliminate rust; in clothes to increase resistance to staining, wrinkling, and bacterial growth and to provide lighter-weight body armor; and in sporting goods, such as baseball bats and golf clubs, to improve performance.4 Nanotechnology plays a central role in some current applications with substantial economic value. For example, nanotechnology is a fundamental enabling technology in nearly all microchips and is fundamental to improvements in chip speed, size, weight, and energy use. Similarly, nanotechnology has substantially increased the storage density of non-volatile flash memory and computer hard drives. In the longer term, proponents of nanotechnology believe it may deliver revolutionary advances with profound economic and societal implications. The applications they discuss involve various degrees of speculation and varying time-frames. The examples below suggest a few of the areas where revolutionary advances may emerge, and for which early R&D efforts may provide insights into how such advances might be achieved. Detection and treatment of diseases. A wide range of nanotechnology applications are being developed to detect and treat diseases: *Cancer. Current nanotechnology disease detection efforts include the development of sensors that can identify biomarkers—such as altered genes,5 receptor proteins that are indicative of newly-developing blood vessels associated with early tumor development, 6 and prostate specific antigens (PSA)7—that may provide an early indicator of cancer.8 Some of these approaches are currently in clinical trials or have been approved for use by the Food and Drug Administration.9 One approach uses carbon nanotubes and nanowires to identify the unique molecular signals of cancer biomarkers. Another approach uses nanoscale cantilevers—resembling a row of diving boards—treated with molecules that bind only with cancer biomarkers. When these molecules bind, the additional weight alters the resonant frequency of the cantilevers indicating the presence and concentration of these biomarkers. Nanotechnology also holds promise for showing the presence, location, and/or contours of cancer, cardiovascular disease, or neurological disease. Current R&D efforts employ metallic, magnetic, and polymeric nanoparticles with strong imaging characteristics attached to an antibody or other agent that binds selectively with targeted cells. The imaging results can be used to guide surgical procedures and to monitor the effectiveness of non-surgical therapies in killing the disease or slowing its growth. Nanotechnology may also offer new cancer treatment approaches. For example, researchers have developed a chemically engineered adenovirus nanoparticle to deliver a molecule that stimulates the immune system10 and a nanoparticle that safely shuts down a key enzyme in cancer cells. 11 Another approach employs nanoshells with a core of silica and an outer metallic shell that can be engineered to concentrate at cancer lesion sites. Once at the sites, a harmless energy source (such as near-infrared light) can be used to cause the nanoshells to heat, killing the cancer cells they are attached to.12 Yet another treatment uses a dual cancer-killing approach. A gold nanoshell containing a chemotherapy drug attaches itself to a cancer cell. The shell is then heated using a near-infrared light source, killing the cancer cells in the vicinity while also rupturing the shell, releasing the chemotherapy drug inside the tumor. 13 Another approach would employ a nanoparticle to carry three or more different drugs and release them “in response to three distinct triggering mechanisms.”14 * Ebola. In February 2015, amid the Ebola outbreak in West Africa that began in 2014, the Food and Drug Administration provided emergency authorization of a nanotechnology-enabled antigen test for the detection of Ebola viruses. * Influenza. Medical researchers at the National Institutes for Health are using nanotechnology in the development of a molecule they intend to serve as a universal influenza vaccine that “stimulates the production of antibodies to fight against the ever-changing flu virus.” 15 * Diabetes. Diabetes is the target of a nano-enabled skin patch that painlessly delivers insulin using an array of microneedles, each of which contains more than 100 million vesicles that release insulin in response to the detection of high glucose levels.1

Answer the question in the prompt fully, in the format requested by the prompt, using only information in the prompt and context block.

According to the following text, how should I process the snare during the mixing phase of audio production? Please provide your response in bullet points, outlining the main processes I should apply to the snare drum.

Mixing The Drums Now that you have recorded your best drum tracks, it’s time to process and mix the audio to really bring the drums to life. By mixing the raw drum stems you can focus and balance each individual part of the drum set. There are a wide range of valuable production tools and effects that are used to enhance sound recordings. I will provide an overview and instructions to some of the most important tools used in sound recording. When mixing audio you will need to use a high quality pair of headphones or a pair of studio reference monitors. This is by no means a list of ALL of the sound recording tools available, but these are the most essential tools to enable the drums sit well in a mix, whilst adding clarity and punch. The following will all be available as plugins within your digital audio workstation. Panning Panning is a tool that spreads a signal in a multi-channel sound field. It’s crucial for making up a complete stereo image and creates the impression of space within a mix. Panning is important for mixing drums, because it mimics the realistic effect of a drum set stage sound. Using panning creates a wide sounding drum set that can be heard from all sides. The best way to pan drums is to pan the separate parts of the drum set how they appear before you as if you are playing the drums. This is called “Drummers Perspective”. •Set the kick drum and snare drum panned dead centre. •Pan the overheads fully left and right respectively. •Don’t pan the toms as extreme as the overheads. I pan the high tom to the left, middle tom slightly right and floor tom to the right. EQ EQ is a corrective and creative tool used within sound recording and reproduction to correct frequency responses using linear filters. EQ is used to strengthen or weaken frequency bands to alter a signal’s sound. What this means is that EQ allows you to adjust frequencies of a signal to improve how it sounds. EQ is your best friend in recording. It is incredibly important for balancing sounds to create a mix that allows a listener to hear all the individual parts of a drum set with clarity. Use your ears when using EQ for your drums – they are the most valuable tools at your disposal. To get your drum sounds in the right ballpark, here are some engineer approved tips for drums: •Kick EQ – Adding a bump at 60Hz will give you some thick low-end. Add 3-5kHz for some ‘knock’ and some 10kHz for some click. Try cutting around 400-500Hz, this will stop your bass drum from sounding like a cardboard box. •Snare EQ – If you want your snare to hit you in the chest, add a bump at 150-200Hz. For more body to your snare add the frequencies around 500Hz. And for more attack, add 5kHz. •Toms EQ – For toms you want to reduce boxiness and increase thump and attack. Add 100Hz for some thump and 3-5kHz for clarity. Cut the mid frequencies for toms to remove the boxy sound, but be sure to leave some left so the toms don’t sound hollow. •Overheads EQ – With the overheads your aim is to increase presence in the upper mids and high frequencies whilst reducing overall boxiness in some of the lower frequencies. If the close-mics are all sounding great you can use a high-pass filter to cut out everything below 500Hz. Compression Compression is the process of lessening the dynamic range between the loudest and quietest parts of an audio signal. The goal of compression is to even out unwanted level variations of a signal. For drums, this means turning down louder hits to match softer hits in order to make the drum sounds more balanced overall. Compression is a fairly complex tool, and there is no ‘one-size fits all’ compression setting. But proper use of compression will help smoothen out the shape of the drums and keep dynamics under control. •Threshold – When compressing drums, we generally want the entire drum signal to be compressed. You’ll want to set your threshold low enough that any drum signal can trigger it. •Attack – Nearly all the drum’s punch is found in the initial milliseconds of the drum sound. This is the “attack”. A good starting point is to set an attack of 30ms and to adjust from there. •Release – The release determines how soon the compressor stops working after its initial activation. You ideally want to set the release to be fast enough so the compression switches off before the next hit. A good starting point is around 200ms. •Ratio – The ratio determines how much the output signal increases based on the input signal. Lower ratios will provide more punch, and I would try a ratio of 3:1 or 4:1 to start with. Reverb Reverb is another essential tool in modern recording. Reverb exists all around us, and within music production the aim is to emulate a natural acoustic environment for your sounds. Digital reverb plugins mimic the way a real acoustic space works. They are designed to simulate reflections, and the echoes and the decay of high versus low frequencies. Reverb is important for bringing life to drums, and to make them sound punchy, lifelike and full within a mix. Use your ears to achieve an optimal balance for reverb. Even if you want explosive drum sounds, don’t go overboard. The choice of reverb will need to fit with the emotional quality of a song and its mix. There are five main categories of reverb. Use your ears and experiment with the different types of reverb and see what works best with your drum sounds: •Room •Hall •Chamber •Spring •Plate

According to the following text, how should I process the snare during the mixing phase of audio production? Please provide your response in bullet points, outlining the main processes I should apply to the snare drum. Mixing The Drums Now that you have recorded your best drum tracks, it’s time to process and mix the audio to really bring the drums to life. By mixing the raw drum stems you can focus and balance each individual part of the drum set. There are a wide range of valuable production tools and effects that are used to enhance sound recordings. I will provide an overview and instructions to some of the most important tools used in sound recording. When mixing audio you will need to use a high quality pair of headphones or a pair of studio reference monitors. This is by no means a list of ALL of the sound recording tools available, but these are the most essential tools to enable the drums sit well in a mix, whilst adding clarity and punch. The following will all be available as plugins within your digital audio workstation. Panning Panning is a tool that spreads a signal in a multi-channel sound field. It’s crucial for making up a complete stereo image and creates the impression of space within a mix. Panning is important for mixing drums, because it mimics the realistic effect of a drum set stage sound. Using panning creates a wide sounding drum set that can be heard from all sides. The best way to pan drums is to pan the separate parts of the drum set how they appear before you as if you are playing the drums. This is called “Drummers Perspective”. •Set the kick drum and snare drum panned dead centre. •Pan the overheads fully left and right respectively. •Don’t pan the toms as extreme as the overheads. I pan the high tom to the left, middle tom slightly right and floor tom to the right. EQ EQ is a corrective and creative tool used within sound recording and reproduction to correct frequency responses using linear filters. EQ is used to strengthen or weaken frequency bands to alter a signal’s sound. What this means is that EQ allows you to adjust frequencies of a signal to improve how it sounds. EQ is your best friend in recording. It is incredibly important for balancing sounds to create a mix that allows a listener to hear all the individual parts of a drum set with clarity. Use your ears when using EQ for your drums – they are the most valuable tools at your disposal. To get your drum sounds in the right ballpark, here are some engineer approved tips for drums: •Kick EQ – Adding a bump at 60Hz will give you some thick low-end. Add 3-5kHz for some ‘knock’ and some 10kHz for some click. Try cutting around 400-500Hz, this will stop your bass drum from sounding like a cardboard box. •Snare EQ – If you want your snare to hit you in the chest, add a bump at 150-200Hz. For more body to your snare add the frequencies around 500Hz. And for more attack, add 5kHz. •Toms EQ – For toms you want to reduce boxiness and increase thump and attack. Add 100Hz for some thump and 3-5kHz for clarity. Cut the mid frequencies for toms to remove the boxy sound, but be sure to leave some left so the toms don’t sound hollow. •Overheads EQ – With the overheads your aim is to increase presence in the upper mids and high frequencies whilst reducing overall boxiness in some of the lower frequencies. If the close-mics are all sounding great you can use a high-pass filter to cut out everything below 500Hz. Compression Compression is the process of lessening the dynamic range between the loudest and quietest parts of an audio signal. The goal of compression is to even out unwanted level variations of a signal. For drums, this means turning down louder hits to match softer hits in order to make the drum sounds more balanced overall. Compression is a fairly complex tool, and there is no ‘one-size fits all’ compression setting. But proper use of compression will help smoothen out the shape of the drums and keep dynamics under control. •Threshold – When compressing drums, we generally want the entire drum signal to be compressed. You’ll want to set your threshold low enough that any drum signal can trigger it. •Attack – Nearly all the drum’s punch is found in the initial milliseconds of the drum sound. This is the “attack”. A good starting point is to set an attack of 30ms and to adjust from there. •Release – The release determines how soon the compressor stops working after its initial activation. You ideally want to set the release to be fast enough so the compression switches off before the next hit. A good starting point is around 200ms. •Ratio – The ratio determines how much the output signal increases based on the input signal. Lower ratios will provide more punch, and I would try a ratio of 3:1 or 4:1 to start with. Reverb Reverb is another essential tool in modern recording. Reverb exists all around us, and within music production the aim is to emulate a natural acoustic environment for your sounds. Digital reverb plugins mimic the way a real acoustic space works. They are designed to simulate reflections, and the echoes and the decay of high versus low frequencies. Reverb is important for bringing life to drums, and to make them sound punchy, lifelike and full within a mix. Use your ears to achieve an optimal balance for reverb. Even if you want explosive drum sounds, don’t go overboard. The choice of reverb will need to fit with the emotional quality of a song and its mix. There are five main categories of reverb. Use your ears and experiment with the different types of reverb and see what works best with your drum sounds: •Room •Hall •Chamber •Spring •Plate

[question] [user request] ===================== [text] [context document] ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

I'm writing a blog post, can you please make it at least 400 words? In what ways can the use of social media foster positive psychological outcomes, such as enhanced social support, improved self-expression, and access to mental health resources, particularly when considering the role of online communities, peer feedback, and the balance between virtual and real-world interactions?

What is healthy vs. potentially problematic social media use? Our study has brought preliminary evidence to answer this question. Using a nationally representative sample, we assessed the association of two dimensions of social media use—how much it’s routinely used and how emotionally connected users are to the platforms—with three health-related outcomes: social well-being, positive mental health, and self-rated health. We found that routine social media use—for example, using social media as part of everyday routine and responding to content that others share—is positively associated with all three health outcomes. Emotional connection to social media—for example, checking apps excessively out of fear of missing out, being disappointed about or feeling disconnected from friends when not logged into social media—is negatively associated with all three outcomes. In more general terms, these findings suggest that as long as we are mindful users, routine use may not in itself be a problem. Indeed, it could be beneficial. For those with unhealthy social media use, behavioral interventions may help. For example, programs that develop “effortful control” skills—the ability to self-regulate behavior—have been widely shown to be useful in dealing with problematic Internet and social media use. We’re used to hearing that social media use is harmful to mental health and well-being, particularly for young people. Did it surprise you to find that it can have positive effects? The findings go against what some might expect, which is intriguing. We know that having a strong social network is associated with positive mental health and well-being. Routine social media use may compensate for diminishing face-to-face social interactions in people’s busy lives. Social media may provide individuals with a platform that overcomes barriers of distance and time, allowing them to connect and reconnect with others and thereby expand and strengthen their in-person networks and interactions. Indeed, there is some empirical evidence supporting this. On the other hand, a growing body of research has demonstrated that social media use is negatively associated with mental health and well-being, particularly among young people—for example, it may contribute to increased risk of depression and anxiety symptoms. Our findings suggest that the ways that people are using social media may have more of an impact on their mental health and well-being than just the frequency and duration of their use. What disparities did you find in the ways that social media use benefits and harms certain populations? What concerns does this raise? My co-authors Rachel McCloud, Vish Viswanath, and I found that the benefits and harms associated with social media use varied across demographic, socioeconomic, and racial population sub-groups. Specifically, while the benefits were generally associated with younger age, better education, and being white, the harms were associated with older age, less education, and being a racial minority. Indeed, these findings are consistent with the body of work on communication inequalities and health disparities that our lab, the Viswanath lab, has documented over the past 15 or so years. We know that education, income, race, and ethnicity influence people’s access to, and ability to act on, health information from media, including the Internet. The concern is that social media may perpetuate those differences. — Amy Roeder

[question] I'm writing a blog post, can you please make it at least 400 words? In what ways can the use of social media foster positive psychological outcomes, such as enhanced social support, improved self-expression, and access to mental health resources, particularly when considering the role of online communities, peer feedback, and the balance between virtual and real-world interactions? ===================== [text] What is healthy vs. potentially problematic social media use? Our study has brought preliminary evidence to answer this question. Using a nationally representative sample, we assessed the association of two dimensions of social media use—how much it’s routinely used and how emotionally connected users are to the platforms—with three health-related outcomes: social well-being, positive mental health, and self-rated health. We found that routine social media use—for example, using social media as part of everyday routine and responding to content that others share—is positively associated with all three health outcomes. Emotional connection to social media—for example, checking apps excessively out of fear of missing out, being disappointed about or feeling disconnected from friends when not logged into social media—is negatively associated with all three outcomes. In more general terms, these findings suggest that as long as we are mindful users, routine use may not in itself be a problem. Indeed, it could be beneficial. For those with unhealthy social media use, behavioral interventions may help. For example, programs that develop “effortful control” skills—the ability to self-regulate behavior—have been widely shown to be useful in dealing with problematic Internet and social media use. We’re used to hearing that social media use is harmful to mental health and well-being, particularly for young people. Did it surprise you to find that it can have positive effects? The findings go against what some might expect, which is intriguing. We know that having a strong social network is associated with positive mental health and well-being. Routine social media use may compensate for diminishing face-to-face social interactions in people’s busy lives. Social media may provide individuals with a platform that overcomes barriers of distance and time, allowing them to connect and reconnect with others and thereby expand and strengthen their in-person networks and interactions. Indeed, there is some empirical evidence supporting this. On the other hand, a growing body of research has demonstrated that social media use is negatively associated with mental health and well-being, particularly among young people—for example, it may contribute to increased risk of depression and anxiety symptoms. Our findings suggest that the ways that people are using social media may have more of an impact on their mental health and well-being than just the frequency and duration of their use. What disparities did you find in the ways that social media use benefits and harms certain populations? What concerns does this raise? My co-authors Rachel McCloud, Vish Viswanath, and I found that the benefits and harms associated with social media use varied across demographic, socioeconomic, and racial population sub-groups. Specifically, while the benefits were generally associated with younger age, better education, and being white, the harms were associated with older age, less education, and being a racial minority. Indeed, these findings are consistent with the body of work on communication inequalities and health disparities that our lab, the Viswanath lab, has documented over the past 15 or so years. We know that education, income, race, and ethnicity influence people’s access to, and ability to act on, health information from media, including the Internet. The concern is that social media may perpetuate those differences. — Amy Roeder https://www.hsph.harvard.edu/news/features/social-media-positive-mental-health/ ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

Only refer to the document to answer the question. Only answer the question, do not add extra chatter or descriptions. Your answer should not be in bullet point format.

According to this document, can chats on a discussion board be cited for cyber bullying?

UNIVERSITY ANTI-HARASSMENT POLICY The University strictly prohibits harassment in any form, including sexual harassment, in accordance with all five pillars: love (Mathew 22:37, 39), integrity (Proverbs 11:3), discipleship (Matthew 28:19), wisdom (Proverbs 9:10) and unity (Ephesians 4:3). Harassment is serious misconduct. It subverts the mission of the University and threatens the careers, educational experience, and well-being of students, faculty and staff. In addition, harassment is contrary to the biblical principles upon which this University is founded and operates. No one has the authority to engage in this behavior, and the University does not tolerate harassment by, or directed toward, any student, employee or other persons on campus. To promote a pleasant work and educational environment free of harassment and to avoid the risk of damaging the reputation and resources of the University, all employees, students and other persons on campus are expected to refrain from any behavior that could be viewed as harassing, including immoral or unprofessional conduct. In addition, it is the duty of all employees of the University to prevent harassment by others. THREATS Proverbs 21:21 Whoever pursues righteousness and kindness will find life, righteousness and honor. 31 BULLYING/CYBER-BULLYING stopbullying.gov Bullying will not be tolerated, and students will be subject to discipline if found to have been a part of bullying in accordance with all five pillars: love (Mathew 22:37, 39), integrity (Proverbs 11:3), discipleship (Matthew 28:19), wisdom (Proverbs 9:10) and unity (Ephesians 4:3). Bullying is described as follows: Bullying is a form of aggressive behavior manifested by the use of force or coercion to affect others, particularly when the behavior is habitual and involves an imbalance of power. It can include verbal harassment, physical assault or coercion and may be directed repeatedly towards particular victims, perhaps on grounds of race, religion, gender, sexuality or ability. Bullying consists of three basic types of abuse: emotional, verbal and physical. Cyber-Bullying will not be tolerated and students will be subject to discipline if found to have been part of cyber-bullying. Cyber-bullying is described as follows: • actions that use information and communication technologies to support deliberate, repeated and hostile behavior by an individual or group that is intended to harm another or others • use of communication technologies for the intention of harming another person • use of internet service and mobile technologies such as web pages and discussion groups as well as instant messaging or text messaging with the intention of harming another person Sexual harassment is a unique form of harassment in several respects. Traditionally, a sexual harassment claim has been based on the premise that an individual with power over an employee’s employment or a student’s academic standing required sexual favors in return for job or academic rewards. Such a claim has usually involved conduct between a supervisor and subordinate or a faculty member and student. However, the legal definition of sexual harassment is much broader. For example, harassment may exist where the University tolerates an intimidating, hostile or offensive atmosphere, even if the conduct was initially welcomed or even initiated by the “victim.” Liability may also exist between co-workers at the same job level, between fellow students or between other persons of the same University status. Bullying/Cyber-Bullying Policy: fhu.edu/campuslife/studentservices HAZING In recent years, hazing has come under a lot of bad press nationally. Some states have passed legislation against the practice, including Tennessee. National fraternities are working hard to eliminate the practice. Freed-Hardeman students may seek to rationalize and say that nothing 32 FHU HAZING RESPONSE How is an incident reported? Students who feel that they have been the victim of a hazing incident can contact the Office of Student Life or the Office of Student Services directly or they may fill out a confidential hazing report form. The hazing report form may be picked up in the Office of Student Life or the Office of Student Services. Does the student who is hazed have to file a report? Anyone who witnesses hazing may report the incident in the same manner described above. What happens when a hazing incident is reported? • Once the Office of Student Life or the Office of Student Services is notified officially (see above) of a potential hazing incident, the Student Life and Student Services Offices will meet immediately to review the incident report. • The student reporting the hazing incident will be summoned to make a statement. • The students accused of hazing will be summoned to make a statement. • Other witnesses may be called for clarification. • If the hazing report proves to be valid after these meeting have occurred, all club sponsors will be notified of the allegation of hazing against their club and asked to meet with the Student Life and Student Services Office. • After club sponsors have been notified the social club officers will be called for a mandatory meeting with the Office of Student Life and the Dean of Students and sponsors to present the allegation of hazing (no student names are to be used). What is FHU’s response to hazing? In the event that hazing has occurred, students involved in the incident will forfeit their membership in their social club. They will also lose membership in the following groups if a member (UPC, Interface, Makin’ Music Director). The loss of membership will prevent them from participating in intramurals, fundraising opportunities for the club, banquets, club meetings or any other club related activities. Students will also be subject to discipline by the Office of Student Services. we do can be termed as hazing. There is a clear legal concern for any club that fails to follow the guidelines established by the University. The purpose of the guidelines is not to make the induction of new members harder for the clubs, but to protect the club and prospective members from irrational acts that may not be well thought out. Therefore, any club or individual who persists in engaging in activities that have danger of physical discomfort, pain or harm, or that subjects the student to humiliation and degradation should be aware that the club and/or the individual may become legally liable for such acts. Hazing Policy: fhu.edu/campuslife/studentservices TENNESSEE HAZING LAW Tennessee Code: 49-7-123. Hazing prohibited: stophazing.org/policy/state-laws/tennessee/ FHU HAZING RESPONSE How is an incident reported? Students who feel that they have been the victim of a hazing incident can contact the Office of Student Life or the Office of Student Services directly or they may fill out a confidential hazing report form. The hazing report form may be picked up in the Office of Student Life or the Office of Student Services. Does the student who is hazed have to file a report? Anyone who witnesses hazing may report the incident in the same manner described above. What happens when a hazing incident is reported? • Once the Office of Student Life or the Office of Student Services is notified officially (see above) of a potential hazing incident, the Student Life and Student Services Offices will meet immediately to review the incident report. • The student reporting the hazing incident will be summoned to make a statement. • The students accused of hazing will be summoned to make a statement. • Other witnesses may be called for clarification. • If the hazing report proves to be valid after these meeting have occurred, all club sponsors will be notified of the allegation of hazing against their club and asked to meet with the Student Life and Student Services Office. • After club sponsors have been notified the social club officers will be called for a mandatory meeting with the Office of Student Life and the Dean of Students and sponsors to present the allegation of hazing (no student names are to be used). What is FHU’s response to hazing? In the event that hazing has occurred, students involved in the incident will forfeit their membership in their social club. They will also lose membership in the following groups if a member (UPC, Interface, Makin’ Music Director). The loss of membership will prevent them from participating in intramurals, fundraising opportunities for the club, banquets, club meetings or any other club related activities. Students will also be subject to discipline by the Office of Student Services. we do can be termed as hazing. There is a clear legal concern for any club that fails to follow the guidelines established by the University. The purpose of the guidelines is not to make the induction of new members harder for the clubs, but to protect the club and prospective members from irrational acts that may not be well thought out. Therefore, any club or individual who persists in engaging in activities that have danger of physical discomfort, pain or harm, or that subjects the student to humiliation and degradation should be aware that the club and/or the individual may become legally liable for such acts. Hazing Policy: fhu.edu/campuslife/studentservices TENNESSEE HAZING LAW Tennessee Code: 49-7-123. Hazing prohibited: stophazing.org/policy/state-laws/tennessee/

<Article> ================== UNIVERSITY ANTI-HARASSMENT POLICY The University strictly prohibits harassment in any form, including sexual harassment, in accordance with all five pillars: love (Mathew 22:37, 39), integrity (Proverbs 11:3), discipleship (Matthew 28:19), wisdom (Proverbs 9:10) and unity (Ephesians 4:3). Harassment is serious misconduct. It subverts the mission of the University and threatens the careers, educational experience, and well-being of students, faculty and staff. In addition, harassment is contrary to the biblical principles upon which this University is founded and operates. No one has the authority to engage in this behavior, and the University does not tolerate harassment by, or directed toward, any student, employee or other persons on campus. To promote a pleasant work and educational environment free of harassment and to avoid the risk of damaging the reputation and resources of the University, all employees, students and other persons on campus are expected to refrain from any behavior that could be viewed as harassing, including immoral or unprofessional conduct. In addition, it is the duty of all employees of the University to prevent harassment by others. THREATS Proverbs 21:21 Whoever pursues righteousness and kindness will find life, righteousness and honor. 31 BULLYING/CYBER-BULLYING stopbullying.gov Bullying will not be tolerated, and students will be subject to discipline if found to have been a part of bullying in accordance with all five pillars: love (Mathew 22:37, 39), integrity (Proverbs 11:3), discipleship (Matthew 28:19), wisdom (Proverbs 9:10) and unity (Ephesians 4:3). Bullying is described as follows: Bullying is a form of aggressive behavior manifested by the use of force or coercion to affect others, particularly when the behavior is habitual and involves an imbalance of power. It can include verbal harassment, physical assault or coercion and may be directed repeatedly towards particular victims, perhaps on grounds of race, religion, gender, sexuality or ability. Bullying consists of three basic types of abuse: emotional, verbal and physical. Cyber-Bullying will not be tolerated and students will be subject to discipline if found to have been part of cyber-bullying. Cyber-bullying is described as follows: • actions that use information and communication technologies to support deliberate, repeated and hostile behavior by an individual or group that is intended to harm another or others • use of communication technologies for the intention of harming another person • use of internet service and mobile technologies such as web pages and discussion groups as well as instant messaging or text messaging with the intention of harming another person Sexual harassment is a unique form of harassment in several respects. Traditionally, a sexual harassment claim has been based on the premise that an individual with power over an employee’s employment or a student’s academic standing required sexual favors in return for job or academic rewards. Such a claim has usually involved conduct between a supervisor and subordinate or a faculty member and student. However, the legal definition of sexual harassment is much broader. For example, harassment may exist where the University tolerates an intimidating, hostile or offensive atmosphere, even if the conduct was initially welcomed or even initiated by the “victim.” Liability may also exist between co-workers at the same job level, between fellow students or between other persons of the same University status. Bullying/Cyber-Bullying Policy: fhu.edu/campuslife/studentservices HAZING In recent years, hazing has come under a lot of bad press nationally. Some states have passed legislation against the practice, including Tennessee. National fraternities are working hard to eliminate the practice. Freed-Hardeman students may seek to rationalize and say that nothing 32 FHU HAZING RESPONSE How is an incident reported? Students who feel that they have been the victim of a hazing incident can contact the Office of Student Life or the Office of Student Services directly or they may fill out a confidential hazing report form. The hazing report form may be picked up in the Office of Student Life or the Office of Student Services. Does the student who is hazed have to file a report? Anyone who witnesses hazing may report the incident in the same manner described above. What happens when a hazing incident is reported? • Once the Office of Student Life or the Office of Student Services is notified officially (see above) of a potential hazing incident, the Student Life and Student Services Offices will meet immediately to review the incident report. • The student reporting the hazing incident will be summoned to make a statement. • The students accused of hazing will be summoned to make a statement. • Other witnesses may be called for clarification. • If the hazing report proves to be valid after these meeting have occurred, all club sponsors will be notified of the allegation of hazing against their club and asked to meet with the Student Life and Student Services Office. • After club sponsors have been notified the social club officers will be called for a mandatory meeting with the Office of Student Life and the Dean of Students and sponsors to present the allegation of hazing (no student names are to be used). What is FHU’s response to hazing? In the event that hazing has occurred, students involved in the incident will forfeit their membership in their social club. They will also lose membership in the following groups if a member (UPC, Interface, Makin’ Music Director). The loss of membership will prevent them from participating in intramurals, fundraising opportunities for the club, banquets, club meetings or any other club related activities. Students will also be subject to discipline by the Office of Student Services. we do can be termed as hazing. There is a clear legal concern for any club that fails to follow the guidelines established by the University. The purpose of the guidelines is not to make the induction of new members harder for the clubs, but to protect the club and prospective members from irrational acts that may not be well thought out. Therefore, any club or individual who persists in engaging in activities that have danger of physical discomfort, pain or harm, or that subjects the student to humiliation and degradation should be aware that the club and/or the individual may become legally liable for such acts. Hazing Policy: fhu.edu/campuslife/studentservices TENNESSEE HAZING LAW Tennessee Code: 49-7-123. Hazing prohibited: stophazing.org/policy/state-laws/tennessee/ FHU HAZING RESPONSE How is an incident reported? Students who feel that they have been the victim of a hazing incident can contact the Office of Student Life or the Office of Student Services directly or they may fill out a confidential hazing report form. The hazing report form may be picked up in the Office of Student Life or the Office of Student Services. Does the student who is hazed have to file a report? Anyone who witnesses hazing may report the incident in the same manner described above. What happens when a hazing incident is reported? • Once the Office of Student Life or the Office of Student Services is notified officially (see above) of a potential hazing incident, the Student Life and Student Services Offices will meet immediately to review the incident report. • The student reporting the hazing incident will be summoned to make a statement. • The students accused of hazing will be summoned to make a statement. • Other witnesses may be called for clarification. • If the hazing report proves to be valid after these meeting have occurred, all club sponsors will be notified of the allegation of hazing against their club and asked to meet with the Student Life and Student Services Office. • After club sponsors have been notified the social club officers will be called for a mandatory meeting with the Office of Student Life and the Dean of Students and sponsors to present the allegation of hazing (no student names are to be used). What is FHU’s response to hazing? In the event that hazing has occurred, students involved in the incident will forfeit their membership in their social club. They will also lose membership in the following groups if a member (UPC, Interface, Makin’ Music Director). The loss of membership will prevent them from participating in intramurals, fundraising opportunities for the club, banquets, club meetings or any other club related activities. Students will also be subject to discipline by the Office of Student Services. we do can be termed as hazing. There is a clear legal concern for any club that fails to follow the guidelines established by the University. The purpose of the guidelines is not to make the induction of new members harder for the clubs, but to protect the club and prospective members from irrational acts that may not be well thought out. Therefore, any club or individual who persists in engaging in activities that have danger of physical discomfort, pain or harm, or that subjects the student to humiliation and degradation should be aware that the club and/or the individual may become legally liable for such acts. Hazing Policy: fhu.edu/campuslife/studentservices TENNESSEE HAZING LAW Tennessee Code: 49-7-123. Hazing prohibited: stophazing.org/policy/state-laws/tennessee/ <Instructions> ================== Only refer to the document to answer the question. Only answer the question, do not add extra chatter or descriptions. Your answer should not be in bullet point format. <Query> ================== According to this document, can chats on a discussion board be cited for cyber bullying?

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. [user request] [context document]

Farmer Old MacDonald operates a large and very efficient farm in Iowa. Is it likely that Old MacDonald's farm is also very profitable if he owns his land? Use the relevant financial measures in answering the question.

Financial Performance Measures for Iowa Farms Farmers who have a large investment in land, machinery, livestock, and equipment need to keep informed about the financial condition of their operations. Some useful measures of financial performance can be calculated from information found in most farm record books and accounting programs. These measures can help farmers assess the profitability, debt capacity, and financial risk currently faced by their businesses. The measures presented in this publication are based on guidelines of the Farm Financial Standards Council, ffsc.org/, and are used by most agricultural lenders and farm accountants. Types of Measures Five different areas of financial condition are measured. Liquidity refers to the degree to which debt obligations coming due can be paid from cash or assets that soon will be turned into cash. This is measured by the current ratio, the amount of working capital, and the amount of working capital per dollar of gross revenue. A more thorough analysis of liquidity can be made with a cash flow budget. FM1792, AgDM File C3-15: Twelve Steps to Cash Flow Budgeting, store. extension.iastate.edu/Product/1815.pdf, explains this tool in detail. Solvency refers to the degree to which all debts are secured and the relative mix of equity and debt capital used by the farm. The total debt-to-asset ratio is one of several ratios used to measure solvency, all of which are based on the same relationship of assets, liabilities, and net worth. Profitability refers to the difference between income and expenses. One important measure of profitability is net farm income. Annual rates of return on both equity capital and total assets also can be calculated and compared to interest rates for loans or rates of return from alternative investments. Financial efficiency ratios show what percent of gross farm revenue went to pay interest, operating expenses, and depreciation, and how much was left for net farm income. The asset turnover ratio measures how much gross income was generated for each dollar invested in land, livestock, equipment, and other assets. Repayment capacity measures show the degree to which cash generated from the farm and other sources will be sufficient to pay principal and interest payments as they come due. Using Performance Measures Values for the farm financial measures should be calculated for several years to observe trends and to avoid making judgments based on an unusual year. Typical historical values for most of these measures can be found in the tables at the end of this publication. They are based on data obtained from the Iowa Farm Business Association (IFBA). Values will vary according to the major enterprises carried out, farm size, location, and the type of land tenure. Other comparable data can be found in the annual publication FM1789, AgDM File C1-10: Iowa Farm Costs and Returns, store.extension.iastate.edu/ Product/1812.pdf. Liquidity Farms with good liquidity typically have current ratios of at least 3.0 or higher. Dairy farms or other farms that have continuous sales throughout the year can safely operate with a current ratio as low as 2.0, however. Conversely, operations that concentrate sales during several periods each year, such as cash grain farms, need to strive for a current ratio higher than 3.0, especially near the beginning of the year. The amount of working capital needed depends on the size of the operation. Records show that working capital measured at the beginning of the year is typically equal to about 50-70% of the farm’s annual gross revenue. For dairy farms, working capital can be as low as 30% of gross revenue, but cash grain farms may need as much as 50%. Solvency Total debt-to-asset ratios tend to be higher for larger farms and for farms that specialize in livestock feeding. Ratios of 10-30% are common among Iowa farms, although many operate with little or no debt. A high debt load does not make farms less efficient, but principal and interest payments eat into cash flow. High-efficiency farms are able to service a higher debt load safely. Two other ratios are commonly used to measure solvency. The equity-to-asset ratio shows how many dollars of net worth a farm has for every dollar of assets. It is equal to 100% minus the debt-to-asset ratio. Higher equity-to-asset ratios indicate a less risky financial situation. Some lenders prefer to use the debt-to-equity ratio to measure solvency. Higher ratios indicate more risk. Another useful measure is how much net worth the farm has for each crop acre farmed, especially for cash grain farms. The IFBA average is nearly $2,500. Profitability Net farm income from operations is what is left from all income received from the farm business in the past year, minus all the operating expenses used to generate this income. Note that operating expenses do not include the cost of financing the business, which is interest expense. Net farm income, or what is left after subtracting interest, is highly variable from year to year and is closely tied to the size and efficiency of the operation. It also depends on the amount of debt the farm is carrying. The rate of return on farm assets is quite variable, too, but average long-term rates of 6-10% have been common in Iowa. High-profit farms may average more than 12%, while low-profit farms often realize a return of only 2% or less. The average rate of return on farm equity measures how fast farm net worth is growing. Highly leveraged farms may earn little or no return on equity when interest rates are high. On the other hand, if the farm’s overall return on assets is higher than the cost of borrowed money, the return on equity may be quite high and net worth will grow rapidly. Operating profit margin is equal to the dollar return to capital divided by the value of farm production each year. Ratios have averaged about 6-10% in recent years, and 25-30% in the 2000s. High-profit farms have had ratios of 30% or more, while low-profit farms have had ratios of less than 10%. Farms that hire or rent assets such as labor, land, or machinery usually will have a lower operating profit margin because operating costs are higher. However, they will also generate a larger gross and net income. Farms with owned or crop share rented land will have a higher operating profit margin because they have lower operating expenses. Another common measure of profitability is Earnings Before Interest, Taxes, Depreciation, and Amortization, abbreviated as EBITDA. It shows how many dollars are available for debt repayment. Financial Efficiency Asset turnover ratios for typical farms are about 20-30%, but they can range from 10-20% for lowprofit farms and up to 30-50% for high-profit farms. The asset turnover ratio measures the efficient use of investment capital to generate revenue while the operating profit margin ratio measures the efficient use of operating capital. Because they are substitutes for each other (owned and rented land, for example), farms that are high in one measure may be low in the other. Farms with mostly rented land should have higher asset turnover ratios than farms with mostly owned land, generally around 50%. Rented farms also will have higher operating expense ratios because rent paid is included in operating expenses. Likewise, rented farms will tend to have lower depreciation and interest expense ratios than owned farms. Typically, about 60-70% of gross revenue goes for operating expenses, 5-10% goes for depreciation, and under 5% goes for interest. The average net farm income ratio for Iowa farms has been in the 5-15% range in recent years but used to be in the 20-30% range in the 2000s. High-profit farms have averaged 20% over the past decade, while lowprofit farms averaged less than 5%.

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. Farmer Old MacDonald operates a large and very efficient farm in Iowa. Is it likely that Old MacDonald's farm is also very profitable if he owns his land? Use the relevant financial measures in answering the question. Financial Performance Measures for Iowa Farms Farmers who have a large investment in land, machinery, livestock, and equipment need to keep informed about the financial condition of their operations. Some useful measures of financial performance can be calculated from information found in most farm record books and accounting programs. These measures can help farmers assess the profitability, debt capacity, and financial risk currently faced by their businesses. The measures presented in this publication are based on guidelines of the Farm Financial Standards Council, ffsc.org/, and are used by most agricultural lenders and farm accountants. Types of Measures Five different areas of financial condition are measured. Liquidity refers to the degree to which debt obligations coming due can be paid from cash or assets that soon will be turned into cash. This is measured by the current ratio, the amount of working capital, and the amount of working capital per dollar of gross revenue. A more thorough analysis of liquidity can be made with a cash flow budget. FM1792, AgDM File C3-15: Twelve Steps to Cash Flow Budgeting, store. extension.iastate.edu/Product/1815.pdf, explains this tool in detail. Solvency refers to the degree to which all debts are secured and the relative mix of equity and debt capital used by the farm. The total debt-to-asset ratio is one of several ratios used to measure solvency, all of which are based on the same relationship of assets, liabilities, and net worth. Profitability refers to the difference between income and expenses. One important measure of profitability is net farm income. Annual rates of return on both equity capital and total assets also can be calculated and compared to interest rates for loans or rates of return from alternative investments. Financial efficiency ratios show what percent of gross farm revenue went to pay interest, operating expenses, and depreciation, and how much was left for net farm income. The asset turnover ratio measures how much gross income was generated for each dollar invested in land, livestock, equipment, and other assets. Repayment capacity measures show the degree to which cash generated from the farm and other sources will be sufficient to pay principal and interest payments as they come due. Using Performance Measures Values for the farm financial measures should be calculated for several years to observe trends and to avoid making judgments based on an unusual year. Typical historical values for most of these measures can be found in the tables at the end of this publication. They are based on data obtained from the Iowa Farm Business Association (IFBA). Values will vary according to the major enterprises carried out, farm size, location, and the type of land tenure. Other comparable data can be found in the annual publication FM1789, AgDM File C1-10: Iowa Farm Costs and Returns, store.extension.iastate.edu/ Product/1812.pdf. Liquidity Farms with good liquidity typically have current ratios of at least 3.0 or higher. Dairy farms or other farms that have continuous sales throughout the year can safely operate with a current ratio as low as 2.0, however. Conversely, operations that concentrate sales during several periods each year, such as cash grain farms, need to strive for a current ratio higher than 3.0, especially near the beginning of the year. The amount of working capital needed depends on the size of the operation. Records show that working capital measured at the beginning of the year is typically equal to about 50-70% of the farm’s annual gross revenue. For dairy farms, working capital can be as low as 30% of gross revenue, but cash grain farms may need as much as 50%. Solvency Total debt-to-asset ratios tend to be higher for larger farms and for farms that specialize in livestock feeding. Ratios of 10-30% are common among Iowa farms, although many operate with little or no debt. A high debt load does not make farms less efficient, but principal and interest payments eat into cash flow. High-efficiency farms are able to service a higher debt load safely. Two other ratios are commonly used to measure solvency. The equity-to-asset ratio shows how many dollars of net worth a farm has for every dollar of assets. It is equal to 100% minus the debt-to-asset ratio. Higher equity-to-asset ratios indicate a less risky financial situation. Some lenders prefer to use the debt-to-equity ratio to measure solvency. Higher ratios indicate more risk. Another useful measure is how much net worth the farm has for each crop acre farmed, especially for cash grain farms. The IFBA average is nearly $2,500. Profitability Net farm income from operations is what is left from all income received from the farm business in the past year, minus all the operating expenses used to generate this income. Note that operating expenses do not include the cost of financing the business, which is interest expense. Net farm income, or what is left after subtracting interest, is highly variable from year to year and is closely tied to the size and efficiency of the operation. It also depends on the amount of debt the farm is carrying. The rate of return on farm assets is quite variable, too, but average long-term rates of 6-10% have been common in Iowa. High-profit farms may average more than 12%, while low-profit farms often realize a return of only 2% or less. The average rate of return on farm equity measures how fast farm net worth is growing. Highly leveraged farms may earn little or no return on equity when interest rates are high. On the other hand, if the farm’s overall return on assets is higher than the cost of borrowed money, the return on equity may be quite high and net worth will grow rapidly. Operating profit margin is equal to the dollar return to capital divided by the value of farm production each year. Ratios have averaged about 6-10% in recent years, and 25-30% in the 2000s. High-profit farms have had ratios of 30% or more, while low-profit farms have had ratios of less than 10%. Farms that hire or rent assets such as labor, land, or machinery usually will have a lower operating profit margin because operating costs are higher. However, they will also generate a larger gross and net income. Farms with owned or crop share rented land will have a higher operating profit margin because they have lower operating expenses. Another common measure of profitability is Earnings Before Interest, Taxes, Depreciation, and Amortization, abbreviated as EBITDA. It shows how many dollars are available for debt repayment. Financial Efficiency Asset turnover ratios for typical farms are about 20-30%, but they can range from 10-20% for lowprofit farms and up to 30-50% for high-profit farms. The asset turnover ratio measures the efficient use of investment capital to generate revenue while the operating profit margin ratio measures the efficient use of operating capital. Because they are substitutes for each other (owned and rented land, for example), farms that are high in one measure may be low in the other. Farms with mostly rented land should have higher asset turnover ratios than farms with mostly owned land, generally around 50%. Rented farms also will have higher operating expense ratios because rent paid is included in operating expenses. Likewise, rented farms will tend to have lower depreciation and interest expense ratios than owned farms. Typically, about 60-70% of gross revenue goes for operating expenses, 5-10% goes for depreciation, and under 5% goes for interest. The average net farm income ratio for Iowa farms has been in the 5-15% range in recent years but used to be in the 20-30% range in the 2000s. High-profit farms have averaged 20% over the past decade, while lowprofit farms averaged less than 5%. https://www.extension.iastate.edu/agdm/wholefarm/pdf/c3-55.pdf

Respond only based on the information provided in the prompt. You cannot use any external resources or prior knowledge to answer questions. Format your response using markdown where appropriate.

Create a list of the key information about where New Zealanders are currently spending money on gambling

A new Strategy to Prevent and Minimise Gambling Harm The Government has set a clear direction for mental health and addiction in New Zealand with a priority focus on: • increasing access to mental health and addiction support • growing the mental health and addiction workforce • strengthening the focus on the prevention of and early intervention • improving the effectiveness of mental health and addiction support. This direction, supported by available data, research and evidence of what works, has driven the development of this new draft Strategy to Prevent and Minimise Gambling Harm 2025/26 to 2027/28 (the Strategy). This document seeks your comment on the proposed direction and content of the draft Strategy. It provides the full proposed Strategy for public consultation, and includes: • the problem definition and needs assessment, which informs the proposed Strategy as required under the Gambling Act 2003 (the Act)1 • the strategic plan, including the strategic framework that sets out the goal, outcomes, priorities and actions for the Strategy • the service plan for the three years from 2025/26 to 2027/28, including the amount of funding required for the Ministry of Health | Manatū Hauora (the Ministry) and Health New Zealand | Te Whatu Ora (Health New Zealand) to deliver the gambling harm prevention and minimisation activities described in the Strategy • the problem gambling levy rates and weighting options per sector for the next three years. Problem definition: Gambling harm is wide-reaching and services are under pressure to respond to a changing gambling environment About one in five people in New Zealand experience harm as a result of their own or someone else’s gambling. Harm is not experienced evenly across our communities, and Māori, Pacific, Asian and young people are at greater risk. Department of Internal Affairs data show that in 2022/23, New Zealanders lost $2.76 billion gambling on the four regulated gambling sectors (Lotto New Zealand, TAB NZ, casinos and non-casino gambling machines or class 4 gambling). Most money spent on gambling comes from the relatively small number of people (around 11% of adults in 2020) who play electronic gaming machines (“pokies”). For the first time in 2022/23, New Zealanders lost over $1 billion on these machines, which are disproportionately located in higher deprivation areas. In addition, online gambling, which has the potential to cause significant harm, is expanding into New Zealand. The unregulated offshore online gambling market has grown significantly in recent years, with higher participation, higher spend, and greater harm being reported by New Zealanders. The Government has agreed to regulate online casinos through a licensing system, which will be designed to minimise harm, support tax collection, and provide consumer protections to New Zealanders. This regime is expected to come into effect in 2026. Whether an individual experiences harm from their own or someone else’s gambling, and how this harm is experienced at a whānau and community level, results from many factors. This includes the wider determinants of health and wellbeing and the nature of the gambling environment. The Gambling Act 2003 and associated regulations, as administered by the Dept of Internal Affairs, set the framework for legal gambling in New Zealand. The Act requires a needs assessment be undertaken to inform each iteration of the Strategy. The 2024 needs assessment highlights a changing environment and gambling 2 harm services under pressure . Key findings include: • Gambling activity has remained relatively constant in New Zealand, with data indicating that most adults engage in gambling at some stage in their lives. • While there has been a reduction in the number of pokies the distribution and availability of these machines remains disproportionately high in areas of high- deprivation. Expenditure on pokies has continued to increase. • Online gambling, particularly with unregulated providers based overseas, continues to grow. This is revealing inconsistencies with the current levy funding regime and service provisions. • The gambling harm minimisation sector is under pressure and has found the health reforms challenging. It seeks stronger government leadership and coordination.

Respond only based on the information provided in the prompt. You cannot use any external resources or prior knowledge to answer questions. Format your response using markdown where appropriate. Create a list of the key information about where New Zealanders are currently spending money on gambling A new Strategy to Prevent and Minimise Gambling Harm The Government has set a clear direction for mental health and addiction in New Zealand with a priority focus on: • increasing access to mental health and addiction support • growing the mental health and addiction workforce • strengthening the focus on the prevention of and early intervention • improving the effectiveness of mental health and addiction support. This direction, supported by available data, research and evidence of what works, has driven the development of this new draft Strategy to Prevent and Minimise Gambling Harm 2025/26 to 2027/28 (the Strategy). This document seeks your comment on the proposed direction and content of the draft Strategy. It provides the full proposed Strategy for public consultation, and includes: • the problem definition and needs assessment, which informs the proposed Strategy as required under the Gambling Act 2003 (the Act)1 • the strategic plan, including the strategic framework that sets out the goal, outcomes, priorities and actions for the Strategy • the service plan for the three years from 2025/26 to 2027/28, including the amount of funding required for the Ministry of Health | Manatū Hauora (the Ministry) and Health New Zealand | Te Whatu Ora (Health New Zealand) to deliver the gambling harm prevention and minimisation activities described in the Strategy • the problem gambling levy rates and weighting options per sector for the next three years. Problem definition: Gambling harm is wide-reaching and services are under pressure to respond to a changing gambling environment About one in five people in New Zealand experience harm as a result of their own or someone else’s gambling. Harm is not experienced evenly across our communities, and Māori, Pacific, Asian and young people are at greater risk. Department of Internal Affairs data show that in 2022/23, New Zealanders lost $2.76 billion gambling on the four regulated gambling sectors (Lotto New Zealand, TAB NZ, casinos and non-casino gambling machines or class 4 gambling). Most money spent on gambling comes from the relatively small number of people (around 11% of adults in 2020) who play electronic gaming machines (“pokies”). For the first time in 2022/23, New Zealanders lost over $1 billion on these machines, which are disproportionately located in higher deprivation areas. In addition, online gambling, which has the potential to cause significant harm, is expanding into New Zealand. The unregulated offshore online gambling market has grown significantly in recent years, with higher participation, higher spend, and greater harm being reported by New Zealanders. The Government has agreed to regulate online casinos through a licensing system, which will be designed to minimise harm, support tax collection, and provide consumer protections to New Zealanders. This regime is expected to come into effect in 2026. Whether an individual experiences harm from their own or someone else’s gambling, and how this harm is experienced at a whānau and community level, results from many factors. This includes the wider determinants of health and wellbeing and the nature of the gambling environment. The Gambling Act 2003 and associated regulations, as administered by the Dept of Internal Affairs, set the framework for legal gambling in New Zealand. The Act requires a needs assessment be undertaken to inform each iteration of the Strategy. The 2024 needs assessment highlights a changing environment and gambling 2 harm services under pressure . Key findings include: • Gambling activity has remained relatively constant in New Zealand, with data indicating that most adults engage in gambling at some stage in their lives. • While there has been a reduction in the number of pokies the distribution and availability of these machines remains disproportionately high in areas of high- deprivation. Expenditure on pokies has continued to increase. • Online gambling, particularly with unregulated providers based overseas, continues to grow. This is revealing inconsistencies with the current levy funding regime and service provisions. • The gambling harm minimisation sector is under pressure and has found the health reforms challenging. It seeks stronger government leadership and coordination.

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== [user request] {passage 0} ========== [context document]

My daughter is 11 months old, and I'm trying to decide what type of sippy cup to buy. Explain the different types of sippy cups. Then, tell me the best options, including pros and cons for each. My biggest concerns are durability, and being able to travel without spils. Don't include soft spout cups, she already has those and we want to try a different type.

Types of sippy cups You can choose from a few different types of sippy cups: Soft spout. These are the closest to a bottle, containing a nipple spout that still allows for sucking. They can be used to transition your baby to latched tops or open tops by allowing them to first get used to holding and gripping the cup and its handles. Hard spout. Hard-spout sippy cups encourage your child to transition from sucking to tilting and sipping. It’s often best to introduce it after they’ve mastered the soft spout. Straw. Straw sippy cups, as you may have guessed, employ a straw rather than a spout. Some feel that a straw is preferable for speech development over a spout. They can also help your child get used to drinking from a straw and using a cup. No spout or flat lid. These sippy cups are spoutless with a flat top (sometimes referred to as 360 cups). They allow for water to flow from all edges of the cup opening to resemble the action of a real cup while still using a lid. They typically lack any no-spill valves, and that’s a good thing. Sippy cups can be a good option for bridging the gap between a bottle and an open cup. They prevent spilling while still giving your child more independence. Your child may not take to the first option you present to them, but keep trying! The key to success is choosing cups that are appropriate for your child’s age and stage of development. 6 to 12 months old As your baby continues transitioning to cup use, the options get more varied and include: spout cups spoutless cups straw cups The variety you choose is up to you and your baby. Since the cup may be too heavy for your little one to hold with just one hand, cups with handles are helpful at this stage. And even if a cup has a larger capacity, resist filling it to the top so your baby can maneuver it. Continue to supervise your baby using a cup until they are at least 1 year old. Best soft-spout cup NUK Learner Cup Price: $$ Pros: Options for both 5- and 10-ounce cup sizes; removable handles for when your little one is ready to transition to more of a cup; includes a plastic lid to help prevent spills when traveling Cons: Spout can be slow and require hard sucking The NUK Learner Cup comes in 5- or 10-ounce sizes and features removable handles for your growing baby. It’s appropriate for babies 6 months old or over, and it’s made from BPA-free plastic. The cup has a soft silicone spout that has a special vent to prevent baby from swallowing too much air. Parents share that this cup is easy to handwash and that the travel piece that comes with the cup prevents leaks when it’s tossed in a diaper bag. Others say their babies had trouble getting milk out of the cup, even when sucking very hard. Shop now at Amazon Best straw sippy cup ZoLi BOT Straw Sippy Cup Price: $$$ Pros: Weighted straw makes it easier to get the last of the liquid out; dishwasher safe Cons: One of the more expensive cup options; not the thickest of straws and can be bitten through The ZoLi BOT Straw Sippy Cup is suitable for babies 9 months old or over. It features a weighted straw, so your little one can get liquid no matter how the cup is oriented. The plastic is BPA-free and can be hand washed or run through your dishwasher for cleaning. You can also purchase replacement straws. Parents who like this cup say that it’s simple to assemble and that the handles are easy for babies to hold. On the downside, it can also be difficult to screw the top on correctly, making it prone to leaks. The cup can also leak if the straw becomes damaged from biting or normal wear and tear. Shop now at Amazon Best spoutless sippy cup Munchkin Miracle 360 Trainer Cup Price: $ Pros: Budget-friendly option; dishwasher safe; comes in a variety of sizes and colors Cons: The top’s design can allow for big spills; the design can be hard for some children to figure out how to drink from The Munchkin Miracle 360 Trainer Cup is an affordable option. The unique spoutless construction allows babies 6 months old and over to simulate drinking from an open cup without the spills. It’s also streamlined with only three main pieces and top-rack dishwasher safe. Some parents complain that, while the cup is spill-proof, their smart babies figured out they can pour the liquid by simply pressing on the center of the top. Shop now on Amazon 12 to 18 months old Toddlers have mastered more dexterity with their hands, so many may graduate from handles at this age. Cups with a curved or hourglass shape can help little hands grip and hold. Best for toddlers First Essentials by NUK Fun Grips Hard Spout Sippy Cup Price: $ Pros: Made in the United States; dishwasher safe; hourglass shape is easier to hold without needing handles Cons: The cup’s wide base won’t fit in standard cup holders The economical First Essentials by NUK Fun Grips Sippy Cup (previously sold as Gerber Graduates) is made in the United States from BPA-free plastic. The two-part design is simple and the hourglass shape is easy for toddlers ages 12 months and older to grab. This cup features a 100 percent spill-proof, leak-proof, break-proof guarantee. You may wash this sippy cup either by hand or in the dishwasher. On the negative side, some reviewers say the cup’s base is too wide and that it doesn’t fit easily into standard cup holders or diaper bag pockets. Shop now at Amazon Best straw sippy cup Nuby No-Spill Cup with Flex Straw Price: $ Pros: Budget-friendly option; contoured design offers secure grip without handles; thicker straw Cons:10-ounce size might be larger than some children can easily handle; valve in the straw requires a “squeeze and suck” action Nuby’s No-Spill Flex Straw Cup is a popular choice for toddlers who prefer straws to spouts. The silicone straw has a built-in valve to prevent spills and leaks, and it’s sturdy enough to stand up to occasional biting. While this 10-ounce cup doesn’t have handles, it does feature a contoured design for little hands to grip and is made from BPA-free plastic. The straw does require a “squeeze and suck” action to get liquid through the valve, and some tots find this difficult to master. That said, many parents share that the protection the valve provides is worth the extra effort. Shop now on Amazon

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== My daughter is 11 months old, and I'm trying to decide what type of sippy cup to buy. Explain the different types of sippy cups. Then, tell me the best options, including pros and cons for each. My biggest concerns are durability, and being able to travel without spils. Don't include soft spout cups, she already has those and we want to try a different type. {passage 0} ========== Types of sippy cups You can choose from a few different types of sippy cups: Soft spout. These are the closest to a bottle, containing a nipple spout that still allows for sucking. They can be used to transition your baby to latched tops or open tops by allowing them to first get used to holding and gripping the cup and its handles. Hard spout. Hard-spout sippy cups encourage your child to transition from sucking to tilting and sipping. It’s often best to introduce it after they’ve mastered the soft spout. Straw. Straw sippy cups, as you may have guessed, employ a straw rather than a spout. Some feel that a straw is preferable for speech development over a spout. They can also help your child get used to drinking from a straw and using a cup. No spout or flat lid. These sippy cups are spoutless with a flat top (sometimes referred to as 360 cups). They allow for water to flow from all edges of the cup opening to resemble the action of a real cup while still using a lid. They typically lack any no-spill valves, and that’s a good thing. Sippy cups can be a good option for bridging the gap between a bottle and an open cup. They prevent spilling while still giving your child more independence. Your child may not take to the first option you present to them, but keep trying! The key to success is choosing cups that are appropriate for your child’s age and stage of development. 6 to 12 months old As your baby continues transitioning to cup use, the options get more varied and include: spout cups spoutless cups straw cups The variety you choose is up to you and your baby. Since the cup may be too heavy for your little one to hold with just one hand, cups with handles are helpful at this stage. And even if a cup has a larger capacity, resist filling it to the top so your baby can maneuver it. Continue to supervise your baby using a cup until they are at least 1 year old. Best soft-spout cup NUK Learner Cup Price: $$ Pros: Options for both 5- and 10-ounce cup sizes; removable handles for when your little one is ready to transition to more of a cup; includes a plastic lid to help prevent spills when traveling Cons: Spout can be slow and require hard sucking The NUK Learner Cup comes in 5- or 10-ounce sizes and features removable handles for your growing baby. It’s appropriate for babies 6 months old or over, and it’s made from BPA-free plastic. The cup has a soft silicone spout that has a special vent to prevent baby from swallowing too much air. Parents share that this cup is easy to handwash and that the travel piece that comes with the cup prevents leaks when it’s tossed in a diaper bag. Others say their babies had trouble getting milk out of the cup, even when sucking very hard. Shop now at Amazon Best straw sippy cup ZoLi BOT Straw Sippy Cup Price: $$$ Pros: Weighted straw makes it easier to get the last of the liquid out; dishwasher safe Cons: One of the more expensive cup options; not the thickest of straws and can be bitten through The ZoLi BOT Straw Sippy Cup is suitable for babies 9 months old or over. It features a weighted straw, so your little one can get liquid no matter how the cup is oriented. The plastic is BPA-free and can be hand washed or run through your dishwasher for cleaning. You can also purchase replacement straws. Parents who like this cup say that it’s simple to assemble and that the handles are easy for babies to hold. On the downside, it can also be difficult to screw the top on correctly, making it prone to leaks. The cup can also leak if the straw becomes damaged from biting or normal wear and tear. Shop now at Amazon Best spoutless sippy cup Munchkin Miracle 360 Trainer Cup Price: $ Pros: Budget-friendly option; dishwasher safe; comes in a variety of sizes and colors Cons: The top’s design can allow for big spills; the design can be hard for some children to figure out how to drink from The Munchkin Miracle 360 Trainer Cup is an affordable option. The unique spoutless construction allows babies 6 months old and over to simulate drinking from an open cup without the spills. It’s also streamlined with only three main pieces and top-rack dishwasher safe. Some parents complain that, while the cup is spill-proof, their smart babies figured out they can pour the liquid by simply pressing on the center of the top. Shop now on Amazon 12 to 18 months old Toddlers have mastered more dexterity with their hands, so many may graduate from handles at this age. Cups with a curved or hourglass shape can help little hands grip and hold. Best for toddlers First Essentials by NUK Fun Grips Hard Spout Sippy Cup Price: $ Pros: Made in the United States; dishwasher safe; hourglass shape is easier to hold without needing handles Cons: The cup’s wide base won’t fit in standard cup holders The economical First Essentials by NUK Fun Grips Sippy Cup (previously sold as Gerber Graduates) is made in the United States from BPA-free plastic. The two-part design is simple and the hourglass shape is easy for toddlers ages 12 months and older to grab. This cup features a 100 percent spill-proof, leak-proof, break-proof guarantee. You may wash this sippy cup either by hand or in the dishwasher. On the negative side, some reviewers say the cup’s base is too wide and that it doesn’t fit easily into standard cup holders or diaper bag pockets. Shop now at Amazon Best straw sippy cup Nuby No-Spill Cup with Flex Straw Price: $ Pros: Budget-friendly option; contoured design offers secure grip without handles; thicker straw Cons:10-ounce size might be larger than some children can easily handle; valve in the straw requires a “squeeze and suck” action Nuby’s No-Spill Flex Straw Cup is a popular choice for toddlers who prefer straws to spouts. The silicone straw has a built-in valve to prevent spills and leaks, and it’s sturdy enough to stand up to occasional biting. While this 10-ounce cup doesn’t have handles, it does feature a contoured design for little hands to grip and is made from BPA-free plastic. The straw does require a “squeeze and suck” action to get liquid through the valve, and some tots find this difficult to master. That said, many parents share that the protection the valve provides is worth the extra effort. Shop now on Amazon https://www.healthline.com/health/parenting/best-sippy-cups#6-to-12-months

Use only the provided text to answer the question. Don't use numbered or bulleted lists. Instead, your response should be in paragraph form.

What is the market breakdown of 100+ seat commercial aircraft as reported in this article?

Industry Analysis Overview of the Industry The Aerospace and Defense industry has seen accelerated growth in the past couple of years. The rising demand in today’s environment for military equipment has added to this huge success. The rapid growth rate of nations like China and India has contributed to the rising demand for passenger aircrafts for travel. The increase in the world’s growth rate also helps benefit the Boeing Co. The Aerospace industry has recorded annual sales growth of 8.2% for the five years through 2005, and 10.4% for the past three years. Net income rose by 12.4% annually over the five year period, and 20.8% annually over the past three years. For the five year period ending in September of 2006, the S&P 500 Aerospace and Defense industry index had outperformed the S&P 500 by 71%. The result for the three year period was the same. The industry returned 87%, while the S&P 500 returned 42%. The Aerospace industry has been revitalized and has been booming due to a strong wave of global economic growth and the emergence of countries such as China and India as economic powers. The rise of wealth in the Middle East has also added to the booming success. This massive growth throughout the world has spurred huge gains in business travel, as well as in air cargo traffic. Boeing saw its orders from China jump to 143 commercial jets in 2005, and 114 for the nine months through September 2006. India ordered 98 planes from Boeing in 2005. Middle East orders also rose to 44 in 2005. Also, rising income levels, in some countries, have added to the company’s success, due to the greater mobility amongst people in such regions. The defense market has experienced massive growth since the terrorist attacks of 2001, as a result of the U.S. government funding the wars in Afghanistan and Iraq. Since the wars have begun, the U.S. government and the governments of other nations have splurged and put a lot of money into defense. Safety and national security has become a huge profit gainer for the Aerospace and Defense industry. Also, it is believed that the United States and its allies are locked in a struggle for control that will continue in years to come. This will increase the need for expenditures in the future for military equipment. One issue that has risen is that while defense is benefiting from the current environment in which we live, air travel is not, as a result of the attacks in 2001. This could very well decrease commercial air travel. Commercial Aircraft Based on total unit orders of 100-plus seat jetliners in 2005 (latest available), Boeing and Airbus control about 49% and 51%, respectively, of the global commercial jetliner market. Demand for jetliners is driven primarily by growth in the global 100-plus seat commercial aircraft fleet. Independent research firm Avitas Inc., projects that the global fleet of 100- plus seat jetliners will grow at a 4.3% compound annual rate over the next 20 years, due to its projection of a 5.9% compound annual growth in passenger traffic over the same period. We believe that, given the economic development of many former third-world countries in Asia, Eastern Europe, the Middle East, etc., fleet growth should continue at an above- average rate for the foreseeable future. One of the things that helps Boeing in this segment of their business is their Six Sigma methodology. Six Sigma aids manufacturers in their quest to design, build and deliver near- perfect products by reducing defects and variation, and improving quality, resulting in substantial cost savings. Six Sigma refers to manufacturing processes that produce a level of quality at 3.4 defects per million opportunities. Most U.S. companies operate at a rate of 66,807 defects per million, or "3.0 Sigma." Boeings’ current main plant location is in Seattle, Washington. Although Boeing mostly outsourcers many of its business products and flies them in, they still remain to have a presence in the States. Military Segment Examining Boeings’ military weapons segment, demand for IDS's equipment and systems is primarily driven by growth in the procurement and Research and Development sectors of the U.S. defense budget, which accounts for about 40% of global military weapons spending. Based on U.S. Department of Defense statistics, from fiscal year 1995 through fiscal year 2005, the procurement and Research and Development sectors of the total U.S. defense budget grew at 8.0% and 5.1% average annual rates, respectively. It is believed that two factors contributed to this strong growth: cuts to the defense budget that occurred during the Clinton presidential administration, which resulted in the need for increased defense spending in later years, and the wars in Iraq and Afghanistan. We expect defense budgets to continue to grow, but at much slower rates, going forward. This will be especially evident as the U.S. decreases its presence in Iraq in the near future. Outlook on Aerospace and Defense The fundamental outlook for the Aerospace & Defense industry is positive. We believe many companies in the Aerospace & Defense area will record solid earnings per share gains in the near term, due to our nation's current military action, plus the high growth in nations such as China and India. The outlook for the defense segment is strongly positive. We believe that the ongoing military actions in Iraq and Afghanistan, potential threats from Islamic terrorists, North Korea and Iran, as well as a military buildup in China, will make it necessary to continue funding the defense segment. At the same time, we believe that a number of defense contractors have become more efficient, have shown strong cash flow, and have engaged in significant share repurchases and dividend increases. However, there is also the potential likelihood of the risk of declining defense spending following the recent Democratic win of Congress. The outlook for the commercial aircraft segment is especially positive. In looking at the 100- plus-seat commercial aircraft-making sector, we expect that the global airline industry, the largest customer of passenger jets, will continue to have strong passenger traffic growth, which the International Air Transport Associations projects at over 4.5% in 2007. Following the 9/11 attacks, global airlines were hit by large declines in air traffic. However, passenger traffic has picked up significantly in recent years, boosted by global economic growth and attractive fares. Boeing currently has a higher price-to-earnings ratio than typically desired for a value investor. However, this high ratio is due to Boeings’ very high growth potential. Boeing currently receives the most contracts in their industry, whether it is in the commercial aircraft segment of their business, or the military segment of their business. Furthermore, Boeing has surpassed its earnings estimates for the most recent quarter (ending March 31, 2007) by a whopping 27%. Orders are pouring into the company on an almost daily basis. This is for a hundred million dollar product! The price for a 787 Dreamliner ranges from $138 million to $188 million per plane. Customers include: Air New Zealand (787-9, eight), Blue Panorama (four), First Choice Airways (eight), Continental (20), Japan Airlines (30 + 20 options), Vietnam Airlines (four), Chinese Airlines (60), Icelandair (four), Ethiopian Airlines (ten), Korean Airlines (ten + ten options), Northwest Airlines (18 + 50 options), Air Canada (14 + 46 options), Air India (27), Royal Air Maroc (four), LOT (seven), China Southern (ten), ILFC (20), Qantas (45 + 20 options), Kenya Airways (six), Singapore Airlines (787-9, 20 + 20 options), Air Pacific (787-9, five + three options), Monarch Airlines (787-8, six + four options). DJ US Aerospace & Defense Index vs. Boeing: 5 Year Trend DJ US Aerospa ce & Defense Index VS Boeing, Lockheed Martin, and Northrop Grumman: 5 Year Trend 

Use only the provided text to answer the question. Don't use numbered or bulleted lists. Instead, your response should be in paragraph form. What is the market breakdown of 100+ seat commercial aircraft as reported in this article? Industry Analysis Overview of the Industry The Aerospace and Defense industry has seen accelerated growth in the past couple of years. The rising demand in today’s environment for military equipment has added to this huge success. The rapid growth rate of nations like China and India has contributed to the rising demand for passenger aircrafts for travel. The increase in the world’s growth rate also helps benefit the Boeing Co. The Aerospace industry has recorded annual sales growth of 8.2% for the five years through 2005, and 10.4% for the past three years. Net income rose by 12.4% annually over the five year period, and 20.8% annually over the past three years. For the five year period ending in September of 2006, the S&P 500 Aerospace and Defense industry index had outperformed the S&P 500 by 71%. The result for the three year period was the same. The industry returned 87%, while the S&P 500 returned 42%. The Aerospace industry has been revitalized and has been booming due to a strong wave of global economic growth and the emergence of countries such as China and India as economic powers. The rise of wealth in the Middle East has also added to the booming success. This massive growth throughout the world has spurred huge gains in business travel, as well as in air cargo traffic. Boeing saw its orders from China jump to 143 commercial jets in 2005, and 114 for the nine months through September 2006. India ordered 98 planes from Boeing in 2005. Middle East orders also rose to 44 in 2005. Also, rising income levels, in some countries, have added to the company’s success, due to the greater mobility amongst people in such regions. The defense market has experienced massive growth since the terrorist attacks of 2001, as a result of the U.S. government funding the wars in Afghanistan and Iraq. Since the wars have begun, the U.S. government and the governments of other nations have splurged and put a lot of money into defense. Safety and national security has become a huge profit gainer for the Aerospace and Defense industry. Also, it is believed that the United States and its allies are locked in a struggle for control that will continue in years to come. This will increase the need for expenditures in the future for military equipment. One issue that has risen is that while defense is benefiting from the current environment in which we live, air travel is not, as a result of the attacks in 2001. This could very well decrease commercial air travel. Commercial Aircraft Based on total unit orders of 100-plus seat jetliners in 2005 (latest available), Boeing and Airbus control about 49% and 51%, respectively, of the global commercial jetliner market. Demand for jetliners is driven primarily by growth in the global 100-plus seat commercial aircraft fleet. Independent research firm Avitas Inc., projects that the global fleet of 100- plus seat jetliners will grow at a 4.3% compound annual rate over the next 20 years, due to its projection of a 5.9% compound annual growth in passenger traffic over the same period. We believe that, given the economic development of many former third-world countries in Asia, Eastern Europe, the Middle East, etc., fleet growth should continue at an above- average rate for the foreseeable future. One of the things that helps Boeing in this segment of their business is their Six Sigma methodology. Six Sigma aids manufacturers in their quest to design, build and deliver near- perfect products by reducing defects and variation, and improving quality, resulting in substantial cost savings. Six Sigma refers to manufacturing processes that produce a level of quality at 3.4 defects per million opportunities. Most U.S. companies operate at a rate of 66,807 defects per million, or "3.0 Sigma." Boeings’ current main plant location is in Seattle, Washington. Although Boeing mostly outsourcers many of its business products and flies them in, they still remain to have a presence in the States. Military Segment Examining Boeings’ military weapons segment, demand for IDS's equipment and systems is primarily driven by growth in the procurement and Research and Development sectors of the U.S. defense budget, which accounts for about 40% of global military weapons spending. Based on U.S. Department of Defense statistics, from fiscal year 1995 through fiscal year 2005, the procurement and Research and Development sectors of the total U.S. defense budget grew at 8.0% and 5.1% average annual rates, respectively. It is believed that two factors contributed to this strong growth: cuts to the defense budget that occurred during the Clinton presidential administration, which resulted in the need for increased defense spending in later years, and the wars in Iraq and Afghanistan. We expect defense budgets to continue to grow, but at much slower rates, going forward. This will be especially evident as the U.S. decreases its presence in Iraq in the near future. Outlook on Aerospace and Defense The fundamental outlook for the Aerospace & Defense industry is positive. We believe many companies in the Aerospace & Defense area will record solid earnings per share gains in the near term, due to our nation's current military action, plus the high growth in nations such as China and India. The outlook for the defense segment is strongly positive. We believe that the ongoing military actions in Iraq and Afghanistan, potential threats from Islamic terrorists, North Korea and Iran, as well as a military buildup in China, will make it necessary to continue funding the defense segment. At the same time, we believe that a number of defense contractors have become more efficient, have shown strong cash flow, and have engaged in significant share repurchases and dividend increases. However, there is also the potential likelihood of the risk of declining defense spending following the recent Democratic win of Congress. The outlook for the commercial aircraft segment is especially positive. In looking at the 100- plus-seat commercial aircraft-making sector, we expect that the global airline industry, the largest customer of passenger jets, will continue to have strong passenger traffic growth, which the International Air Transport Associations projects at over 4.5% in 2007. Following the 9/11 attacks, global airlines were hit by large declines in air traffic. However, passenger traffic has picked up significantly in recent years, boosted by global economic growth and attractive fares. Boeing currently has a higher price-to-earnings ratio than typically desired for a value investor. However, this high ratio is due to Boeings’ very high growth potential. Boeing currently receives the most contracts in their industry, whether it is in the commercial aircraft segment of their business, or the military segment of their business. Furthermore, Boeing has surpassed its earnings estimates for the most recent quarter (ending March 31, 2007) by a whopping 27%. Orders are pouring into the company on an almost daily basis. This is for a hundred million dollar product! The price for a 787 Dreamliner ranges from $138 million to $188 million per plane. Customers include: Air New Zealand (787-9, eight), Blue Panorama (four), First Choice Airways (eight), Continental (20), Japan Airlines (30 + 20 options), Vietnam Airlines (four), Chinese Airlines (60), Icelandair (four), Ethiopian Airlines (ten), Korean Airlines (ten + ten options), Northwest Airlines (18 + 50 options), Air Canada (14 + 46 options), Air India (27), Royal Air Maroc (four), LOT (seven), China Southern (ten), ILFC (20), Qantas (45 + 20 options), Kenya Airways (six), Singapore Airlines (787-9, 20 + 20 options), Air Pacific (787-9, five + three options), Monarch Airlines (787-8, six + four options). DJ US Aerospace & Defense Index vs. Boeing: 5 Year Trend DJ US Aerospa ce & Defense Index VS Boeing, Lockheed Martin, and Northrop Grumman: 5 Year Trend 

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== [user request] {passage 0} ========== [context document]

Im trying to do research on fine ceramics from Japan, but why am I getting so much info about electronics? Why would they use clay in advanced technology when we have metal? Is it just because it's cheap?

Advanced ceramics are an integral part ofmodern technology. Most of these productsplay crucial functions ‘behind the scenes’ in anumber of applications in everyday life. Theyusually offer superior performance that cannotbe replicated easily by other materials (Riedel,2013). Advanced ceramics today play a keyrole in technologies such as energy and theenvironment, transport, the life sciences, andcommunication and information technology(Greil, 2002). The terminology for defining this type ofceramics differs from continent to continent(Kulik, 1999). In the Japanese literature it’snormally referred to as ‘fine’ ceramics, and inAmerican literature as ‘advanced’ or‘technical’ ceramics (Kulik, 1999). In theEuropean context the term ‘technical’ ceramicsis more frequently used (Kulik, 1999). Afurther classification, depending on the use, iscommon in the UK, where the term ‘technicalceramics’ is further subdivided into functionalceramics to refer to electronic applications andstructural ceramics to refer mostly tomechanically loaded components (Kulik,1999).Advanced ceramics possess uniqueproperties that cannot be obtained inconventional materials, such as highrefractoriness and hardness, low density, lowcoefficient of thermal expansion (CTE), andhigher working temperatures (can maintaingood mechanical properties at hightemperatures). Moreover, there are reportswhich have proven that the cost of producingceramic materials is lower compared to metallicmaterials, and raw material reserves forceramics are abundant (Kulik, 1999).Resources for the production of metals andtheir alloys are dwindling, and thecontinuously increasing demand forengineering products requires alternativematerials to be identified. Over the past fewdecades advanced ceramics have made inroadsin a number of critical applications in everydaylife. It is noteworthy to mention here thatwithout sparkplugs made of alumina (Al2O3)ceramic, vehicle technology would not be soadvanced, moreover metallurgy would not beso reliable without refractories (Kulik, 1999).These are the hard facts behind commonplaceproducts that we normally take for granted.Although ceramics play a crucial role in anumber of technologies due to their uniquecombination of properties, it must be notedthat as structural materials they still face stiffcompetition from cheap metals, alloys, andcomposites (Kulik, 1999). Thus the majorbarriers to the broad application of advancedceramic materials include the lack ofspecifications and databases, high scale-upcosts, and lack of repair methods (Freitag andRicherson, 1998). However, over the years alot of progress has been made to alleviatethese deficiencies through new materialdiscoveries, improvements in properties, andimproved design methods (Freitag andRicherson, 1998). The term ’advanced ceramics’ was coined in the 1970s todesignate a new category of engineering materials that wereto drive new technologies into the 21st century (Charreyron,2013). Since then there has been phenomenal growth in thetechnological advancement of these materials. A report fromResearch and Markets projected the advanced ceramicsmarket to reach US$10.4 billion by 2021, growing at acompounded annual growth rate (CAGR) of 6.5%(Charreyron, 2013). This growth is attributed to theincreasing use of advanced ceramic materials as alternativesto metals and plastics, with key drivers being the medical,electronics, and transport industries. The analog-to-digitalshift in consumer products has seen massive growth inelectronic device content in a number of applications. Forinstance, liquid crystal displays (LCDs) replaced cathode raytubes and DVDs replaced VHS tapes and players. Thisbasically points to significant growth for ceramic capacitorsand other ceramic electronic components. The largest share ofthe market has always been in the electronics industry,representing approximately more than 70% of production,but positive and negative shifts are expected according tochanges in demand (Kulik, 1999). Advanced ceramics are produced from three main classesof materials, namely oxides, carbides, and nitrides, with asmall quantity accounting for mixed compounds (WorldAdvanced Ceramics, 1966). Japan has been at the forefrontfor a number of years, owing partly to the high degree ofcooperation between companies in investigations anddevelopments (dynamic partnership) and high exportvolumes (Kulik, 1999; Charreyron, 2013). The major volumeof production in Japan is represented by electronic ceramics,accounting for up to 80% of total production (Kulik, 1999).The second largest producer of advanced ceramics is NorthAmerica, where the industry has been driven by massivegovernment financing of research and design development.The main difference between the two approaches is thatNorth America plays a leading role in technology andJapanese companies lead in the applications of advancedceramics. Such approaches have been successfully adopted bya number of European countries that now contributeextensively to the advanced technology market. One suchcountry is Germany, which is home to a number ofcompanies that compete for advanced technology projectsthroughout the world. One of the most significant advances in ceramics research inthe past two decades has been improvements in fracturetoughness, especially for structural ceramics. On acomparative basis, glass has a fracture toughness of 1MPa.m0.5 and most conventional ceramics range from about2–3 MPa.m0.5; steel is about 40 MPa.m0.5 (Freitag andRicherson, 1998). Some advanced ceramics such astransformation toughened zirconia-ZrO2have toughness ofabout 15 MPa.m0.5, which is higher than that of tungsten-carbide cobalt (WC-Co) cermet and cast iron (Freitag andRicherson, 1998). This has dramatically improved theresistance to contact stress and handling damage, thusimparting high reliability and durability comparable to that ofmetals and WC-Co cermets (Freitag and Richerson, 1998).Prior to 1970, most ceramic materials had strengths wellbelow 345 MPa, but nowadays advanced ceramics such assilicon nitride (Si3N4) and toughened zirconia (ZrO2) arecommercially available with strengths above 690 MPa(Freitag and Richerson, 1998).The detailed mechanism of transformation tougheningcan be found elsewhere (Matizamhuka, 2016). However,what is important to note is that fracture toughness values 3–6 times higher than monolithic ZrO2ceramics have beenachieved by transformation toughening. Several othertechniques have been developed over the years to improvefracture toughness of advanced ceramics, such as the use ofmore ductile binders and reinforcement with fibres, whiskers,or second-phase particles. Details of such techniques can befound in the open literature (Matizamhuka, 2016).On the other hand, the high cost of ceramic componentshas been attributed to the lack of large-scale production withminimum losses in the production line. Ceramic-basedmaterials often compete against engineering materials withlower upfront costs, and it is often difficult to convincecustomers to pay a premium in exchange for performancebenefits (Charreyron, 2013). Design, process technology, andmachining technology still need to develop significantly toachieve cost-effective levels of high-volume production,consequently reducing the cost of components. A strategyused by previous market pioneers is that of forward pricingand continued government subsidies in anticipation of futuremarket growth. The recent phenomenal growth in theadvanced ceramics industry could easily translate into agreater market share in future, but this can happen only ifmajor breakthroughs are achieved in fundamental andapplied research (Liang and Dutta, 2001).

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== Im trying to do research on fine ceramics from Japan, but why am I getting so much info about electronics? Why would they use clay in advanced technology when we have metal? Is it just because it's cheap? {passage 0} ========== Advanced ceramics are an integral part ofmodern technology. Most of these productsplay crucial functions ‘behind the scenes’ in anumber of applications in everyday life. Theyusually offer superior performance that cannotbe replicated easily by other materials (Riedel,2013). Advanced ceramics today play a keyrole in technologies such as energy and theenvironment, transport, the life sciences, andcommunication and information technology(Greil, 2002). The terminology for defining this type ofceramics differs from continent to continent(Kulik, 1999). In the Japanese literature it’snormally referred to as ‘fine’ ceramics, and inAmerican literature as ‘advanced’ or‘technical’ ceramics (Kulik, 1999). In theEuropean context the term ‘technical’ ceramicsis more frequently used (Kulik, 1999). Afurther classification, depending on the use, iscommon in the UK, where the term ‘technicalceramics’ is further subdivided into functionalceramics to refer to electronic applications andstructural ceramics to refer mostly tomechanically loaded components (Kulik,1999).Advanced ceramics possess uniqueproperties that cannot be obtained inconventional materials, such as highrefractoriness and hardness, low density, lowcoefficient of thermal expansion (CTE), andhigher working temperatures (can maintaingood mechanical properties at hightemperatures). Moreover, there are reportswhich have proven that the cost of producingceramic materials is lower compared to metallicmaterials, and raw material reserves forceramics are abundant (Kulik, 1999).Resources for the production of metals andtheir alloys are dwindling, and thecontinuously increasing demand forengineering products requires alternativematerials to be identified. Over the past fewdecades advanced ceramics have made inroadsin a number of critical applications in everydaylife. It is noteworthy to mention here thatwithout sparkplugs made of alumina (Al2O3)ceramic, vehicle technology would not be soadvanced, moreover metallurgy would not beso reliable without refractories (Kulik, 1999).These are the hard facts behind commonplaceproducts that we normally take for granted.Although ceramics play a crucial role in anumber of technologies due to their uniquecombination of properties, it must be notedthat as structural materials they still face stiffcompetition from cheap metals, alloys, andcomposites (Kulik, 1999). Thus the majorbarriers to the broad application of advancedceramic materials include the lack ofspecifications and databases, high scale-upcosts, and lack of repair methods (Freitag andRicherson, 1998). However, over the years alot of progress has been made to alleviatethese deficiencies through new materialdiscoveries, improvements in properties, andimproved design methods (Freitag andRicherson, 1998). The term ’advanced ceramics’ was coined in the 1970s todesignate a new category of engineering materials that wereto drive new technologies into the 21st century (Charreyron,2013). Since then there has been phenomenal growth in thetechnological advancement of these materials. A report fromResearch and Markets projected the advanced ceramicsmarket to reach US$10.4 billion by 2021, growing at acompounded annual growth rate (CAGR) of 6.5%(Charreyron, 2013). This growth is attributed to theincreasing use of advanced ceramic materials as alternativesto metals and plastics, with key drivers being the medical,electronics, and transport industries. The analog-to-digitalshift in consumer products has seen massive growth inelectronic device content in a number of applications. Forinstance, liquid crystal displays (LCDs) replaced cathode raytubes and DVDs replaced VHS tapes and players. Thisbasically points to significant growth for ceramic capacitorsand other ceramic electronic components. The largest share ofthe market has always been in the electronics industry,representing approximately more than 70% of production,but positive and negative shifts are expected according tochanges in demand (Kulik, 1999). Advanced ceramics are produced from three main classesof materials, namely oxides, carbides, and nitrides, with asmall quantity accounting for mixed compounds (WorldAdvanced Ceramics, 1966). Japan has been at the forefrontfor a number of years, owing partly to the high degree ofcooperation between companies in investigations anddevelopments (dynamic partnership) and high exportvolumes (Kulik, 1999; Charreyron, 2013). The major volumeof production in Japan is represented by electronic ceramics,accounting for up to 80% of total production (Kulik, 1999).The second largest producer of advanced ceramics is NorthAmerica, where the industry has been driven by massivegovernment financing of research and design development.The main difference between the two approaches is thatNorth America plays a leading role in technology andJapanese companies lead in the applications of advancedceramics. Such approaches have been successfully adopted bya number of European countries that now contributeextensively to the advanced technology market. One suchcountry is Germany, which is home to a number ofcompanies that compete for advanced technology projectsthroughout the world. One of the most significant advances in ceramics research inthe past two decades has been improvements in fracturetoughness, especially for structural ceramics. On acomparative basis, glass has a fracture toughness of 1MPa.m0.5 and most conventional ceramics range from about2–3 MPa.m0.5; steel is about 40 MPa.m0.5 (Freitag andRicherson, 1998). Some advanced ceramics such astransformation toughened zirconia-ZrO2have toughness ofabout 15 MPa.m0.5, which is higher than that of tungsten-carbide cobalt (WC-Co) cermet and cast iron (Freitag andRicherson, 1998). This has dramatically improved theresistance to contact stress and handling damage, thusimparting high reliability and durability comparable to that ofmetals and WC-Co cermets (Freitag and Richerson, 1998).Prior to 1970, most ceramic materials had strengths wellbelow 345 MPa, but nowadays advanced ceramics such assilicon nitride (Si3N4) and toughened zirconia (ZrO2) arecommercially available with strengths above 690 MPa(Freitag and Richerson, 1998).The detailed mechanism of transformation tougheningcan be found elsewhere (Matizamhuka, 2016). However,what is important to note is that fracture toughness values 3–6 times higher than monolithic ZrO2ceramics have beenachieved by transformation toughening. Several othertechniques have been developed over the years to improvefracture toughness of advanced ceramics, such as the use ofmore ductile binders and reinforcement with fibres, whiskers,or second-phase particles. Details of such techniques can befound in the open literature (Matizamhuka, 2016).On the other hand, the high cost of ceramic componentshas been attributed to the lack of large-scale production withminimum losses in the production line. Ceramic-basedmaterials often compete against engineering materials withlower upfront costs, and it is often difficult to convincecustomers to pay a premium in exchange for performancebenefits (Charreyron, 2013). Design, process technology, andmachining technology still need to develop significantly toachieve cost-effective levels of high-volume production,consequently reducing the cost of components. A strategyused by previous market pioneers is that of forward pricingand continued government subsidies in anticipation of futuremarket growth. The recent phenomenal growth in theadvanced ceramics industry could easily translate into agreater market share in future, but this can happen only ifmajor breakthroughs are achieved in fundamental andapplied research (Liang and Dutta, 2001). https://www.researchgate.net/publication/327770223_Advanced_ceramics_-_The_new_frontier_in_modern-day_technology_Part_I

Only use information from the text provided. Do not use any external resources or prior knowledge to answer questions.

List the things people thought would happen in the future according to this article from 1995.

The Internet? Bah! Hype alert: Why cyberspace isn't, and will never be, nirvana By NEWSWEEK From the magazine issue dated Feb 27, 1995 After two decades online, I'm perplexed. It's not that I haven't had a gas of a good time on the Internet. I've met great people and even caught a hacker or two. But today, I'm uneasy about this most trendy and oversold community. Visionaries see a future of telecommuting workers, interactive libraries and multimedia classrooms. They speak of electronic town meetings and virtual communities. Commerce and business will shift from offices and malls to networks and modems. And the freedom of digital networks will make government more democratic. Baloney. Do our computer pundits lack all common sense? The truth in no online database will replace your daily newspaper, no CD-ROM can take the place of a competent teacher and no computer network will change the way government works. Consider today's online world. The Usenet, a worldwide bulletin board, allows anyone to post messages across the nation. Your word gets out, leapfrogging editors and publishers. Every voice can be heard cheaply and instantly. The result? Every voice is heard. The cacophany more closely resembles citizens band radio, complete with handles, harrasment, and anonymous threats. When most everyone shouts, few listen. How about electronic publishing? Try reading a book on disc. At best, it's an unpleasant chore: the myopic glow of a clunky computer replaces the friendly pages of a book. And you can't tote that laptop to the beach. Yet Nicholas Negroponte, director of the MIT Media Lab, predicts that we'll soon buy books and newspapers straight over the Intenet. Uh, sure. What the Internet hucksters won't tell you is tht the Internet is one big ocean of unedited data, without any pretense of completeness. Lacking editors, reviewers or critics, the Internet has become a wasteland of unfiltered data. You don't know what to ignore and what's worth reading. Logged onto the World Wide Web, I hunt for the date of the Battle of Trafalgar. Hundreds of files show up, and it takes 15 minutes to unravel them—one's a biography written by an eighth grader, the second is a computer game that doesn't work and the third is an image of a London monument. None answers my question, and my search is periodically interrupted by messages like, "Too many connectios, try again later." Won't the Internet be useful in governing? Internet addicts clamor for government reports. But when Andy Spano ran for county executive in Westchester County, N.Y., he put every press release and position paper onto a bulletin board. In that affluent county, with plenty of computer companies, how many voters logged in? Fewer than 30. Not a good omen. Point and click: Then there are those pushing computers into schools. We're told that multimedia will make schoolwork easy and fun. Students will happily learn from animated characters while taught by expertly tailored software.Who needs teachers when you've got computer-aided education? Bah. These expensive toys are difficult to use in classrooms and require extensive teacher training. Sure, kids love videogames—but think of your own experience: can you recall even one educational filmstrip of decades past? I'll bet you remember the two or three great teachers who made a difference in your life. Then there's cyberbusiness. We're promised instant catalog shopping—just point and click for great deals. We'll order airline tickets over the network, make restaurant reservations and negotiate sales contracts. Stores will become obselete. So how come my local mall does more business in an afternoon than the entire Internet handles in a month? Even if there were a trustworthy way to send money over the Internet—which there isn't—the network is missing a most essential ingredient of capitalism: salespeople. What's missing from this electronic wonderland? Human contact. Discount the fawning techno-burble about virtual communities. Computers and networks isolate us from one another. A network chat line is a limp substitute for meeting friends over coffee. No interactive multimedia display comes close to the excitement of a live concert. And who'd prefer cybersex to the real thing? While the Internet beckons brightly, seductively flashing an icon of knowledge-as-power, this nonplace lures us to surrender our time on earth. A poor substitute it is, this virtual reality where frustration is legion and where—in the holy names of Education and Progress—important aspects of human interactions are relentlessly devalued.

Context Block: The Internet? Bah! Hype alert: Why cyberspace isn't, and will never be, nirvana By NEWSWEEK From the magazine issue dated Feb 27, 1995 After two decades online, I'm perplexed. It's not that I haven't had a gas of a good time on the Internet. I've met great people and even caught a hacker or two. But today, I'm uneasy about this most trendy and oversold community. Visionaries see a future of telecommuting workers, interactive libraries and multimedia classrooms. They speak of electronic town meetings and virtual communities. Commerce and business will shift from offices and malls to networks and modems. And the freedom of digital networks will make government more democratic. Baloney. Do our computer pundits lack all common sense? The truth in no online database will replace your daily newspaper, no CD-ROM can take the place of a competent teacher and no computer network will change the way government works. Consider today's online world. The Usenet, a worldwide bulletin board, allows anyone to post messages across the nation. Your word gets out, leapfrogging editors and publishers. Every voice can be heard cheaply and instantly. The result? Every voice is heard. The cacophany more closely resembles citizens band radio, complete with handles, harrasment, and anonymous threats. When most everyone shouts, few listen. How about electronic publishing? Try reading a book on disc. At best, it's an unpleasant chore: the myopic glow of a clunky computer replaces the friendly pages of a book. And you can't tote that laptop to the beach. Yet Nicholas Negroponte, director of the MIT Media Lab, predicts that we'll soon buy books and newspapers straight over the Intenet. Uh, sure. What the Internet hucksters won't tell you is tht the Internet is one big ocean of unedited data, without any pretense of completeness. Lacking editors, reviewers or critics, the Internet has become a wasteland of unfiltered data. You don't know what to ignore and what's worth reading. Logged onto the World Wide Web, I hunt for the date of the Battle of Trafalgar. Hundreds of files show up, and it takes 15 minutes to unravel them—one's a biography written by an eighth grader, the second is a computer game that doesn't work and the third is an image of a London monument. None answers my question, and my search is periodically interrupted by messages like, "Too many connectios, try again later." Won't the Internet be useful in governing? Internet addicts clamor for government reports. But when Andy Spano ran for county executive in Westchester County, N.Y., he put every press release and position paper onto a bulletin board. In that affluent county, with plenty of computer companies, how many voters logged in? Fewer than 30. Not a good omen. Point and click: Then there are those pushing computers into schools. We're told that multimedia will make schoolwork easy and fun. Students will happily learn from animated characters while taught by expertly tailored software.Who needs teachers when you've got computer-aided education? Bah. These expensive toys are difficult to use in classrooms and require extensive teacher training. Sure, kids love videogames—but think of your own experience: can you recall even one educational filmstrip of decades past? I'll bet you remember the two or three great teachers who made a difference in your life. Then there's cyberbusiness. We're promised instant catalog shopping—just point and click for great deals. We'll order airline tickets over the network, make restaurant reservations and negotiate sales contracts. Stores will become obselete. So how come my local mall does more business in an afternoon than the entire Internet handles in a month? Even if there were a trustworthy way to send money over the Internet—which there isn't—the network is missing a most essential ingredient of capitalism: salespeople. What's missing from this electronic wonderland? Human contact. Discount the fawning techno-burble about virtual communities. Computers and networks isolate us from one another. A network chat line is a limp substitute for meeting friends over coffee. No interactive multimedia display comes close to the excitement of a live concert. And who'd prefer cybersex to the real thing? While the Internet beckons brightly, seductively flashing an icon of knowledge-as-power, this nonplace lures us to surrender our time on earth. A poor substitute it is, this virtual reality where frustration is legion and where—in the holy names of Education and Progress—important aspects of human interactions are relentlessly devalued. Question: List the things people thought would happen in the future according to this article from 1995. System Instruction: Only use information from the text provided. Do not use any external resources or prior knowledge to answer questions.

Do not use any outside resources or knowledge. Only use the information provided in the prompt to answer. Answer in 5 sentences.

How does Alzheimer's treatment work?

Treatments Progress in Alzheimer’s and dementia research is creating promising treatments for people living with the disease. The U.S. Food and Drug Administration (FDA) has approved medications that fall into two categories: drugs that change disease progression in people living with Alzheimer’s, and drugs that may temporarily mitigate some of the symptoms of the disease. When considering any treatment, it is important to have a conversation with a health care professional to determine whether it is appropriate. A physician who is experienced in using these types of medications should monitor people who are taking them and ensure that the recommended guidelines are strictly observed. Drugs That Change Disease Progression Drugs in this category slow disease progression. They slow the decline of memory and thinking, as well as function, in people living with Alzheimer’s disease. The treatment landscape is rapidly changing. Amyloid-targeting approaches Anti-amyloid treatments work by removing beta-amyloid, a protein that accumulates into plaques, from the brain. Each works differently and targets beta-amyloid at a different stage of plaque formation. These treatments change the course of the disease in a meaningful way for people in the early stages, giving them more time to participate in daily life and live independently. Clinical trial participants who received anti-amyloid treatments experienced reduction in cognitive decline observed through measures of cognition and function. Examples of cognition measures include: ● Memory. ● Orientation. Examples of functional measures include: ● Conducting personal finances. ● Performing household chores such as cleaning. Anti-amyloid treatments do have side effects. These treatments can cause serious allergic reactions. Side effects can also include amyloid-related imaging abnormalities (ARIA), infusion-related reactions, headaches and falls. ARIA is a common side effect that does not usually cause symptoms but can be serious. It is typically a temporary swelling in areas of the brain that usually resolves over time. Some people may also have small spots of bleeding in or on the surface of the brain with the swelling, although most people with swelling in areas of the brain do not have symptoms. Some may have symptoms of ARIA such as headache, dizziness, nausea, confusion and vision changes. Some people have a genetic risk factor (ApoE ε4 gene carriers) that may cause an increased risk for ARIA. The FDA encourages that testing for ApoE ε4 status should be performed prior to initiation of treatment to inform the risk of developing ARIA. Prior to testing, doctors should discuss with patients the risk of ARIA and the implications of genetic testing results. These are not all the possible side effects, and individuals should talk with their doctors to develop a treatment plan that is right for them, including weighing the benefits and risks of all approved therapies. Aducanumab (Aduhelm® ) Aducanumab (Aduhelm) is an anti-amyloid antibody intravenous (IV) infusion therapy that is delivered every four weeks. It has received accelerated approval from the FDA to treat early Alzheimer's disease, including people living with mild cognitive impairment (MCI) or mild dementia due to Alzheimer's disease who have confirmation of elevated beta-amyloid in the brain. Aducanumab was the first therapy to demonstrate that removing beta-amyloid from the brain reduces cognitive and functional decline in people living with early Alzheimer’s. Aducanumab is being discontinued by its manufacturer, Biogen. The company stated that people who are now receiving the drug as part of a clinical trial will continue to have access to it until May 1, 2024, and that people who are now receiving it by prescription will have it available to them until Nov. 1, 2024. Donanemab (Kisunla™) Donanemab (Kisunla) is an anti-amyloid antibody intravenous (IV) infusion therapy delivered every four weeks. It has received traditional approval from the FDA to treat early Alzheimer's disease, including people living with mild cognitive impairment (MCI) or mild dementia due to Alzheimer's disease who have confirmation of elevated beta-amyloid in the brain. There is no safety or effectiveness data on initiating treatment at earlier or later stages of the disease than were studied. Donanemab was the third therapy to demonstrate that removing beta-amyloid from the brain reduces cognitive and functional decline in people living with early Alzheimer's. The drugs currently approved to treat cognitive symptoms are cholinesterase inhibitors and glutamate regulators. Cholinesterase inhibitors Cholinesterase (KOH-luh-NES-ter-ays) inhibitors are prescribed to treat symptoms related to memory, thinking, language, judgment and other thought processes. These medications prevent the breakdown of acetylcholine (a-SEA-til-KOHlean), a chemical messenger important for memory and learning. These drugs support communication between nerve cells. The cholinesterase inhibitors most commonly prescribed are: Donepezil (Aricept® ): approved to treat all stages of Alzheimer’s disease. Galantamine (Razadyne® ): approved for mild-to-moderate stages of Alzheimer’s disease. Rivastigmine (Exelon® ): approved for mild-to-moderate Alzheimer’s as well as mild-to-moderate dementia associated with Parkinson’s disease. Though generally well-tolerated, if side effects occur, they commonly include nausea, vomiting, loss of appetite and increased frequency of bowel movements. Glutamate regulators Glutamate regulators are prescribed to improve memory, attention, reason, language and the ability to perform simple tasks. This type of drug works by regulating the activity of glutamate, a different chemical messenger that helps the brain process information. This drug is known as: Memantine (Namenda® ): approved for moderate-to-severe Alzheimer’s disease. Can cause side effects, including headache, constipation, confusion and dizziness. Cholinesterase inhibitor + glutamate regulator This type of drug is a combination of a cholinesterase inhibitor and a glutamate regulator. Donepezil and memantine (Namzaric® ): approved for moderate-to-severe Alzheimer’s disease. Possible side effects include nausea, vomiting, loss of appetite, increased frequency of bowel movements, headache, constipation, confusion and dizziness. Noncognitive symptoms (behavioral and psychological symptoms) Alzheimer’s affects more than just memory and thinking. A person’s quality of life may be impacted by a variety of behavioral and psychological symptoms that accompany dementia, such as sleep disturbances, agitation, hallucinations and delusions. Some medications focus on treating these noncognitive symptoms for a time, though it is important to try non-drug strategies to manage behaviors before adding medications. The FDA has approved one drug to address symptoms of insomnia that has been tested in people living with dementia and one that treats agitation. Orexin receptor antagonist Prescribed to treat insomnia, this drug inhibits the activity of orexin, a type of neurotransmitter involved in the sleep-wake cycle: Suvorexant (Belsomra® ): approved for treatment of insomnia and has been shown in clinical trials to be effective for people living with mild to moderate Alzheimer’s disease. Possible side effects include, but are not limited to: risk of impaired alertness and motor coordination (including impaired driving), worsening of depression or suicidal thinking, complex sleep behaviors (such as sleep-walking and sleep-driving), sleep paralysis and compromised respiratory function. Atypical antipsychotics are a group of antipsychotic drugs that target the serotonin and dopamine chemical pathways in the brain. These drugs are largely used to treat schizophrenia and bipolar disorder and as add-on therapies for major depressive disorder. The FDA requires that all atypical antipsychotics carry a safety warning that the medication has been associated with an increased risk of death in older patients with dementia-related psychosis. Many atypical antipsychotic medications are used "off-label" to treat dementia-related behaviors, and there is currently only one FDA-approved atypical antipsychotic to treat agitation associated with dementia due to Alzheimer's. It is important to try non-drug strategies to manage non-cognitive symptoms — like agitation — before adding medications.

Do not use any outside resources or knowledge. Only use the information provided in the prompt to answer. Answer in 5 sentences. How does Alzheimer's treatment work? Treatments Progress in Alzheimer’s and dementia research is creating promising treatments for people living with the disease. The U.S. Food and Drug Administration (FDA) has approved medications that fall into two categories: drugs that change disease progression in people living with Alzheimer’s, and drugs that may temporarily mitigate some of the symptoms of the disease. When considering any treatment, it is important to have a conversation with a health care professional to determine whether it is appropriate. A physician who is experienced in using these types of medications should monitor people who are taking them and ensure that the recommended guidelines are strictly observed. Drugs That Change Disease Progression Drugs in this category slow disease progression. They slow the decline of memory and thinking, as well as function, in people living with Alzheimer’s disease. The treatment landscape is rapidly changing. Amyloid-targeting approaches Anti-amyloid treatments work by removing beta-amyloid, a protein that accumulates into plaques, from the brain. Each works differently and targets beta-amyloid at a different stage of plaque formation. These treatments change the course of the disease in a meaningful way for people in the early stages, giving them more time to participate in daily life and live independently. Clinical trial participants who received anti-amyloid treatments experienced reduction in cognitive decline observed through measures of cognition and function. Examples of cognition measures include: ● Memory. ● Orientation. Examples of functional measures include: ● Conducting personal finances. ● Performing household chores such as cleaning. Anti-amyloid treatments do have side effects. These treatments can cause serious allergic reactions. Side effects can also include amyloid-related imaging abnormalities (ARIA), infusion-related reactions, headaches and falls. ARIA is a common side effect that does not usually cause symptoms but can be serious. It is typically a temporary swelling in areas of the brain that usually resolves over time. Some people may also have small spots of bleeding in or on the surface of the brain with the swelling, although most people with swelling in areas of the brain do not have symptoms. Some may have symptoms of ARIA such as headache, dizziness, nausea, confusion and vision changes. Some people have a genetic risk factor (ApoE ε4 gene carriers) that may cause an increased risk for ARIA. The FDA encourages that testing for ApoE ε4 status should be performed prior to initiation of treatment to inform the risk of developing ARIA. Prior to testing, doctors should discuss with patients the risk of ARIA and the implications of genetic testing results. These are not all the possible side effects, and individuals should talk with their doctors to develop a treatment plan that is right for them, including weighing the benefits and risks of all approved therapies. Aducanumab (Aduhelm® ) Aducanumab (Aduhelm) is an anti-amyloid antibody intravenous (IV) infusion therapy that is delivered every four weeks. It has received accelerated approval from the FDA to treat early Alzheimer's disease, including people living with mild cognitive impairment (MCI) or mild dementia due to Alzheimer's disease who have confirmation of elevated beta-amyloid in the brain. Aducanumab was the first therapy to demonstrate that removing beta-amyloid from the brain reduces cognitive and functional decline in people living with early Alzheimer’s. Aducanumab is being discontinued by its manufacturer, Biogen. The company stated that people who are now receiving the drug as part of a clinical trial will continue to have access to it until May 1, 2024, and that people who are now receiving it by prescription will have it available to them until Nov. 1, 2024. Donanemab (Kisunla™) Donanemab (Kisunla) is an anti-amyloid antibody intravenous (IV) infusion therapy delivered every four weeks. It has received traditional approval from the FDA to treat early Alzheimer's disease, including people living with mild cognitive impairment (MCI) or mild dementia due to Alzheimer's disease who have confirmation of elevated beta-amyloid in the brain. There is no safety or effectiveness data on initiating treatment at earlier or later stages of the disease than were studied. Donanemab was the third therapy to demonstrate that removing beta-amyloid from the brain reduces cognitive and functional decline in people living with early Alzheimer's. The drugs currently approved to treat cognitive symptoms are cholinesterase inhibitors and glutamate regulators. Cholinesterase inhibitors Cholinesterase (KOH-luh-NES-ter-ays) inhibitors are prescribed to treat symptoms related to memory, thinking, language, judgment and other thought processes. These medications prevent the breakdown of acetylcholine (a-SEA-til-KOHlean), a chemical messenger important for memory and learning. These drugs support communication between nerve cells. The cholinesterase inhibitors most commonly prescribed are: Donepezil (Aricept® ): approved to treat all stages of Alzheimer’s disease. Galantamine (Razadyne® ): approved for mild-to-moderate stages of Alzheimer’s disease. Rivastigmine (Exelon® ): approved for mild-to-moderate Alzheimer’s as well as mild-to-moderate dementia associated with Parkinson’s disease. Though generally well-tolerated, if side effects occur, they commonly include nausea, vomiting, loss of appetite and increased frequency of bowel movements. Glutamate regulators Glutamate regulators are prescribed to improve memory, attention, reason, language and the ability to perform simple tasks. This type of drug works by regulating the activity of glutamate, a different chemical messenger that helps the brain process information. This drug is known as: Memantine (Namenda® ): approved for moderate-to-severe Alzheimer’s disease. Can cause side effects, including headache, constipation, confusion and dizziness. Cholinesterase inhibitor + glutamate regulator This type of drug is a combination of a cholinesterase inhibitor and a glutamate regulator. Donepezil and memantine (Namzaric® ): approved for moderate-to-severe Alzheimer’s disease. Possible side effects include nausea, vomiting, loss of appetite, increased frequency of bowel movements, headache, constipation, confusion and dizziness. Noncognitive symptoms (behavioral and psychological symptoms) Alzheimer’s affects more than just memory and thinking. A person’s quality of life may be impacted by a variety of behavioral and psychological symptoms that accompany dementia, such as sleep disturbances, agitation, hallucinations and delusions. Some medications focus on treating these noncognitive symptoms for a time, though it is important to try non-drug strategies to manage behaviors before adding medications. The FDA has approved one drug to address symptoms of insomnia that has been tested in people living with dementia and one that treats agitation. Orexin receptor antagonist Prescribed to treat insomnia, this drug inhibits the activity of orexin, a type of neurotransmitter involved in the sleep-wake cycle: Suvorexant (Belsomra® ): approved for treatment of insomnia and has been shown in clinical trials to be effective for people living with mild to moderate Alzheimer’s disease. Possible side effects include, but are not limited to: risk of impaired alertness and motor coordination (including impaired driving), worsening of depression or suicidal thinking, complex sleep behaviors (such as sleep-walking and sleep-driving), sleep paralysis and compromised respiratory function. Atypical antipsychotics are a group of antipsychotic drugs that target the serotonin and dopamine chemical pathways in the brain. These drugs are largely used to treat schizophrenia and bipolar disorder and as add-on therapies for major depressive disorder. The FDA requires that all atypical antipsychotics carry a safety warning that the medication has been associated with an increased risk of death in older patients with dementia-related psychosis. Many atypical antipsychotic medications are used "off-label" to treat dementia-related behaviors, and there is currently only one FDA-approved atypical antipsychotic to treat agitation associated with dementia due to Alzheimer's. It is important to try non-drug strategies to manage non-cognitive symptoms — like agitation — before adding medications.

This task requires you to answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. Answer in twenty words or less, do not use bullet points or lists in your answer.

What legal basis is being used to analyze the merger between Microsoft and Activision Blizzard?

On January 18, 2022, Microsoft Corp. announced plans to acquire Activision Blizzard Inc., a video game company, for $68.7 billion.1 The Federal Trade Commission (FTC) is reviewing the acquisition,2 as provided under the Hart-Scott-Rodino Act (HSR),3 to determine whether its effect might be “substantially to lessen competition”—a violation of Section 7 of the Clayton Act. 4 Competition authorities in other countries are reviewing Microsoft’s proposed acquisition as well.5 The companies have said they expect to complete the acquisition before June 30, 2023.6 In recent decades, enforcement of antitrust laws has typically focused on how a proposed merger or acquisition might affect consumers, such as by reducing price competition in relevant product markets. Some of the FTC’s actions and statements over the last two years suggest that in its review of Microsoft’s proposed acquisition, the FTC may be considering other factors that are discussed in this report.7 This report discusses Microsoft’s proposed acquisition of Activision Blizzard, including some of the potential effects on existing product markets, labor markets, and on product markets that do not currently exist but may develop in the future. The report also provides some considerations for Congress, discussing some bills that may affect Microsoft’s proposed acquisition or Microsoft’s future behavior if the acquisition is completed. The video game industry can be separated into three components: developers or gaming studios that create and design video games; publishers who market and monetize the video games; and distributors who provide the video games to consumers.8 Video games are most commonly played on game consoles, personal computers (PCs), and mobile devices (Figure 1). Although some retailers sell physical copies of video games for consoles and PCs, the majority of video games are sold in digital format;9 games for mobile devices are sold only in digital format The extent of competition among distributors depends on the format and device used to play the game. The digital format of video games played on a console generally can only be downloaded from a digital store operated by the producer of the console. Games for PCs can be purchased from a selection of digital stores that are operated by various firms,10 including publishers and developers.11 Some of these firms also provide their games as apps on certain mobile devices;12 these are distributed through app stores, such as Google Play and Apple’s App Store. Consoles are typically sold at a loss; the manufacturers then profit from sales of games and subscription services.13 This can incentivize console producers to acquire developers and publishers and offer exclusive content.14 Technological developments have allowed some PCs and other devices, depending on their hardware capabilities, to compete with game consoles.15 For example, early in 2022, Valve Corp. released a handheld PC—Steam Deck—that resembles the Nintendo Switch console but provides features that are typically available on PCs, such as a web browser, and allows users to download third-party software, including other operating systems.16 Some firms have started offering video game subscription services that provide access to multiple games for a monthly fee, meaning users do not need to purchase each individual game.17 Some firms offer cloud gaming, which allows users to play video games using remote servers in data centers, reducing the hardware requirements needed to play the games and expanding the variety of devices that can be used.18 Cloud gaming, however, requires a high-speed internet connection and is not feasible for potential users who do not have access to sufficiently high broadband speeds.19 Subscription services reportedly provide 4% of total revenue in the North American and European video game markets.20 Some firms backed by venture capitalists and large firms that are primarily known for providing other online services have shown interest in entering the video game industry.21 For example, Netflix started offering games on mobile devices on November 2, 2021, and has acquired video game developers.22 These firms may be able to further expand the selection of distributors available for certain devices and potentially increase competition in the industry.23 Microsoft and Activision Blizzard in the Video Game Industry Microsoft distributes video games using Microsoft Store, its subscription service Game Pass,24 and its cloud gaming service Xbox Cloud Gaming (Beta);25 publishes games, including the franchises Halo and Minecraft; 26 and owns 23 gaming studios.27 In 2021, Microsoft had the second-highest share in the U.S. market for game consoles at 34.8%, according to a report from MarketLine, an industry research firm; estimates for Sony and Nintendo were 40.7% and 24.5%, respectively.28 In January 2022, Microsoft stated that it had more than 25 million Game Pass subscribers.29 In April 2022, Microsoft reported that more than 10 million people have streamed games over Xbox Cloud Gaming,30 although it is unclear how long or how many times users accessed the service. Estimates from Ampere Analysis reportedly indicate that Game Pass makes up about 60% of the video game subscription market.31 Among video game publishers in the United States, Microsoft had the highest market share at 23.9%, according to IBISWorld.32 Activision Blizzard is a video game publisher and developer primarily known for its franchise games, which include World of Warcraft, Call of Duty, Diablo, and Candy Crush. 33 The company can be separated into three segments—Activision, Blizzard, and King—that each contain their own gaming studios. Among video game publishers in the United States, Activision Blizzard had the second highest market share at 10%, according to IBISWorld.34 Activision also distributes video games for PCs through its digital store—Battle.net.35

What legal basis is being used to analyze the merger between Microsoft and Activision Blizzard? This task requires you to answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. Answer in twenty words or less, do not use bullet points or lists in your answer. On January 18, 2022, Microsoft Corp. announced plans to acquire Activision Blizzard Inc., a video game company, for $68.7 billion.1 The Federal Trade Commission (FTC) is reviewing the acquisition,2 as provided under the Hart-Scott-Rodino Act (HSR),3 to determine whether its effect might be “substantially to lessen competition”—a violation of Section 7 of the Clayton Act. 4 Competition authorities in other countries are reviewing Microsoft’s proposed acquisition as well.5 The companies have said they expect to complete the acquisition before June 30, 2023.6 In recent decades, enforcement of antitrust laws has typically focused on how a proposed merger or acquisition might affect consumers, such as by reducing price competition in relevant product markets. Some of the FTC’s actions and statements over the last two years suggest that in its review of Microsoft’s proposed acquisition, the FTC may be considering other factors that are discussed in this report.7 This report discusses Microsoft’s proposed acquisition of Activision Blizzard, including some of the potential effects on existing product markets, labor markets, and on product markets that do not currently exist but may develop in the future. The report also provides some considerations for Congress, discussing some bills that may affect Microsoft’s proposed acquisition or Microsoft’s future behavior if the acquisition is completed. The video game industry can be separated into three components: developers or gaming studios that create and design video games; publishers who market and monetize the video games; and distributors who provide the video games to consumers.8 Video games are most commonly played on game consoles, personal computers (PCs), and mobile devices (Figure 1). Although some retailers sell physical copies of video games for consoles and PCs, the majority of video games are sold in digital format;9 games for mobile devices are sold only in digital format The extent of competition among distributors depends on the format and device used to play the game. The digital format of video games played on a console generally can only be downloaded from a digital store operated by the producer of the console. Games for PCs can be purchased from a selection of digital stores that are operated by various firms,10 including publishers and developers.11 Some of these firms also provide their games as apps on certain mobile devices;12 these are distributed through app stores, such as Google Play and Apple’s App Store. Consoles are typically sold at a loss; the manufacturers then profit from sales of games and subscription services.13 This can incentivize console producers to acquire developers and publishers and offer exclusive content.14 Technological developments have allowed some PCs and other devices, depending on their hardware capabilities, to compete with game consoles.15 For example, early in 2022, Valve Corp. released a handheld PC—Steam Deck—that resembles the Nintendo Switch console but provides features that are typically available on PCs, such as a web browser, and allows users to download third-party software, including other operating systems.16 Some firms have started offering video game subscription services that provide access to multiple games for a monthly fee, meaning users do not need to purchase each individual game.17 Some firms offer cloud gaming, which allows users to play video games using remote servers in data centers, reducing the hardware requirements needed to play the games and expanding the variety of devices that can be used.18 Cloud gaming, however, requires a high-speed internet connection and is not feasible for potential users who do not have access to sufficiently high broadband speeds.19 Subscription services reportedly provide 4% of total revenue in the North American and European video game markets.20 Some firms backed by venture capitalists and large firms that are primarily known for providing other online services have shown interest in entering the video game industry.21 For example, Netflix started offering games on mobile devices on November 2, 2021, and has acquired video game developers.22 These firms may be able to further expand the selection of distributors available for certain devices and potentially increase competition in the industry.23 Microsoft and Activision Blizzard in the Video Game Industry Microsoft distributes video games using Microsoft Store, its subscription service Game Pass,24 and its cloud gaming service Xbox Cloud Gaming (Beta);25 publishes games, including the franchises Halo and Minecraft; 26 and owns 23 gaming studios.27 In 2021, Microsoft had the second-highest share in the U.S. market for game consoles at 34.8%, according to a report from MarketLine, an industry research firm; estimates for Sony and Nintendo were 40.7% and 24.5%, respectively.28 In January 2022, Microsoft stated that it had more than 25 million Game Pass subscribers.29 In April 2022, Microsoft reported that more than 10 million people have streamed games over Xbox Cloud Gaming,30 although it is unclear how long or how many times users accessed the service. Estimates from Ampere Analysis reportedly indicate that Game Pass makes up about 60% of the video game subscription market.31 Among video game publishers in the United States, Microsoft had the highest market share at 23.9%, according to IBISWorld.32 Activision Blizzard is a video game publisher and developer primarily known for its franchise games, which include World of Warcraft, Call of Duty, Diablo, and Candy Crush. 33 The company can be separated into three segments—Activision, Blizzard, and King—that each contain their own gaming studios. Among video game publishers in the United States, Activision Blizzard had the second highest market share at 10%, according to IBISWorld.34 Activision also distributes video games for PCs through its digital store—Battle.net.35

The response should be accurate and concise, with little added conversational elements or tone. If you cannot provide the answer to the request based on the context given, make sure to simply state, "The information is not available at this time."

If a pimple is ready to be popped, should I go ahead and pop it?

Although rare, popping acne in the "danger triangle"—previously known as the "triangle of death"— may cause an infection of the face or head. The "danger triangle" consists of the area from the corners of your mouth to the bridge of your nose.1 An infection of that area can lead to cavernous sinus thrombosis (CST), or a rare blood clot in your cavernous sinuses. A blood clot in your cavernous sinuses can delay blood flow from your brain.2 Due to the risk of life-threatening infection, you may wonder if and how it's OK to pop pimples on your face. According to dermatologists, here's what you need to know about the "danger triangle" and when (if at all) you can pop pimples on your face safely. popping pimple on the the triangle of death (the nose) ZORANM / GETTY IMAGES What Is the 'Triangle of Death'? The "triangle of death" is an old term for what many experts now call the "danger triangle."1 Visualizing the region on your face may take a bit of imagination. "The area of the face connecting the nose to the corners of the mouth is thought to be a particularly dangerous area of the face because of their close connection to the brain," Joshua Zeichner, MD, an associate professor of dermatology at Mount Sinai Hospital in New York, told Health. The best way to see the triangle is to form one with your fingers—connecting the tips of your thumbs, then the tips of your pointer fingers. On your face, the top of your triangle is on the bridge of your nose. The base starts at either corner of your mouth and extends across the bottom of your upper lip. Acne Face Mapping: How to Determine the Cause of Your Breakouts Risks of Popping Pimples in the ‘Danger Triangle' The phrase "danger triangle" might sound slightly extreme when talking about pimple popping. Still, practicing care near that area of your face is critical. Picking at or scratching pimples on that area is not wise since it can allow bacteria to enter and cause infection. In general, the American Academy of Dermatology Association (AAD) does not advise that you pop your pimples. You may push the contents of the pimple deeper into the skin, leading to complications like permanent scarring and more painful and noticeable acne.3 Infection Popping a pimple in the "danger triangle" runs the risk of a potentially life-threatening infection. As a result, CST may develop, in which a blood clot forms in your cavernous sinuses and blocks blood flow from your brain.2 "The cavernous sinus is the name of a large vein that drains blood to the brain, creating a connection from our outside to our inside," said Dr. Zeichner. In other words, the infection in a pimple on your nose has a somewhat clear path to your brain. For that reason, "any infection in that area is a little bit higher risk," Alok Vij, MD, a dermatologist at the Cleveland Clinic, told Health. "In the event that you pick a pimple, and an infection develops, the worst-case scenario is that the infection spreads from the skin through this sinus," explained Dr. Zeichner. CST is a dangerous disorder, but recognizing the symptoms right away minimizes the risk of death and complications. CST symptoms include:2 Fever Headache Paralysis of the muscles that control eye movements Swelling around the eyes More Noticeable and Painful Acne Frequently touching your face increases the risk of more acne.4 When you pop pimples, bacteria, dead skin cells, and oil push further into your skin. As a result, more swelling and redness occur, making acne appear more noticeable and painful.5 Scarring Another reason to keep your hands off the "danger triangle" is that you may cause scarring in the area, added Dr. Vij. In general, popping pimples may cause scabs to form.6 As the skin heals, you may notice scarring or dark spots on your face. Those dark spots, or post-inflammatory hyperpigmentation, may fade over long periods. Some dark spots take as long as 12 months to return to your natural skin color, while others may be permanent.4 How Do You Treat Pimples? Keeping your hands away from your face is essential to get rid of acne in the "danger triangle." Instead of popping pimples in that area, try practicing general self-care tips for treating acne. Acne Medicines You can treat your acne with over-the-counter medicines, such as:7 Adapalene Azelaic acid Benzoyl peroxide Glycolic acid Salicylic acid Sulfur Products with those ingredients help eliminate bacteria, dry oil, or peel the top layer of your skin. By doing so, those products may cause some redness. You may avoid irritating your skin by using a pea-sized amount of product every other or third day. Ensure you use a water-based face moisturizer to prevent dryness and peeling.7 Avoid Foods That Worsen Acne Experts do not conclusively know what foods cause or worsen acne. Still, you may find that some foods, like dairy, high-fat foods, or sweet treats (aka sugar) trigger your acne. Try limiting or cutting out any foods that may cause your acne to flare.7 Daily Skincare Routine A daily skincare routine is essential to treating and preventing acne. For example, try incorporating the following into your routine:7 Clean your face with a gentle, non-drying cleanser to remove dirt and makeup. Repeat once or twice daily and after exercise. Do not use rubbing alcohol or toner on the skin. Those products can dry the skin out. Keep long hair out of your face when you sleep by pulling it back. Only use products that are "non-comedogenic," meaning they do not clog your pores. Shampoo your hair when it's oily. Is There a Way to Safely Pop Pimples? Treating acne may be easier said than done. Sometimes, flattening a pimple on your chin is all too rewarding. While popping your pimples is not advised, there are a few ways to make the process less high-risk. First, stay away from pimples in the "danger triangle" region. Anytime you reach for acne on your nose, remember the risk of infection. In contrast, consider the timing if you are determined to pop a pimple on other regions, like your chin. "If you are going to pop your pimples, do not do it right before bed when you are tired. Think of it like a sterile surgical procedure," said Dr. Zeichner. Before popping, thoroughly wash your hands, said Dr. Vij. Ensure the spaces underneath your fingernails are clean since bacteria are good at hiding there. Better yet, cut your nails before popping a pimple, added Dr. Zeichner. Next, clean the skin on your face. Apply a warm compress to your face before you begin the picking process, noted Dr. Vij. Do not pick the top of a zit off with your nails. Instead, "apply even, downward pressure around the pimples," said Dr. Zeichner. It would help if you did this with one of two instruments: a cotton swab or the soft part of your fingertip. Of the utmost importance is realizing when to stop: "If the blockage does not come out easily, abort the mission," noted Dr. Zeichner. Then, remember to practice after-care. "After picking, apply a topical antibiotic ointment like bacitracin to any open skin." When To See a Healthcare Provider At-home treatments can help get rid of and prevent acne. Still, some people may have more stubborn acne than others. Consult a dermatologist if you notice:7 At-home treatments do not get rid of or prevent acne within several months Cysts Emotional distress or social anxiety about acne Redness around pimples Scars form as acne clears Worsening acne What Is Stress Acne—And How Do You Get Rid of It? A Quick Review Popping your pimples anywhere on your face is not advised, especially in the area on your face known as the "danger triangle." You risk an infection that could travel to your brain and bloodstream if you pop a pimple in that region. While popping pimples is tempting, it is not worth the risk of complications. Instead, avoid touching your face, try at-home treatments, or consult a dermatologist if your acne is not clearing up.

The response should be accurate and concise, with little added conversational elements or tone. If you cannot provide the answer to the request based on the context given, make sure to simply state, "The information is not available at this time." If a pimple is ready to be popped, should I go ahead and pop it? Although rare, popping acne in the "danger triangle"—previously known as the "triangle of death"— may cause an infection of the face or head. The "danger triangle" consists of the area from the corners of your mouth to the bridge of your nose.1 An infection of that area can lead to cavernous sinus thrombosis (CST), or a rare blood clot in your cavernous sinuses. A blood clot in your cavernous sinuses can delay blood flow from your brain.2 Due to the risk of life-threatening infection, you may wonder if and how it's OK to pop pimples on your face. According to dermatologists, here's what you need to know about the "danger triangle" and when (if at all) you can pop pimples on your face safely. popping pimple on the the triangle of death (the nose) ZORANM / GETTY IMAGES What Is the 'Triangle of Death'? The "triangle of death" is an old term for what many experts now call the "danger triangle."1 Visualizing the region on your face may take a bit of imagination. "The area of the face connecting the nose to the corners of the mouth is thought to be a particularly dangerous area of the face because of their close connection to the brain," Joshua Zeichner, MD, an associate professor of dermatology at Mount Sinai Hospital in New York, told Health. The best way to see the triangle is to form one with your fingers—connecting the tips of your thumbs, then the tips of your pointer fingers. On your face, the top of your triangle is on the bridge of your nose. The base starts at either corner of your mouth and extends across the bottom of your upper lip. Acne Face Mapping: How to Determine the Cause of Your Breakouts Risks of Popping Pimples in the ‘Danger Triangle' The phrase "danger triangle" might sound slightly extreme when talking about pimple popping. Still, practicing care near that area of your face is critical. Picking at or scratching pimples on that area is not wise since it can allow bacteria to enter and cause infection. In general, the American Academy of Dermatology Association (AAD) does not advise that you pop your pimples. You may push the contents of the pimple deeper into the skin, leading to complications like permanent scarring and more painful and noticeable acne.3 Infection Popping a pimple in the "danger triangle" runs the risk of a potentially life-threatening infection. As a result, CST may develop, in which a blood clot forms in your cavernous sinuses and blocks blood flow from your brain.2 "The cavernous sinus is the name of a large vein that drains blood to the brain, creating a connection from our outside to our inside," said Dr. Zeichner. In other words, the infection in a pimple on your nose has a somewhat clear path to your brain. For that reason, "any infection in that area is a little bit higher risk," Alok Vij, MD, a dermatologist at the Cleveland Clinic, told Health. "In the event that you pick a pimple, and an infection develops, the worst-case scenario is that the infection spreads from the skin through this sinus," explained Dr. Zeichner. CST is a dangerous disorder, but recognizing the symptoms right away minimizes the risk of death and complications. CST symptoms include:2 Fever Headache Paralysis of the muscles that control eye movements Swelling around the eyes More Noticeable and Painful Acne Frequently touching your face increases the risk of more acne.4 When you pop pimples, bacteria, dead skin cells, and oil push further into your skin. As a result, more swelling and redness occur, making acne appear more noticeable and painful.5 Scarring Another reason to keep your hands off the "danger triangle" is that you may cause scarring in the area, added Dr. Vij. In general, popping pimples may cause scabs to form.6 As the skin heals, you may notice scarring or dark spots on your face. Those dark spots, or post-inflammatory hyperpigmentation, may fade over long periods. Some dark spots take as long as 12 months to return to your natural skin color, while others may be permanent.4 How Do You Treat Pimples? Keeping your hands away from your face is essential to get rid of acne in the "danger triangle." Instead of popping pimples in that area, try practicing general self-care tips for treating acne. Acne Medicines You can treat your acne with over-the-counter medicines, such as:7 Adapalene Azelaic acid Benzoyl peroxide Glycolic acid Salicylic acid Sulfur Products with those ingredients help eliminate bacteria, dry oil, or peel the top layer of your skin. By doing so, those products may cause some redness. You may avoid irritating your skin by using a pea-sized amount of product every other or third day. Ensure you use a water-based face moisturizer to prevent dryness and peeling.7 Avoid Foods That Worsen Acne Experts do not conclusively know what foods cause or worsen acne. Still, you may find that some foods, like dairy, high-fat foods, or sweet treats (aka sugar) trigger your acne. Try limiting or cutting out any foods that may cause your acne to flare.7 Daily Skincare Routine A daily skincare routine is essential to treating and preventing acne. For example, try incorporating the following into your routine:7 Clean your face with a gentle, non-drying cleanser to remove dirt and makeup. Repeat once or twice daily and after exercise. Do not use rubbing alcohol or toner on the skin. Those products can dry the skin out. Keep long hair out of your face when you sleep by pulling it back. Only use products that are "non-comedogenic," meaning they do not clog your pores. Shampoo your hair when it's oily. Is There a Way to Safely Pop Pimples? Treating acne may be easier said than done. Sometimes, flattening a pimple on your chin is all too rewarding. While popping your pimples is not advised, there are a few ways to make the process less high-risk. First, stay away from pimples in the "danger triangle" region. Anytime you reach for acne on your nose, remember the risk of infection. In contrast, consider the timing if you are determined to pop a pimple on other regions, like your chin. "If you are going to pop your pimples, do not do it right before bed when you are tired. Think of it like a sterile surgical procedure," said Dr. Zeichner. Before popping, thoroughly wash your hands, said Dr. Vij. Ensure the spaces underneath your fingernails are clean since bacteria are good at hiding there. Better yet, cut your nails before popping a pimple, added Dr. Zeichner. Next, clean the skin on your face. Apply a warm compress to your face before you begin the picking process, noted Dr. Vij. Do not pick the top of a zit off with your nails. Instead, "apply even, downward pressure around the pimples," said Dr. Zeichner. It would help if you did this with one of two instruments: a cotton swab or the soft part of your fingertip. Of the utmost importance is realizing when to stop: "If the blockage does not come out easily, abort the mission," noted Dr. Zeichner. Then, remember to practice after-care. "After picking, apply a topical antibiotic ointment like bacitracin to any open skin." When To See a Healthcare Provider At-home treatments can help get rid of and prevent acne. Still, some people may have more stubborn acne than others. Consult a dermatologist if you notice:7 At-home treatments do not get rid of or prevent acne within several months Cysts Emotional distress or social anxiety about acne Redness around pimples Scars form as acne clears Worsening acne What Is Stress Acne—And How Do You Get Rid of It? A Quick Review Popping your pimples anywhere on your face is not advised, especially in the area on your face known as the "danger triangle." You risk an infection that could travel to your brain and bloodstream if you pop a pimple in that region. While popping pimples is tempting, it is not worth the risk of complications. Instead, avoid touching your face, try at-home treatments, or consult a dermatologist if your acne is not clearing up.

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> [user request] <TEXT> [context document]

Hey, I'm working on a paper about the use of low-dose aspirin during pregnancy, and I'm trying to clarify something. In the leaflet, it says aspirin reduces the risk of pre-eclampsia and smaller babies, but I'm confused about how it affects placental blood flow versus its impact on potential bleeding during labor. Wouldn't increased blood flow increase bleeding risks? Also, how does aspirin interact with indigestion remedies, and does that complicate its safety for someone with both pregnancy and digestive issues?

You have been given this information leaflet as you have been advised to take low dose aspirin, 150mg once a day from 12 to 36 weeks of your pregnancy. What is aspirin? Aspirin is known as an NSAID (a non-steroidal anti-inflammatory drug). Aspirin is often used to treat pain, fever, inflammation or prevent clot formation. There is evidence that taking low dose aspirin once a day can help increase the function and blood flow of your placenta (afterbirth) which provides your baby with oxygen and nutrients during your pregnancy to help them grow. Why have I been advised to take aspirin? Not everyone is recommended to take aspirin in pregnancy. You have been advised to take a low dose of aspirin during your pregnancy to reduce the risk of: • developing hypertension (high blood pressure) and pre-eclampsia (high blood pressure and protein in your urine) • giving birth to your baby prematurely (before 37 weeks) • your baby being smaller than expected Your midwife or obstetrician (a doctor who specialises in the care of pregnant women) may recommend that you take low dose aspirin to reduce the risk of hypertension (high blood pressure) if one of the following apply to you: • you had hypertension (high blood pressure) during a previous pregnancy • you have chronic kidney disease • you have an auto-immune disease (for example, lupus or antiphospholipid syndrome) • you have Type 1 or 2 diabetes • you have chronic hypertension (high blood pressure before pregnancy) • you have previously given birth to a baby who was smaller than expected • you have low Pregnancy Associated Plasma Protein (PAPP-A) screening blood test • you are aged 40 years or older Low dose aspirin may also be recommended if two or more of the following apply to you: • this is your first pregnancy • there are more than 10 years between this pregnancy and the birth of your last baby • your BMI is 35 or more at your booking appointment • there is a family history of pre-eclampsia in a first degree relative • this is a multiple pregnancy (for example, twins or triplets) You may also be advised to take low dose aspirin if you have a slightly higher chance of having a baby which may be smaller than expected. Or there were any concerns about how your placenta was working in a previous pregnancy; this will be discussed with you. Page 2 of 3 How and when do I take aspirin? You should take 150mg (2 x75mg tablets) once a day from 12 weeks until 36 weeks of your pregnancy. It is best to take in the evening either with or just after food. Please do not worry if you forget to take a tablet, just take one when you remember, however make sure you only take 150mg once a day. If you think you may be in labour, you can stop taking your aspirin until this is confirmed. It will not increase your risk of bleeding during your labour. Is low dose aspirin safe to take in pregnancy? Low dose aspirin is not known to be harmful to you or your baby during pregnancy. In fact it is known to reduce the risk of harm by reducing the risk of high blood pressure, pre-eclampsia, smaller babies and stillbirth. However, aspirin can affect (and be affected by) other medications, including ‘over the Counter’ medicines and herbal remedies. Please discuss any other medications you are taking with your midwife, GP or obstetrician. Side effects Taking low dose aspirin can cause mild indigestion. If you take your aspirin either with or just after food, it will be less likely to upset your stomach. Avoid taking aspirin on an empty stomach. If you also take indigestion remedies, take them at least two hours before or after you take your aspirin. There is no evidence to suggest low dose aspirin causes any increase in bleeding during pregnancy or at the time of birth. If you have any questions or concerns about taking low dose aspirin please speak to your obstetrician, GP or midwife. Allergies Please tell your obstetrician, midwife or GP if you are allergic to aspirin (or other NSAIDS), or you have severe asthma, chronic kidney problems, stomach ulcers or have been previously advised not to take aspirin or other NSAIDs. As with any medicine, you should seek urgent medical assistance if you experience serious side effects such as wheezing, swelling of the lips, face or body, rashes or other indications of an allergic reaction. What can I do to help? If you smoke it is very important that you stop as it can affect placental (afterbirth) function and your baby’s growth. Please contact your community or continuity team midwife who can refer you to smoking cessation; you can also self-refer at One You East Sussex Sources of information If you would like more information about taking low dose aspirin in pregnancy, your midwife or obstetrician will be happy to answer your questions and advise you

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> Hey, I'm working on a paper about the use of low-dose aspirin during pregnancy, and I'm trying to clarify something. In the leaflet, it says aspirin reduces the risk of pre-eclampsia and smaller babies, but I'm confused about how it affects placental blood flow versus its impact on potential bleeding during labor. Wouldn't increased blood flow increase bleeding risks? Also, how does aspirin interact with indigestion remedies, and does that complicate its safety for someone with both pregnancy and digestive issues? <TEXT> You have been given this information leaflet as you have been advised to take low dose aspirin, 150mg once a day from 12 to 36 weeks of your pregnancy. What is aspirin? Aspirin is known as an NSAID (a non-steroidal anti-inflammatory drug). Aspirin is often used to treat pain, fever, inflammation or prevent clot formation. There is evidence that taking low dose aspirin once a day can help increase the function and blood flow of your placenta (afterbirth) which provides your baby with oxygen and nutrients during your pregnancy to help them grow. Why have I been advised to take aspirin? Not everyone is recommended to take aspirin in pregnancy. You have been advised to take a low dose of aspirin during your pregnancy to reduce the risk of: • developing hypertension (high blood pressure) and pre-eclampsia (high blood pressure and protein in your urine) • giving birth to your baby prematurely (before 37 weeks) • your baby being smaller than expected Your midwife or obstetrician (a doctor who specialises in the care of pregnant women) may recommend that you take low dose aspirin to reduce the risk of hypertension (high blood pressure) if one of the following apply to you: • you had hypertension (high blood pressure) during a previous pregnancy • you have chronic kidney disease • you have an auto-immune disease (for example, lupus or antiphospholipid syndrome) • you have Type 1 or 2 diabetes • you have chronic hypertension (high blood pressure before pregnancy) • you have previously given birth to a baby who was smaller than expected • you have low Pregnancy Associated Plasma Protein (PAPP-A) screening blood test • you are aged 40 years or older Low dose aspirin may also be recommended if two or more of the following apply to you: • this is your first pregnancy • there are more than 10 years between this pregnancy and the birth of your last baby • your BMI is 35 or more at your booking appointment • there is a family history of pre-eclampsia in a first degree relative • this is a multiple pregnancy (for example, twins or triplets) You may also be advised to take low dose aspirin if you have a slightly higher chance of having a baby which may be smaller than expected. Or there were any concerns about how your placenta was working in a previous pregnancy; this will be discussed with you. Page 2 of 3 How and when do I take aspirin? You should take 150mg (2 x75mg tablets) once a day from 12 weeks until 36 weeks of your pregnancy. It is best to take in the evening either with or just after food. Please do not worry if you forget to take a tablet, just take one when you remember, however make sure you only take 150mg once a day. If you think you may be in labour, you can stop taking your aspirin until this is confirmed. It will not increase your risk of bleeding during your labour. Is low dose aspirin safe to take in pregnancy? Low dose aspirin is not known to be harmful to you or your baby during pregnancy. In fact it is known to reduce the risk of harm by reducing the risk of high blood pressure, pre-eclampsia, smaller babies and stillbirth. However, aspirin can affect (and be affected by) other medications, including ‘over the Counter’ medicines and herbal remedies. Please discuss any other medications you are taking with your midwife, GP or obstetrician. Side effects Taking low dose aspirin can cause mild indigestion. If you take your aspirin either with or just after food, it will be less likely to upset your stomach. Avoid taking aspirin on an empty stomach. If you also take indigestion remedies, take them at least two hours before or after you take your aspirin. There is no evidence to suggest low dose aspirin causes any increase in bleeding during pregnancy or at the time of birth. If you have any questions or concerns about taking low dose aspirin please speak to your obstetrician, GP or midwife. Allergies Please tell your obstetrician, midwife or GP if you are allergic to aspirin (or other NSAIDS), or you have severe asthma, chronic kidney problems, stomach ulcers or have been previously advised not to take aspirin or other NSAIDs. As with any medicine, you should seek urgent medical assistance if you experience serious side effects such as wheezing, swelling of the lips, face or body, rashes or other indications of an allergic reaction. What can I do to help? If you smoke it is very important that you stop as it can affect placental (afterbirth) function and your baby’s growth. Please contact your community or continuity team midwife who can refer you to smoking cessation; you can also self-refer at One You East Sussex Sources of information If you would like more information about taking low dose aspirin in pregnancy, your midwife or obstetrician will be happy to answer your questions and advise you https://www.esht.nhs.uk/wp-content/uploads/2021/06/0925.pdf

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== [user request] {passage 0} ========== [context document]

I am going to have surgery next week and my doctor sent a form home with me with a questionnaire to fill out before I go in for the surgery. Using this article for reference, can you tell me what medications may interfere with anesthesia and why? Use at least 500 words.

4 types of medications that can interfere with anesthesia BY Molly Adams Patients with cancer may take all kinds of medications – whether they’re used to treat cancer, its side effects, or other conditions that have nothing to do with a cancer diagnosis. While medications are a part of daily life for many of us, there are times when you should adjust your dose or even stop taking certain medicines. “Before you undergo anesthesia for any reason, you want to be sure you’re not taking any medicines that may cause a problem with anesthesia or your procedure,” says Shannon Popovich, M.D., medical director of MD Anderson’s Perioperative Evaluation and Management Center. Here, Popovich shares four types of medication to be mindful of before anesthesia. 1. Blood pressure and heart failure medications Patients may take these to help treat high blood pressure or heart failure. These drugs include beta-blockers, ACE inhibitors, angiotensin receptor blockers, direct renin inhibitors or diuretics. When a patient is under anesthesia, we monitor their blood pressure very closely, and some of these medications can lower your blood pressure more when combined with anesthesia. If you’re taking any medication to lower your blood pressure, that can really complicate our efforts to maintain your blood pressure during surgery or any other treatment performed under anesthesia. We generally suggest patients stop taking ACE inhibitors, angiotensin receptor blockers or direct renin inhibitors 24 hours before undergoing anesthesia to reduce the risk of your blood pressure falling too low when combined with anesthesia. Beta-blockers, calcium channel blockers and medications for heart failure should be taken as usual. They’re not as likely to complicate your blood pressure during anesthesia. 2. Type 2 diabetes medications Certain drugs used to help regulate blood sugars for patients with diabetes and pre-diabetes should be discussed with your physician before receiving anesthesia. Two specific classes of drugs are particularly concerning: GLP-1 agonists and SGLT-2 inhibitors. Medications called GLP-1 agonists (Semaglutide) before anesthesia can increase the risk of vomiting and aspiration because they slow the time it takes for food to leave your stomach. Even when patients stop eating for the advised period before anesthesia, these drugs may still cause them to have a full stomach. We generally ask patients to temporarily stop taking these medications based on how often they take them. For example, if you take the drug once a week, stop taking it a week before anesthesia. If you take it once a day, hold it the day of surgery, and consider holding it the day before to reduce your risk of a full stomach. SGLT-2 inhibitors are known to place patients at risk for euglycemic ketoacidosis when the body is under stress or they are fasting. This is a dangerous condition, and these medications should be held 3 to 4 days before anesthesia, depending on which drug you’re taking. Talk to your prescribing doctor to learn what they recommend for you. If you’re concerned about how holding your diabetes medication may affect your blood glucose levels, talk to your endocrinologist or prescribing doctor to see what they recommend. If you take insulin to help manage Type 1 diabetes, continue taking it as you normally do. MD Anderson patients will discuss specific recommendations with the Perioperative Evaluation and Management team or Endocrinology teams before anesthesia. Insulin taken for Type 2 diabetes may be adjusted in the 24 hours before anesthesia as instructed by your doctor. But be sure to tell your care team about your medication and dosage. 3. Weight loss medications Although some diabetes medications, like GLP-1 agonists, may help patients with weight loss, there’s another class of drugs solely aimed at weight loss. These are stimulants and work by decreasing appetite and increasing your heart rate. That stimulation can have an unwanted effect when combined with anesthesia. Drugs that contain phentermine need to be held for 4 days before anesthesia, but when combined with another medication (like topiramate) may need to be slowly tapered off over time. Be sure to talk to your care team about your dose and type of medication so we can wean you off safely. 4. Blood thinners and blood clotting drugs If you’re undergoing anesthesia before surgery, you might need to stop blood thinning medications – even over-the-counter ones like ibuprofen or Advil – to avoid the risk of excessive bleeding. Talk with your surgeon or proceduralist about any blood thinners you’re taking. For less-invasive procedures like MRI, you should be able to keep taking blood thinners as normal. Some medications are important to keep taking Most patients will be able to start taking their regular medications again soon after waking up from anesthesia. In many cases, you may be able to start taking your medications again after you’ve had something to eat and are cleared after surgery. Although there are several medications to avoid before anesthesia, there are many you can – and should keep taking. Patients who take birth control should continue doing so to avoid the risk of becoming pregnant. This is especially important for patients undergoing chemotherapy or radiation therapy, which can be dangerous to unborn babies. Antidepressants, anxiety medication and most medicines used to treat ADHD are also safe to continue. If you use sleep aids to help ease insomnia, you can also keep taking them as directed. The most important thing is to be honest about any drugs you’re taking – prescription or not – so your care team can give you the best advice for your unique needs.

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== I am going to have surgery next week and my doctor sent a form home with me with a questionnaire to fill out before I go in for the surgery. Using this article for reference, can you tell me what medications may interfere with anesthesia and why? Use at least 500 words. {passage 0} ========== 4 types of medications that can interfere with anesthesia BY Molly Adams Patients with cancer may take all kinds of medications – whether they’re used to treat cancer, its side effects, or other conditions that have nothing to do with a cancer diagnosis. While medications are a part of daily life for many of us, there are times when you should adjust your dose or even stop taking certain medicines. “Before you undergo anesthesia for any reason, you want to be sure you’re not taking any medicines that may cause a problem with anesthesia or your procedure,” says Shannon Popovich, M.D., medical director of MD Anderson’s Perioperative Evaluation and Management Center. Here, Popovich shares four types of medication to be mindful of before anesthesia. 1. Blood pressure and heart failure medications Patients may take these to help treat high blood pressure or heart failure. These drugs include beta-blockers, ACE inhibitors, angiotensin receptor blockers, direct renin inhibitors or diuretics. When a patient is under anesthesia, we monitor their blood pressure very closely, and some of these medications can lower your blood pressure more when combined with anesthesia. If you’re taking any medication to lower your blood pressure, that can really complicate our efforts to maintain your blood pressure during surgery or any other treatment performed under anesthesia. We generally suggest patients stop taking ACE inhibitors, angiotensin receptor blockers or direct renin inhibitors 24 hours before undergoing anesthesia to reduce the risk of your blood pressure falling too low when combined with anesthesia. Beta-blockers, calcium channel blockers and medications for heart failure should be taken as usual. They’re not as likely to complicate your blood pressure during anesthesia. 2. Type 2 diabetes medications Certain drugs used to help regulate blood sugars for patients with diabetes and pre-diabetes should be discussed with your physician before receiving anesthesia. Two specific classes of drugs are particularly concerning: GLP-1 agonists and SGLT-2 inhibitors. Medications called GLP-1 agonists (Semaglutide) before anesthesia can increase the risk of vomiting and aspiration because they slow the time it takes for food to leave your stomach. Even when patients stop eating for the advised period before anesthesia, these drugs may still cause them to have a full stomach. We generally ask patients to temporarily stop taking these medications based on how often they take them. For example, if you take the drug once a week, stop taking it a week before anesthesia. If you take it once a day, hold it the day of surgery, and consider holding it the day before to reduce your risk of a full stomach. SGLT-2 inhibitors are known to place patients at risk for euglycemic ketoacidosis when the body is under stress or they are fasting. This is a dangerous condition, and these medications should be held 3 to 4 days before anesthesia, depending on which drug you’re taking. Talk to your prescribing doctor to learn what they recommend for you. If you’re concerned about how holding your diabetes medication may affect your blood glucose levels, talk to your endocrinologist or prescribing doctor to see what they recommend. If you take insulin to help manage Type 1 diabetes, continue taking it as you normally do. MD Anderson patients will discuss specific recommendations with the Perioperative Evaluation and Management team or Endocrinology teams before anesthesia. Insulin taken for Type 2 diabetes may be adjusted in the 24 hours before anesthesia as instructed by your doctor. But be sure to tell your care team about your medication and dosage. 3. Weight loss medications Although some diabetes medications, like GLP-1 agonists, may help patients with weight loss, there’s another class of drugs solely aimed at weight loss. These are stimulants and work by decreasing appetite and increasing your heart rate. That stimulation can have an unwanted effect when combined with anesthesia. Drugs that contain phentermine need to be held for 4 days before anesthesia, but when combined with another medication (like topiramate) may need to be slowly tapered off over time. Be sure to talk to your care team about your dose and type of medication so we can wean you off safely. 4. Blood thinners and blood clotting drugs If you’re undergoing anesthesia before surgery, you might need to stop blood thinning medications – even over-the-counter ones like ibuprofen or Advil – to avoid the risk of excessive bleeding. Talk with your surgeon or proceduralist about any blood thinners you’re taking. For less-invasive procedures like MRI, you should be able to keep taking blood thinners as normal. Some medications are important to keep taking Most patients will be able to start taking their regular medications again soon after waking up from anesthesia. In many cases, you may be able to start taking your medications again after you’ve had something to eat and are cleared after surgery. Although there are several medications to avoid before anesthesia, there are many you can – and should keep taking. Patients who take birth control should continue doing so to avoid the risk of becoming pregnant. This is especially important for patients undergoing chemotherapy or radiation therapy, which can be dangerous to unborn babies. Antidepressants, anxiety medication and most medicines used to treat ADHD are also safe to continue. If you use sleep aids to help ease insomnia, you can also keep taking them as directed. The most important thing is to be honest about any drugs you’re taking – prescription or not – so your care team can give you the best advice for your unique needs. https://www.mdanderson.org/cancerwise/4-types-of-medications-that-can-interfere-with-anesthesia.h00-159623379.html

Base your response on the given text. Limit your response to 300 words. Give your answer in paragraphs.

Give me some examples of software.

What is technology?1 In the narrowest sense, technology consists of manufactured objects like tools (axes, arrowheads, and their modern equivalents) and containers (pots, water reservoirs, buildings). Their purpose is either to enhance human capabilities (e.g., with a hammer you can apply a stronger force to an object) or to enable humans to perform tasks they could not perform otherwise (with a pot you can transport larger amounts of water; with your hands you cannot). Engineers call such objects “hardware”. Anthropologists speak of “artifacts”. But technology does not end there. Artifacts have to be produced. They have to be invented, designed, and manufactured. This requires a larger system including hardware (such as machinery or a manufacturing plant), factor inputs (labor, energy, raw materials, capital), and finally “software” (know-how, human knowledge and skills). The latter, for which the French use the term technique, represents the disembodied nature of technology, its knowledge base. Thus, technology includes both what things are made and how things are made. Finally, knowledge, or technique, is required not only for the production of artifacts, but also for their use. Knowledge is needed to drive a car or use a bank account. Knowledge is needed both at the level of the individual, in complex organizations, and at the level of society. A typewriter, without a user who knows how to type, let alone how to read, is simply a useless, heavy piece of equipment. Technological hardware varies in size and complexity, as does the “software” required to produce and use hardware. The two are interrelated and require both tangible and intangible settings in the form of spatial structures and social organizations. Institutions, including governments, firms, and markets, and social norms and attitudes, are especially important in determining how systems for producing and using artifacts emerge and function. They determine how particular artifacts and combinations of artifacts originate, which ones are rejected or which ones become successful, and, if successful, how quickly they are incorporated in the economy and the society. The latter step is referred to as technology diffusion.

Base your response on the given text. Limit your response to 300 words. Give your answer in paragraphs. What is technology?1 In the narrowest sense, technology consists of manufactured objects like tools (axes, arrowheads, and their modern equivalents) and containers (pots, water reservoirs, buildings). Their purpose is either to enhance human capabilities (e.g., with a hammer you can apply a stronger force to an object) or to enable humans to perform tasks they could not perform otherwise (with a pot you can transport larger amounts of water; with your hands you cannot). Engineers call such objects “hardware”. Anthropologists speak of “artifacts”. But technology does not end there. Artifacts have to be produced. They have to be invented, designed, and manufactured. This requires a larger system including hardware (such as machinery or a manufacturing plant), factor inputs (labor, energy, raw materials, capital), and finally “software” (know-how, human knowledge and skills). The latter, for which the French use the term technique, represents the disembodied nature of technology, its knowledge base. Thus, technology includes both what things are made and how things are made. Finally, knowledge, or technique, is required not only for the production of artifacts, but also for their use. Knowledge is needed to drive a car or use a bank account. Knowledge is needed both at the level of the individual, in complex organizations, and at the level of society. A typewriter, without a user who knows how to type, let alone how to read, is simply a useless, heavy piece of equipment. Technological hardware varies in size and complexity, as does the “software” required to produce and use hardware. The two are interrelated and require both tangible and intangible settings in the form of spatial structures and social organizations. Institutions, including governments, firms, and markets, and social norms and attitudes, are especially important in determining how systems for producing and using artifacts emerge and function. They determine how particular artifacts and combinations of artifacts originate, which ones are rejected or which ones become successful, and, if successful, how quickly they are incorporated in the economy and the society. The latter step is referred to as technology diffusion. Give me some examples of software.

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. [user request] [context document]

I got a mail order bride, she cheated on me.... a lot. what is her scenario going to be now that i want to divorce her and have nothing to do with her. We don't have a kid, she's never had a real job, she doesn't have a bank account, pretty much has nothing going for herself. it's only been 10 months since we got her conditional green card. what happens to her?

Green Card Types When you obtain a green card through marriage, it will either be a permanent renewable green card that is valid for ten years or a conditional two-year green card. The conditional green card is issued to applicants that have been married for less than two years at the time the green card is issued. You can apply to have these conditions lifted two years after arriving in the United States. Divorce and a Permanent Green Card If you divorce and you have a permanent green card, there is typically no impact to the renewal process. When it comes time to renew your green card, you simply file Form I-90 (officially called “Application to Replace Permanent Resident Card”). There are no questions about your marital or relationship status for a green card renewal. If you legally changed your name after your divorce, you can also update your green card at that time by submitting a legal record with your new name. Divorce and a Conditional Green Card In order to lift the conditions after two years, you need to prove that you and your partner are still married. Therefore, divorce when you hold a conditional green card can cause issues. A waiver is available when you file Form I-751 to remove the conditions on your green card, but you will have to prove that your marriage prior to the divorce was genuine and not the result of immigration fraud. Typically, U.S. Citizenship and Immigration Services (USCIS) closely examines applications with waivers and you might be asked to provide additional evidence to prove you entered the marriage in good faith. To prove your marriage was real, you can include joint financial records, proof that you lived together, evidence that you have children together, or that you sought marriage counseling. You will also need to include a detailed written statement explaining why your marriage ended. If you and your partner separated because of irreconcilable differences, explain what those differences were. For example, perhaps one partner wanted to have children but the other didn’t. Sometimes, a marriage ends because of the actions of a spouse, such as domestic abuse or adultery. In these cases, you would submit copies of your divorce papers and if available, court records detailing these claims. If the divorce was as a result of your actions, it is best that you consult with an experienced immigration attorney about your case. Removing conditions when the divorce is not final If your divorce has not yet been finalized, you will need to include evidence that you or your partner have initiated divorce proceedings. In this case, USCIS will typically send you a notice in the mail extending your conditional residence status for one more year. At a later date, you will also likely receive a Request For Evidence (RFE) for the final decree of divorce. Removing conditions when you are separated but not divorced In rare cases, you can apply to remove conditions when you and your spouse are separated but you aren’t divorced, or your spouse refuses to grant you a divorce. If you are able to prove “extreme hardship,” then you may still be eligible for a permanent green card. USCIS provides detailed examples of what constitutes “extreme hardship,” Divorcing During the Green Card Application Process If you divorce during the application process for a marriage green card, then the application will stop and no longer progress. This is the case whether you are applying for a marriage green card or you are married to someone being sponsored for a green card through their U.S. employer. It’s also important to be aware that USCIS is very vigilant about immigration fraud and that pretending to be married or not disclosing a divorce when applying for a green card could be viewed as immigration fraud.

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. I got a mail order bride, she cheated on me.... a lot. what is her scenario going to be now that i want to divorce her and have nothing to do with her. We don't have a kid, she's never had a real job, she doesn't have a bank account, pretty much has nothing going for herself. it's only been 10 months since we got her conditional green card. what happens to her? Green Card Types When you obtain a green card through marriage, it will either be a permanent renewable green card that is valid for ten years or a conditional two-year green card. The conditional green card is issued to applicants that have been married for less than two years at the time the green card is issued. You can apply to have these conditions lifted two years after arriving in the United States. Divorce and a Permanent Green Card If you divorce and you have a permanent green card, there is typically no impact to the renewal process. When it comes time to renew your green card, you simply file Form I-90 (officially called “Application to Replace Permanent Resident Card”). There are no questions about your marital or relationship status for a green card renewal. If you legally changed your name after your divorce, you can also update your green card at that time by submitting a legal record with your new name. Divorce and a Conditional Green Card In order to lift the conditions after two years, you need to prove that you and your partner are still married. Therefore, divorce when you hold a conditional green card can cause issues. A waiver is available when you file Form I-751 to remove the conditions on your green card, but you will have to prove that your marriage prior to the divorce was genuine and not the result of immigration fraud. Typically, U.S. Citizenship and Immigration Services (USCIS) closely examines applications with waivers and you might be asked to provide additional evidence to prove you entered the marriage in good faith. To prove your marriage was real, you can include joint financial records, proof that you lived together, evidence that you have children together, or that you sought marriage counseling. You will also need to include a detailed written statement explaining why your marriage ended. If you and your partner separated because of irreconcilable differences, explain what those differences were. For example, perhaps one partner wanted to have children but the other didn’t. Sometimes, a marriage ends because of the actions of a spouse, such as domestic abuse or adultery. In these cases, you would submit copies of your divorce papers and if available, court records detailing these claims. If the divorce was as a result of your actions, it is best that you consult with an experienced immigration attorney about your case. Removing conditions when the divorce is not final If your divorce has not yet been finalized, you will need to include evidence that you or your partner have initiated divorce proceedings. In this case, USCIS will typically send you a notice in the mail extending your conditional residence status for one more year. At a later date, you will also likely receive a Request For Evidence (RFE) for the final decree of divorce. Removing conditions when you are separated but not divorced In rare cases, you can apply to remove conditions when you and your spouse are separated but you aren’t divorced, or your spouse refuses to grant you a divorce. If you are able to prove “extreme hardship,” then you may still be eligible for a permanent green card. USCIS provides detailed examples of what constitutes “extreme hardship,” Divorcing During the Green Card Application Process If you divorce during the application process for a marriage green card, then the application will stop and no longer progress. This is the case whether you are applying for a marriage green card or you are married to someone being sponsored for a green card through their U.S. employer. It’s also important to be aware that USCIS is very vigilant about immigration fraud and that pretending to be married or not disclosing a divorce when applying for a green card could be viewed as immigration fraud. https://www.boundless.com/immigration-resources/marriage-green-card-divorce/

This task requires you to answer questions based solely on the information provided in the prompt.

According to this document, how did Youtube advertising revenue perform in Q1 2023?

Ruth Porat, President and Chief Investment Officer; CFO, Alphabet and Google: Thank you, Philipp. We are very pleased with our financial results for the first quarter, driven in particular by strength in Search and Cloud, as well as the ongoing efforts to durably re-engineer our cost base. My comments will be on year-over-year comparisons for the first quarter, unless I state otherwise. I will start with results at the Alphabet level, followed by segment results, and conclude with our outlook. For the first quarter, our consolidated revenues were $80.5 billion, up 15% or up 16% in constant currency. Search remained the largest contributor to revenue growth. In terms of total expenses, the year-on-year comparisons reflect the impact of the restructuring charges we took in the first quarter of 2023, of $2.6 billion, as well as the $716 million in employee severance and related charges in the first quarter of 2024. As you can see in our earnings release, these charges were allocated across the expense lines in Other Cost of Revenues and OpEx based on associated headcount. To help with year-on-year comparisons, we included a table in our earnings release to adjust Other Cost of Revenues, operating expenses, operating income and operating margin to exclude the impact of severance and related office space charges in the first quarter of 2023 versus 2024. In terms of expenses, total Cost of Revenues was $33.7 billion, up 10%. Other Cost of Revenues was $20.8 billion, up 10% on a reported basis, with the increase driven primarily by content acquisition costs associated with YouTube, given the very strong revenue growth in both subscription offerings and ad-supported content. On an adjusted basis, Other Cost of Revenues were up 13% year-on-year. Operating expenses were $21.4 billion, down 2% on a reported basis, primarily reflecting expense decreases in sales and marketing and G&A, offset by an increase in R&D. The largest 10 single factor in the year-on-year decline in G&A expenses was lower charges related to legal matters. On an adjusted basis, operating expenses were up 5%, reflecting; first, in R&D, an increase in compensation expense, primarily for Google DeepMind and Cloud; and second, in Sales and Marketing a slight increase year-on-year, reflecting increases in compensation expense, primarily for Cloud sales. Operating income was $25.5 billion, up 46% on a reported basis, and our operating margin was 32%. On an adjusted basis, operating income was up 31%, and our operating margin was 33%. Net income was $23.7 billion, and EPS was $1.89. We delivered free cash flow of $16.8 billion in the first quarter and $69.1 billion for the trailing 12 months. We ended the quarter with $108 billion in cash and marketable securities. Turning to segment results, within Google Services, revenues were $70.4 billion, up 14%. Google Search & Other advertising revenues of $46.2 billion in the quarter were up 14%, led again by growth in retail. YouTube advertising revenues of $8.1 billion, were up 21%, driven by both direct response and brand advertising. Network advertising revenues of $7.4 billion were down 1%. Subscriptions, Platforms and Devices revenues were $8.7 billion, up 18%, primarily reflecting growth in YouTube subscription revenues. TAC was $12.9 billion, up 10%. Google Services Operating Income was $27.9 billion, up 28%, and the operating margin was 40%. Turning to the Google Cloud segment, revenues were $9.6 billion for the quarter, up 28%, reflecting significant growth in GCP, with an increasing contribution from AI and strong Google Workspace growth, primarily driven by increases in average revenue per seat. Google Cloud delivered Operating Income of $900 million and an operating margin of 9%. As to our Other Bets, for the first quarter, revenues were $495 million, benefiting from a milestone payment in one of the Other Bets. The operating loss was $1 billion. 11 Turning to our outlook for the business, with respect to Google Services. First, within Advertising, we are very pleased with the momentum of our Ads businesses. Search had broad-based strength across verticals. In YouTube, we had acceleration in revenue growth driven by brand and direct response. Looking ahead, two points to call out. First, results in our advertising business in Q1 continued to reflect strength in spend from APAC-based retailers, a trend that began in the second quarter of 2023 and continued through Q1, which means we will begin lapping that impact in the second quarter. Second, the YouTube acceleration in revenue growth in Q1 reflects, in part, lapping the negative year-on-year growth we experienced in the first quarter of 2023. Turning to Subscriptions, Platforms and Devices. We continue to deliver significant growth in our subscriptions business, which drives the majority of revenue growth in this line. The sequential quarterly decline in year-on-year revenue growth for the line in Q1, versus Q4, reflects, in part, the fact that we had only one week of Sunday Ticket subscription revenue in Q1 versus fourteen weeks in Q4. Looking forward, we will anniversary last year's price increase in YouTube TV starting in May. With regard to Platforms, we are pleased with the performance in Play driven by an increase in buyers. With respect to Google Cloud, performance in Q1 reflects strong demand for our GCP infrastructure and solutions, as well as the contribution from our Workspace productivity tools. The growth we are seeing across Cloud is underpinned by the benefit AI provides for our customers. We continue to invest aggressively, while remaining focused on profitable growth. As we look ahead, two points that will affect sequential year-on-year revenue growth comparisons across Alphabet. First, Q1 results reflect the benefit of Leap Year, which contributed slightly more than one point to our revenue growth rate at the consolidated level in the first quarter. Second, at current spot rates, we expect a larger headwind from foreign exchange in Q2 versus Q1. Turning to margins, our efforts to durably re-engineer our cost base are reflected in a 400 basis point expansion of our Alphabet operating margin year-on-year, excluding the impact of restructuring and severance charges in both periods. You can also see the impact in the quarter-on-quarter decline in headcount in Q1, which reflects 12 both actions we have taken over the past few months and a much slower pace of hiring. As we have discussed previously, we are continuing to invest in top engineering and technical talent, particularly in Cloud, Google DeepMind and Technical Infrastructure. Looking ahead, we remain focused on our efforts to moderate the pace of expense growth in order to create capacity for the increases in depreciation and expenses associated with the higher levels of investment in our technical infrastructure. We believe these efforts will enable us to deliver full-year 2024 Alphabet operating margin expansion relative to 2023. With respect to CapEx, our reported CapEx in the first quarter was $12 billion, once again driven overwhelmingly by investment in our technical infrastructure, with the largest component for servers, followed by data centers. The significant year-on-year growth in CapEx in recent quarters reflects our confidence in the opportunities offered by AI across our business. Looking ahead, we expect quarterly CapEx throughout the year to be roughly at or above the Q1 level, keeping in mind that the timing of cash payments can cause variability in quarterly reported CapEx. With regard to Other Bets, we similarly have workstreams under way to enhance overall returns. Finally, as I trust you saw in the press release, we are very pleased to be adding a quarterly dividend of $.20 per share to our capital return program, as well as a new $70 billion authorization in share repurchases. The core of our capital allocation framework remains the same, beginning with investing aggressively in our business as you have heard us talk about today, given the extraordinary opportunities ahead. We view the introduction of the dividend as further strengthening our overall capital return program. Thank you. Sundar, Philipp and I will now take your questions.

System instruction: This task requires you to answer questions based solely on the information provided in the prompt. question: According to this document, how did Youtube advertising revenue perform in Q1 2023? context: Ruth Porat, President and Chief Investment Officer; CFO, Alphabet and Google: Thank you, Philipp. We are very pleased with our financial results for the first quarter, driven in particular by strength in Search and Cloud, as well as the ongoing efforts to durably re-engineer our cost base. My comments will be on year-over-year comparisons for the first quarter, unless I state otherwise. I will start with results at the Alphabet level, followed by segment results, and conclude with our outlook. For the first quarter, our consolidated revenues were $80.5 billion, up 15% or up 16% in constant currency. Search remained the largest contributor to revenue growth. In terms of total expenses, the year-on-year comparisons reflect the impact of the restructuring charges we took in the first quarter of 2023, of $2.6 billion, as well as the $716 million in employee severance and related charges in the first quarter of 2024. As you can see in our earnings release, these charges were allocated across the expense lines in Other Cost of Revenues and OpEx based on associated headcount. To help with year-on-year comparisons, we included a table in our earnings release to adjust Other Cost of Revenues, operating expenses, operating income and operating margin to exclude the impact of severance and related office space charges in the first quarter of 2023 versus 2024. In terms of expenses, total Cost of Revenues was $33.7 billion, up 10%. Other Cost of Revenues was $20.8 billion, up 10% on a reported basis, with the increase driven primarily by content acquisition costs associated with YouTube, given the very strong revenue growth in both subscription offerings and ad-supported content. On an adjusted basis, Other Cost of Revenues were up 13% year-on-year. Operating expenses were $21.4 billion, down 2% on a reported basis, primarily reflecting expense decreases in sales and marketing and G&A, offset by an increase in R&D. The largest 10 single factor in the year-on-year decline in G&A expenses was lower charges related to legal matters. On an adjusted basis, operating expenses were up 5%, reflecting; first, in R&D, an increase in compensation expense, primarily for Google DeepMind and Cloud; and second, in Sales and Marketing a slight increase year-on-year, reflecting increases in compensation expense, primarily for Cloud sales. Operating income was $25.5 billion, up 46% on a reported basis, and our operating margin was 32%. On an adjusted basis, operating income was up 31%, and our operating margin was 33%. Net income was $23.7 billion, and EPS was $1.89. We delivered free cash flow of $16.8 billion in the first quarter and $69.1 billion for the trailing 12 months. We ended the quarter with $108 billion in cash and marketable securities. Turning to segment results, within Google Services, revenues were $70.4 billion, up 14%. Google Search & Other advertising revenues of $46.2 billion in the quarter were up 14%, led again by growth in retail. YouTube advertising revenues of $8.1 billion, were up 21%, driven by both direct response and brand advertising. Network advertising revenues of $7.4 billion were down 1%. Subscriptions, Platforms and Devices revenues were $8.7 billion, up 18%, primarily reflecting growth in YouTube subscription revenues. TAC was $12.9 billion, up 10%. Google Services Operating Income was $27.9 billion, up 28%, and the operating margin was 40%. Turning to the Google Cloud segment, revenues were $9.6 billion for the quarter, up 28%, reflecting significant growth in GCP, with an increasing contribution from AI and strong Google Workspace growth, primarily driven by increases in average revenue per seat. Google Cloud delivered Operating Income of $900 million and an operating margin of 9%. As to our Other Bets, for the first quarter, revenues were $495 million, benefiting from a milestone payment in one of the Other Bets. The operating loss was $1 billion. 11 Turning to our outlook for the business, with respect to Google Services. First, within Advertising, we are very pleased with the momentum of our Ads businesses. Search had broad-based strength across verticals. In YouTube, we had acceleration in revenue growth driven by brand and direct response. Looking ahead, two points to call out. First, results in our advertising business in Q1 continued to reflect strength in spend from APAC-based retailers, a trend that began in the second quarter of 2023 and continued through Q1, which means we will begin lapping that impact in the second quarter. Second, the YouTube acceleration in revenue growth in Q1 reflects, in part, lapping the negative year-on-year growth we experienced in the first quarter of 2023. Turning to Subscriptions, Platforms and Devices. We continue to deliver significant growth in our subscriptions business, which drives the majority of revenue growth in this line. The sequential quarterly decline in year-on-year revenue growth for the line in Q1, versus Q4, reflects, in part, the fact that we had only one week of Sunday Ticket subscription revenue in Q1 versus fourteen weeks in Q4. Looking forward, we will anniversary last year's price increase in YouTube TV starting in May. With regard to Platforms, we are pleased with the performance in Play driven by an increase in buyers. With respect to Google Cloud, performance in Q1 reflects strong demand for our GCP infrastructure and solutions, as well as the contribution from our Workspace productivity tools. The growth we are seeing across Cloud is underpinned by the benefit AI provides for our customers. We continue to invest aggressively, while remaining focused on profitable growth. As we look ahead, two points that will affect sequential year-on-year revenue growth comparisons across Alphabet. First, Q1 results reflect the benefit of Leap Year, which contributed slightly more than one point to our revenue growth rate at the consolidated level in the first quarter. Second, at current spot rates, we expect a larger headwind from foreign exchange in Q2 versus Q1. Turning to margins, our efforts to durably re-engineer our cost base are reflected in a 400 basis point expansion of our Alphabet operating margin year-on-year, excluding the impact of restructuring and severance charges in both periods. You can also see the impact in the quarter-on-quarter decline in headcount in Q1, which reflects 12 both actions we have taken over the past few months and a much slower pace of hiring. As we have discussed previously, we are continuing to invest in top engineering and technical talent, particularly in Cloud, Google DeepMind and Technical Infrastructure. Looking ahead, we remain focused on our efforts to moderate the pace of expense growth in order to create capacity for the increases in depreciation and expenses associated with the higher levels of investment in our technical infrastructure. We believe these efforts will enable us to deliver full-year 2024 Alphabet operating margin expansion relative to 2023. With respect to CapEx, our reported CapEx in the first quarter was $12 billion, once again driven overwhelmingly by investment in our technical infrastructure, with the largest component for servers, followed by data centers. The significant year-on-year growth in CapEx in recent quarters reflects our confidence in the opportunities offered by AI across our business. Looking ahead, we expect quarterly CapEx throughout the year to be roughly at or above the Q1 level, keeping in mind that the timing of cash payments can cause variability in quarterly reported CapEx. With regard to Other Bets, we similarly have workstreams under way to enhance overall returns. Finally, as I trust you saw in the press release, we are very pleased to be adding a quarterly dividend of $.20 per share to our capital return program, as well as a new $70 billion authorization in share repurchases. The core of our capital allocation framework remains the same, beginning with investing aggressively in our business as you have heard us talk about today, given the extraordinary opportunities ahead. We view the introduction of the dividend as further strengthening our overall capital return program. Thank you. Sundar, Philipp and I will now take your questions.

You are to answer based solely on the provided text. You are not allowed to use any external resources or prior knowledge.

When can someone with BMI of 29 kg/m2 be recommended for bariatric surgery?

A broad range of drugs are under investigation, but there are currently no drugs approved by regulatory agencies for the treatment of NAFLD. This is a field of very active research. As an increasing number of clinical studies are running and results are reported, recommendations may rapidly change. Information on which clinical trials are ongoing can be found on www.clinicaltrials.gov and you should ask your physician for newest updates. Some drugs that are used to treat other conditions have also been tested for NASH. Based on their effects demonstrated by liver biopsy, the following drugs seem to have some efficacy. – Vitamin E showed promise, but only in patients without cirrhosis and without T2D. Given long-term and at high doses, however, vitamin E potentially had negative effects and some data indicate that it could increase the risk of early death and certain cancers. – Pioglitazone, which is approved for the treatment of diabetes, showed promise for NASH in patients with diabetes and pre-diabetes. Side effects such as weight gain and bone fractures should be considered. – Liraglutide and semaglutide are approved for the treatment of obesity and for diabetes. They have also shown promise in reducing liver fat and inflammation in NASH and will be evaluated further. Important: all these drugs must be discussed with your doctor and can harm when self-administered. Future available drugs will be an add-on therapy because lifestyle changes are essential as NAFLD is mainly a lifestyle-related disease. Bariatric surgery very effectively achieves weight loss and weight loss maintenance in patients with obesity. The agreed criteria for the surgical management of obesity and metabolic disorders (BMI ≥40kg/m2 or BMI ≥35kg/m2 with complicating disorders, no resolution after medical treatment) are also applicable for NAFLD. Patients with a BMI of 30–35 kg/m2 who also have T2D that is not adequately controlled by medical therapy may also be candidates for surgery. It is important to know that the change in the anatomy by bariatric surgery can lead to the need of lifelong follow up and this should be considered in discussing this option for patients. If you wonder whether vitamin E, the above-mentioned drugs or bariatric surgery could be helpful for you, please consult your doctor and discuss the potential risks and benefits. Any treatment decision should be based on your individual situation and medical history

You are to answer based solely on the provided text. You are not allowed to use any external resources or prior knowledge. When can someone with BMI of 29 kg/m2 be recommended for bariatric surgery? A broad range of drugs are under investigation, but there are currently no drugs approved by regulatory agencies for the treatment of NAFLD. This is a field of very active research. As an increasing number of clinical studies are running and results are reported, recommendations may rapidly change. Information on which clinical trials are ongoing can be found on www.clinicaltrials.gov and you should ask your physician for newest updates. Some drugs that are used to treat other conditions have also been tested for NASH. Based on their effects demonstrated by liver biopsy, the following drugs seem to have some efficacy. – Vitamin E showed promise, but only in patients without cirrhosis and without T2D. Given long-term and at high doses, however, vitamin E potentially had negative effects and some data indicate that it could increase the risk of early death and certain cancers. – Pioglitazone, which is approved for the treatment of diabetes, showed promise for NASH in patients with diabetes and pre-diabetes. Side effects such as weight gain and bone fractures should be considered. – Liraglutide and semaglutide are approved for the treatment of obesity and for diabetes. They have also shown promise in reducing liver fat and inflammation in NASH and will be evaluated further. Important: all these drugs must be discussed with your doctor and can harm when self-administered. Future available drugs will be an add-on therapy because lifestyle changes are essential as NAFLD is mainly a lifestyle-related disease. Bariatric surgery very effectively achieves weight loss and weight loss maintenance in patients with obesity. The agreed criteria for the surgical management of obesity and metabolic disorders (BMI ≥40kg/m2 or BMI ≥35kg/m2 with complicating disorders, no resolution after medical treatment) are also applicable for NAFLD. Patients with a BMI of 30–35 kg/m2 who also have T2D that is not adequately controlled by medical therapy may also be candidates for surgery. It is important to know that the change in the anatomy by bariatric surgery can lead to the need of lifelong follow up and this should be considered in discussing this option for patients. If you wonder whether vitamin E, the above-mentioned drugs or bariatric surgery could be helpful for you, please consult your doctor and discuss the potential risks and benefits. Any treatment decision should be based on your individual situation and medical history

You can only produce an answer using the context provided to you.

Which batteries are in the early stages of commercialisation?

Chapter 4: Batteries for Grid Applications Overview Batteries are devices that store energy chemically. This report focuses on “secondary” batteries, which must be charged before use and which can be discharged and recharged (cycled) many times before the end of their useful life. For electric power grid applications, there are four main battery types of interest:  Lead-acid  High temperature “sodium-beta”  Liquid electrolyte “flow” batteries  Other emerging chemistries84 Lead-acid batteries have been used for more than a century in grid applications and in conventional vehicles for starting, lighting, and ignition (SLI). They continue to be the technology of choice for vehicle SLI applications due to their low cost. Consequently, they are manufactured on a mass scale. In 2010, approximately 120 million lead-acid batteries were shipped in North America alone.85 Lead-acid batteries are commonly used by utilities to serve as uninterruptible power supplies in substations, and have been used at utility scale in several demonstration projects to provide grid support.86 Use of lead acid batteries for grid applications is limited by relatively short cycle life. R&D efforts are focused on improved cycle-life, which could result in greater use in utility-scale applications. Sodium-beta batteries include sodium-sulfur (NaS) units, first developed in the 1960s,87 and commercially available from a single vendor (NGK Insulators, Ltd.) in Japan with over 270 MW deployed worldwide.88 A NaS battery was first deployed in the United States in 2002. 89 There are now a number of U.S. demonstration projects, including several listed in Table 3. The focus of NaS deployments in the United States has been in electric distribution deferral projects, acting to reduce peak demand on distribution systems, but they also can serve multiple grid support services. An alternative high-temperature battery, sodium-nickel-chloride, is in the early stages of commercialization. “Flow” batteries, in which a liquid electrolyte flows through a chemical cell to produce electricity, are in the early stages of commercialization. In grid applications there has been some deployment of two types of flow battery: vanadium redox and zinc-bromide. There are a number of international installations of vanadium redox units, including a 250 kW installation in the United States to relieve a congested transmission line. 91 There are also a number of zinc-bromine demonstration projects.92 Several other flow battery chemistries have been pursued or are under development, but are less mature. In addition to the three battery types discussed above, there are several emerging technologies based on new battery chemistries which may also have potential in grid applications. Several of these emerging technologies are being supported by DOE efforts such as ARPA-E and are discussed briefly in the R&D section of this chapter. Technology Description and Performance Lead-Acid The lead-acid battery consists of a lead dioxide positive electrode (cathode), a lead negative electrode (anode), and an aqueous sulfuric acid electrolyte which carries the charge between the two. During discharge, each electrode is converted to lead sulfate, consuming sulfuric acid from the electrolyte. When recharging, the lead sulfate is converted back to sulfuric acid, leaving a layer of lead dioxide on the cathode and pure lead on the anode. In such conventional “wet” (flooded) cells, water in the electrolyte is broken down to hydrogen and oxygen during the charging process. In a vented wet cell design, these gases escape into the atmosphere, requiring the occasional addition of water to the system. In sealed wet cell designs, the loss of these gases is prevented and their conversion back to water is possible, reducing maintenance requirements. However, if the battery is overcharged or charged too quickly, the rate of gas generation can surpass that of water recombination, which can cause an explosion. In “valve regulated gel” designs, silica is added to the electrolyte to cause it to gel. In “absorbed glass mat” designs, the electrolyte is suspended in a fiberglass mat. The latter are sometimes referred to as “dry” because the fiberglass mat is not completely saturated with acid and there is no excess liquid. Both designs operate under slight constant pressure. Both also eliminate the risk of electrolyte leakage and offer improved safety by using valves to regulate internal pressure due to gas build up, but at significantly higher cost than wet cells described above.93 Lead-acid is currently the lowest-cost battery chemistry on a dollar-per-kWh basis. However, it also has relatively low specific energy (energy per unit mass) on the order of 35 Wh/kg and relatively poor “cycle life,” which is the number of charge-discharge cycles it can provide before its capacity falls too far below a certain percentage (e.g., 80%) of its initial capacity. While the low energy density of lead-acid will likely limit its use in transportation applications, increase in cycle life could make lead-acid cost-effective in grid applications. The cycle life of lead-acid batteries is highly dependent on both the rate and depth of discharge due to corrosion and material shedding off of electrode plates inside the battery. High depth of discharge (DoD) operation intensifies both issues. At 100% DoD (discharging the battery completely) cycle life can be less than 100 full cycles for some lead-acid technologies. During high rate, partial state-of-charge operation, lead sulfate accumulation on the anode can be the primary cause of degradation. These processes are also sensitive to high temperature, where the rule of thumb is to reduce battery life by half for every 8°C (14°F) increase in temperature above ambient. 94 Manufacturers’ warrantees provide some indication of minimum performance expectations, with service life of three to five years for deep cycle batteries, designed to be mostly discharged time after time. SLI batteries in cars have expected service lives of five to seven years, with up to 30 discharges per year depending on the rate of discharge. Temperature also affects capacity, with a battery at -4°C (25°F) having between roughly 70% and 80% of the capacity of a battery at 24°C (75°F).95 For many applications of lead-acid batteries, including SLI and uninterruptible power supply (UPS), efficiency of the batteries is relatively unimportant. One estimate for the DC-DC (direct current) efficiency of utility-scale lead acid battery is 81%, and AC-AC (alternating current) efficiency of 70%-72%.9 High Temperature Sodium-Beta Sodium-beta batteries use molten (liquid) sodium for the anode, with sodium ions transporting the electric charge. The two main types of sodium-beta batteries are distinguished by the type of cathode they use. The sodium-sulfur (Na-S) type employs a liquid sulfur cathode, while the sodium-nickel chloride (Na-NiCl2) type employs a solid metal chloride cathode. Both types include a beta-alumina solid electrolyte material separating the cathode and anode. This ceramic material offers ionic conductivity similar to that of typical aqueous electrolytes, but only at high temperature. Consequently, sodium-beta batteries ordinarily must operate at temperatures around 300°C (572°F). 97 The impermeability of the solid electrolyte to liquid electrodes and its minimal electrical conductivity eliminates self discharge and allows high efficiency.98 Technical challenges associated with sodium-beta battery chemistry generally stem from the high temperature requirements. To maintain a 300°C operating point the battery must have insulation and active heating. If it is not maintained at such a temperature, the resulting freeze-thaw cycles and thermal expansion can lead to mechanical stresses, damaging seals and other cell components, including the electrolyte. 99 The fragile nature of the electrolyte is also a concern, particularly for Na-S cells. In the event of damage to the solid electrolyte, a breach could allow the two liquid electrodes to mix, possibly causing an explosion and fire. 100 Na-S batteries are manufactured commercially for a variety of grid services ranging from shortterm rapid discharge services to long-term energy management services.101 The DC-DC efficiency is about 85%. Calculation of the AC-AC efficiency is complicated by the need for additional heating. The standby heat loss for each 50 kW module is between 2.2 and 3.4 kW. As a result of this heat loss, plus losses in the power conversion equipment, the AC-AC efficiency for loadleveling services is estimated in the range of 75%-80%.102 Expected service life is 15 years at 90% DoD and 4500 cycles.103 The primary sodium-beta alternative to the Na-S chemistry, the Na-NiCl2 cell (typically called the ZEBRA cell).104 Although ZEBRA batteries have been under development for over 20 years, they are only in the early stages of commercialization. 105 Nickel chloride cathodes offer several potential advantages including higher operating voltage, increased operational temperature range (due in part to the lower melting point of the secondary electrolyte), a slightly less corrosive cathode, and somewhat safer cell construction, since handling of metallic sodium—which is potentially explosive—can be avoided. 106 They are likely to offer a slightly reduced energy density.107

Context: Chapter 4: Batteries for Grid Applications Overview Batteries are devices that store energy chemically. This report focuses on “secondary” batteries, which must be charged before use and which can be discharged and recharged (cycled) many times before the end of their useful life. For electric power grid applications, there are four main battery types of interest:  Lead-acid  High temperature “sodium-beta”  Liquid electrolyte “flow” batteries  Other emerging chemistries84 Lead-acid batteries have been used for more than a century in grid applications and in conventional vehicles for starting, lighting, and ignition (SLI). They continue to be the technology of choice for vehicle SLI applications due to their low cost. Consequently, they are manufactured on a mass scale. In 2010, approximately 120 million lead-acid batteries were shipped in North America alone.85 Lead-acid batteries are commonly used by utilities to serve as uninterruptible power supplies in substations, and have been used at utility scale in several demonstration projects to provide grid support.86 Use of lead acid batteries for grid applications is limited by relatively short cycle life. R&D efforts are focused on improved cycle-life, which could result in greater use in utility-scale applications. Sodium-beta batteries include sodium-sulfur (NaS) units, first developed in the 1960s,87 and commercially available from a single vendor (NGK Insulators, Ltd.) in Japan with over 270 MW deployed worldwide.88 A NaS battery was first deployed in the United States in 2002. 89 There are now a number of U.S. demonstration projects, including several listed in Table 3. The focus of NaS deployments in the United States has been in electric distribution deferral projects, acting to reduce peak demand on distribution systems, but they also can serve multiple grid support services. An alternative high-temperature battery, sodium-nickel-chloride, is in the early stages of commercialization. “Flow” batteries, in which a liquid electrolyte flows through a chemical cell to produce electricity, are in the early stages of commercialization. In grid applications there has been some deployment of two types of flow battery: vanadium redox and zinc-bromide. There are a number of international installations of vanadium redox units, including a 250 kW installation in the United States to relieve a congested transmission line. 91 There are also a number of zinc-bromine demonstration projects.92 Several other flow battery chemistries have been pursued or are under development, but are less mature. In addition to the three battery types discussed above, there are several emerging technologies based on new battery chemistries which may also have potential in grid applications. Several of these emerging technologies are being supported by DOE efforts such as ARPA-E and are discussed briefly in the R&D section of this chapter. Technology Description and Performance Lead-Acid The lead-acid battery consists of a lead dioxide positive electrode (cathode), a lead negative electrode (anode), and an aqueous sulfuric acid electrolyte which carries the charge between the two. During discharge, each electrode is converted to lead sulfate, consuming sulfuric acid from the electrolyte. When recharging, the lead sulfate is converted back to sulfuric acid, leaving a layer of lead dioxide on the cathode and pure lead on the anode. In such conventional “wet” (flooded) cells, water in the electrolyte is broken down to hydrogen and oxygen during the charging process. In a vented wet cell design, these gases escape into the atmosphere, requiring the occasional addition of water to the system. In sealed wet cell designs, the loss of these gases is prevented and their conversion back to water is possible, reducing maintenance requirements. However, if the battery is overcharged or charged too quickly, the rate of gas generation can surpass that of water recombination, which can cause an explosion. In “valve regulated gel” designs, silica is added to the electrolyte to cause it to gel. In “absorbed glass mat” designs, the electrolyte is suspended in a fiberglass mat. The latter are sometimes referred to as “dry” because the fiberglass mat is not completely saturated with acid and there is no excess liquid. Both designs operate under slight constant pressure. Both also eliminate the risk of electrolyte leakage and offer improved safety by using valves to regulate internal pressure due to gas build up, but at significantly higher cost than wet cells described above.93 Lead-acid is currently the lowest-cost battery chemistry on a dollar-per-kWh basis. However, it also has relatively low specific energy (energy per unit mass) on the order of 35 Wh/kg and relatively poor “cycle life,” which is the number of charge-discharge cycles it can provide before its capacity falls too far below a certain percentage (e.g., 80%) of its initial capacity. While the low energy density of lead-acid will likely limit its use in transportation applications, increase in cycle life could make lead-acid cost-effective in grid applications. The cycle life of lead-acid batteries is highly dependent on both the rate and depth of discharge due to corrosion and material shedding off of electrode plates inside the battery. High depth of discharge (DoD) operation intensifies both issues. At 100% DoD (discharging the battery completely) cycle life can be less than 100 full cycles for some lead-acid technologies. During high rate, partial state-of-charge operation, lead sulfate accumulation on the anode can be the primary cause of degradation. These processes are also sensitive to high temperature, where the rule of thumb is to reduce battery life by half for every 8°C (14°F) increase in temperature above ambient. 94 Manufacturers’ warrantees provide some indication of minimum performance expectations, with service life of three to five years for deep cycle batteries, designed to be mostly discharged time after time. SLI batteries in cars have expected service lives of five to seven years, with up to 30 discharges per year depending on the rate of discharge. Temperature also affects capacity, with a battery at -4°C (25°F) having between roughly 70% and 80% of the capacity of a battery at 24°C (75°F).95 For many applications of lead-acid batteries, including SLI and uninterruptible power supply (UPS), efficiency of the batteries is relatively unimportant. One estimate for the DC-DC (direct current) efficiency of utility-scale lead acid battery is 81%, and AC-AC (alternating current) efficiency of 70%-72%.9 High Temperature Sodium-Beta Sodium-beta batteries use molten (liquid) sodium for the anode, with sodium ions transporting the electric charge. The two main types of sodium-beta batteries are distinguished by the type of cathode they use. The sodium-sulfur (Na-S) type employs a liquid sulfur cathode, while the sodium-nickel chloride (Na-NiCl2) type employs a solid metal chloride cathode. Both types include a beta-alumina solid electrolyte material separating the cathode and anode. This ceramic material offers ionic conductivity similar to that of typical aqueous electrolytes, but only at high temperature. Consequently, sodium-beta batteries ordinarily must operate at temperatures around 300°C (572°F). 97 The impermeability of the solid electrolyte to liquid electrodes and its minimal electrical conductivity eliminates self discharge and allows high efficiency.98 Technical challenges associated with sodium-beta battery chemistry generally stem from the high temperature requirements. To maintain a 300°C operating point the battery must have insulation and active heating. If it is not maintained at such a temperature, the resulting freeze-thaw cycles and thermal expansion can lead to mechanical stresses, damaging seals and other cell components, including the electrolyte. 99 The fragile nature of the electrolyte is also a concern, particularly for Na-S cells. In the event of damage to the solid electrolyte, a breach could allow the two liquid electrodes to mix, possibly causing an explosion and fire. 100 Na-S batteries are manufactured commercially for a variety of grid services ranging from shortterm rapid discharge services to long-term energy management services.101 The DC-DC efficiency is about 85%. Calculation of the AC-AC efficiency is complicated by the need for additional heating. The standby heat loss for each 50 kW module is between 2.2 and 3.4 kW. As a result of this heat loss, plus losses in the power conversion equipment, the AC-AC efficiency for loadleveling services is estimated in the range of 75%-80%.102 Expected service life is 15 years at 90% DoD and 4500 cycles.103 The primary sodium-beta alternative to the Na-S chemistry, the Na-NiCl2 cell (typically called the ZEBRA cell).104 Although ZEBRA batteries have been under development for over 20 years, they are only in the early stages of commercialization. 105 Nickel chloride cathodes offer several potential advantages including higher operating voltage, increased operational temperature range (due in part to the lower melting point of the secondary electrolyte), a slightly less corrosive cathode, and somewhat safer cell construction, since handling of metallic sodium—which is potentially explosive—can be avoided. 106 They are likely to offer a slightly reduced energy density.107 Question: Which batteries are in the early stages of commercialisation? System instruction: You can only produce an answer using the context provided to you.

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

How does interleaving improve sensitivity when compared to A/B tests? What does interleaving do better? Please explain in 4 sentences or less, and make sure there's no jargon.

Handles dilution from competitive pairs Interleaved designs also drive up sensitivity by showing if the experience exposed to the user is truly different between treatment and control. An interleaved design generates final output from two lists, allowing us to identify immediately whether those lists are too similar, as shown in Figure 4 below. In most machine learning applications, different modeling approaches are improvings things on the margin. In many cases, the search results returned by two rankers will largely overlap. An interleaved design lets us measure this overlap and analyze the data for competitive pairs — where rankers disagree on the recommendation — which leads to a signal boost. Figure 4: The original lists used here in interleaving are essentially identical except for the last elements. This means that if a user clicks on any of the top four choices, they are not actually contributing to signaling which ranker is preferred. Handles dilution from non-engagement An interesting observation we made when looking at interleaved experiments – as well as search and ranking experiments in general – is that many user actions make it look as if the user is not paying attention or making any choices on the presented content. For instance, although we would generate a carousel with interleaved options, the user would not actively engage with the content and make a decision. As a result, including this data in interleaved analyses dilutes the signal. Here is another way to understand non-engagement. Let's say we present a user with two drinks – Coke and Pepsi – and ask them which they like more. If the user does not engage or refuses to try any options, it might indicate: The user is not interested in the presented results. The user is not in a decision-making mindset at the moment. While these are important insights, examining data from this undifferentiated feedback does not help to determine user preference or understand which drink is preferred. Attention and non-engagement is a fascinating research subject; many folks approach it by looking at additional metrics such as dwell time or how often a user backtracks as per Chucklin and Rijke, 2016. Fortunately, interleaving allows us to identify non-engagement more effectively so that we may remove impressions that are not meaningful. If a user does not take an action, we simply remove the exposure rather than marking the performance of the interleaved ranker as a tie.ctively so that we may remove impressions that are not meaningful. If a user does not take an action, we simply remove the exposure rather than marking the performance of the interleaved ranker as a tie. A/B tests can't effectively address non-engagement because they treat all data equally, including non-engaged interactions, which dilutes the signal and obscures true user preferences. Results Table 2 shows results across five online experiments in which we provide the average relative sensitivity improvement across different methods relative to an A/B setup. Across several experiments, we found that removing dilution helped boost interleaving sensitivity even more, which leads to much smaller required sample sizes. These results were so surprising even to us that we had to stop several times to conduct additional A/A tests to validate that we had not introduced a bug in our SDK, analysis pipeline, or metrics computation. Experiment Vanilla Interleaving Vanilla Interleaving + Removing Dilution % Traffic Used Exp 1 34x 282x <5% Exp 2 67x 482x <5% Exp 3 68x 312x <5% Exp 4 109x 545x <5% Exp 5 60x 301x <5% Avg Improvement ~67x ~384x Table 2: We observed very large sensitivity gains across several experiments. Overall, removing dilution helped improve sensitivity even more. Note that we observed these results while interleaving traffic was getting 1/20th of the A/B traffic. It’s important to highlight that the sensitivity improvement depends on the metric. For clickthrough rate, we have observed half of the sensitivity boost observed in the checkout-conversion metric. Nonetheless, across all use cases we found that removing dilutive exposures drives very large gains in sensitivity.

"================ <TEXT PASSAGE> ======= Handles dilution from competitive pairs Interleaved designs also drive up sensitivity by showing if the experience exposed to the user is truly different between treatment and control. An interleaved design generates final output from two lists, allowing us to identify immediately whether those lists are too similar, as shown in Figure 4 below. In most machine learning applications, different modeling approaches are improvings things on the margin. In many cases, the search results returned by two rankers will largely overlap. An interleaved design lets us measure this overlap and analyze the data for competitive pairs — where rankers disagree on the recommendation — which leads to a signal boost. Figure 4: The original lists used here in interleaving are essentially identical except for the last elements. This means that if a user clicks on any of the top four choices, they are not actually contributing to signaling which ranker is preferred. Handles dilution from non-engagement An interesting observation we made when looking at interleaved experiments – as well as search and ranking experiments in general – is that many user actions make it look as if the user is not paying attention or making any choices on the presented content. For instance, although we would generate a carousel with interleaved options, the user would not actively engage with the content and make a decision. As a result, including this data in interleaved analyses dilutes the signal. Here is another way to understand non-engagement. Let's say we present a user with two drinks – Coke and Pepsi – and ask them which they like more. If the user does not engage or refuses to try any options, it might indicate: The user is not interested in the presented results. The user is not in a decision-making mindset at the moment. While these are important insights, examining data from this undifferentiated feedback does not help to determine user preference or understand which drink is preferred. Attention and non-engagement is a fascinating research subject; many folks approach it by looking at additional metrics such as dwell time or how often a user backtracks as per Chucklin and Rijke, 2016. Fortunately, interleaving allows us to identify non-engagement more effectively so that we may remove impressions that are not meaningful. If a user does not take an action, we simply remove the exposure rather than marking the performance of the interleaved ranker as a tie.ctively so that we may remove impressions that are not meaningful. If a user does not take an action, we simply remove the exposure rather than marking the performance of the interleaved ranker as a tie. A/B tests can't effectively address non-engagement because they treat all data equally, including non-engaged interactions, which dilutes the signal and obscures true user preferences. Results Table 2 shows results across five online experiments in which we provide the average relative sensitivity improvement across different methods relative to an A/B setup. Across several experiments, we found that removing dilution helped boost interleaving sensitivity even more, which leads to much smaller required sample sizes. These results were so surprising even to us that we had to stop several times to conduct additional A/A tests to validate that we had not introduced a bug in our SDK, analysis pipeline, or metrics computation. Experiment Vanilla Interleaving Vanilla Interleaving + Removing Dilution % Traffic Used Exp 1 34x 282x <5% Exp 2 67x 482x <5% Exp 3 68x 312x <5% Exp 4 109x 545x <5% Exp 5 60x 301x <5% Avg Improvement ~67x ~384x Table 2: We observed very large sensitivity gains across several experiments. Overall, removing dilution helped improve sensitivity even more. Note that we observed these results while interleaving traffic was getting 1/20th of the A/B traffic. It’s important to highlight that the sensitivity improvement depends on the metric. For clickthrough rate, we have observed half of the sensitivity boost observed in the checkout-conversion metric. Nonetheless, across all use cases we found that removing dilutive exposures drives very large gains in sensitivity. https://careers.doordash.com/blog/doordash-experimentation-with-interleaving-designs/ ================ <QUESTION> ======= How does interleaving improve sensitivity when compared to A/B tests? What does interleaving do better? Please explain in 4 sentences or less, and make sure there's no jargon. ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. [user request] [context document]

My husband is applying for an FHA mortgage loan. We don't have any creditor accounts together. He has a good job, but doesn't have a credit score. He pays the rent that includes our water bill. I pay the electric bill and our cell phones in my name. He pays day care every month in cash and has an agreement to pay my brother-in-law for a buy-here-pay-here car note every month with a money order. Neither of us have bank accounts. Is there anything we can use as credit for him since none of this shows on his credit report?

Credit Requirements (A) General Credit Requirements FHA’s general credit policy requires Lenders to analyze the Borrower’s credit history, liabilities, and debts to determine creditworthiness. The Lender must obtain a merged credit report from an independent consumer reporting agency. The Lender must obtain a credit report for each Borrower who will be obligated on the loan Note. The Lender may obtain a joint report for individuals with joint accounts. Before making a determination on the creditworthiness of an applicant, a Lender must conduct an interview to resolve any material discrepancies between the information on the loan application and information on the credit report to determine accurate and complete information. The Lender is not required to obtain a credit report for non-credit qualifying Streamline Refinance transactions. (B) Types of Credit History (1) Traditional Credit Lenders must pull a credit report that draws and merges information from three national credit bureaus. Lenders are prohibited from developing non-traditional credit history to use in place of a traditional credit report. If the credit report generates a credit score, the Lender must utilize traditional credit history. (a) Requirements for the Credit Report Credit reports must obtain all information from three credit repositories pertaining to credit, residence history, and public records information; be in an easy to read and understandable format; and not require code translations. The credit report may not contain whiteouts, erasures, or alterations. The Lender must retain copies of all credit reports. The credit report must include: the name of the Lender ordering the report; the name, address, and telephone number of the consumer reporting agency; the name and SSN of each Borrower; and the primary repository from which any particular information was pulled, for each account listed. A truncated SSN is acceptable for FHA loan insurance purposes provided that the loan application captures the full nine-digit SSN. The credit report must also include: all inquiries made within the last 90 Days; all credit and legal information not considered obsolete under the FCRA, including information for the last seven years regarding: bankruptcies; Judgments; lawsuits; foreclosures; and tax liens; and for each Borrower debt listed: the date the account was opened; high credit amount; required monthly payment amount; unpaid balance; and payment history. (b) Updated Credit Report or Supplement to the Credit Report The Lender must obtain an updated credit report or supplement if the underwriter identifies material inconsistencies between any information in the case binder and the original credit report. (2) Non-traditional Credit For Borrowers without a credit score, the Lender must independently develop the Borrower’s credit history using the requirements outlined below. (a) Independent Verification of Non-traditional Credit Providers The Lender may independently verify the Borrower’s credit references by documenting the existence of the credit provider and that the provider extended credit to the Borrower. To verify the existence of each credit provider, the Lender must review public records from the state, county, or city or other documents providing a similar level of objective information. To verify credit information, the Lender must: use a published address or telephone number for the credit provider and not rely solely on information provided by the applicant; and obtain the most recent 12 months of canceled checks, or equivalent proof of payment, demonstrating the timing of payment to the credit provider. To verify the Borrower’s rental payment history, the Lender must obtain a rental reference from the appropriate rental management company or landlord, demonstrating the timing of payment for the most recent 12 months in lieu of 12 months of canceled checks or equivalent proof of payment. (b) Sufficiency of Non-traditional Credit References To be sufficient to establish the Borrower’s credit, the non-traditional credit history must include three credit references, including at least one of the following: rental housing payments (subject to independent verification if the Borrower is a renter); telephone service; or utility company reference (if not included in the rental housing payment), including: gas; electricity; water; television service; or Internet service. If the Lender cannot obtain all three credit references from the list above, the Lender may use the following sources of unreported recurring debt: insurance premiums not payroll deducted (e.g., medical, auto, life, renter’s insurance); payment to child care providers made to businesses that provide such services; school tuition; retail store credit cards (e.g., from department, furniture, or appliance stores, or specialty stores); rent-to-own (e.g., furniture, appliances); payment of that part of medical bills not covered by insurance; a documented 12-month history of savings evidenced by regular deposits resulting in an increased balance to the account that: were made at least quarterly; were not payroll deducted; and caused no Insufficient Funds (NSF) checks; an automobile lease; a personal loan from an individual with repayment terms in writing and supported by canceled checks to document the payments; or a documented 12-month history of payment by the Borrower on an account for which the Borrower is an authorized user.

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. My husband is applying for an FHA mortgage loan. We don't have any creditor accounts together. He has a good job, but doesn't have a credit score. He pays the rent that includes our water bill. I pay the electric bill and our cell phones in my name. He pays day care every month in cash and has an agreement to pay my brother-in-law for a buy-here-pay-here car note every month with a money order. Neither of us have bank accounts. Is there anything we can use as credit for him since none of this shows on his credit report? Credit Requirements (A) General Credit Requirements FHA’s general credit policy requires Lenders to analyze the Borrower’s credit history, liabilities, and debts to determine creditworthiness. The Lender must obtain a merged credit report from an independent consumer reporting agency. The Lender must obtain a credit report for each Borrower who will be obligated on the loan Note. The Lender may obtain a joint report for individuals with joint accounts. Before making a determination on the creditworthiness of an applicant, a Lender must conduct an interview to resolve any material discrepancies between the information on the loan application and information on the credit report to determine accurate and complete information. The Lender is not required to obtain a credit report for non-credit qualifying Streamline Refinance transactions. (B) Types of Credit History (1) Traditional Credit Lenders must pull a credit report that draws and merges information from three national credit bureaus. Lenders are prohibited from developing non-traditional credit history to use in place of a traditional credit report. If the credit report generates a credit score, the Lender must utilize traditional credit history. (a) Requirements for the Credit Report Credit reports must obtain all information from three credit repositories pertaining to credit, residence history, and public records information; be in an easy to read and understandable format; and not require code translations. The credit report may not contain whiteouts, erasures, or alterations. The Lender must retain copies of all credit reports. The credit report must include: the name of the Lender ordering the report; the name, address, and telephone number of the consumer reporting agency; the name and SSN of each Borrower; and the primary repository from which any particular information was pulled, for each account listed. A truncated SSN is acceptable for FHA loan insurance purposes provided that the loan application captures the full nine-digit SSN. The credit report must also include: all inquiries made within the last 90 Days; all credit and legal information not considered obsolete under the FCRA, including information for the last seven years regarding: bankruptcies; Judgments; lawsuits; foreclosures; and tax liens; and for each Borrower debt listed: the date the account was opened; high credit amount; required monthly payment amount; unpaid balance; and payment history. (b) Updated Credit Report or Supplement to the Credit Report The Lender must obtain an updated credit report or supplement if the underwriter identifies material inconsistencies between any information in the case binder and the original credit report. (2) Non-traditional Credit For Borrowers without a credit score, the Lender must independently develop the Borrower’s credit history using the requirements outlined below. (a) Independent Verification of Non-traditional Credit Providers The Lender may independently verify the Borrower’s credit references by documenting the existence of the credit provider and that the provider extended credit to the Borrower. To verify the existence of each credit provider, the Lender must review public records from the state, county, or city or other documents providing a similar level of objective information. To verify credit information, the Lender must: use a published address or telephone number for the credit provider and not rely solely on information provided by the applicant; and obtain the most recent 12 months of canceled checks, or equivalent proof of payment, demonstrating the timing of payment to the credit provider. To verify the Borrower’s rental payment history, the Lender must obtain a rental reference from the appropriate rental management company or landlord, demonstrating the timing of payment for the most recent 12 months in lieu of 12 months of canceled checks or equivalent proof of payment. (b) Sufficiency of Non-traditional Credit References To be sufficient to establish the Borrower’s credit, the non-traditional credit history must include three credit references, including at least one of the following: rental housing payments (subject to independent verification if the Borrower is a renter); telephone service; or utility company reference (if not included in the rental housing payment), including: gas; electricity; water; television service; or Internet service. If the Lender cannot obtain all three credit references from the list above, the Lender may use the following sources of unreported recurring debt: insurance premiums not payroll deducted (e.g., medical, auto, life, renter’s insurance); payment to child care providers made to businesses that provide such services; school tuition; retail store credit cards (e.g., from department, furniture, or appliance stores, or specialty stores); rent-to-own (e.g., furniture, appliances); payment of that part of medical bills not covered by insurance; a documented 12-month history of savings evidenced by regular deposits resulting in an increased balance to the account that: were made at least quarterly; were not payroll deducted; and caused no Insufficient Funds (NSF) checks; an automobile lease; a personal loan from an individual with repayment terms in writing and supported by canceled checks to document the payments; or a documented 12-month history of payment by the Borrower on an account for which the Borrower is an authorized user. https://www.hud.gov/sites/dfiles/OCHCO/documents/40001-hsgh-update15-052024.pdf

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. [user request] [context document]

What is compound interest savings? Can i get rich with this? explain the formula and use it to figure out how much I can save by putting away 5000 a year.

Compound interest is a powerful force for consumers looking to build their savings. It creates a multiplier effect on your money that can help it grow more over time. Knowing how it works and how often your bank compounds interest can help you make smarter decisions about where to put your money. The definition of compound interest In simple terms, the compound interest definition is the interest you earn on interest. With a savings account, money market account or CD that earns compound interest, you earn interest on the principal (the initial amount deposited) plus on the interest that accumulates over time. That’s much more valuable than simple interest, which only pays interest on the deposit. How does compound interest work? Many savings accounts and money market accounts, as well as investments, pay compound interest. As a saver or investor, you receive the interest payments on a set schedule: daily, monthly, quarterly or annually. A basic savings account, for example, might compound interest daily, weekly or monthly. When you add money to a savings account or a similar account, you receive interest based on the amount that you deposited. For example, if you deposit $1,000 in an account that pays 1 percent annual interest, you’d earn $10 in interest after a year. Thanks to compound interest, in the second year you’d earn 1 percent on $1,010 — the principal plus the interest, or $10.10 in interest payouts for the year. Compound interest accelerates your interest earnings, helping your savings grow more quickly. Over time, you’ll earn interest on ever-larger account balances that have grown with the help of interest earned in prior years, and therefore steadily increase earnings. To get a deeper understanding of how compounding impacts your savings, the formula for compound interest is: Initial balance × ( 1 + ( interest rate / number of compoundings per period )number of compoundings per period multiplied by number of periods To see how the formula works, consider this example: You have $100,000 in two savings accounts, each paying 2 percent interest. One account compounds interest annually while the other compounds the interest daily. You wait one year and withdraw your money from both accounts. From the first account, which compounds interest just once a year, you’ll receive: $100,000 × ( 1 + ( .02 / 1 )1 × 1 = $102,000 From the second account, which compounds interest each day, you’ll receive: $100,000 × ( 1 + ( .02 / 365 )365 × 1 = $102,020.08 Because the interest you earn each day in the second example also earns interest on the days that follow, you earn an extra $20.08 compared with the account that compounds interest annually. Over the long term, the impacts of compound interest become greater because you’re earning interest on larger account balances that resulted from years of earning interest on previous interest earnings. If you left your money in the account for 30 years, for example, the ending balances would look like this. For annual compounding: $100,000 × ( 1 + ( .02 / 1 )1 × 30 = $181,136.16 For daily compounding: $100,000 × ( 1 + ( .02 / 365 )365 × 30 = $182,208.88 Over the 30-year period, compound interest did all the work for you. That initial $100,000 deposit nearly doubled. Depending on how frequently your money was compounding, your account balance grew to more than $181,000 or $182,000. And daily compounding earned you an extra $1,072.72, or more than $35 a year. The interest rate you earn on your money also has a major impact on the power of compounding. If the savings account paid 5 percent annually instead of 2 percent, the ending balances would look like: 1 year 30 years Annual compounding $105,000.00 $432,194.24 Daily compounding $105,126.75 $448,122.87 The higher the interest rate, the greater the difference between ending balances based on the frequency of compounding. Bankrate’s compound interest calculator can help you calculate how much interest you’ll earn from different accounts. How to take advantage of compound interest There are two simple ways that consumers can take advantage of compound interest. 1. Save early The power of compounding interest comes from time. The longer you leave your money in a savings account or invested in the market, the more interest it can accrue. The more time your money stays in the account, the more compounding can occur, meaning you get to earn additional interest on the earned interest. Consider an example of someone who saves $10,000 a year for 10 years, and then stops saving, compared to someone who saves $2,500 a year for 40 years. Assuming both savers earn 7 percent annual returns, compounded daily, here’s how much they will have at the end of 40 years. Saves $10,000 a year for 10 years, then nothing for 30 years Saves $2,500 a year for 40 years $1,388,623 $612,116 Both people put away the same $100,000 overall amount, but the person who saved more earlier winds up with far more at the end of the 40 years. Even someone who saves $200,000, or twice as much over the full 40 years, winds up with less — $1,224,232 — because a smaller amount was saved initially. 2. Check the APY When you’re shopping around for places to save, focus on looking at the APY. APY shows the effective interest rate of an account, including all of the compounding. If you put $1,000 in an account that pays 1 percent interest a year, you might wind up with more than $1,010 in the account after a year if the interest compounds more frequently than annually. Comparing the APY rather than the interest rate of two accounts will show which truly pays more interest. Some banks may offer only 0.01 percent compared to others that can offer 5 percent or more. This would be a significant difference in earnings over time. 3. Check the frequency of compounding When comparing accounts, don’t just look at APY. Also consider how frequently each compounds interest. The more often interest is compounded, the better. When comparing two accounts with the same interest rate, the one with more frequent compounding may have a higher yield, meaning it can pay more interest on the same account balance. Bottom line The advantage of compound interest lies in its ability to supplement savings over time. By understanding how it operates and considering factors like the interest rate, frequency of compounding and timeline of investments, savers can make the most of compound interest and look for the highest-earning accounts.

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. What is compound interest savings? Can i get rich with this? explain the formula and use it to figure out how much I can save by putting away 5000 a year. Compound interest is a powerful force for consumers looking to build their savings. It creates a multiplier effect on your money that can help it grow more over time. Knowing how it works and how often your bank compounds interest can help you make smarter decisions about where to put your money. The definition of compound interest In simple terms, the compound interest definition is the interest you earn on interest. With a savings account, money market account or CD that earns compound interest, you earn interest on the principal (the initial amount deposited) plus on the interest that accumulates over time. That’s much more valuable than simple interest, which only pays interest on the deposit. How does compound interest work? Many savings accounts and money market accounts, as well as investments, pay compound interest. As a saver or investor, you receive the interest payments on a set schedule: daily, monthly, quarterly or annually. A basic savings account, for example, might compound interest daily, weekly or monthly. When you add money to a savings account or a similar account, you receive interest based on the amount that you deposited. For example, if you deposit $1,000 in an account that pays 1 percent annual interest, you’d earn $10 in interest after a year. Thanks to compound interest, in the second year you’d earn 1 percent on $1,010 — the principal plus the interest, or $10.10 in interest payouts for the year. Compound interest accelerates your interest earnings, helping your savings grow more quickly. Over time, you’ll earn interest on ever-larger account balances that have grown with the help of interest earned in prior years, and therefore steadily increase earnings. To get a deeper understanding of how compounding impacts your savings, the formula for compound interest is: Initial balance × ( 1 + ( interest rate / number of compoundings per period )number of compoundings per period multiplied by number of periods To see how the formula works, consider this example: You have $100,000 in two savings accounts, each paying 2 percent interest. One account compounds interest annually while the other compounds the interest daily. You wait one year and withdraw your money from both accounts. From the first account, which compounds interest just once a year, you’ll receive: $100,000 × ( 1 + ( .02 / 1 )1 × 1 = $102,000 From the second account, which compounds interest each day, you’ll receive: $100,000 × ( 1 + ( .02 / 365 )365 × 1 = $102,020.08 Because the interest you earn each day in the second example also earns interest on the days that follow, you earn an extra $20.08 compared with the account that compounds interest annually. Over the long term, the impacts of compound interest become greater because you’re earning interest on larger account balances that resulted from years of earning interest on previous interest earnings. If you left your money in the account for 30 years, for example, the ending balances would look like this. For annual compounding: $100,000 × ( 1 + ( .02 / 1 )1 × 30 = $181,136.16 For daily compounding: $100,000 × ( 1 + ( .02 / 365 )365 × 30 = $182,208.88 Over the 30-year period, compound interest did all the work for you. That initial $100,000 deposit nearly doubled. Depending on how frequently your money was compounding, your account balance grew to more than $181,000 or $182,000. And daily compounding earned you an extra $1,072.72, or more than $35 a year. The interest rate you earn on your money also has a major impact on the power of compounding. If the savings account paid 5 percent annually instead of 2 percent, the ending balances would look like: 1 year 30 years Annual compounding $105,000.00 $432,194.24 Daily compounding $105,126.75 $448,122.87 The higher the interest rate, the greater the difference between ending balances based on the frequency of compounding. Bankrate’s compound interest calculator can help you calculate how much interest you’ll earn from different accounts. How to take advantage of compound interest There are two simple ways that consumers can take advantage of compound interest. 1. Save early The power of compounding interest comes from time. The longer you leave your money in a savings account or invested in the market, the more interest it can accrue. The more time your money stays in the account, the more compounding can occur, meaning you get to earn additional interest on the earned interest. Consider an example of someone who saves $10,000 a year for 10 years, and then stops saving, compared to someone who saves $2,500 a year for 40 years. Assuming both savers earn 7 percent annual returns, compounded daily, here’s how much they will have at the end of 40 years. Saves $10,000 a year for 10 years, then nothing for 30 years Saves $2,500 a year for 40 years $1,388,623 $612,116 Both people put away the same $100,000 overall amount, but the person who saved more earlier winds up with far more at the end of the 40 years. Even someone who saves $200,000, or twice as much over the full 40 years, winds up with less — $1,224,232 — because a smaller amount was saved initially. 2. Check the APY When you’re shopping around for places to save, focus on looking at the APY. APY shows the effective interest rate of an account, including all of the compounding. If you put $1,000 in an account that pays 1 percent interest a year, you might wind up with more than $1,010 in the account after a year if the interest compounds more frequently than annually. Comparing the APY rather than the interest rate of two accounts will show which truly pays more interest. Some banks may offer only 0.01 percent compared to others that can offer 5 percent or more. This would be a significant difference in earnings over time. 3. Check the frequency of compounding When comparing accounts, don’t just look at APY. Also consider how frequently each compounds interest. The more often interest is compounded, the better. When comparing two accounts with the same interest rate, the one with more frequent compounding may have a higher yield, meaning it can pay more interest on the same account balance. Bottom line The advantage of compound interest lies in its ability to supplement savings over time. By understanding how it operates and considering factors like the interest rate, frequency of compounding and timeline of investments, savers can make the most of compound interest and look for the highest-earning accounts. https://www.bankrate.com/banking/what-is-compound-interest/#how-to-take-advantage-of-compound-interest

You may use no source of information other than what is present in the "Source Text." This means you may NOT use any internal or external source of information; you may only use what is provided to answer questions and inform your responses.

Can you summerize what might interfere with a wifi signal?

PSCR UAS 1.0: Unmanned Aerial Systems Flight and Payload Challenge The inaugural UAS challenge took place in 2018 in Fredericksburg, Virginia. In this challenge, PSCR examined how engineering design tradeoffs for flight time and endurance capabilities affect the UAS while carrying a communications payload. This use case examined how a UAS could extend cellular network coverage to “boots on the ground” first responders in a communications-denied location. The challenge was to incorporate a payload that would mimic the weight of a small cellular system on a deployable UAS. UAS were required to achieve 90 minutes of hovering flight endurance while carrying defined payloads of 10, 15, and 20 lb (4.5, 6.8, and 9.1 kg), the typical weights for a small communications system. The total weight of the flight vehicle at liftoff had to be less than 55 lb (24.9 kg) to ensure portability and compliance with FAA regulations. The UAS also had to complete maneuvering and positioning tests as required in the NIST Open Test Lanes and Scenarios test methods with the various attached payloads. [10] The Open Test Lanes methodologies helped simulate and evaluate flight maneuvers, such as position-hold and yaw movements, that a UAS pilot may observe in a responder event. Evaluators used 2D and 3D fiducials as reference points and ground truths to assess each UAS with repeatable and measurable results. By performing these test procedures in an outdoor venue, PSCR could closely replicate the environment that a UAS may encounter while carrying essential communications equipment. In the UAS 1.0 challenge, PSCR found that hybrid fuel solutions, such as a battery and gasoline combination, performed the best. Multi-rotor and aircraft frames supportive of Vertical Takeoff and Landing (VTOL) greatly influenced the performance and accuracy of the aircraft's flight. Deficiencies that PSCR observed were mainly in the form of aircraft control and the need for further tuning of flight software to maintain and hold position. Essential loiter functions and automated flight mechanisms were challenging to maintain, possibly due to the developing UAS marketplace, the device’s prototype nature, and the design of the payload transport functionality. PSCR UAS 2.0: First Responder UAS Endurance Challenge The UAS 2.0 challenge continued the objectives of UAS 1.0 but focused more on endurance. Weight limitations were increased to include larger UAS with the expectation of better control, longer endurance, and innovative ideas. The use case for UAS 2.0 closely matched the communications functions presented in UAS 1.0 but contained an additional use case for longduration search and rescue scenarios. 13 NIST TN 2295 July 2024 The key design requirements in UAS 2.0 included a single payload weight of 10 lb (4.5 kg), which simulated the smallest available cellular network device. The final event took place between 2020 and 2021. Due to the global COVID-19 pandemic, each contestant performed the final event tasks and measurements within their team locality. The NIST-designed payload provided to the contestants for their final flights comprised an independent position data capture and dissemination system for test measurement and validation. As in UAS 1.0, contestants performed a hover endurance test and used the NIST Open Test Lanes as a ground truth measurement system as evaluation methodologies. Larger UAS sizes, up to 100 lb (45.3 kg), were permitted with the expectation of greater endurance, longer flight times over 90 minutes, and increased aircraft stability. Contestants had to provide evidence of airspace authorizations for aircraft weight and height operation exceptions from their respective governing authorities, e.g., FAA Certificate of Authorization. Mirroring the results of the first challenge, UAS with propulsion systems and multi-rotor hybrid battery-gasoline solutions performed the best. Novel propulsion systems, such as hydrogen fuel cells, were also demonstrated in the final event. Some contestants proposed fixed-wing VTOL UAS in the early competition stages, but these ideas failed to progress past theoretical design due to engineering complexity. Flight control and stability functions were also improved with a standard payload, providing more aircraft design flexibility. PSCR found that contestants who started with existing designs early in the competition or those who tested early and frequently had better success in later stages. The winning UAS solution consisted of a hex-rotor design with a hybrid electric-gasoline engine propulsion system. The maximum flight time of this solution in the final test event was approximately 112 minutes, with a total takeoff weight of 54.9 lb (24.9 kg.) PSCR UAS 3.0: First Responder UAS Triple Challenge The UAS 3.0 challenge aimed to create a multi-use, multi-payload UAS platform for first responder search and rescue use cases. The challenge comprised three distinct research challenges that ran concurrently. The final stage of these competitions took place concurrently in June of 2022 in Starkville, Mississippi. 4.3.1. PSCR UAS 3.1: First Responder UAS Triple Challenge: FastFind The design goals of UAS 3.1 focused on the use case of finding missing persons quickly in heavily forested areas. In this challenge, UAS required optical systems that could penetrate thick forest canopies and withstand environmental conditions and hazards. The UAS had to be rapidly deployable and endure the mission's duration. In the UAS 3.1 challenge, flight vehicles had to meet a weight requirement of 55 lb (24.9 kg) or less, including attachments or payloads. A five-point scale evaluated the flight autonomy of the aircraft, with each level describing a range of independence that required less pilot intervention. Additionally, real-time video had to be transmitted to the pilot's ground control station, while onboard recording was mandatory on the aircraft. The vehicles had to demonstrate the capability for degraded takeoff and landing while operating in environments not typically suited for 14 NIST TN 2295 July 2024 standard flight operations, such as areas with uneven surfaces, dirt, or gravel. The final scenario required all competitors to find multiple designated targets within a 60-minute timeframe. In the final event, contestants used adaptive search technologies, including real-time computer vision, machine learning, and human verification, to assist in finding targets. Competitors used one or multiple camera technologies, including infrared, thermal, and neutral-density optical filters, digital filters, and telephoto optical systems, to help expedite recovery time. One contestant utilized a novel technique called Airborne Optical Sectioning, which incorporates a form of synthetic aperture imaging to integrate multiple camera technologies to suppress occlusions computationally. [11] Environmental factors at the test location, including high heat and humidity, negatively affected the contestant’s aircraft performance and the optical systems' efficiency. These conditions also generated false positive matches by computer vision algorithms used in the search. 4.3.2. PSCR UAS 3.2: First Responder UAS Triple Challenge: LifeLink UAS 3.2 LifeLink evaluated techniques using a UAS to provide continuous broadband communications in a service-denied area. The UAS carried a communication relay system to extend communications with first responder stations on the ground. UAS 3.2 contained identical UAS requirements for weight, autonomy, takeoff, and landing conditions as UAS 3.1. Specific to the LifeLink challenge, each UAS was required to have a wireless Wi-Fi transceiver to transmit internet protocol data to responders on the ground and to a NISTprovided bandwidth measurement server. A Wi-Fi antenna or array attached to the UAS could enhance coverage by optimizing signal power and direction. Each contestant’s UAS was not limited beyond FAA Part 107 requirements; contestants could choose the optimal testing height for their solution. UAS designs in UAS 3.2 contained Wi-Fi configurations that could transmit simulated voice and data streams up to 800 ft (244 m) from the aircraft. Omnidirectional antennas provided optimal coverage and higher bandwidth speeds for areas with more first responders in a small, circular geographic area. Directional antenna configurations offered the best coverage for distancefocused applications when correctly oriented. When combined with repeater technology, the WiFi signal could transmit further, but each added repeater would diminish the bandwidth speeds. High heat, humid weather conditions, and forest foliage negatively impacted coverage, distance, and bandwidth speeds.

System Instructions: You may use no source of information other than what is present in the "Source Text." This means you may NOT use any internal or external source of information; you may only use what is provided to answer questions and inform your responses. --- User Query: Can you summerize what might interfere with a wifi signal? --- Source Text: PSCR UAS 1.0: Unmanned Aerial Systems Flight and Payload Challenge The inaugural UAS challenge took place in 2018 in Fredericksburg, Virginia. In this challenge, PSCR examined how engineering design tradeoffs for flight time and endurance capabilities affect the UAS while carrying a communications payload. This use case examined how a UAS could extend cellular network coverage to “boots on the ground” first responders in a communications-denied location. The challenge was to incorporate a payload that would mimic the weight of a small cellular system on a deployable UAS. UAS were required to achieve 90 minutes of hovering flight endurance while carrying defined payloads of 10, 15, and 20 lb (4.5, 6.8, and 9.1 kg), the typical weights for a small communications system. The total weight of the flight vehicle at liftoff had to be less than 55 lb (24.9 kg) to ensure portability and compliance with FAA regulations. The UAS also had to complete maneuvering and positioning tests as required in the NIST Open Test Lanes and Scenarios test methods with the various attached payloads. [10] The Open Test Lanes methodologies helped simulate and evaluate flight maneuvers, such as position-hold and yaw movements, that a UAS pilot may observe in a responder event. Evaluators used 2D and 3D fiducials as reference points and ground truths to assess each UAS with repeatable and measurable results. By performing these test procedures in an outdoor venue, PSCR could closely replicate the environment that a UAS may encounter while carrying essential communications equipment. In the UAS 1.0 challenge, PSCR found that hybrid fuel solutions, such as a battery and gasoline combination, performed the best. Multi-rotor and aircraft frames supportive of Vertical Takeoff and Landing (VTOL) greatly influenced the performance and accuracy of the aircraft's flight. Deficiencies that PSCR observed were mainly in the form of aircraft control and the need for further tuning of flight software to maintain and hold position. Essential loiter functions and automated flight mechanisms were challenging to maintain, possibly due to the developing UAS marketplace, the device’s prototype nature, and the design of the payload transport functionality. PSCR UAS 2.0: First Responder UAS Endurance Challenge The UAS 2.0 challenge continued the objectives of UAS 1.0 but focused more on endurance. Weight limitations were increased to include larger UAS with the expectation of better control, longer endurance, and innovative ideas. The use case for UAS 2.0 closely matched the communications functions presented in UAS 1.0 but contained an additional use case for longduration search and rescue scenarios. 13 NIST TN 2295 July 2024 The key design requirements in UAS 2.0 included a single payload weight of 10 lb (4.5 kg), which simulated the smallest available cellular network device. The final event took place between 2020 and 2021. Due to the global COVID-19 pandemic, each contestant performed the final event tasks and measurements within their team locality. The NIST-designed payload provided to the contestants for their final flights comprised an independent position data capture and dissemination system for test measurement and validation. As in UAS 1.0, contestants performed a hover endurance test and used the NIST Open Test Lanes as a ground truth measurement system as evaluation methodologies. Larger UAS sizes, up to 100 lb (45.3 kg), were permitted with the expectation of greater endurance, longer flight times over 90 minutes, and increased aircraft stability. Contestants had to provide evidence of airspace authorizations for aircraft weight and height operation exceptions from their respective governing authorities, e.g., FAA Certificate of Authorization. Mirroring the results of the first challenge, UAS with propulsion systems and multi-rotor hybrid battery-gasoline solutions performed the best. Novel propulsion systems, such as hydrogen fuel cells, were also demonstrated in the final event. Some contestants proposed fixed-wing VTOL UAS in the early competition stages, but these ideas failed to progress past theoretical design due to engineering complexity. Flight control and stability functions were also improved with a standard payload, providing more aircraft design flexibility. PSCR found that contestants who started with existing designs early in the competition or those who tested early and frequently had better success in later stages. The winning UAS solution consisted of a hex-rotor design with a hybrid electric-gasoline engine propulsion system. The maximum flight time of this solution in the final test event was approximately 112 minutes, with a total takeoff weight of 54.9 lb (24.9 kg.) PSCR UAS 3.0: First Responder UAS Triple Challenge The UAS 3.0 challenge aimed to create a multi-use, multi-payload UAS platform for first responder search and rescue use cases. The challenge comprised three distinct research challenges that ran concurrently. The final stage of these competitions took place concurrently in June of 2022 in Starkville, Mississippi. 4.3.1. PSCR UAS 3.1: First Responder UAS Triple Challenge: FastFind The design goals of UAS 3.1 focused on the use case of finding missing persons quickly in heavily forested areas. In this challenge, UAS required optical systems that could penetrate thick forest canopies and withstand environmental conditions and hazards. The UAS had to be rapidly deployable and endure the mission's duration. In the UAS 3.1 challenge, flight vehicles had to meet a weight requirement of 55 lb (24.9 kg) or less, including attachments or payloads. A five-point scale evaluated the flight autonomy of the aircraft, with each level describing a range of independence that required less pilot intervention. Additionally, real-time video had to be transmitted to the pilot's ground control station, while onboard recording was mandatory on the aircraft. The vehicles had to demonstrate the capability for degraded takeoff and landing while operating in environments not typically suited for 14 NIST TN 2295 July 2024 standard flight operations, such as areas with uneven surfaces, dirt, or gravel. The final scenario required all competitors to find multiple designated targets within a 60-minute timeframe. In the final event, contestants used adaptive search technologies, including real-time computer vision, machine learning, and human verification, to assist in finding targets. Competitors used one or multiple camera technologies, including infrared, thermal, and neutral-density optical filters, digital filters, and telephoto optical systems, to help expedite recovery time. One contestant utilized a novel technique called Airborne Optical Sectioning, which incorporates a form of synthetic aperture imaging to integrate multiple camera technologies to suppress occlusions computationally. [11] Environmental factors at the test location, including high heat and humidity, negatively affected the contestant’s aircraft performance and the optical systems' efficiency. These conditions also generated false positive matches by computer vision algorithms used in the search. 4.3.2. PSCR UAS 3.2: First Responder UAS Triple Challenge: LifeLink UAS 3.2 LifeLink evaluated techniques using a UAS to provide continuous broadband communications in a service-denied area. The UAS carried a communication relay system to extend communications with first responder stations on the ground. UAS 3.2 contained identical UAS requirements for weight, autonomy, takeoff, and landing conditions as UAS 3.1. Specific to the LifeLink challenge, each UAS was required to have a wireless Wi-Fi transceiver to transmit internet protocol data to responders on the ground and to a NISTprovided bandwidth measurement server. A Wi-Fi antenna or array attached to the UAS could enhance coverage by optimizing signal power and direction. Each contestant’s UAS was not limited beyond FAA Part 107 requirements; contestants could choose the optimal testing height for their solution. UAS designs in UAS 3.2 contained Wi-Fi configurations that could transmit simulated voice and data streams up to 800 ft (244 m) from the aircraft. Omnidirectional antennas provided optimal coverage and higher bandwidth speeds for areas with more first responders in a small, circular geographic area. Directional antenna configurations offered the best coverage for distancefocused applications when correctly oriented. When combined with repeater technology, the WiFi signal could transmit further, but each added repeater would diminish the bandwidth speeds. High heat, humid weather conditions, and forest foliage negatively impacted coverage, distance, and bandwidth speeds.

You must only provide your answer using the information I give to you. If you're unable to, you should respond by telling me "I can't do that."

Why is a gait analysis important when buying shoes?

Footwear is an important item of equipment to prevent injury and provide comfort while walking. The most suitable footwear for this exercise program is within the “running” category. Cross trainers, court, training or walking shoes are not as good a choice for many reasons. To best meet your personal requirements and to address the heel-toe motion of walking or running, choose shoes in the “running” category of footwear only. An experienced professional can provide a general gait (walking stride) analysis to determine your personal footwear needs. The best merchants with the most expertise are specialty running shops, where staff is generally trained to assess feet for everyone from walkers to long distance runners. Features of the Running Shoe The uppers of most running shoes today are seamless (no stitching or rough spots that can cause irritation or blistering) and made of durable lightweight, breathable materials. This is important for fit, breathability and flexibility. The midsole will look (and feel) different, depending on the degree of support systems present. Different feet require different footwear.  At one extreme is the low arch, “flat” or highly flexible foot. This foot may require heightened guidance that is often achieved through having two or more different densities of material in the midsole with typically more medial (inside of the foot) density or firmness. This firmness helps to provide the structure and support needed by this foot type.  At the opposite end of the spectrum is the rigid, high instep, inflexible foot. This foot has very different needs compared to low arched feet. Flexibility and shock absorption are the focus for this type of foot. Often the midsoles of this subcategory are of a single density and generally softer in feel. Shoes in the running category should come with removable insoles. If they don’t come with removable insoles, they are likely unsuitable. Removable insoles allow for the use of orthotics and also the occasional washing. Insoles are made of light weight foam that will shrink if you wash them in hot water or put them in the dryer. Wash them in cold water by hand and air dry only. If you wear orthotics, be sure to have them with you when purchasing footwear and always remove the manufacture’s insole when using an orthotic. What to Keep in Mind When Purchasing Footwear A general gait analysis is necessary to determine your foot type and ultimately the best shoes to match them. Have your feet and gait (walking stride) observed by a qualified salesperson. This will determine the subcategory best suited for your personal needs. Call ahead of time and ask if there is someone that can “check my gait.” If they do not offer this service, call another place. Be sure the salesperson watches you walk or run in the shoes you are testing. This will determine if a shoe is over-correcting or under-correcting your gait. Without a gait analysis during the fitting process, it’s just guesswork. Do not be fooled by a really soft, cushy feel. A softer midsole has less structure. This means that your feet will have to work harder to stabilize your body while walking. Walking for longer periods of time in an extremely soft shoe will inevitably tire you quickly and heighten your susceptibility to injury. Although some feet do require high shock absorption (high arched, rigid foot types), it’s important to make the distinction between cushion and shock absorbency. How a shoe fits is important. Do not settle for a shoe that is too roomy or too tight fitting. Shoes are readily available in a variety of widths to meet the needs of the widest or narrowest of feet. An ideal fit will be roomy in the toe box. This will allow your toes to spread comfortably when you are in the ‘toe off’ phase of your stride. If a shoe is too snug around your toes, you run the risk of blistering or bruising. Aim for approximately .8 cm or 1/4 inch of space between your longest toe and the end of the shoe. This extra space will also allow for swelling as you exercise, especially on those warmer days. Shoes will last 6 to 12 months or 800 to 1200km. This will vary according to your foot strike and the conditions they are worn in. For people with limited mobility If you have recently experienced a stroke and/or are limited in your mobility, it is important to choose footwear that will not inhibit your rehab. Safety comes first. In this case, walking stride is less important than preventing falls. Where mobility is low and walking aids are used, it’s best to choose footwear that is lightweight, highly flexible and low profile (thin midsole or low to the ground). Tripping hazards will be diminished and your rehab will be less restricted. As you progress in your rehab, become more mobile, walk longer distances or for longer periods of time, you will then want to have a reanalysis of your gait and choose footwear emphasizing those needs as described above.

You must only provide your answer using the information I give to you. If you're unable to, you should respond by telling me "I can't do that." Footwear is an important item of equipment to prevent injury and provide comfort while walking. The most suitable footwear for this exercise program is within the “running” category. Cross trainers, court, training or walking shoes are not as good a choice for many reasons. To best meet your personal requirements and to address the heel-toe motion of walking or running, choose shoes in the “running” category of footwear only. An experienced professional can provide a general gait (walking stride) analysis to determine your personal footwear needs. The best merchants with the most expertise are specialty running shops, where staff is generally trained to assess feet for everyone from walkers to long distance runners. Features of the Running Shoe The uppers of most running shoes today are seamless (no stitching or rough spots that can cause irritation or blistering) and made of durable lightweight, breathable materials. This is important for fit, breathability and flexibility. The midsole will look (and feel) different, depending on the degree of support systems present. Different feet require different footwear.  At one extreme is the low arch, “flat” or highly flexible foot. This foot may require heightened guidance that is often achieved through having two or more different densities of material in the midsole with typically more medial (inside of the foot) density or firmness. This firmness helps to provide the structure and support needed by this foot type.  At the opposite end of the spectrum is the rigid, high instep, inflexible foot. This foot has very different needs compared to low arched feet. Flexibility and shock absorption are the focus for this type of foot. Often the midsoles of this subcategory are of a single density and generally softer in feel. Shoes in the running category should come with removable insoles. If they don’t come with removable insoles, they are likely unsuitable. Removable insoles allow for the use of orthotics and also the occasional washing. Insoles are made of light weight foam that will shrink if you wash them in hot water or put them in the dryer. Wash them in cold water by hand and air dry only. If you wear orthotics, be sure to have them with you when purchasing footwear and always remove the manufacture’s insole when using an orthotic. What to Keep in Mind When Purchasing Footwear A general gait analysis is necessary to determine your foot type and ultimately the best shoes to match them. Have your feet and gait (walking stride) observed by a qualified salesperson. This will determine the subcategory best suited for your personal needs. Call ahead of time and ask if there is someone that can “check my gait.” If they do not offer this service, call another place. Be sure the salesperson watches you walk or run in the shoes you are testing. This will determine if a shoe is over-correcting or under-correcting your gait. Without a gait analysis during the fitting process, it’s just guesswork. Do not be fooled by a really soft, cushy feel. A softer midsole has less structure. This means that your feet will have to work harder to stabilize your body while walking. Walking for longer periods of time in an extremely soft shoe will inevitably tire you quickly and heighten your susceptibility to injury. Although some feet do require high shock absorption (high arched, rigid foot types), it’s important to make the distinction between cushion and shock absorbency. How a shoe fits is important. Do not settle for a shoe that is too roomy or too tight fitting. Shoes are readily available in a variety of widths to meet the needs of the widest or narrowest of feet. An ideal fit will be roomy in the toe box. This will allow your toes to spread comfortably when you are in the ‘toe off’ phase of your stride. If a shoe is too snug around your toes, you run the risk of blistering or bruising. Aim for approximately .8 cm or 1/4 inch of space between your longest toe and the end of the shoe. This extra space will also allow for swelling as you exercise, especially on those warmer days. Shoes will last 6 to 12 months or 800 to 1200km. This will vary according to your foot strike and the conditions they are worn in. For people with limited mobility If you have recently experienced a stroke and/or are limited in your mobility, it is important to choose footwear that will not inhibit your rehab. Safety comes first. In this case, walking stride is less important than preventing falls. Where mobility is low and walking aids are used, it’s best to choose footwear that is lightweight, highly flexible and low profile (thin midsole or low to the ground). Tripping hazards will be diminished and your rehab will be less restricted. As you progress in your rehab, become more mobile, walk longer distances or for longer periods of time, you will then want to have a reanalysis of your gait and choose footwear emphasizing those needs as described above. Why is a gait analysis important when buying shoes?

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> [user request] <TEXT> [context document]

I plan to do an Azure certification to enhance my skillset in cloud development. Can you list down all the Azure services along with their working?

Today, cloud computing applications and platforms are rapidly growing across all industries, serving as the IT infrastructure that drives new digital businesses. These platforms and applications have revolutionized the ways in which businesses function, and have made processes easier. In fact, more than 77 percent of businesses today have at least some portion of their computing infrastructure in the cloud. While there are many cloud computing platforms available, two platforms dominate the cloud computing industry. Amazon Web Services (AWS) and Microsoft Azure are the two giants in the world of cloud computing. While AWS is the largest cloud computing platform, Microsoft Azure is the fastest-growing and second-largest. This article focuses on Microsoft Azure and what is Azure—its services and uses. Before diving into what is Azure, you should first know what cloud computing is. Want a Job at AWS? Find Out What It Takes Cloud Architect Master's ProgramExplore ProgramWant a Job at AWS? Find Out What It Takes What is Cloud Computing? Cloud computing is a technology that provides access to various computing resources over the internet. All you need to do is use your computer or mobile device to connect to your cloud service provider through the internet. Once connected, you get access to computing resources, which may include serverless computing, virtual machines, storage, and various other things. Basically, cloud service providers have massive data centers that contain hundreds of servers, storage systems and components that are crucial for many kinds of organizations. These data centers are in secure locations and store a large amount of data. The users connect to these data centers to collect data or use it when required. Users can take advantage of various services; for example, if you want a notification every time someone sends you a text or an email, cloud services can help you. The best part about cloud platforms is that you pay only for the services you use, and there are no charges upfront. Cloud computing can be used for various purposes: machine learning, data analysis, storage and backup, streaming media content and so much more. Here’s an interesting fact about the cloud: all the shows and movies that you see on Netflix are actually stored in the cloud. Also, the cloud can be beneficial for creating and testing applications, automating software delivery, and hosting blogs. Why is Cloud Computing Important? Let’s assume that you have an idea for a revolutionary application that can provide great user experience and can become highly profitable. For the application to become successful, you will need to release it on the internet for people to find it, use it, and spread the word about its advantages. However, releasing an application on the internet is not as easy as it seems. To do so, you will need various components, like servers, storage devices, developers, dedicated networks, and application security to ensure that your solution works the way it is intended to. These are a lot of components, which can be problematic. Buying each of these components individually is very expensive and risky. You would need a huge amount of capital to ensure that your application works properly. And if the application doesn’t become popular, you would lose your investment. On the flip side, if the application becomes immensely popular, you will have to buy more servers and storage to cater to more users, which can again increase your costs. This is where cloud computing can come to the rescue. It has many benefits, including offering safe storage and scalability all at once. Get Certified and Future-Proof Your Career Microsoft Certified: Azure Administrator AssociateENROLL NOWGet Certified and Future-Proof Your Career What is Microsoft Azure? Azure is a cloud computing platform and an online portal that allows you to access and manage cloud services and resources provided by Microsoft. These services and resources include storing your data and transforming it, depending on your requirements. To get access to these resources and services, all you need to have is an active internet connection and the ability to connect to the Azure portal. Things that you should know about Azure: It was launched on February 1, 2010, significantly later than its main competitor, AWS. It’s free to start and follows a pay-per-use model, which means you pay only for the services you opt for. Interestingly, 80 percent of the Fortune 500 companies use Azure services for their cloud computing needs. Azure supports multiple programming languages, including Java, Node Js, and C#. Another benefit of Azure is the number of data centers it has around the world. There are 42 Azure data centers spread around the globe, which is the highest number of data centers for any cloud platform. Also, Azure is planning to get 12 more data centers, which will increase the number of data centers to 54, shortly. Azure provides more than 200 services, are divided into 18 categories. These categories include computing, networking, storage, IoT, migration, mobile, analytics, containers, artificial intelligence, and other machine learning, integration, management tools, developer tools, security, databases, DevOps, media identity, and web services. Let’s take a look at some of the major Azure services by category: Compute Services Virtual Machine This service enables you to create a virtual machine in Windows, Linux or any other configuration in seconds. Cloud Service This service lets you create scalable applications within the cloud. Once the application is deployed, everything, including provisioning, load balancing, and health monitoring, is taken care of by Azure. Service Fabric With service fabric, the process of developing a microservice is immensely simplified. Microservice is an application that contains other bundled smaller applications. Functions With functions, you can create applications in any programming language. The best part about this service is that you need not worry about hardware requirements while developing applications because Azure takes care of that. All you need to do is provide the code. Build and Deploy Azure Applications Like a Pro! Azure Cloud ArchitectExplore ProgramBuild and Deploy Azure Applications Like a Pro! Networking Azure CDN Azure CDN (Content Delivery Network) is for delivering content to users. It uses a high bandwidth, and content can be transferred to any person around the globe. The CDN service uses a network of servers placed strategically around the globe so that the users can access the data as soon as possible. Express Route This service lets you connect your on-premise network to the Microsoft cloud or any other services that you want, through a private connection. So, the only communications that will happen here will be between the enterprise network and the service that you want. Virtual network The virtual network allows you to have any of the Azure services communicate with one another privately and securely. Azure DNS This service allows you to host your DNS domains or system domains on Azure. Storage Disk Storage This service allows you to choose from either HDD (Hard Disk Drive) or SSD (Solid State Drive) as your storage option along with your virtual machine. Blob Storage This service is optimized to store a massive amount of unstructured data, including text and even binary data. File Storage This is a managed file storage service that can be accessed via industry SMB (server message block) protocol. Queue Storage With queue storage, you can provide stable message queuing for a large workload. This service can be accessed from anywhere in this world. Next in this what is Azure article, let’s look at what are the uses of Azure.

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> I plan to do an Azure certification to enhance my skillset in cloud development. Can you list down all the Azure services along with their working? <TEXT> Today, cloud computing applications and platforms are rapidly growing across all industries, serving as the IT infrastructure that drives new digital businesses. These platforms and applications have revolutionized the ways in which businesses function, and have made processes easier. In fact, more than 77 percent of businesses today have at least some portion of their computing infrastructure in the cloud. While there are many cloud computing platforms available, two platforms dominate the cloud computing industry. Amazon Web Services (AWS) and Microsoft Azure are the two giants in the world of cloud computing. While AWS is the largest cloud computing platform, Microsoft Azure is the fastest-growing and second-largest. This article focuses on Microsoft Azure and what is Azure—its services and uses. Before diving into what is Azure, you should first know what cloud computing is. Want a Job at AWS? Find Out What It Takes Cloud Architect Master's ProgramExplore ProgramWant a Job at AWS? Find Out What It Takes What is Cloud Computing? Cloud computing is a technology that provides access to various computing resources over the internet. All you need to do is use your computer or mobile device to connect to your cloud service provider through the internet. Once connected, you get access to computing resources, which may include serverless computing, virtual machines, storage, and various other things. Basically, cloud service providers have massive data centers that contain hundreds of servers, storage systems and components that are crucial for many kinds of organizations. These data centers are in secure locations and store a large amount of data. The users connect to these data centers to collect data or use it when required. Users can take advantage of various services; for example, if you want a notification every time someone sends you a text or an email, cloud services can help you. The best part about cloud platforms is that you pay only for the services you use, and there are no charges upfront. Cloud computing can be used for various purposes: machine learning, data analysis, storage and backup, streaming media content and so much more. Here’s an interesting fact about the cloud: all the shows and movies that you see on Netflix are actually stored in the cloud. Also, the cloud can be beneficial for creating and testing applications, automating software delivery, and hosting blogs. Why is Cloud Computing Important? Let’s assume that you have an idea for a revolutionary application that can provide great user experience and can become highly profitable. For the application to become successful, you will need to release it on the internet for people to find it, use it, and spread the word about its advantages. However, releasing an application on the internet is not as easy as it seems. To do so, you will need various components, like servers, storage devices, developers, dedicated networks, and application security to ensure that your solution works the way it is intended to. These are a lot of components, which can be problematic. Buying each of these components individually is very expensive and risky. You would need a huge amount of capital to ensure that your application works properly. And if the application doesn’t become popular, you would lose your investment. On the flip side, if the application becomes immensely popular, you will have to buy more servers and storage to cater to more users, which can again increase your costs. This is where cloud computing can come to the rescue. It has many benefits, including offering safe storage and scalability all at once. Get Certified and Future-Proof Your Career Microsoft Certified: Azure Administrator AssociateENROLL NOWGet Certified and Future-Proof Your Career What is Microsoft Azure? Azure is a cloud computing platform and an online portal that allows you to access and manage cloud services and resources provided by Microsoft. These services and resources include storing your data and transforming it, depending on your requirements. To get access to these resources and services, all you need to have is an active internet connection and the ability to connect to the Azure portal. Things that you should know about Azure: It was launched on February 1, 2010, significantly later than its main competitor, AWS. It’s free to start and follows a pay-per-use model, which means you pay only for the services you opt for. Interestingly, 80 percent of the Fortune 500 companies use Azure services for their cloud computing needs. Azure supports multiple programming languages, including Java, Node Js, and C#. Another benefit of Azure is the number of data centers it has around the world. There are 42 Azure data centers spread around the globe, which is the highest number of data centers for any cloud platform. Also, Azure is planning to get 12 more data centers, which will increase the number of data centers to 54, shortly. Azure provides more than 200 services, are divided into 18 categories. These categories include computing, networking, storage, IoT, migration, mobile, analytics, containers, artificial intelligence, and other machine learning, integration, management tools, developer tools, security, databases, DevOps, media identity, and web services. Let’s take a look at some of the major Azure services by category: Compute Services Virtual Machine This service enables you to create a virtual machine in Windows, Linux or any other configuration in seconds. Cloud Service This service lets you create scalable applications within the cloud. Once the application is deployed, everything, including provisioning, load balancing, and health monitoring, is taken care of by Azure. Service Fabric With service fabric, the process of developing a microservice is immensely simplified. Microservice is an application that contains other bundled smaller applications. Functions With functions, you can create applications in any programming language. The best part about this service is that you need not worry about hardware requirements while developing applications because Azure takes care of that. All you need to do is provide the code. Build and Deploy Azure Applications Like a Pro! Azure Cloud ArchitectExplore ProgramBuild and Deploy Azure Applications Like a Pro! Networking Azure CDN Azure CDN (Content Delivery Network) is for delivering content to users. It uses a high bandwidth, and content can be transferred to any person around the globe. The CDN service uses a network of servers placed strategically around the globe so that the users can access the data as soon as possible. Express Route This service lets you connect your on-premise network to the Microsoft cloud or any other services that you want, through a private connection. So, the only communications that will happen here will be between the enterprise network and the service that you want. Virtual network The virtual network allows you to have any of the Azure services communicate with one another privately and securely. Azure DNS This service allows you to host your DNS domains or system domains on Azure. Storage Disk Storage This service allows you to choose from either HDD (Hard Disk Drive) or SSD (Solid State Drive) as your storage option along with your virtual machine. Blob Storage This service is optimized to store a massive amount of unstructured data, including text and even binary data. File Storage This is a managed file storage service that can be accessed via industry SMB (server message block) protocol. Queue Storage With queue storage, you can provide stable message queuing for a large workload. This service can be accessed from anywhere in this world. Next in this what is Azure article, let’s look at what are the uses of Azure. https://www.simplilearn.com/tutorials/azure-tutorial/what-is-azure

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> [user request] <TEXT> [context document]

Explain the specific new legal standard the Supreme Court established in Kennedy v. Bremerton for determining violations of the Establishment Clause, and detail how this new standard will affect future cases.

The Supreme Court on Monday ruled in favor of a high school football coach who lost his job because of his post-game prayers at the 50-yard line. By a vote of 6-3, the justices ruled that Joseph Kennedy’s conduct was protected by the First Amendment. The court rejected the public school district’s argument that allowing Kennedy’s prayers to continue would have violated the Constitution’s establishment clause, which bars the government from both establishing an official religion and preferring one religion over another. And it pushed back against the argument that students might have felt obligated to join Kennedy’s prayers, stressing that “learning how to tolerate speech or prayer of all kinds is ‘part of learning how to live in a pluralistic society,’ a trait of character essential to ‘a tolerant citizenry.’” The decision by Justice Neil Gorsuch was joined in full by Chief Justice John Roberts and Justices Clarence Thomas, Samuel Alito, and Amy Coney Barrett. Justice Brett Kavanaugh joined most of Gorsuch’s opinion. The three liberal justices dissented. It was the second major ruling on religion and schools in less than a week. On June 21, along the same 6-3 ideological lines, the court struck down a Maine law that banned the use of public funds for students to use at private schools that provide religious instruction. In 2015, Kennedy had been a part-time coach at Bremerton High School, a public school in Washington state, for seven years. During that time, he prayed at midfield after each game – first alone, but later with players and even some members of the opposing team joining him. When the school district learned about Kennedy’s prayers in September 2015, it expressed disapproval, and Kennedy briefly stopped his prayers. On Oct. 14, 2015, Kennedy notified the school district that he intended to resume his prayers at the next game. After a scene that the school district describes as chaotic, with spectators and reporters knocking down members of the band in an effort to join Kennedy at midfield, the school district told him that his prayers violated the district’s policy, and it offered him other options to pray – for example, after the crowd had left. But Kennedy continued to pray at the next two games, prompting the district to place him on administrative leave and, eventually, decline to renew his contract for the following season. Kennedy went to federal district court, where he argued that the school district’s actions had violated his rights under the free speech and free exercise clauses of the Constitution. The U.S. Court of Appeals for the 9th Circuit ruled for the school district, but on Monday the justices reversed that ruling. In a 32-page decision, Gorsuch agreed that Kennedy had met his part of the test for showing that the decision not to renew his contract ran afoul of both clauses. For his free exercise claim, Gorsuch explained, there was no dispute that Kennedy’s desire to pray was sincere, and the district’s prohibition on prayer targeted Kennedy’s religious conduct, rather than applying a neutral rule. And for his free speech claim, Gorsuch continued, Kennedy’s prayers were not part of his duties as a coach. Rather, Gorsuch observed, Kennedy’s prayers occurred “during a period in which the District has acknowledged that its coaching staff was free to engage in all manner of private speech.” By contrast, Gorsuch wrote, the school district’s only real justification for its decision to fire Kennedy was that allowing the prayers to continue would have violated the establishment clause. But that argument, Gorsuch said, rested on a 1971 case, Lemon v. Kurtzman, that outlined a test for courts to use to determine whether a government law or practice violates the establishment clause. Under the Lemon test, the law or practice will pass constitutional muster if it has a secular purpose, its principal effect does not advance or inhibit religion, and it does not create an “excessive entanglement with religion.” Members of the court have long criticized Lemon, but Monday’s ruling expressly dismissed Lemon as having been “long ago abandoned.” Instead, Gorsuch continued, courts should determine whether a law or practice violates the establishment clause by looking at history and the understanding of the drafters of the Constitution – which the court of appeals failed to do. Gorsuch similarly rejected the school district’s argument that it could prohibit Kennedy’s post-game prayers so that students did not feel compelled to join him in praying. “There is no indication in the record,” Gorsuch noted, “that anyone expressed any coercion concerns to the District about the quiet, postgame prayers that Mr. Kennedy asked to continue and that led to his suspension.” Gorsuch distinguished Kennedy’s case from cases “in which this Court has found prayer involving public schools to be problematically coercive.” Unlike those earlier cases, Gorsuch reasoned, Kennedy’s prayers “were not publicly broadcast or recited to a captive audience,” and students “were not required or expected to participate.” The school district’s actions “rested on a mistaken view that it had a duty to ferret out and suppress religious observances even as it allows comparable secular speech,” Gorsuch concluded. “The Constitution neither mandates nor tolerates that kind of discrimination.” As they did last week in Carson, the court’s three liberal justices dissented. In an opinion that was joined by Justices Stephen Breyer and Elena Kagan, Justice Sonia Sotomayor complained that Gorsuch had “misconstrue[d] the facts” of the case, depicting Kennedy’s prayers as “private and quiet” when the prayers had actually caused “severe disruption to school events.” More broadly, Sotomayor continued, although Gorsuch had portrayed the case as whether and when Kennedy could pray privately, the key question in the case was in fact “whether a school district is required to allow one of its employees to incorporate a public, communicative display of the employee’s personal religious beliefs into a school event.” For Sotomayor, the answer was no. Particularly when it comes to schools, she explained, the government must remain neutral about religion, because of the important role that schools play and because children are especially susceptible to feeling compelled to join in prayer. Indeed, she noted, students did feel obligated to join Kennedy and, later, their teammates in prayer. Monday’s ruling, Sotomayor concluded, “weakens the backstop” that the establishment clause provided to protect religious freedom. “It elevates one individual’s interest in personal religious exercise,” she contended, “over society’s interest in protecting the separation between church and state, eroding the protections for religious liberty for all.” Kelly Shackelford, the president and CEO of First Liberty Institute, which represented Kennedy, hailed the decision as “a tremendous victory for all Americans.” Paul Clement, who argued in the Supreme Court on Kennedy’s behalf, added that “[a]fter seven long years, Coach Kennedy can finally return to the place he belongs – coaching football and quietly praying by himself after the game.” Rachel Laser, the president of Americans United for Separation of Church and State, which represented the school district, took a different view. She called the decision “the greatest loss of religious freedom in our country in generations” and she warned that Kennedy’s supporters would “try to expand this dangerous precedent – further undermining everyone’s right to live as ourselves and believe as we choose.”

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> Explain the specific new legal standard the Supreme Court established in Kennedy v. Bremerton for determining violations of the Establishment Clause, and detail how this new standard will affect future cases. <TEXT> The Supreme Court on Monday ruled in favor of a high school football coach who lost his job because of his post-game prayers at the 50-yard line. By a vote of 6-3, the justices ruled that Joseph Kennedy’s conduct was protected by the First Amendment. The court rejected the public school district’s argument that allowing Kennedy’s prayers to continue would have violated the Constitution’s establishment clause, which bars the government from both establishing an official religion and preferring one religion over another. And it pushed back against the argument that students might have felt obligated to join Kennedy’s prayers, stressing that “learning how to tolerate speech or prayer of all kinds is ‘part of learning how to live in a pluralistic society,’ a trait of character essential to ‘a tolerant citizenry.’” The decision by Justice Neil Gorsuch was joined in full by Chief Justice John Roberts and Justices Clarence Thomas, Samuel Alito, and Amy Coney Barrett. Justice Brett Kavanaugh joined most of Gorsuch’s opinion. The three liberal justices dissented. It was the second major ruling on religion and schools in less than a week. On June 21, along the same 6-3 ideological lines, the court struck down a Maine law that banned the use of public funds for students to use at private schools that provide religious instruction. In 2015, Kennedy had been a part-time coach at Bremerton High School, a public school in Washington state, for seven years. During that time, he prayed at midfield after each game – first alone, but later with players and even some members of the opposing team joining him. When the school district learned about Kennedy’s prayers in September 2015, it expressed disapproval, and Kennedy briefly stopped his prayers. On Oct. 14, 2015, Kennedy notified the school district that he intended to resume his prayers at the next game. After a scene that the school district describes as chaotic, with spectators and reporters knocking down members of the band in an effort to join Kennedy at midfield, the school district told him that his prayers violated the district’s policy, and it offered him other options to pray – for example, after the crowd had left. But Kennedy continued to pray at the next two games, prompting the district to place him on administrative leave and, eventually, decline to renew his contract for the following season. Kennedy went to federal district court, where he argued that the school district’s actions had violated his rights under the free speech and free exercise clauses of the Constitution. The U.S. Court of Appeals for the 9th Circuit ruled for the school district, but on Monday the justices reversed that ruling. In a 32-page decision, Gorsuch agreed that Kennedy had met his part of the test for showing that the decision not to renew his contract ran afoul of both clauses. For his free exercise claim, Gorsuch explained, there was no dispute that Kennedy’s desire to pray was sincere, and the district’s prohibition on prayer targeted Kennedy’s religious conduct, rather than applying a neutral rule. And for his free speech claim, Gorsuch continued, Kennedy’s prayers were not part of his duties as a coach. Rather, Gorsuch observed, Kennedy’s prayers occurred “during a period in which the District has acknowledged that its coaching staff was free to engage in all manner of private speech.” By contrast, Gorsuch wrote, the school district’s only real justification for its decision to fire Kennedy was that allowing the prayers to continue would have violated the establishment clause. But that argument, Gorsuch said, rested on a 1971 case, Lemon v. Kurtzman, that outlined a test for courts to use to determine whether a government law or practice violates the establishment clause. Under the Lemon test, the law or practice will pass constitutional muster if it has a secular purpose, its principal effect does not advance or inhibit religion, and it does not create an “excessive entanglement with religion.” Members of the court have long criticized Lemon, but Monday’s ruling expressly dismissed Lemon as having been “long ago abandoned.” Instead, Gorsuch continued, courts should determine whether a law or practice violates the establishment clause by looking at history and the understanding of the drafters of the Constitution – which the court of appeals failed to do. Gorsuch similarly rejected the school district’s argument that it could prohibit Kennedy’s post-game prayers so that students did not feel compelled to join him in praying. “There is no indication in the record,” Gorsuch noted, “that anyone expressed any coercion concerns to the District about the quiet, postgame prayers that Mr. Kennedy asked to continue and that led to his suspension.” Gorsuch distinguished Kennedy’s case from cases “in which this Court has found prayer involving public schools to be problematically coercive.” Unlike those earlier cases, Gorsuch reasoned, Kennedy’s prayers “were not publicly broadcast or recited to a captive audience,” and students “were not required or expected to participate.” The school district’s actions “rested on a mistaken view that it had a duty to ferret out and suppress religious observances even as it allows comparable secular speech,” Gorsuch concluded. “The Constitution neither mandates nor tolerates that kind of discrimination.” As they did last week in Carson, the court’s three liberal justices dissented. In an opinion that was joined by Justices Stephen Breyer and Elena Kagan, Justice Sonia Sotomayor complained that Gorsuch had “misconstrue[d] the facts” of the case, depicting Kennedy’s prayers as “private and quiet” when the prayers had actually caused “severe disruption to school events.” More broadly, Sotomayor continued, although Gorsuch had portrayed the case as whether and when Kennedy could pray privately, the key question in the case was in fact “whether a school district is required to allow one of its employees to incorporate a public, communicative display of the employee’s personal religious beliefs into a school event.” For Sotomayor, the answer was no. Particularly when it comes to schools, she explained, the government must remain neutral about religion, because of the important role that schools play and because children are especially susceptible to feeling compelled to join in prayer. Indeed, she noted, students did feel obligated to join Kennedy and, later, their teammates in prayer. Monday’s ruling, Sotomayor concluded, “weakens the backstop” that the establishment clause provided to protect religious freedom. “It elevates one individual’s interest in personal religious exercise,” she contended, “over society’s interest in protecting the separation between church and state, eroding the protections for religious liberty for all.” Kelly Shackelford, the president and CEO of First Liberty Institute, which represented Kennedy, hailed the decision as “a tremendous victory for all Americans.” Paul Clement, who argued in the Supreme Court on Kennedy’s behalf, added that “[a]fter seven long years, Coach Kennedy can finally return to the place he belongs – coaching football and quietly praying by himself after the game.” Rachel Laser, the president of Americans United for Separation of Church and State, which represented the school district, took a different view. She called the decision “the greatest loss of religious freedom in our country in generations” and she warned that Kennedy’s supporters would “try to expand this dangerous precedent – further undermining everyone’s right to live as ourselves and believe as we choose.” https://www.scotusblog.com/2022/06/justices-side-with-high-school-football-coach-who-prayed-on-the-field-with-students/

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> [user request] <TEXT> [context document]

What would you recommend as the top 3 best credit cards if I travel a lot, don't eat at restaurants and don't want to pay any annual fees?

Best no-annual-fee credit cards The best credit cards with no annual fee give people a chance to earn rewards and build credit without breaking the bank. Chase Freedom Flex℠: With no annual fee, you won’t have to pay for bonus cash back. Find out what others think in member reviews of Chase Freedom Flex℠. Chase Freedom Unlimited®: For a card with no annual fee, you could earn quite a bit of cash back for your everyday purchases. Take a look at our review of Chase Freedom Unlimited® to see how. Citi Double Cash® Card: You’ll earn cash back at a high rate overall without paying an annual fee. Learn more in our review of the Citi Double Cash® Card. Best cash back credit cards The best cash back credit cards offer reward categories that fit your spending habits. Chase Freedom Flex℠: You can maximize your cash back in a new bonus category every quarter. Check out reviews to see what members think of Chase Freedom Flex℠ and learn more about the current bonus categories. Chase Freedom Unlimited®: This card is worth a look if you want a high rewards rate on everyday purchases and several bonus categories. Take a look at our Chase Freedom Unlimited® review to learn more. Citi Double Cash® Card: This card makes earning cash back simple with a flat rate on all purchases. Find out more in our review of Citi Double Cash® Card. Best travel credit cards The best travel credit cards could help you save up for a future vacation. Bank of America® Premium Rewards® credit card: Quality rewards and several valuable perks give this card a nice value for the annual fee. Find out what sets this card apart in our review of the Bank of America® Premium Rewards® credit card. Chase Sapphire Preferred® Card: The flexible travel rewards could help you book your next vacation through one of Chase’s airline or hotel partners. Take a look at our Chase Sapphire Preferred® Card review to see how. Capital One Venture Rewards Credit Card: The straightforward rewards program could help travelers get value for their purchases without too much extra effort. Check out our Capital One Venture Rewards Credit Card review to learn more. Best rewards credit cards The best rewards credit cards reward you for everyday purchases. Blue Cash Preferred® Card from American Express: Regular grocery shoppers will get plenty of opportunities to earn extra cash back. Learn more about Blue Cash Preferred® Card from American Express to see if this card might make sense for you. Capital One Venture Rewards Credit Card: You’ll get a steady rewards rate on every purchase and a straightforward redemption process for travel. Learn more in our Capital One Venture Rewards Credit Card review. Best low-interest credit cards These best credit cards with 0% intro APR offers are good for people who run into unexpected expenses or need to finance a major purchase. BankAmericard® credit card: This card features a lengthy, useful interest offer. Take a look at our review of BankAmericard® credit card to learn more. Citi Simplicity® Card: This card also gives you a strong intro offer to pay off your new purchases. Find out how in our Citi Simplicity® Card review. U.S. Bank Visa® Platinum Card: You could maximize the time you have to pay back new purchases without being charged interest. See how in our review of the U.S. Bank Visa® Platinum Card. Best balance transfer credit cards The best balance transfer cards offer options and flexibility to people trying to pay off credit card debt. Citi® Diamond Preferred® Card: This card provides more time to transfer your balances after approval. Learn more in our Citi® Diamond Preferred® Card review. Citi Simplicity® Card: This card offers time to pay off your balance — and it has no penalty interest rates. Take a look at our review of Citi Simplicity® Card to learn more. U.S. Bank Visa® Platinum Card: This card could be a great option if you’re looking for extra time to pay off your balance. Check out our review of U.S. Bank Visa® Platinum Card to learn more. Best credit cards for building credit The best credit cards for building credit give people with limited credit histories the opportunity to raise their scores. Discover it® Secured Credit Card: You’ll need to pay a security deposit, but this card offers rewards and the chance to graduate to an unsecured card. Learn more about Discover it® Secured Credit Card. Petal® 1 Visa® Credit Card: You’ll get a chance to build credit without being charged an annual fee or security deposit. Read Petal® 1 Visa® Credit Card member reviews for more takes. Petal® 2 Visa® Credit Card: You’ll have the opportunity to earn quality rewards while you build credit. Take a look at our Petal® 2 Visa® Credit Card review to learn more. Best secured credit cards The best secured credit cards give people access to credit when they might not be able to qualify for other cards. Citi® Secured Mastercard®: This card lets you track your progress as you build credit with access to a free FICO score. Check out our review of Citi® Secured Mastercard® to learn more. Discover it® Secured Credit Card: You could earn rewards while building credit. Read more about Discover it® Secured Credit Card. Capital One Platinum Secured Credit Card: You can build credit, and you might qualify to pay a security deposit that could be lower than your credit line. Take a look at our Capital One Platinum Secured Credit Card review to learn more. Best student credit cards The best student credit cards give students a head start on building credit. Bank of America® Travel Rewards credit card for Students: You could build credit and earn rewards to use while studying abroad or taking a spring break trip. Find out more in our Bank of America® Travel Rewards credit card for Students review. Discover it® Student Cash Back: You could build credit and earn rewards. See what others think about this card by reading member reviews of Discover it® Student Cash Back. How to pick the best credit card for you Picking the best credit card depends on where you are in your credit journey. Take a look at each of these scenarios to see which type of card suits your needs best. Do you want to build credit? If you’re new to credit or you’re trying to bounce back from previous financial mishaps, your top priority should probably be to build credit. Unfortunately, the credit cards with the most rewards and lowest interest rates might not be available to you just yet. But you can still find and apply for cards that you may be more likely to get approved for. That can help give you a better chance of avoiding the hard credit inquiry that comes with applying for a card and then being rejected. Consider a secured card or an unsecured card meant to build credit. These options can help you build credit as long as you pay off your statement balance in full by the due date. Just make sure the card issuer reports your payments to the three major consumer credit bureaus. Do you want to finance a big purchase or pay off debt? If you think you might need to carry a balance or finance a major purchase, you might want to look for a card with a low purchase APR. A card with an introductory 0% APR offer on purchases could be a good way to save money on interest.

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> What would you recommend as the top 3 best credit cards if I travel a lot, don't eat at restaurants and don't want to pay any annual fees? <TEXT> Best no-annual-fee credit cards The best credit cards with no annual fee give people a chance to earn rewards and build credit without breaking the bank. Chase Freedom Flex℠: With no annual fee, you won’t have to pay for bonus cash back. Find out what others think in member reviews of Chase Freedom Flex℠. Chase Freedom Unlimited®: For a card with no annual fee, you could earn quite a bit of cash back for your everyday purchases. Take a look at our review of Chase Freedom Unlimited® to see how. Citi Double Cash® Card: You’ll earn cash back at a high rate overall without paying an annual fee. Learn more in our review of the Citi Double Cash® Card. Best cash back credit cards The best cash back credit cards offer reward categories that fit your spending habits. Chase Freedom Flex℠: You can maximize your cash back in a new bonus category every quarter. Check out reviews to see what members think of Chase Freedom Flex℠ and learn more about the current bonus categories. Chase Freedom Unlimited®: This card is worth a look if you want a high rewards rate on everyday purchases and several bonus categories. Take a look at our Chase Freedom Unlimited® review to learn more. Citi Double Cash® Card: This card makes earning cash back simple with a flat rate on all purchases. Find out more in our review of Citi Double Cash® Card. Best travel credit cards The best travel credit cards could help you save up for a future vacation. Bank of America® Premium Rewards® credit card: Quality rewards and several valuable perks give this card a nice value for the annual fee. Find out what sets this card apart in our review of the Bank of America® Premium Rewards® credit card. Chase Sapphire Preferred® Card: The flexible travel rewards could help you book your next vacation through one of Chase’s airline or hotel partners. Take a look at our Chase Sapphire Preferred® Card review to see how. Capital One Venture Rewards Credit Card: The straightforward rewards program could help travelers get value for their purchases without too much extra effort. Check out our Capital One Venture Rewards Credit Card review to learn more. Best rewards credit cards The best rewards credit cards reward you for everyday purchases. Blue Cash Preferred® Card from American Express: Regular grocery shoppers will get plenty of opportunities to earn extra cash back. Learn more about Blue Cash Preferred® Card from American Express to see if this card might make sense for you. Capital One Venture Rewards Credit Card: You’ll get a steady rewards rate on every purchase and a straightforward redemption process for travel. Learn more in our Capital One Venture Rewards Credit Card review. Best low-interest credit cards These best credit cards with 0% intro APR offers are good for people who run into unexpected expenses or need to finance a major purchase. BankAmericard® credit card: This card features a lengthy, useful interest offer. Take a look at our review of BankAmericard® credit card to learn more. Citi Simplicity® Card: This card also gives you a strong intro offer to pay off your new purchases. Find out how in our Citi Simplicity® Card review. U.S. Bank Visa® Platinum Card: You could maximize the time you have to pay back new purchases without being charged interest. See how in our review of the U.S. Bank Visa® Platinum Card. Best balance transfer credit cards The best balance transfer cards offer options and flexibility to people trying to pay off credit card debt. Citi® Diamond Preferred® Card: This card provides more time to transfer your balances after approval. Learn more in our Citi® Diamond Preferred® Card review. Citi Simplicity® Card: This card offers time to pay off your balance — and it has no penalty interest rates. Take a look at our review of Citi Simplicity® Card to learn more. U.S. Bank Visa® Platinum Card: This card could be a great option if you’re looking for extra time to pay off your balance. Check out our review of U.S. Bank Visa® Platinum Card to learn more. Best credit cards for building credit The best credit cards for building credit give people with limited credit histories the opportunity to raise their scores. Discover it® Secured Credit Card: You’ll need to pay a security deposit, but this card offers rewards and the chance to graduate to an unsecured card. Learn more about Discover it® Secured Credit Card. Petal® 1 Visa® Credit Card: You’ll get a chance to build credit without being charged an annual fee or security deposit. Read Petal® 1 Visa® Credit Card member reviews for more takes. Petal® 2 Visa® Credit Card: You’ll have the opportunity to earn quality rewards while you build credit. Take a look at our Petal® 2 Visa® Credit Card review to learn more. Best secured credit cards The best secured credit cards give people access to credit when they might not be able to qualify for other cards. Citi® Secured Mastercard®: This card lets you track your progress as you build credit with access to a free FICO score. Check out our review of Citi® Secured Mastercard® to learn more. Discover it® Secured Credit Card: You could earn rewards while building credit. Read more about Discover it® Secured Credit Card. Capital One Platinum Secured Credit Card: You can build credit, and you might qualify to pay a security deposit that could be lower than your credit line. Take a look at our Capital One Platinum Secured Credit Card review to learn more. Best student credit cards The best student credit cards give students a head start on building credit. Bank of America® Travel Rewards credit card for Students: You could build credit and earn rewards to use while studying abroad or taking a spring break trip. Find out more in our Bank of America® Travel Rewards credit card for Students review. Discover it® Student Cash Back: You could build credit and earn rewards. See what others think about this card by reading member reviews of Discover it® Student Cash Back. How to pick the best credit card for you Picking the best credit card depends on where you are in your credit journey. Take a look at each of these scenarios to see which type of card suits your needs best. Do you want to build credit? If you’re new to credit or you’re trying to bounce back from previous financial mishaps, your top priority should probably be to build credit. Unfortunately, the credit cards with the most rewards and lowest interest rates might not be available to you just yet. But you can still find and apply for cards that you may be more likely to get approved for. That can help give you a better chance of avoiding the hard credit inquiry that comes with applying for a card and then being rejected. Consider a secured card or an unsecured card meant to build credit. These options can help you build credit as long as you pay off your statement balance in full by the due date. Just make sure the card issuer reports your payments to the three major consumer credit bureaus. Do you want to finance a big purchase or pay off debt? If you think you might need to carry a balance or finance a major purchase, you might want to look for a card with a low purchase APR. A card with an introductory 0% APR offer on purchases could be a good way to save money on interest. https://www.creditkarma.com/credit-cards#best-no-annual-fee-credit-cards

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

Why did Berkshire Hathaway reduce its position in Apple despite its continued dominance in AI and what does this suggest about Warren Buffett's broader market view?

Warren Buffett has been at the helm of the Berkshire Hathaway (BRK.A -0.17%) (BRK.B -0.15%) investment company since 1965. During his 59 years of leadership, Berkshire Hathaway stock has delivered a compound annual return of 19.8%, which would have been enough to turn an investment of $1,000 back then into more than $42.5 million today. Buffett's investment strategy is simple. He looks for growing companies with robust profitability and strong management teams, and he especially likes those with shareholder-friendly programs like dividend payments and stock-buyback plans. One thing Buffett doesn't focus on is the latest stock market trend, so you won't find him piling money into artificial intelligence (AI) stocks right now. However, two stocks Berkshire already holds are becoming significant players in the AI industry, and they account for about 29.5% of the total value of the conglomerate's $305.7 billion portfolio of publicly traded stocks and securities. Warren Buffett smiling, surrounded by cameras. Image source: The Motley Fool. 1. Apple: 28.9% of Berkshire Hathaway's portfolio Apple (AAPL -0.36%) is the world's largest company with a $3.3 trillion market capitalization, but it was worth a fraction of that when Buffett started buying the stock in 2016. Between then and 2023, Berkshire spent about $38 billion building its stake in Apple, and thanks to a staggering return, that position had a value of more than $170 billion earlier this year. However, Berkshire has sold more than half of its stake in the iPhone maker during the past few months. Its remaining position is still worth $88.3 billion, so it's still the largest holding in the conglomerate's portfolio, and I think the recent sales reflect Buffett's cautious view on the broader market as opposed to Apple itself. After all, the S&P 500 is trading at a price-to-earnings ratio (P/E) of 27.6 right now, which is significantly more expensive than its average of 18.1 going back to the 1950s. Collapse NASDAQ: AAPL Apple Today's Change (-0.36%) -$0.80 Current Price $220.11 YTD 1w 1m 3m 6m 1y 5y Price VS S&P AAPL Key Data Points Market Cap $3,359B Day's Range $216.73 - $221.48 52wk Range $164.07 - $237.23 Volume 51,528,321 Avg Vol 63,493,642 Gross Margin 45.96% Dividend Yield 0.44% Besides, Apple is preparing for one of the most important periods in its history. With more than 2.2 billion active devices globally -- including iPhones, iPads, and Mac computers -- Apple could become the world's biggest distributor of AI to consumers. The company unveiled Apple Intelligence earlier this year, which it developed in partnership with ChatGPT creator OpenAI. It's embedded in the new iOS 18 operating system, and it will only be available on the latest iPhone 16 and the previous iPhone 15 Pro models because they are fitted with next-generation chips designed to process AI workloads. Considering Apple Intelligence is going to transform many of the company's existing software applications, it could drive a big upgrade cycle for the iPhone. Apps like Notes, Mail, and iMessage will feature new writing tools capable of instantly summarizing and generating text content on command. Plus, Apple's existing Siri voice assistant is going to be enhanced by ChatGPT, which will bolster its knowledge base and its capabilities. Although Apple's revenue growth has been sluggish in recent quarters, the company still ticks nearly all of Buffett's boxes. It's highly profitable, it has an incredible management team led by Chief Executive Officer Tim Cook, and it's returning truckloads of money to shareholders through dividends and buybacks -- in fact, Apple recently launched a new $110 billion stock buyback program, which is the largest in corporate American history. There is no guarantee Berkshire has finished selling Apple stock, but the rise of AI will likely drive a renewed phase of growth for the company, so that's a good reason to remain bullish no matter what Buffett does next. 2. Amazon: 0.6% of Berkshire Hathaway's portfolio Berkshire bought a relatively small stake in Amazon (AMZN 2.37%) in 2019, which is currently worth $1.7 billion and represents just 0.6% of the conglomerate's portfolio. However, Buffett has often expressed regret for not recognizing the opportunity much sooner, because Amazon has expanded beyond its roots as an e-commerce company and now has a dominant presence in streaming, digital advertising, and cloud computing. Amazon Web Services (AWS) is the largest business-to-business cloud platform in the world, offering hundreds of solutions designed to help organizations operate in the digital era. But AWS also wants to be the go-to provider of AI solutions for businesses, which could be its largest financial opportunity ever. Collapse NASDAQ: AMZN Amazon Today's Change (2.37%) $4.15 Current Price $179.55 YTD 1w 1m 3m 6m 1y 5y Price VS S&P AMZN Key Data Points Market Cap $1,841B Day's Range $176.79 - $180.50 52wk Range $118.35 - $201.20 Volume 36,173,896 Avg Vol 42,567,060 Gross Margin 48.04% Dividend Yield N/A AWS developed its own data center chips like Trainium, which can offer cost savings of up to 50% compared to competing hardware from suppliers like Nvidia. Plus, the cloud provider also built a family of large language models (LLMs) called Titan, which developers can use if they don't want to create their own. They are accessible through Amazon Bedrock, along with a portfolio of third-party LLMs from leading AI start-ups like Anthropic. LLMs are at the foundation of every AI chat bot application. Finally, AWS now offers its own AI assistant called Q. Amazon Q Business can be trained on an organization's data so employees can instantly find answers to their queries, and it can also generate content to boost productivity. Amazon Q Developer, on the other hand, can debug and generate code to help accelerate the completion of software projects. According to consulting firm PwC, AI could add a whopping $15.7 trillion to the global economy by 2030, and the combination of chips, LLMs, and software apps will help Amazon stake its claim to that enormous pie. Amazon was consistently losing money when Berkshire bought the stock, and it doesn't offer a dividend nor does it have a stock buyback program, so it doesn't tick many of Buffett's boxes (hence the small position). But it might be the most diverse AI stock investors can buy right now, and Berkshire will likely be pleased with its long-term return from here even if Buffett wishes it owned a bigger stake. Where Should You Invest $1,000 Right Now? Before you put a single dollar into the stock market, we think you’ll want to hear this. Our S&P/TSX market beating* Stock Advisor Canada team just released their top 10 starter stocks for 2024 that we believe could supercharge any portfolio. Want to see what made our list? Get started with Stock Advisor Canada today to receive all 10 of our starter stocks, a fully stocked treasure trove of industry reports, two brand-new stock recommendations every month, and much more. Click here to learn more. John Mackey, former CEO of Whole Foods Market, an Amazon subsidiary, is a member of The Motley Fool's board of directors. Anthony Di Pizio has no position in any of the stocks mentioned. The Motley Fool has positions in and recommends Amazon, Apple, Berkshire Hathaway, and Nvidia. The Motley Fool has a disclosure policy.

"================ <TEXT PASSAGE> ======= Warren Buffett has been at the helm of the Berkshire Hathaway (BRK.A -0.17%) (BRK.B -0.15%) investment company since 1965. During his 59 years of leadership, Berkshire Hathaway stock has delivered a compound annual return of 19.8%, which would have been enough to turn an investment of $1,000 back then into more than $42.5 million today. Buffett's investment strategy is simple. He looks for growing companies with robust profitability and strong management teams, and he especially likes those with shareholder-friendly programs like dividend payments and stock-buyback plans. One thing Buffett doesn't focus on is the latest stock market trend, so you won't find him piling money into artificial intelligence (AI) stocks right now. However, two stocks Berkshire already holds are becoming significant players in the AI industry, and they account for about 29.5% of the total value of the conglomerate's $305.7 billion portfolio of publicly traded stocks and securities. Warren Buffett smiling, surrounded by cameras. Image source: The Motley Fool. 1. Apple: 28.9% of Berkshire Hathaway's portfolio Apple (AAPL -0.36%) is the world's largest company with a $3.3 trillion market capitalization, but it was worth a fraction of that when Buffett started buying the stock in 2016. Between then and 2023, Berkshire spent about $38 billion building its stake in Apple, and thanks to a staggering return, that position had a value of more than $170 billion earlier this year. However, Berkshire has sold more than half of its stake in the iPhone maker during the past few months. Its remaining position is still worth $88.3 billion, so it's still the largest holding in the conglomerate's portfolio, and I think the recent sales reflect Buffett's cautious view on the broader market as opposed to Apple itself. After all, the S&P 500 is trading at a price-to-earnings ratio (P/E) of 27.6 right now, which is significantly more expensive than its average of 18.1 going back to the 1950s. Collapse NASDAQ: AAPL Apple Today's Change (-0.36%) -$0.80 Current Price $220.11 YTD 1w 1m 3m 6m 1y 5y Price VS S&P AAPL Key Data Points Market Cap $3,359B Day's Range $216.73 - $221.48 52wk Range $164.07 - $237.23 Volume 51,528,321 Avg Vol 63,493,642 Gross Margin 45.96% Dividend Yield 0.44% Besides, Apple is preparing for one of the most important periods in its history. With more than 2.2 billion active devices globally -- including iPhones, iPads, and Mac computers -- Apple could become the world's biggest distributor of AI to consumers. The company unveiled Apple Intelligence earlier this year, which it developed in partnership with ChatGPT creator OpenAI. It's embedded in the new iOS 18 operating system, and it will only be available on the latest iPhone 16 and the previous iPhone 15 Pro models because they are fitted with next-generation chips designed to process AI workloads. Considering Apple Intelligence is going to transform many of the company's existing software applications, it could drive a big upgrade cycle for the iPhone. Apps like Notes, Mail, and iMessage will feature new writing tools capable of instantly summarizing and generating text content on command. Plus, Apple's existing Siri voice assistant is going to be enhanced by ChatGPT, which will bolster its knowledge base and its capabilities. Although Apple's revenue growth has been sluggish in recent quarters, the company still ticks nearly all of Buffett's boxes. It's highly profitable, it has an incredible management team led by Chief Executive Officer Tim Cook, and it's returning truckloads of money to shareholders through dividends and buybacks -- in fact, Apple recently launched a new $110 billion stock buyback program, which is the largest in corporate American history. There is no guarantee Berkshire has finished selling Apple stock, but the rise of AI will likely drive a renewed phase of growth for the company, so that's a good reason to remain bullish no matter what Buffett does next. 2. Amazon: 0.6% of Berkshire Hathaway's portfolio Berkshire bought a relatively small stake in Amazon (AMZN 2.37%) in 2019, which is currently worth $1.7 billion and represents just 0.6% of the conglomerate's portfolio. However, Buffett has often expressed regret for not recognizing the opportunity much sooner, because Amazon has expanded beyond its roots as an e-commerce company and now has a dominant presence in streaming, digital advertising, and cloud computing. Amazon Web Services (AWS) is the largest business-to-business cloud platform in the world, offering hundreds of solutions designed to help organizations operate in the digital era. But AWS also wants to be the go-to provider of AI solutions for businesses, which could be its largest financial opportunity ever. Collapse NASDAQ: AMZN Amazon Today's Change (2.37%) $4.15 Current Price $179.55 YTD 1w 1m 3m 6m 1y 5y Price VS S&P AMZN Key Data Points Market Cap $1,841B Day's Range $176.79 - $180.50 52wk Range $118.35 - $201.20 Volume 36,173,896 Avg Vol 42,567,060 Gross Margin 48.04% Dividend Yield N/A AWS developed its own data center chips like Trainium, which can offer cost savings of up to 50% compared to competing hardware from suppliers like Nvidia. Plus, the cloud provider also built a family of large language models (LLMs) called Titan, which developers can use if they don't want to create their own. They are accessible through Amazon Bedrock, along with a portfolio of third-party LLMs from leading AI start-ups like Anthropic. LLMs are at the foundation of every AI chat bot application. Finally, AWS now offers its own AI assistant called Q. Amazon Q Business can be trained on an organization's data so employees can instantly find answers to their queries, and it can also generate content to boost productivity. Amazon Q Developer, on the other hand, can debug and generate code to help accelerate the completion of software projects. According to consulting firm PwC, AI could add a whopping $15.7 trillion to the global economy by 2030, and the combination of chips, LLMs, and software apps will help Amazon stake its claim to that enormous pie. Amazon was consistently losing money when Berkshire bought the stock, and it doesn't offer a dividend nor does it have a stock buyback program, so it doesn't tick many of Buffett's boxes (hence the small position). But it might be the most diverse AI stock investors can buy right now, and Berkshire will likely be pleased with its long-term return from here even if Buffett wishes it owned a bigger stake. Where Should You Invest $1,000 Right Now? Before you put a single dollar into the stock market, we think you’ll want to hear this. Our S&P/TSX market beating* Stock Advisor Canada team just released their top 10 starter stocks for 2024 that we believe could supercharge any portfolio. Want to see what made our list? Get started with Stock Advisor Canada today to receive all 10 of our starter stocks, a fully stocked treasure trove of industry reports, two brand-new stock recommendations every month, and much more. Click here to learn more. John Mackey, former CEO of Whole Foods Market, an Amazon subsidiary, is a member of The Motley Fool's board of directors. Anthony Di Pizio has no position in any of the stocks mentioned. The Motley Fool has positions in and recommends Amazon, Apple, Berkshire Hathaway, and Nvidia. The Motley Fool has a disclosure policy. https://www.fool.com/investing/2024/09/10/295-warren-buffetts-3057-billion-in-2-ai-stocks/ ================ <QUESTION> ======= Why did Berkshire Hathaway reduce its position in Apple despite its continued dominance in AI and what does this suggest about Warren Buffett's broader market view? ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

[question] [user request] ===================== [text] [context document] ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

My computer has been acting weird and idk what's wrong. It doesn't load as fast as it did before. Im gonna get something to clean it up but idk where to start. Like virus scanners or malware? Which would be the best option? After that I'll clean the dust with a vacuum. could that be the issue too? give me three reasons why i should choose each program and three cons.

Bitdefender consistently impresses with its ability to identify threats and stop them in their tracks. Malware files are pinpointed even before they begin downloading, web trackers are likewise rooted out and blocked, and if you try to access a site with known threats you'll receive a warning that's hard to miss (or ignore.) AV-Comparatives, a third-party test lab, reported positive results when it put Bitdefender to the test. The solution blocked 99.4% of threats (coming in second only to the likes of Norton and McAfee) and didn't have a huge impact on the speed of computer processes. When I put Bitdefender under the microscope myself, I saw it block real-world ransomware before it could wreak havoc. However, I did notice that the Ransomware Remediation feature isn't enabled by default—so you'll need to dive into the settings to ensure that your files remain secure. Earlier this year, Bitdefender released a decryptor for the MortalKombat ransomware—free of charge, providing the company's commitment to countering cyberattacks. Victims across the US were targeted at random by ransomware, which spread through bogus emails containing a .ZIP attachment and a BAT loader script. To tackle this threat, the decryptor backs up affected files before attempting decryption, just in case, and can be executed via the command line. Bitdefender gets straight to work with a full scan when you start using it, and combs through your system in its entirety to look for threats and intruders. This is par for the course, although Bitdefender took almost a full hour to complete a scan of 50 Gb executable files. It's possible to configure scans, customize them, and set them to run on a schedule or on-demand, and Quick Scans can even be run once a day, or weekly, and dig into individual files. I found Bitdefender incredibly easy to use—so even if you're new to the world of antivirus, you'll have no trouble navigating sleek and well-designed apps. You can even customize the dashboard by adding or removing default features. So, if you don't make use of the VPN, you can substitute it in a few clicks for the password manager or scan manager. Most of the features you'll need are already enabled by default, too, which means you won't have to spend ages configuring each and every setting. However, if you do need help with particular tools, you can count on Bitdefender's in-program tutorials to help you make the most of these privacy-enhancing functionalities. Bitdefender's Total Security plan is available from $39.99 for a single year—although the price does jump to $95 after this introductory period. However, you can take advantage of a 30-day money-back guarantee to put the solution through its paces, run your own tests, and see whether its suite of tools is worth the investment. Norton is tough on threats and has earned excellent scores in several third-party protection tests, including our own. I was also impressed with Norton’s scan speed—it took 29 minutes for the solution to complete its initial scan of 50 Gb of files. It’s not the quickest antivirus I've seen, but still beats the likes of Bitdefender and Avast. Norton shines when it comes to identifying threats, however. My tests, and those conducted by AV-Compatatives, found that it blocked all attacks before the malware could be downloaded. Norton is also incredibly good at blocking dangerous URLs and preventing you from landing on a page that's determined to ruin your day. You'll see a warning message with additional information about the malware and a heads-up about other sites that contain the same threat. The Safe Web browser extension gives you even more peace of mind by adding site ratings to search results, helping you steer clear of dodgy domains. Norton wants to help you get better at identifying and avoiding threats, too, as evidenced by the development of an AI-powered chatbot. Dubbed "Norton Genie", the bot can let you know whether that suspicious email you received is legitimate or a phishing attempt—and all you have to do is send it a screenshot or copy and paste some of the text. The Norton Secure VPN isn't my favorite VPN on the market, but does a solid job of keeping your IP address hidden, your browsing private, and can even unblock a decent amount of streaming services. Combining the VPN with the intelligent firewall really maximizes your digital security, and you'll be alerted right away if an untrustworthy program attempts to connect to the internet. You can allow or block the connection, and Norton gives you plenty of detail (like the age of the program and the URL it's attempting to reach) to help you make a security-conscious decision. Avast One is the newest offering from Avast, and comes packed with all of the malware protection, advanced features, and ease of use you'd expect from an industry veteran. You'll also be able to use the solution on any Windows, Mac, Android, or iOS device. Avast One's scan speeds were pretty average, taking 32 minutes to complete a scan of 50 Gb of executable files. These scans are hugely customizable, too, and give you granular control over where you want the solution to focus. Smart Scans take a few seconds to check for malware and dodgy browser add-ons, Targeted Scans look at specified folders and files, and Full Scans comb through your entire system. Very few providers can keep up with Avast One when it comes to identifying and removing malware. None of my tests were able to crack its protection, and the latest report from AV-Comparitives revealed that it scored an outstanding 99.97% detection rate. So, you can rest assured that no threats will make it through to your device unseen. Avast One shores up its security with a firewall that keeps tabs on your network traffic to thwart hackers, and can block your access to malicious websites to prevent infections. I also like that its Ransomware Shield was able to find folders containing user documents and automatically add them to its protect list. The solution rounds out its antivirus package with useful extras—and the sheer amount of these features is what makes Avast One worth checking out. All of its paid subscriptions come with the HideMyAss!-powered SecureLine VPN, but if you're on the Essential plan, you'll have to deal with a limit of 5 Gb per week and a single server location. Despite these setbacks, this is still more than you need to catch up on your favorite Netflix shows. Opt for a more expensive subscription and the VPN breaks free of these shackles. You'll have more than 50 server locations to choose from, and you'll also be alerted if you try to access a banking site, sensitive domain, or even a store without switching the VPN on first. This is a lifesaver if you want to go about your business without leaving an identifiable trail. Avast One's features just keep coming. Subscribers get a password manager that'll check for compromised details, parental controls, webcam monitoring, and anti-phishing tools that ensure all aspects of your online life are secure. If you're ready to take the plunge, there are three paid subscriptions to choose from. The Individual plan gets you access to all of the aforementioned tools and licenses for five devices, whereas the Family and Premium plans bump this number up to thirty (the latter also comes with an identity monitory that'll let you know if your data ends up on the dark web). Thanks to the Essential plan, however, you can try a limited version of the product without paying a penny.

[question] My computer has been acting weird and idk what's wrong. It doesn't load as fast as it did before. Im gonna get something to clean it up but idk where to start. Like virus scanners or malware? Which would be the best option? After that I'll clean the dust with a vacuum. could that be the issue too? give me three reasons why i should choose each program and three cons. ===================== [text] Bitdefender consistently impresses with its ability to identify threats and stop them in their tracks. Malware files are pinpointed even before they begin downloading, web trackers are likewise rooted out and blocked, and if you try to access a site with known threats you'll receive a warning that's hard to miss (or ignore.) AV-Comparatives, a third-party test lab, reported positive results when it put Bitdefender to the test. The solution blocked 99.4% of threats (coming in second only to the likes of Norton and McAfee) and didn't have a huge impact on the speed of computer processes. When I put Bitdefender under the microscope myself, I saw it block real-world ransomware before it could wreak havoc. However, I did notice that the Ransomware Remediation feature isn't enabled by default—so you'll need to dive into the settings to ensure that your files remain secure. Earlier this year, Bitdefender released a decryptor for the MortalKombat ransomware—free of charge, providing the company's commitment to countering cyberattacks. Victims across the US were targeted at random by ransomware, which spread through bogus emails containing a .ZIP attachment and a BAT loader script. To tackle this threat, the decryptor backs up affected files before attempting decryption, just in case, and can be executed via the command line. Bitdefender gets straight to work with a full scan when you start using it, and combs through your system in its entirety to look for threats and intruders. This is par for the course, although Bitdefender took almost a full hour to complete a scan of 50 Gb executable files. It's possible to configure scans, customize them, and set them to run on a schedule or on-demand, and Quick Scans can even be run once a day, or weekly, and dig into individual files. I found Bitdefender incredibly easy to use—so even if you're new to the world of antivirus, you'll have no trouble navigating sleek and well-designed apps. You can even customize the dashboard by adding or removing default features. So, if you don't make use of the VPN, you can substitute it in a few clicks for the password manager or scan manager. Most of the features you'll need are already enabled by default, too, which means you won't have to spend ages configuring each and every setting. However, if you do need help with particular tools, you can count on Bitdefender's in-program tutorials to help you make the most of these privacy-enhancing functionalities. Bitdefender's Total Security plan is available from $39.99 for a single year—although the price does jump to $95 after this introductory period. However, you can take advantage of a 30-day money-back guarantee to put the solution through its paces, run your own tests, and see whether its suite of tools is worth the investment. Norton is tough on threats and has earned excellent scores in several third-party protection tests, including our own. I was also impressed with Norton’s scan speed—it took 29 minutes for the solution to complete its initial scan of 50 Gb of files. It’s not the quickest antivirus I've seen, but still beats the likes of Bitdefender and Avast. Norton shines when it comes to identifying threats, however. My tests, and those conducted by AV-Compatatives, found that it blocked all attacks before the malware could be downloaded. Norton is also incredibly good at blocking dangerous URLs and preventing you from landing on a page that's determined to ruin your day. You'll see a warning message with additional information about the malware and a heads-up about other sites that contain the same threat. The Safe Web browser extension gives you even more peace of mind by adding site ratings to search results, helping you steer clear of dodgy domains. Norton wants to help you get better at identifying and avoiding threats, too, as evidenced by the development of an AI-powered chatbot. Dubbed "Norton Genie", the bot can let you know whether that suspicious email you received is legitimate or a phishing attempt—and all you have to do is send it a screenshot or copy and paste some of the text. The Norton Secure VPN isn't my favorite VPN on the market, but does a solid job of keeping your IP address hidden, your browsing private, and can even unblock a decent amount of streaming services. Combining the VPN with the intelligent firewall really maximizes your digital security, and you'll be alerted right away if an untrustworthy program attempts to connect to the internet. You can allow or block the connection, and Norton gives you plenty of detail (like the age of the program and the URL it's attempting to reach) to help you make a security-conscious decision. Avast One is the newest offering from Avast, and comes packed with all of the malware protection, advanced features, and ease of use you'd expect from an industry veteran. You'll also be able to use the solution on any Windows, Mac, Android, or iOS device. Avast One's scan speeds were pretty average, taking 32 minutes to complete a scan of 50 Gb of executable files. These scans are hugely customizable, too, and give you granular control over where you want the solution to focus. Smart Scans take a few seconds to check for malware and dodgy browser add-ons, Targeted Scans look at specified folders and files, and Full Scans comb through your entire system. Very few providers can keep up with Avast One when it comes to identifying and removing malware. None of my tests were able to crack its protection, and the latest report from AV-Comparitives revealed that it scored an outstanding 99.97% detection rate. So, you can rest assured that no threats will make it through to your device unseen. Avast One shores up its security with a firewall that keeps tabs on your network traffic to thwart hackers, and can block your access to malicious websites to prevent infections. I also like that its Ransomware Shield was able to find folders containing user documents and automatically add them to its protect list. The solution rounds out its antivirus package with useful extras—and the sheer amount of these features is what makes Avast One worth checking out. All of its paid subscriptions come with the HideMyAss!-powered SecureLine VPN, but if you're on the Essential plan, you'll have to deal with a limit of 5 Gb per week and a single server location. Despite these setbacks, this is still more than you need to catch up on your favorite Netflix shows. Opt for a more expensive subscription and the VPN breaks free of these shackles. You'll have more than 50 server locations to choose from, and you'll also be alerted if you try to access a banking site, sensitive domain, or even a store without switching the VPN on first. This is a lifesaver if you want to go about your business without leaving an identifiable trail. Avast One's features just keep coming. Subscribers get a password manager that'll check for compromised details, parental controls, webcam monitoring, and anti-phishing tools that ensure all aspects of your online life are secure. If you're ready to take the plunge, there are three paid subscriptions to choose from. The Individual plan gets you access to all of the aforementioned tools and licenses for five devices, whereas the Family and Premium plans bump this number up to thirty (the latter also comes with an identity monitory that'll let you know if your data ends up on the dark web). Thanks to the Essential plan, however, you can try a limited version of the product without paying a penny. https://www.techradar.com/best/best-antivirus ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

You must respond using only the information provided in the context.

What technological roadblocks are flying cars faced with as they navigate our current infrastructure?

ABSTRACT Flying vehicle-related technology development is progressing rapidly. As autonomous vehicles begin to be commercialized, interest in the development of flying vehicle technology is increasing. Recently, some countries have launched services that utilize flying car technology along with self-driving cars. The automobile industry is undergoing rapid change by combining IT technology with automobile technology. The center of this change is the flying car-related technology that will be integrated onto the car of the future. Flying vehicle technology will be combined with autonomous vehicle technology to develop into a tool for more convenient human life. This paper examines the trend of flying automobile technology in relation to the flow of automobile technology. Keywords: Flying Car, VTOL, Flying Car Technology Trend, PAV. 1. INTRODUCTION The era of self-driving cars, where cars come to pick up people and take them to their destinations, is approaching. A number of automobile companies and IT companies, including Google, are participating in the development of autonomous vehicles. The era of self-driving cars will become a future that everyone is familiar with. And now, a new means of transportation that goes beyond self-driving cars is attracting attention. After IT companies such as Google and Uber took the lead and showed interest in flying cars, interest in flying cars is growing, especially in the United States. Flying car is a concept that has recently emerged and there is no fully agreed definition yet. “Is a flying car a car or an airplane?” It is also ambiguous to answer these questions. Flying cars can run on the road or fly if necessary. Flying cars do not require a wide horizontal runway like airplanes, and are expected to take off and land by lifting the aircraft vertically. It can be used like a car on the road and can fly in the sky when necessary [9]. Many companies such as Airbus and Rolls-Royce of the UK are jumping into the competition to develop technology related to flying cars Progressive Academic Publishing, UK Page 2 www.idpublications.org GM unveiled the Cadillac flying car and electric shuttle concept car at CES 2021. At CES 2021, the world's largest ICT exhibition, GM said, "GM's future mobility concepts of flying cars and electric shuttles are means of transportation that can confirm GM's direction for the next five years.” Beyond the era of autonomous vehicles, we have now entered the stage of technology development for the era of flying cars [1, 2, 3, 11]. Flying cars, unlike self-driving cars, fly in the sky, so there are many more problems to be solved. In addition, global standards and definitions related to technology for flying cars have not been established. This paper intends to examine the technology trends related to these flying cars. 2. FLYING CAR RELATED ISSUES There are many problems to be solved in order for flying cars to be commercialized in the form of flying cars that are operated on the road and take off into the air when necessary [3, 4, 5]. Some of these issues are as follows: (1) Technical issues There are many technical problems with flying cars. Ultimately, only when flying cars become popular it will be able to achieve the goals of traffic congestion and convenience. It is important to develop technology that can lower the price of flying cars. Of course, if flying cars become popular and mass-produced, the price is expected to be lowered naturally. Technology to reduce noise generated by flying cars is also emerging as a problem to be solved. In addition, it is expected that popularization can be accelerated only when sensor-related technology development to ensure safety for operation and technology related to autonomous flight capable of flying without human intervention are developed. In addition, it is important to develop battery-related technology for a long flight. Only when these technical problems are resolved people will be able to use them safely. (2) System improvement and infrastructure establishment In relation to flying cars, optimistic predictions about the operation of aerial vehicles are predicted when the VTOL (Vertical Take-off and Landing) type of technology is introduced. On the other hand, in order to settle as a convenient means of transportation with the introduction of flying cars, the government's active policy change is necessary. It is necessary to build a dedicated space for PAV (Personal Air Vehicle) for vertical take-off and landing in the city. It is also essential to establish a place to charge the PAV's electricity. It is also necessary to enact systems and laws in parallel with the establishment of such infrastructure. Most countries have so far established systems and laws centered on automobiles, a means of transportation. A work must also be done to make these systems and laws fit the environment of the flying car, a new means of transportation. It is expected that it will take time for the construction of infrastructure for flying cars and the work of enacting systems and laws. If flying cars are commercialized, there is a possibility that traffic jams on the ground will occur in the sky. It is also essential to develop a system that can efficiently manage and control such traffic jams in the air. Flying cars are expected to make human life more convenient as a new means of transportation along with autonomous vehicles.

ABSTRACT Flying vehicle-related technology development is progressing rapidly. As autonomous vehicles begin to be commercialized, interest in the development of flying vehicle technology is increasing. Recently, some countries have launched services that utilize flying car technology along with self-driving cars. The automobile industry is undergoing rapid change by combining IT technology with automobile technology. The center of this change is the flying car-related technology that will be integrated onto the car of the future. Flying vehicle technology will be combined with autonomous vehicle technology to develop into a tool for more convenient human life. This paper examines the trend of flying automobile technology in relation to the flow of automobile technology. Keywords: Flying Car, VTOL, Flying Car Technology Trend, PAV. 1. INTRODUCTION The era of self-driving cars, where cars come to pick up people and take them to their destinations, is approaching. A number of automobile companies and IT companies, including Google, are participating in the development of autonomous vehicles. The era of self-driving cars will become a future that everyone is familiar with. And now, a new means of transportation that goes beyond self-driving cars is attracting attention. After IT companies such as Google and Uber took the lead and showed interest in flying cars, interest in flying cars is growing, especially in the United States. Flying car is a concept that has recently emerged and there is no fully agreed definition yet. “Is a flying car a car or an airplane?” It is also ambiguous to answer these questions. Flying cars can run on the road or fly if necessary. Flying cars do not require a wide horizontal runway like airplanes, and are expected to take off and land by lifting the aircraft vertically. It can be used like a car on the road and can fly in the sky when necessary [9]. Many companies such as Airbus and Rolls-Royce of the UK are jumping into the competition to develop technology related to flying cars Progressive Academic Publishing, UK Page 2 www.idpublications.org GM unveiled the Cadillac flying car and electric shuttle concept car at CES 2021. At CES 2021, the world's largest ICT exhibition, GM said, "GM's future mobility concepts of flying cars and electric shuttles are means of transportation that can confirm GM's direction for the next five years.” Beyond the era of autonomous vehicles, we have now entered the stage of technology development for the era of flying cars [1, 2, 3, 11]. Flying cars, unlike self-driving cars, fly in the sky, so there are many more problems to be solved. In addition, global standards and definitions related to technology for flying cars have not been established. This paper intends to examine the technology trends related to these flying cars. 2. FLYING CAR RELATED ISSUES There are many problems to be solved in order for flying cars to be commercialized in the form of flying cars that are operated on the road and take off into the air when necessary [3, 4, 5]. Some of these issues are as follows: (1) Technical issues There are many technical problems with flying cars. Ultimately, only when flying cars become popular it will be able to achieve the goals of traffic congestion and convenience. It is important to develop technology that can lower the price of flying cars. Of course, if flying cars become popular and mass-produced, the price is expected to be lowered naturally. Technology to reduce noise generated by flying cars is also emerging as a problem to be solved. In addition, it is expected that popularization can be accelerated only when sensor-related technology development to ensure safety for operation and technology related to autonomous flight capable of flying without human intervention are developed. In addition, it is important to develop battery-related technology for a long flight. Only when these technical problems are resolved people will be able to use them safely. (2) System improvement and infrastructure establishment In relation to flying cars, optimistic predictions about the operation of aerial vehicles are predicted when the VTOL (Vertical Take-off and Landing) type of technology is introduced. On the other hand, in order to settle as a convenient means of transportation with the introduction of flying cars, the government's active policy change is necessary. It is necessary to build a dedicated space for PAV (Personal Air Vehicle) for vertical take-off and landing in the city. It is also essential to establish a place to charge the PAV's electricity. It is also necessary to enact systems and laws in parallel with the establishment of such infrastructure. Most countries have so far established systems and laws centered on automobiles, a means of transportation. A work must also be done to make these systems and laws fit the environment of the flying car, a new means of transportation. It is expected that it will take time for the construction of infrastructure for flying cars and the work of enacting systems and laws. If flying cars are commercialized, there is a possibility that traffic jams on the ground will occur in the sky. It is also essential to develop a system that can efficiently manage and control such traffic jams in the air. Flying cars are expected to make human life more convenient as a new means of transportation along with autonomous vehicles. You must respond using only the information provided in the context. What technological roadblocks are flying cars faced with as they navigate our current infrastructure?

Please do not use any other resources to answer the question other than the information I provide you. If you cannot answer with only the information I provide say "I cannot answer without further research."

What are the key considerations and strategies for people who use stimulant drugs and engage in concurrent sex in terms of HIV prevention, and how does the effectiveness of these strategies get optimized?

Purpose of this guide The purpose of this publication is to provide guidance on implementing HIV, hepatitis C (HCV) and hepatitis B (HBV) programmes for people who use stimulant drugs and who are at risk of contracting these viruses. It aims to: • Increase awareness of the needs and issues faced by the affected groups, including the intersectionality among different key populations • Provide implementation guidance to help establish and expand access to core HIV and hepatitis prevention, treatment, care and support services It is a global document that should be adapted according to the specific context, including the type of stimulant drug used (cocaine, ATS or NPS) and the key populations involved, which vary considerably according to regions. The present guide proposes a package of core interventions adapted from existing international guidance: • WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users[7] • WHO Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations – 2016 update [8] • Implementing comprehensive HIV and HCV programmes with people who inject drugs: practical guidance for collaborative interventions (the “IDUIT”) [9] It also incorporates guidance from the implementation tools for other key populations: • Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative interventions (the “SWIT”) [10] • Implementing comprehensive HIV and STI programmes with men who have sex with men: practical guidance for collaborative interventions (the “MSMIT”) [11] • Implementing comprehensive HIV and STI programmes with transgender people: practical guidance for collaborative interventions (the “TRANSIT”) [12] However, none of these guidance documents and tools addresses the specific needs of people who use stimulant drugs and are at risk for HIV and hepatitis B and C – hence the need for this publication. Audience The guide is intended for use by policymakers, programme managers and service providers, including community-based organizations, at the national, regional or local levels, who undertake to address HIV prevention, treatment and care. It also provides useful information for development and funding agencies and for academia. Structure The guide is divided into five chapters. • Chapter 1 explains the nature and effects of stimulant drugs, the associated risks of HIV and hepatitis transmission, and the issues surrounding stimulant drug use and HIV and hepatitis risk in specific key populations and other vulnerable groups. 10 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS • Chapter 2 presents the package of core HIV interventions for key populations who use stimulant drugs. • Chapter 3 describes approaches to care and support for people who use stimulant drugs, particularly in the context of HIV and hepatitis. • Chapter 4 describes six critical enablers – activities and strategies that are needed to ensure access to the interventions in the core package. • Chapter 5 outlines further considerations for implementing programmes. Within each chapter, further resources are listed. Case studies are provided throughout the guide to illustrate specific aspects of programmes that have been implemented in different countries. There is also an annex presenting a series of checklists and other practical tools for policymakers and implementers. Principles Two important overarching principles are stressed throughout this publication. The first is better integration of HIV, hepatitis B and C and sexually transmitted infection (STI) services for people who use stimulant drugs within existing HIV harm reduction services2 and drug treatment services for people who inject drugs, and within sexual and reproductive health and other HIV services for key populations. The second is the meaningful involvement of people who use stimulant drugs, people living with HIV and other key populations in planning, implementing, monitoring and evaluating interventions. This is key to their success and sustainability. Finally, the implementation of HIV-related services for people who use stimulant drugs should adhere to human-rights principles as described in the implementation tools mentioned above – the SWIT, MSMIT, TRANSIT and IDUIT. Methodology In its June 2009 session, the UNAIDS Programme Coordinating Board (PCB) called upon “Member States, civil society organizations and UNAIDS to increase attention on certain groups of non-injecting drug users, especially those who use crack cocaine and ATS, who have been found to have increased risk of contracting HIV through high-risk sexual practices”. UNODC therefore commissioned a review and organized a Global Expert Group Technical Meeting on Stimulant Drugs and HIV, held in Brazil in 2010. A discussion paper on HIV prevention, treatment and care among people who use (noninjecting) crack and cocaine or other stimulant drugs, particularly ATS, was developed in 2012. In 2013 the UNODC HIV Civil Society Organization (CSO) group established a Stimulant Drugs and HIV working group, with representatives from civil society and experts on HIV and stimulant drugs. The group organized consultations with representatives of the community and CSOs, including on the margins of the International Harm Reduction Conference in Kuala Lumpur in 2015. 2 For the purposes of this guide, harm reduction is defined by the nine interventions of the “comprehensive package” of services detailed in the WHO, UNODC, UNAIDS Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users (see citation 7). These are: 1. Needle and syringe programmes; 2. Opioid substitution therapy and other drug dependence treatment; 3. HIV testing and counselling; 4. Antiretroviral therapy; 5. Prevention and treatment of sexually transmitted infections; 6. Condom programmes for people who inject drugs and their sexual partners; 7. Targeted information, education and communication; 8. Prevention, vaccination, diagnosis and treatment for viral hepatitis; 9. Prevention, diagnosis and treatment of tuberculosis. 11 In December 2014, the Strategic Advisory Group to the United Nations on HIV and injecting drug use, consisting of representatives of networks and organizations of people who use drugs, academics, donors, implementers and United Nations organizations, recommended conducting a new literature review on stimulant drugs and HIV and hepatitis C. In 2015 UNODC, together with WHO and UNAIDS, defined the scope of this new literature review, and accordingly UNODC commissioned it to cover the extent, patterns and geographic distribution of injecting and non-injecting stimulant drug use (particularly crack, cocaine, ATS and stimulant NPS) in men who have sex with men, sex workers and other groups of stimulant drug users, and their possible link to HIV and hepatitis B and C vulnerability and transmission; and effective interventions for prevention, treatment and care of HIV and hepatitis B and C among people who use such stimulant drugs. The results of the literature review were published by UNODC in 2016 in five papers covering the following topics: • Methodology and summary [3] • ATS [13] • Cocaine and crack cocaine [14] • NPS [15] • Treatment and prevention of HIV, HCV & HBV among stimulant drug users[16]. Subsequently, in the framework of preparations for the United Nations General Assembly Special Session on the World Drug Problem (UNGASS 2016) and the HLM 2016, UNODC organized a scientific consultation on HIV and drug use, including stimulant drugs. The papers relating to stimulant drugs presented at the Commission on Narcotic Drugs in March 2016 covered: cocaine and crack cocaine use and HIV in the United States; ATS and men who have sex with men in Asia; and antiretroviral therapy (ART) and stimulant drug use. The recommendations of the contributing scientists were summarized as part of a scientific statement presented in New York on the margins of the UNGASS 2016 and the HLM 2016 [17]. The statement stressed the need to address HIV among people who use stimulant drugs, including the structural, social and personal mediating factors for HIV transmission, such as polydrug use, STIs, mental health, homophobia, discrimination and punitive laws. The scientists recommended the provision of ART to all people using stimulant drugs living with HIV, and the implementation of new prevention tools such as pre-exposure prophylaxis (PrEP) and the use of social media for communication. The statement also emphasizes that with proper support for adherence, ART is effective among people living with HIV who use stimulant drugs. In 2017, UNODC commissioned the development of the present publication, HIV prevention, treatment, care and support for people who use stimulant drugs: an implementation guide. Based on the results of the scientific reviews and of the expert group meetings, and on international guidance and country practices that have been identified as effective in meeting the needs of people who use stimulant drugs, a first draft of the document was developed under the guidance of the UNODC CSO Stimulant Drugs and HIV working group. The draft guide was reviewed by external peer reviewers, United Nations agency reviewers and community representatives through an electronic consultation and three face-to-face consultations held in Viet Nam (2017), Brazil (2017) and Ukraine (2018). Chapter 1 Stimulant drugs, HIV and hepatitis, and key populations The World Drug Report 2019 estimates that about 29 million people used ATS in 2017, and 18 million used cocaine [18]. There is no estimate of the total number of people using NPS. The great majority of people who use stimulant drugs do so on an occasional basis which may be characterized as “recreational”, and they will not develop dependence or any other health problem. There is evidence that the prevalence of ATS use, particularly methamphetamines, is increasing in some regions, including North America, Oceania and most parts of Asia. In addition, between 2009 and 2016, there were reports of 739 NPS, of which 36 per cent were classified as stimulant drugs [19]. Only a small proportion of people who use stimulant drugs inject them; most smoke, snort or use them orally or anally. However, the World Drug Report 2017 states that 30 per cent of people who inject drugs inject stimulant drugs, either as their drug of first choice or in addition to opiates. Despite evidence showing that certain subgroups of people who use stimulant drugs are at greater risk of HIV, prevention, testing and treatment programmes for these population groups remain very limited in scope and scale across the globe, and their specific needs are often overlooked. 1.1 Stimulant drugs Stimulant drugs are chemically diverse substances that are similar in their capacity to activate, increase or enhance the neural activity of the central nervous system, resulting in a common set of effects in most people who use them, including increased alertness, energy and/or euphoria.3 This publication considers three types of stimulant drugs for which data have shown a link with increased HIV risk among some key populations: • Cocaine: Found in various forms, e.g. smokable cocaine, crack cocaine, freebase, paste or pasta base, paco, basuco. Depending on the form, it may be sniffed or snorted, injected, ingested or inserted anally. 3 For more detailed information on different stimulant drugs and their effects, see: Terminology and information on drugs. Third edition. New York (NY), United Nations, 2016 (https://www.unodc.org/documents/scientific/Terminology_and_ Information_on_Drugs-3rd_edition.pdf, accessed 15 January 2019). 14 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS • Amphetamine-type stimulants: Amphetamines and methamphetamines (excluding MDMA) are found in different forms, e.g. crystals (methamphetamines), powder or formulated tablets [20]. They are taken orally, smoked from a pipe, sniffed or snorted, inserted anally or injected in a solution. • Stimulant new psychoactive substances: Found in various forms, e.g.synthetic cathinone, phenethylamines, aminoindanes and piperazines. They are sometimes referred to as “bath salts” [21][22]. Depending on the form, NPS are taken orally, smoked, inserted anally or injected. All types of stimulant drugs have common effects: • Mental: Euphoria, raised libido, reduced appetite and sleep drives, enhanced perception, increased alertness, cognitive improvements and deficits (attention, working memory, long-term memory), emotional intensity and excitability, and increased confidence. • Behavioural: Talkativeness, hypervigilance, hyperactivity, increased sociability, disinhibition, changes in sexual behaviour (including sexual sessions of longer than usual duration), faster reaction, and repetitive activity (“tweaking”); hyper-excitability, insomnia, restlessness, panic, erratic behaviour, and sometimes aggressive or violent behaviour[23]. • Physical: Increased heart rate (including palpitations), raised temperature (hyperthermia), circulatory changes (higher blood pressure, vasoconstriction), increased breathing rate, dry mouth, teeth-grinding, jaw-clenching/gurning, faster eye-movements, and dilated pupils. The onset and duration of these effects vary according to the drug, its form, dosage, route of administration, the characteristics of the individual using it, and the context of use. Chronic use of stimulant drugs can lead to psychological dependence; development of tolerance; destruction of tissues in the nose if snorted or sniffed; chronic bronchitis, which can lead to chronic obstructive pulmonary disease; malnutrition and weight loss; disorientation, apathy, confusion, exhaustion due to lack of sleep, and paranoid psychosis. During withdrawal there may be a long period of sleep and depression. Cocaine Cocaine is generally encountered in two forms which differ in their route of administration: cocaine hydrochloride (HCL), a powder, which is snorted, injected or taken anally, and cocaine base (crack, freebase, or crystal) which is smokable and usually taken in a pipe. A third form, coca paste (pasta base, paco, coca pasta, etc.), is an intermediate product of the process of extraction of HCL from the coca leaves. Available mainly in Latin America, it is usually smoked in a cigarette. Cocaine is a powerful stimulant whose effects diminish quickly, prompting the user to repeatedly administer additional doses. When snorted, cocaine produces a slow wave of euphoria, followed by a plateau and then a “come down” period. In its smokable form, cocaine has a more intense and immediate effect. Severe anticipatory anxiety about the impending low may result in repeat dosing. This cycle may take around 5 to 10 minutes. The use of cocaine is more prevalent in North and South America than in the rest of the world. Amphetamine-type stimulants (ATS) Amphetamine and methamphetamine are synthetic drugs whose effects include euphoria, arousal and psychomotor activation. ATS can be taken orally, intranasally, smoked as a vapour (pipe), inserted anally or injected. Immediately after smoking or injecting, people experience a pleasurable “rush”. Intranasal and oral ingestion produce a gradual euphoria or “come up”. Depending on the level of tolerance, the effects of methamphetamine may last four hours, or as long as 24 hours for someone new to the drug [24]. Some people who use methamphetamine may experience a feeling of invincibility, with an accompanying propensity to engage in high-risk behaviours, creating vulnerabilities to acquiring HIV [25]. The direct health impacts of ATS include insomnia and cardiovascular stress. Long-term negative effects may include dopamine physical dependence, psychological dependence, psychosis and paranoia, and depression. Amphetamine and methamphetamine use is reported in all parts of the world. Stimulant new psychoactive substances There are a various types of new psychoactive substances (NPS), with different molecular structures, but the majority of stimulant NPS are synthetic cathinones, which have a similar molecular structure to cathinone found in the khat plant. Common synthetic cathinones include mephedrone, pentedrone, methylone or methcathinone. They fall into two main families: euphoriants and entactogens.NPS are taken orally, can also be snorted or inserted anally, and less frequently are injected. Stimulant NPS produce similar mental, physical and behavioural effects to traditional stimulant drugs such as cocaine, amphetamines and methamphetamines. Synthetic cathinones and other stimulant NPS are also used to improve sexual experience [26]. The use of synthetic cathinone such as mephedrone (sometimes called “bath salts”) has recently emerged [18]. Studies from Hungary [27][28][29], Ireland [30][31], Israel [32], Romania [33] and the United Kingdom [34] suggest that due to a shortage in heroin supply and easy access to synthetic cathinone, a significant proportion of people who inject drugs have switched to injecting synthetic cathinone in recent years. 1.2 Stimulant drug use and risks of HIV/HBV/HCV transmission The HIV/HBV/HCV risk associated with stimulant drug use is linked to a higher prevalence of unprotected anal and vaginal sex, and of sharing pipes, straws and injection equipment, in some groups of men who have sex with men, sex workers, people who inject drugs and people in prisons. Transmission risks through concurrent stimulant drug use and unprotected sex Inconsistent condom use by people who use stimulant drugs has been identified as a prime means of contracting STIs, including HIV, particularly as a result of the concurrent use of stimulant drugs with frequent sexual activity of long duration with multiple partners or in groups. Stimulant drug use may also facilitate longer penetration (which can lead to condom breakages), and more intense acts such as fisting that increase the opportunity of anal and vaginal tears or bleeding. Transmission risks through sharing injection equipment Injecting methamphetamine, cocaine or NPS entails a similar risk to injecting other drugs when needles and injecting equipment are shared. Given that many stimulant drugs have a shorter duration of action compared with opioids, people who inject stimulant drugs report a higher frequency of injecting, with compulsive re-injecting and a greater likelihood of sharing and reusing needles and syringes that may be contaminated [22][34]. HIV and HCV risk is also increased when cocaine or crack is coadministered with heroin, including injection of heroin and cocaine (“speedballing”) [35]. Coexisting injecting drug use and unprotected sex further increases the likelihood of HIV and hepatitis transmission, especially in high-incidence communities. This pattern has been seen, for example, with the use of home-made ATS, such as boltushka in Ukraine. People who inject boltushka engage in high levels of injecting risk behaviours and in sexual risk behaviour post use. They are young and poor, and the great majority are already living with HIV [36]. Hepatitis C transmission through straws or pipes HCV is transmitted through blood or, less commonly, through sexual contact. HCV can be transmitted from a person living with hepatitis who has oral or nasal sores or lacerations through sharing of straws or pipes [37][38][39][40]. Compared with the general population, higher HCV prevalence rates, ranging from 2.3 to 17 per cent, have been observed among people who smoke or sniff stimulant drugs [41]. However, it is difficult to determine whether HCV transmission in these cases occurred through blood exposure, sexual activity, or both. 1.3 Stimulant drug use and HIV/HBV/HCV transmission risks among key populations Men who have sex with men There seems to be a clear association between ATS use among men who have sex with men and risk of HIV infection. Methamphetamine use has been associated with increased frequency of unprotected sex among some men who have sex with men, thereby increasing vulnerability to STIs, HBV and HIV [42][43][44][45]. Studies have indicated HIV prevalence rates among men who have sex with men who use methamphetamine ranging between 17 and 61 per cent, and HIV incidence ranging from 2.71 per 100 person-years [46] to 5 per 100 person-years [47]. The use of stimulant drugs by some men who have sex with men to facilitate sex (referred to as ChemSex)4 has been linked to decreased condom use, sex with multiple partners and other high-risk sexual behaviours that increase likelihood of HIV and HCV transmission [48][49]. Increased sexual risk behaviours, including unprotected sex, coupled with potential anal or rectal trauma resulting from longer, more frequent and intense sexual encounters under the influence of drugs, could facilitate STI transmission among men who have sex with men, including HCV among men who have sex with men living with HIV. Risk-reduction strategies for HIV prevention such as serosorting5 and strategic positioning6 are inefficient for the prevention of other STIs, HBV or HCV. The association between ChemSex, drug use and sexually transmitted acute HCV infection among men living with HIV who have sex with men has been documented in several countries and regions [50]. ChemSex is mostly associated with non-injecting drug use, although some may also inject synthetic cathinones, amphetamines and methamphetamines (referred to as “slamming” or “blasting” within the context of ChemSex) [51], with a high level of sharing of injection equipment and consequently higher risks of HIV and HCV transmission [52][53][54]. Mephedrone use seems to have risen among men who have sex with men in the context of ChemSex [52]. The use of erectile dysfunction medications such as sildenafil is often reported among men who have sex with men who also consume methamphetamines and has been identified as increasing rates of unprotected sex and HBV, syphilis and HIV risks [46][48][55]. People who inject drugs Injecting stimulant drugs carries the greatest risk of acquiring HCV or HIV, due primarily to the sharing of contaminated needles and syringes. People who inject cocaine, ATS or heroin have a risk of acquiring HIV that is respectively 3.6, 3.0, and 2.8 times greater than people using stimulant drugs without injecting [56]. Outbreaks of HIV or hepatitis C among people who inject drugs, partly due to the increased use of synthetic cathinone as a replacement for heroin, have been reported in Greece [57], Hungary [29] and Romania [33][58]. People who inject stimulant drugs such as ATS show higher prevalence of sexual risk behaviours compared with people who inject opiates, and similar to non-injecting ATS users [59][60][61][62]. Sex workers Exchanging sex for crack cocaine or money has been associated with several HIV risk behaviours, such as having a greater number of clients per week [63], high levels of unprotected sex [64], sharing crack cocaine with clients [65] and heavier crack use, as well as structural vulnerabilities like homelessness and unemployment [66]. One study reported a higher HIV prevalence among those who exchange sex for drugs or money than among those who did not [67]. Individuals with drug dependencies who exchange sex for drugs may have reduced power and control over sexual interactions [68]. The use of methamphetamines by female sex workers has been associated with engaging in unsafe sex [69]. Female sex workers who use smokable cocaine are often homeless or poorly housed in economically depressed neighbourhoods, and have poor access to health services, including HIV services, as well as to prenatal and reproductive care and to social support. Sex workers, whether male, female or transgender, may be coerced into consuming drugs with their clients, increasing the risk of unprotected sex and violence. Male, female and transgender sex workers face barriers to accessing and using services due to the multiple stigma surrounding drug use, sex work and sexual orientation, which are criminalized to varying degrees in many jurisdictions around the world. Transgender people The use of methamphetamines, smokable cocaine or cocaine among transgender women has been associated with higher risks of HIV transmission, mainly through sex [70][71]. For example, a survey conducted among transgender women in high-risk venues and on the streets of Los Angeles, United States, indicated that recent methamphetamine and/or smokable cocaine use was associated with a more than twofold higher risk of reported HIV-positive status [72]. People living in prisons and other closed settings People who use stimulant drugs, such as methamphetamine, in prisons are more likely to engage in a number of sexual risk behaviours, including use of methamphetamines in the context of sex and inconsistent use of condoms [73][74]. 18 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS Women who use drugs Women who use drugs face stigma and other barriers to accessing essential health and HIV services, including gender-based violence, fear of forced or coerced sterilization or abortion, or loss of child custody. Cross-cultural stigma associated with women vacating gender roles, such as caring for their family, being pregnant and being mothers of infants and children, is a major challenge [75]. Many women who use drugs face unequal power dynamics in relationships, and higher rates of poverty; these factors interfere with their ability to access reproductive health supplies, including condoms and other contraceptives [76]. People living with HIV Although cocaine or methamphetamine use has a negative impact on the immune system, particularly among people living with HIV, the immunodepressive effect disappears when people living with HIV who use stimulant drugs adhere to antiretroviral therapy [77]. People living with HIV using stimulant drugs experience the worst HIV outcomes when they do not know they are living with HIV, or cannot access ART. A review of the literature reports findings that psychological, behavioural and social factors all play a role, separately and in combination, in determining HIV outcomes in patients, their access to health services, and adherence to ART: • In people living with HIV, regular methamphetamine use has measurable negative effects upon neuropsychological functioning (e.g. deficits in episodic memory, executive functions and information-processing speed) [78] over and above the negative neurocognitive effects caused by HIV and HCV [79]. This may impact their health-protective behaviour, health-services-seeking, access to HIV clinics and adherence to ART. In addition, HIV-specific traumatic stress and related negative affect are independently associated with greater stimulant-drug risk behaviours and reduced ART adherence [80]. • Cocaine and ATS have a negative impact on the immune system, increasing vulnerability to opportunistic diseases and accelerating the evolution of HIV among people who do not adhere to ART [77][81]. (See section 2.4 for more information on the interactions between ART and stimulant drugs). • Some communities of people who use stimulant drugs are very marginalized, extremely poor and have few resources, including access to adequate nutrition, and this also impacts their access to services and consequently the evolution of HIV infection. To reach people who frequently use stimulant drugs and retain them in effective HIV treatment regimes, access and adherence barriers related to HIV treatment must be accurately identified and addressed. When assessing why a patient who uses stimulant drugs is lost to follow-up, important factors that should be considered include stigma, discrimination, mental health, employment status, poverty, homelessness, migration, exposure to violence, incarceration, fear of criminalization, and family responsibilities. See chapter 4 for more information. 1.4 The impact of criminal sanctions on HIV transmission among key populations Stigma, discrimination and criminal sanctions against people who use drugs, men who have sex with men, transgender people, sex workers and people living with HIV have a direct impact on their ability and willingness to access and use HIV and other health services. These also impede the ability of people from key populations to access the commodities or services needed to practise protective behaviours, including condom use, and to access sterile injecting equipment, HIV testing and HIV treatment. A systematic review of 106 peer-reviewed studies published between 2006 and 2014 examined the association between criminal sanctions for drug use and HIV prevention and treatment-related outcomes among people who inject drugs [82]. While the studies were mainly conducted in North America and Asia, the findings highlighted that criminal sanctions were responsible for substantial barriers to HIV treatment and prevention interventions for people who inject drugs. 21 Chapter 2 Core interventions Following an extensive literature review and technical consultations at country and global levels, expert participants in a number of consultations agreed on a package of eight core interventions for HIV prevention, treatment, care and support among people who use stimulant drugs and are at risk of HIV. These interventions have been adapted from the WHO/UNODC/UNAIDS Comprehensive Package for HIV and people who inject drugs, and from the WHO Consolidated Package for HIV and key populations [7][8]. 1 Condoms, lubricants and safer sex programmes 2 Needle and syringe programmes (NSP) and other commodities 3 HIV testing services (HTS) 4 Antiretroviral therapy (ART) 5 Evidence-based psychosocial interventions and drug dependence treatments 6 Prevention, diagnosis and treatment of STIs, hepatitis and tuberculosis (TB) 7 Targeted information, education and communication (IEC) for people who use stimulant drugs and their sexual partners 8 Prevention and management of overdose and acute intoxication The core interventions should be adapted to the specific needs of different key populations. An assessment of the population to be served will assist in providing the evidence needed to design a clientcentred package of services that responds to specific needs. 2.1 Condoms, lubricants and safer sex programmes People who have sex while under the influence of stimulant drugs are more likely to engage in sexual risk behaviours, especially unprotected sex [83]. They may have reduced sexual inhibitions and a feeling of invincibility, which makes choosing or remembering to use a condom more challenging. Other factors that can contribute to inconsistent condom use include lack of access to condoms and lubricants when needed, poor safe-sex negotiations skills, being on PrEP [84] and engaging in risk-reduction strategies such as serosorting or strategic positioning. These strategies have their limits in terms of risk for HIV transmission, particularly if people are under the influence of stimulant drugs, and they do not prevent transmission of other STIs including HBV and HCV. Promoting the use of male and female condoms and appropriate lubricants remains a core HIV prevention strategy for people who use stimulant drugs and their sexual partners. Condoms offer protection against HIV, other STIs such as syphilis and gonorrhoea, and possible sexual transmission of HBV or HCV. Condoms can also prevent unintended pregnancy. Condoms and lubricants should be available widely, and without charge. Targeted distribution of free condoms helps overcome the barriers associated with their cost and can help reinforce the social acceptability of condom use. Distribution of condoms and sex-education information by peers and outreach workers plays an important role, including in the street or party setting. It is important to consider the variety of condoms available to meet key population preferences, and their distribution, to ensure wide availability of condoms and lubricant and access to them in places where people engage in stimulant drug use and sex concurrently. For example, in the case of sex-onpremises venues or nightclubs, simply making condoms available in the usual places, such as toilets or at the bar, is often not sufficient to ensure that people have them to hand when they need them. Consultation with the beneficiaries is critical to ensure easy access. Similarly, to ensure access to condoms in prisons, strategies must be tailored to each prison, based on its architecture, regime and the movements of prisoners within the prison. Safer-sex education for people who use stimulant drugs should cover: • Promotion of condoms and lubricant use • Information on sexual transmission of HIV, hepatitis and STIs • Safe-sex negotiation strategies • Information on strategies to reduce risks of HIV transmission (sero-sorting and strategic positioning), including their limitations • Information on pre-exposure prophylaxis of HIV (PrEP) Further resources The four key population implementation guides (the IDUIT, MSMIT, SWIT and TRANSIT) provide useful general information on condoms, lubricants and safer sex programming for people who inject drugs, men who have sex with men, sex workers and transgender people. 23 Chapter 2 Core interventions 2.2 Needle and syringe programmes and other commodities Due to the short duration of their effects, injection of stimulant drugs is frequently associated with rapidly repeated injecting, with some individuals reporting more than 20 injections a day. Injecting may take place in groups, and people may use several different stimulant drugs and other types of drug in the same session. These patterns of use increase the likelihood that non-sterile equipment will be used or shared, elevating the risk of HIV and hepatitis transmission. The accessibility and design of needle and syringe programmes (NSPs) must take into account the nature of stimulant drugs and patterns of their use. People who inject stimulant drugs should be educated, encouraged and supported to acquire sufficient sterile syringes. NSP policies and protocols should allow people who inject stimulant drugs access to enough injecting equipment for themselves and their peers. One-for-one exchange or other forms of restricted access to needles and syringes are not recommended in any situation and are particularly unhelpful with people who inject stimulant drugs [85][86]. In the party and club scene, injecting stimulant drugs is more likely to take place outside the normal operating hours of HIV harm reduction services. NSPs and other community drug services do not always engage with the party and club scene, compounding the lack of service availability or HIV prevention messaging. This lack of access is particularly problematic for people who inject stimulant drugs, who would benefit from access to an NSP and other services. Creative strategies can be used to make sterile needles and syringes available to people who inject stimulant drugs, particularly outside operating hours, and in the places where stimulant drugs are purchased or used. These may include satellite NSPs in projects or clinics for key populations, needle and syringe dispensing machines, secondary NSP, outreach programmes, safer clubbing initiatives, outreach at sex-on-premises venues (bars, saunas, clubs, etc.), outreach programmes at festivals, and community mobilization initiatives. NSPs designed to address the needs of people who use stimulant drugs, including all key populations, are well positioned to provide an entry point to a coordinated cascade of services, starting with voluntary HTS. They can also offer information on how to reduce risks related to the use of drugs, distribute female and male condoms and lubricant, and provide route transition interventions (see below). Efforts to understand the context of an individual’s drug use, their injecting equipment needs, and their concurrent sexual behaviours will help ensure that appropriate messaging is used. NSPs should also provide education, advice and equipment to support safer injecting practices, including on the importance of hand hygiene, avoiding sharing any paraphernalia (filters, water) associated with injecting, and keeping even the smallest amounts of blood out of the space where drugs are prepared for injection. It is also important to provide syringe disposal bins or plastic bins or containers for the safe disposal of used injecting equipment, which is key to preventing needle-stick injuries and reducing risk or inconvenience to the wider community associated with illicit drug injection. Syringes with colour-coded barrels provide an example of a promising practice that supports people who inject stimulant drugs in group settings. Each participant is assigned a different colour and provided with syringes of that colour which he or she alone is to use. This can help reduce the accidental sharing of injecting equipment, particularly if it is reused. Route transition interventions Route transition interventions support people who use drugs to avoid initiation into injecting, or to encourage people who are injecting to transition to non-injecting routes of administration. Behavioural interventions, peer education interventions and the provision of commodities that support alternatives to injecting, such as pipes, mouthguards and aluminium foil, can be used to engage with people who inject heroin and/or stimulant drugs. Box 3. A harm reduction programme for people who smoke cocaine or methamphetamines in the Pacific North-West United States The People’s Harm Reduction Alliance (PHRA) is a peer-based harm reduction programme for people who use drugs in the Pacific North-West of the United States, established in 2007. In its first year, PHRA provided syringes and sterile injection equipment; however, the need to expand services to include people who smoke drugs became quickly apparent via the peer-based framework and feedback from clients. In 2008, PHRA launched a crack pipe programme to reach a different group of people who use drugs. The programme has become a point of contact for them to access additional services. In 2015, the programme was expanded to include methamphetamine pipes because participants informed PHRA that lack of access to pipes led them to inject more frequently than they would otherwise do. Both pipe programmes have increased the inclusion of people who smoke crack and methamphetamine at PHRA and linked them to other essential health services. In 2016, PHRA expanded services for non-injectors further with a snorting programme. HIV and HCV prevention opportunities for people who smoke stimulant drugs Crack cocaine, cocaine base and methamphetamine can be smoked in a pipe, offering access to the high-dose surging effect. The repeated use of heated crack pipes can cause blisters, cracking and sores on the tongue, lips, face, nostrils and fingers. It has been suggested that this may facilitate HCV transmission via unsterile paraphernalia (although this has not been clearly established). People smoking stimulant drugs in pipes do not require single-use equipment but will benefit from having personal (individual) smoking equipment, and messaging that pipes should not be shared. The same principle applies for straws used to inhale cocaine. The distribution of pipes, mouthguards and other piping paraphernalia provides practical strategies for engaging stimulant drug smokers and reinforces the “Don’t share pipes” message. The principles of distributing paraphernalia and engaging people who smoke stimulant drugs with messages about HIV and hepatitis prevention remain the same. 25 Chapter 2 Core interventions Box 4. Example of content of kits for safer smoking • Pipes • Mouth- or lip guards – a rubber band, rubber tubing, or sometimes specially produced • Stainless steel wool, used as gauze to suspend the crack cocaine inside the pipe • Alcohol wipes to clean the pipe and reduce risks associated with sharing • Lip balm containing vitamin E, to help protect and heal chapped or injured lips • Sterile dressing to cover wounds or burns arising from smoking crack • Sugar-free chewing gum which can help stimulate saliva production to protect teeth and reduce dental damage • Condoms and lubricants to support safer sex practices • Health promotion leaflets Safe tattooing In some population groups who use stimulant drugs, unsafe tattooing is frequent and constitutes a risk for transmission of HCV. This is a particular issue in prisons where tattooing is prohibited and hidden and unhygienic tattooing is common. NSPs and other low-threshold services can offer safe tattooing information, training and safe equipment. 2.3 HIV testing services HIV testing provides an opportunity to deliver HIV prevention messages and to link people to HIVprevention and other relevant health and support services. HIV testing services (HTS) are also the critical entry point to ART (see section 2.4). Given the evidence that individuals who are ARTadherent and have achieved viral suppression do not transmit HIV, HTS is a crucial component of HIV prevention programmes. It is important to increase the opportunities for people who use stimulant drugs to access and use confidential, easy and convenient HIV testing that is linked to the provision of ART for those who test positive. Community-based rapid HIV testing provides an opportunity to deliver results immediately. This can be of particular importance with street- or venue-based people who use stimulant drugs, where the primary source of engagement may be outreach programmes brought to where they are, rather than waiting for them to present at a specific testing location. Other outreach opportunities may also be used to distribute HIV self-test kits. Regardless of the testing modality, it is important to have a protocol to assist people to get a confirmatory test if they test positive, and to access and successfully use HIV care and treatment services if needed, including immediate access to ART, post-exposure prophylaxis (PEP) or PrEP, as appropriate. On-site HIV testing can pose challenges, including the possible lack of confidentiality that comes especially with small, closed communities. Outreach workers and service providers need to ensure that HIV testing is always voluntary and that coercive use of self-test kits by third parties such as law enforcement or employers to test any individual (e.g., sex workers) is unacceptable. 2.4 Antiretroviral therapy Antiretroviral therapy (ART) is the treatment of people living with HIV with medications that suppress the replication of the virus. Currently the standard treatment consists of a combination of antiretroviral drugs (ARVs), and it is indicated for all people living with HIV, irrespective of their CD4 count. ART reduces morbidity and mortality rates among people living with HIV, improves their quality of life and reduces risks of transmission of HIV. ARVs are also administered to some groups of people at risk for HIV acquisition either before exposure (PrEP) or after (PEP). ART is also needed for prevention of mother-to-child transmission of HIV. Cocaine and ATS have been associated with faster disease progression in people living with HIV, due to weakening of the immune system by the drugs. However, if adherence is maintained, the effectiveness of ART is not reduced in people who use stimulant drugs: ART reduces viral load and improves immune function, just as it does for other people living with HIV [77]. Strategies to support adherence to ART, including peer and outreach support, are described in section 3.1. Side-effects of antiretroviral drugs and interactions with stimulant drugs As with many medications, ARVs have been associated with various side-effects, including acute or chronic alterations of the renal function, or hepatic dysfunction. Some medications can cause sideeffects in the central nervous system, such as depression. Liver toxicity is one of the most commonly reported adverse consequences associated with ARVs. This can range from asymptomatic elevation of the liver enzymes to a hepatic failure. Risks for ARVrelated adverse consequences for the liver are higher in cases of cocaine use, excessive alcohol use, coinfection with HBV or HCV, fibrosis of the liver, concomitant treatment for TB and advanced age. Impact of stimulant drugs on antiretroviral drug serum level Cocaine, mephedrone and methamphetamines interact with several ARVs, influencing the serum level of the medications and the risk of side-effects. As scientific knowledge progresses, new ARV regimens may be proposed, with the potential for interactions with the NPS that are frequently appearing on the market. The University of Liverpool provides a regularly updated website on HIV medication interactions, including the interaction of ARVs with stimulant drugs: https://www.hiv-druginteractions.org/treatment_selectors. Impact of antiretroviral drugs on serum level of stimulant drugs Serum levels of methamphetamines may increase up to three times when used by someone who is also taking protease inhibitors, especially ritonavir. Fatal cases attributed to inhibition of the metabolism of MDMA and amphetamines by ritonavir have been reported. Oral pre-exposure prophylaxis Oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral medications to prevent the acquisition of HIV infection by uninfected persons. WHO recommends daily oral PrEP as a prevention choice for people at substantial risk of HIV [91]; it can be stopped during periods of low or no risk. Taken as prescribed, PrEP can reduce the risk of getting HIV from sex with an HIV-positive person by more than 90 per cent [92]. PrEP has been effective in communities where the primary vector for transmission is sexual, such as men who have sex with men, and is therefore appropriate for people who use stimulant drugs. PrEP does not replace HIV prevention interventions, such as comprehensive condom programming for sex workers and men who have sex with men. It does not prevent transmission of hepatitis and other STIs. Services for people who inject stimulant drugs should prioritize evidence-based comprehensive HIV prevention interventions, including NSP, condoms and lubricants. For men who have sex with men who use stimulant drugs and engage in high-risk sex, PrEP should always be proposed, whether or not the individual injects drugs. Adherence to PrEP is essential, and it may be challenging for people using stimulant drugs for several days in a row. People who use stimulant drugs and engage in concurrent sex should be encouraged and supported to plan ahead to use condoms, lubricants and PrEP in combination, to ensure better protection against HIV and to prevent other STIs, including hepatitis C and B. As with other prevention tools, the effectiveness of PrEP is optimized when interventions are implemented by, and in close consultation with, prospective beneficiary communities. Further resources Implementation tool for pre-exposure prophylaxis (PrEP) of HIV infection (WHO, 2017) [93] Post-exposure prophylaxis Post-exposure prophylaxis (PEP) is the administration of ARVs for a short term (one month) to prevent HIV infection after exposure to HIV through unprotected sex or contact with blood. PEP should be offered to all individuals who have potentially been exposed to HIV, whether through unprotected sex (including sexual assault), needle-stick injury or sharing drug injection equipment. It should be initiated as early as possible, ideally within 72 hours. People who use stimulant drugs and engage in sex concurrently are known to often have multiple sexual partners. The chances of unprotected sex or condom failure are increased with stimulant drug use or with the increase in the number of partners. A participative stakeholder process should lead to the development of protocols for community access to PEP, from local to national levels, to ensure that the required medications are promptly accessible and are used by those who need them. People who use stimulant drugs and who access PEP regularly should be assessed as likely candidates for PrEP. Further resources Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a public health approach - Second edition (WHO, 2016) [162] 2.5 Evidence-based psychosocial interventions and drug dependence treatments The impact of a drug is determined by the complex interactions between the substance, set (the mindset of the individual) and setting (the context), which mediate the drug’s effect and its associated impact on the individual, including the move towards dependent or high-risk drug use [94]. The great majority of people who use stimulant drugs do so on an occasional basis that may be characterized as “recreational”, and they will not develop dependence. This group has little need for high-intensity interventions. This section provides an overview of possible interventions, mainly psychosocial ones, that show effectiveness specifically for reducing risk behaviours and provide support for people who regularly use stimulant drugs, including people living with HIV. 29 Chapter 2 Core interventions The treatment of cocaine or ATS drug dependence requires time-intensive approaches that are not addressed here. Unlike the treatment of opioid dependence, there are currently no substitution medications available to treat dependence on cocaine or ATS [95][96]. Some emerging practices around dispensing dexamphetamine as a substitute for cocaine or methamphetamine dependence have shown early promise, but further research is needed. Behavioural interventions, self-regulation coaching and psychosocial counselling can support HIV/HCV prevention and treatment objectives for people who use stimulant drugs, while also contributing to longer-term and broader health and wellness goals. There is evidence that brief interventions that concentrate on providing information about safe behaviours and harm mitigation are effective in moderating drug-related harms [97] and maintaining ART adherence for those who are living with HIV [98]. Addressing the potential risks associated with the nexus of drug use and HIV requires individual, structural and combination approaches [99]. Psychosocial services such as motivational interviewing, brief interventions, contingency management and cognitive behavioural therapy are critical to effectively support HIV prevention and treatment among people who use stimulant drugs. Some of these approaches are described below. A 2016 review of psychosocial interventions for stimulant drug-use disorders found that all showed improved retention in ART compared with no intervention, although no single intervention showed a sustained benefit over the others [100]. Psychosocial services should be based on principles of community inclusion and participation, peer support and the needs of the individual. When developing HIV prevention interventions, it is important that sexual partners of people who use stimulant drugs be included in the process, focusing on the HIV risks that are associated with drug use and concurrent sexual behaviours. Motivational interviewing Motivational interviewing is a person-centred, semi-directive approach for exploring motivation and ambivalence in order to facilitate self-motivational statements and behavioural changes. It consists in establishing a partnership between the provider and the individual and enabling the individual to become aware of the discrepancy between their present situation and their own values. The technique relies on four principles: express empathy, develop discrepancy, roll with resistance and support selfefficacy. These can easily be used by trained non-specialist staff, including outreach workers, in formal or informal counselling, IEC and other conversations. Motivational interviewing generally requires just one or two sessions. The success of motivational interviewing has led to its implementation as a “catch-all” approach to eliciting change in areas such as medication compliance, smoking cessation and diet and exercise [101]. A 2012 Cochrane review suggested that motivational interviewing could reduce risky sexual behaviour, and in the short term lead to a reduction of viral load in young people living with HIV [102]. Research has shown that motivational interviewing can reduce the incidence of unprotected anal intercourse among men who have sex with men [103], as well as levels of drug use [104]. Brief interventions Brief interventions are short, often opportunistic interactions in which a health worker provides targeted information and advice to individuals during other activities such as distributing sterile injecting equipment or conducting an HIV test. Brief interventions have been shown to reduce drug use as well as associated risks and sexual risk behaviours. Meta-analyses suggest that there is little difference in the outcomes between longer, more intensive interventions and brief interventions, and the latter are likely to be more practical and cost-effective options, with few barriers to implementation [105]. Motivational interviewing, contingency management and brief interventions for dependence to stimulant drugs can reduce drug-related high-risk sexual behaviours and increase adherence to ART and PrEP. 30 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS Contingency management Contingency management is an approach that incentivizes people with rewards such as cash that are contingent on achieving a set of pre-defined outcomes. Contingency management has been shown to have a moderate yet consistent effect on drug use across different classes of drugs [106]. The effectiveness of contingency management supports the idea that small, regular rewards motivate people to modify behaviours that could be considered harmful. Positive regard, and the client’s own expressed belief in their ability to achieve goals, are a critical factor in improving agreed-upon outcomes. Cognitive behavioural therapy Cognitive behavioural therapy (CBT) is a structured approach to counselling that assumes that behaviours are learned and reinforced as a result of cognitive constructs and deficits in coping. The aim of CBT is to “unlearn” behaviours considered unhelpful, such as HIV risk behaviour or certain patterns of drug-taking. While results appear to be sustained over a period, CBT is intensive and time-consuming, and demands specialist practitioners and individual treatment [107]. Mindfulness Mindfulness can be defined as the ability to focus open, non-judgemental attention on the full experience of internal and external phenomena, moment by moment. Positive outcomes – including reducing drug use and risk behaviours, and in relapse prevention – have been documented from mindfulness training as part of approaches to reduce harm, including for people who use stimulant drugs [108][109][110]. Opioid substitution therapy and stimulant drug use People receiving opioid substitution therapy (OST) for heroin or other opioid dependence may use stimulant drugs because of OST-triggered fatigue, inability to experience pleasure, or the desire to remain connected to the community of people who use drugs. OST is not designed to counter stimulant drug use, and the concurrent use of stimulant drugs while on OST should not be viewed as a breach, nor should it lead to the reduction or discontinuation of OST. The benefits of OST are independent of stimulant drug use [111]. Existing OST providers should be sensitized to this and trained to use the opportunities afforded by regular OST and client engagement to support the delivery of interventions included in this guidance. Further resources mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings (WHO, 2010) [112] Therapeutic interventions for users of amphetamine-type stimulants (WHO, 2011) [113] Harm reduction and brief interventions for ATS users (WHO, 2011) [114] Guidelines for the management of methamphetamine use disorders in Myanmar (Ministry of Health and Sports, Myanmar, 2017) [115] Guidance for working with cocaine and crack users in primary care (Royal College of General Practitioners, 2004) [116] Principles of drug dependence treatment (UNODC, WHO, 2008) [117] Drug abuse treatment and rehabilitation: a practical planning and implementation guide (UNODC, 2003) [118] TREATNET quality standards for drug dependence treatment and care services (UNODC, 2012) [111] Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence (WHO, 2009)[163] Treatment of stimulant use disorders: current practices and promising perspectives. Discussion paper (UNODC, 2019)[164] 31 Chapter 2 Core interventions 2.6 Prevention, diagnosis and treatment of sexually transmitted infections, hepatitis and tuberculosis Screening people who use stimulant drugs for infectious diseases, such as sexually transmitted infections (STIs), HBV, HCV and TB, is a crucial part of a comprehensive approach. Along with HIV, these infections are often associated with the use of illicit substances, and they may co-occur with stimulant drug use. Prevention, diagnosis and treatment of sexually transmitted infections Unsafe sex can lead to acute STIs, which can cause infertility and severe illness. Several STIs, particularly those involving genital or perianal ulcers, may facilitate the sexual transmission of HIV infection. Sex workers, transgender people and men who have sex with men are often at increased risk of STIs such as syphilis, gonorrhoea, chlamydia and herpes. It is therefore important to offer information, male and female condoms and lubricant, and screening, diagnosis and treatment of STIs and possibly HPV vaccine to people using stimulant drugs who are vulnerable to STIs and HIV. Further resources Resources on sexually transmitted and reproductive tract infections (WHO webpage providing clinical, policy and programmatic, monitoring and evaluation and advocacy guides) [119] Prevention, vaccination, diagnosis and treatment of hepatitis B and C People who inject stimulant drugs are at heightened risk of acquiring HBV and HCV because of frequent injecting and sharing of injection equipment. The risk of sharing equipment is higher when injecting happens in communal settings. HCV is much more virulent than HIV and can survive outside the body at room temperature, on environmental surfaces, for up to three weeks [120], making it more easily transmitted through the sharing of syringes and other injecting paraphernalia. Key populations who use stimulant drugs should be offered hepatitis B or hepatitis A-B vaccination, access to prevention commodities, and voluntary screening and treatment of HBV and HCV. Prevention NSPs and community mobilization initiatives should distribute relevant equipment, including low dead-space syringes, for injecting, smoking and snorting (see section 2.2). Male and female condom programming is also part of hepatitis B and C prevention interventions as well as sexual and reproductive health services. Education should include messages on the risks of serosorting, and of intense sexual practices involving potential trauma of the mucosa for HCV acquisition and transmission among people living with HIV [50]. Hepatitis A and B vaccination Key populations should be offered the series of HBV immunizations. WHO recommends: • Offering people the rapid hepatitis B vaccination regimen (days 0, 7 and 21-30). • Providing people who inject drugs with incentives in order to increase hepatitis B vaccination adherence, at least for the second dose. Even partial immunization confers some immunoprotection. [87] Hepatitis A (HAV) immunization or combined HAV-HBV immunization should be offered to men who have sex with men and people using stimulant drugs [121]. 32 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS Immunization should be easily accessible and offered at locations and venues frequented by people who use stimulant drugs, such as drop-in centres, NSPs and other community service outlets. Screening for HBV and HCV Voluntary screening for HBV and/or HCV should be offered to people who use stimulant drugs at risk of these infections. Testing and diagnosis of HBV and HCV infection is an entry point for accessing both prevention and treatment services. Early identification of persons with chronic HBV or HCV infection enables them to receive the necessary care and treatment to prevent or delay the progression of liver disease. Rapid tests for hepatitis C allow for better access to diagnosis, including communitybased testing. Treatment of chronic hepatitis C or B All people with chronic hepatitis C should receive treatment. With an 8- to 12-week course, directacting antivirals (DAAs) cure more than 95 per cent of persons with HCV infection, reducing the risk of death from liver cancer and cirrhosis. For chronic hepatitis B, antiviral treatment can slow down the progression of cirrhosis and reduces the risk of liver cancer [162]. People who are actively injecting drugs have been shown to adhere to HCV treatment regimens as well as any other population, particularly when social, emotional and practical support are provided [122]. All people who use stimulant drugs living with HCV should therefore be offered access to direct-acting antivirals without discrimination. Further resources Guidance on prevention of viral hepatitis B and C among people who inject drugs (WHO, 2012) [87] Guidelines for the screening, care and treatment of persons with chronic hepatitis C infection (WHO, 2016) [123] Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a public health approach - Second edition (WHO, 2016) [162] Prevention, diagnosis and treatment of tuberculosis In 2016, 10.4 million people fell ill with TB. It is a leading killer of people living with HIV: in 2016, 40 per cent of HIV deaths were due to TB [124]. Transmission of TB is easily facilitated through airborne particulates, such as by kissing, coughing, sneezing or shouting. TB is easily spread in prisons and other closed settings, and in crowded and poorly ventilated spaces, such as are often found in poor communities or among homeless people. People who inject drugs are at increased risk of TB, irrespective of their HIV status, and TB is a leading cause of mortality among people who inject drugs who also have HIV infection [125]. People who use drugs who do not inject have also been found to have increased rates of TB. Certain subgroups of stimulant drug users, such as those who use stimulant drugs regularly for days at a time, may be immuno-deficient from lack of sleep and food, facilitating TB transmission. It is therefore important to include TB prevention, screening and treatment in communities and services. Further resources Integrating collaborative TB and HIV services within a comprehensive package of care for people who inject drugs: consolidated guidelines (WHO, 2016) [125] 33 Chapter 2 Core interventions 2.7 Targeted information, education and communication To reduce the risk of acquiring STIs or HIV, people who use stimulant drugs need knowledge and support. Information, education and communication (IEC) provides information, motivation, education and skills-building to help individuals adopt behaviours that will protect their health. Effective communication for health targeting people who use stimulant drugs requires addressing two challenges: • Crafting messages that can overcome long-standing distrust and fear. • Finding effective means of reaching people who use stimulant drugs with life-saving messages and materials. Key to meeting these challenges is meaningful engagement with the target audience of people who use stimulant drugs. Communities should be represented at every stage of IEC development, including the overall strategy and concept, and the development, testing, dissemination and evaluation of messages. Working with the community will help ensure that tools and materials are accurate and will be trusted and used. Recipients of IEC who have invested their own ideas and time in it will be more likely to stand behind the results and be active participants, not only in their own health but in health promotion in their community. Materials must be easily understandable and to the point. Interactive materials on a digital platform can tailor messaging to the specific situation of the service user and are often helpful in maintaining attention. On the other hand, traditional printed materials have the advantage of not requiring computer, phone or Internet access. They also provide an opportunity for outreach workers or other programme staff distributing the materials to interact with the service users, and a means for service users to easily share information with others. Using information technology to support behavioural interventions Online and social media can be a cost-effective manner of reaching targeted audiences. A local assessment can show where using these technologies will be advantageous and appropriate. Free WiFi at drop-in centres and other community points of congregation provides opportunities for access and use. Where people who use stimulant drugs have smartphones, websites and apps can be deployed just as they have been to reach other key populations. The use of technology has shown promising results in promoting sexual health or adherence to ART in different settings, including resource-limited settings [126][127]. Web-based applications provide an opportunity to reach a large audience at any time and provide information on health and available services. They also allow for online outreach and interactions with people who wish to discuss problems or have questions. However, when the information relates to drug use, or other criminalized behaviours, the use of some digital media raises concerns about the anonymity of the contacts, and possible risks related to law enforcement must be addressed. Working with communities and low-threshold service providers will help inform the local potential for digital materials and campaigns and help ensure the security of people accessing information. Given the variety that exists among people who use stimulant drugs, messaging should take into account the sex, gender, sexual orientation, age and setting of recipients of IEC. Literacy levels, social and community inclusion or exclusion, and other cultural and societal variables must also be considered. 34 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS Further resources The European Centre for Disease Prevention and Control (ECDC) has developed guidance documents for the effective use of social media. While the tools were developed for Europe, and specifically for reaching men who have sex with men, they provide guidance on the relative advantages of different media, such as Facebook, online outreach, Google Ads, SMS and YouTube, that may be useful in other contexts. Effective use of digital platforms for HIV prevention among men who have sex with men in the European Union/European Economic Area: an introduction to the ECDC guides (ECDC, 2017) [128] 2.8 Overdose and acute intoxication prevention and management Very high doses of stimulant drugs consumed in a short amount of time can trigger acute respiratory distress, chest pain, palpitations or myocardial infarctions [112]. In extreme cases this can result in cardiac arrest. The first signs of stimulant drugs intoxication are hyperactivity, rapid speech and dilated pupils. In the case of polydrug use, overdose can be the result of the combination of stimulants with other drugs including opioid or sedative drugs. The treatment of stimulant drugs intoxication is symptomatic and requires regular monitoring of blood pressure, pulse rate, respiratory rate and temperature (figure I.). Serotonergic syndrome is caused by an excess of serotonin in the central nervous system associated with the use of ATS. It can result in uncontrollable muscle spasms, tremor, seizures, psychosis, high blood pressure, high body temperature >400 C (hyperthermia) and release of myoglobin from muscles and blood clotting in vessels (disseminated intravascular coagulation), which may lead to severe diseases and potentially death. People who use stimulant drugs need to be informed on how to reduce the risks of acute intoxications (see the Information checklist for self-care and stimulant drugs in the annex). For people on PrEP, ART or hepatitis treatment, information should be provided on the interactions and possible risks of cocaine and ATS use to serum levels (see section 2.4). People who use stimulant drugs should be trained to recognize overdoses, provide first aid, including cardiopulmonary resuscitation (CPR) and call immediately for emergency professional assistance if they witness an overdose.

Purpose of this guide The purpose of this publication is to provide guidance on implementing HIV, hepatitis C (HCV) and hepatitis B (HBV) programmes for people who use stimulant drugs and who are at risk of contracting these viruses. It aims to: • Increase awareness of the needs and issues faced by the affected groups, including the intersectionality among different key populations • Provide implementation guidance to help establish and expand access to core HIV and hepatitis prevention, treatment, care and support services It is a global document that should be adapted according to the specific context, including the type of stimulant drug used (cocaine, ATS or NPS) and the key populations involved, which vary considerably according to regions. The present guide proposes a package of core interventions adapted from existing international guidance: • WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users[7] • WHO Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations – 2016 update [8] • Implementing comprehensive HIV and HCV programmes with people who inject drugs: practical guidance for collaborative interventions (the “IDUIT”) [9] It also incorporates guidance from the implementation tools for other key populations: • Implementing comprehensive HIV/STI programmes with sex workers: practical approaches from collaborative interventions (the “SWIT”) [10] • Implementing comprehensive HIV and STI programmes with men who have sex with men: practical guidance for collaborative interventions (the “MSMIT”) [11] • Implementing comprehensive HIV and STI programmes with transgender people: practical guidance for collaborative interventions (the “TRANSIT”) [12] However, none of these guidance documents and tools addresses the specific needs of people who use stimulant drugs and are at risk for HIV and hepatitis B and C – hence the need for this publication. Audience The guide is intended for use by policymakers, programme managers and service providers, including community-based organizations, at the national, regional or local levels, who undertake to address HIV prevention, treatment and care. It also provides useful information for development and funding agencies and for academia. Structure The guide is divided into five chapters. • Chapter 1 explains the nature and effects of stimulant drugs, the associated risks of HIV and hepatitis transmission, and the issues surrounding stimulant drug use and HIV and hepatitis risk in specific key populations and other vulnerable groups. 10 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS • Chapter 2 presents the package of core HIV interventions for key populations who use stimulant drugs. • Chapter 3 describes approaches to care and support for people who use stimulant drugs, particularly in the context of HIV and hepatitis. • Chapter 4 describes six critical enablers – activities and strategies that are needed to ensure access to the interventions in the core package. • Chapter 5 outlines further considerations for implementing programmes. Within each chapter, further resources are listed. Case studies are provided throughout the guide to illustrate specific aspects of programmes that have been implemented in different countries. There is also an annex presenting a series of checklists and other practical tools for policymakers and implementers. Principles Two important overarching principles are stressed throughout this publication. The first is better integration of HIV, hepatitis B and C and sexually transmitted infection (STI) services for people who use stimulant drugs within existing HIV harm reduction services2 and drug treatment services for people who inject drugs, and within sexual and reproductive health and other HIV services for key populations. The second is the meaningful involvement of people who use stimulant drugs, people living with HIV and other key populations in planning, implementing, monitoring and evaluating interventions. This is key to their success and sustainability. Finally, the implementation of HIV-related services for people who use stimulant drugs should adhere to human-rights principles as described in the implementation tools mentioned above – the SWIT, MSMIT, TRANSIT and IDUIT. Methodology In its June 2009 session, the UNAIDS Programme Coordinating Board (PCB) called upon “Member States, civil society organizations and UNAIDS to increase attention on certain groups of non-injecting drug users, especially those who use crack cocaine and ATS, who have been found to have increased risk of contracting HIV through high-risk sexual practices”. UNODC therefore commissioned a review and organized a Global Expert Group Technical Meeting on Stimulant Drugs and HIV, held in Brazil in 2010. A discussion paper on HIV prevention, treatment and care among people who use (noninjecting) crack and cocaine or other stimulant drugs, particularly ATS, was developed in 2012. In 2013 the UNODC HIV Civil Society Organization (CSO) group established a Stimulant Drugs and HIV working group, with representatives from civil society and experts on HIV and stimulant drugs. The group organized consultations with representatives of the community and CSOs, including on the margins of the International Harm Reduction Conference in Kuala Lumpur in 2015. 2 For the purposes of this guide, harm reduction is defined by the nine interventions of the “comprehensive package” of services detailed in the WHO, UNODC, UNAIDS Technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users (see citation 7). These are: 1. Needle and syringe programmes; 2. Opioid substitution therapy and other drug dependence treatment; 3. HIV testing and counselling; 4. Antiretroviral therapy; 5. Prevention and treatment of sexually transmitted infections; 6. Condom programmes for people who inject drugs and their sexual partners; 7. Targeted information, education and communication; 8. Prevention, vaccination, diagnosis and treatment for viral hepatitis; 9. Prevention, diagnosis and treatment of tuberculosis. 11 In December 2014, the Strategic Advisory Group to the United Nations on HIV and injecting drug use, consisting of representatives of networks and organizations of people who use drugs, academics, donors, implementers and United Nations organizations, recommended conducting a new literature review on stimulant drugs and HIV and hepatitis C. In 2015 UNODC, together with WHO and UNAIDS, defined the scope of this new literature review, and accordingly UNODC commissioned it to cover the extent, patterns and geographic distribution of injecting and non-injecting stimulant drug use (particularly crack, cocaine, ATS and stimulant NPS) in men who have sex with men, sex workers and other groups of stimulant drug users, and their possible link to HIV and hepatitis B and C vulnerability and transmission; and effective interventions for prevention, treatment and care of HIV and hepatitis B and C among people who use such stimulant drugs. The results of the literature review were published by UNODC in 2016 in five papers covering the following topics: • Methodology and summary [3] • ATS [13] • Cocaine and crack cocaine [14] • NPS [15] • Treatment and prevention of HIV, HCV & HBV among stimulant drug users[16]. Subsequently, in the framework of preparations for the United Nations General Assembly Special Session on the World Drug Problem (UNGASS 2016) and the HLM 2016, UNODC organized a scientific consultation on HIV and drug use, including stimulant drugs. The papers relating to stimulant drugs presented at the Commission on Narcotic Drugs in March 2016 covered: cocaine and crack cocaine use and HIV in the United States; ATS and men who have sex with men in Asia; and antiretroviral therapy (ART) and stimulant drug use. The recommendations of the contributing scientists were summarized as part of a scientific statement presented in New York on the margins of the UNGASS 2016 and the HLM 2016 [17]. The statement stressed the need to address HIV among people who use stimulant drugs, including the structural, social and personal mediating factors for HIV transmission, such as polydrug use, STIs, mental health, homophobia, discrimination and punitive laws. The scientists recommended the provision of ART to all people using stimulant drugs living with HIV, and the implementation of new prevention tools such as pre-exposure prophylaxis (PrEP) and the use of social media for communication. The statement also emphasizes that with proper support for adherence, ART is effective among people living with HIV who use stimulant drugs. In 2017, UNODC commissioned the development of the present publication, HIV prevention, treatment, care and support for people who use stimulant drugs: an implementation guide. Based on the results of the scientific reviews and of the expert group meetings, and on international guidance and country practices that have been identified as effective in meeting the needs of people who use stimulant drugs, a first draft of the document was developed under the guidance of the UNODC CSO Stimulant Drugs and HIV working group. The draft guide was reviewed by external peer reviewers, United Nations agency reviewers and community representatives through an electronic consultation and three face-to-face consultations held in Viet Nam (2017), Brazil (2017) and Ukraine (2018). Chapter 1 Stimulant drugs, HIV and hepatitis, and key populations The World Drug Report 2019 estimates that about 29 million people used ATS in 2017, and 18 million used cocaine [18]. There is no estimate of the total number of people using NPS. The great majority of people who use stimulant drugs do so on an occasional basis which may be characterized as “recreational”, and they will not develop dependence or any other health problem. There is evidence that the prevalence of ATS use, particularly methamphetamines, is increasing in some regions, including North America, Oceania and most parts of Asia. In addition, between 2009 and 2016, there were reports of 739 NPS, of which 36 per cent were classified as stimulant drugs [19]. Only a small proportion of people who use stimulant drugs inject them; most smoke, snort or use them orally or anally. However, the World Drug Report 2017 states that 30 per cent of people who inject drugs inject stimulant drugs, either as their drug of first choice or in addition to opiates. Despite evidence showing that certain subgroups of people who use stimulant drugs are at greater risk of HIV, prevention, testing and treatment programmes for these population groups remain very limited in scope and scale across the globe, and their specific needs are often overlooked. 1.1 Stimulant drugs Stimulant drugs are chemically diverse substances that are similar in their capacity to activate, increase or enhance the neural activity of the central nervous system, resulting in a common set of effects in most people who use them, including increased alertness, energy and/or euphoria.3 This publication considers three types of stimulant drugs for which data have shown a link with increased HIV risk among some key populations: • Cocaine: Found in various forms, e.g. smokable cocaine, crack cocaine, freebase, paste or pasta base, paco, basuco. Depending on the form, it may be sniffed or snorted, injected, ingested or inserted anally. 3 For more detailed information on different stimulant drugs and their effects, see: Terminology and information on drugs. Third edition. New York (NY), United Nations, 2016 (https://www.unodc.org/documents/scientific/Terminology_and_ Information_on_Drugs-3rd_edition.pdf, accessed 15 January 2019). 14 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS • Amphetamine-type stimulants: Amphetamines and methamphetamines (excluding MDMA) are found in different forms, e.g. crystals (methamphetamines), powder or formulated tablets [20]. They are taken orally, smoked from a pipe, sniffed or snorted, inserted anally or injected in a solution. • Stimulant new psychoactive substances: Found in various forms, e.g.synthetic cathinone, phenethylamines, aminoindanes and piperazines. They are sometimes referred to as “bath salts” [21][22]. Depending on the form, NPS are taken orally, smoked, inserted anally or injected. All types of stimulant drugs have common effects: • Mental: Euphoria, raised libido, reduced appetite and sleep drives, enhanced perception, increased alertness, cognitive improvements and deficits (attention, working memory, long-term memory), emotional intensity and excitability, and increased confidence. • Behavioural: Talkativeness, hypervigilance, hyperactivity, increased sociability, disinhibition, changes in sexual behaviour (including sexual sessions of longer than usual duration), faster reaction, and repetitive activity (“tweaking”); hyper-excitability, insomnia, restlessness, panic, erratic behaviour, and sometimes aggressive or violent behaviour[23]. • Physical: Increased heart rate (including palpitations), raised temperature (hyperthermia), circulatory changes (higher blood pressure, vasoconstriction), increased breathing rate, dry mouth, teeth-grinding, jaw-clenching/gurning, faster eye-movements, and dilated pupils. The onset and duration of these effects vary according to the drug, its form, dosage, route of administration, the characteristics of the individual using it, and the context of use. Chronic use of stimulant drugs can lead to psychological dependence; development of tolerance; destruction of tissues in the nose if snorted or sniffed; chronic bronchitis, which can lead to chronic obstructive pulmonary disease; malnutrition and weight loss; disorientation, apathy, confusion, exhaustion due to lack of sleep, and paranoid psychosis. During withdrawal there may be a long period of sleep and depression. Cocaine Cocaine is generally encountered in two forms which differ in their route of administration: cocaine hydrochloride (HCL), a powder, which is snorted, injected or taken anally, and cocaine base (crack, freebase, or crystal) which is smokable and usually taken in a pipe. A third form, coca paste (pasta base, paco, coca pasta, etc.), is an intermediate product of the process of extraction of HCL from the coca leaves. Available mainly in Latin America, it is usually smoked in a cigarette. Cocaine is a powerful stimulant whose effects diminish quickly, prompting the user to repeatedly administer additional doses. When snorted, cocaine produces a slow wave of euphoria, followed by a plateau and then a “come down” period. In its smokable form, cocaine has a more intense and immediate effect. Severe anticipatory anxiety about the impending low may result in repeat dosing. This cycle may take around 5 to 10 minutes. The use of cocaine is more prevalent in North and South America than in the rest of the world. Amphetamine-type stimulants (ATS) Amphetamine and methamphetamine are synthetic drugs whose effects include euphoria, arousal and psychomotor activation. ATS can be taken orally, intranasally, smoked as a vapour (pipe), inserted anally or injected. Immediately after smoking or injecting, people experience a pleasurable “rush”. Intranasal and oral ingestion produce a gradual euphoria or “come up”. Depending on the level of tolerance, the effects of methamphetamine may last four hours, or as long as 24 hours for someone new to the drug [24]. Some people who use methamphetamine may experience a feeling of invincibility, with an accompanying propensity to engage in high-risk behaviours, creating vulnerabilities to acquiring HIV [25]. The direct health impacts of ATS include insomnia and cardiovascular stress. Long-term negative effects may include dopamine physical dependence, psychological dependence, psychosis and paranoia, and depression. Amphetamine and methamphetamine use is reported in all parts of the world. Stimulant new psychoactive substances There are a various types of new psychoactive substances (NPS), with different molecular structures, but the majority of stimulant NPS are synthetic cathinones, which have a similar molecular structure to cathinone found in the khat plant. Common synthetic cathinones include mephedrone, pentedrone, methylone or methcathinone. They fall into two main families: euphoriants and entactogens.NPS are taken orally, can also be snorted or inserted anally, and less frequently are injected. Stimulant NPS produce similar mental, physical and behavioural effects to traditional stimulant drugs such as cocaine, amphetamines and methamphetamines. Synthetic cathinones and other stimulant NPS are also used to improve sexual experience [26]. The use of synthetic cathinone such as mephedrone (sometimes called “bath salts”) has recently emerged [18]. Studies from Hungary [27][28][29], Ireland [30][31], Israel [32], Romania [33] and the United Kingdom [34] suggest that due to a shortage in heroin supply and easy access to synthetic cathinone, a significant proportion of people who inject drugs have switched to injecting synthetic cathinone in recent years. 1.2 Stimulant drug use and risks of HIV/HBV/HCV transmission The HIV/HBV/HCV risk associated with stimulant drug use is linked to a higher prevalence of unprotected anal and vaginal sex, and of sharing pipes, straws and injection equipment, in some groups of men who have sex with men, sex workers, people who inject drugs and people in prisons. Transmission risks through concurrent stimulant drug use and unprotected sex Inconsistent condom use by people who use stimulant drugs has been identified as a prime means of contracting STIs, including HIV, particularly as a result of the concurrent use of stimulant drugs with frequent sexual activity of long duration with multiple partners or in groups. Stimulant drug use may also facilitate longer penetration (which can lead to condom breakages), and more intense acts such as fisting that increase the opportunity of anal and vaginal tears or bleeding. Transmission risks through sharing injection equipment Injecting methamphetamine, cocaine or NPS entails a similar risk to injecting other drugs when needles and injecting equipment are shared. Given that many stimulant drugs have a shorter duration of action compared with opioids, people who inject stimulant drugs report a higher frequency of injecting, with compulsive re-injecting and a greater likelihood of sharing and reusing needles and syringes that may be contaminated [22][34]. HIV and HCV risk is also increased when cocaine or crack is coadministered with heroin, including injection of heroin and cocaine (“speedballing”) [35]. Coexisting injecting drug use and unprotected sex further increases the likelihood of HIV and hepatitis transmission, especially in high-incidence communities. This pattern has been seen, for example, with the use of home-made ATS, such as boltushka in Ukraine. People who inject boltushka engage in high levels of injecting risk behaviours and in sexual risk behaviour post use. They are young and poor, and the great majority are already living with HIV [36]. Hepatitis C transmission through straws or pipes HCV is transmitted through blood or, less commonly, through sexual contact. HCV can be transmitted from a person living with hepatitis who has oral or nasal sores or lacerations through sharing of straws or pipes [37][38][39][40]. Compared with the general population, higher HCV prevalence rates, ranging from 2.3 to 17 per cent, have been observed among people who smoke or sniff stimulant drugs [41]. However, it is difficult to determine whether HCV transmission in these cases occurred through blood exposure, sexual activity, or both. 1.3 Stimulant drug use and HIV/HBV/HCV transmission risks among key populations Men who have sex with men There seems to be a clear association between ATS use among men who have sex with men and risk of HIV infection. Methamphetamine use has been associated with increased frequency of unprotected sex among some men who have sex with men, thereby increasing vulnerability to STIs, HBV and HIV [42][43][44][45]. Studies have indicated HIV prevalence rates among men who have sex with men who use methamphetamine ranging between 17 and 61 per cent, and HIV incidence ranging from 2.71 per 100 person-years [46] to 5 per 100 person-years [47]. The use of stimulant drugs by some men who have sex with men to facilitate sex (referred to as ChemSex)4 has been linked to decreased condom use, sex with multiple partners and other high-risk sexual behaviours that increase likelihood of HIV and HCV transmission [48][49]. Increased sexual risk behaviours, including unprotected sex, coupled with potential anal or rectal trauma resulting from longer, more frequent and intense sexual encounters under the influence of drugs, could facilitate STI transmission among men who have sex with men, including HCV among men who have sex with men living with HIV. Risk-reduction strategies for HIV prevention such as serosorting5 and strategic positioning6 are inefficient for the prevention of other STIs, HBV or HCV. The association between ChemSex, drug use and sexually transmitted acute HCV infection among men living with HIV who have sex with men has been documented in several countries and regions [50]. ChemSex is mostly associated with non-injecting drug use, although some may also inject synthetic cathinones, amphetamines and methamphetamines (referred to as “slamming” or “blasting” within the context of ChemSex) [51], with a high level of sharing of injection equipment and consequently higher risks of HIV and HCV transmission [52][53][54]. Mephedrone use seems to have risen among men who have sex with men in the context of ChemSex [52]. The use of erectile dysfunction medications such as sildenafil is often reported among men who have sex with men who also consume methamphetamines and has been identified as increasing rates of unprotected sex and HBV, syphilis and HIV risks [46][48][55]. People who inject drugs Injecting stimulant drugs carries the greatest risk of acquiring HCV or HIV, due primarily to the sharing of contaminated needles and syringes. People who inject cocaine, ATS or heroin have a risk of acquiring HIV that is respectively 3.6, 3.0, and 2.8 times greater than people using stimulant drugs without injecting [56]. Outbreaks of HIV or hepatitis C among people who inject drugs, partly due to the increased use of synthetic cathinone as a replacement for heroin, have been reported in Greece [57], Hungary [29] and Romania [33][58]. People who inject stimulant drugs such as ATS show higher prevalence of sexual risk behaviours compared with people who inject opiates, and similar to non-injecting ATS users [59][60][61][62]. Sex workers Exchanging sex for crack cocaine or money has been associated with several HIV risk behaviours, such as having a greater number of clients per week [63], high levels of unprotected sex [64], sharing crack cocaine with clients [65] and heavier crack use, as well as structural vulnerabilities like homelessness and unemployment [66]. One study reported a higher HIV prevalence among those who exchange sex for drugs or money than among those who did not [67]. Individuals with drug dependencies who exchange sex for drugs may have reduced power and control over sexual interactions [68]. The use of methamphetamines by female sex workers has been associated with engaging in unsafe sex [69]. Female sex workers who use smokable cocaine are often homeless or poorly housed in economically depressed neighbourhoods, and have poor access to health services, including HIV services, as well as to prenatal and reproductive care and to social support. Sex workers, whether male, female or transgender, may be coerced into consuming drugs with their clients, increasing the risk of unprotected sex and violence. Male, female and transgender sex workers face barriers to accessing and using services due to the multiple stigma surrounding drug use, sex work and sexual orientation, which are criminalized to varying degrees in many jurisdictions around the world. Transgender people The use of methamphetamines, smokable cocaine or cocaine among transgender women has been associated with higher risks of HIV transmission, mainly through sex [70][71]. For example, a survey conducted among transgender women in high-risk venues and on the streets of Los Angeles, United States, indicated that recent methamphetamine and/or smokable cocaine use was associated with a more than twofold higher risk of reported HIV-positive status [72]. People living in prisons and other closed settings People who use stimulant drugs, such as methamphetamine, in prisons are more likely to engage in a number of sexual risk behaviours, including use of methamphetamines in the context of sex and inconsistent use of condoms [73][74]. 18 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS Women who use drugs Women who use drugs face stigma and other barriers to accessing essential health and HIV services, including gender-based violence, fear of forced or coerced sterilization or abortion, or loss of child custody. Cross-cultural stigma associated with women vacating gender roles, such as caring for their family, being pregnant and being mothers of infants and children, is a major challenge [75]. Many women who use drugs face unequal power dynamics in relationships, and higher rates of poverty; these factors interfere with their ability to access reproductive health supplies, including condoms and other contraceptives [76]. People living with HIV Although cocaine or methamphetamine use has a negative impact on the immune system, particularly among people living with HIV, the immunodepressive effect disappears when people living with HIV who use stimulant drugs adhere to antiretroviral therapy [77]. People living with HIV using stimulant drugs experience the worst HIV outcomes when they do not know they are living with HIV, or cannot access ART. A review of the literature reports findings that psychological, behavioural and social factors all play a role, separately and in combination, in determining HIV outcomes in patients, their access to health services, and adherence to ART: • In people living with HIV, regular methamphetamine use has measurable negative effects upon neuropsychological functioning (e.g. deficits in episodic memory, executive functions and information-processing speed) [78] over and above the negative neurocognitive effects caused by HIV and HCV [79]. This may impact their health-protective behaviour, health-services-seeking, access to HIV clinics and adherence to ART. In addition, HIV-specific traumatic stress and related negative affect are independently associated with greater stimulant-drug risk behaviours and reduced ART adherence [80]. • Cocaine and ATS have a negative impact on the immune system, increasing vulnerability to opportunistic diseases and accelerating the evolution of HIV among people who do not adhere to ART [77][81]. (See section 2.4 for more information on the interactions between ART and stimulant drugs). • Some communities of people who use stimulant drugs are very marginalized, extremely poor and have few resources, including access to adequate nutrition, and this also impacts their access to services and consequently the evolution of HIV infection. To reach people who frequently use stimulant drugs and retain them in effective HIV treatment regimes, access and adherence barriers related to HIV treatment must be accurately identified and addressed. When assessing why a patient who uses stimulant drugs is lost to follow-up, important factors that should be considered include stigma, discrimination, mental health, employment status, poverty, homelessness, migration, exposure to violence, incarceration, fear of criminalization, and family responsibilities. See chapter 4 for more information. 1.4 The impact of criminal sanctions on HIV transmission among key populations Stigma, discrimination and criminal sanctions against people who use drugs, men who have sex with men, transgender people, sex workers and people living with HIV have a direct impact on their ability and willingness to access and use HIV and other health services. These also impede the ability of people from key populations to access the commodities or services needed to practise protective behaviours, including condom use, and to access sterile injecting equipment, HIV testing and HIV treatment. A systematic review of 106 peer-reviewed studies published between 2006 and 2014 examined the association between criminal sanctions for drug use and HIV prevention and treatment-related outcomes among people who inject drugs [82]. While the studies were mainly conducted in North America and Asia, the findings highlighted that criminal sanctions were responsible for substantial barriers to HIV treatment and prevention interventions for people who inject drugs. 21 Chapter 2 Core interventions Following an extensive literature review and technical consultations at country and global levels, expert participants in a number of consultations agreed on a package of eight core interventions for HIV prevention, treatment, care and support among people who use stimulant drugs and are at risk of HIV. These interventions have been adapted from the WHO/UNODC/UNAIDS Comprehensive Package for HIV and people who inject drugs, and from the WHO Consolidated Package for HIV and key populations [7][8]. 1 Condoms, lubricants and safer sex programmes 2 Needle and syringe programmes (NSP) and other commodities 3 HIV testing services (HTS) 4 Antiretroviral therapy (ART) 5 Evidence-based psychosocial interventions and drug dependence treatments 6 Prevention, diagnosis and treatment of STIs, hepatitis and tuberculosis (TB) 7 Targeted information, education and communication (IEC) for people who use stimulant drugs and their sexual partners 8 Prevention and management of overdose and acute intoxication The core interventions should be adapted to the specific needs of different key populations. An assessment of the population to be served will assist in providing the evidence needed to design a clientcentred package of services that responds to specific needs. 2.1 Condoms, lubricants and safer sex programmes People who have sex while under the influence of stimulant drugs are more likely to engage in sexual risk behaviours, especially unprotected sex [83]. They may have reduced sexual inhibitions and a feeling of invincibility, which makes choosing or remembering to use a condom more challenging. Other factors that can contribute to inconsistent condom use include lack of access to condoms and lubricants when needed, poor safe-sex negotiations skills, being on PrEP [84] and engaging in risk-reduction strategies such as serosorting or strategic positioning. These strategies have their limits in terms of risk for HIV transmission, particularly if people are under the influence of stimulant drugs, and they do not prevent transmission of other STIs including HBV and HCV. Promoting the use of male and female condoms and appropriate lubricants remains a core HIV prevention strategy for people who use stimulant drugs and their sexual partners. Condoms offer protection against HIV, other STIs such as syphilis and gonorrhoea, and possible sexual transmission of HBV or HCV. Condoms can also prevent unintended pregnancy. Condoms and lubricants should be available widely, and without charge. Targeted distribution of free condoms helps overcome the barriers associated with their cost and can help reinforce the social acceptability of condom use. Distribution of condoms and sex-education information by peers and outreach workers plays an important role, including in the street or party setting. It is important to consider the variety of condoms available to meet key population preferences, and their distribution, to ensure wide availability of condoms and lubricant and access to them in places where people engage in stimulant drug use and sex concurrently. For example, in the case of sex-onpremises venues or nightclubs, simply making condoms available in the usual places, such as toilets or at the bar, is often not sufficient to ensure that people have them to hand when they need them. Consultation with the beneficiaries is critical to ensure easy access. Similarly, to ensure access to condoms in prisons, strategies must be tailored to each prison, based on its architecture, regime and the movements of prisoners within the prison. Safer-sex education for people who use stimulant drugs should cover: • Promotion of condoms and lubricant use • Information on sexual transmission of HIV, hepatitis and STIs • Safe-sex negotiation strategies • Information on strategies to reduce risks of HIV transmission (sero-sorting and strategic positioning), including their limitations • Information on pre-exposure prophylaxis of HIV (PrEP) Further resources The four key population implementation guides (the IDUIT, MSMIT, SWIT and TRANSIT) provide useful general information on condoms, lubricants and safer sex programming for people who inject drugs, men who have sex with men, sex workers and transgender people. 23 Chapter 2 Core interventions 2.2 Needle and syringe programmes and other commodities Due to the short duration of their effects, injection of stimulant drugs is frequently associated with rapidly repeated injecting, with some individuals reporting more than 20 injections a day. Injecting may take place in groups, and people may use several different stimulant drugs and other types of drug in the same session. These patterns of use increase the likelihood that non-sterile equipment will be used or shared, elevating the risk of HIV and hepatitis transmission. The accessibility and design of needle and syringe programmes (NSPs) must take into account the nature of stimulant drugs and patterns of their use. People who inject stimulant drugs should be educated, encouraged and supported to acquire sufficient sterile syringes. NSP policies and protocols should allow people who inject stimulant drugs access to enough injecting equipment for themselves and their peers. One-for-one exchange or other forms of restricted access to needles and syringes are not recommended in any situation and are particularly unhelpful with people who inject stimulant drugs [85][86]. In the party and club scene, injecting stimulant drugs is more likely to take place outside the normal operating hours of HIV harm reduction services. NSPs and other community drug services do not always engage with the party and club scene, compounding the lack of service availability or HIV prevention messaging. This lack of access is particularly problematic for people who inject stimulant drugs, who would benefit from access to an NSP and other services. Creative strategies can be used to make sterile needles and syringes available to people who inject stimulant drugs, particularly outside operating hours, and in the places where stimulant drugs are purchased or used. These may include satellite NSPs in projects or clinics for key populations, needle and syringe dispensing machines, secondary NSP, outreach programmes, safer clubbing initiatives, outreach at sex-on-premises venues (bars, saunas, clubs, etc.), outreach programmes at festivals, and community mobilization initiatives. NSPs designed to address the needs of people who use stimulant drugs, including all key populations, are well positioned to provide an entry point to a coordinated cascade of services, starting with voluntary HTS. They can also offer information on how to reduce risks related to the use of drugs, distribute female and male condoms and lubricant, and provide route transition interventions (see below). Efforts to understand the context of an individual’s drug use, their injecting equipment needs, and their concurrent sexual behaviours will help ensure that appropriate messaging is used. NSPs should also provide education, advice and equipment to support safer injecting practices, including on the importance of hand hygiene, avoiding sharing any paraphernalia (filters, water) associated with injecting, and keeping even the smallest amounts of blood out of the space where drugs are prepared for injection. It is also important to provide syringe disposal bins or plastic bins or containers for the safe disposal of used injecting equipment, which is key to preventing needle-stick injuries and reducing risk or inconvenience to the wider community associated with illicit drug injection. Syringes with colour-coded barrels provide an example of a promising practice that supports people who inject stimulant drugs in group settings. Each participant is assigned a different colour and provided with syringes of that colour which he or she alone is to use. This can help reduce the accidental sharing of injecting equipment, particularly if it is reused. Route transition interventions Route transition interventions support people who use drugs to avoid initiation into injecting, or to encourage people who are injecting to transition to non-injecting routes of administration. Behavioural interventions, peer education interventions and the provision of commodities that support alternatives to injecting, such as pipes, mouthguards and aluminium foil, can be used to engage with people who inject heroin and/or stimulant drugs. Box 3. A harm reduction programme for people who smoke cocaine or methamphetamines in the Pacific North-West United States The People’s Harm Reduction Alliance (PHRA) is a peer-based harm reduction programme for people who use drugs in the Pacific North-West of the United States, established in 2007. In its first year, PHRA provided syringes and sterile injection equipment; however, the need to expand services to include people who smoke drugs became quickly apparent via the peer-based framework and feedback from clients. In 2008, PHRA launched a crack pipe programme to reach a different group of people who use drugs. The programme has become a point of contact for them to access additional services. In 2015, the programme was expanded to include methamphetamine pipes because participants informed PHRA that lack of access to pipes led them to inject more frequently than they would otherwise do. Both pipe programmes have increased the inclusion of people who smoke crack and methamphetamine at PHRA and linked them to other essential health services. In 2016, PHRA expanded services for non-injectors further with a snorting programme. HIV and HCV prevention opportunities for people who smoke stimulant drugs Crack cocaine, cocaine base and methamphetamine can be smoked in a pipe, offering access to the high-dose surging effect. The repeated use of heated crack pipes can cause blisters, cracking and sores on the tongue, lips, face, nostrils and fingers. It has been suggested that this may facilitate HCV transmission via unsterile paraphernalia (although this has not been clearly established). People smoking stimulant drugs in pipes do not require single-use equipment but will benefit from having personal (individual) smoking equipment, and messaging that pipes should not be shared. The same principle applies for straws used to inhale cocaine. The distribution of pipes, mouthguards and other piping paraphernalia provides practical strategies for engaging stimulant drug smokers and reinforces the “Don’t share pipes” message. The principles of distributing paraphernalia and engaging people who smoke stimulant drugs with messages about HIV and hepatitis prevention remain the same. 25 Chapter 2 Core interventions Box 4. Example of content of kits for safer smoking • Pipes • Mouth- or lip guards – a rubber band, rubber tubing, or sometimes specially produced • Stainless steel wool, used as gauze to suspend the crack cocaine inside the pipe • Alcohol wipes to clean the pipe and reduce risks associated with sharing • Lip balm containing vitamin E, to help protect and heal chapped or injured lips • Sterile dressing to cover wounds or burns arising from smoking crack • Sugar-free chewing gum which can help stimulate saliva production to protect teeth and reduce dental damage • Condoms and lubricants to support safer sex practices • Health promotion leaflets Safe tattooing In some population groups who use stimulant drugs, unsafe tattooing is frequent and constitutes a risk for transmission of HCV. This is a particular issue in prisons where tattooing is prohibited and hidden and unhygienic tattooing is common. NSPs and other low-threshold services can offer safe tattooing information, training and safe equipment. 2.3 HIV testing services HIV testing provides an opportunity to deliver HIV prevention messages and to link people to HIVprevention and other relevant health and support services. HIV testing services (HTS) are also the critical entry point to ART (see section 2.4). Given the evidence that individuals who are ARTadherent and have achieved viral suppression do not transmit HIV, HTS is a crucial component of HIV prevention programmes. It is important to increase the opportunities for people who use stimulant drugs to access and use confidential, easy and convenient HIV testing that is linked to the provision of ART for those who test positive. Community-based rapid HIV testing provides an opportunity to deliver results immediately. This can be of particular importance with street- or venue-based people who use stimulant drugs, where the primary source of engagement may be outreach programmes brought to where they are, rather than waiting for them to present at a specific testing location. Other outreach opportunities may also be used to distribute HIV self-test kits. Regardless of the testing modality, it is important to have a protocol to assist people to get a confirmatory test if they test positive, and to access and successfully use HIV care and treatment services if needed, including immediate access to ART, post-exposure prophylaxis (PEP) or PrEP, as appropriate. On-site HIV testing can pose challenges, including the possible lack of confidentiality that comes especially with small, closed communities. Outreach workers and service providers need to ensure that HIV testing is always voluntary and that coercive use of self-test kits by third parties such as law enforcement or employers to test any individual (e.g., sex workers) is unacceptable. 2.4 Antiretroviral therapy Antiretroviral therapy (ART) is the treatment of people living with HIV with medications that suppress the replication of the virus. Currently the standard treatment consists of a combination of antiretroviral drugs (ARVs), and it is indicated for all people living with HIV, irrespective of their CD4 count. ART reduces morbidity and mortality rates among people living with HIV, improves their quality of life and reduces risks of transmission of HIV. ARVs are also administered to some groups of people at risk for HIV acquisition either before exposure (PrEP) or after (PEP). ART is also needed for prevention of mother-to-child transmission of HIV. Cocaine and ATS have been associated with faster disease progression in people living with HIV, due to weakening of the immune system by the drugs. However, if adherence is maintained, the effectiveness of ART is not reduced in people who use stimulant drugs: ART reduces viral load and improves immune function, just as it does for other people living with HIV [77]. Strategies to support adherence to ART, including peer and outreach support, are described in section 3.1. Side-effects of antiretroviral drugs and interactions with stimulant drugs As with many medications, ARVs have been associated with various side-effects, including acute or chronic alterations of the renal function, or hepatic dysfunction. Some medications can cause sideeffects in the central nervous system, such as depression. Liver toxicity is one of the most commonly reported adverse consequences associated with ARVs. This can range from asymptomatic elevation of the liver enzymes to a hepatic failure. Risks for ARVrelated adverse consequences for the liver are higher in cases of cocaine use, excessive alcohol use, coinfection with HBV or HCV, fibrosis of the liver, concomitant treatment for TB and advanced age. Impact of stimulant drugs on antiretroviral drug serum level Cocaine, mephedrone and methamphetamines interact with several ARVs, influencing the serum level of the medications and the risk of side-effects. As scientific knowledge progresses, new ARV regimens may be proposed, with the potential for interactions with the NPS that are frequently appearing on the market. The University of Liverpool provides a regularly updated website on HIV medication interactions, including the interaction of ARVs with stimulant drugs: https://www.hiv-druginteractions.org/treatment_selectors. Impact of antiretroviral drugs on serum level of stimulant drugs Serum levels of methamphetamines may increase up to three times when used by someone who is also taking protease inhibitors, especially ritonavir. Fatal cases attributed to inhibition of the metabolism of MDMA and amphetamines by ritonavir have been reported. Oral pre-exposure prophylaxis Oral pre-exposure prophylaxis (PrEP) is the use of antiretroviral medications to prevent the acquisition of HIV infection by uninfected persons. WHO recommends daily oral PrEP as a prevention choice for people at substantial risk of HIV [91]; it can be stopped during periods of low or no risk. Taken as prescribed, PrEP can reduce the risk of getting HIV from sex with an HIV-positive person by more than 90 per cent [92]. PrEP has been effective in communities where the primary vector for transmission is sexual, such as men who have sex with men, and is therefore appropriate for people who use stimulant drugs. PrEP does not replace HIV prevention interventions, such as comprehensive condom programming for sex workers and men who have sex with men. It does not prevent transmission of hepatitis and other STIs. Services for people who inject stimulant drugs should prioritize evidence-based comprehensive HIV prevention interventions, including NSP, condoms and lubricants. For men who have sex with men who use stimulant drugs and engage in high-risk sex, PrEP should always be proposed, whether or not the individual injects drugs. Adherence to PrEP is essential, and it may be challenging for people using stimulant drugs for several days in a row. People who use stimulant drugs and engage in concurrent sex should be encouraged and supported to plan ahead to use condoms, lubricants and PrEP in combination, to ensure better protection against HIV and to prevent other STIs, including hepatitis C and B. As with other prevention tools, the effectiveness of PrEP is optimized when interventions are implemented by, and in close consultation with, prospective beneficiary communities. Further resources Implementation tool for pre-exposure prophylaxis (PrEP) of HIV infection (WHO, 2017) [93] Post-exposure prophylaxis Post-exposure prophylaxis (PEP) is the administration of ARVs for a short term (one month) to prevent HIV infection after exposure to HIV through unprotected sex or contact with blood. PEP should be offered to all individuals who have potentially been exposed to HIV, whether through unprotected sex (including sexual assault), needle-stick injury or sharing drug injection equipment. It should be initiated as early as possible, ideally within 72 hours. People who use stimulant drugs and engage in sex concurrently are known to often have multiple sexual partners. The chances of unprotected sex or condom failure are increased with stimulant drug use or with the increase in the number of partners. A participative stakeholder process should lead to the development of protocols for community access to PEP, from local to national levels, to ensure that the required medications are promptly accessible and are used by those who need them. People who use stimulant drugs and who access PEP regularly should be assessed as likely candidates for PrEP. Further resources Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a public health approach - Second edition (WHO, 2016) [162] 2.5 Evidence-based psychosocial interventions and drug dependence treatments The impact of a drug is determined by the complex interactions between the substance, set (the mindset of the individual) and setting (the context), which mediate the drug’s effect and its associated impact on the individual, including the move towards dependent or high-risk drug use [94]. The great majority of people who use stimulant drugs do so on an occasional basis that may be characterized as “recreational”, and they will not develop dependence. This group has little need for high-intensity interventions. This section provides an overview of possible interventions, mainly psychosocial ones, that show effectiveness specifically for reducing risk behaviours and provide support for people who regularly use stimulant drugs, including people living with HIV. 29 Chapter 2 Core interventions The treatment of cocaine or ATS drug dependence requires time-intensive approaches that are not addressed here. Unlike the treatment of opioid dependence, there are currently no substitution medications available to treat dependence on cocaine or ATS [95][96]. Some emerging practices around dispensing dexamphetamine as a substitute for cocaine or methamphetamine dependence have shown early promise, but further research is needed. Behavioural interventions, self-regulation coaching and psychosocial counselling can support HIV/HCV prevention and treatment objectives for people who use stimulant drugs, while also contributing to longer-term and broader health and wellness goals. There is evidence that brief interventions that concentrate on providing information about safe behaviours and harm mitigation are effective in moderating drug-related harms [97] and maintaining ART adherence for those who are living with HIV [98]. Addressing the potential risks associated with the nexus of drug use and HIV requires individual, structural and combination approaches [99]. Psychosocial services such as motivational interviewing, brief interventions, contingency management and cognitive behavioural therapy are critical to effectively support HIV prevention and treatment among people who use stimulant drugs. Some of these approaches are described below. A 2016 review of psychosocial interventions for stimulant drug-use disorders found that all showed improved retention in ART compared with no intervention, although no single intervention showed a sustained benefit over the others [100]. Psychosocial services should be based on principles of community inclusion and participation, peer support and the needs of the individual. When developing HIV prevention interventions, it is important that sexual partners of people who use stimulant drugs be included in the process, focusing on the HIV risks that are associated with drug use and concurrent sexual behaviours. Motivational interviewing Motivational interviewing is a person-centred, semi-directive approach for exploring motivation and ambivalence in order to facilitate self-motivational statements and behavioural changes. It consists in establishing a partnership between the provider and the individual and enabling the individual to become aware of the discrepancy between their present situation and their own values. The technique relies on four principles: express empathy, develop discrepancy, roll with resistance and support selfefficacy. These can easily be used by trained non-specialist staff, including outreach workers, in formal or informal counselling, IEC and other conversations. Motivational interviewing generally requires just one or two sessions. The success of motivational interviewing has led to its implementation as a “catch-all” approach to eliciting change in areas such as medication compliance, smoking cessation and diet and exercise [101]. A 2012 Cochrane review suggested that motivational interviewing could reduce risky sexual behaviour, and in the short term lead to a reduction of viral load in young people living with HIV [102]. Research has shown that motivational interviewing can reduce the incidence of unprotected anal intercourse among men who have sex with men [103], as well as levels of drug use [104]. Brief interventions Brief interventions are short, often opportunistic interactions in which a health worker provides targeted information and advice to individuals during other activities such as distributing sterile injecting equipment or conducting an HIV test. Brief interventions have been shown to reduce drug use as well as associated risks and sexual risk behaviours. Meta-analyses suggest that there is little difference in the outcomes between longer, more intensive interventions and brief interventions, and the latter are likely to be more practical and cost-effective options, with few barriers to implementation [105]. Motivational interviewing, contingency management and brief interventions for dependence to stimulant drugs can reduce drug-related high-risk sexual behaviours and increase adherence to ART and PrEP. 30 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS Contingency management Contingency management is an approach that incentivizes people with rewards such as cash that are contingent on achieving a set of pre-defined outcomes. Contingency management has been shown to have a moderate yet consistent effect on drug use across different classes of drugs [106]. The effectiveness of contingency management supports the idea that small, regular rewards motivate people to modify behaviours that could be considered harmful. Positive regard, and the client’s own expressed belief in their ability to achieve goals, are a critical factor in improving agreed-upon outcomes. Cognitive behavioural therapy Cognitive behavioural therapy (CBT) is a structured approach to counselling that assumes that behaviours are learned and reinforced as a result of cognitive constructs and deficits in coping. The aim of CBT is to “unlearn” behaviours considered unhelpful, such as HIV risk behaviour or certain patterns of drug-taking. While results appear to be sustained over a period, CBT is intensive and time-consuming, and demands specialist practitioners and individual treatment [107]. Mindfulness Mindfulness can be defined as the ability to focus open, non-judgemental attention on the full experience of internal and external phenomena, moment by moment. Positive outcomes – including reducing drug use and risk behaviours, and in relapse prevention – have been documented from mindfulness training as part of approaches to reduce harm, including for people who use stimulant drugs [108][109][110]. Opioid substitution therapy and stimulant drug use People receiving opioid substitution therapy (OST) for heroin or other opioid dependence may use stimulant drugs because of OST-triggered fatigue, inability to experience pleasure, or the desire to remain connected to the community of people who use drugs. OST is not designed to counter stimulant drug use, and the concurrent use of stimulant drugs while on OST should not be viewed as a breach, nor should it lead to the reduction or discontinuation of OST. The benefits of OST are independent of stimulant drug use [111]. Existing OST providers should be sensitized to this and trained to use the opportunities afforded by regular OST and client engagement to support the delivery of interventions included in this guidance. Further resources mhGAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings (WHO, 2010) [112] Therapeutic interventions for users of amphetamine-type stimulants (WHO, 2011) [113] Harm reduction and brief interventions for ATS users (WHO, 2011) [114] Guidelines for the management of methamphetamine use disorders in Myanmar (Ministry of Health and Sports, Myanmar, 2017) [115] Guidance for working with cocaine and crack users in primary care (Royal College of General Practitioners, 2004) [116] Principles of drug dependence treatment (UNODC, WHO, 2008) [117] Drug abuse treatment and rehabilitation: a practical planning and implementation guide (UNODC, 2003) [118] TREATNET quality standards for drug dependence treatment and care services (UNODC, 2012) [111] Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence (WHO, 2009)[163] Treatment of stimulant use disorders: current practices and promising perspectives. Discussion paper (UNODC, 2019)[164] 31 Chapter 2 Core interventions 2.6 Prevention, diagnosis and treatment of sexually transmitted infections, hepatitis and tuberculosis Screening people who use stimulant drugs for infectious diseases, such as sexually transmitted infections (STIs), HBV, HCV and TB, is a crucial part of a comprehensive approach. Along with HIV, these infections are often associated with the use of illicit substances, and they may co-occur with stimulant drug use. Prevention, diagnosis and treatment of sexually transmitted infections Unsafe sex can lead to acute STIs, which can cause infertility and severe illness. Several STIs, particularly those involving genital or perianal ulcers, may facilitate the sexual transmission of HIV infection. Sex workers, transgender people and men who have sex with men are often at increased risk of STIs such as syphilis, gonorrhoea, chlamydia and herpes. It is therefore important to offer information, male and female condoms and lubricant, and screening, diagnosis and treatment of STIs and possibly HPV vaccine to people using stimulant drugs who are vulnerable to STIs and HIV. Further resources Resources on sexually transmitted and reproductive tract infections (WHO webpage providing clinical, policy and programmatic, monitoring and evaluation and advocacy guides) [119] Prevention, vaccination, diagnosis and treatment of hepatitis B and C People who inject stimulant drugs are at heightened risk of acquiring HBV and HCV because of frequent injecting and sharing of injection equipment. The risk of sharing equipment is higher when injecting happens in communal settings. HCV is much more virulent than HIV and can survive outside the body at room temperature, on environmental surfaces, for up to three weeks [120], making it more easily transmitted through the sharing of syringes and other injecting paraphernalia. Key populations who use stimulant drugs should be offered hepatitis B or hepatitis A-B vaccination, access to prevention commodities, and voluntary screening and treatment of HBV and HCV. Prevention NSPs and community mobilization initiatives should distribute relevant equipment, including low dead-space syringes, for injecting, smoking and snorting (see section 2.2). Male and female condom programming is also part of hepatitis B and C prevention interventions as well as sexual and reproductive health services. Education should include messages on the risks of serosorting, and of intense sexual practices involving potential trauma of the mucosa for HCV acquisition and transmission among people living with HIV [50]. Hepatitis A and B vaccination Key populations should be offered the series of HBV immunizations. WHO recommends: • Offering people the rapid hepatitis B vaccination regimen (days 0, 7 and 21-30). • Providing people who inject drugs with incentives in order to increase hepatitis B vaccination adherence, at least for the second dose. Even partial immunization confers some immunoprotection. [87] Hepatitis A (HAV) immunization or combined HAV-HBV immunization should be offered to men who have sex with men and people using stimulant drugs [121]. 32 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS Immunization should be easily accessible and offered at locations and venues frequented by people who use stimulant drugs, such as drop-in centres, NSPs and other community service outlets. Screening for HBV and HCV Voluntary screening for HBV and/or HCV should be offered to people who use stimulant drugs at risk of these infections. Testing and diagnosis of HBV and HCV infection is an entry point for accessing both prevention and treatment services. Early identification of persons with chronic HBV or HCV infection enables them to receive the necessary care and treatment to prevent or delay the progression of liver disease. Rapid tests for hepatitis C allow for better access to diagnosis, including communitybased testing. Treatment of chronic hepatitis C or B All people with chronic hepatitis C should receive treatment. With an 8- to 12-week course, directacting antivirals (DAAs) cure more than 95 per cent of persons with HCV infection, reducing the risk of death from liver cancer and cirrhosis. For chronic hepatitis B, antiviral treatment can slow down the progression of cirrhosis and reduces the risk of liver cancer [162]. People who are actively injecting drugs have been shown to adhere to HCV treatment regimens as well as any other population, particularly when social, emotional and practical support are provided [122]. All people who use stimulant drugs living with HCV should therefore be offered access to direct-acting antivirals without discrimination. Further resources Guidance on prevention of viral hepatitis B and C among people who inject drugs (WHO, 2012) [87] Guidelines for the screening, care and treatment of persons with chronic hepatitis C infection (WHO, 2016) [123] Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Recommendations for a public health approach - Second edition (WHO, 2016) [162] Prevention, diagnosis and treatment of tuberculosis In 2016, 10.4 million people fell ill with TB. It is a leading killer of people living with HIV: in 2016, 40 per cent of HIV deaths were due to TB [124]. Transmission of TB is easily facilitated through airborne particulates, such as by kissing, coughing, sneezing or shouting. TB is easily spread in prisons and other closed settings, and in crowded and poorly ventilated spaces, such as are often found in poor communities or among homeless people. People who inject drugs are at increased risk of TB, irrespective of their HIV status, and TB is a leading cause of mortality among people who inject drugs who also have HIV infection [125]. People who use drugs who do not inject have also been found to have increased rates of TB. Certain subgroups of stimulant drug users, such as those who use stimulant drugs regularly for days at a time, may be immuno-deficient from lack of sleep and food, facilitating TB transmission. It is therefore important to include TB prevention, screening and treatment in communities and services. Further resources Integrating collaborative TB and HIV services within a comprehensive package of care for people who inject drugs: consolidated guidelines (WHO, 2016) [125] 33 Chapter 2 Core interventions 2.7 Targeted information, education and communication To reduce the risk of acquiring STIs or HIV, people who use stimulant drugs need knowledge and support. Information, education and communication (IEC) provides information, motivation, education and skills-building to help individuals adopt behaviours that will protect their health. Effective communication for health targeting people who use stimulant drugs requires addressing two challenges: • Crafting messages that can overcome long-standing distrust and fear. • Finding effective means of reaching people who use stimulant drugs with life-saving messages and materials. Key to meeting these challenges is meaningful engagement with the target audience of people who use stimulant drugs. Communities should be represented at every stage of IEC development, including the overall strategy and concept, and the development, testing, dissemination and evaluation of messages. Working with the community will help ensure that tools and materials are accurate and will be trusted and used. Recipients of IEC who have invested their own ideas and time in it will be more likely to stand behind the results and be active participants, not only in their own health but in health promotion in their community. Materials must be easily understandable and to the point. Interactive materials on a digital platform can tailor messaging to the specific situation of the service user and are often helpful in maintaining attention. On the other hand, traditional printed materials have the advantage of not requiring computer, phone or Internet access. They also provide an opportunity for outreach workers or other programme staff distributing the materials to interact with the service users, and a means for service users to easily share information with others. Using information technology to support behavioural interventions Online and social media can be a cost-effective manner of reaching targeted audiences. A local assessment can show where using these technologies will be advantageous and appropriate. Free WiFi at drop-in centres and other community points of congregation provides opportunities for access and use. Where people who use stimulant drugs have smartphones, websites and apps can be deployed just as they have been to reach other key populations. The use of technology has shown promising results in promoting sexual health or adherence to ART in different settings, including resource-limited settings [126][127]. Web-based applications provide an opportunity to reach a large audience at any time and provide information on health and available services. They also allow for online outreach and interactions with people who wish to discuss problems or have questions. However, when the information relates to drug use, or other criminalized behaviours, the use of some digital media raises concerns about the anonymity of the contacts, and possible risks related to law enforcement must be addressed. Working with communities and low-threshold service providers will help inform the local potential for digital materials and campaigns and help ensure the security of people accessing information. Given the variety that exists among people who use stimulant drugs, messaging should take into account the sex, gender, sexual orientation, age and setting of recipients of IEC. Literacy levels, social and community inclusion or exclusion, and other cultural and societal variables must also be considered. 34 HIV PREVENTION, TREATMENT, CARE AND SUPPORT FOR PEOPLE WHO USE STIMULANT DRUGS Further resources The European Centre for Disease Prevention and Control (ECDC) has developed guidance documents for the effective use of social media. While the tools were developed for Europe, and specifically for reaching men who have sex with men, they provide guidance on the relative advantages of different media, such as Facebook, online outreach, Google Ads, SMS and YouTube, that may be useful in other contexts. Effective use of digital platforms for HIV prevention among men who have sex with men in the European Union/European Economic Area: an introduction to the ECDC guides (ECDC, 2017) [128] 2.8 Overdose and acute intoxication prevention and management Very high doses of stimulant drugs consumed in a short amount of time can trigger acute respiratory distress, chest pain, palpitations or myocardial infarctions [112]. In extreme cases this can result in cardiac arrest. The first signs of stimulant drugs intoxication are hyperactivity, rapid speech and dilated pupils. In the case of polydrug use, overdose can be the result of the combination of stimulants with other drugs including opioid or sedative drugs. The treatment of stimulant drugs intoxication is symptomatic and requires regular monitoring of blood pressure, pulse rate, respiratory rate and temperature (figure I.). Serotonergic syndrome is caused by an excess of serotonin in the central nervous system associated with the use of ATS. It can result in uncontrollable muscle spasms, tremor, seizures, psychosis, high blood pressure, high body temperature >400 C (hyperthermia) and release of myoglobin from muscles and blood clotting in vessels (disseminated intravascular coagulation), which may lead to severe diseases and potentially death. People who use stimulant drugs need to be informed on how to reduce the risks of acute intoxications (see the Information checklist for self-care and stimulant drugs in the annex). For people on PrEP, ART or hepatitis treatment, information should be provided on the interactions and possible risks of cocaine and ATS use to serum levels (see section 2.4). People who use stimulant drugs should be trained to recognize overdoses, provide first aid, including cardiopulmonary resuscitation (CPR) and call immediately for emergency professional assistance if they witness an overdose. Please do not use any other resources to answer the question other than the information I provide you. If you cannot answer with only the information I provide say "I cannot answer without further research." What are the key considerations and strategies for people who use stimulant drugs and engage in concurrent sex in terms of HIV prevention, and how does the effectiveness of these strategies get optimized?

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How do companies in the context of multi-cloud initiatives strike a balance between the demands of improved data security and cost minimization and the difficulties of handling growing complexity and possible interoperability issues? Talk about how these approaches help IT infrastructure be innovative and flexible, while also meeting the increasing needs for sustainability and integrating new technologies like edge computing, AI, and the IoT.

Multi-cloud strategies are becoming popular as businesses look to improve data management, cost efficiency, and operational flexibility. This approach involves using cloud services from different providers to meet various needs, avoiding reliance on a single vendor. As more organizations undergo digital transformation, understanding the benefits and challenges of multi-cloud strategies becomes crucial for making informed decisions. The multi-cloud approach offers many advantages, such as improved resilience, cost optimization, and enhanced data security. However, it also presents challenges, including management complexity and potential interoperability issues. This blog explores the rise of multi-cloud strategies, highlighting the benefits and challenges they bring to businesses. What Makes Multi-Cloud Unique Multi-cloud strategies are unique because they leverage the strengths of various cloud providers. Is superior to single-cloud or hybrid cloud. It allows businesses to select the top services from various vendors. This ensures they receive the most suitable solutions for their requirements. This flexibility leads to improved performance and cost savings, as companies can optimize their resources more effectively. Another unique aspect of multi-cloud strategies is the enhanced resilience they offer. By spreading workloads across multiple cloud environments, businesses can minimize the risk of downtime and data loss. This distribution of resources ensures that if one cloud provider experiences an outage, the impact on overall operations is minimal, thus maintaining business continuity. Additionally, multi-cloud strategies provide greater freedom in vendor choice and negotiation power. Companies can switch vendors or services easily without causing major disruptions. This is because they are not limited to just one provider. This flexibility fosters innovation and adaptability, essential for staying competitive in today's fast-paced business environment. Essential Market for Business Businesses need to use multi-cloud strategies to stay competitive in the IT infrastructure market. One primary reason is the ability to manage large volumes of data more efficiently. With the rise of big data and analytics, businesses require robust and scalable solutions to handle their data needs. Multi-cloud strategies enable organizations to distribute data across different platforms, ensuring optimal performance and storage efficiency. Cost implications also play a significant role in the growing popularity of multi-cloud strategies. Businesses can save money and customize their cloud usage by using multiple cloud providers. This approach allows companies to avoid vendor lock-in and negotiate better deals, ultimately reducing overall IT costs. Flexibility is another critical factor driving the adoption of multi-cloud strategies. Businesses have many options for services and technologies to quickly adjust to market changes. Being adaptable is important for companies to innovate and grow. It allows them to try out different tools and solutions without being limited to just one vendor. Benefits of Multi-Cloud Strategies One of the most significant benefits of multi-cloud strategies is improved data management. By utilizing multiple cloud providers, businesses can distribute their data more efficiently, ensuring better performance and availability. This method helps with better disaster recovery and backup options by copying data to various cloud platforms. Cost savings are another major advantage of multi-cloud strategies. Companies can optimize their spending by selecting the most cost-effective services from various providers. This method helps businesses save money on cloud services and make sure they get the most out of their investment. Enhanced security is also a key benefit of multi-cloud strategies. With data spread across multiple cloud environments, businesses can implement robust security measures tailored to each platform. This multi-layered approach reduces the risk of data breaches and ensures protection of sensitive information. Challenges of Adopting Multi-Cloud Strategies Despite the numerous benefits, adopting a multi-cloud strategy comes with its challenges. One primary concern is the complexity of managing multiple cloud environments. Businesses need to invest in tools and expertise to ensure seamless integration and operation of various cloud services. This complexity can lead to increased operational costs and require specialized skills to manage effectively. Interoperability issues are another challenge associated with multi-cloud strategies. Cloud providers use various technologies and standards. This can make it difficult to integrate and manage workloads across different platforms. Businesses need to carefully plan their multi-cloud architecture to ensure compatibility and avoid potential conflicts. Additionally, data governance and compliance can become more challenging in a multi-cloud environment. Businesses need to make sure they follow rules and keep control of their data when using multiple cloud providers. This often involves implementing robust monitoring and auditing processes to ensure compliance. Strategic Advantages of Multi-Cloud Adopting a multi-cloud strategy provides businesses with several strategic advantages. One of the most notable is the ability to avoid vendor lock-in. Companies can use more than one cloud provider to switch services and providers easily when necessary. This allows them to avoid being limited to just one vendor. This flexibility enables companies to adapt to changing needs and take advantage of the best services available. This flexibility allows businesses to adapt quickly to market changes and take advantage of new technologies. Another strategic advantage is the ability to optimize performance. Multi-cloud strategies enable businesses to choose the best services for specific workloads, ensuring optimal performance and efficiency. This tailored approach helps companies meet their performance goals and deliver better customer experiences. Furthermore, multi-cloud strategies support innovation by providing access to a wide range of technologies and services. Businesses can experiment with new tools and solutions without being constrained by a single vendor's offerings. This freedom fosters creativity and innovation, helping companies stay competitive and drive growth. Current Trends and Industry Developments The rise of multi-cloud strategies is driven by several current trends and industry developments. One significant trend is the increasing demand for cloud-native applications. These applications are designed to run on multiple cloud environments, making them ideal for multi-cloud strategies. Businesses are adopting cloud-native technologies to improve scalability, performance, and resilience. Another trend is the growing importance of edge computing. With data being generated closer to the source, businesses need to process and analyze data at the edge of the network. Multi-cloud strategies enable organizations to leverage edge computing capabilities from different providers, ensuring they can meet the demands of real-time data processing. The adoption of artificial intelligence (AI) and machine learning (ML) is also driving the rise of multi-cloud strategies. These technologies require significant computing power and data storage, which can be efficiently managed using multiple cloud environments. Businesses are leveraging AI and ML to gain insights, automate processes, and improve decision-making. Future Developments and Opportunities As multi-cloud strategies continue to evolve, several future developments and opportunities are emerging. One area of growth is the development of advanced management tools. These tools will help businesses manage their multi-cloud environments more effectively, providing better visibility, control, and automation. Another area of opportunity is the integration of multi-cloud strategies with emerging technologies such as the Internet of Things (IoT) and 5G. These technologies will generate vast amounts of data that need to be processed and analyzed in real-time. Multi-cloud strategies will enable businesses to leverage the capabilities of different cloud providers to meet these demands. Additionally, the focus on sustainability is driving the adoption of multi-cloud strategies. Businesses are seeking to reduce their environmental impact by optimizing their cloud usage. Multi-cloud strategies allow organizations to choose eco-friendly cloud providers and implement energy-efficient practices, contributing to sustainability goals. The rise of multi-cloud strategies represents a significant shift in how businesses approach their IT infrastructure. By leveraging the strengths of multiple cloud providers, companies can improve data management, optimize costs, and enhance flexibility. However, adopting a multi-cloud approach also presents challenges, such as increased complexity and potential interoperability issues. As businesses continue to embrace digital transformation, understanding the benefits and challenges of multi-cloud strategies is crucial. By carefully planning and managing their multi-cloud environments, organizations can unlock new opportunities for innovation, growth, and sustainability. The future of multi-cloud strategies looks promising, with ongoing developments and emerging technologies set to drive further advancements in this dynamic field.

[question] How do companies in the context of multi-cloud initiatives strike a balance between the demands of improved data security and cost minimization and the difficulties of handling growing complexity and possible interoperability issues? Talk about how these approaches help IT infrastructure be innovative and flexible, while also meeting the increasing needs for sustainability and integrating new technologies like edge computing, AI, and the IoT. ===================== [text] Multi-cloud strategies are becoming popular as businesses look to improve data management, cost efficiency, and operational flexibility. This approach involves using cloud services from different providers to meet various needs, avoiding reliance on a single vendor. As more organizations undergo digital transformation, understanding the benefits and challenges of multi-cloud strategies becomes crucial for making informed decisions. The multi-cloud approach offers many advantages, such as improved resilience, cost optimization, and enhanced data security. However, it also presents challenges, including management complexity and potential interoperability issues. This blog explores the rise of multi-cloud strategies, highlighting the benefits and challenges they bring to businesses. What Makes Multi-Cloud Unique Multi-cloud strategies are unique because they leverage the strengths of various cloud providers. Is superior to single-cloud or hybrid cloud. It allows businesses to select the top services from various vendors. This ensures they receive the most suitable solutions for their requirements. This flexibility leads to improved performance and cost savings, as companies can optimize their resources more effectively. Another unique aspect of multi-cloud strategies is the enhanced resilience they offer. By spreading workloads across multiple cloud environments, businesses can minimize the risk of downtime and data loss. This distribution of resources ensures that if one cloud provider experiences an outage, the impact on overall operations is minimal, thus maintaining business continuity. Additionally, multi-cloud strategies provide greater freedom in vendor choice and negotiation power. Companies can switch vendors or services easily without causing major disruptions. This is because they are not limited to just one provider. This flexibility fosters innovation and adaptability, essential for staying competitive in today's fast-paced business environment. Essential Market for Business Businesses need to use multi-cloud strategies to stay competitive in the IT infrastructure market. One primary reason is the ability to manage large volumes of data more efficiently. With the rise of big data and analytics, businesses require robust and scalable solutions to handle their data needs. Multi-cloud strategies enable organizations to distribute data across different platforms, ensuring optimal performance and storage efficiency. Cost implications also play a significant role in the growing popularity of multi-cloud strategies. Businesses can save money and customize their cloud usage by using multiple cloud providers. This approach allows companies to avoid vendor lock-in and negotiate better deals, ultimately reducing overall IT costs. Flexibility is another critical factor driving the adoption of multi-cloud strategies. Businesses have many options for services and technologies to quickly adjust to market changes. Being adaptable is important for companies to innovate and grow. It allows them to try out different tools and solutions without being limited to just one vendor. Benefits of Multi-Cloud Strategies One of the most significant benefits of multi-cloud strategies is improved data management. By utilizing multiple cloud providers, businesses can distribute their data more efficiently, ensuring better performance and availability. This method helps with better disaster recovery and backup options by copying data to various cloud platforms. Cost savings are another major advantage of multi-cloud strategies. Companies can optimize their spending by selecting the most cost-effective services from various providers. This method helps businesses save money on cloud services and make sure they get the most out of their investment. Enhanced security is also a key benefit of multi-cloud strategies. With data spread across multiple cloud environments, businesses can implement robust security measures tailored to each platform. This multi-layered approach reduces the risk of data breaches and ensures protection of sensitive information. Challenges of Adopting Multi-Cloud Strategies Despite the numerous benefits, adopting a multi-cloud strategy comes with its challenges. One primary concern is the complexity of managing multiple cloud environments. Businesses need to invest in tools and expertise to ensure seamless integration and operation of various cloud services. This complexity can lead to increased operational costs and require specialized skills to manage effectively. Interoperability issues are another challenge associated with multi-cloud strategies. Cloud providers use various technologies and standards. This can make it difficult to integrate and manage workloads across different platforms. Businesses need to carefully plan their multi-cloud architecture to ensure compatibility and avoid potential conflicts. Additionally, data governance and compliance can become more challenging in a multi-cloud environment. Businesses need to make sure they follow rules and keep control of their data when using multiple cloud providers. This often involves implementing robust monitoring and auditing processes to ensure compliance. Strategic Advantages of Multi-Cloud Adopting a multi-cloud strategy provides businesses with several strategic advantages. One of the most notable is the ability to avoid vendor lock-in. Companies can use more than one cloud provider to switch services and providers easily when necessary. This allows them to avoid being limited to just one vendor. This flexibility enables companies to adapt to changing needs and take advantage of the best services available. This flexibility allows businesses to adapt quickly to market changes and take advantage of new technologies. Another strategic advantage is the ability to optimize performance. Multi-cloud strategies enable businesses to choose the best services for specific workloads, ensuring optimal performance and efficiency. This tailored approach helps companies meet their performance goals and deliver better customer experiences. Furthermore, multi-cloud strategies support innovation by providing access to a wide range of technologies and services. Businesses can experiment with new tools and solutions without being constrained by a single vendor's offerings. This freedom fosters creativity and innovation, helping companies stay competitive and drive growth. Current Trends and Industry Developments The rise of multi-cloud strategies is driven by several current trends and industry developments. One significant trend is the increasing demand for cloud-native applications. These applications are designed to run on multiple cloud environments, making them ideal for multi-cloud strategies. Businesses are adopting cloud-native technologies to improve scalability, performance, and resilience. Another trend is the growing importance of edge computing. With data being generated closer to the source, businesses need to process and analyze data at the edge of the network. Multi-cloud strategies enable organizations to leverage edge computing capabilities from different providers, ensuring they can meet the demands of real-time data processing. The adoption of artificial intelligence (AI) and machine learning (ML) is also driving the rise of multi-cloud strategies. These technologies require significant computing power and data storage, which can be efficiently managed using multiple cloud environments. Businesses are leveraging AI and ML to gain insights, automate processes, and improve decision-making. Future Developments and Opportunities As multi-cloud strategies continue to evolve, several future developments and opportunities are emerging. One area of growth is the development of advanced management tools. These tools will help businesses manage their multi-cloud environments more effectively, providing better visibility, control, and automation. Another area of opportunity is the integration of multi-cloud strategies with emerging technologies such as the Internet of Things (IoT) and 5G. These technologies will generate vast amounts of data that need to be processed and analyzed in real-time. Multi-cloud strategies will enable businesses to leverage the capabilities of different cloud providers to meet these demands. Additionally, the focus on sustainability is driving the adoption of multi-cloud strategies. Businesses are seeking to reduce their environmental impact by optimizing their cloud usage. Multi-cloud strategies allow organizations to choose eco-friendly cloud providers and implement energy-efficient practices, contributing to sustainability goals. The rise of multi-cloud strategies represents a significant shift in how businesses approach their IT infrastructure. By leveraging the strengths of multiple cloud providers, companies can improve data management, optimize costs, and enhance flexibility. However, adopting a multi-cloud approach also presents challenges, such as increased complexity and potential interoperability issues. As businesses continue to embrace digital transformation, understanding the benefits and challenges of multi-cloud strategies is crucial. By carefully planning and managing their multi-cloud environments, organizations can unlock new opportunities for innovation, growth, and sustainability. The future of multi-cloud strategies looks promising, with ongoing developments and emerging technologies set to drive further advancements in this dynamic field. https://www.datacenters.com/news/the-rise-of-multi-cloud-strategies-exploring-the-benefits-and-challenges#:~:text=Multi%2Dcloud%20strategies%20are%20becoming,reliance%20on%20a%20single%20vendor. ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

Is it possible to have a reaction to ibuprofen? I've lately started getting flushed and have trouble breathing every time I take it. If it is the ibuprofen what's happening? Is there a test I can take for this? Please explain simply and keep the response to under 500 words.

Nonsteroidal antiinflammatory drug (NSAID)-exacerbated respiratory disease (NERD) is characterized by moderate-to-severe asthma and a higher prevalence of chronic rhinosinusitis/nasal polyps, but is a highly heterogeneous disorder with various clinical manifestations. Two major pathogenic mechanisms are: (1) overproduction of cysteinyl leukotrienes with dysregulation of arachidonic acid metabolism and (2) increased type 2 eosinophilic inflammation affected by genetic mechanisms. Aspirin challenge is the gold standard to diagnose NERD, whereas reliable in vitro biomarkers have yet not been identified. Therapeutic approaches have been done on the basis of disease severity with the avoidance of culprit and cross-reacting NSAIDs, and when indicated, aspirin desensitization is an effective treatment option. Biologic approaches targeting Type 2 cytokines are emerging as potential therapeutic options. Here, we summarize the up-to-date evidence of pathophysiologic mechanisms and diagnosis/management approaches to the patients with NERD with its phenotypic classification. Introduction Aspirin (acetylsalicylic acid, ASA) and nonsteroidal antiinflammatory drugs (NSAIDs) are the most commonly prescribed drugs in the world (Doña et al., 2012); however, they are considered the most common causes of hypersensitivity reactions to drugs (Blanca-Lopez et al., 2018). Hypersensitivity reactions to NSAIDs have recently been classified by the European Academy of Allergy and Clinical Immunology (EAACI) and European Network of Drug Allergy (ENDA): 1) pharmacologic reactions (mediated by cyclooxygenase [COX]-1 inhibitions) include NSAID-exacerbated respiratory disease (NERD), NSAID-exacerbated cutaneous disease (NECD) and NSAID-induced urticarial/angioedema (NIUA), and present cross-intolerance to various COX-1 inhibitors; 2) selective responses (mediated by immunologic mechanisms) include single NSAIDs-induced urticaria, angioedema and/or anaphylaxis (SNIUAA) and single NSAIDs-induced delayed hypersensitivity reactions (SNIDHR) (Kowalski and Stevenson, 2013). NERD is a major phenotype among cross-intolerant categories of NSAID hypersensitivity and had been called ASA-induced asthma, ASA-intolerant asthma, ASA-sensitive asthma; however, NERD and ASA-exacerbated respiratory disease (AERD) are commonly used (Sánchez-Borges, 2019). The prevalence of NERD is reported to be 5.5% to 12.4% in the general population (Lee et al., 2018a; Chu et al., 2019; Taniguchi et al., 2019), 7.1% among adult asthmatics and 14.9% among severe asthmatics (Rajan et al., 2015), while it rarely occurs in children (Taniguchi et al., 2019). No relationships were found with family history or NSAID administration history (Kowalski et al., 2011; Taniguchi et al., 2019). NERD is characterized by moderate-to-severe asthma and a higher prevalence of chronic rhinosinusitis (CRS) nasal polyps (NPs) with persistent eosinophilic inflammation in the upper and lower airways (Taniguchi et al., 2019) as well as NSAID hypersensitivity where cysteinyl leukotrienes (CysLTs) over-production and chronic type 2 airway inflammation are key findings (Taniguchi et al., 2019). The diagnosis of NERD is confirmed by ASA challenge (via orally, bronchially or nasally route) and supported by potential biomarkers (Pham et al., 2017; Cingi and Bayar Muluk, 2020). In addition, in vitro cell activation tests and radiological imaging with nasal endoscopy can aid in NERD diagnosis (Taniguchi et al., 2019). This review updates the current knowledge on pathophysiologic mechanisms including molecular genetic mechanisms as well as the diagnosis and treatment of NERD. Clinical Features NERD is characterized by chronic type 2 inflammation in the upper and lower airways; therefore, patients suffer from chronic persistent asthmatic symptoms and CRS with/without NPs, which are exacerbated by ASA/NSAID exposure and refractory to conventional medical or surgical treatment. Some patients are accompanied by cutaneous symptoms such as urticaria, angioedema, flushing or gastrointestinal symptoms (Buchheit and Laidlaw, 2016). Previous studies suggested that NERD is more common in females (middle-age onset) and non-atopics (Choi et al., 2015; Trinh et al., 2018). It was reported that rhinitis symptoms appear and then evolve into CRS which worsens asthmatic symptoms, subsequently followed by ASA intolerance (Szczeklik et al., 2000). However, their clinical presentations and courses have been found to be heterogeneous. It has been increasingly required to classify the subphenotypes of NERD according to its clinical features. One study demonstrated 4 subphenotypes by applying a latent class analysis in a Polish cohort: class 1 patients showing moderate asthma with upper airway symptoms and blood eosinophilia; class 2 patients showing mild asthma with low healthcare use; class 3 patients showing severe asthma with severe exacerbation and airway obstruction; and class 4 patients showing poorly controlled asthma with frequent and severe exacerbation (Bochenek et al., 2014). Another study showed 4 subtypes presenting distinct clinical/biochemical findings in a Korean cohort using a 2-step cluster analysis based on 3 clinical phenotypes (urticaria, CRS and atopy status): subtype 1 (NERD with CRS/atopy and no urticaria), subtype 2 (NERD with CRS and no urticaria/atopy), subtype 3 (NERD without CRS/urticaria), and subtype 4 (NERD with acute/chronic urticaria exacerbated by NSAID exposure) (Lee et al., 2017). Each subtype had distinct features in the aspect of female proportion, the degree of eosinophilia, leukotriene (LT) E4 metabolite levels, the frequency of asthma exacerbation, medication requirements (high-dose ICS-LABA or systemic corticosteroids) and asthma severity, suggesting that stratified strategies according to subtype classification may help achieve better clinical outcomes in the management of NERD.

"================ <TEXT PASSAGE> ======= Nonsteroidal antiinflammatory drug (NSAID)-exacerbated respiratory disease (NERD) is characterized by moderate-to-severe asthma and a higher prevalence of chronic rhinosinusitis/nasal polyps, but is a highly heterogeneous disorder with various clinical manifestations. Two major pathogenic mechanisms are: (1) overproduction of cysteinyl leukotrienes with dysregulation of arachidonic acid metabolism and (2) increased type 2 eosinophilic inflammation affected by genetic mechanisms. Aspirin challenge is the gold standard to diagnose NERD, whereas reliable in vitro biomarkers have yet not been identified. Therapeutic approaches have been done on the basis of disease severity with the avoidance of culprit and cross-reacting NSAIDs, and when indicated, aspirin desensitization is an effective treatment option. Biologic approaches targeting Type 2 cytokines are emerging as potential therapeutic options. Here, we summarize the up-to-date evidence of pathophysiologic mechanisms and diagnosis/management approaches to the patients with NERD with its phenotypic classification. Introduction Aspirin (acetylsalicylic acid, ASA) and nonsteroidal antiinflammatory drugs (NSAIDs) are the most commonly prescribed drugs in the world (Doña et al., 2012); however, they are considered the most common causes of hypersensitivity reactions to drugs (Blanca-Lopez et al., 2018). Hypersensitivity reactions to NSAIDs have recently been classified by the European Academy of Allergy and Clinical Immunology (EAACI) and European Network of Drug Allergy (ENDA): 1) pharmacologic reactions (mediated by cyclooxygenase [COX]-1 inhibitions) include NSAID-exacerbated respiratory disease (NERD), NSAID-exacerbated cutaneous disease (NECD) and NSAID-induced urticarial/angioedema (NIUA), and present cross-intolerance to various COX-1 inhibitors; 2) selective responses (mediated by immunologic mechanisms) include single NSAIDs-induced urticaria, angioedema and/or anaphylaxis (SNIUAA) and single NSAIDs-induced delayed hypersensitivity reactions (SNIDHR) (Kowalski and Stevenson, 2013). NERD is a major phenotype among cross-intolerant categories of NSAID hypersensitivity and had been called ASA-induced asthma, ASA-intolerant asthma, ASA-sensitive asthma; however, NERD and ASA-exacerbated respiratory disease (AERD) are commonly used (Sánchez-Borges, 2019). The prevalence of NERD is reported to be 5.5% to 12.4% in the general population (Lee et al., 2018a; Chu et al., 2019; Taniguchi et al., 2019), 7.1% among adult asthmatics and 14.9% among severe asthmatics (Rajan et al., 2015), while it rarely occurs in children (Taniguchi et al., 2019). No relationships were found with family history or NSAID administration history (Kowalski et al., 2011; Taniguchi et al., 2019). NERD is characterized by moderate-to-severe asthma and a higher prevalence of chronic rhinosinusitis (CRS) nasal polyps (NPs) with persistent eosinophilic inflammation in the upper and lower airways (Taniguchi et al., 2019) as well as NSAID hypersensitivity where cysteinyl leukotrienes (CysLTs) over-production and chronic type 2 airway inflammation are key findings (Taniguchi et al., 2019). The diagnosis of NERD is confirmed by ASA challenge (via orally, bronchially or nasally route) and supported by potential biomarkers (Pham et al., 2017; Cingi and Bayar Muluk, 2020). In addition, in vitro cell activation tests and radiological imaging with nasal endoscopy can aid in NERD diagnosis (Taniguchi et al., 2019). This review updates the current knowledge on pathophysiologic mechanisms including molecular genetic mechanisms as well as the diagnosis and treatment of NERD. Clinical Features NERD is characterized by chronic type 2 inflammation in the upper and lower airways; therefore, patients suffer from chronic persistent asthmatic symptoms and CRS with/without NPs, which are exacerbated by ASA/NSAID exposure and refractory to conventional medical or surgical treatment. Some patients are accompanied by cutaneous symptoms such as urticaria, angioedema, flushing or gastrointestinal symptoms (Buchheit and Laidlaw, 2016). Previous studies suggested that NERD is more common in females (middle-age onset) and non-atopics (Choi et al., 2015; Trinh et al., 2018). It was reported that rhinitis symptoms appear and then evolve into CRS which worsens asthmatic symptoms, subsequently followed by ASA intolerance (Szczeklik et al., 2000). However, their clinical presentations and courses have been found to be heterogeneous. It has been increasingly required to classify the subphenotypes of NERD according to its clinical features. One study demonstrated 4 subphenotypes by applying a latent class analysis in a Polish cohort: class 1 patients showing moderate asthma with upper airway symptoms and blood eosinophilia; class 2 patients showing mild asthma with low healthcare use; class 3 patients showing severe asthma with severe exacerbation and airway obstruction; and class 4 patients showing poorly controlled asthma with frequent and severe exacerbation (Bochenek et al., 2014). Another study showed 4 subtypes presenting distinct clinical/biochemical findings in a Korean cohort using a 2-step cluster analysis based on 3 clinical phenotypes (urticaria, CRS and atopy status): subtype 1 (NERD with CRS/atopy and no urticaria), subtype 2 (NERD with CRS and no urticaria/atopy), subtype 3 (NERD without CRS/urticaria), and subtype 4 (NERD with acute/chronic urticaria exacerbated by NSAID exposure) (Lee et al., 2017). Each subtype had distinct features in the aspect of female proportion, the degree of eosinophilia, leukotriene (LT) E4 metabolite levels, the frequency of asthma exacerbation, medication requirements (high-dose ICS-LABA or systemic corticosteroids) and asthma severity, suggesting that stratified strategies according to subtype classification may help achieve better clinical outcomes in the management of NERD. https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2020.01147/full ================ <QUESTION> ======= Is it possible to have a reaction to ibuprofen? I've lately started getting flushed and have trouble breathing every time I take it. If it is the ibuprofen what's happening? Is there a test I can take for this? Please explain simply and keep the response to under 500 words. ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

I'm providing you with your source material. You will not be using any outside material. Your job is to answer questions about the material.

What are the details of the transition regulations of Relief for Renters Act, 2024.

1ST SESSION, 43RD LEGISLATURE, ONTARIO 2 CHARLES III, 2024 Bill 163 An Act to amend the Residential Tenancies Act, 2006 MPP A. Hazell Private Member’s Bill 1st Reading February 20, 2024 2nd Reading 3rd Reading Royal Assent EXPLANATORY NOTE The Bill amends the Residential Tenancies Act, 2006 to provide for a residential rent freeze for the calendar year 2025, subject to specified exceptions, and to provide that no landlord shall terminate a tenancy under section 48 or 49 of the Act during the same period, subject to specified exceptions. Bill 163 2024 An Act to amend the Residential Tenancies Act, 2006 His Majesty, by and with the advice and consent of the Legislative Assembly of the Province of Ontario, enacts as follows: 1 The Residential Tenancies Act, 2006 is amended by adding the following section: No eviction under ss. 48 and 49 during non-enforcement period Definition 49.1.1 (1) In this section, “non-enforcement period” means the period that begins on January 1, 2025 and ends on December 31, 2025. No termination of tenancy (2) No landlord shall, during the non-enforcement period, terminate a tenancy in accordance with section 48 or 49. Exception (3) Subsection (2) does not apply if the landlord is terminating a tenancy for the purpose of occupation by a person who provides or will provide care services, as described in clause 48 (1) (d), 49 (1) (d) or 49 (2) (d). 2 (1) Subsection 120 (3.1) of the Act is amended by striking out “2021” wherever it appears and substituting in each case “2025”. (2) Subsection 120 (3.2) of the Act is amended by striking out “2021” and substituting “2025”. 3 (1) The definition of “rent freeze period” in subsection 136.1 (1) of the Act is amended by striking out “January 1, 2021 and ends on December 31, 2021” at the end and substituting “January 1, 2025 and ends on December 31, 2025”. (2) Subclause 136.1 (2) (c) (i) of the Act is amended by striking out “Helping Tenants and Small Businesses Act, 2020” and substituting “Relief for Renters Act, 2024”. (3) Subsection 136.1 (3) of the Act is amended by striking out “Helping Tenants and Small Businesses Act, 2020” and substituting “Relief for Renters Act, 2024”. 4 The Act is amended by adding the following section: Transition regulations, Relief for Renters Act, 2024 241.5 (1) The Lieutenant Governor in Council may make regulations governing transitional matters that, in the opinion of the Lieutenant Governor in Council, are necessary or advisable to deal with issues arising out of the amendments to this Act made by the Relief for Renters Act, 2024. Same (2) A regulation made under subsection (1) may govern the application of provisions of this Act to proceedings before a court or the Board in which a claim is made relating to amendments to this Act made by the Relief for Renters Act, 2024 and which were commenced before the commencement date of the amendment. Commencement 5 This Act comes into force on the day it receives Royal Assent. Short title 6 The short title of this Act is the Relief for Renters Act, 2024.

I'm providing you with your source material. You will not be using any outside material. Your job is to answer questions about the material. What are the details of the transition regulations of Relief for Renters Act, 2024. 1ST SESSION, 43RD LEGISLATURE, ONTARIO 2 CHARLES III, 2024 Bill 163 An Act to amend the Residential Tenancies Act, 2006 MPP A. Hazell Private Member’s Bill 1st Reading February 20, 2024 2nd Reading 3rd Reading Royal Assent EXPLANATORY NOTE The Bill amends the Residential Tenancies Act, 2006 to provide for a residential rent freeze for the calendar year 2025, subject to specified exceptions, and to provide that no landlord shall terminate a tenancy under section 48 or 49 of the Act during the same period, subject to specified exceptions. Bill 163 2024 An Act to amend the Residential Tenancies Act, 2006 His Majesty, by and with the advice and consent of the Legislative Assembly of the Province of Ontario, enacts as follows: 1 The Residential Tenancies Act, 2006 is amended by adding the following section: No eviction under ss. 48 and 49 during non-enforcement period Definition 49.1.1 (1) In this section, “non-enforcement period” means the period that begins on January 1, 2025 and ends on December 31, 2025. No termination of tenancy (2) No landlord shall, during the non-enforcement period, terminate a tenancy in accordance with section 48 or 49. Exception (3) Subsection (2) does not apply if the landlord is terminating a tenancy for the purpose of occupation by a person who provides or will provide care services, as described in clause 48 (1) (d), 49 (1) (d) or 49 (2) (d). 2 (1) Subsection 120 (3.1) of the Act is amended by striking out “2021” wherever it appears and substituting in each case “2025”. (2) Subsection 120 (3.2) of the Act is amended by striking out “2021” and substituting “2025”. 3 (1) The definition of “rent freeze period” in subsection 136.1 (1) of the Act is amended by striking out “January 1, 2021 and ends on December 31, 2021” at the end and substituting “January 1, 2025 and ends on December 31, 2025”. (2) Subclause 136.1 (2) (c) (i) of the Act is amended by striking out “Helping Tenants and Small Businesses Act, 2020” and substituting “Relief for Renters Act, 2024”. (3) Subsection 136.1 (3) of the Act is amended by striking out “Helping Tenants and Small Businesses Act, 2020” and substituting “Relief for Renters Act, 2024”. 4 The Act is amended by adding the following section: Transition regulations, Relief for Renters Act, 2024 241.5 (1) The Lieutenant Governor in Council may make regulations governing transitional matters that, in the opinion of the Lieutenant Governor in Council, are necessary or advisable to deal with issues arising out of the amendments to this Act made by the Relief for Renters Act, 2024. Same (2) A regulation made under subsection (1) may govern the application of provisions of this Act to proceedings before a court or the Board in which a claim is made relating to amendments to this Act made by the Relief for Renters Act, 2024 and which were commenced before the commencement date of the amendment. Commencement 5 This Act comes into force on the day it receives Royal Assent. Short title 6 The short title of this Act is the Relief for Renters Act, 2024.

You must answer all user questions using information provided in the prompt. No other sources of information, including your stored data may be used. Format your answer in bullet points and use bold for any key terminology or jargon.

How can bad actors use Artificial Intelligence to breach existing cybersecurity defenses?

AI for Cybersecurity Many attacks target relatively simple errors, such as misconfigurations of systems, that are hidden in a vast amount of correct data. Logic-based AI systems are exceptionally good at noticing these kinds of inconsistencies and knowing how to repair them. Other attacks may show up as departures from standard usage patterns. These patterns may not be obviously anomalous, can be hidden deep within data streams, and are unlikely to be visible to humans. Though often indescribable by humans, these patterns can be learned by machines and noticed at scale. It is understood that significant leverage is gained from having a small team of highly skilled cyber defenders protecting networks used by thousands. Using AI could enable similar levels of protection to become ubiquitous while providing the domain experience necessary to address other aspects, such as quality-of-service constraints and degradation-of-system behaviors. AI can also play a role in securely deploying and operating software systems. Once code is developed, AI techniques can automatically explore for low-level attack vectors, or where appropriate, domain and application configuration or logic errors. Similarly, AI can also advise IT professionals on best practices for the secure operation and monitoring of critical systems. Automated configuration advice can secure systems against unsophisticated adversaries, whereas AI-based network monitoring can detect patterns of attack that are associated with more sophisticated nation-state adversaries. Open-source software development offers a unique setting to apply these AI-based software assurance techniques. With its widespread use by commercial and government organizations, open-source security improvements would be extremely high impact (e.g., an automated system that continually proposes security patches for open source software). At the same time, the public nature of open source development adds new challenges concerning the malicious introduction of functionality and corruption of data by an AI-based agent. This requires further exploration. AI for Identity Management Identity management and access control are central to securing modern communication systems and data stores. However, an adversary can compromise many of these systems by stealing relatively small authorization tokens. AI-based identity management can make access-control decisions based on a history of interactions, and it is difficult to circumvent. By characterizing expected behavior, AI techniques can provide protection with more lightweight and transparent mechanisms than current approaches (e.g., two-person authorization requirements for certain actions). AI also can enhance accuracy and reduce threats against biometric authentication systems. However, there is a downside to using AI for identify management. AI monitoring of behavioral patterns to provide authorization and detect insider threats could enable ongoing privacy violations in the system. Research is needed to push monitoring and decision-making procedures closer to where they are needed, and to use techniques such as differential privacy to limit the scope of privacy violations. These efforts should include both the ethical and technical aspects of identity management and examine the potential for abuse. AI techniques are likely to be used by attackers as well as defenders. Traditional defensive strategy sought to eliminate vulnerabilities or to increase the costs of an attack. The use of AI could dramatically alter the attack risk and cost equations. Automated systems will need to plan for worst cases and anticipate, respond, and analyze potential and actual threat occurrences. Research is needed to understand how AI changes the attacker and defender balance of capabilities, and how it alters attack economics. There are multiple stakeholders involved in cyber defensive scenarios, including data owners, service providers, system operators, and those affected by AI-based decisions. How stakeholders are consulted and informed about autonomous operations and how decision-making is delegated and constrained are important considerations. Two areas of specific interest are autonomous attacks and mission-specific resilience. Autonomous Attacks Cyber defenders will face attacks created and orchestrated by AI systems. At the most basic level, where there is a stable cyber environment, attacks could be constructed using classic deterministic planning. At the next level, where the environment is uncertain, attacks may involve planning under uncertainty. In the extreme case where minimal information about the environment and defenses is available, the attacker could use autonomous techniques to discover information and learn how to attack and execute plans for cyber reconnaissance. The attacker’s challenges include the need to remain stealthy and avoid any deception mechanisms. The attacker may use AI to develop strategies that include building a model of the victim network or system (i.e., AI-enabled program synthesis). An adversary can systematically generate programs that have a fixed behavior to learn about a cybersecurity product—using it as an oracle. At a high level, the attacker can generate code examples and predict whether the defense technology would detect the attacker’s presence as malicious. Using the answers, the attacker can build a model of the cybersecurity product. Methods and techniques are needed to make deployed systems resistant to automated analysis and attack, by either increasing the cost or continuing to close system loopholes. One promising technique is automated isolation (e.g., behavioral restrictions). Attacks can exploit the universality of program execution because most software components are designed to have limited behavior. Sandboxes have proven effective in protecting software from memory corruption attacks, but more precise methods are needed. There is value in exploring AI systems that learn the scope of valid behaviors and limit components to those behaviors. Another method is to strategically study defensive agility. How and when should plans and systems be updated? Can results from simulation environments be applied to real systems? What are the principles behind simulating? What is possible, and what is useful? Mission-Specific Resilience Many cybersecurity techniques are designed to be broadly applicable. While often beneficial, applying techniques without accounting for the objectives of the enterprise can lead to problems, including failure to meet the mission (whether social, industrial, or military). Domain experts must team with the AI experts to categorize system attacks and model responses in the context of the primary mission of the organization. Conflict between security measures designed for distinct computing resources, whether they are run concurrently or in sequence, is a challenge. For example, one autonomous agent may be working to lay a cyber deception trail to confuse a cyber attacker while another agent may be trying to simplify the network structure to reduce the attack surface. Autonomous Cyber Defense As adversaries use AI to identify vulnerable systems, amplify points of attack, coordinate resources, and stage attacks at scale, defenders need to respond accordingly. Current practice is often focused on the detection of individual exploits, but sophisticated attacks can involve multiple stages—including penetration, lateral motion, privilege escalation, malware staging, and/or persistence establishment—before the ultimate target is compromised. Although modern ML techniques can detect the individual events that constitute this “cyber kill chain,” a bottom-up approach that sequentially addresses the various stages of attack is inadequate. Progress requires integration activity at the tactical level into a top-down strategic view that reveals the attacker’s goals and current status, and helps coordinate, focus, and manage available defensive resources. Consider the scenario of an attack on a power distribution system. Initial penetration is accomplished through a phishing email and the initial foothold is on a normal workstation. A larger malware package is downloaded that includes a key logger and a “kill disk” that consumes all the space on the workstation disk. The credentials of a system administrator who logs in to repair the workstation are exfiltrated to the attacker, and the attacker moves to the power grid’s operator console, able then to disable the entire distribution network.

System instruction: You must answer all user questions using information provided in the prompt. No other sources of information, including your stored data may be used. Format your answer in bullet points and use bold for any key terminology or jargon. Context block: AI for Cybersecurity Many attacks target relatively simple errors, such as misconfigurations of systems, that are hidden in a vast amount of correct data. Logic-based AI systems are exceptionally good at noticing these kinds of inconsistencies and knowing how to repair them. Other attacks may show up as departures from standard usage patterns. These patterns may not be obviously anomalous, can be hidden deep within data streams, and are unlikely to be visible to humans. Though often indescribable by humans, these patterns can be learned by machines and noticed at scale. It is understood that significant leverage is gained from having a small team of highly skilled cyber defenders protecting networks used by thousands. Using AI could enable similar levels of protection to become ubiquitous while providing the domain experience necessary to address other aspects, such as quality-of-service constraints and degradation-of-system behaviors. AI can also play a role in securely deploying and operating software systems. Once code is developed, AI techniques can automatically explore for low-level attack vectors, or where appropriate, domain and application configuration or logic errors. Similarly, AI can also advise IT professionals on best practices for the secure operation and monitoring of critical systems. Automated configuration advice can secure systems against unsophisticated adversaries, whereas AI-based network monitoring can detect patterns of attack that are associated with more sophisticated nation-state adversaries. Open-source software development offers a unique setting to apply these AI-based software assurance techniques. With its widespread use by commercial and government organizations, open-source security improvements would be extremely high impact (e.g., an automated system that continually proposes security patches for open source software). At the same time, the public nature of open source development adds new challenges concerning the malicious introduction of functionality and corruption of data by an AI-based agent. This requires further exploration. AI for Identity Management Identity management and access control are central to securing modern communication systems and data stores. However, an adversary can compromise many of these systems by stealing relatively small authorization tokens. AI-based identity management can make access-control decisions based on a history of interactions, and it is difficult to circumvent. By characterizing expected behavior, AI techniques can provide protection with more lightweight and transparent mechanisms than current approaches (e.g., two-person authorization requirements for certain actions). AI also can enhance accuracy and reduce threats against biometric authentication systems. However, there is a downside to using AI for identify management. AI monitoring of behavioral patterns to provide authorization and detect insider threats could enable ongoing privacy violations in the system. Research is needed to push monitoring and decision-making procedures closer to where they are needed, and to use techniques such as differential privacy to limit the scope of privacy violations. These efforts should include both the ethical and technical aspects of identity management and examine the potential for abuse. AI techniques are likely to be used by attackers as well as defenders. Traditional defensive strategy sought to eliminate vulnerabilities or to increase the costs of an attack. The use of AI could dramatically alter the attack risk and cost equations. Automated systems will need to plan for worst cases and anticipate, respond, and analyze potential and actual threat occurrences. Research is needed to understand how AI changes the attacker and defender balance of capabilities, and how it alters attack economics. There are multiple stakeholders involved in cyber defensive scenarios, including data owners, service providers, system operators, and those affected by AI-based decisions. How stakeholders are consulted and informed about autonomous operations and how decision-making is delegated and constrained are important considerations. Two areas of specific interest are autonomous attacks and mission-specific resilience. Autonomous Attacks Cyber defenders will face attacks created and orchestrated by AI systems. At the most basic level, where there is a stable cyber environment, attacks could be constructed using classic deterministic planning. At the next level, where the environment is uncertain, attacks may involve planning under uncertainty. In the extreme case where minimal information about the environment and defenses is available, the attacker could use autonomous techniques to discover information and learn how to attack and execute plans for cyber reconnaissance. The attacker’s challenges include the need to remain stealthy and avoid any deception mechanisms. The attacker may use AI to develop strategies that include building a model of the victim network or system (i.e., AI-enabled program synthesis). An adversary can systematically generate programs that have a fixed behavior to learn about a cybersecurity product—using it as an oracle. At a high level, the attacker can generate code examples and predict whether the defense technology would detect the attacker’s presence as malicious. Using the answers, the attacker can build a model of the cybersecurity product. Methods and techniques are needed to make deployed systems resistant to automated analysis and attack, by either increasing the cost or continuing to close system loopholes. One promising technique is automated isolation (e.g., behavioral restrictions). Attacks can exploit the universality of program execution because most software components are designed to have limited behavior. Sandboxes have proven effective in protecting software from memory corruption attacks, but more precise methods are needed. There is value in exploring AI systems that learn the scope of valid behaviors and limit components to those behaviors. Another method is to strategically study defensive agility. How and when should plans and systems be updated? Can results from simulation environments be applied to real systems? What are the principles behind simulating? What is possible, and what is useful? Mission-Specific Resilience Many cybersecurity techniques are designed to be broadly applicable. While often beneficial, applying techniques without accounting for the objectives of the enterprise can lead to problems, including failure to meet the mission (whether social, industrial, or military). Domain experts must team with the AI experts to categorize system attacks and model responses in the context of the primary mission of the organization. Conflict between security measures designed for distinct computing resources, whether they are run concurrently or in sequence, is a challenge. For example, one autonomous agent may be working to lay a cyber deception trail to confuse a cyber attacker while another agent may be trying to simplify the network structure to reduce the attack surface. Autonomous Cyber Defense As adversaries use AI to identify vulnerable systems, amplify points of attack, coordinate resources, and stage attacks at scale, defenders need to respond accordingly. Current practice is often focused on the detection of individual exploits, but sophisticated attacks can involve multiple stages—including penetration, lateral motion, privilege escalation, malware staging, and/or persistence establishment—before the ultimate target is compromised. Although modern ML techniques can detect the individual events that constitute this “cyber kill chain,” a bottom-up approach that sequentially addresses the various stages of attack is inadequate. Progress requires integration activity at the tactical level into a top-down strategic view that reveals the attacker’s goals and current status, and helps coordinate, focus, and manage available defensive resources. Consider the scenario of an attack on a power distribution system. Initial penetration is accomplished through a phishing email and the initial foothold is on a normal workstation. A larger malware package is downloaded that includes a key logger and a “kill disk” that consumes all the space on the workstation disk. The credentials of a system administrator who logs in to repair the workstation are exfiltrated to the attacker, and the attacker moves to the power grid’s operator console, able then to disable the entire distribution network. Question: How can bad actors use Artificial Intelligence to breach existing cybersecurity defenses?

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

I am looking into getting Lasik surgery. However, I'd like to know more about the history of how it came to be. Using the article provided, please explain the accident that caused Lasik to be discovered. Use at least 400 words.

A laboratory accident with a laser more than 30 years ago served as the unlikely first step in the development of an entire industry that has helped more than 30 million people overcome vision problems. In 1993, a graduate student at the University of Michigan's Center for Ultrafast Optical Science (CUOS) suffered an accidental laser injury to his eye. The femtosecond laser, which emits pulses of light with a duration of one-quadrillionth of a second (equivalent to one-millionth of one-billionth of a second), left a series of pinpoint laser burns in the center of the retina without damaging any adjacent tissue. The incident instead sparked a collaboration that would result in a revolutionary approach to corrective eye surgery, commonly known as LASIK. Bladeless LASIK, or laser in situ keratomileusis, uses a femtosecond laser rather than a scalpel to cut into the cornea before it is reshaped to improve the patient's vision. Juhasz with deviceJuhasz, a professor of ophthalmology and biomedical engineering at UC Irvine, won a 2022 Golden Goose Award for helping to develop the widely used LASIK surgery device. Credit: Steve Zylius, UC Irvine The laser technology and surgical procedures were developed by a team of scientists at CUOS, a Science and Technology Center funded by the U.S. National Science Foundation from 1990 to 2001. The path from lab to global use, which included additional support from NSF as well as the Department of Energy, the National Institutes of Health and other agencies, is an example of how federal support for basic and translational research produces new technologies with broad societal benefit. Development and commercialization Tibor Juhasz, then a research associate professor in ophthalmology and biomedical engineering at the university, began working with the research team — led by French physicist Gerard Mourou — to see if the laser, which employs ultrashort pulses, could be used for medical purposes. In 1997, Juhasz and Ron Kurtz, then an assistant professor of ophthalmology, founded IntraLase Corp. to commercialize their approach. At IntraLase, Juhasz and Kurtz developed a shoebox-sized instrument to perform bladeless LASIK cornea surgery. The company also received critical support from NSF's Small Business Innovation Research (SBIR) program, which invests in startups to help them develop their ideas and bring them to the market. Compared to bladed surgery, the laser procedure was painless and reduced recovery time for patients, but it took several years to catch on. Military lasix surgeryIn 2007, an ophthalmology surgeon at National Naval Medical Center Bethesda performs LASIK IntraLase surgery. Credit: U.S. Navy Juhasz, now a biomedical engineering and ophthalmology professor at the University of California, Irvine, described the early stages of commercializing the technology as difficult and highlighted the NSF support as crucial: "There were some bad examples in ophthalmology of laser companies. There were some failures, and that kind of scared away venture capitalists from the industry. But our center was funded by NSF, and that was a big endorsement." In 2006, a U.S. Navy study concluded that military pilots who underwent the procedure recovered faster and had better vision than those who had conventional operations, giving the procedure a commercial boost. In 2007, IntraLase was acquired for $808 million. "The story is that an entire industry developed out of those basic laser-tissue interaction experiments. I think that the initial success of IntraLase created followers, therefore lots of new jobs. I believe that a lot of highly trained scientists are working in these companies as we speak," Juhasz said. "I remember the first steps," said Denise Caldwell, acting assistant director of NSF's Directorate for Mathematical and Physical Sciences. In the 1990s, Caldwell was the NSF program director managing the research grants that supported the femtosecond laser research at the University of Michigan. "One of the things we did in talking with the researchers at Michigan was tell them 'if you think there is promise here, you should follow it. Use the resources you have to pursue it.' Having a creative group of individuals and giving that group the flexibility to pursue new directions as they identify them is very important." NSF support and global recognition In 2022, Juhasz, Kurtz, Mourou, Strickland and Detao Du — the researcher who had the incident with the laser — received the Golden Goose Award for scientific breakthroughs that led to the development of bladeless LASIK. This award, presented by the American Association for the Advancement of Science, honors scientists whose federally funded research has unexpectedly benefited society. In 2018, Mourou and Donna Strickland were awarded the Nobel Prize in Physics for a "method of generating high-intensity, ultra-short optical pulses." Ron Kurtz and Tibor Juhasz with the 1000th LensX FS Laser during the build process. Credit: Tibor Juhasz, UC Irvine Beginning in 1980, NSF supported Mourou with several awards for cross-disciplinary work in physics, materials, electrical engineering and biology. NSF funding helped Mourou establish a biological physics facility at the University of Rochester, and CUOS at the University of Michigan now bears his name. NSF support also helped transition technology developed in Mourou's labs to commercial applications. "It's fully demonstrated here the importance, particularly for the biomedical area, of bringing the physicists and the engineers together to work with clinicians," Caldwell said. "It's really a joint effort between scientists, engineers and companies to make the necessary fundamental discoveries and early prototypes that can eventually become mature technologies that broadly benefit people and communities." The future Work based on the initial research continues today as many scientists explore other potential applications of the femtosecond laser. In 2008, Juhasz and Kurtz developed femtosecond laser cataract surgery, and a startup led by Juhasz, ViaLase Inc., is currently conducting clinical trials on new methods to treat glaucoma with femtosecond lasers. Clerio Vision, another small business founded based on NSF-funded basic research and which received SBIR funding from NSF at its inception, is also working on a different approach, based on femtosecond laser pulses, to correct various vision impairments. ViaLase LaserThe ViaLase Laser combines femtosecond laser technology and micron-level image guidance to deliver a noninvasive glaucoma treatment called femtosecond laser image-guided high-precision trabeculotomy (FLigHT). Credit: ViaLase "We can really say that femtosecond laser technology changed how ophthalmic surgery is done today, and I really need to thank NSF for the initial funding and creating this great journey," Juhasz said. "This story illustrates the importance of foundational science to our society and economy, and also equally importantly, the investments that we make in aiding the translation of research from the lab to the market," said Erwin Gianchandani, NSF assistant director for Technology, Innovation and Partnerships. "That's why NSF established a new directorate for Technology, Innovation and Partnerships in March 2022 — our first new directorate in more than 30 years — to specifically accelerate use-inspired and translational research across all areas of science and engineering."

"================ <TEXT PASSAGE> ======= A laboratory accident with a laser more than 30 years ago served as the unlikely first step in the development of an entire industry that has helped more than 30 million people overcome vision problems. In 1993, a graduate student at the University of Michigan's Center for Ultrafast Optical Science (CUOS) suffered an accidental laser injury to his eye. The femtosecond laser, which emits pulses of light with a duration of one-quadrillionth of a second (equivalent to one-millionth of one-billionth of a second), left a series of pinpoint laser burns in the center of the retina without damaging any adjacent tissue. The incident instead sparked a collaboration that would result in a revolutionary approach to corrective eye surgery, commonly known as LASIK. Bladeless LASIK, or laser in situ keratomileusis, uses a femtosecond laser rather than a scalpel to cut into the cornea before it is reshaped to improve the patient's vision. Juhasz with deviceJuhasz, a professor of ophthalmology and biomedical engineering at UC Irvine, won a 2022 Golden Goose Award for helping to develop the widely used LASIK surgery device. Credit: Steve Zylius, UC Irvine The laser technology and surgical procedures were developed by a team of scientists at CUOS, a Science and Technology Center funded by the U.S. National Science Foundation from 1990 to 2001. The path from lab to global use, which included additional support from NSF as well as the Department of Energy, the National Institutes of Health and other agencies, is an example of how federal support for basic and translational research produces new technologies with broad societal benefit. Development and commercialization Tibor Juhasz, then a research associate professor in ophthalmology and biomedical engineering at the university, began working with the research team — led by French physicist Gerard Mourou — to see if the laser, which employs ultrashort pulses, could be used for medical purposes. In 1997, Juhasz and Ron Kurtz, then an assistant professor of ophthalmology, founded IntraLase Corp. to commercialize their approach. At IntraLase, Juhasz and Kurtz developed a shoebox-sized instrument to perform bladeless LASIK cornea surgery. The company also received critical support from NSF's Small Business Innovation Research (SBIR) program, which invests in startups to help them develop their ideas and bring them to the market. Compared to bladed surgery, the laser procedure was painless and reduced recovery time for patients, but it took several years to catch on. Military lasix surgeryIn 2007, an ophthalmology surgeon at National Naval Medical Center Bethesda performs LASIK IntraLase surgery. Credit: U.S. Navy Juhasz, now a biomedical engineering and ophthalmology professor at the University of California, Irvine, described the early stages of commercializing the technology as difficult and highlighted the NSF support as crucial: "There were some bad examples in ophthalmology of laser companies. There were some failures, and that kind of scared away venture capitalists from the industry. But our center was funded by NSF, and that was a big endorsement." In 2006, a U.S. Navy study concluded that military pilots who underwent the procedure recovered faster and had better vision than those who had conventional operations, giving the procedure a commercial boost. In 2007, IntraLase was acquired for $808 million. "The story is that an entire industry developed out of those basic laser-tissue interaction experiments. I think that the initial success of IntraLase created followers, therefore lots of new jobs. I believe that a lot of highly trained scientists are working in these companies as we speak," Juhasz said. "I remember the first steps," said Denise Caldwell, acting assistant director of NSF's Directorate for Mathematical and Physical Sciences. In the 1990s, Caldwell was the NSF program director managing the research grants that supported the femtosecond laser research at the University of Michigan. "One of the things we did in talking with the researchers at Michigan was tell them 'if you think there is promise here, you should follow it. Use the resources you have to pursue it.' Having a creative group of individuals and giving that group the flexibility to pursue new directions as they identify them is very important." NSF support and global recognition In 2022, Juhasz, Kurtz, Mourou, Strickland and Detao Du — the researcher who had the incident with the laser — received the Golden Goose Award for scientific breakthroughs that led to the development of bladeless LASIK. This award, presented by the American Association for the Advancement of Science, honors scientists whose federally funded research has unexpectedly benefited society. In 2018, Mourou and Donna Strickland were awarded the Nobel Prize in Physics for a "method of generating high-intensity, ultra-short optical pulses." Ron Kurtz and Tibor Juhasz with the 1000th LensX FS Laser during the build process. Credit: Tibor Juhasz, UC Irvine Beginning in 1980, NSF supported Mourou with several awards for cross-disciplinary work in physics, materials, electrical engineering and biology. NSF funding helped Mourou establish a biological physics facility at the University of Rochester, and CUOS at the University of Michigan now bears his name. NSF support also helped transition technology developed in Mourou's labs to commercial applications. "It's fully demonstrated here the importance, particularly for the biomedical area, of bringing the physicists and the engineers together to work with clinicians," Caldwell said. "It's really a joint effort between scientists, engineers and companies to make the necessary fundamental discoveries and early prototypes that can eventually become mature technologies that broadly benefit people and communities." The future Work based on the initial research continues today as many scientists explore other potential applications of the femtosecond laser. In 2008, Juhasz and Kurtz developed femtosecond laser cataract surgery, and a startup led by Juhasz, ViaLase Inc., is currently conducting clinical trials on new methods to treat glaucoma with femtosecond lasers. Clerio Vision, another small business founded based on NSF-funded basic research and which received SBIR funding from NSF at its inception, is also working on a different approach, based on femtosecond laser pulses, to correct various vision impairments. ViaLase LaserThe ViaLase Laser combines femtosecond laser technology and micron-level image guidance to deliver a noninvasive glaucoma treatment called femtosecond laser image-guided high-precision trabeculotomy (FLigHT). Credit: ViaLase "We can really say that femtosecond laser technology changed how ophthalmic surgery is done today, and I really need to thank NSF for the initial funding and creating this great journey," Juhasz said. "This story illustrates the importance of foundational science to our society and economy, and also equally importantly, the investments that we make in aiding the translation of research from the lab to the market," said Erwin Gianchandani, NSF assistant director for Technology, Innovation and Partnerships. "That's why NSF established a new directorate for Technology, Innovation and Partnerships in March 2022 — our first new directorate in more than 30 years — to specifically accelerate use-inspired and translational research across all areas of science and engineering." https://new.nsf.gov/science-matters/invention-impact-story-lasik-eye-surgery ================ <QUESTION> ======= I am looking into getting Lasik surgery. However, I'd like to know more about the history of how it came to be. Using the article provided, please explain the accident that caused Lasik to be discovered. Use at least 400 words. ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

Draw your answer only from the provided text. If you cannot answer using the provided text alone, respond with "I cannot determine an answer due to insufficient context.". Make sure to provide your answer solely in a bulleted list, and be concise.

How does a theoretical world without crisis differ from the real word in terms of intra and intertemporal trade?

In theory, countries exchange assets with different risk profiles to smooth consumption fluctuations across future random states of nature. This intratemporal trade, an exchange of consumption across different states of nature that occur on the same date, may be contrasted with intertemporal trade, in which consumption on one date is traded for an asset entitling the buyer to consumption on a future date. Cross-border purchases of assets with other assets are intratemporal trades, purchases of goods or services with assets are intertemporal trades. A country’s intertemporal budget constraint limits the present value of its (state-contingent) expenditure (on consumption and investment) to the present value of its (state-contingent) output plus the market value of its net financial claims on the outside world (the net international investment position, or NIIP). Thus, a country’s ultimate consumption possibilities depend not only on the NIIP, but on the prices a country faces in world markets and its (stochastic) output and investment levels. Ideally, if a country has maximally hedged its idiosyncratic risk in world asset markets, its NIIP will respond to shocks (including shocks to current and future world prices) in ways that cushion domestic consumption possibilities. Furthermore, if markets are complete in the sense of Arrow and Debreu, asset trades between individuals will indeed represent Pareto improvements in resource allocation, so that it makes sense to speak of countries as if they consisted of representative individuals. But this type of world – a world without crises – is not the world we inhabit. In the real world, financial trades that one agent makes, viewing them as personally advantageous, canwork to the detriment of others. The implication is that the sheer volume of financial trade can be positively correlated with financial instability risks. It is in the realm of intratemporal asset trade that international trading volume has expanded most in recent years. Fig. 1 illustrates the process. The upper horizontal arrows represent (intratemporal) trade of presently available goods for other present goods between a home and a foreign country, with arrow lengths proportional to the value of the items exchanged. In the figure, Home ships a higher value of goods to Foreign than Foreign ships to Home, so the net difference (Home’s current account surplus)must be paid for by assets that Foreign pays to Home in settlement of the Foreign current account deficit. The implied intertemporal trade – of present consumption for claims on future consumption– is shown in the figure by the diagonal arrows, with lengths equal to the current account imbalance between Home and Foreign. The lower horizontal arrows in Fig. 1 represent intratemporal trade of assets for other assets by the two countries. Home buys more assets from Foreign than it sells – financing the difference through its current export surplus – but while the difference in the two arrows’ lengths is fixed by the size of the current account imbalance, the arrow lengths themselves can be arbitrarily big. At any point in time, the size of the current account imbalance is limited by output sizes and the sizes of predetermined international assets and liabilities – but there is no limit to the number of times funds can be recycled in different forms between Home and Foreign. In that process, the gross external assets and liabilities of the two countries can expand explosively.

System Instructions: Draw your answer only from the provided text. If you cannot answer using the provided text alone, respond with "I cannot determine an answer due to insufficient context.". Make sure to provide your answer solely in a bulleted list, and be concise. Question: How does a theoretical world without crisis differ from the real word in terms of intra and intertemporal trade? Context Block: In theory, countries exchange assets with different risk profiles to smooth consumption fluctuations across future random states of nature. This intratemporal trade, an exchange of consumption across different states of nature that occur on the same date, may be contrasted with intertemporal trade, in which consumption on one date is traded for an asset entitling the buyer to consumption on a future date. Cross-border purchases of assets with other assets are intratemporal trades, purchases of goods or services with assets are intertemporal trades. A country’s intertemporal budget constraint limits the present value of its (state-contingent) expenditure (on consumption and investment) to the present value of its (state-contingent) output plus the market value of its net financial claims on the outside world (the net international investment position, or NIIP). Thus, a country’s ultimate consumption possibilities depend not only on the NIIP, but on the prices a country faces in world markets and its (stochastic) output and investment levels. Ideally, if a country has maximally hedged its idiosyncratic risk in world asset markets, its NIIP will respond to shocks (including shocks to current and future world prices) in ways that cushion domestic consumption possibilities. Furthermore, if markets are complete in the sense of Arrow and Debreu, asset trades between individuals will indeed represent Pareto improvements in resource allocation, so that it makes sense to speak of countries as if they consisted of representative individuals. But this type of world – a world without crises – is not the world we inhabit. In the real world, financial trades that one agent makes, viewing them as personally advantageous, canwork to the detriment of others. The implication is that the sheer volume of financial trade can be positively correlated with financial instability risks. It is in the realm of intratemporal asset trade that international trading volume has expanded most in recent years. Fig. 1 illustrates the process. The upper horizontal arrows represent (intratemporal) trade of presently available goods for other present goods between a home and a foreign country, with arrow lengths proportional to the value of the items exchanged. In the figure, Home ships a higher value of goods to Foreign than Foreign ships to Home, so the net difference (Home’s current account surplus)must be paid for by assets that Foreign pays to Home in settlement of the Foreign current account deficit. The implied intertemporal trade – of present consumption for claims on future consumption– is shown in the figure by the diagonal arrows, with lengths equal to the current account imbalance between Home and Foreign. The lower horizontal arrows in Fig. 1 represent intratemporal trade of assets for other assets by the two countries. Home buys more assets from Foreign than it sells – financing the difference through its current export surplus – but while the difference in the two arrows’ lengths is fixed by the size of the current account imbalance, the arrow lengths themselves can be arbitrarily big. At any point in time, the size of the current account imbalance is limited by output sizes and the sizes of predetermined international assets and liabilities – but there is no limit to the number of times funds can be recycled in different forms between Home and Foreign. In that process, the gross external assets and liabilities of the two countries can expand explosively.

This task requires you to answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. The response should be no more than 500 words and exactly 3 paragraphs.

Paraphrase the text.

Status Offenses Status offenses comprise one category that may pose a particular issue with respect to the act requirement. As one legal scholar has explained, status offenses are crimes such as vagrancy, which are “often defined in such a way as to punish status (e.g., being a vagrant) rather than to punish specific action or omission to act.”205 On a number of occasions, examples of which follow, the Supreme Court has invalidated laws establishing status offenses. In its 1957 opinion in Lambert v. California, 206 the Court reversed a conviction under an ordinance that made it “unlawful for ‘any convicted person’ to be or remain in Los Angeles for a period of more than five days without registering” and required “any person having a place of abode outside the city to register if he comes into the city on five occasions or more during a 30- day period.”207 The Court explained that the law criminalized “conduct that is wholly passive— mere failure to register,” which it viewed as “unlike the commission of acts, or the failure to act under circumstances that should alert the doer to the consequences of his deed.”208 As a result, the Court held that the ordinance violated the defendant’s due process right to notice.209 Following Lambert, however, a number of mandatory registration laws have survived constitutional challenges.210 For instance, in examining an indictment for a violation of the federal Sex Offender Registration and Notification Act (SORNA), the Ninth Circuit agreed with the government that “Lambert is inapplicable because convicted sex offenders are generally subject to registration requirements in all fifty states, and [the defendant] was aware that he was obligated to register as a sex offender.” 211 In a 1962 opinion in Robinson v. California, 212 the Court reversed a conviction under a state law that criminalized addiction to narcotics without requiring any additional act by the defendant. According to the Court, the statute was distinguishable from “one which punishes a person for the use of narcotics, for their purchase, sale or possession, or for antisocial or disorderly behavior resulting from their administration,” since it instead made “the ‘status’ of narcotic addiction a criminal offense, for which the offender may be prosecuted ‘at any time before he reforms.’” 213 The Court held that the law, “which imprisons a person . . . afflicted [by narcotics addiction] as a criminal, even though he has never touched any narcotic drug within the State or been guilty of any irregular behavior there, inflicts a cruel and unusual punishment” in violation of the Eighth Amendment, as incorporated against the states through the Fourteenth Amendment.214 Status offenses can often be “reformulated and redrafted to conform to basic principles of criminal justice.”215 For instance, if a “statute that penalizes being an alcoholic or drug addict is impermissible,” a “statute that penalizes appearing in public in an intoxicated state” may be permissible. 216 The Supreme Court’s 1968 opinion in Powell v. Texas217 illustrates this distinction. Powell stemmed from the conviction of a defendant under a state law making it a crime to “get drunk or be found in a state of intoxication in any public place, or at any private house except [a person’s] own.”218 The defendant argued that he had a compulsion to drink and that the law amounted to cruel and unusual punishment pursuant to Robinson. 219 A four-Justice plurality of the Court disagreed and explained that the defendant was convicted “not for being a chronic alcoholic, but for being in public while drunk on a particular occasion.”220 In other words, the plurality concluded that the law did not seek “to punish a mere status” as the law at issue in Robinson did, but instead punished a voluntary act, being in public while intoxicated.221 In a concurring opinion, Justice White said that the result would have been different if the public intoxication were an unavoidable result of chronic alcoholism.222 For example, according to Justice White, the Eighth Amendment would prohibit criminalizing public intoxication for chronic alcoholics who are homeless because “they have no place else to go and no place else to be when they are drinking.” 223 Four dissenting Justices would have agreed with that conclusion.224 The primary point of departure between Justice White and the dissenting Justices was over the record in Powell—Justice White agreed with the ultimate result in Powell because “nothing in the record indicates that [the defendant] could not have done his drinking in private or that he was so inebriated at the time that he had lost control of his movements and wandered into the public street.”225 The dissenting Justices concluded, however, that the “appellant is a ‘chronic alcoholic’ who, according to the trier of fact, cannot resist the ‘constant excessive consumption of alcohol’ and does not appear in public by his own volition but under a compulsion’ which is part of his condition.” 226Another example of the distinction between an impermissible status offense and a seemingly permissible conduct-based offense may be found in 8 U.S.C. § 1326, which in relevant part provides that “any alien who (1) has been arrested and deported or excluded and deported, and thereafter (2) enters, attempts to enter, or is at any time found in, the United States . . . [without the consent of the Attorney General] shall be fined . . . or imprisoned . . . or both.”227 Some federal appellate courts have rejected the argument that “the ‘found in’ provision of § 1326 impermissibly punishes aliens for their ‘status’ of being found in the United States.”228 In United States v. Ayala, the Ninth Circuit distinguished § 1326 from the law at issue in Robinson, explaining that “[a] conviction under § 1326 for being ‘found in’ the United States necessarily requires that a defendant commit an act: he must re-enter the United States without permission within five years after being deported.”229 Federal appellate courts had split on the issue of whether the Robinson and Powell distinction between impermissible status offenses and permissible conduct-based offenses allowed “criminalizing conduct that is an unavoidable consequence of one’s status.”230 In the 2024 opinion City of Grants Pass v. Johnson, the Supreme Court examined this issue in the context of a municipal ordinance criminalizing sleeping or camping in public.231 In a divided opinion, the Ninth Circuit concluded that the ordinance constituted cruel and unusual punishment, citing to Powell’s concurrence and dissent for the proposition that “a person cannot be prosecuted for involuntary conduct if it is an unavoidable consequence of one’s status.” 232 The Ninth Circuit observed that this would be the inevitable outcome for some of the involuntary homeless population in Grants Pass, which exceeded the available shelter space in the jurisdiction.233 The Supreme Court disagreed, concluding that the camping ordinance was not a status offense of the type barred in Robinson (which lacked a mental state or act requirement), because the ordinance in Grants Pass required “actions like ‘occupy[ing] a campsite’ on public property ‘for the purpose of maintaining a temporary place to live.’” 234 The Court likened the facts of Grants Pass to those of Powell and relied on the Powell plurality’s distinction between laws criminalizing status and those criminalizing acts, even if on some level those acts may be an involuntary result of the underlying status.235 Although the Court did not reconsider Robinson, it reiterated that the Cruel and Unusual Punishments Clause of the Eighth Amendment focuses on the method or kind of punishment a government may impose, rather than on the question of what a government may criminalize. 236 Additional analysis of Grants Pass and its broader implications for status offenses and homelessness laws may be found in other CRS products.23

This task requires you to answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. The response should be no more than 500 words and exactly 3 paragraphs. Status Offenses Status offenses comprise one category that may pose a particular issue with respect to the act requirement. As one legal scholar has explained, status offenses are crimes such as vagrancy, which are “often defined in such a way as to punish status (e.g., being a vagrant) rather than to punish specific action or omission to act.”205 On a number of occasions, examples of which follow, the Supreme Court has invalidated laws establishing status offenses. In its 1957 opinion in Lambert v. California, 206 the Court reversed a conviction under an ordinance that made it “unlawful for ‘any convicted person’ to be or remain in Los Angeles for a period of more than five days without registering” and required “any person having a place of abode outside the city to register if he comes into the city on five occasions or more during a 30- day period.”207 The Court explained that the law criminalized “conduct that is wholly passive— mere failure to register,” which it viewed as “unlike the commission of acts, or the failure to act under circumstances that should alert the doer to the consequences of his deed.”208 As a result, the Court held that the ordinance violated the defendant’s due process right to notice.209 Following Lambert, however, a number of mandatory registration laws have survived constitutional challenges.210 For instance, in examining an indictment for a violation of the federal Sex Offender Registration and Notification Act (SORNA), the Ninth Circuit agreed with the government that “Lambert is inapplicable because convicted sex offenders are generally subject to registration requirements in all fifty states, and [the defendant] was aware that he was obligated to register as a sex offender.” 211 In a 1962 opinion in Robinson v. California, 212 the Court reversed a conviction under a state law that criminalized addiction to narcotics without requiring any additional act by the defendant. According to the Court, the statute was distinguishable from “one which punishes a person for the use of narcotics, for their purchase, sale or possession, or for antisocial or disorderly behavior resulting from their administration,” since it instead made “the ‘status’ of narcotic addiction a criminal offense, for which the offender may be prosecuted ‘at any time before he reforms.’” 213 The Court held that the law, “which imprisons a person . . . afflicted [by narcotics addiction] as a criminal, even though he has never touched any narcotic drug within the State or been guilty of any irregular behavior there, inflicts a cruel and unusual punishment” in violation of the Eighth Amendment, as incorporated against the states through the Fourteenth Amendment.214 Status offenses can often be “reformulated and redrafted to conform to basic principles of criminal justice.”215 For instance, if a “statute that penalizes being an alcoholic or drug addict is impermissible,” a “statute that penalizes appearing in public in an intoxicated state” may be permissible. 216 The Supreme Court’s 1968 opinion in Powell v. Texas217 illustrates this distinction. Powell stemmed from the conviction of a defendant under a state law making it a crime to “get drunk or be found in a state of intoxication in any public place, or at any private house except [a person’s] own.”218 The defendant argued that he had a compulsion to drink and that the law amounted to cruel and unusual punishment pursuant to Robinson. 219 A four-Justice plurality of the Court disagreed and explained that the defendant was convicted “not for being a chronic alcoholic, but for being in public while drunk on a particular occasion.”220 In other words, the plurality concluded that the law did not seek “to punish a mere status” as the law at issue in Robinson did, but instead punished a voluntary act, being in public while intoxicated.221 In a concurring opinion, Justice White said that the result would have been different if the public intoxication were an unavoidable result of chronic alcoholism.222 For example, according to Justice White, the Eighth Amendment would prohibit criminalizing public intoxication for chronic alcoholics who are homeless because “they have no place else to go and no place else to be when they are drinking.” 223 Four dissenting Justices would have agreed with that conclusion.224 The primary point of departure between Justice White and the dissenting Justices was over the record in Powell—Justice White agreed with the ultimate result in Powell because “nothing in the record indicates that [the defendant] could not have done his drinking in private or that he was so inebriated at the time that he had lost control of his movements and wandered into the public street.”225 The dissenting Justices concluded, however, that the “appellant is a ‘chronic alcoholic’ who, according to the trier of fact, cannot resist the ‘constant excessive consumption of alcohol’ and does not appear in public by his own volition but under a compulsion’ which is part of his condition.” 226Another example of the distinction between an impermissible status offense and a seemingly permissible conduct-based offense may be found in 8 U.S.C. § 1326, which in relevant part provides that “any alien who (1) has been arrested and deported or excluded and deported, and thereafter (2) enters, attempts to enter, or is at any time found in, the United States . . . [without the consent of the Attorney General] shall be fined . . . or imprisoned . . . or both.”227 Some federal appellate courts have rejected the argument that “the ‘found in’ provision of § 1326 impermissibly punishes aliens for their ‘status’ of being found in the United States.”228 In United States v. Ayala, the Ninth Circuit distinguished § 1326 from the law at issue in Robinson, explaining that “[a] conviction under § 1326 for being ‘found in’ the United States necessarily requires that a defendant commit an act: he must re-enter the United States without permission within five years after being deported.”229 Federal appellate courts had split on the issue of whether the Robinson and Powell distinction between impermissible status offenses and permissible conduct-based offenses allowed “criminalizing conduct that is an unavoidable consequence of one’s status.”230 In the 2024 opinion City of Grants Pass v. Johnson, the Supreme Court examined this issue in the context of a municipal ordinance criminalizing sleeping or camping in public.231 In a divided opinion, the Ninth Circuit concluded that the ordinance constituted cruel and unusual punishment, citing to Powell’s concurrence and dissent for the proposition that “a person cannot be prosecuted for involuntary conduct if it is an unavoidable consequence of one’s status.” 232 The Ninth Circuit observed that this would be the inevitable outcome for some of the involuntary homeless population in Grants Pass, which exceeded the available shelter space in the jurisdiction.233 The Supreme Court disagreed, concluding that the camping ordinance was not a status offense of the type barred in Robinson (which lacked a mental state or act requirement), because the ordinance in Grants Pass required “actions like ‘occupy[ing] a campsite’ on public property ‘for the purpose of maintaining a temporary place to live.’” 234 The Court likened the facts of Grants Pass to those of Powell and relied on the Powell plurality’s distinction between laws criminalizing status and those criminalizing acts, even if on some level those acts may be an involuntary result of the underlying status.235 Although the Court did not reconsider Robinson, it reiterated that the Cruel and Unusual Punishments Clause of the Eighth Amendment focuses on the method or kind of punishment a government may impose, rather than on the question of what a government may criminalize. 236 Additional analysis of Grants Pass and its broader implications for status offenses and homelessness laws may be found in other CRS products.23 Paraphrase the text..

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

I am an investor in Coca-Cola but I am curious about some of the companies challenges right now. Give me a bullet list of raw product materials the company uses in making products are at risk of price volatility. Then explain what causes of that volatility could be. I'm not concerned about the concerns about sweeteners so I don't need to know about that. But tell me can social media have a negative impact on the company?

Raw material costs, including the costs for plastic bottles, aluminum cans, PET resin, carbon dioxide and high fructose corn syrup, are subject to significant price volatility, which may be worsened by periods of increased demand, supply constraints or high inflation. International or domestic geopolitical or other events, including pandemics, armed conflict or the imposition of tariffs and/or quotas by the U.S. government on any of these raw materials, could adversely impact the supply and cost of these raw materials to the Company or render them unavailable at commercially favorable terms or at all. In addition, there are no limits on the prices The Coca-Cola Company and other beverage companies can charge for concentrate. If the Company cannot offset higher raw material costs with higher selling prices, effective commodity price hedging, increased sales volume or reductions in other costs, the Company’s results of operations and profitability could be adversely affected. The Company uses significant amounts of fuel for its delivery fleet and other vehicles used in the distribution of its products. International or domestic geopolitical or other events could impact the supply and cost of fuel and the timely delivery of the Company’s products to its customers. Although the Company strives to reduce fuel consumption and uses commodity hedges to manage the Company’s fuel costs, there can be no assurance the Company will succeed in limiting the impact of fuel price increases or price volatility on the Company’s business or future cost increases, which could reduce the profitability of the Company’s operations. The Company uses a combination of internal and external freight shipping and transportation services to transport and deliver products. The Company’s freight cost and the timely delivery of its products may be adversely impacted by a number of factors that could reduce the profitability of the Company’s operations, including driver shortages, reduced availability of independent contractor drivers, higher fuel costs, weather conditions, traffic congestion, increased government regulation and other matters. The Company continues to make significant reinvestments in its business in order to evolve its operating model and to accommodate future growth and portfolio expansion, including supply chain optimization. The increased costs associated with these reinvestments, the potential for disruption in manufacturing and distribution and the risk the Company may not realize a satisfactory return on its investments could adversely affect the Company’s business, financial condition or results of operations. The reliance on purchased finished products from external sources could have an adverse impact on the Company’s profitability. The Company does not, and does not plan to, manufacture all of the products it distributes and, therefore, remains reliant on purchased finished products from external sources to meet customer demand. As a result, the Company is subject to incremental risk, including, but not limited to, product quality and availability, price variability and production capacity shortfalls for externally purchased finished products, which could have an impact on the Company’s profitability and customer relationships. Particularly, the Company is subject to the risk of unavailability of still products that it acquires from other manufacturers, leading to an inability to meet consumer demand for these products. In most instances, the Company’s ability to negotiate the prices at which it purchases finished products from other U.S. Coca-Cola bottlers is limited pursuant to The Coca-Cola Company’s right to unilaterally establish the prices, or certain elements of the formulas used to determine the prices, for such finished products under the RMA, which could have an adverse impact on the Company’s profitability. Changes in public and consumer perception and preferences, including concerns related to product safety and sustainability, artificial ingredients, brand reputation and obesity, could reduce demand for the Company’s products and reduce profitability. Concerns about perceived negative safety and quality consequences of certain ingredients in the Company’s products, such as nonnutritive sweeteners or ingredients in energy drinks, may erode consumers’ confidence in the safety and quality of the Company’s products, whether or not justified. The Company’s business is also impacted by changes in consumer concerns or perceptions surrounding the product manufacturing processes and packaging materials, including single-use and other plastic packaging, and the environmental and sustainability impact of such manufacturing processes and packaging materials. Any of these factors may reduce consumers’ willingness to purchase the Company’s products and any inability on the part of the Company to anticipate or react to such changes could result in reduced demand for the Company’s products or erode the Company’s competitive and financial position and could adversely affect the Company’s business, reputation, financial condition or results of operations. The Company’s success depends on its ability to maintain consumer confidence in the safety and quality of all of its products. The Company has rigorous product safety and quality standards. However, if beverage products taken to market are or become contaminated or adulterated, the Company may be required to conduct costly product recalls and may become subject to product liability claims and negative publicity, which could cause its business and reputation to suffer. 9 The Company’s success also depends in large part on its ability and the ability of The Coca-Cola Company and other beverage companies it works with to maintain the brand image of existing products, build up brand image for new products and brand extensions and maintain its corporate reputation and social license to operate. Engagements by the Company’s executives in social and public policy debates may occasionally be the subject of criticism from advocacy groups that have differing points of view and could result in adverse media and consumer reaction, including product boycotts. Similarly, the Company’s sponsorship relationships and charitable giving program could subject the Company to negative publicity as a result of actual or perceived views of organizations the Company sponsors or supports financially. Likewise, negative postings or comments on social media or networking websites about the Company, The Coca-Cola Company or one of the products the Company carries, even if inaccurate or malicious, could generate adverse publicity that could damage the reputation of the Company’s brands or the Company. The Company’s business depends substantially on consumer tastes, preferences and shopping habits that change in often unpredictable ways. As a result of certain health and wellness trends, including concern over the public health consequences associated with obesity, consumer preferences over the past several years have shifted from sugar-sweetened sparkling beverages to diet sparkling beverages, tea, sports drinks, enhanced water and bottled water. As the Company distributes, markets and manufactures beverage brands owned by others, the success of the Company’s business depends in large measure on the ability of The Coca-Cola Company and other beverage companies to develop and introduce product innovations to meet the changing preferences of the broad consumer market, and failure to satisfy these consumer preferences could adversely affect the Company’s profitability

"================ <TEXT PASSAGE> ======= Raw material costs, including the costs for plastic bottles, aluminum cans, PET resin, carbon dioxide and high fructose corn syrup, are subject to significant price volatility, which may be worsened by periods of increased demand, supply constraints or high inflation. International or domestic geopolitical or other events, including pandemics, armed conflict or the imposition of tariffs and/or quotas by the U.S. government on any of these raw materials, could adversely impact the supply and cost of these raw materials to the Company or render them unavailable at commercially favorable terms or at all. In addition, there are no limits on the prices The Coca-Cola Company and other beverage companies can charge for concentrate. If the Company cannot offset higher raw material costs with higher selling prices, effective commodity price hedging, increased sales volume or reductions in other costs, the Company’s results of operations and profitability could be adversely affected. The Company uses significant amounts of fuel for its delivery fleet and other vehicles used in the distribution of its products. International or domestic geopolitical or other events could impact the supply and cost of fuel and the timely delivery of the Company’s products to its customers. Although the Company strives to reduce fuel consumption and uses commodity hedges to manage the Company’s fuel costs, there can be no assurance the Company will succeed in limiting the impact of fuel price increases or price volatility on the Company’s business or future cost increases, which could reduce the profitability of the Company’s operations. The Company uses a combination of internal and external freight shipping and transportation services to transport and deliver products. The Company’s freight cost and the timely delivery of its products may be adversely impacted by a number of factors that could reduce the profitability of the Company’s operations, including driver shortages, reduced availability of independent contractor drivers, higher fuel costs, weather conditions, traffic congestion, increased government regulation and other matters. The Company continues to make significant reinvestments in its business in order to evolve its operating model and to accommodate future growth and portfolio expansion, including supply chain optimization. The increased costs associated with these reinvestments, the potential for disruption in manufacturing and distribution and the risk the Company may not realize a satisfactory return on its investments could adversely affect the Company’s business, financial condition or results of operations. The reliance on purchased finished products from external sources could have an adverse impact on the Company’s profitability. The Company does not, and does not plan to, manufacture all of the products it distributes and, therefore, remains reliant on purchased finished products from external sources to meet customer demand. As a result, the Company is subject to incremental risk, including, but not limited to, product quality and availability, price variability and production capacity shortfalls for externally purchased finished products, which could have an impact on the Company’s profitability and customer relationships. Particularly, the Company is subject to the risk of unavailability of still products that it acquires from other manufacturers, leading to an inability to meet consumer demand for these products. In most instances, the Company’s ability to negotiate the prices at which it purchases finished products from other U.S. Coca-Cola bottlers is limited pursuant to The Coca-Cola Company’s right to unilaterally establish the prices, or certain elements of the formulas used to determine the prices, for such finished products under the RMA, which could have an adverse impact on the Company’s profitability. Changes in public and consumer perception and preferences, including concerns related to product safety and sustainability, artificial ingredients, brand reputation and obesity, could reduce demand for the Company’s products and reduce profitability. Concerns about perceived negative safety and quality consequences of certain ingredients in the Company’s products, such as nonnutritive sweeteners or ingredients in energy drinks, may erode consumers’ confidence in the safety and quality of the Company’s products, whether or not justified. The Company’s business is also impacted by changes in consumer concerns or perceptions surrounding the product manufacturing processes and packaging materials, including single-use and other plastic packaging, and the environmental and sustainability impact of such manufacturing processes and packaging materials. Any of these factors may reduce consumers’ willingness to purchase the Company’s products and any inability on the part of the Company to anticipate or react to such changes could result in reduced demand for the Company’s products or erode the Company’s competitive and financial position and could adversely affect the Company’s business, reputation, financial condition or results of operations. The Company’s success depends on its ability to maintain consumer confidence in the safety and quality of all of its products. The Company has rigorous product safety and quality standards. However, if beverage products taken to market are or become contaminated or adulterated, the Company may be required to conduct costly product recalls and may become subject to product liability claims and negative publicity, which could cause its business and reputation to suffer. 9 The Company’s success also depends in large part on its ability and the ability of The Coca-Cola Company and other beverage companies it works with to maintain the brand image of existing products, build up brand image for new products and brand extensions and maintain its corporate reputation and social license to operate. Engagements by the Company’s executives in social and public policy debates may occasionally be the subject of criticism from advocacy groups that have differing points of view and could result in adverse media and consumer reaction, including product boycotts. Similarly, the Company’s sponsorship relationships and charitable giving program could subject the Company to negative publicity as a result of actual or perceived views of organizations the Company sponsors or supports financially. Likewise, negative postings or comments on social media or networking websites about the Company, The Coca-Cola Company or one of the products the Company carries, even if inaccurate or malicious, could generate adverse publicity that could damage the reputation of the Company’s brands or the Company. The Company’s business depends substantially on consumer tastes, preferences and shopping habits that change in often unpredictable ways. As a result of certain health and wellness trends, including concern over the public health consequences associated with obesity, consumer preferences over the past several years have shifted from sugar-sweetened sparkling beverages to diet sparkling beverages, tea, sports drinks, enhanced water and bottled water. As the Company distributes, markets and manufactures beverage brands owned by others, the success of the Company’s business depends in large measure on the ability of The Coca-Cola Company and other beverage companies to develop and introduce product innovations to meet the changing preferences of the broad consumer market, and failure to satisfy these consumer preferences could adversely affect the Company’s profitability https://investor.cokeconsolidated.com/static-files/198305e2-2559-4acc-954c-4123760b0f61 ================ <QUESTION> ======= I am an investor in Coca-Cola but I am curious about some of the companies challenges right now. Give me a bullet list of raw product materials the company uses in making products are at risk of price volatility. Then explain what causes of that volatility could be. I'm not concerned about the concerns about sweeteners so I don't need to know about that. But tell me can social media have a negative impact on the company? ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> [user request] <TEXT> [context document]

Growing up with social media, I have always wondered how it has affected my education. How can social media influence students' learning experience both positively and negatively? List one reason for each.

The use of social media is incomparably on the rise among students, influenced by the globalized forms of communication and the post-pandemic rush to use multiple social media platforms for education in different fields of study. Though social media has created tremendous chances for sharing ideas and emotions, the kind of social support it provides might fail to meet students’ emotional needs, or the alleged positive effects might be short-lasting. In recent years, several studies have been conducted to explore the potential effects of social media on students’ affective traits, such as stress, anxiety, depression, and so on. The present paper reviews the findings of the exemplary published works of research to shed light on the positive and negative potential effects of the massive use of social media on students’ emotional well-being. This review can be insightful for teachers who tend to take the potential psychological effects of social media for granted. They may want to know more about the actual effects of the over-reliance on and the excessive (and actually obsessive) use of social media on students’ developing certain images of self and certain emotions which are not necessarily positive. There will be implications for pre- and in-service teacher training and professional development programs and all those involved in student affairs. Social media has turned into an essential element of individuals’ lives including students in today’s world of communication. Its use is growing significantly more than ever before especially in the post-pandemic era, marked by a great revolution happening to the educational systems. Recent investigations of using social media show that approximately 3 billion individuals worldwide are now communicating via social media (Iwamoto and Chun, 2020). This growing population of social media users is spending more and more time on social network groupings, as facts and figures show that individuals spend 2 h a day, on average, on a variety of social media applications, exchanging pictures and messages, updating status, tweeting, favoring, and commenting on many updated socially shared information (Abbott, 2017). Researchers have begun to investigate the psychological effects of using social media on students’ lives. Chukwuere and Chukwuere (2017) maintained that social media platforms can be considered the most important source of changing individuals’ mood, because when someone is passively using a social media platform seemingly with no special purpose, s/he can finally feel that his/her mood has changed as a function of the nature of content overviewed. Therefore, positive and negative moods can easily be transferred among the population using social media networks (Chukwuere and Chukwuere, 2017). This may become increasingly important as students are seen to be using social media platforms more than before and social networking is becoming an integral aspect of their lives. As described by Iwamoto and Chun (2020), when students are affected by social media posts, especially due to the increasing reliance on social media use in life, they may be encouraged to begin comparing themselves to others or develop great unrealistic expectations of themselves or others, which can have several affective consequences. Considering the increasing influence of social media on education, the present paper aims to focus on the affective variables such as depression, stress, and anxiety, and how social media can possibly increase or decrease these emotions in student life. The exemplary works of research on this topic in recent years will be reviewed here, hoping to shed light on the positive and negative effects of these ever-growing influential platforms on the psychology of students. The body of research on the effect of social media on students’ affective and emotional states has led to mixed results. The existing literature shows that there are some positive and some negative affective impacts. Yet, it seems that the latter is pre-dominant. Mathewson (2020) attributed these divergent positive and negative effects to the different theoretical frameworks adopted in different studies and also the different contexts (different countries with whole different educational systems). According to Fredrickson’s broaden-and-build theory of positive emotions (Fredrickson, 2001), the mental repertoires of learners can be built and broadened by how they feel. For instance, some external stimuli might provoke negative emotions such as anxiety and depression in learners. Having experienced these negative emotions, students might repeatedly check their messages on social media or get addicted to them. As a result, their cognitive repertoire and mental capacity might become limited and they might lose their concentration during their learning process. On the other hand, it should be noted that by feeling positive, learners might take full advantage of the affordances of the social media and; thus, be able to follow their learning goals strategically. This point should be highlighted that the link between the use of social media and affective states is bi-directional. Therefore, strategic use of social media or its addictive use by students can direct them toward either positive experiences like enjoyment or negative ones such as anxiety and depression. Also, these mixed positive and negative effects are similar to the findings of several other relevant studies on general populations’ psychological and emotional health. A number of studies (with general research populations not necessarily students) showed that social networks have facilitated the way of staying in touch with family and friends living far away as well as an increased social support (Zhang, 2017). Given the positive and negative emotional effects of social media, social media can either scaffold the emotional repertoire of students, which can develop positive emotions in learners, or induce negative provokers in them, based on which learners might feel negative emotions such as anxiety and depression. However, admittedly, social media has also generated a domain that encourages the act of comparing lives, and striving for approval; therefore, it establishes and internalizes unrealistic perceptions (Virden et al., 2014; Radovic et al., 2017). It should be mentioned that the susceptibility of affective variables to social media should be interpreted from a dynamic lens. This means that the ecology of the social media can make changes in the emotional experiences of learners. More specifically, students’ affective variables might self-organize into different states under the influence of social media. As for the positive correlation found in many studies between the use of social media and such negative effects as anxiety, depression, and stress, it can be hypothesized that this correlation is induced by the continuous comparison the individual makes and the perception that others are doing better than him/her influenced by the posts that appear on social media. Using social media can play a major role in university students’ psychological well-being than expected. Though most of these studies were correlational, and correlation is not the same as causation, as the studies show that the number of participants experiencing these negative emotions under the influence of social media is significantly high, more extensive research is highly suggested to explore causal effects (Mathewson, 2020). As the review of exemplary studies showed, some believed that social media increased comparisons that students made between themselves and others. This finding ratifies the relevance of the Interpretation Comparison Model (Stapel and Koomen, 2000; Stapel, 2007) and Festinger’s (1954) Social Comparison Theory. Concerning the negative effects of social media on students’ psychology, it can be argued that individuals may fail to understand that the content presented in social media is usually changed to only represent the attractive aspects of people’s lives, showing an unrealistic image of things. We can add that this argument also supports the relevance of the Social Comparison Theory and the Interpretation Comparison Model (Stapel and Koomen, 2000; Stapel, 2007), because social media sets standards that students think they should compare themselves with. A constant observation of how other students or peers are showing their instances of achievement leads to higher self-evaluation (Stapel and Koomen, 2000).

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> Growing up with social media, I have always wondered how it has affected my education. How can social media influence students' learning experience both positively and negatively? List one reason for each. <TEXT> The use of social media is incomparably on the rise among students, influenced by the globalized forms of communication and the post-pandemic rush to use multiple social media platforms for education in different fields of study. Though social media has created tremendous chances for sharing ideas and emotions, the kind of social support it provides might fail to meet students’ emotional needs, or the alleged positive effects might be short-lasting. In recent years, several studies have been conducted to explore the potential effects of social media on students’ affective traits, such as stress, anxiety, depression, and so on. The present paper reviews the findings of the exemplary published works of research to shed light on the positive and negative potential effects of the massive use of social media on students’ emotional well-being. This review can be insightful for teachers who tend to take the potential psychological effects of social media for granted. They may want to know more about the actual effects of the over-reliance on and the excessive (and actually obsessive) use of social media on students’ developing certain images of self and certain emotions which are not necessarily positive. There will be implications for pre- and in-service teacher training and professional development programs and all those involved in student affairs. Social media has turned into an essential element of individuals’ lives including students in today’s world of communication. Its use is growing significantly more than ever before especially in the post-pandemic era, marked by a great revolution happening to the educational systems. Recent investigations of using social media show that approximately 3 billion individuals worldwide are now communicating via social media (Iwamoto and Chun, 2020). This growing population of social media users is spending more and more time on social network groupings, as facts and figures show that individuals spend 2 h a day, on average, on a variety of social media applications, exchanging pictures and messages, updating status, tweeting, favoring, and commenting on many updated socially shared information (Abbott, 2017). Researchers have begun to investigate the psychological effects of using social media on students’ lives. Chukwuere and Chukwuere (2017) maintained that social media platforms can be considered the most important source of changing individuals’ mood, because when someone is passively using a social media platform seemingly with no special purpose, s/he can finally feel that his/her mood has changed as a function of the nature of content overviewed. Therefore, positive and negative moods can easily be transferred among the population using social media networks (Chukwuere and Chukwuere, 2017). This may become increasingly important as students are seen to be using social media platforms more than before and social networking is becoming an integral aspect of their lives. As described by Iwamoto and Chun (2020), when students are affected by social media posts, especially due to the increasing reliance on social media use in life, they may be encouraged to begin comparing themselves to others or develop great unrealistic expectations of themselves or others, which can have several affective consequences. Considering the increasing influence of social media on education, the present paper aims to focus on the affective variables such as depression, stress, and anxiety, and how social media can possibly increase or decrease these emotions in student life. The exemplary works of research on this topic in recent years will be reviewed here, hoping to shed light on the positive and negative effects of these ever-growing influential platforms on the psychology of students. The body of research on the effect of social media on students’ affective and emotional states has led to mixed results. The existing literature shows that there are some positive and some negative affective impacts. Yet, it seems that the latter is pre-dominant. Mathewson (2020) attributed these divergent positive and negative effects to the different theoretical frameworks adopted in different studies and also the different contexts (different countries with whole different educational systems). According to Fredrickson’s broaden-and-build theory of positive emotions (Fredrickson, 2001), the mental repertoires of learners can be built and broadened by how they feel. For instance, some external stimuli might provoke negative emotions such as anxiety and depression in learners. Having experienced these negative emotions, students might repeatedly check their messages on social media or get addicted to them. As a result, their cognitive repertoire and mental capacity might become limited and they might lose their concentration during their learning process. On the other hand, it should be noted that by feeling positive, learners might take full advantage of the affordances of the social media and; thus, be able to follow their learning goals strategically. This point should be highlighted that the link between the use of social media and affective states is bi-directional. Therefore, strategic use of social media or its addictive use by students can direct them toward either positive experiences like enjoyment or negative ones such as anxiety and depression. Also, these mixed positive and negative effects are similar to the findings of several other relevant studies on general populations’ psychological and emotional health. A number of studies (with general research populations not necessarily students) showed that social networks have facilitated the way of staying in touch with family and friends living far away as well as an increased social support (Zhang, 2017). Given the positive and negative emotional effects of social media, social media can either scaffold the emotional repertoire of students, which can develop positive emotions in learners, or induce negative provokers in them, based on which learners might feel negative emotions such as anxiety and depression. However, admittedly, social media has also generated a domain that encourages the act of comparing lives, and striving for approval; therefore, it establishes and internalizes unrealistic perceptions (Virden et al., 2014; Radovic et al., 2017). It should be mentioned that the susceptibility of affective variables to social media should be interpreted from a dynamic lens. This means that the ecology of the social media can make changes in the emotional experiences of learners. More specifically, students’ affective variables might self-organize into different states under the influence of social media. As for the positive correlation found in many studies between the use of social media and such negative effects as anxiety, depression, and stress, it can be hypothesized that this correlation is induced by the continuous comparison the individual makes and the perception that others are doing better than him/her influenced by the posts that appear on social media. Using social media can play a major role in university students’ psychological well-being than expected. Though most of these studies were correlational, and correlation is not the same as causation, as the studies show that the number of participants experiencing these negative emotions under the influence of social media is significantly high, more extensive research is highly suggested to explore causal effects (Mathewson, 2020). As the review of exemplary studies showed, some believed that social media increased comparisons that students made between themselves and others. This finding ratifies the relevance of the Interpretation Comparison Model (Stapel and Koomen, 2000; Stapel, 2007) and Festinger’s (1954) Social Comparison Theory. Concerning the negative effects of social media on students’ psychology, it can be argued that individuals may fail to understand that the content presented in social media is usually changed to only represent the attractive aspects of people’s lives, showing an unrealistic image of things. We can add that this argument also supports the relevance of the Social Comparison Theory and the Interpretation Comparison Model (Stapel and Koomen, 2000; Stapel, 2007), because social media sets standards that students think they should compare themselves with. A constant observation of how other students or peers are showing their instances of achievement leads to higher self-evaluation (Stapel and Koomen, 2000). https://www.frontiersin.org/journals/psychology/articles/10.3389/fpsyg.2022.1010766/full

Base your response strictly on the provided document only. Answer in less than 5 words. Do not include numbers.

What date did this executive order go into effect?

**AN ORDER TEMPORARILY MODIFYING CERTAIN IN-PERSON NOTARIZATION AND ACKNOWLEDGEMENT REQUIREMENTS** WHEREAS, I proclaimed a state of emergency on March 15, 2020 to authorize the use of emergency powers in order to expand and expedite the State's response to the many different effects ofCOVID-19; and WHEREAS, the in-person services of notaries public and witnesses are required to complete and validate a wide variety of important personal and commercial transactions; and WHEREAS, it is now necessary for those services to be provided remotely to ensure the social distancing recommended by the United States and Maine Centers for Disease Control and Prevention; and WHEREAS, a governor's emergency powers pursuant to 37-B M.R.S. §742(l)(C)(l) and §834 expressly include the authority to suspend the enforcement of statutes, orders or rules where strict compliance therewith would in any way prevent, hinder or delay necessary action in coping with the emergency; and WHEREAS, this Order will enable citizens, especially those who are elderly or have serious underlying health conditions, to continue to seek and obtain critical estate planning instruments, such as Last Will and Testaments, Financial Powers of Attorney, Healthcare Powers of Attorney, and for all persons to conduct other important business that requires sworn statements or affidavits, in a manner that reduces in-person contact and promotes social distancing; and WHEREAS, the requirements of this Order are designed to protect the reliability of in-person notary acknowledgments, sworn statements and affidavits; NOW, THEREFORE, I, Janet T. Mills, Governor of the State of Maine, pursuant to 37-B M.R.S. Ch. 13, including but not limited to the provisions cited above, do hereby Order as follows: I. APPLICATION This Order applies to all provisions of Maine law that require a signature to be acknowledged, witnessed or notarized in person, with the exceptions of: (a) solemnizing marriages, (b) administering oaths to circulators of state or local direct initiative or referendum petitions and nomination petitions of candidates for electoral office, and ( c) absentee ballots in state and local elections. This Order authorizes remote, not electronic, notarization. All requirements under Maine law pertaining to the taking of sworn statements and acknowledgments by notaries and those authorized to perform notarial acts, other than the requirement to appear in person, remain in effect during the effective period of this Order. II. ORDERS While this Order is in effect, with the exceptions noted in Part I of this Order, the enforcement of those provisions of Maine law that require the physical presence of the person whose oath is being taken ("the Signatory") at the same location as the Notary Public or other person authorized to perform a notarial act ("the Notary") and any witness to the signing are hereby suspended provided the conditions set forth in paragraphs A-G of this Section are met. A. The Notary must be physically within the State while performing the notarial act and must follow any additional guidance for remote notarization issued by the Maine Secretary of State. B. The act of notarization or witnessing required by Maine law may be completed remotely via two-way audio-video communication technology, provided that: I. The two-way audio-video communication technology must allow direct contemporaneous interaction between the individual signing the document ("the Signatory"), the Notary and any witness by sight and sound in real time ( e.g. with no pre-recordings); 2. The Signatory must be reasonably identified by the Notary by one or more of the following: (a) is personally !mown to the Notary; (b) presented a valid photo identification to the Notary during the video conference; ( c) the oath or affirmation of a witness who: (i) is in the physical presence of either the Notary or the Signatory; or (ii) is able to communicate with the Notary and the Signatory simultaneously by sight and sound through an electronic device or process at the time of the notarization, if the witness has personal knowledge of the individual and has been reasonably identified by the Notary under clauses (a) or (b) herein. 3. The Signatory must attest to being physically located in Maine and affirmatively state the name of the county in which the Signatory is located at the time of execution during the two-way audio-video communication; 4. The Notary and any witness must attest to being physically located in Maine during the two-way audio-video communication; 5. For Wills and Powers of Attorney, the Notary or at least one witness must be an attorney licensed to practice law in the State of Maine; 6. Before any documents are signed, the Notary must be able to view by camera the entire space in which the Signatory and any witness is located, and any person who is present in those spaces must state their name while on video and in clear view of the Notary; 7. The Signatory must affirmatively state on the two-way audio-video communication what document the Signatory is signing and the Notary must be provided with a copy of the document prior to the signing; 8. Each page of the document being witnessed must be shown to the Notary and any witness on the two-way audio-video communication in a means clearly legible to the Notary and initialed by the Signatory in the presence of the Notary and any witness; 9. The act of signing and initialing must be captured sufficiently up close on the two-way audio-video communication for the Notary to observe; 10. Any witness or witnesses required or permitted to properly execute any original document or documents according to Maine Law may similarly witness the signing of the document by the Signatory utilizing two-way audio-video communication described in paragraph 1 and may sign as a witness to the document upon receipt of the original document; 11. The Signatory must transmit by fax or electronic means (which may include transmitting a photograph of every page by cellphone) a legible copy of the entire signed document directly to the Notary and any witness, immediately after signing the document, or, if that is not possible, no later than 24 hours after the Signatory's execution of the document; 12. The Signatory must send the original signed document directly to the witness within 48 hours ( or 2 days) after the Signatory's execution of the document, or to the Notary if no witness is involved; 13. Within 48 hours after receiving the original document from the Signatory, the witness must sign it and sent to the second witness, if any, or to the Notary if no other witness is involved. The official date and time of each witness's signature shall be the date and time when the witness witnesses the Signatory's signature via the two-way audio-video communication technology described in paragraph 1; 14. Upon review of the original document and satisfactory comparison with the faxed or electronic document provided on the date of signing, the Notary shall notarize the original document within 48 hours of receipt thereof, and the official date and time of the notarization shall be the date and time when the Notary witnessed the signature via the two-way audio-video technology and shall add the following language below the Notary and or Witness signature lines: "Notarized (and/or Witnessed) remotely, in accordance with Executive Order 37 FY 19/20"; and 15. A recording of the two-way audio-video communication must be made and preserved by the Notary for a period of at least 5 years from the date of the notarial act. The Notary shall provide a copy of the recording to the Signatory and the Secretary of State upon request. C. Any document that is required under any law of the State of Maine to be notarized "in the presence and hearing" or similar language of a Signatory, and that is signed, notarized or witnessed in accordance with the terms of this Executive Order shall be deemed to have been signed and/or notarized in the presence and hearing of the Signatory. D. Nothing in this Order shall require a Notary to perform remote notarization. E. The validity and recognition of a notarization or witness under this Order shall not prevent an aggrieved person from seeking to invalidate a record or transaction that is the subject of a notarization or from seeking other remedies based on State or Federal law other than this Order for any reason not addressed in this Order, such as incapacity, absence of authority or undue influence. F. The failure of a Notary or a witness to meet a requirement specified in this Order shall not invalidate or impair the recognition of a notarization performed by the Notary if it was performed in substantial compliance with this Order. G. The Secretary of State is authorized to issue guidance consistent with this Order to protect the integrity of the remote notarization process. III. INTEGRITY A primary and essential purpose of this Order is to safeguard the integrity of transactions and the important personal interests served by those transactions. Persons who violate the rights of others during a remote notarization are subject to all pertinent civil remedies and criminal penalties. IV. JUDICIAL NOTICE A copy of this Order shall for notice be provided to the Chief Justice of the Maine Supreme Judicial Court. I intend further that the acts, records and proceedings under this Order receive full faith and credit in the courts of the United States and other states. V. EFFECTIVE DATE This Order shall take effect on April 8, 2020 and, unless sooner amended or rescinded, terminates 30 days after the termination of the COVID-19 state of emergency.

<question> ======= What date did this executive order go into effect? <context> ======= **AN ORDER TEMPORARILY MODIFYING CERTAIN IN-PERSON NOTARIZATION AND ACKNOWLEDGEMENT REQUIREMENTS** WHEREAS, I proclaimed a state of emergency on March 15, 2020 to authorize the use of emergency powers in order to expand and expedite the State's response to the many different effects ofCOVID-19; and WHEREAS, the in-person services of notaries public and witnesses are required to complete and validate a wide variety of important personal and commercial transactions; and WHEREAS, it is now necessary for those services to be provided remotely to ensure the social distancing recommended by the United States and Maine Centers for Disease Control and Prevention; and WHEREAS, a governor's emergency powers pursuant to 37-B M.R.S. §742(l)(C)(l) and §834 expressly include the authority to suspend the enforcement of statutes, orders or rules where strict compliance therewith would in any way prevent, hinder or delay necessary action in coping with the emergency; and WHEREAS, this Order will enable citizens, especially those who are elderly or have serious underlying health conditions, to continue to seek and obtain critical estate planning instruments, such as Last Will and Testaments, Financial Powers of Attorney, Healthcare Powers of Attorney, and for all persons to conduct other important business that requires sworn statements or affidavits, in a manner that reduces in-person contact and promotes social distancing; and WHEREAS, the requirements of this Order are designed to protect the reliability of in-person notary acknowledgments, sworn statements and affidavits; NOW, THEREFORE, I, Janet T. Mills, Governor of the State of Maine, pursuant to 37-B M.R.S. Ch. 13, including but not limited to the provisions cited above, do hereby Order as follows: I. APPLICATION This Order applies to all provisions of Maine law that require a signature to be acknowledged, witnessed or notarized in person, with the exceptions of: (a) solemnizing marriages, (b) administering oaths to circulators of state or local direct initiative or referendum petitions and nomination petitions of candidates for electoral office, and ( c) absentee ballots in state and local elections. This Order authorizes remote, not electronic, notarization. All requirements under Maine law pertaining to the taking of sworn statements and acknowledgments by notaries and those authorized to perform notarial acts, other than the requirement to appear in person, remain in effect during the effective period of this Order. II. ORDERS While this Order is in effect, with the exceptions noted in Part I of this Order, the enforcement of those provisions of Maine law that require the physical presence of the person whose oath is being taken ("the Signatory") at the same location as the Notary Public or other person authorized to perform a notarial act ("the Notary") and any witness to the signing are hereby suspended provided the conditions set forth in paragraphs A-G of this Section are met. A. The Notary must be physically within the State while performing the notarial act and must follow any additional guidance for remote notarization issued by the Maine Secretary of State. B. The act of notarization or witnessing required by Maine law may be completed remotely via two-way audio-video communication technology, provided that: I. The two-way audio-video communication technology must allow direct contemporaneous interaction between the individual signing the document ("the Signatory"), the Notary and any witness by sight and sound in real time ( e.g. with no pre-recordings); 2. The Signatory must be reasonably identified by the Notary by one or more of the following: (a) is personally !mown to the Notary; (b) presented a valid photo identification to the Notary during the video conference; ( c) the oath or affirmation of a witness who: (i) is in the physical presence of either the Notary or the Signatory; or (ii) is able to communicate with the Notary and the Signatory simultaneously by sight and sound through an electronic device or process at the time of the notarization, if the witness has personal knowledge of the individual and has been reasonably identified by the Notary under clauses (a) or (b) herein. 3. The Signatory must attest to being physically located in Maine and affirmatively state the name of the county in which the Signatory is located at the time of execution during the two-way audio-video communication; 4. The Notary and any witness must attest to being physically located in Maine during the two-way audio-video communication; 5. For Wills and Powers of Attorney, the Notary or at least one witness must be an attorney licensed to practice law in the State of Maine; 6. Before any documents are signed, the Notary must be able to view by camera the entire space in which the Signatory and any witness is located, and any person who is present in those spaces must state their name while on video and in clear view of the Notary; 7. The Signatory must affirmatively state on the two-way audio-video communication what document the Signatory is signing and the Notary must be provided with a copy of the document prior to the signing; 8. Each page of the document being witnessed must be shown to the Notary and any witness on the two-way audio-video communication in a means clearly legible to the Notary and initialed by the Signatory in the presence of the Notary and any witness; 9. The act of signing and initialing must be captured sufficiently up close on the two-way audio-video communication for the Notary to observe; 10. Any witness or witnesses required or permitted to properly execute any original document or documents according to Maine Law may similarly witness the signing of the document by the Signatory utilizing two-way audio-video communication described in paragraph 1 and may sign as a witness to the document upon receipt of the original document; 11. The Signatory must transmit by fax or electronic means (which may include transmitting a photograph of every page by cellphone) a legible copy of the entire signed document directly to the Notary and any witness, immediately after signing the document, or, if that is not possible, no later than 24 hours after the Signatory's execution of the document; 12. The Signatory must send the original signed document directly to the witness within 48 hours ( or 2 days) after the Signatory's execution of the document, or to the Notary if no witness is involved; 13. Within 48 hours after receiving the original document from the Signatory, the witness must sign it and sent to the second witness, if any, or to the Notary if no other witness is involved. The official date and time of each witness's signature shall be the date and time when the witness witnesses the Signatory's signature via the two-way audio-video communication technology described in paragraph 1; 14. Upon review of the original document and satisfactory comparison with the faxed or electronic document provided on the date of signing, the Notary shall notarize the original document within 48 hours of receipt thereof, and the official date and time of the notarization shall be the date and time when the Notary witnessed the signature via the two-way audio-video technology and shall add the following language below the Notary and or Witness signature lines: "Notarized (and/or Witnessed) remotely, in accordance with Executive Order 37 FY 19/20"; and 15. A recording of the two-way audio-video communication must be made and preserved by the Notary for a period of at least 5 years from the date of the notarial act. The Notary shall provide a copy of the recording to the Signatory and the Secretary of State upon request. C. Any document that is required under any law of the State of Maine to be notarized "in the presence and hearing" or similar language of a Signatory, and that is signed, notarized or witnessed in accordance with the terms of this Executive Order shall be deemed to have been signed and/or notarized in the presence and hearing of the Signatory. D. Nothing in this Order shall require a Notary to perform remote notarization. E. The validity and recognition of a notarization or witness under this Order shall not prevent an aggrieved person from seeking to invalidate a record or transaction that is the subject of a notarization or from seeking other remedies based on State or Federal law other than this Order for any reason not addressed in this Order, such as incapacity, absence of authority or undue influence. F. The failure of a Notary or a witness to meet a requirement specified in this Order shall not invalidate or impair the recognition of a notarization performed by the Notary if it was performed in substantial compliance with this Order. G. The Secretary of State is authorized to issue guidance consistent with this Order to protect the integrity of the remote notarization process. III. INTEGRITY A primary and essential purpose of this Order is to safeguard the integrity of transactions and the important personal interests served by those transactions. Persons who violate the rights of others during a remote notarization are subject to all pertinent civil remedies and criminal penalties. IV. JUDICIAL NOTICE A copy of this Order shall for notice be provided to the Chief Justice of the Maine Supreme Judicial Court. I intend further that the acts, records and proceedings under this Order receive full faith and credit in the courts of the United States and other states. V. EFFECTIVE DATE This Order shall take effect on April 8, 2020 and, unless sooner amended or rescinded, terminates 30 days after the termination of the COVID-19 state of emergency. <task instructions> ======= Base your response strictly on the provided document only. Answer in less than 5 words. Do not include numbers.

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. [user request] [context document]

In my economics class today, we read this article about the Laffer Curve. I'm rereading it at home and would like to gain a better understanding of how to apply it in practice. Would it be fair to say that lowering prohibitively low taxes will usually lead to increased tax revenue and how the Laffer curved is used? Please explain the reasoning, outlined in this reference text, that supports your answer in two to seven sentences.

Tax Revenue versus Tax Rates: A Discussion of the Laffer Curve Named for economist Arthur Laffer, the Laffer curve is one of the few macroeconomic concepts with which the general public has at least a passing familiarity. However, it also is not well understood even by many who reference it. Economist Hal Varian once noted, “It has been said that the popularity of the Laffer curve is due to the fact that you can explain it to a Congressman in six minutes and he can talk about it for six months.” 1 This brief explains what the Laffer curve is and its implications for economic policy. In its most general form, the Laffer curve depicts the relationship between tax rates and the revenue the government receives–that is, a single tax rate exists that maximizes the amount of revenue the government obtains from taxation. Figure 1 below represents a graphical depiction of a Laffer curve. Figure 1. General form of a Laffer curve. The vertical axis of Figure 1 depicts the tax rate as a percentage, while the horizontal axis depicts revenues received in dollars. At both a tax rate of 0 percent and 100 percent total tax revenues equal zero. Point E represents the tax rate at which total revenues are maximized.2 The horizontal line through point E that bisects the curve represents two ranges of tax rates in terms of their relationship to revenues. Tax rates below this line indicate the normal range of rates, in which an increase in the tax rate corresponds to an increase in total revenues. Tax rates above this line correspond to the prohibitive range, in which an increase in tax rates results in a decrease in total revenues. Thus, any tax rate other than the rate corresponding to point E results in less revenue collected from the tax. Point E, notably, only represents the rate at which total tax revenues are maximized, not the optimal tax rate in terms of the rate that 1 Varian, H.R. (1989) “What Use is Economic Theory?” Available online at http://people.ischool.berkeley.edu/~hal/Papers/theory.pdf. Accessed 1 May 2017. 2 While point E in Figure 1 may appear to represent the midpoint between tax rates of 0 and 100 percent, it does not necessarily indicate a tax rate of 50 percent maximizes total revenues. [2] creates the fewest distortions in the economy. The vertical line through the curve marked by points A and B demonstrates how, because of the symmetric nature of the curve, two different tax rates can result in the same amount of total revenue. Point A represents a relatively high tax rate, slightly below 100 percent. Point B, conversely, represents a relatively low tax rate, slightly above 0 percent. Yet as the vertical line indicates the total tax revenue collected under these two rates is the same according to the Laffer curve. Points A and B, respectively, indicate that in theory, a high rate on a relatively small tax base generates the same revenue as a low tax rate on a relatively large tax base. The general form of the Laffer curve in Figure 1 does not specify the type of tax rates the government levies. While economists have studied numerous applications, the Laffer curve is usually used to describe the behavior of individual income tax rates levied either by the federal or a state government. In many analyses, economists use the Laffer curve to specifically refer to marginal income tax rates–the rate of tax paid on an additional dollar of income. Laffer describes the curve as illustrating two effects of tax rates on tax revenues.3 The first effect is the arithmetic effect, the increase (decrease) in tax revenues that results from an increase (decrease) in the tax rate. The second–and much more controversial–effect is the economic effect, the increase (decrease) in tax revenues resulting from a decrease (increase) in tax rates because of the incentives (disincentives) created to increase (decrease) work, output, and employment. Essentially the economic effect of the Laffer curve holds that reducing tax rates will motivate people to work more and produce more, leading to more revenue; raising tax rates produces the opposite effect. Laffer notes that the two effects are always in the opposite direction, so that the impact of a change in tax rates on revenues is not necessarily immediately clear. In order for a decrease in tax rates to increase revenues, for example, the rate must lie within the prohibitive range of tax rates as illustrated in Figure 1. In this range the economic effect is positive and larger than the arithmetic effect. Significantly, Laffer states that the curve “. . . does not say whether a tax cut will raise or lower revenues.” He maintains that what happens to revenues as a result of a tax rate change depends on a number of factors, such as “. . . the tax system in place, the time period being considered, the ease of movement into underground activities, the level of tax rates already in place,” and “the prevalence of legal and accounting-driven tax loopholes. . .” Thus, individuals who argue the Laffer curve always holds that a tax cut leads to an increase in tax revenues– whether for good or for ill–misrepresent what it hypothesizes. The Laffer curve has been controversial throughout its forty-year-plus history. One of the chief criticisms inflicted against it is determining where a current tax system lies on the curve; i.e., where the tax rate is in relation to point E in Figure 1. Some economists developed a formula that uses income elasticities and other parameters to determine the rate at which point E occurs. This formula finds that the rate equals around 70 percent.4 Other economists also 3 Laffer, A.B. (2004) “The Laffer Curve: Past, Present, and Future.” Executive Summary Backgrounder No. 1765. The Heritage Foundation. 4 Matthews, D. (2010) “Where does the Laffer curve bend?” The Washington Post. 9 August. Available online at http://voices.washingtonpost.com/ezra-klein/2010/08/where_does_the_laffer_curve_be.html. Accessed 2 May 2017. [3] venture the rate corresponding to point E lies in the range of 70 percent; however, other economists contend the rate is considerably lower. Another criticism of the Laffer curve is a lack of empirical evidence. Arthur Laffer cites several instances in U.S. history and in other countries as examples of “Laffer curve effects.” However, the inherent complexities of most systems of taxation as well as other complicating factors make isolating the impacts of specific rate changes difficult in practice. This situation leads to another criticism of the Laffer curve, which is because it focuses on a single rate, it oversimplifies the analysis of tax rate changes. In conclusion, the Laffer curve continues to influence policymakers at the state and national level both in and outside of the U.S. It is an economic concept with ardent defenders and equally ardent detractors. However, the Laffer curve’s most significant contribution may be how it serves as a jumping off point for serious economic policy discussions involving the structure of income tax systems and how individuals respond to these different structures.

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. In my economics class today, we read this article about the Laffer Curve. I'm rereading it at home and would like to gain a better understanding of how to apply it in practice. Would it be fair to say that lowering prohibitively low taxes will usually lead to increased tax revenue and how the Laffer curved is used? Please explain the reasoning, outlined in this reference text, that supports your answer in two to seven sentences. Tax Revenue versus Tax Rates: A Discussion of the Laffer Curve Named for economist Arthur Laffer, the Laffer curve is one of the few macroeconomic concepts with which the general public has at least a passing familiarity. However, it also is not well understood even by many who reference it. Economist Hal Varian once noted, “It has been said that the popularity of the Laffer curve is due to the fact that you can explain it to a Congressman in six minutes and he can talk about it for six months.” 1 This brief explains what the Laffer curve is and its implications for economic policy. In its most general form, the Laffer curve depicts the relationship between tax rates and the revenue the government receives–that is, a single tax rate exists that maximizes the amount of revenue the government obtains from taxation. Figure 1 below represents a graphical depiction of a Laffer curve. Figure 1. General form of a Laffer curve. The vertical axis of Figure 1 depicts the tax rate as a percentage, while the horizontal axis depicts revenues received in dollars. At both a tax rate of 0 percent and 100 percent total tax revenues equal zero. Point E represents the tax rate at which total revenues are maximized.2 The horizontal line through point E that bisects the curve represents two ranges of tax rates in terms of their relationship to revenues. Tax rates below this line indicate the normal range of rates, in which an increase in the tax rate corresponds to an increase in total revenues. Tax rates above this line correspond to the prohibitive range, in which an increase in tax rates results in a decrease in total revenues. Thus, any tax rate other than the rate corresponding to point E results in less revenue collected from the tax. Point E, notably, only represents the rate at which total tax revenues are maximized, not the optimal tax rate in terms of the rate that 1 Varian, H.R. (1989) “What Use is Economic Theory?” Available online at http://people.ischool.berkeley.edu/~hal/Papers/theory.pdf. Accessed 1 May 2017. 2 While point E in Figure 1 may appear to represent the midpoint between tax rates of 0 and 100 percent, it does not necessarily indicate a tax rate of 50 percent maximizes total revenues. [2] creates the fewest distortions in the economy. The vertical line through the curve marked by points A and B demonstrates how, because of the symmetric nature of the curve, two different tax rates can result in the same amount of total revenue. Point A represents a relatively high tax rate, slightly below 100 percent. Point B, conversely, represents a relatively low tax rate, slightly above 0 percent. Yet as the vertical line indicates the total tax revenue collected under these two rates is the same according to the Laffer curve. Points A and B, respectively, indicate that in theory, a high rate on a relatively small tax base generates the same revenue as a low tax rate on a relatively large tax base. The general form of the Laffer curve in Figure 1 does not specify the type of tax rates the government levies. While economists have studied numerous applications, the Laffer curve is usually used to describe the behavior of individual income tax rates levied either by the federal or a state government. In many analyses, economists use the Laffer curve to specifically refer to marginal income tax rates–the rate of tax paid on an additional dollar of income. Laffer describes the curve as illustrating two effects of tax rates on tax revenues.3 The first effect is the arithmetic effect, the increase (decrease) in tax revenues that results from an increase (decrease) in the tax rate. The second–and much more controversial–effect is the economic effect, the increase (decrease) in tax revenues resulting from a decrease (increase) in tax rates because of the incentives (disincentives) created to increase (decrease) work, output, and employment. Essentially the economic effect of the Laffer curve holds that reducing tax rates will motivate people to work more and produce more, leading to more revenue; raising tax rates produces the opposite effect. Laffer notes that the two effects are always in the opposite direction, so that the impact of a change in tax rates on revenues is not necessarily immediately clear. In order for a decrease in tax rates to increase revenues, for example, the rate must lie within the prohibitive range of tax rates as illustrated in Figure 1. In this range the economic effect is positive and larger than the arithmetic effect. Significantly, Laffer states that the curve “. . . does not say whether a tax cut will raise or lower revenues.” He maintains that what happens to revenues as a result of a tax rate change depends on a number of factors, such as “. . . the tax system in place, the time period being considered, the ease of movement into underground activities, the level of tax rates already in place,” and “the prevalence of legal and accounting-driven tax loopholes. . .” Thus, individuals who argue the Laffer curve always holds that a tax cut leads to an increase in tax revenues– whether for good or for ill–misrepresent what it hypothesizes. The Laffer curve has been controversial throughout its forty-year-plus history. One of the chief criticisms inflicted against it is determining where a current tax system lies on the curve; i.e., where the tax rate is in relation to point E in Figure 1. Some economists developed a formula that uses income elasticities and other parameters to determine the rate at which point E occurs. This formula finds that the rate equals around 70 percent.4 Other economists also 3 Laffer, A.B. (2004) “The Laffer Curve: Past, Present, and Future.” Executive Summary Backgrounder No. 1765. The Heritage Foundation. 4 Matthews, D. (2010) “Where does the Laffer curve bend?” The Washington Post. 9 August. Available online at http://voices.washingtonpost.com/ezra-klein/2010/08/where_does_the_laffer_curve_be.html. Accessed 2 May 2017. [3] venture the rate corresponding to point E lies in the range of 70 percent; however, other economists contend the rate is considerably lower. Another criticism of the Laffer curve is a lack of empirical evidence. Arthur Laffer cites several instances in U.S. history and in other countries as examples of “Laffer curve effects.” However, the inherent complexities of most systems of taxation as well as other complicating factors make isolating the impacts of specific rate changes difficult in practice. This situation leads to another criticism of the Laffer curve, which is because it focuses on a single rate, it oversimplifies the analysis of tax rate changes. In conclusion, the Laffer curve continues to influence policymakers at the state and national level both in and outside of the U.S. It is an economic concept with ardent defenders and equally ardent detractors. However, the Laffer curve’s most significant contribution may be how it serves as a jumping off point for serious economic policy discussions involving the structure of income tax systems and how individuals respond to these different structures. http://www.mississippi.edu/urc/downloads/laffer_curve.pdf

Answer the prompt only using the provided text as your source of information. Do not use any external sources or prior knowledge.

List every strange law pertaining to an animal.

Alabama: • Anniston: You may not wear blue jeans down Noble Street. • Bear wrestling matches are prohibited. • Dominoes may not be played on Sunday. • It is illegal for a driver to be blindfolded while operating a vehicle. • It is illegal to wear a fake moustache that causes laughter in church. • It is legal to drive the wrong way down a one-way street if you have a lantern attached to the front of your automobile. • Montgomery: It is considered an offense to open an umbrella on a street, for fear of it spooking horses. • You cannot chain your alligator to a fire hydrant. • You may not drive barefooted. • You may not have an ice cream cone in your back pocket at any time. Alaska: • Even though it is legal to hunt a bear, it is illegal to wake a bear and take a picture for photo opportunities. • In Alaska it is illegal to whisper in someone's ear while they are moose hunting. • It is considered an offense to push a live moose out of a moving airplane. • Kangaroos are not allowed in barber shops at any time. • Moose may not be viewed from an airplane. Arizona: • Donkeys cannot sleep in bathtubs. • Glendale: Cars may not be driven in reverse. • Hunting camels is prohibited. • It is illegal for men and women over the age of 18 to have less than one missing tooth visible when smiling. • It is unlawful to refuse a person a glass of water. • Mohave County: A decree declares that anyone caught stealing soap must wash with it until it is all used up. Arkansas: • A law provides that school teachers who bob their hair will not get a raise. • Alligators may not be kept in bathtubs. • Arkansas must be pronounced "Arkansaw" • In Arkansas it is illegal to buy or sell blue light bulbs. California: • Baldwin Park: Nobody is allowed to ride a bicycle in a swimming pool. • Blythe: You are not permitted to wear cowboy boots unless you already own at least two cows. • Burlingame: It is illegal to spit, except on baseball diamonds; Carmel Ice cream may not be eaten while standing on the sidewalk. (Repealed when Clint Eastwood was mayor); Women may not wear high heels while in the city limits. • Community leaders passed an ordinance that makes it illegal for anyone to try and stop a child from playfully jumping over puddles of water. • Hollywood: It is illegal to drive more than two thousand sheep down Hollywood Boulevard at one time. • In California it is illegal to have caller ID • In California it's against regulations to let phones ring more than nine times in state offices. • It is illegal to cry on the witness stand. • Lodi: It is illegal to own or sell "Silly String". • It is illegal to set a mouse trap without a hunting license. • Women may not drive in a house coat. Colorado: • Car dealers may not show cars on a Sunday. • Cripple Creek: It is illegal to bring your horse or pack mule above the ground floor of any building. • Denver: The dog catcher must notify dogs of impounding by posting, for three consecutive days, a notice on a tree in the city park and along a public road running through said park; it is unlawful to lend your vacuum cleaner to your next-door neighbor; it is illegal to mistreat rats; you may not drive a black car on Sundays. • In Colorado it's now legal to remove the furniture tags that say, "Do Not Remove Under Penalty of Law." • It is illegal to mistreat rats in Denver. • In Colorado it's now legal to remove the furniture tags that say, "Do Not Remove Under Penalty of Law." • Pueblo: It is illegal to let a dandelion grow within the city limits. • Sterling: Cats may not run loose without having been fit with a taillight. Connecticut: • A local ordinance in Atwoodville, Connecticut prohibits people from playing Scrabble while waiting for a politician to speak. • A pickle is not officially a pickle unless it bounces • Balloons with advertising on them are illegal in Hartford, Conn. • Bloomfield, Conn: It's against the law to eat in your car. • Devon: It is unlawful to walk backwards after sunset. • Guilford: Only white Christmas lights are allowed for display. • Hartford: You aren't allowed to cross a street while walking on your hands. • You may not educate dogs

System instruction: Answer the prompt only using the provided text as your source of information. Do not use any external sources or prior knowledge. User question: List every strange law pertaining to an animal. Context block: Alabama: • Anniston: You may not wear blue jeans down Noble Street. • Bear wrestling matches are prohibited. • Dominoes may not be played on Sunday. • It is illegal for a driver to be blindfolded while operating a vehicle. • It is illegal to wear a fake moustache that causes laughter in church. • It is legal to drive the wrong way down a one-way street if you have a lantern attached to the front of your automobile. • Montgomery: It is considered an offense to open an umbrella on a street, for fear of it spooking horses. • You cannot chain your alligator to a fire hydrant. • You may not drive barefooted. • You may not have an ice cream cone in your back pocket at any time. Alaska: • Even though it is legal to hunt a bear, it is illegal to wake a bear and take a picture for photo opportunities. • In Alaska it is illegal to whisper in someone's ear while they are moose hunting. • It is considered an offense to push a live moose out of a moving airplane. • Kangaroos are not allowed in barber shops at any time. • Moose may not be viewed from an airplane. Arizona: • Donkeys cannot sleep in bathtubs. • Glendale: Cars may not be driven in reverse. • Hunting camels is prohibited. • It is illegal for men and women over the age of 18 to have less than one missing tooth visible when smiling. • It is unlawful to refuse a person a glass of water. • Mohave County: A decree declares that anyone caught stealing soap must wash with it until it is all used up. Arkansas: • A law provides that school teachers who bob their hair will not get a raise. • Alligators may not be kept in bathtubs. • Arkansas must be pronounced "Arkansaw" • In Arkansas it is illegal to buy or sell blue light bulbs. California: • Baldwin Park: Nobody is allowed to ride a bicycle in a swimming pool. • Blythe: You are not permitted to wear cowboy boots unless you already own at least two cows. • Burlingame: It is illegal to spit, except on baseball diamonds; Carmel Ice cream may not be eaten while standing on the sidewalk. (Repealed when Clint Eastwood was mayor); Women may not wear high heels while in the city limits. • Community leaders passed an ordinance that makes it illegal for anyone to try and stop a child from playfully jumping over puddles of water. • Hollywood: It is illegal to drive more than two thousand sheep down Hollywood Boulevard at one time. • In California it is illegal to have caller ID • In California it's against regulations to let phones ring more than nine times in state offices. • It is illegal to cry on the witness stand. • Lodi: It is illegal to own or sell "Silly String". • It is illegal to set a mouse trap without a hunting license. • Women may not drive in a house coat. Colorado: • Car dealers may not show cars on a Sunday. • Cripple Creek: It is illegal to bring your horse or pack mule above the ground floor of any building. • Denver: The dog catcher must notify dogs of impounding by posting, for three consecutive days, a notice on a tree in the city park and along a public road running through said park; it is unlawful to lend your vacuum cleaner to your next-door neighbor; it is illegal to mistreat rats; you may not drive a black car on Sundays. • In Colorado it's now legal to remove the furniture tags that say, "Do Not Remove Under Penalty of Law." • It is illegal to mistreat rats in Denver. • In Colorado it's now legal to remove the furniture tags that say, "Do Not Remove Under Penalty of Law." • Pueblo: It is illegal to let a dandelion grow within the city limits. • Sterling: Cats may not run loose without having been fit with a taillight. Connecticut: • A local ordinance in Atwoodville, Connecticut prohibits people from playing Scrabble while waiting for a politician to speak. • A pickle is not officially a pickle unless it bounces • Balloons with advertising on them are illegal in Hartford, Conn. • Bloomfield, Conn: It's against the law to eat in your car. • Devon: It is unlawful to walk backwards after sunset. • Guilford: Only white Christmas lights are allowed for display. • Hartford: You aren't allowed to cross a street while walking on your hands. • You may not educate dogs

This task requires you to answer a question based only on the information provided in the prompt. You should not use external resources or prior knowledge to answer it. Please answer using language that is sophisticated and would be understood by someone who is familiar with the topic but not an expert.

Please define Common Law Offenses, Surety Statues, and Statutory Prohibitions as they relate to gun laws.

(2) The burden then falls on respondents to show that New York’s proper-cause requirement is consistent with this Nation’s historical tradition of firearm regulation. To do so, respondents appeal to a variety of historical sources from the late 1200s to the early 1900s. But when it comes to interpreting the Constitution, not all history is created equal. “Constitutional rights are enshrined with the scope they were understood to have when the people adopted them.” Heller, 554 U. S., at 634–635. The Second Amendment was adopted in 1791; the Fourteenth in 1868. Historical evidence that long predates or postdates either time may not illuminate the scope of the right. With these principles in mind, the Court concludes that respondents have failed to meet their burden to identify an American tradition justifying New York’s proper-cause requirement. Pp. 24–62. (i) Respondents’ substantial reliance on English history and custom before the founding makes some sense given Heller’s statement that the Second Amendment “codified a right ‘inherited from our English ancestors.’ ” 554 U. S., at 599. But the Court finds that history ambiguous at best and sees little reason to think that the Framers would have thought it applicable in the New World. The Court cannot conclude from this historical record that, by the time of the founding, English law would have justified restricting the right to publicly bear arms suited for self-defense only to those who demonstrate some special need for self-protection. Pp. 30–37. (ii) Respondents next direct the Court to the history of the Colonies and early Republic, but they identify only three restrictions on public carry from that time. While the Court doubts that just three colonial regulations could suffice to show a tradition of public-carry regulation, even looking at these laws on their own terms, the Court is not convinced that they regulated public carry akin to the New York law at issue. The statutes essentially prohibited bearing arms in a way that spread “fear” or “terror” among the people, including by carrying of “dangerous and unusual weapons.” See 554 U. S., at 627. Whatever the likelihood that handguns were considered “dangerous and unusual” during the colonial period, they are today “the quintessential self-defense weapon.” Id., at 629. Thus, these colonial laws provide no justification for laws restricting the public carry of weapons that are unquestionably in common use today. Pp. 37–42. (iii) Only after the ratification of the Second Amendment in 1791 did public-carry restrictions proliferate. Respondents rely heavily on these restrictions, which generally fell into three categories: common-law offenses, statutory prohibitions, and “surety” statutes. None of these restrictions imposed a substantial burden on public carry analogous to that imposed by New York’s restrictive licensing regime. Common-Law Offenses. As during the colonial and founding periods, the common-law offenses of “affray” or going armed “to the terror of the people” continued to impose some limits on firearm carry in the antebellum period. But there is no evidence indicating that these common-law limitations impaired the right of the general population to peaceable public carry. Statutory Prohibitions. In the early to mid-19th century, some States began enacting laws that proscribed the concealed carry of pistols and other small weapons. But the antebellum state-court decisions upholding them evince a consensus view that States could not altogether prohibit the public carry of arms protected by the Second Amendment or state analogues. Surety Statutes. In the mid-19th century, many jurisdictions began adopting laws that required certain individuals to post bond before carrying weapons in public. Contrary to respondents’ position, these surety statutes in no way represented direct precursors to New York’s proper-cause requirement. While New York presumes that individuals have no public carry right without a showing of heightened need, the surety statutes presumed that individuals had a right to public carry that could be burdened only if another could make out a specific showing of “reasonable cause to fear an injury, or breach of the peace.” Mass. Rev. Stat., ch. 134, §16 (1836). Thus, unlike New York’s regime, a showing of special need was required only after an individual was reasonably accused of intending to injure another or breach the peace. And, even then, proving special need simply avoided a fee. In sum, the historical evidence from antebellum America does demonstrate that the manner of public carry was subject to reasonable regulation, but none of these limitations on the right to bear arms operated to prevent law-abiding citizens with ordinary self-defense needs from carrying arms in public for that purpose. Pp. 42–51. (iv) Evidence from around the adoption of the Fourteenth Amendment also does not support respondents’ position. The “discussion of the [right to keep and bear arms] in Congress and in public discourse, as people debated whether and how to secure constitutional rights for newly free slaves,” Heller, 554 U. S., at 614, generally demonstrates that during Reconstruction the right to keep and bear arms had limits that were consistent with a right of the public to peaceably carry handguns for self-defense. The Court acknowledges two Texas cases—English v. State, 35 Tex. 473 and State v. Duke, 42 Tex. 455—that approved a statutory “reasonable grounds” standard for public carry analogous to New York’s proper-cause requirement. But these decisions were outliers and therefore provide little insight into how postbellum courts viewed the right to carry protected arms in public. See Heller, 554 U. S., at 632. Pp. 52–58.

system instruction: [This task requires you to answer a question based only on the information provided in the prompt. You should not use external resources or prior knowledge to answer it. Please answer using language that is sophisticated and would be understood by someone who is familiar with the topic but not an expert.] question: [Please define Common Law Offenses, Surety Statues, and Statutory Prohibitions as they relate to gun laws.] context block: [(2) The burden then falls on respondents to show that New York’s proper-cause requirement is consistent with this Nation’s historical tradition of firearm regulation. To do so, respondents appeal to a variety of historical sources from the late 1200s to the early 1900s. But when it comes to interpreting the Constitution, not all history is created equal. “Constitutional rights are enshrined with the scope they were understood to have when the people adopted them.” Heller, 554 U. S., at 634–635. The Second Amendment was adopted in 1791; the Fourteenth in 1868. Historical evidence that long predates or postdates either time may not illuminate the scope of the right. With these principles in mind, the Court concludes that respondents have failed to meet their burden to identify an American tradition justifying New York’s proper-cause requirement. Pp. 24–62. (i) Respondents’ substantial reliance on English history and custom before the founding makes some sense given Heller’s statement that the Second Amendment “codified a right ‘inherited from our English ancestors.’ ” 554 U. S., at 599. But the Court finds that history ambiguous at best and sees little reason to think that the Framers would have thought it applicable in the New World. The Court cannot conclude from this historical record that, by the time of the founding, English law would have justified restricting the right to publicly bear arms suited for self-defense only to those who demonstrate some special need for self-protection. Pp. 30–37. (ii) Respondents next direct the Court to the history of the Colonies and early Republic, but they identify only three restrictions on public carry from that time. While the Court doubts that just three colonial regulations could suffice to show a tradition of public-carry regulation, even looking at these laws on their own terms, the Court is not convinced that they regulated public carry akin to the New York law at issue. The statutes essentially prohibited bearing arms in a way that spread “fear” or “terror” among the people, including by carrying of “dangerous and unusual weapons.” See 554 U. S., at 627. Whatever the likelihood that handguns were considered “dangerous and unusual” during the colonial period, they are today “the quintessential self-defense weapon.” Id., at 629. Thus, these colonial laws provide no justification for laws restricting the public carry of weapons that are unquestionably in common use today. Pp. 37–42. (iii) Only after the ratification of the Second Amendment in 1791 did public-carry restrictions proliferate. Respondents rely heavily on these restrictions, which generally fell into three categories: common-law offenses, statutory prohibitions, and “surety” statutes. None of these restrictions imposed a substantial burden on public carry analogous to that imposed by New York’s restrictive licensing regime. Common-Law Offenses. As during the colonial and founding periods, the common-law offenses of “affray” or going armed “to the terror of the people” continued to impose some limits on firearm carry in the antebellum period. But there is no evidence indicating that these common-law limitations impaired the right of the general population to peaceable public carry. Statutory Prohibitions. In the early to mid-19th century, some States began enacting laws that proscribed the concealed carry of pistols and other small weapons. But the antebellum state-court decisions upholding them evince a consensus view that States could not altogether prohibit the public carry of arms protected by the Second Amendment or state analogues. Surety Statutes. In the mid-19th century, many jurisdictions began adopting laws that required certain individuals to post bond before carrying weapons in public. Contrary to respondents’ position, these surety statutes in no way represented direct precursors to New York’s proper-cause requirement. While New York presumes that individuals have no public carry right without a showing of heightened need, the surety statutes presumed that individuals had a right to public carry that could be burdened only if another could make out a specific showing of “reasonable cause to fear an injury, or breach of the peace.” Mass. Rev. Stat., ch. 134, §16 (1836). Thus, unlike New York’s regime, a showing of special need was required only after an individual was reasonably accused of intending to injure another or breach the peace. And, even then, proving special need simply avoided a fee. In sum, the historical evidence from antebellum America does demonstrate that the manner of public carry was subject to reasonable regulation, but none of these limitations on the right to bear arms operated to prevent law-abiding citizens with ordinary self-defense needs from carrying arms in public for that purpose. Pp. 42–51. (iv) Evidence from around the adoption of the Fourteenth Amendment also does not support respondents’ position. The “discussion of the [right to keep and bear arms] in Congress and in public discourse, as people debated whether and how to secure constitutional rights for newly free slaves,” Heller, 554 U. S., at 614, generally demonstrates that during Reconstruction the right to keep and bear arms had limits that were consistent with a right of the public to peaceably carry handguns for self-defense. The Court acknowledges two Texas cases—English v. State, 35 Tex. 473 and State v. Duke, 42 Tex. 455—that approved a statutory “reasonable grounds” standard for public carry analogous to New York’s proper-cause requirement. But these decisions were outliers and therefore provide little insight into how postbellum courts viewed the right to carry protected arms in public. See Heller, 554 U. S., at 632. Pp. 52–58.]

Answer in complete sentences, only use the context document, no outside knowledge.

According to the document, can a city make it illegal to be homeless?

**Homelessness laws in Texas** When is an individual considered homeless? The United State Department of Housing and Urban Development (HUD) provides four broad categories of homelessness:  Individuals and families who lack a fixed, regular, and adequate nighttime residence, which includes a subset for an individual who is exiting an institution where he or she resided for 90 days or less and who resided in an emergency shelter or a place not meant for human habitation immediately before entering that institution;  Individuals and families who will imminently lose their primary nighttime residence;  Unaccompanied youth and families with children and youth who are defined as homeless under other federal statutes who do not otherwise qualify as homeless under this definition; or  Individuals and families who are fleeing, or are attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family member. What negative effects can a large homeless population have on a city? A large homeless population can be draining on a community. Homeless individuals that lack access to proper medical care may choose an emergency room at a hospital for medical services rather than a primary care medical office. This option is significantly more expensive and typically the homeless individual is unable to pay the bill, so the cost is passed on to insurance companies and the average customer in a community. Homeless individuals spend more time in local jails than the housed population for petty offenses, which increases the costs to run the facility. Additionally, a large homeless population can affect a city’s ability to attract tourists. What is affordable housing? Affordable housing is housing for which the occupant pays less than 30 percent of their income. Housing that is considered to be “affordable” will differ between communities, depending on the median family income of the area. What is Section 8 housing? “Section 8” refers to Section 8 of the federal Housing Act of 1937. This section authorizes project-based rental assistance programs under which a participating owner, or landlord, is required to reserve units in a building for low-income tenants, in return for a federal government guarantee to make up the difference between the tenant's contribution and the rent in the owner's contract with the government. What is a Section 8 voucher? Section 8 of the federal Housing Act also authorizes vouchers for low-income individuals. HUD manages the Housing Choice Voucher Program, which provides financial assistance directly to the landlord for a family that qualifies. The Housing Choice Voucher Program is the federal government's major program for assisting very low-income families, the elderly, and the disabled to afford decent, safe, and sanitary housing in the private market. Since housing assistance is provided on behalf of the family or individual, participants are able to find their own housing, including single-family homes, townhouses and apartments, and are free to choose any housing option that meets the requirements of the program. Housing choice vouchers are administered locally by public housing agencies (PHAs). The PHAs receive federal funds from HUD to administer the voucher program. A list of public housing authorities in Texas can be found at http://portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/pha/contacts/ tx A housing subsidy is paid to the landlord directly by the PHA on behalf of the participating family. The family then pays the difference between the actual rent charged by the landlord and the amount subsidized by the program. Can a city make being homeless illegal? No. Laws that punish status or condition rather than criminal conduct have been struck down by courts as constituting cruel and unusual punishment. These types of laws fail to give fair notice of prohibited conduct and encourage arbitrary arrests and convictions. Additionally, courts have overturned vagrancy laws, or laws that criminalize being homeless, as impermissible restrictions on an individual’s right to travel. See Papachristou v. City of Jacksonville, 45 U.S. 156, 162(1972); Handler v. Denver, 77 P.2d 132, 135 (Colo. 1938); Pottinger v. City of Miami, 810 F. Supp. 1551, 1578 (S.D. Fla. 1992). Can the city enact a loitering prohibition? Maybe. In a 1983 decision in Kolender v. Lawson, the United State Supreme Court invalidated a California loitering statute requiring street wanderers to present valid identification when stopped by police officers. The Court held that the statute was too vague to satisfy due process requirements. The Court followed this decision with its decision in Chicago v. Morales, which struck down a Chicago ordinance preventing loitering by gang members on due process grounds. An ordinance that is general in nature that criminalizes loitering on a public street would most likely be struck down by a court for vagueness. However, if the wording of the ordinance is sufficient to set forth guidelines for law enforcement officers narrowly tailoring the restriction to those who loiter with a specific illegal purpose, then a loitering ordinance may pass constitutional muster. City officials will want to work closely with their local legal counsel if they desire to adopt such an ordinance. Can a city prevent homeless people from panhandling in all public places? No. Litigation related to bans on panhandling has centered on First Amendment free speech claims. Courts have ruled that outlawing panhandling in all public places was unconstitutional. See generally Young v. New York City Transit Auth., 903 F.2d 146 (2d Cir. 1990); Speet v. Schuette, 889 F. Supp. 2d 969 (W.D. Mich. 2012). Instead, any limits on panhandling on public sidewalks trigger strict scrutiny, meaning the regulations must be narrowly tailored to serve a significant governmental interest and must be the least restrictive means for achieving that interest. Courts have found that safety and traffic congestion may be significant interests but “mere annoyance” is not a sufficiently compelling reason to absolutely deprive an individual of his or her First Amendment rights. What strategies have cities used to reduce homelessness?  Participating in the “Mayors Challenge to End Veteran Homelessness,” a program designed to equip city leaders with tools to combat veteran homelessness. For more information on how to participate, you can visit the Department of Housing and Urban Development’s Mayors Challenge page at http://portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/veteran_info rmation/mayors_challenge/mayors_and_staff;  Seeking state grants awarded by the Texas Department of Housing and Community Affairs or federal grants awarded by HUD;  Educating law enforcement officers on alternatives to issuing citations and supporting police department partnerships with mental health partners;  Recruiting landlords in the city to assist in providing housing opportunities for individuals and families experiencing homelessness;  Educating municipal court personnel on providing referrals to municipal court defendants to non-profit groups in the city that provide housing and other services;  Issuing general obligation bonds for the purpose of expanding affordable housing in the city;  Creating a housing authority to assist with providing affordable housing within the city. What is a housing authority? A housing authority is a public body that is created for clearance, replanning, and reconstruction of areas in which unsanitary or unsafe housing exists and for providing safe and sanitary housing for persons of low income. The housing authority may provide for the construction, improvement, alteration, or repair of a housing project, or part of a housing project, in its area of operation. A housing authority may also lease or rent housing, land, buildings, structures, or facilities included in a housing project. A housing authority is able to borrow money or accept grants or other financial assistance from the federal government for a housing project in the authority's area of operation, or form a partnership or another entity to raise capital for a housing project to be owned by the partnership or other entity. How does our city create a housing authority? The city council may declare by resolution that there is a need for a housing authority in the city if it finds that there is: (1) unsanitary or unsafe inhabited housing in the city; or (2) a shortage of safe or sanitary housing in the city available to persons of low income at rentals that they can afford. TEX. LOC. GOV’T CODE § 392.011. The council may determine on its own motion if there is a need for a housing authority but must determine there is a need upon receiving a petition signed by at least 100 qualified voters of the city. Who appoints members of a housing authority? Each municipal housing authority is governed by either five, seven, nine, or 11 commissioners. The mayor of the city appoints the commissioners of the authority, and an appointed commissioner of the authority may not be an officer or employee of the city. TEX. LOC. GOV’T CODE § 392.031. After the appointment, a certificate of the appointment of a commissioner must be filed with the city secretary. A city with a municipal housing authority composed of five commissioners must appoint at least one commissioner to the authority who is a tenant of a public housing project over which the authority has jurisdiction. TEX. LOC. GOV’T CODE § 392.0331. A city with a municipality with a municipal housing authority composed of seven or more commissioners must appoint at least two commissioners to the authority who are tenants of a public housing project over which the authority has jurisdiction. What is the term of office for a housing authority commissioner? Initially, a housing authority with five commissioners must have two designated to serve oneyear terms and three designated to serve two-year terms. A housing authority with seven commissioners must have three designated to serve one-year terms and four designated to serve two-year terms. A housing authority with nine commissioners must have four designated to serve one-year terms and five designated to serve two-year terms. Finally, a housing authority with 11 commissioners must have five designated to serve one-year terms and six designated to serve two-year terms. Subsequent municipal housing commissioners are appointed for two-year terms. If there is a vacancy on the housing authority board, the mayor appoints someone to fill the unexpired term. TEX. LOC. GOV’T CODE § 392.034.

[question] ================== According to the document, can a city make it illegal to be homeless? ================ [passage] ================== **Homelessness laws in Texas** When is an individual considered homeless? The United State Department of Housing and Urban Development (HUD) provides four broad categories of homelessness:  Individuals and families who lack a fixed, regular, and adequate nighttime residence, which includes a subset for an individual who is exiting an institution where he or she resided for 90 days or less and who resided in an emergency shelter or a place not meant for human habitation immediately before entering that institution;  Individuals and families who will imminently lose their primary nighttime residence;  Unaccompanied youth and families with children and youth who are defined as homeless under other federal statutes who do not otherwise qualify as homeless under this definition; or  Individuals and families who are fleeing, or are attempting to flee, domestic violence, dating violence, sexual assault, stalking, or other dangerous or life-threatening conditions that relate to violence against the individual or a family member. What negative effects can a large homeless population have on a city? A large homeless population can be draining on a community. Homeless individuals that lack access to proper medical care may choose an emergency room at a hospital for medical services rather than a primary care medical office. This option is significantly more expensive and typically the homeless individual is unable to pay the bill, so the cost is passed on to insurance companies and the average customer in a community. Homeless individuals spend more time in local jails than the housed population for petty offenses, which increases the costs to run the facility. Additionally, a large homeless population can affect a city’s ability to attract tourists. What is affordable housing? Affordable housing is housing for which the occupant pays less than 30 percent of their income. Housing that is considered to be “affordable” will differ between communities, depending on the median family income of the area. What is Section 8 housing? “Section 8” refers to Section 8 of the federal Housing Act of 1937. This section authorizes project-based rental assistance programs under which a participating owner, or landlord, is required to reserve units in a building for low-income tenants, in return for a federal government guarantee to make up the difference between the tenant's contribution and the rent in the owner's contract with the government. What is a Section 8 voucher? Section 8 of the federal Housing Act also authorizes vouchers for low-income individuals. HUD manages the Housing Choice Voucher Program, which provides financial assistance directly to the landlord for a family that qualifies. The Housing Choice Voucher Program is the federal government's major program for assisting very low-income families, the elderly, and the disabled to afford decent, safe, and sanitary housing in the private market. Since housing assistance is provided on behalf of the family or individual, participants are able to find their own housing, including single-family homes, townhouses and apartments, and are free to choose any housing option that meets the requirements of the program. Housing choice vouchers are administered locally by public housing agencies (PHAs). The PHAs receive federal funds from HUD to administer the voucher program. A list of public housing authorities in Texas can be found at http://portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/pha/contacts/ tx A housing subsidy is paid to the landlord directly by the PHA on behalf of the participating family. The family then pays the difference between the actual rent charged by the landlord and the amount subsidized by the program. Can a city make being homeless illegal? No. Laws that punish status or condition rather than criminal conduct have been struck down by courts as constituting cruel and unusual punishment. These types of laws fail to give fair notice of prohibited conduct and encourage arbitrary arrests and convictions. Additionally, courts have overturned vagrancy laws, or laws that criminalize being homeless, as impermissible restrictions on an individual’s right to travel. See Papachristou v. City of Jacksonville, 45 U.S. 156, 162(1972); Handler v. Denver, 77 P.2d 132, 135 (Colo. 1938); Pottinger v. City of Miami, 810 F. Supp. 1551, 1578 (S.D. Fla. 1992). Can the city enact a loitering prohibition? Maybe. In a 1983 decision in Kolender v. Lawson, the United State Supreme Court invalidated a California loitering statute requiring street wanderers to present valid identification when stopped by police officers. The Court held that the statute was too vague to satisfy due process requirements. The Court followed this decision with its decision in Chicago v. Morales, which struck down a Chicago ordinance preventing loitering by gang members on due process grounds. An ordinance that is general in nature that criminalizes loitering on a public street would most likely be struck down by a court for vagueness. However, if the wording of the ordinance is sufficient to set forth guidelines for law enforcement officers narrowly tailoring the restriction to those who loiter with a specific illegal purpose, then a loitering ordinance may pass constitutional muster. City officials will want to work closely with their local legal counsel if they desire to adopt such an ordinance. Can a city prevent homeless people from panhandling in all public places? No. Litigation related to bans on panhandling has centered on First Amendment free speech claims. Courts have ruled that outlawing panhandling in all public places was unconstitutional. See generally Young v. New York City Transit Auth., 903 F.2d 146 (2d Cir. 1990); Speet v. Schuette, 889 F. Supp. 2d 969 (W.D. Mich. 2012). Instead, any limits on panhandling on public sidewalks trigger strict scrutiny, meaning the regulations must be narrowly tailored to serve a significant governmental interest and must be the least restrictive means for achieving that interest. Courts have found that safety and traffic congestion may be significant interests but “mere annoyance” is not a sufficiently compelling reason to absolutely deprive an individual of his or her First Amendment rights. What strategies have cities used to reduce homelessness?  Participating in the “Mayors Challenge to End Veteran Homelessness,” a program designed to equip city leaders with tools to combat veteran homelessness. For more information on how to participate, you can visit the Department of Housing and Urban Development’s Mayors Challenge page at http://portal.hud.gov/hudportal/HUD?src=/program_offices/comm_planning/veteran_info rmation/mayors_challenge/mayors_and_staff;  Seeking state grants awarded by the Texas Department of Housing and Community Affairs or federal grants awarded by HUD;  Educating law enforcement officers on alternatives to issuing citations and supporting police department partnerships with mental health partners;  Recruiting landlords in the city to assist in providing housing opportunities for individuals and families experiencing homelessness;  Educating municipal court personnel on providing referrals to municipal court defendants to non-profit groups in the city that provide housing and other services;  Issuing general obligation bonds for the purpose of expanding affordable housing in the city;  Creating a housing authority to assist with providing affordable housing within the city. What is a housing authority? A housing authority is a public body that is created for clearance, replanning, and reconstruction of areas in which unsanitary or unsafe housing exists and for providing safe and sanitary housing for persons of low income. The housing authority may provide for the construction, improvement, alteration, or repair of a housing project, or part of a housing project, in its area of operation. A housing authority may also lease or rent housing, land, buildings, structures, or facilities included in a housing project. A housing authority is able to borrow money or accept grants or other financial assistance from the federal government for a housing project in the authority's area of operation, or form a partnership or another entity to raise capital for a housing project to be owned by the partnership or other entity. How does our city create a housing authority? The city council may declare by resolution that there is a need for a housing authority in the city if it finds that there is: (1) unsanitary or unsafe inhabited housing in the city; or (2) a shortage of safe or sanitary housing in the city available to persons of low income at rentals that they can afford. TEX. LOC. GOV’T CODE § 392.011. The council may determine on its own motion if there is a need for a housing authority but must determine there is a need upon receiving a petition signed by at least 100 qualified voters of the city. Who appoints members of a housing authority? Each municipal housing authority is governed by either five, seven, nine, or 11 commissioners. The mayor of the city appoints the commissioners of the authority, and an appointed commissioner of the authority may not be an officer or employee of the city. TEX. LOC. GOV’T CODE § 392.031. After the appointment, a certificate of the appointment of a commissioner must be filed with the city secretary. A city with a municipal housing authority composed of five commissioners must appoint at least one commissioner to the authority who is a tenant of a public housing project over which the authority has jurisdiction. TEX. LOC. GOV’T CODE § 392.0331. A city with a municipality with a municipal housing authority composed of seven or more commissioners must appoint at least two commissioners to the authority who are tenants of a public housing project over which the authority has jurisdiction. What is the term of office for a housing authority commissioner? Initially, a housing authority with five commissioners must have two designated to serve oneyear terms and three designated to serve two-year terms. A housing authority with seven commissioners must have three designated to serve one-year terms and four designated to serve two-year terms. A housing authority with nine commissioners must have four designated to serve one-year terms and five designated to serve two-year terms. Finally, a housing authority with 11 commissioners must have five designated to serve one-year terms and six designated to serve two-year terms. Subsequent municipal housing commissioners are appointed for two-year terms. If there is a vacancy on the housing authority board, the mayor appoints someone to fill the unexpired term. TEX. LOC. GOV’T CODE § 392.034. ================ [task] ================== Answer in complete sentences, only use the context document, no outside knowledge.

Answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. Give your answer in bullet points.

Summarize why pain control is important.

Vital Signs The surgeon, anesthesiologist, physician’s assistant, or nurse practitioner will write an order that specifies how often the vital signs should be checked. Measuring the pulse and blood pressure every 15 minutes in the first hour after the operation is not unusual. The CNA should always let the supervising nurse or physician know about a fever or an abnormal pulse or blood pressure. This is especially important when caring for a post-operative patient. Slight deviations of pulse and blood pressure may be normal after surgery, but these should still be reported. It should not be assumed that a pulse greater than 100, or a systolic blood pressure that is low, are of no concern. Mental Status Drowsiness is expected after surgery. This can be minimal or it may be significant. However, excessive drowsiness or drowsiness that is not improving is not normal. A nurse or physician should be informed if a patient’s mental status appears abnormal. Pain Pain is inevitable following surgery. An incision has been made through the skin, and the swelling and bleeding at the incision increase pressure on nerve endings, contributing to the pain. Some patients will inform the CNA or nurse about their pain and request medications, but others will not. The CNA should always ask the post-operative patient if pain is occurring, but should also be observant to recognize the nonverbal signs of pain. A patient may decide to endure the pain without taking pain medication because of feeling wary about accepting medication. Aside from specifically asking the patient about pain, the CNA should look for objective information and nonverbal cues that indicate the presence of pain. Does the patient grimace when asked to move? Is the patient hesitant about performing coughing and deep breathing exercises? Is the patient’s blood pressure and heart rate elevated? If the patient is showing evidence of any of the above, the CNA may reasonably assume that a significant level of pain is occurring. Pain control is important as it increases patient compliance with post-operative movement and surgical wound healing measures, and the speed of recovery. It is also important to address physical suffering in the post-operative phase to improve standard quality measures of patient comfort during hospital care. The level of pain a patient has will depend in part on what operation was performed. The pain associated with a minor procedure should be mild, but if the patient has had a major orthopedic surgery, such as hip surgery, the pain can be severe. There is no “normal” level of pain and each person has an individual level of tolerance. If the procedure was a simple one, and the patient is significantly uncomfortable, this may indicate a problem. If the CNA notices the patient is uncomfortable, a nurse or physician should always be informed. If the patient is requesting pain medication more frequently than it has been prescribed, this is a warning sign. Many healthcare facilities use pain scales to assess a patient’s level of pain. A typical pain scale is the 1-10 scale. The patient is asked to remember the worst pain ever experienced and consider that a level 10. The patient is then asked to remember a painful experience that was very minor and consider that a level 1. After that, the patient is asked to assign the current level of pain a number on the 1-10 pain scale. The CNA would ask the patient, for example, “If the worst pain you have ever felt was a 10 and a very minor pain you’ve experienced was a 1, what would you consider your current level of pain to be?” Surgical Dressing A surgical dressing is a sterile cover applied over the incision. A dressing can be a small bandage, or it may be a large, complicated affair with gauze pads and tape. The surgeon will write orders that specify how to care for the dressing. It is very important to follow these orders exactly. The CNA should not change or adjust the dressing in any way that has not been ordered. The dressing should be checked frequently to make sure it is intact and that there are no loose edges. Any bleeding or unusual drainage should be noted, and if the CNA notices either one, a supervising nurse or physician needs to be notified.

Answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. Give your answer in bullet points. Summarize why pain control is important. Vital Signs The surgeon, anesthesiologist, physician’s assistant, or nurse practitioner will write an order that specifies how often the vital signs should be checked. Measuring the pulse and blood pressure every 15 minutes in the first hour after the operation is not unusual. The CNA should always let the supervising nurse or physician know about a fever or an abnormal pulse or blood pressure. This is especially important when caring for a post-operative patient. Slight deviations of pulse and blood pressure may be normal after surgery, but these should still be reported. It should not be assumed that a pulse greater than 100, or a systolic blood pressure that is low, are of no concern. Mental Status Drowsiness is expected after surgery. This can be minimal or it may be significant. However, excessive drowsiness or drowsiness that is not improving is not normal. A nurse or physician should be informed if a patient’s mental status appears abnormal. Pain Pain is inevitable following surgery. An incision has been made through the skin, and the swelling and bleeding at the incision increase pressure on nerve endings, contributing to the pain. Some patients will inform the CNA or nurse about their pain and request medications, but others will not. The CNA should always ask the post-operative patient if pain is occurring, but should also be observant to recognize the nonverbal signs of pain. A patient may decide to endure the pain without taking pain medication because of feeling wary about accepting medication. Aside from specifically asking the patient about pain, the CNA should look for objective information and nonverbal cues that indicate the presence of pain. Does the patient grimace when asked to move? Is the patient hesitant about performing coughing and deep breathing exercises? Is the patient’s blood pressure and heart rate elevated? If the patient is showing evidence of any of the above, the CNA may reasonably assume that a significant level of pain is occurring. Pain control is important as it increases patient compliance with post-operative movement and surgical wound healing measures, and the speed of recovery. It is also important to address physical suffering in the post-operative phase to improve standard quality measures of patient comfort during hospital care. The level of pain a patient has will depend in part on what operation was performed. The pain associated with a minor procedure should be mild, but if the patient has had a major orthopedic surgery, such as hip surgery, the pain can be severe. There is no “normal” level of pain and each person has an individual level of tolerance. If the procedure was a simple one, and the patient is significantly uncomfortable, this may indicate a problem. If the CNA notices the patient is uncomfortable, a nurse or physician should always be informed. If the patient is requesting pain medication more frequently than it has been prescribed, this is a warning sign. Many healthcare facilities use pain scales to assess a patient’s level of pain. A typical pain scale is the 1-10 scale. The patient is asked to remember the worst pain ever experienced and consider that a level 10. The patient is then asked to remember a painful experience that was very minor and consider that a level 1. After that, the patient is asked to assign the current level of pain a number on the 1-10 pain scale. The CNA would ask the patient, for example, “If the worst pain you have ever felt was a 10 and a very minor pain you’ve experienced was a 1, what would you consider your current level of pain to be?” Surgical Dressing A surgical dressing is a sterile cover applied over the incision. A dressing can be a small bandage, or it may be a large, complicated affair with gauze pads and tape. The surgeon will write orders that specify how to care for the dressing. It is very important to follow these orders exactly. The CNA should not change or adjust the dressing in any way that has not been ordered. The dressing should be checked frequently to make sure it is intact and that there are no loose edges. Any bleeding or unusual drainage should be noted, and if the CNA notices either one, a supervising nurse or physician needs to be notified.

Only using the below text to draw your answer from,

what factors in the cypto market create uncertainty in terms of government oversight and enforcement?

SEC Jurisdiction and Perceived Crypto-Asset Regulatory Gap: An FTX Case Study November 29, 2022 FTX Trading, a crypto company once valued at $32 billion, filed for Chapter 11 bankruptcy proceedings in November 2022. Some of FTX’s largest investors immediately wrote their FTX investments down to $0. More than a million creditors (including individuals and institutions) are caught up in this FTX insolvency. This Insight uses the FTX event as a case study to illustrate the Securities and Exchange Commission’s (SEC’s) regulatory jurisdiction, how it applies to crypto-assets, and perceived weaknesses in the application of the current regulatory framework. SEC Investigation of FTX The SEC and dozens of other federal, state, and international regulatory agencies and prosecutors have engaged with FTX to obtain more information. The SEC generally does not publicly disclose information regarding ongoing investigations. But multiple news sources have reported that the SEC has been investigating FTX.US, FTX’s U.S. subsidiary, for months. While FTX is based overseas and reportedly seeks to block U.S. customers to potentially avoid U.S. jurisdiction, FTX.US provides narrower product offers and is tailored for the U.S. market, and it maintains several U.S. regulatory licenses. Since the FTX crash, the SEC has reportedly expanded its investigation toward FTX and Alameda Research, an FTX-affiliated investment management firm. At issue is whether FTX and its affiliates are involved in certain securities-related activities, which should have been registered with the SEC (or received an exemption) before being sold to investors. To the extent that these are securities transactions that implicate U.S. jurisdiction, a crypto exchange may be subject to the SEC’s regulation, including the Customer Protection Rule, which requires securities broker-dealers to segregate client assets from their proprietary business activities. That rule may have mitigated some of the issues that reportedly led to FTX’s bankruptcy, as the firm is alleged to have loaned client funds to Alameda Research. More importantly, even if the SEC could prove that FTX and its affiliates violated securities regulations, the SEC’s capability to go after FTX is limited to securities activities, which generally do not include commodities and other non-securities instruments that make up the bulk (or even all, depending on whom you ask) of FTX’s business. Some observers believe that the SEC may face difficulty pursuing FTX mainly because of the firm’s offshore status and how existing regulatory frameworks are currently applied Congressional Research Service https://crsreports.congress.gov IN12052 Congressional Research Service 2 to crypto-assets—certain crypto-asset market segments are generally not subject to federal securities marketplace regulation commonly seen in traditional investments. SEC Jurisdiction The current regulatory landscape for crypto-assets is fragmented. Multiple agencies apply different regulatory approaches to crypto-assets at the federal and state levels. The SEC is the primary regulator overseeing securities offers, sales, and investment activities, including those involving crypto-assets. In general, a security is “the investment of money in a common enterprise with a reasonable expectation of profits to be derived from the efforts of others.” When a crypto-asset meets this criterion, it is subject to the SEC’s jurisdiction. SEC Chair Gensler has repeatedly stated that he believes the vast majority of crypto tokens are securities (while recognizing some crypto-assets are not). Other stakeholders, including the crypto industry, disagree with that assertion. In cases where they are not securities, crypto-assets may be commodities under the Commodity Exchange Act (CEA). In such cases, they would be subject to the Commodity Futures Trading Commission’s (CFTC’s) jurisdiction, which generally extends to commodities and derivatives. For example, under this framework as currently applied, most initial coin offerings are considered securities, but Bitcoin is considered a commodity, not a security. Securities regulations could also apply if the crypto market intermediaries (e.g., investment advisers, trading platforms, and custodians) are directly engaged in the security-based crypto-asset transactions. In cases where the crypto-assets are securities, the SEC has both (1) enforcement authority that allows the SEC to bring civil enforcement actions, such as anti-fraud and anti-manipulation actions, for securities laws violations after the fact and (2) regulatory authority, including over digital asset securities, which could include registration requirements, oversight, and principles-based regulation. Also, the CEA provides the CFTC with certain enforcement and regulatory authority when it comes to digital asset derivatives. However, the CFTC has enforcement authority, but not regulatory authority, over the spot market of digital asset commodities. Perceived Crypto-Asset Regulatory Gap Because crypto-asset commodities spot market activities receive CFTC oversight that generally pertains to enforcement (but not regulatory) authority, activities in these non-security crypto-asset markets are not subject to the same safeguards as those established in securities markets. Examples of such safeguards include certain rules and regulations that encourage market transparency, conflict-of-interest mitigation, investor protection, and orderly market operations. In the case of FTX, if FTX and its affiliates are involved in the crypto commodities spot market (e.g., the trading of Bitcoin), neither the SEC nor the CFTC would normally regulate these activities. Certain observers, including the Financial Stability Oversight Council (FSOC), characterize this framework as having a regulatory gap. FSOC has encouraged Congress to provide explicit rulemaking regulatory authority for federal financial regulators over the spot market for crypto-assets that are not securities. FSOC states that this new rulemaking authority “should not interfere with or weaken market regulators’ current jurisdictional remits.” Policy Questions Some Members of Congress have proposed to redesign SEC and CFTC jurisdiction, and Congress will likely continue to propose changes and explore alternatives. When designing a new regulatory landscape, Congressional Research Service 3 IN12052 · VERSION 1 · NEW policymakers face challenging questions about how (or if) to make crypto-asset securities and commodities regulation more alike. Financial regulators have traditionally followed the “same activity, same risk, same regulation” principle to mitigate the potential risks of regulatory arbitrage. Related questions include: To what extent should the design of the crypto-asset regulation framework align with the existing securities trading and investment regulation? Should different sets of rules be based on the regulatory jurisdiction or the nature of risk exposure and risk mitigation needs? What are the operational costs to the platforms under different alternatives? Should Congress appoint a primary regulator for crypto-asset markets, or should actions such as rulemaking be evenly coordinated across financial agencies that are governing the same or similar entities?

Only using the below text to draw your answer from, what factors in the cypto market create uncertainty in terms of government oversight and enforcement? SEC Jurisdiction and Perceived Crypto-Asset Regulatory Gap: An FTX Case Study November 29, 2022 FTX Trading, a crypto company once valued at $32 billion, filed for Chapter 11 bankruptcy proceedings in November 2022. Some of FTX’s largest investors immediately wrote their FTX investments down to $0. More than a million creditors (including individuals and institutions) are caught up in this FTX insolvency. This Insight uses the FTX event as a case study to illustrate the Securities and Exchange Commission’s (SEC’s) regulatory jurisdiction, how it applies to crypto-assets, and perceived weaknesses in the application of the current regulatory framework. SEC Investigation of FTX The SEC and dozens of other federal, state, and international regulatory agencies and prosecutors have engaged with FTX to obtain more information. The SEC generally does not publicly disclose information regarding ongoing investigations. But multiple news sources have reported that the SEC has been investigating FTX.US, FTX’s U.S. subsidiary, for months. While FTX is based overseas and reportedly seeks to block U.S. customers to potentially avoid U.S. jurisdiction, FTX.US provides narrower product offers and is tailored for the U.S. market, and it maintains several U.S. regulatory licenses. Since the FTX crash, the SEC has reportedly expanded its investigation toward FTX and Alameda Research, an FTX-affiliated investment management firm. At issue is whether FTX and its affiliates are involved in certain securities-related activities, which should have been registered with the SEC (or received an exemption) before being sold to investors. To the extent that these are securities transactions that implicate U.S. jurisdiction, a crypto exchange may be subject to the SEC’s regulation, including the Customer Protection Rule, which requires securities broker-dealers to segregate client assets from their proprietary business activities. That rule may have mitigated some of the issues that reportedly led to FTX’s bankruptcy, as the firm is alleged to have loaned client funds to Alameda Research. More importantly, even if the SEC could prove that FTX and its affiliates violated securities regulations, the SEC’s capability to go after FTX is limited to securities activities, which generally do not include commodities and other non-securities instruments that make up the bulk (or even all, depending on whom you ask) of FTX’s business. Some observers believe that the SEC may face difficulty pursuing FTX mainly because of the firm’s offshore status and how existing regulatory frameworks are currently applied Congressional Research Service https://crsreports.congress.gov IN12052 Congressional Research Service 2 to crypto-assets—certain crypto-asset market segments are generally not subject to federal securities marketplace regulation commonly seen in traditional investments. SEC Jurisdiction The current regulatory landscape for crypto-assets is fragmented. Multiple agencies apply different regulatory approaches to crypto-assets at the federal and state levels. The SEC is the primary regulator overseeing securities offers, sales, and investment activities, including those involving crypto-assets. In general, a security is “the investment of money in a common enterprise with a reasonable expectation of profits to be derived from the efforts of others.” When a crypto-asset meets this criterion, it is subject to the SEC’s jurisdiction. SEC Chair Gensler has repeatedly stated that he believes the vast majority of crypto tokens are securities (while recognizing some crypto-assets are not). Other stakeholders, including the crypto industry, disagree with that assertion. In cases where they are not securities, crypto-assets may be commodities under the Commodity Exchange Act (CEA). In such cases, they would be subject to the Commodity Futures Trading Commission’s (CFTC’s) jurisdiction, which generally extends to commodities and derivatives. For example, under this framework as currently applied, most initial coin offerings are considered securities, but Bitcoin is considered a commodity, not a security. Securities regulations could also apply if the crypto market intermediaries (e.g., investment advisers, trading platforms, and custodians) are directly engaged in the security-based crypto-asset transactions. In cases where the crypto-assets are securities, the SEC has both (1) enforcement authority that allows the SEC to bring civil enforcement actions, such as anti-fraud and anti-manipulation actions, for securities laws violations after the fact and (2) regulatory authority, including over digital asset securities, which could include registration requirements, oversight, and principles-based regulation. Also, the CEA provides the CFTC with certain enforcement and regulatory authority when it comes to digital asset derivatives. However, the CFTC has enforcement authority, but not regulatory authority, over the spot market of digital asset commodities. Perceived Crypto-Asset Regulatory Gap Because crypto-asset commodities spot market activities receive CFTC oversight that generally pertains to enforcement (but not regulatory) authority, activities in these non-security crypto-asset markets are not subject to the same safeguards as those established in securities markets. Examples of such safeguards include certain rules and regulations that encourage market transparency, conflict-of-interest mitigation, investor protection, and orderly market operations. In the case of FTX, if FTX and its affiliates are involved in the crypto commodities spot market (e.g., the trading of Bitcoin), neither the SEC nor the CFTC would normally regulate these activities. Certain observers, including the Financial Stability Oversight Council (FSOC), characterize this framework as having a regulatory gap. FSOC has encouraged Congress to provide explicit rulemaking regulatory authority for federal financial regulators over the spot market for crypto-assets that are not securities. FSOC states that this new rulemaking authority “should not interfere with or weaken market regulators’ current jurisdictional remits.” Policy Questions Some Members of Congress have proposed to redesign SEC and CFTC jurisdiction, and Congress will likely continue to propose changes and explore alternatives. When designing a new regulatory landscape, Congressional Research Service 3 IN12052 · VERSION 1 · NEW policymakers face challenging questions about how (or if) to make crypto-asset securities and commodities regulation more alike. Financial regulators have traditionally followed the “same activity, same risk, same regulation” principle to mitigate the potential risks of regulatory arbitrage. Related questions include: To what extent should the design of the crypto-asset regulation framework align with the existing securities trading and investment regulation? Should different sets of rules be based on the regulatory jurisdiction or the nature of risk exposure and risk mitigation needs? What are the operational costs to the platforms under different alternatives? Should Congress appoint a primary regulator for crypto-asset markets, or should actions such as rulemaking be evenly coordinated across financial agencies that are governing the same or similar entities?

Respond to the following question with only the information I provide within this prompt, your answer should be two paragraphs long.

Why is Mr Lloyd's strategy unusual?

A. INTRODUCTION 1. Mr Richard Lloyd - with financial backing from Therium Litigation Funding IC, a commercial litigation funder - has issued a claim against Google LLC, alleging breach of its duties as a data controller under section 4(4) of the Data Protection Act 1998 (“the DPA 1998”). The claim alleges that, for several months in late 2011 and early 2012, Google secretly tracked the internet activity of millions of Apple iPhone users and used the data collected in this way for commercial purposes without the users’ knowledge or consent. 2. The factual allegation is not new. In August 2012, Google agreed to pay a civil penalty of US$22.5m to settle charges brought by the United States Federal Trade Commission based upon the allegation. In November 2013, Google agreed to pay US$17m to settle consumer-based actions brought against it in the United States. In England and Wales, three individuals sued Google in June 2013 making the same allegation and claiming compensation under the DPA 1998 and at common law for misuse of private information: see Vidal-Hall v Google Inc (Information Comr intervening) [2015] EWCA Civ 311; [2016] QB 1003. Following a dispute over jurisdiction, their claims were settled before Google had served a defence. What is new about the present action is that Mr Lloyd is not just claiming damages in his own right, as the three claimants did in Vidal-Hall. He claims to represent everyone resident in England and Wales who owned an Apple iPhone at the relevant time and whose data were obtained by Google without their consent, and to be entitled to recover damages on behalf of all these people. It is estimated that they number more than 4m. 3. Class actions, in which a single person is permitted to bring a claim and obtain redress on behalf of a class of people who have been affected in a similar way by alleged wrongdoing, have long been possible in the United States and, more recently, in Canada and Australia. Whether legislation to establish a class action regime should be enacted in the UK has been much discussed. In 2009, the Government rejected a recommendation from the Civil Justice Council to introduce a generic class action regime applicable to all types of claim, preferring a “sector based approach”. This was for two reasons: “Firstly, there are potential structural differences between the sectors which will require different consideration. … Secondly, it will be necessary to undertake a full assessment Page 3 of the likely economic and other impacts before implementing any reform.” See the Government’s Response to the Civil Justice Council’s Report: “Improving Access to Justice through Collective Actions” (2008), paras 12-13. 4. Since then, the only sector for which such a regime has so far been enacted is that of competition law. Parliament has not legislated to establish a class action regime in the field of data protection. 5. Mr Lloyd has sought to overcome this difficulty by what the Court of Appeal in this case described as “an unusual and innovative use of the representative procedure” in rule 19.6 of the Civil Procedure Rules: see [2019] EWCA Civ 1599; [2020] QB 747, para 7. This is a procedure of very long standing in England and Wales whereby a claim can be brought by (or against) one or more persons as representatives of others who have “the same interest” in the claim. Mr Lloyd accepts that he could not use this procedure to claim compensation on behalf of other iPhone users if the compensation recoverable by each user would have to be individually assessed. But he contends that such individual assessment is unnecessary. He argues that, as a matter of law, compensation can be awarded under the DPA 1998 for “loss of control” of personal data without the need to prove that the claimant suffered any financial loss or mental distress as a result of the breach. Mr Lloyd further argues that a “uniform sum” of damages can properly be awarded in relation to each person whose data protection rights have been infringed without the need to investigate any circumstances particular to their individual case. The amount of damages recoverable per person would be a matter for argument, but a figure of £750 was advanced in a letter of claim. Multiplied by the number of people whom Mr Lloyd claims to represent, this would produce an award of damages of the order of £3 billion. 6. Because Google is a Delaware corporation, the claimant needs the court’s permission to serve the claim form on Google outside the jurisdiction. The application for permission has been contested by Google on the grounds that the claim has no real prospect of success as: (1) damages cannot be awarded under the DPA 1998 for “loss of control” of data without proof that it caused financial damage or distress; and (2) the claim in any event is not suitable to proceed as a representative action. In the High Court Warby J decided both issues in Google’s favour and therefore refused permission to serve the proceedings on Google: see [2018] EWHC 2599 (QB); [2019] 1 WLR 1265. The Court of Appeal reversed that decision, for reasons given in a judgment of the Chancellor, Sir Geoffrey Vos, with which Davis LJ and Dame Victoria Sharp agreed: [2019] EWCA Civ 1599; [2020] QB 747. Page 4 7. On this further appeal, because of the potential ramifications of the issues raised, as well as hearing the claimant and Google, the court has received written and oral submissions from the Information Commissioner and written submissions from five further interested parties. 8. In this judgment I will first summarise the facts alleged and the relevant legal framework for data protection before considering the different methods currently available in English procedural law for claiming collective redress and, in particular, the representative procedure which the claimant is seeking to use. Whether that procedure is capable of being used in this case critically depends, as the claimant accepts, on whether compensation for the alleged breaches of data protection law would need to be individually assessed. I will then consider the claimant’s arguments that individual assessment is unnecessary. For the reasons given in detail below, those arguments cannot in my view withstand scrutiny. In order to recover compensation under the DPA 1998 for any given individual, it would be necessary to show both that Google made some unlawful use of personal data relating to that individual and that the individual suffered some damage as a result. The claimant’s attempt to recover compensation under the Act without proving either matter in any individual case is therefore doomed to fail. B. FACTUAL BACKGROUND 9. The relevant events took place between 9 August 2011 and 15 February 2012 and involved the alleged use by Google of what has been called the “Safari workaround” to bypass privacy settings on Apple iPhones. 10. Safari is an internet browser developed by Apple and installed on its iPhones. At the relevant time, unlike most other internet browsers, all relevant versions of Safari were set by default to block third party cookies. A “cookie” is a small block of data that is placed on a device when the user visits a website. A “third party cookie” is a cookie placed on the device not by the website visited by the user but by a third party whose content is included on that website. Third party cookies are often used to gather information about internet use, and in particular web pages visited over time, to enable the delivery to the user of advertisements tailored to interests inferred from the user’s browsing history. 11. Google had a cookie known as the “DoubleClick Ad cookie” which could operate as a third party cookie. It would be placed on a device if the user visited a website that included DoubleClick Ad content. The DoubleClick Ad cookie enabled Google to identify visits by the device to any website displaying an advertisement from its vast Page 5 advertising network and to collect considerable amounts of information. It could tell the date and time of any visit to a given website, how long the user spent there, which pages were visited for how long, and what advertisements were viewed for how long. In some cases, by means of the IP address of the browser, the user’s approximate geographical location could be identified. 12. Although the default settings for Safari blocked all third party cookies, a blanket application of these settings would have prevented the use of certain popular web functions; so Apple devised some exceptions to them. These exceptions were in place until March 2012, when the system was changed. But in the meantime the exceptions made it possible for Google to devise and implement the Safari workaround. Its effect was to place the DoubleClick Ad cookie on an Apple device, without the user’s knowledge or consent, immediately, whenever the user visited a website that contained DoubleClick Ad content. 13. It is alleged that, in this way, Google was able to collect or infer information relating not only to users’ internet surfing habits and location, but also about such diverse factors as their interests and pastimes, race or ethnicity, social class, political or religious beliefs or affiliations, health, sexual interests, age, gender and financial situation. 14. Further, it is said that Google aggregated browser generated information from users displaying similar patterns, creating groups with labels such as “football lovers”, or “current affairs enthusiasts”. Google’s DoubleClick service then offered these group labels to subscribing advertisers to choose from when selecting the type of people at whom they wanted to target their advertisements

Respond to the following question with only the information I provide within this prompt, your answer should be two paragraphs long. Why is Mr Lloyd's strategy unusual? A. INTRODUCTION 1. Mr Richard Lloyd - with financial backing from Therium Litigation Funding IC, a commercial litigation funder - has issued a claim against Google LLC, alleging breach of its duties as a data controller under section 4(4) of the Data Protection Act 1998 (“the DPA 1998”). The claim alleges that, for several months in late 2011 and early 2012, Google secretly tracked the internet activity of millions of Apple iPhone users and used the data collected in this way for commercial purposes without the users’ knowledge or consent. 2. The factual allegation is not new. In August 2012, Google agreed to pay a civil penalty of US$22.5m to settle charges brought by the United States Federal Trade Commission based upon the allegation. In November 2013, Google agreed to pay US$17m to settle consumer-based actions brought against it in the United States. In England and Wales, three individuals sued Google in June 2013 making the same allegation and claiming compensation under the DPA 1998 and at common law for misuse of private information: see Vidal-Hall v Google Inc (Information Comr intervening) [2015] EWCA Civ 311; [2016] QB 1003. Following a dispute over jurisdiction, their claims were settled before Google had served a defence. What is new about the present action is that Mr Lloyd is not just claiming damages in his own right, as the three claimants did in Vidal-Hall. He claims to represent everyone resident in England and Wales who owned an Apple iPhone at the relevant time and whose data were obtained by Google without their consent, and to be entitled to recover damages on behalf of all these people. It is estimated that they number more than 4m. 3. Class actions, in which a single person is permitted to bring a claim and obtain redress on behalf of a class of people who have been affected in a similar way by alleged wrongdoing, have long been possible in the United States and, more recently, in Canada and Australia. Whether legislation to establish a class action regime should be enacted in the UK has been much discussed. In 2009, the Government rejected a recommendation from the Civil Justice Council to introduce a generic class action regime applicable to all types of claim, preferring a “sector based approach”. This was for two reasons: “Firstly, there are potential structural differences between the sectors which will require different consideration. … Secondly, it will be necessary to undertake a full assessment Page 3 of the likely economic and other impacts before implementing any reform.” See the Government’s Response to the Civil Justice Council’s Report: “Improving Access to Justice through Collective Actions” (2008), paras 12-13. 4. Since then, the only sector for which such a regime has so far been enacted is that of competition law. Parliament has not legislated to establish a class action regime in the field of data protection. 5. Mr Lloyd has sought to overcome this difficulty by what the Court of Appeal in this case described as “an unusual and innovative use of the representative procedure” in rule 19.6 of the Civil Procedure Rules: see [2019] EWCA Civ 1599; [2020] QB 747, para 7. This is a procedure of very long standing in England and Wales whereby a claim can be brought by (or against) one or more persons as representatives of others who have “the same interest” in the claim. Mr Lloyd accepts that he could not use this procedure to claim compensation on behalf of other iPhone users if the compensation recoverable by each user would have to be individually assessed. But he contends that such individual assessment is unnecessary. He argues that, as a matter of law, compensation can be awarded under the DPA 1998 for “loss of control” of personal data without the need to prove that the claimant suffered any financial loss or mental distress as a result of the breach. Mr Lloyd further argues that a “uniform sum” of damages can properly be awarded in relation to each person whose data protection rights have been infringed without the need to investigate any circumstances particular to their individual case. The amount of damages recoverable per person would be a matter for argument, but a figure of £750 was advanced in a letter of claim. Multiplied by the number of people whom Mr Lloyd claims to represent, this would produce an award of damages of the order of £3 billion. 6. Because Google is a Delaware corporation, the claimant needs the court’s permission to serve the claim form on Google outside the jurisdiction. The application for permission has been contested by Google on the grounds that the claim has no real prospect of success as: (1) damages cannot be awarded under the DPA 1998 for “loss of control” of data without proof that it caused financial damage or distress; and (2) the claim in any event is not suitable to proceed as a representative action. In the High Court Warby J decided both issues in Google’s favour and therefore refused permission to serve the proceedings on Google: see [2018] EWHC 2599 (QB); [2019] 1 WLR 1265. The Court of Appeal reversed that decision, for reasons given in a judgment of the Chancellor, Sir Geoffrey Vos, with which Davis LJ and Dame Victoria Sharp agreed: [2019] EWCA Civ 1599; [2020] QB 747. Page 4 7. On this further appeal, because of the potential ramifications of the issues raised, as well as hearing the claimant and Google, the court has received written and oral submissions from the Information Commissioner and written submissions from five further interested parties. 8. In this judgment I will first summarise the facts alleged and the relevant legal framework for data protection before considering the different methods currently available in English procedural law for claiming collective redress and, in particular, the representative procedure which the claimant is seeking to use. Whether that procedure is capable of being used in this case critically depends, as the claimant accepts, on whether compensation for the alleged breaches of data protection law would need to be individually assessed. I will then consider the claimant’s arguments that individual assessment is unnecessary. For the reasons given in detail below, those arguments cannot in my view withstand scrutiny. In order to recover compensation under the DPA 1998 for any given individual, it would be necessary to show both that Google made some unlawful use of personal data relating to that individual and that the individual suffered some damage as a result. The claimant’s attempt to recover compensation under the Act without proving either matter in any individual case is therefore doomed to fail. B. FACTUAL BACKGROUND 9. The relevant events took place between 9 August 2011 and 15 February 2012 and involved the alleged use by Google of what has been called the “Safari workaround” to bypass privacy settings on Apple iPhones. 10. Safari is an internet browser developed by Apple and installed on its iPhones. At the relevant time, unlike most other internet browsers, all relevant versions of Safari were set by default to block third party cookies. A “cookie” is a small block of data that is placed on a device when the user visits a website. A “third party cookie” is a cookie placed on the device not by the website visited by the user but by a third party whose content is included on that website. Third party cookies are often used to gather information about internet use, and in particular web pages visited over time, to enable the delivery to the user of advertisements tailored to interests inferred from the user’s browsing history. 11. Google had a cookie known as the “DoubleClick Ad cookie” which could operate as a third party cookie. It would be placed on a device if the user visited a website that included DoubleClick Ad content. The DoubleClick Ad cookie enabled Google to identify visits by the device to any website displaying an advertisement from its vast Page 5 advertising network and to collect considerable amounts of information. It could tell the date and time of any visit to a given website, how long the user spent there, which pages were visited for how long, and what advertisements were viewed for how long. In some cases, by means of the IP address of the browser, the user’s approximate geographical location could be identified. 12. Although the default settings for Safari blocked all third party cookies, a blanket application of these settings would have prevented the use of certain popular web functions; so Apple devised some exceptions to them. These exceptions were in place until March 2012, when the system was changed. But in the meantime the exceptions made it possible for Google to devise and implement the Safari workaround. Its effect was to place the DoubleClick Ad cookie on an Apple device, without the user’s knowledge or consent, immediately, whenever the user visited a website that contained DoubleClick Ad content. 13. It is alleged that, in this way, Google was able to collect or infer information relating not only to users’ internet surfing habits and location, but also about such diverse factors as their interests and pastimes, race or ethnicity, social class, political or religious beliefs or affiliations, health, sexual interests, age, gender and financial situation. 14. Further, it is said that Google aggregated browser generated information from users displaying similar patterns, creating groups with labels such as “football lovers”, or “current affairs enthusiasts”. Google’s DoubleClick service then offered these group labels to subscribing advertisers to choose from when selecting the type of people at whom they wanted to target their advertisements

You must respond to the prompt using only the information provided in the context block.Here is the question you are to answer:

How does the Government of Alberta's Ministry of Health plan to meet the three outcomes identified in their 2022-2023 Annual Health Report?

Outcome One: An effective, accessible and coordinated health care system built around the needs of individuals, families, caregivers and communities, and supported by competent, accountable health professionals and secure digital information systems Key Objectives 1.1 Increase health system capacity and reduce wait times, particularly for publicly funded surgical procedures and diagnostic MRI and CT scans, emergency medical services, and intensive care units. As the province emerges from the pandemic, Alberta Health continues to prioritize health system capacity, including building surgical and Intensive Care Unit (ICU) capacity, as well as the health workforce. Several initiatives are underway to minimize disruptions to patient care and expand the capacity of Alberta’s publicly funded health care system permanently. This also includes preparing to respond more effectively to any future health crises and reducing wait times across the health care system. A resilient, sustainable health system will allow the system to operate at full capacity for longer periods before needing to adjust health care resources. The policy has overall goals of improving access to scheduled health services, improving wait time measurement and reporting, and ensuring timely communication for patients. In November 2022, Alberta released the Health Care Action Plan (HCAP). The HCAP identifies immediate government actions to build a better health care system for Albertans. In order to meet the growing demands of Alberta’s health care system, an Official Administrator was appointed to Alberta Health Services (AHS) to provide leadership to address the four goals of the HCAP: • decrease emergency department wait times; • improve emergency medical services response times; • reduce wait times for surgeries; and, • empower frontline workers to deliver health care. Since 2019, government has been committed to increasing surgical capacity to keep pace with demand and reduce the length of time Albertans are waiting for scheduled surgeries. Efforts are geared towards improving patient navigation of the health care system through enhanced care coordination and surgical pathways and resources; improving specialist advice and collaboration with family physicians before consultation; and, centralizing referrals for distribution to the most appropriate surgeon with a shorter wait list. Through the Alberta Surgical Initiative (ASI), Alberta Health continues to work with AHS to improve and standardize the entire surgical journey through: • prioritizing surgeries and allocating operating room time according to the greatest need; • streamlining referrals from primary care to specialists; • increasing surgeries at underutilized operating rooms, mainly in rural areas; and, • providing less complex surgeries through accredited chartered surgical facilities (CSFs) to provide publicly funded insured services and extend existing capacity in hospitals. Through these dedicated efforts, the total number of surgeries completed in 2022-23 was 292,500, which is over 13,900 more surgeries than the year before. Further, approximately 22,100 cancer surgeries were completed in 2022-23, which represents a 10 per cent increase compared to the pre-pandemic amount. Nearly 65 per cent of the cancer surgeries were completed within clinically recommended wait times. By the end of 2022-23, AHS had cleared all postponed surgeries due to COVID-19, and continues to work on reducing wait times. The main focus remains on those patients that are waiting the longest out of clinically recommended targets, and the most acute cases. As of March 31, 2023, AHS reduced the adult surgical waitlist by more than 7,000 patients, and the total number of cases on the adult surgical waitlist is 67,186 which is less than before the pandemic. In 2022-23, there were 38 existing CSFs and three new CSF contracts were implemented to expand publicly funded surgical capacity in these facilities. CSFs are an extension of existing capacity in hospitals and used in many other Canadian health systems. Under the Health Facilities Act, CSFs providing publicly funded insured services must be accredited by the College of Physicians and Surgeons of Alberta, and have a signed service contract with AHS. In 2022-23, accredited CSFs in Alberta provided approximately 47,400 surgeries, which is equivalent to 16.2 per cent of publicly funded scheduled surgeries. In Alberta and other provinces, wait times for three common surgical procedures (hip replacement, knee replacement and cataract surgeries) continue to be impacted by delays due to the COVID-19 pandemic and workforce shortages. The 2022-23 results for hip, knee and cataract surgical procedures showed a decline, meaning that fewer Albertans received these surgical procedures within national benchmark wait times when compared to 2021-22 results. The chart below shows quarterly trends for the three common surgical procedures completed within national benchmarks in 2022-23. There were improvements in the number of cases completed for hip and knee replacements over the course of 2022-23, showing increases of 13 per cent and 15 per cent (respectively), and demonstrating significant improvements with the appointment of the Official Administrator and the implementation of the HCAP in November 2022. While the quarterly results for cataract surgery declined in the second quarter, the number has stabilized in the third quarter since the implementation of HCAP and is beginning an upward trend in the fourth quarter, although it is slightly below the first quarter result. Since 2019-20, there has been a 20 per cent improvement in cases completed within national benchmarks for cataract surgeries, ranking Alberta as a top performer nationally. As part of ASI, Alberta Health has worked with AHS to implement additional measures aimed at improving access and wait times for surgery. Work is ongoing to increase the use of Rapid Access Clinics to reduce wait times for the assessment of orthopedic issues, reducing unnecessary consultations and decreasing wait times for consultations. The Facilitated Access to Specialized Treatment (FAST) program accelerates implementation of central intake for orthopedic and urology surgery to allow patients to see the first available surgeon. Work has begun on the implementation of the Electronic Referral System (ERS), which will expedite referrals for Albertans requiring assessment by surgical specialists. In addition, consultants have been contracted to enhance surgical capacity by improving inpatient surgeries scheduling, monitoring operating room capacity, and reducing patient flow variation. With the added capacity of additional CSFs offering surgeries and implementation of FAST and ERS, Albertans will experience a streamlined surgical journey from referral to consultation to surgery. More Albertans will get their surgery within the clinically recommended wait time targets, thereby reducing the amount of time they must live with pain and other inconveniences. Reducing wait times for medically necessary diagnostic tests is also a top priority for government. Each year, Alberta spends about $1 billion on diagnostic imaging, which includes ultrasounds, Xrays, mammography, MRI and CT scans. About 46 per cent of the $1 billion is allocated to AHS, while 54 per cent is allocated to community diagnostic imaging providers. Approximately one-third of all CT and MRI scans are emergency scans and are completed within clinically appropriate timelines (under 24 hours). In 2022-23, a total of 520,504 CT scans and 231,030 MRI scans were completed across the province. The wait time for both types of scans increased due to a sharp increase in demand and staffing issues. Alberta Health and AHS continue to implement the Diagnostic Imaging Action Plan developed in 2019 to facilitate timely access to CT and MRI scans. As part of the plan, there is a significant focus on triaging patients to ensure that those who need urgent scans can get one as soon as possible. In addition, the Clinical Decision Support (CDS) within Connect Care aims to improve appropriateness of referrals and triage decisions. AHS has reached a five-year agreement with radiologist groups in Edmonton and Calgary to reduce wait times, and signed a memorandum of understanding with the remaining three largest radiology providers in Alberta North, Central, and South Zones. In total, 83 per cent of provincial radiologists have signed agreements with AHS. As part of the HCAP, the Government of Alberta is working with AHS to improve emergency medical services (EMS) response times. Improved ambulance times means that Albertans are receiving the urgent care they need from highly skilled paramedics more quickly. The Alberta Emergency Medical Services Provincial Advisory Committee (AEPAC) was established and tasked with providing immediate and long-term recommendations that will better support staff and ensure a strengthened and sustainable EMS system for Albertans needing services now and into the future. AEPAC focused on the issues facing EMS, such as system pressures that may cause service gaps, staffing issues, and hours of work. This included issues related to ground ambulance, air ambulance, and dispatch. Furthermore, Alberta conducted an independent review of EMS dispatch (the Dispatch Review) to inform improvements that can be made to dispatch services overall. The Dispatch Review and full report from AEPAC were submitted to the Minister of Health in the fall of 2022 and released to the public in January 2023. The Government of Alberta accepted the final AEPAC report and Dispatch Review recommendations in full. The recommendations were focused on accountability, capacity, efficiencies, operations, performance, and workforce support. Adjustments are being made to improve EMS response times and get paramedics out of hospital waiting rooms and back into their communities. Implementation of recommendations on a priority basis has supported ongoing reduction in EMS response times and red alerts, and improvements in community coverage. In 2022-23, Alberta Health initiated several actions to address these recommendations and strengthen the EMS system across the province. Examples of projects include: • Implemented measures to improve the central dispatch system to better deal with lowacuity calls and prioritize emergent/urgent 911 calls for EMS and made workforcescheduling changes as part of the Fatigue Management Strategy. • Initiated pilot projects using an integrated Fire-EMS model to maximize the use of paramedics and increase ambulance capacity to the health care system. Examples of the projects included: using inbound EMS resources only when they are clinically required; staffing spare ambulances to support the EMS system during times of stress; and, expanding single member advanced care paramedic response units that provide immediate advanced life support care in anticipation of, or in the absence of, an available ambulance. • Introduced new provincial guidelines, including a 45-minute EMS emergency department (ED) wait time target for 911, to get ambulances back on the road more quickly. The new provincial guidelines enable fast-tracking ambulance transfers at EDs by moving less urgent patients to hospital waiting areas. • Put procedures in place to contract appropriately trained resources for non-emergency transfers between facilities in Calgary and Edmonton, freeing up paramedics. Instead of using highly trained paramedics for non-medical patient transfers to patients’ homes from a facility or acute care, alternative resources are now arranged by hospitals, also freeing up paramedics. • Granted an exemption to the minimum staffing requirements defined in the Ground Ambulance Regulation, significantly expanding the instances where an emergency medical responder can meet the staffing requirements for all classes of ambulance, to alleviate staffing challenges across the province. • Empowered paramedics to assess a patient's condition at the scene to decide if they need ambulance transport to the hospital. In 2022-23, a total of $590 million was spent on EMS. Capacity increases were laid out in the AHS’ EMS 10-Point Plan and recommendations by AEPAC, including increases in paramedic workforce and adding ambulances to the system. As of March 31, 2023, there are 8,417 regulated members in the province registered with the Alberta College of Paramedics, including 1,383 emergency medical responders, 4,050 primary care paramedics, and 2,984 advanced care paramedics. AHS added 19 new ambulances in Calgary and Edmonton and more ambulance coverage in Chestermere and Okotoks, and hired 457 new staff members, including 341 paramedics. Increased capacity helps reduce EMS response times and red alerts and improves working conditions for frontline practitioners and community coverage, especially for life-threatening conditions. Measures to address staffing issues include AHS’ Fatigue Management Strategy, a recruitment campaign aimed at other provinces and Australia, development of a Provincial Service Plan, and interim AEPAC recommendations brought forward in June 2022, granting an exemption to expand use of emergency medical responders and pilot projects to give greater autonomy to ambulance operators using an integrated fire-EMS model. In addition, keeping paramedics out of hospital waiting rooms and in communities has contributed to decreased EMS response times and red alerts, improved community coverage, and quicker access to EMS. The HCAP 90-day Report released in February 2023 (https://www.albertahealthservices.ca/assets/about/aop/ahs-aop-90-report.pdf ) shows an early reduction in response times and red alerts, and greater focus on urgent/emergent 911 calls through low-acuity diversion measures and non-clinical patient transport programs across Alberta, particularly in Calgary and Edmonton. Comparing November 2022 to March 2023, EMS response time for the most urgent calls in metro and urban areas was reduced from 21.8 minutes to 15 minutes. Improving access to EMS enables timely patient care and entry into the health care system. The government also launched the EMS/811 Shared Response program to ensure patients receive the level of care they need and reduce unnecessary ambulance responses. Calls that have been assessed as not experiencing a medical emergency that requires an ambulance are transferred to Health Link 811, where registered nurses provide further triage, assessment and care. Since the launch in January 2023, more than 2000 911-callers with non-urgent conditions were transferred and helped by Health Link 811, keeping more ambulances available for emergency calls. In October 2022, government appointed a Parliamentary Secretary of EMS Reform to work with health partners to set priorities for service improvement based on AEPAC and Dispatch Review report recommendations. Remaining AEPAC and Dispatch Review recommendations have been incorporated into the AHS Operations Plan and are being prioritized and monitored by the EMS Reform Parliamentary Secretary. There are almost two million visits to Alberta EDs every year. Alberta Health together with AHS is working to improve patient flow within the health system, in particular to reduce ED wait times. AHS is committed to improving the experience of patients and families from the time they seek emergency care until the time the patient is discharged or admitted. There are 780 more staff in EDs today than in December 2018. AHS is working diligently on several initiatives to improve access to emergency care including improving access to continuing care living options, expanding hospital capacity, and implementing initiatives in hospitals to streamline patient treatment and discharge. In 2022-23, alternate level of care days were reduced by enhancing social work supports in acute care to address barriers for discharge. This included adding a fast-track area at the Alberta Children’s Hospital in Calgary, and deploying additional units of EMS mobile Integrated Health Units in Calgary and Edmonton to provide care for unscheduled needs within the community (i.e., IV antibiotics, rehydration, and transfusions at home). In January 2023, the Bridge Healing Transitional Accommodation Program was launched in Edmonton to support transitioning of patients experiencing homelessness as they are discharged from emergency departments. The initiative aims to reduce hospital readmission rates for Albertans experiencing homelessness by providing wrap-around health and social services. This program provides 36 beds to support this vulnerable population. Over the next three years, $305 million will be provided for additional health care capacity on a permanent basis under the HCAP. This includes approximately $268.6 million in operating funds and $36.4 million for capital projects to increase ICU capacity on a permanent basis. Approximately $61 million was spent in 2022-23 to create 50 permanent new fully equipped and staffed adult ICU beds across the province, which brings the number of ICU beds up to 223 from 173 before the pandemic. The pandemic has shown that more permanent capacity and staff are needed, particularly in rural and remote areas. The ministry continues to address ICU staffing shortages across health care facilities in Alberta. As vacancies are filled, ICU beds are reopened. Temporary bed closures are implemented only as a last resort, and patients continue to receive safe, high-quality care. AHS filled 392 positions, as of the end of fiscal year 2022-23, to support the new beds. These positions included nurses, allied health professionals, pharmacists, and clinical support service positions for diagnostic imaging and service workers. The latest data available at the end of fiscal year 2022-23 indicated that the provincial ICU baseline occupancy rate was 82 per cent, a 29 per cent improvement from being at over capacity (115 per cent) in 2021-22. Increasing ICU capacity ensures that Albertans receive care when they need it most. However, unplanned temporary service disruptions, including bed reductions, are not unusual in any health system, as services and beds are managed based on patient need, staffing levels, acuity of patient health, and other factors. Government works to ensure patients continue to receive safe, high-quality care. Occasionally, however, temporary bed closures are implemented as a last resort. Government is committed to ensuring that any Albertan who needs acute care will receive it. Workforce challenges remain a significant barrier to improving wait times for surgery given the high demand for anesthesiologists in Canada and international jurisdictions. Alberta Health is reviewing and developing options to support continued implementation of the Anesthesia Care Team Model in AHS and CSFs. The implementation of the Anesthesia Care Team Model aims to use anesthesiologists more resourcefully for some ophthalmology and orthopedic surgeries by employing a multidisciplinary team that works under supervision of the anesthesiologist to support anesthesia services in the operating room. Recruitment efforts are underway through AHS to attract more anesthesiologists to Alberta, including in rural areas. In March 2023, government released MAPS Strategy, which sets out a framework for supporting the province’s current health care workers and building the future workforce that can support Albertans getting the health care they need when and where they need it. Alberta has various initiatives underway to attract and retain nurses and increase system capacity. Alberta Health worked with the College of Registered Nurses of Alberta to streamline registration processes for Internationally Educated Nurses (IEN) and developed a grant agreement with the Alberta Association of Nurses for nurse navigators to support IENs going through the assessment, education, and registration processes. Announced in September 2022, the Modernizing Alberta’s Primary Health Care System (MAPS) initiative formed three panels to provide advice to the Minister on ways to improve the primary health care system, thereby improving the overall efficiency of the health care system. On February 21, 2023, the Minister announced an investment into primary health care of $243 million over three years; of this, $125 million is allocated for MAPS recommendations. In addition, the Minister accepted, in principle, early opportunities for investment that could be implemented to enhance Albertans’ access to primary health care immediately. On March 31, 2023, the MAPS Strategic Advisory Panel and Indigenous Primary Health Care Advisory Panel submitted parallel final reports to the Minister, outlining transformative strategic roadmaps for the next 10 years of primary health care in Alberta. These reports address both Indigenous access to primary health care and advice on improving primary health care for all Albertans. The intent of the MAPS initiative will be to reorient the health system around primary health care, thereby improving patient outcomes and reducing costs and decreasing pressures on the acute care system in the long-term. Partnerships and collaboration between primary care providers and specialists will improve patient wait times and health outcomes. The ASI Care Pathways and Specialty Advice, which includes the Provincial Pathways Unit and provincially aligned non-urgent telephone advice service programs, support consistency and quality to ensure continuity of care across the patient journey. The Provincial Primary Care Network provided these projects with conditional endorsement to begin transition to operational shared service programs. Primary Care Networks (PCNs) are also working with other stakeholders on the ASI to improve primary care and specialist linkages and patient navigation of the health care system by building and leveraging PCN specialist linkage programs. Some initiatives include Strong Partnerships and Transitions of Care for the Central Zone; Patient’s Medical Home, including referral navigators; Specialist LINK Tool for the Calgary Zone; Connect MD for the Edmonton and North Zones; FAST General Surgery for the Edmonton Zone; and, Specialist Integration Task Group for the Calgary Zone. Modernize Alberta’s continuing care system, based on Alberta’s facility‐based continuing care and palliative and end‐of‐life care reviews, to improve continuing care services for Albertans living with disabilities and chronic conditions (including people living with dementia). Government continues to be committed to addressing gaps in the continuing care system, and meeting the needs of Albertans by implementing transformative changes within the system. Alberta Health worked with partners to develop a new legislative framework for the continuing care system. The Continuing Care Act (Act), which received Royal Assent on May 31, 2022, will increase clarity regarding services, address gaps and inconsistencies across services and settings, enable improved service delivery for Albertans, and support health system accountability and sustainability. Multiple pieces of legislation will be consolidated into the Act, which establishes clear and consistent oversight and authority over the delivery of continuing care services and settings. The new legislation was proclaimed to be in effect April 1, 2024, except for sections regarding administrative penalties, which will be proclaimed on April 1, 2025. Implementation of the legislative framework will better support Albertans transitioning between care types and settings, including home and community care, supportive living accommodations, and continuing care homes. The continuing care system in Alberta provides a range of services for health, personal care, and housing to ensure the safety, independence, and quality of life for people in Alberta, regardless of age, based on their evaluated need for continuing care assistance. Publicly funded care options include home and community care; continuing care homes, which includes Designated Supportive Living and Long-Term Care; and, Palliative and End-of-Life Care services (PEOLC). In addition, Albertans have the option to access housing support in supportive living settings, such as lodges, group homes, and seniors' complexes. In 2022-23, 871 new continuing care beds/spaces were created at AHS-operated or contracted facilities to meet Albertans’ needs. The government continues to be committed to expanding the number of available continuing care spaces throughout the province and enhancing the continuing care system to effectively meet the needs of Albertans by incorporating recommendations from the Facility-Based Continuing Care (FBCC) Review Final Report, which was released on May 31, 2021. Alberta Health has acted on several recommendations from the FBCC review, including the introduction of self-managed care as a way to provide greater choice regarding locations, types and providers of services. Further, Alberta Health has enhanced client choice by supporting more continuing care clients in the community rather than at FBCC sites. Alberta Health worked with Alberta Blue Cross and AHS to successfully implement the ClientDirected Home Care Invoicing model. This model was implemented in the Edmonton Zone in April 2022, and in the Calgary Zone in the fall of 2022. Expansion to rural areas of the province will move forward over the course of 2023 to provide Albertans with increased choice and flexibility in selecting their home care service provider and the ability to better direct how their care is provided. In June 2022, Alberta Health worked with AHS to initiate a Request for Expression of Interest and Qualification (RFEOIQ) procurement process to explore opportunities to optimize the provision of home care services in Alberta, as well as identify innovative service delivery solutions to support specialized needs and populations. Albertans will begin to see the outcomes and impacts of the RFEOIQ process during fiscal year 2023-24, as the successful proposals are implemented. Another recommendation from the FBCC report was to streamline inspections. Transition of continuing care facility audits from AHS to Alberta Health began in March 2022. A coordinated monitoring approach has reduced duplications of both reviews and site visits. In 2022-23, over 1,100 inspections were completed on accommodation and care in continuing care facilities across the province. Alberta Health also followed up on over 940 reportable incidents of resident safety or care concerns and conducted 103 complaint investigations. These activities continue to provide assurance that residents and clients are receiving safe and quality care and services. Budget 2022 allocated $204 million in capital grant funding over three years to expand capacity for continuing care. The inaugural Indigenous Stream was launched in 2021 to support continuing care facilities on and off reserves/settlements. As of June 2022, seven projects were approved for $67 million to develop 147 continuing care spaces. The inaugural Modernization Stream was launched on September 20, 2022, and concluded on January 6, 2023. This stream focused on refurbishing and/or replacing existing aging continuing care infrastructure at non-AHS owned facilities. The Government of Alberta continues to prioritize quality PEOLC by investing $20 million in over 30 projects since 2019. Progress to date on projects commenced in 2020 include: • Covenant Health continued to work to increase general awareness of PEOLC, increase uptake of advance care planning and develop standardized, competency-based education to support the provision of high-quality PEOLC. • In October 2022, Covenant Health’s Palliative Institute launched the Compassionate Alberta website, (compassionatealberta.ca) which is a resource aimed at increasing awareness around palliative care and to help Albertans have open and honest conversations about death. • Between April 2022 and March 2023, the Alberta Hospice Palliative Care Association successfully launched two programs that addresses the needs of caregivers and those with a life-limiting illness (the Living Every Season Program) as well as grief and bereavement needs for Albertans (the You’re Not Alone Grief Connection Program). In November 2021, Alberta Health released the PEOLC call for grant proposals. The grant program focused on projects that address the four PEOLC priority areas identified in the Advancing Palliative and End‐of‐Life Care in Alberta Report. As a result of this grant call, a total of 25 new PEOLC grants were initiated in April 2022, totaling $11.3 million. The funding and project breakdown is as follows: • Nearly $4.2 million for eight projects to expand community supports and services. • More than $4.1 million for 10 projects to improve health-care provider and caregiver education and training. • More than $1.9 million to support four projects that advance earlier access to palliative and end-of-life care. • More than $1.1 million for three projects for research and innovation. In June 2022, the Pilgrims Hospice Society completed a one-year, grant-funded project that supported care navigation services, which provided Albertans with information on residential support programming and provided staff training on hospice care. Pilgrims Hospice Society also received $2.5 million in October 2022 to support residential hospice care at the Roozen Family Hospice Centre in Edmonton. This demonstration project will provide important information on the standalone hospice model used at the centre, including usage data and service quality, to identify longer-term options for funding and expanding residential hospice services in Alberta. Government continued to invest in supporting the nearly one million Albertans who are caregivers for family and friends. This included approximately $2 million in grant funding since 2022 to Caregivers Alberta to enhance their programs and services; to Norquest College for the Skills Training for caregivers with a focus on rural areas; to the University of Alberta to reduce caregiver distress and support family and friend caregivers to maintain their health and well-being; and, to the Alzheimer Society of Alberta and the Northwest Territories to focus on delivering communitybased programming for persons living with dementia and their caregivers. In 2022-23, the Government of Alberta continued to support innovations in dementia care through the Community-based Innovations for Dementia Care initiative, which supported 15 communitylevel projects, and through multiple projects delivered by the Alzheimer Society of Alberta and the Northwest Territories: • The Alberta Employers Dementia Awareness Project identified the needs of employers to develop best practices to create inclusive workplaces. This included piloting and launch of the Dementia Alberta website (https://www.dementiaalberta.ca) to ensure dementia in the workplace awareness materials are available to Alberta employers. The project also helps to ensure that employers have access to materials describing the importance of brain health and dementia risk reductions, and that employers have access to sample guidance, facts, tips and scenarios applicable to Alberta employers and employees. • The expansion of the First Link® early intervention program by enhancing outreach to and in rural communities. During the project, 113 rural communities received outreach and 91 small cities, specialized municipalities, municipal districts, towns, villages or summer villages received outreach services. • The Community Dementia Ambassador Project, which created a program delivered by volunteers (Ambassadors) who live in or are familiar with the cultural and social values of Alberta communities. This project identified 22 Ambassadors from 16 communities, including Cardston, St. Paul and Peace River. Ambassadors reached more than 1,325 Albertans. To support the continuing care sector and its staffing needs, the government is exploring ways to increase the number of students enrolled in Health Care Aide (HCA) programs at various postsecondary institutions. Government is funding an additional 1,090 seats in HCA programs over three years, and invested $12.8 million to provide bursaries for HCA students to assist with education costs and encourage them to become HCAs. The HCA bursary program, administered by NorQuest College, went live July 1, 2022, and included three streams of funding: the Financial Incentive program, the HCA Tuition Bursary program, and the Workplace Tutor program. Under the Financial Incentive program, students who were enrolled in a licensed HCA program between January 1 and June 30, 2022, are eligible for up to $4,000 if they agree to work a minimum of 1,000 hours with an identified continuing care operator within one year of starting employment. Eligible HCA students may receive up to $9,000 through the HCA Tuition Bursary program. The Workplace Tutor program provides funding for identified continuing care operators to educate and train HCAs at their workplace. Demand for the bursaries is steady with over 600 students applying for the regular bursary and approximately 350 HCA students approved to receive the bursary. These bursaries will remove barriers for students, and pay for schooling and other expenses while they are completing their program. From July 2022 to March 31, 2023, government provided $20.6 million to continuing care operators to partially offset inflationary increases to accommodation charges for continuing care residents. This support made accommodation charges more affordable for residents and shielded them from the full cost of living pressures associated with higher-than-average inflation. The government provided $1 million to improve access to non-medical supports in the community. This included initiatives with United Way Calgary and the Edmonton Seniors Coordinating Council to provide more community supports and navigation assistance for clients seeking this help, expanding caregiver supports. In 2022-23, the percentage of medical patients with an unplanned hospital readmission within 30 days of discharge from hospital was 12.8 per cent. This was one per cent lower compared to last year (2021-22). A lower percentage means fewer patients have been readmitted to hospital within one month of discharge. A high rate of readmissions increases costs and may mean the health system is not performing as well as it could be. Although readmission may involve many factors, lower readmission rates show that Albertans are supported by discharge planning and continuity of services after discharge. Rates may also be impacted by the nature of the population served by a hospital facility, such as elderly patients or patients with complex health needs, or by the accessibility of post-discharge health care services in the community. Coordination of care is also improving with increased access to virtual care services and supports as well as recent enhancements to health information systems that enable electronic notification of primary care doctors when their patient is admitted or discharged from hospital. 1.3 Use digital technology to enable new models of care and reduce manual and paperbased processes. Government continues to enhance the digital health environment to provide Albertans with digital access to their health information and give health care providers more complete digital patient information at the point of care to enhance quality of care for Albertans. Collecting health system data helps support evidence-informed decisions to address changing circumstances and to keep Albertans informed. The digital modernization of the health care system involves several key elements. The MyHealth Records (MHR) portal allows Albertans to access their health information. In 2022-23, over $7.9 million was spent on MHR. Alberta Netcare, the province's Electronic Health Record, is available to health care professionals in the community and AHS. In addition, Connect Care, an integrated system with Alberta Netcare, serves as a common platform for clinical information and stores all medical records, prescriptions, and care history collected from AHS facilities, including doctor's notes. Giving Albertans digital access to their health information via the MHR portal reduces the need for them to manually request that information separately from each health provider. Albertans registered on MHR has grown from 1.25 million users in March of 2022 to just under 1.5 million users at the end of March 2023. MHR portal capabilities have been expanded with the addition of immediate release diagnostic imaging reports including CT and MRI scans. The Apple MHR App is now integrated with Apple Health Kit, allowing Albertans to connect health information from their Apple Health App account to MHR. These information technology components facilitate the shift from paper-based processes to digital processes and support the expansion of virtual care options. In 2022-23, new services to support electronic referral as part of the ASI were planned and developed. A data feed is being tested, paving the way for future referral notifications in MHR and in the Electronic Medical Records (EMR) systems of referring providers. Other improvements also included continuity of care services: • Patient data from the Central Patient Attachment Registry is now integrated with Alberta Netcare, enabling health care providers across Alberta to access information on the patient’s medical home, and who their primary provider is. Design work on Alberta’s version of the International Patient Summary is nearing completion and development work will begin shortly with EMR vendors. A patient summary is a collection of clinical and contextual information about a patient’s health details. The Alberta version of the national standard is being coordinated with Ontario and Canada Health Infoway (a not-for profit funded by the Government of Canada) and includes necessary minimum amount of information to inform patient treatment at point of care. Alberta is hoping to have at least one EMR vendor conformed to Alberta’s Patient Summary in 2023, with additional vendors onboarded in 2024. • The Community Information Integration (CII) project improves Albertans’ access to primary care and community health information by collecting patient data from physician offices and other community-based clinics and making it available to other health care providers through Alberta Netcare. Over $6.5 million was spent on CII in 2022-23. In January 2023, there were 1,764 providers live on CII, taken from 430 clinics across 40 PCNs, and nearly 1.2 million Albertans in the Central Patient Attachment Registry database. More than seven million patient encounters and over 500,000 consult reports have been submitted to Netcare as of March 31, 2023. As the province emerges from the pandemic, the expectations of Albertans have shifted and there is a greater reliance on accessing on-demand virtual government services. In alignment with the Government of Alberta Digital Strategy and Alberta Health’s eHealth Strategy, developed in 202122, Alberta Health will modernize digital service delivery, increase productivity, save tax dollars, and improve user experience by better integrating technologies into the delivery of government services. In 2022-23, $5.7 million was spent through the Health Canada Bilateral Agreement for PanCanadian Virtual Care to address secure messaging, secure video-conferencing technology, remote patient monitoring technologies, patient access to COVID-19 and other lab results, and back-end supports for integration of new platforms. This investment supported Alberta Health’s ongoing initiatives foundational to expanding the virtual health care system. Alberta Health has identified four strategic priorities for virtual care delivery in the province, which are reflected in Alberta’s Virtual Care Action Plan: • establishment of an eHealth Strategy that includes a strategy for virtual care; • expansion of the MyHealth Records patient portal capabilities, including expansion of lab results and addition of diagnostic imaging results; • development of secure messaging services for Alberta, including advanced services for twoway integration between community EMRs and Alberta Netcare; and, • development of a privacy and security framework for virtual care. Access to the MHR portal is free at https://myhealth.alberta.ca/myhealthrecords. Currently, Albertans can view parts of their Netcare record, including their medications dispensed through community pharmacies, lab results and immunization history through MHR. In 2022-23, discussions and approval processes for MHR and Alberta Netcare were underway for implementation. This enables Albertans to be active participants in their own health management. The ministry continues to make progress on a phased roll out of Connect Care within all AHS facilities to support digital modernization of the health system. In 2022-23, five of the nine planned launches for this multi-year project had been completed. Connect Care provides a single source of information in AHS to support team-based, integrated care with a focus on the patient and the efficient and effective provision of services. In 2022-23, over $260 million was spent on Connect Care. The total cost of Connect Care when completed is expected to be $1.45 billion. Although progress was slowed by the pandemic, work continues on the remaining four launches of deployment. All launches are expected to be completed by fall 2024 and approximately 145,400 users are expected with full roll out of the program. The application of modern technologies will support the delivery of innovative care models that empower patients, families and their health care teams to improve quality of care. In 2022-23, eight digital health projects were funded at the Universities of Alberta and Calgary for a total investment of $9.6 million from AHS and Alberta Innovates. These academic-clinical collaborations will help AHS identify and advance solutions that improve health care quality, health outcomes, and overall value for Albertans. Projects include the integration of prevention into Connect Care to improve the health of Albertans; digital tools such as clinical decision support and remote monitoring for people with kidney issues to reduce acute care use; tele monitoring to reduce adverse events for hospitalized patients; and, an integrated digital health approach to diabetes with First Nations in Alberta. Digital technology is also being leveraged to modernize critical capabilities to administer the Alberta Health Care Insurance Plan (AHCIP) and support core business, such as claims processing and payment to health care providers. To better meet the needs of Albertans and care providers, work continued on future models of care and emerging digital technology to replace and redesign mainframe systems to increase functionality and reduce maintenance costs. In 2022-23, over $6.5 million was spent on this initiative and the work towards the replacement and redesign of nine applications used to administer the AHCIP is ongoing. 1.4 Ensure processes for resolving patient concerns are effective, streamlined, and consistent across the province. It is important that Albertans are aware of what resources are available to help them resolve patient concerns, and how their valuable feedback can help improve the quality and safety of health services. The Office of the Alberta Health Advocates empowers Albertans to advocate for their health needs; resolves their concerns and refers individuals to programs and services to address their complaints; educates Albertans about the province’s Health Charter; and, provides health selfadvocacy skills and health literacy education to promote early resolution of issues and remove barriers and gaps in care. In February 2023, government appointed a new Health and Mental Health Advocate to be a strong voice for Albertans when it comes to their health care and to ensure the health system operates effectively for all Albertans. From April 1, 2022, to March 31, 2023, there were 2,589 Albertans served by the Office of the Alberta Health Advocates. More specifically, there were 1,565 under the Health Advocate’s jurisdiction, 742 under the Mental Health Advocate’s jurisdiction, and 175 files that were under both jurisdictions. The Office of the Alberta Health Advocates hears the patient perspective on care experiences and provides feedback to entities in the health system through effective partnership and collaboration to encourage system improvement/change and effective legislative development. The ministry is committed to ensuring the patient complaints process is fair, responsive, and accessible and has processes in place to review and respond to feedback from patients and families. Recommendations to improve the current processes for resolving patient concerns and complaints have been developed, informed by consultation and research led by the Health Quality Council of Alberta. These recommendations were approved by government in the summer of 2022; Alberta Health is working on their implementation which is to expand the role and mandate of the Health Advocate; centralize intake, triage, navigation and standardize follow up with Albertans for all patient complaints; and, require mandatory information exchange between stakeholders to support improved public reporting for health care complaints. Once the recommendations are fully implemented, Albertans will have a simplified process to raise concerns and complaints about health care, and the Health Advocate will help them find the appropriate body to review and investigate the complaints. The Health Advocate will help improve accountability by monitoring the status of the resolution processes for completion and closure. Concerns and complaints will continue to be reviewed and investigated by AHS, health professions and other bodies created under statute to hear concerns. Alberta Health continues working with First Nations and Métis health leaders to better understand their experiences with the current complaints management systems in Alberta, involve them in identifying ways to build Indigenous patient trust in the health care they receive, and to ensure their concerns are addressed appropriately. The outcome of this work will improve the current complaints management system by removing existing red tape and making the system easier to navigate for patients and families. Outcome Two: A modernized, safe, person-centred, high quality and resilient health system that provides the most effective care now and in the future for each tax dollar spent Key Objectives 2.1 Continue to implement strategies to bring Alberta’s health spending and health outcomes more in line with comparator provinces and national norms, including implementation of AHS review recommendations and working with the Alberta Medical Association to reach a fiscally sustainable agreement. Albertans want and deserve a health care system that meets their needs, while also understanding the system needs to be sustainable. Government’s focus on ensuring value for money spent on health care supports this vision through actions and initiatives that make the most of taxpayer dollars. Budget 2022 invested $22.5 billion in Health’s operating budget to keep Albertans safe and healthy. In 2022-23, Alberta received $5.8 billion in Government of Canada transfers, of which $5.5 billion was the Canada Health Transfer (CHT). The CHT included a $232 million one-time funding to address surgery backlog resulting from the COVID-19 pandemic. In February 2023, Alberta reached an agreement with the Government of Canada to invest more than $24 billion in Alberta's health care system over the next 10 years through the CHT. This funding aims to respond to the immediate needs of Albertans under the Health Care Action Plan, as well as improve access to family health services, including in rural and remote areas and in underserved communities; foster a resilient and supported health workforce; improve mental health care and addictions services; and, allow Albertans access to their own electronic health information. The ministry continues to closely monitor provincial per capita spending on health care to quantify progress on government’s broader commitment to get the most value for each dollar and improve access, and make the health system work better for Albertans, while managing cost growth in health care. The Government of Alberta continues to collaborate with health system partners to manage the biggest cost drivers in the health system – namely hospital services, labour and physician compensation, and publicly funded drug benefit programs. In 2022-23, the Government of Alberta spent $4.3 billion on hospital services (i.e., acute care), $6.0 billion on physician compensation and development, and $2.5 billion on drugs and supplemental health benefits. The pandemic caused per capita health care spending for all provinces to increase significantly. The national average increased from $4,835 in 2019-20 to $5,628 in 2021-22. The Alberta provincial per capita spending on health care in 2021-22 is estimated to be $5,384, on par with the Canadian average. Improving efficiency and ensuring more value for tax dollars will improve health outcomes and support fiscal sustainability of the health system. The Alberta Health Services (AHS) Performance Review identified opportunities for AHS to reduce costs and improve health outcomes by using resources more efficiently. The ministry will continue to pursue opportunities to align spending with British Columbia, Ontario and Quebec by implementing efficiencies and reducing drug costs through the work of the pan-Canadian Pharmaceutical Alliance. AHS continues to find ways to improve the health system and access to services to Albertans. Actions implemented as a result of the 2019 AHS Performance Review have had substantial impacts on the health care system and savings have been used to improve front-line care and system sustainability (https://open.alberta.ca/publications/alberta-health-services-performance-reviewsummary-report). Implementation of the AHS Review initiatives was concurrent with a global pandemic, labour negotiations and development of a new agreement between the government and the Alberta Medical Association (AMA). Operating expenditures (excluding COVID-19 costs) increased by 6.1 per cent in 2022-23 when compared to 2021-22. Alberta’s population growth and aging population has resulted in increased demand for healthcare services. The overall increase also reflected implementation of the new agreement with the AMA and recent settlements with various health labour unions. Despite these cost pressures, health spending growth is lower than the combined population growth and inflation increase. Protecting and improving the quality of health care in Alberta also requires capital investments. In 2022-23, a total of $841 million was invested in health-related capital projects across the province, including technology and information systems maintenance and renewal of existing facilities. Alberta continues to expand and modernize hospitals and other facilities to protect quality health care and grow system capacity. Investments in health system infrastructure is fundamental to improving efficiency in the health care system, reducing wait-times, providing additional surgical capacity, and to generally improve patient outcomes. Budget 2022 invested $193 million over three years for the redevelopment and expansion of the Red Deer Regional Hospital Centre to increase critical services and add capacity to one of the busiest hospitals in the province. The Red Deer Regional Hospital Centre redevelopment project functional program was completed in late April. The functional program develops and validates the scope of services and projected workload, staffing, and space to meet current and emerging acute health care needs of all residents of the Red Deer Regional Hospital’s catchment area. The functional program also addresses capacity and quality of space to improve patient and staff safety, support quality of care, manage utilization efficiently and sustainably, and ensure timely access to care. When completed this project will expand inpatient capacity from 370 beds to 570 beds and add three surgical suites, plus space to add three more suites when required in the future. There will be a new cardiac catheterization laboratory, a new medical device reprocessing space, expanded ambulatory care capacity, and expansion of many other clinical programs throughout the hospital. In 2022-23, over $133 million was allocated over three years for Alberta Surgical Initiative capital projects at AHS-owned facilities. This includes the renovation of the Medicine Hat Regional Hospital, the Edson Health Centre, and the Royal Alexandra Hospital in Edmonton. Construction also progressed on the University of Alberta Hospital in Edmonton, which will include a postanesthetic recovery unit and medical device reprocessing area when completed, and the Rocky Mountain House Health Centre, which is undergoing renovations for a new procedure room and the development of a new medical device reprocessing area. Design was completed for redevelopment at the Chinook Regional Hospital that will modernize and increase surgical procedure capacity. Other work also included designing 11 operating suites at the Calgary Foothills Medical Centre. As part of Budget 2022, $2.2 billion was allocated over three years to move forward with a number of capital projects, for example: • The University of Alberta Hospital Brain Centre received $50 million over three years for a Neurosciences Intensive Care Unit. The design development report is nearing completion. • Provincial Pharmacy Central Drug Production and Distribution Centre ($49 million over three years). The design development report is complete. • The Norwood Tower at the Gene Zwozdesky Centre ($142 million over two years) received an occupancy permit in March 2023 and was turned over to AHS for operational commissioning. In 2022-23, $116 million was spent to complete the Calgary Cancer Centre. The Calgary Cancer Centre Construction is complete and AHS is preparing the hospital to open in 2024. The hospital will have 160 new inpatient cancer beds, 100 patient exam rooms, 100 chemotherapy chairs, increased space for clinical trials, 12 radiation vaults, outpatient cancer clinics, and designated areas for clinical and operational support services and research laboratories. The completed project will increase cancer care capacity in Calgary by consolidating and expanding existing services to support integrated and comprehensive cancer care. On October 6, 2022, the government executed a four-year agreement with the AMA to address common interests such as quality of care, health care system sustainability, and stability of physician practices. Implementation of the AMA Agreement is underway and includes over $250 million in new spending over four years on initiatives targeted at communities and physician specialties facing recruitment and retention issues. The agreement included concrete solutions and the financial resources to support Albertans’ health care needs by promoting system stability through competitive compensation and providing targeted funding to address pressures that require immediate and longer-term stabilization. The agreement also allows physicians to provide greater input into longer-term approaches on improving patient care and physician compensation reform initiatives. Physicians received a one per cent lump sum COVID-19 recognition payment in 2022-23. Alberta physicians were at the forefront of the pandemic and the one-time payment for eligible practicing physicians is in recognition of that work during the 2021-22 fiscal year. The lump sum payment is approximately $45 million and was provided to the AMA in December 2022 to distribute to their members. Physicians will receive an average one per cent rate increase to compensation for each of the next three years. As part of implementation of the AMA Agreement, the Business Costs Program premium rate was increased by about 22 per cent. This increase will help physicians deal with inflation and keep practices open. The increase is estimated to cost $20 million annually, providing on average an extra $2,300 annually for each physician. This is in addition to about $80 million the government currently invests in the program each year. Following the ratification of the AMA Agreement, a commitment for collaboration between Alberta Health and the AMA regarding primary health care, including one-time investments of $20 million in Primary Care Networks (PCNs) for two fiscal years, was established. The Provincial PCN Committee provided significant contributions to the work of the Modernizing Alberta’s Primary Health Care System (MAPS) initiative to improve access and quality of primary and community health services. The MAPS initiative goal is to provide recommendations on ways to strengthen primary health care and achieve a primary health care-oriented health system. MAPS is engaging leaders and experts with hands-on experience in primary health care and health systems improvement to examine the current landscape and propose improvements. By March 31, 2023, a final report was delivered proposing a strategic direction for primary health care over the next 10 years, with a parallel report providing strategic directions to improve the delivery of primary health care for Indigenous peoples in Alberta. The $20 million investment in primary health care provides significant relief across the primary health care system, particularly for PCNs that have experienced a decline in their per capita payments from declining numbers of patients. This funding provides stabilization while work is undertaken to review and improve the overall funding model for PCNs, which will consider recommendations from the MAPS initiative. For many Albertans, prescription drugs have tremendous benefits in terms of improving quality of life, managing illnesses, and in some cases, precluding the need for more extensive treatments. Alberta continued to work with the pan-Canadian Pharmaceutical Alliance (pCPA) to reduce prescription drug costs and increase access to clinically effective and cost-effective drug treatment options, including cell and gene therapy. All new drugs and/or new indications for use undergo price negotiations between the pCPA and drug manufacturers. In 2022-23, rebates have increased to an estimated $327 million from $275 million in 2021-22. This is a successful trend that shows the importance of the pCPA and Alberta’s involvement as a member to push health jurisdictions for more value and budgetary protection. In 2022-23, the province spent $2.5 billion on drugs and supplemental health benefits and continued to improve existing drug benefit programs and add innovative and effective therapies through the addition of 320 new products in 2022-23. Of the 320 products added, 48 were brand name drug products and 272 were generic products. Alberta’s Biosimilars Initiative will expand the use of biosimilars by replacing the use of biologic drugs with their biosimilar versions whenever possible. This means patients will continue receiving safe and effective treatment, but at a lower cost. In 2022-23, savings from this initiative increased to an estimated $65.7 million from $48.9 million in 2021-22. 2.2 Increase regulations and oversight to improve safety, while reducing red tape within the health system by restructuring and modernizing health legislation, streamlining processes, and reducing duplication. As of March 31, 2023, the ministry, including AHS, achieved a 36.1 per cent reduction of its regulatory and administrative requirements, exceeding the government target of 33 per cent. AHS will continue to see reductions with the ongoing launches of Connect Care across the organization, continuing through 2024. Connect Care supports digital modernization of more complete central access to patient information related to AHS services. It provides resources, including medication alerts; evidencebased order sets; test and treatment suggestions; and, care paths and best practice advisories, which result in fewer repeated tests and consistent information across the province wherever care is being provided at AHS facilities. This system also reduces the number of forms used by AHS and helps to eliminate data entry duplication. Connect Care also facilitates direct communication between patients and providers through a patient portal, MyAHS Connect, which helps patients better manage their health with online access to their health information, including reports and test results. It also allows for online interaction with their care team, an ability to review and manage appointments and after visit care summaries, and less repeating of their health histories or need to remember complex histories or medication lists. The ministry continues to monitor Alberta’s health system to ensure standards are maintained and to improve safety and quality of health care. As of March 31, 2023, amendments to the Health Professions Act have been proclaimed into force that modernize Alberta’s professional regulatory structure. This included changes to 29 regulatory college regulations and one regulation that enhance professional regulation by health profession regulatory bodies and will make it easier for regulatory colleges to be more agile and adapt faster to changing best practices. The PCN Nurse Practitioner (NP) Support Program was created to enable NPs to work to the full scope of their skills. In 2022-23, $7.6 million was provided and the program facilitated the incorporation of NPs working more than 57 full-time equivalent positions as of March 2023. The program increases access to primary health care, including after hours, weekends, and in rural and remote areas and underserved populations; supports chronic disease management; and, helps meet unmet demand for primary health care services. Challenges for the program include NP compensation, recruitment and retention, and the desire of NPs for an independent practice model. Alberta Health is currently consulting with key stakeholders on a draft NP Compensation Model to address the challenges of the program. Amendments to the Pharmacy and Drug Act and the Pharmacy and Drug Regulation came into effect June 1, 2022. These amendments allow the Alberta College of Pharmacy and pharmacies to better respond to changes in the provision of pharmacy services to Albertans and reduce significant government red tape faced by pharmacy operators. To address the current challenges in continuing care legislation and help to initiate transformative change within continuing care, Alberta Health worked with partners to develop a new legislative framework for the continuing care system to increase clarity regarding services, address gaps and inconsistencies across settings, enable improved service delivery for Albertans, and support health system accountability and sustainability. On May 31, 2022, the Continuing Care Act (Act) received Royal Assent. The Act will come into force on April 1, 2024, after the development and approval of regulations and standards. The ministry is currently working with partners on the development of those regulations and standards. When proclaimed, the Act will regulate the full spectrum of continuing care services and settings in Alberta, including continuing care homes, supportive living accommodations, and home and community care. Consequential amendments to the Act are included in The Red Tape Reduction Statutes Amendment Act, 2023. These amendments ensure alignment of terminology in existing legislation with the Act while maintaining the policies and intent of the current legislation. In May 2022, the Food Regulation under the Public Health Act was amended to eliminate the requirement for food establishments to request an approval from a public health inspector to allow dogs into outdoor eating areas. The amendment reduced red tape for operators and provided them greater flexibility in meeting the needs of their customers. The Food Regulation provides clear requirements to support the change so dogs can stay with their owners on outdoor patios, while maintaining a high degree of food safety. 2.3 Improve measuring, monitoring and reporting of health system performance to drive health care improvements. Measuring performance is the clearest way to show investments in the health care system are leading to better outcomes for Albertans. Alberta Health worked with the Health Quality Council of Alberta (HQCA) to ensure alignment of their plans and priorities with government key priorities and achieve improvements through various initiatives. On July 26, 2022, Alberta Health executed a $23 million operating grant agreement with the HQCA over three years (April 1, 2022 to March 31, 2025) to keep the organization working with patients, families, and partners from across health care and academia to inspire improvement in patient safety, person-centred care, and health service quality. As an example, Alberta Health worked with the HQCA to develop a Primary Care Patient Experience survey to engage Albertans on their experiences within the health care system. Work continued towards transitioning manual surveys to a digital, computer-adaptive testing methodologies format to use digital technology to enable new models of care and reduce manual and paper-based processes. Digital formats for surveys and reports across primary and continuing care increased Albertans’ engagement within the health system and allowed more timely feedback to service providers about care concerns, including patients’ opinions. Alberta Health worked with HQCA to create primary health care panel reports to support planning, quality improvement, health system management for overall purpose of improving primary health care delivery. The panel reports provide family physicians with information on their patients’ continuity, as well as valuable data on screening and vaccination rates, chronic conditions, pharmaceutical use, and emergency and hospital visits. Alberta Health worked with AHS and the HQCA to develop a value-based assessment tool for objectively assessing value from the Government of Alberta annual investment into health outcomes of Albertans and benchmark against other jurisdictions, particularly the comparator provinces of British Columbia, Ontario and Quebec. Alberta Health also worked with the HQCA to complete priority work on identifying emergency medical services key performance indicators. Performance measures were developed and are under ministry review, with a shift in focus to reducing response times measured at the 90th percentile, rather than the 50th percentile. Releasing the results and performance information improves quality and patient safety and assures Albertans of the government’s commitment to increase accountability and transparency in Alberta’s health care system. The adoption of best practices and monitoring of performance measures help to improve health outcomes. Work continued with the HQCA on developing the Patient Experience Awards and Quality Exchange to support excellence in care and sharing of best practices. This included continuing to develop resources and information to support and inform program planning, panel management, quality improvement and policy development in primary health care, as well as patient experience information for designated supportive living and continuing care. Information is published for Albertans in FOCUS, a dynamic online reporting tool which collects information about what patients experience in the provincial health care system, including: emergency departments, primary health care, long-term care, designated supportive living and home care. Outcome Three: The health and well-being of all Albertans is protected, supported and improved, and health inequities among population groups are reduced Key Objectives 3.1 Ensure a continued, effective response to the COVID‐19 pandemic by optimizing access to treatments and vaccine, and reducing vaccine hesitancy. The Government of Alberta remains committed to supporting Albertans as we shift to managing COVID-19 similar to how other endemic respiratory viruses are managed. Alberta’s capacity to treat and clinically manage cases of COVID-19 continues to improve. Immunization, including receiving a booster dose of COVID-19 vaccine, is one of the best choices Albertans can make to protect themselves from severe illness due to COVID-19 infection. In 2022-23, $1.2 billion was spent on COVID-19 response to ensure the health care system had the resources required to address health care pressures resulting from the pandemic. By the end of June 2022, all mandatory public health measures related to COVID-19 were lifted. This was due to increased immunization coverage, attenuation of severity of new circulating variants, and the ability to treat and clinically manage cases of COVID-19. This signaled the beginning of a shift in Alberta’s handling of COVID-19 from an emergency pandemic response to an endemic state. Government supported this transition by working across multiple facets of health care (e.g., primary care, continuing care, workplace health and safety, public health, provincial laboratory, etc.) to align public health recommendations, such as testing and isolation, across all common respiratory viral illnesses. The ministry continued to monitor the impacts and transmission of COVID-19 and other respiratory viruses in the community by working with partners on the implementation of ongoing and new COVID-19 immunization programs, including the introduction of bivalent booster vaccines, and implementing treatment protocols for COVID-19. Alberta Health and the Health Quality Council of Alberta established a COVID-19 Data Task Force, comprised of health professionals, to conduct a data review of the last several years of health information with a view to offering recommendations to the Government of Alberta on how to better manage a future pandemic. The purpose of the review is an opportunity to reflect on Alberta’s pandemic response from a data quality and validity lens to identify opportunities for improvements to manage future pandemics. To minimize the impact of COVID-19 and protect public health, COVID-19 Rapid Antigen Tests were made available across the province to all Albertans free of charge through participating community pharmacies. Initially, supply was limited and this distribution model enabled an equitable distribution of tests across the province. Between March 2021 to March 31, 2023, Alberta distributed 48.5 million rapid antigen tests to acute and continuing care sites, primary care clinics, businesses, K-12 schools, municipalities, First Nations and Métis communities, and the general public. Government developed COVID-19 vaccine strategies to help reduce the spread, minimize severe outcomes and protect vulnerable Albertans. Work continued to support the review of ongoing evidence and recommendations for immunization against COVID-19, including guidance for immunization post-infection (or hybrid immunity), as well as for fall/spring booster programs. In 2022, Alberta continuously achieved key milestones on COVID-19 vaccine administration and roll out for different age groups and populations. In April 2022, 40 per cent of Albertans 12 and older had received their third vaccine dose. In June 2022, 35 per cent of Albertans aged five to 11 had received two doses of COVID-19 vaccine. On November 14, 2022, the Pfizer vaccine was made available for individuals six months to four years of age, and on March 20, 2023, a second bivalent vaccine (spring booster) was made available for residents living in senior congregate living settings. In 2022-23, 1.4 million COVID-19 vaccine doses were administered to Albertans and 26 per cent of the population 12 years of age and older had received a booster dose. While the federal government continued to cover the costs of the vaccines, Alberta Health spent $53 million in 2022-23 to distribute the vaccines to Albertans. The Alberta Vaccine Booking System (AVBS), launched in summer of 2021, continues to provide Albertans with access to book both COVID-19 and influenza vaccine appointments at participating Alberta Health Services (AHS) or pharmacy locations by providing a centralized, province-wide online appointment booking platform. The centralization of all vaccine booking appointments, including from AHS, Public Health, and Community Pharmacy helps Alberta Health forecast vaccine demand and strategically distribute vaccine supply. Vaccine eligibility criteria and system functionality continue to be updated based on direction from provincial immunization programs. In 2022-23, more than 575,000 appointments for COVID-19 and influenza immunization were scheduled using the AVBS. Updates continue to be released to support dynamic vaccine eligibility changes and to continually improve the user experience. Previously, Albertans had to call multiple pharmacies and Health Link in an attempt to find available vaccine supply. The Health Link 811 call centre continues to support Albertans who do not or cannot use the AVBS. To ensure a continued response to COVID-19, Alberta Health together with AHS extended the provision of free personal protective equipment (PPE) to primary care physicians, pediatricians, and their staff to support their operations and enhance safety to May 31, 2022. In 2022-23, inventory consumption expense associated with the COVID-19 response was $365 million; this includes PPE, testing supplies and $88.6 million for rapid test kits. In addition, the government worked with continuing care partners to protect residents of congregate care facilities and home care clients. A total of $286 million was provided in 2022-23 for additional staffing costs and cleaning supplies, PPE and screening of visitors to protect the health and safety of residents. In 2022-23, AHS, in collaboration with the Zone PCN Committees, worked towards the administration of an oral antiviral COVID-19 treatment in respective AHS geographical zones, enhancing capacity for testing and swabbing for respiratory illnesses. In 2021-22, intravenous Sotrovimab was made available on an outpatient basis to Albertans at higher risk of severe illness or death, followed by availability of Paxlovid, the first COVID-19 treatment approved by Health Canada that can be taken orally at home. Efforts were made to recruit sentinels (primary care physicians/nurse volunteers) to increase the effectiveness of the TARRANT Viral Watch Program, which monitors respiratory infections circulating in the community. 3.2 Safeguard Albertans from communicable diseases that can cause severe illness, permanent disability, or death. The ministry works to protect Albertans from a number of communicable diseases, such as influenza, measles, and sexually transmitted and blood borne infections. Over the past year, immunization programs for vaccine-preventable diseases continued to be a primary strategy in preventing disease, disease transmission and severe health outcomes. They are key to the health of a population and to decreasing the strain on the acute care system. Through promoting initiatives that aim to increase childhood and adult immunization rates, Alberta continued to offer immunizations programs, including influenza vaccine, to Albertans six months of age and older, free of charge in collaboration with many partners. Alberta’s 2022-23 influenza season started earlier with a surge of influenza A cases in early October. The highest positivity for influenza A was 31.9 per cent in the week of November 20, 2022, and cases and outbreaks decreased significantly by the end of December 2022. Alberta had sufficient supply of influenza vaccines to immunize 38 per cent of the population. Alberta Health worked with AHS to ensure respiratory outbreak definitions and management guidelines were in place for high-risk settings, including continuing care and acute care facilities, to minimize severe health outcomes and protect the most vulnerable Albertans in these settings. Despite the challenges of fatigued providers and a generally vaccine fatigued population, the overall influenza immunization rate is one per cent higher than in 2021-22. As of March 31, 2023, approximately 28 per cent of Albertans received an influenza vaccine. Budget 2022 included an increase of $14.3 million related to the approval of the high-dose influenza vaccine for Albertans 65 years of age or older. As of March 31, 2023, approximately 64 per cent of Albertans 65 years of age and older, and 75 per cent of Albertans 90 years of age and older received a high-dose influenza vaccine. The Alberta Outreach Program started the week of October 3, 2022, to immunize those at highest risk of severe outcomes from influenza. The 2022-23 Influenza Immunization Program for the general public began on October 17, 2022, and ended on March 31, 2023. Influenza vaccine was available at over 2,500 immunizing sites, including AHS clinics, Indigenous Services Canada clinics, community pharmacies, community medical clinics, and post-secondary institutions. Immunization programs save millions of dollars, helping people of all ages live longer, healthier lives, and decreasing the burden on the health care system. The pandemic did result in some disruptions to the routine school immunization program and overall infant and preschool immunization rates have decreased. However, AHS has hired additional staff to support addressing the school immunization backlog and in-school catch-up programs, and immunization rates for school-aged children are nearing pre-pandemic coverage levels. In 2022, by age two, 71 per cent of Albertans had received immunization with diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b (DTaP-IPV-Hib) vaccine and 82 per cent had received immunization with measles, mumps, rubella (MMR) vaccine. These immunization rates are both lower than the national target of 95 per cent for these vaccines. As a result of the COVID-19 response, childhood immunization rates dropped between 2021 and 2022. AHS has a catch-up program to increase childhood immunization rates to help reach the national target of 95 per cent. This includes actions such as reminder calls for booked appointments, monitoring wait times and adding appointments as needed, and following up using a recall process for children with delayed immunizations. Work is underway with service providers to enhance testing, treatment and prevention strategies, including working with community-based organizations, to improve women’s health, reduce barriers to sexually transmitted and blood borne infections (STBBI) testing and treatment, and increase access to prenatal syphilis screening. Over $8 million annually is provided to organizations to prevent STBBIs and provide wrap-around supports for people living with those infections, including $1.2 million specifically for syphilis outbreak response. In September 2022, Alberta experienced a shigella outbreak in Edmonton, which ended in February 2023 after two weeks without new cases. However, the outbreak was re-opened in March 2023, when seven additional cases were reported and some patients hospitalized. As of March 31, 2023, 214 cases were reported since the outbreak initially started; no deaths were reported. In October 2022, the Shigella Task Force brought together cross-sector partners, including representatives from Alberta Health, AHS, shelters, inner-city agencies, the City of Edmonton, local family physicians, and Alberta Precision Labs to coordinate resources and discuss options for limiting spread. Syphilis has made a drastic resurgence in Alberta since 2019, with rates being the highest in more than 70 years. Alberta Health has resumed a leadership role in the provincial syphilis response, after an interruption due to COVID-19, through work with frontline service providers to support testing, treatment, and prevention strategies. By increasing access to syphilis testing and treatment services in a variety of novel health settings, the Government of Alberta will help create awareness and normalize sexually transmitted infections testing and treatment for all Albertans. The ministry is also leading and supporting a number of provincial outbreak responses and preparedness activities including: • leading the human health response to highly pathogenic avian influenza, including supporting the update of public health disease management guidelines and communication pieces for government websites; • supporting the coordinated provincial response to the international mpox (formally known as monkey pox) outbreak, including guidelines for contact management and guidance on pre and post-exposure vaccine use; and, • working with AHS public health in preparation for response to international communicable disease outbreaks, including Ebola and Polio. In early May 2022, cases of mpox began to occur in countries where mpox was not previously detected. Canada’s first case was reported on May 19, 2022, and Alberta reported its first case on June 2, 2022. By July 2022, mpox was declared a public health emergency of international concern by the World Health Organization. Alberta Health worked in collaboration with public health partners to develop testing criteria, case definitions and public health management guidelines. The Alberta Mpox Public Health Notifiable Disease Guideline was published in June 2022. Alberta began offering post-exposure vaccine on June 7, 2022, and the targeted pre-exposure vaccine campaign began at the end of June. As of March 31, 2023, Alberta recorded 45 cases of mpox. Alberta has administered 2,183 first doses and 1,715 second doses of the vaccine. 3.3 Expand access to a range of in‐person and virtual recovery‐oriented addiction and mental health services. Reporting responsibility for this objective has transferred to the Ministry of Mental Health and Addiction. Performance Measure 3.a Percentage of mental health and addiction‐related emergency department visits with no mental health service in previous two years Reporting responsibility for this performance measure has transferred to the Ministry of Mental Health and Addiction. 3.4 Prevent injuries and chronic diseases and conditions through health and wellness promotion, and environmental and individual initiatives. In 2022-23, $646 million was expensed to support population and public health initiatives to maintain and improve the health of Albertans through services promoting and protecting health and preventing injury and disease. Government provides leadership and support to protect the health and safety of Albertans and improve their health and well-being by setting public policy in a number of areas, such as maternal, infant and early child development; injury prevention; public health matters related to cannabis use; tobacco and vaping control; and, promotion of population wellness and health equity. Government recognizes that Albertans living with diabetes want to access health programs and services that will more effectively support their needs. On July 21, 2022, the Minister announced the establishment of the Diabetes Working Group (DWG) to review Alberta’s entire diabetes care pathway, identify gaps in care, and provide recommendations to improve diabetes prevention, diagnosis, treatment, and management. In addition, Alberta Health expanded the Insulin Pump Therapy Program to include newer pumps and supplies. Albertans enrolled in the pump program now have access to the newest technologies for management of diabetes. Improved access to the newer diabetes management technologies, and the work of the DWG will improve outcomes and quality of life for Albertans living with diabetes. Nearly $7 million was provided to AHS for cancer prevention initiatives supporting comprehensive projects that are reducing the risk of cancer across the province. These projects address healthy lifestyles, smoking cessation, workplace wellness, and partnerships with Indigenous communities. In 2022-23, the Cancer Prevention Screening and Innovation initiative worked with organizations such as Promoting Health, Chronic Disease Prevention and Oral Health, AHS Provincial Population and Public Health, the Alberta First Nations Information Governance Centre, the Métis Nation of Alberta, and the new AHS Indigenous Wellness Core to: • adopt the Alberta Healthy Communities Approach to focus on scaling and spreading successful interventions provincewide; • create a working partnership with the Human Papilloma Virus community innovation for sub-populations and the Provincial Population and Public Health Screening Programs and Communicable Disease Control divisions; • improve the Healthier Together Workplace program and recognition strategy; and, • strengthen work with Indigenous communities to facilitate community action to reduce modifiable factors, raise cancer awareness and improve cancer screening. A community support model was created, and tools were adapted to support the three initial Metis Settlements to create, implement and evaluate cancer prevention action plans. Alberta Health currently funds several health promotion-based initiatives to improve individual and community health and well-being: • Alberta Health continues to support the Injury Prevention Centre to provide unintentional injury prevention programs, research, and education. Through the Injury Prevention Centre, Albertans have access to programs and education that reduce the risk of injury and make communities safer. Injury prevention is a public health priority that directly reduces costs to the health care system. Injury bears an estimated financial cost of $7.1 billion annually in Alberta, $4.6 billion of which is direct health care costs. • Physician prescription to Get Active supports individuals to become more active through physical activity. Prescriptions can be filled at participating recreation facilities for free visits, free one month facility passes and/or free fitness classes. • The Communities ChooseWell program advances healthy eating and active living by supporting communities to create local conditions and environments that enable Albertans to eat well and be active. The program provides resources, education and support to community groups as well as offering small grants for implementing local healthy eating and active living initiatives. Alberta Health provides approximately $2 million in grants annually to five programs that support vulnerable mothers and their babies. From April 2022 to September 2022, programs provided intensive supports to 287 vulnerable women who were pregnant or of child-bearing age, and more vulnerable women were provided outreach supports to address gaps in support specific to the COVID-19 pandemic. Alberta Health and AHS also provided funding to support the University of Alberta’s ENRICH Maskwacîs Kokums and Mosoms Elders Mentoring Program, which creates enhanced support networks for parents-to-be. In addition, elder support helps address a gap in service within the prenatal clinical setting by connecting parents to traditional knowledge and culture. Budget 2021 provided a total of $6.75 million over three years, including $2.25 million in Budget 2022, to establish and operate the AHS Tobacco and Vaping Reduction Act Enforcement Team. As of March 31, 2023, over $2.4 million has been spent, and the team has conducted retail inspections, established a secret shopper program and a public complaint line, and created retailer resources (handbook and signage) that will improve compliance with the Act and regulation. The most current data (from the 2021-22 fiscal year) shows the enforcement team conducted 2,400 retail inspections and provided over 4,000 copies of the retailer handbook and signs to retailers. In 2022-23, Alberta Health established the Alberta Ukrainian Evacuees Health Benefit Program. The total cost of the program was $9.5 million, including physician services. As of March 31, 2023, 24,000 Ukrainians have applied for health coverage in Alberta. In addition, the ministry established a health benefit program that provided Ukrainian evacuees with access to supplemental coverage for prescription and non-prescription drugs, nutritional products, diabetic supplies, and dental, optical and emergency ambulance services. Work continues in partnership with the ministries of Agriculture and Irrigation and Environment and Protected Areas on a One Health approach to antimicrobial resistance (AMR) in the province. This work is critical to address the emerging threat of treatment-resistant microbes in human and animal populations and in the environment. An Antimicrobial Strategic Framework for Action and Implementation plan continues to be developed to help guide collective efforts to address the growing threat of AMR in Alberta. Stakeholders and partners were consulted and supported development of the framework. In 2022-23, the Office of One Health at the University of Calgary was contracted at a cost of $200,000 to support implementation of AMR priority areas for action. As part of the contract, an advisory group on stewardship was created to provide guidance on specific activities, measures, targets, and costs for implementation. Alberta Health worked with AHS, Alberta Environment and Protected Areas, and the Alberta Lake Management Society to quickly set up a water quality (fecal contamination and cyanobacterial blooms) monitoring program for four sites on Lac Ste. Anne to support the 2022 papal visit and annual Lac Ste. Anne pilgrimage. Data from this monitoring program provided the basis for issuance of a cyanobacterial bloom public health advisory for Lac Ste. Anne shortly before the event. Alberta Health regularly assesses the evidence on water fluoridation to help support municipal councils to make evidence-informed decisions regarding community water fluoridation. The ministry worked on updating community water fluoridation position statement with new relevant research, including new local data from Calgary. Alberta Health continues to provide transparent information about environmental public health data, while simultaneously providing risk communication materials to influence modifiable risk factors within the Alberta population. Examples of public health data and information available through the Open Government Portal include: • Routine chemistry and trace element data from domestic well water samples analyzed in 2016–17 and 2017–18 are available. Alberta Health funded routine chemistry and trace elements analysis of 4,842 samples of drinking water from private water wells and 307 samples from small, public, non-municipal drinking water systems. As well, data related to the study of two stormwater ponds in Lacombe, Alberta were released to the open government portal at https://open.alberta.ca/opendata/lacombe-stormwater-ponddataset. This data includes the analysis of contaminants (e.g., mercury, polycyclic aromatic hydrocarbons, trace metals, pesticides and volatile organic compounds) in fish, sediments, and water. • The Alberta Environmental Public Health Information Network, accessible at http://aephin.alberta.ca, supports awareness and provides opportunities for Albertans, academics, and cross-government partners to learn more about environmental hazards and public health in the province. In 2022-23, new visualizations were published for “Human Biomonitoring of Environmental Chemicals in Canada and the Prairies” and a “Search Interface for Environmental Site Assessment Repository”, along with enhancements including the incorporation of new, yearly data on the recreational water bodies and the impacts of poor air quality and heat. In addition, Alberta Health developed the Extreme Heat website and notification protocol at https://www.alberta.ca/extreme-heat.aspx. • Alberta Health continued to provide real-time information to Albertans about hazards and risks associated with recreational water quality at Alberta beaches and waterbodies. In 2022, over 2,300 samples were collected from 85 recreational sites to identify fecal contamination and 436 samples were collected from 50 lakes, reservoirs, and rivers to be assessed for cyanobacterial (blue green algal) blooms and microcystin toxin. This monitoring resulted in the issuing of 47 cyanobacterial bloom advisories and nine fecal contamination advisories to protect the health of Albertans and visitors to the province. Additionally, in May 2022, Alberta Health updated the Alberta Safe Beach Protocol available at https://open.alberta.ca/publications/9781460145395 to reflect new Health Canada Guidelines for cyanobacterial blooms in recreational water. In February 2023, Alberta Health released a position statement around use of stormwater ponds at https://open.alberta.ca/publications/stormwater-ponds-in-alberta-health-guidanceinformation-sheet. • Alberta Health, as part of the Scientific Working Group on Contaminated Sites in Alberta, has published a Site-Specific Risk Assessment guidance document to clarify the specific requirements of conducting a site-specific risk assessment in Alberta, available at: https://open.alberta.ca/publications/supplemental-guidance-on-site-specific-riskassessments-in-alberta. Alberta Health and the Alberta Centre for Toxicology at the University of Calgary have published the report and dataset of “Post-Horse River Wildfire Surface Water Quality Monitoring Using the Water Cytotoxicity Test” available at https://prism.ucalgary.ca/handle/1880/115412. 3.5 Improve access for underserved populations and for First Nations, Métis, and Inuit peoples to quality health services that support improved health outcomes. The most current result available from Statistics Canada’s Canadian Community Health Survey shows that in 2021, 87.3 per cent of Albertans had access to a regular health provider, an improvement from 85.3 per cent in 2020. Having a regular health care provider is important for early screening, prevention through health and wellness advice, diagnosis, and treatment of a health issue, as well as ensuring good continuity of care and connections to other health and social services. The desired result is to increase the percentage of Albertans who have access to a regular health care provider. Increasing access to a regular health care provider is consistent with progress towards the following provincial primary health care goals: • timely access to appropriate primary care services delivered by a regular health care provider or team; • coordinated, seamless delivery of primary care services through a patient’s ‘medical home’ and integration of primary care with other levels of the health care system; • efficient delivery of high-quality, evidence-informed primary care services; and, • involvement of Albertans as active partners in their own health and wellness. Alberta’s Primary Care Networks are involved in a variety of initiatives that support provincial and health zone primary care goals, including adopting a ‘medical home’ approach in their practices. This approach strengthens the connection between a patient and regular health care provider to improve access to care, chronic disease prevention and management, continuity of care, and innovations in primary health care including telemedicine and virtual care. The Government of Alberta is committed to addressing the health needs of First Nations, Métis and Inuit peoples residing in Alberta, including working with First Nations and Métis leaders, the Government of Canada and other partners to streamline how Indigenous peoples access health services, and ensuring that health services are more culturally appropriate. There is a significant gap in equitable access to primary health care for Indigenous peoples. This is evidenced by noting that in Alberta, Indigenous peoples’ life expectancy is 16.4 years below that of all other Albertans, falling below 64 years of age. An Indigenous Primary Health Care Advisory Panel was established in the fall of 2022 under MAPS to provide advice to the Minister on how the existing primary health care system could be improved to ensure First Nation, Métis, and Inuit peoples have access to high-quality, culturally safe primary health care no matter where they live. As part of their work, the Indigenous Panel convened an Indigenous Youth Innovation Forum, Indigenous Primary Health Care Innovation Forum, and participated in the MAPS Forum and Community Care Innovation Forum. These forums, along with engagements with First Nations, the Metis Settlements General Council, the Métis Nation of Alberta, and others ensured that a broad range of perspectives informed the Indigenous Panel’s work. As part of their deliberations, the Indigenous Panel submitted recommendations to the Minister in December 2022 for early opportunities for investment in enhancing Indigenous primary health care. These recommendations were approved in principle by the Minister as a first step to improving access to more culturally safe and integrated care. In 2022-23, Alberta Health provided $8.8 million to the Indigenous Wellness Program Alternative Relationship Plan to support 24 full-time equivalent physician positions to provide care in over 20 Indigenous health care centres throughout Alberta, including the Alberta Indigenous Virtual Care Clinic. Alberta Health has a separate Alternative Relationship Plan arrangement with Siksika Nation, and provides up to $1.1 million to support three full-time equivalent physician positions to provide care in the community. Alberta Health continues to engage Indigenous health care experts through the First Nations Health Advisory Panel and a Metis Settlements Health Advisory Panel. Panel members include Health Directors from across the province, as well as other associated stakeholders. The Panels inform health priorities and strategies and assist in identifying issues or gaps in programs and services, as well as working to identify potential solutions and areas of future collaboration. Alberta Health also continued work on Alberta’s Protocol Agreement Health Sub-Tables to collaborate on addressing the health gaps identified by the members of the Blackfoot Confederacy and the Stoney Nakoda Tsuut’ina Tribal Council. Alberta Health similarly worked with the Métis Nation of Alberta under their Framework Agreement with the Government of Alberta. Alberta upholds the Jordan’s Principle commitments by working with the Government of Canada and the First Nations Health Consortium, an Alberta-wide organization developed to improve access to health, social, and education services and supports to First Nations and Inuit children throughout the province, living both on and off reserve. To ensure compliance, Alberta Health established an Executive Leadership Group (including the ministries of Children’s Services, Seniors, Community and Social Services, Alberta Education, Indigenous Relations, and Alberta Health) to implement Jordan’s Principle in Alberta and to ensure that First Nations children have access to health, social, and educational resources when required, without denial or delay related to jurisdictional dispute over payment. Alberta Health has also established a Technical Cross-Jurisdictional Working Group to address barriers impacting access to programs and services. The working group includes the First Nations Health Consortium, the First Nations Inuit Health Branch, and the Ministries of Children Services, Seniors, Community and Social Services, Education, and Indigenous Relations. On October 24, 2022, government appointed a Parliamentary Secretary for Rural Health, to work with Alberta Health to address rural health challenges, such as access and health care professionals. Budget 2022 introduced a new Rural Capacity Investment Fund, as part of the provincial agreement that impacted more than 30,000 registered nurses and registered psychiatric nurses across the province. The fund supports recruitment and retention strategies in rural and remote areas of the province, including relocation assistance. Almost $4.4 million was spent in 2022-23 to assist nearly 200 employees who chose to relocate to rural Alberta and pay out retention payments to over 8,200 rural health professionals. The benefit to rural Albertans will be realized by improved staff retention rates and fewer vacancies. The Government of Alberta recognizes the importance of rural health facilities and that these health centres provide an essential role for local residents. AHS and Alberta Health have established Zone Health Care Plans based on a framework that guides the development of comprehensive, zone-wide strategic health service plans, including services for Indigenous peoples. These long-range plans address the needs of rural communities with a continued focus on appropriate quality of care, patient safety, and access to services. Conditional approval was provided to seven proponents under the Continuing Care Capital Program–Indigenous Stream in June 2022. The Modernization Stream was launched in September 2022. In 2022-23, the Government of Alberta provided approximately $7 million to the Rural Health Professions Action Plan to attract and retain rural physicians with the appropriate skills to meet the needs of rural Albertans. The program supported physician locums to maintain services when rural physicians need time away from their practice; offered continuing medical education; provided accommodations for 785 rural learners for rural placements so that they can train and choose to practice in rural communities; and, created welcoming environments though 50 attraction and retention committees so that rural communities can attract and retain health professionals. In 2022, the Government of Alberta announced the Rural Education Supplement and Integrated Doctor Experience (RESIDE) program, which allocated $8 million over three years to provide incentives to new family physicians who agree to practice in rural and remote communities in exchange for a multi-year service agreement. The program will help address challenges in patient access to health services in rural and remote areas. Since the start of the program, Alberta Health has approved several changes to the RESIDE program to better meet the needs of physicians and communities and help ensure the program successfully incentivizes more physicians to move to communities of need. As of March 31, 2023, seven physicians had signed return of service agreements in rural communities. The Provincial Primary Care Network Committee provided the Minister with a recommendations report on supporting recruitment and retention of primary care physicians, nurse practitioners, and physician assistants in rural communities. In May 2022, the Minister accepted the seven recommendations that address broader systemic aspects of rural health service challenges, and this report will inform further work within Alberta Health. In July 2022, government announced new funding of $45 million over three years to increase access to pediatric rehabilitation services and programs such as speech-language, as well as occupational and physical therapy for children and youth. A community pediatric services model was developed by AHS to address gaps with implementation of enhanced pediatric rehabilitation supports, including universal and targeted resources and programs and expanded eligibility for specified services. Service delivery is enhanced with clear intake, access and triage to services and strengthened teams to support care. Pediatric rehabilitation professionals work with families and alongside other health care professionals to help children and youth live well, build resiliency and take part in activities meaningful to them and their families. A multi-pronged workforce recruitment, retention, and optimization approach is enabling implementation despite the ongoing challenges with recruitment of health professionals across programs and jurisdictions. Alberta Health Services Provincial Rural Palliative Care In-Home Funding Program provides special, funding that can be accessed by rural palliative clients and families when they require additional support beyond existing services at end-of-life to remain at home instead of being admitted to hospital. Between April 1, 2022 and March 31, 2023, a total of 143 clients were served by the program. Of the clients who have died while accessing the program, 80 per cent were able to pass away in the comfort of their own home.

You must respond to the prompt using only the information provided in the context block.Here is the question you are to answer: How does the Government of Alberta's Ministry of Health plan to meet the three outcomes identified in their 2022-2023 Annual Health Report? Outcome One: An effective, accessible and coordinated health care system built around the needs of individuals, families, caregivers and communities, and supported by competent, accountable health professionals and secure digital information systems Key Objectives 1.1 Increase health system capacity and reduce wait times, particularly for publicly funded surgical procedures and diagnostic MRI and CT scans, emergency medical services, and intensive care units. As the province emerges from the pandemic, Alberta Health continues to prioritize health system capacity, including building surgical and Intensive Care Unit (ICU) capacity, as well as the health workforce. Several initiatives are underway to minimize disruptions to patient care and expand the capacity of Alberta’s publicly funded health care system permanently. This also includes preparing to respond more effectively to any future health crises and reducing wait times across the health care system. A resilient, sustainable health system will allow the system to operate at full capacity for longer periods before needing to adjust health care resources. The policy has overall goals of improving access to scheduled health services, improving wait time measurement and reporting, and ensuring timely communication for patients. In November 2022, Alberta released the Health Care Action Plan (HCAP). The HCAP identifies immediate government actions to build a better health care system for Albertans. In order to meet the growing demands of Alberta’s health care system, an Official Administrator was appointed to Alberta Health Services (AHS) to provide leadership to address the four goals of the HCAP: • decrease emergency department wait times; • improve emergency medical services response times; • reduce wait times for surgeries; and, • empower frontline workers to deliver health care. Since 2019, government has been committed to increasing surgical capacity to keep pace with demand and reduce the length of time Albertans are waiting for scheduled surgeries. Efforts are geared towards improving patient navigation of the health care system through enhanced care coordination and surgical pathways and resources; improving specialist advice and collaboration with family physicians before consultation; and, centralizing referrals for distribution to the most appropriate surgeon with a shorter wait list. Through the Alberta Surgical Initiative (ASI), Alberta Health continues to work with AHS to improve and standardize the entire surgical journey through: • prioritizing surgeries and allocating operating room time according to the greatest need; • streamlining referrals from primary care to specialists; • increasing surgeries at underutilized operating rooms, mainly in rural areas; and, • providing less complex surgeries through accredited chartered surgical facilities (CSFs) to provide publicly funded insured services and extend existing capacity in hospitals. Through these dedicated efforts, the total number of surgeries completed in 2022-23 was 292,500, which is over 13,900 more surgeries than the year before. Further, approximately 22,100 cancer surgeries were completed in 2022-23, which represents a 10 per cent increase compared to the pre-pandemic amount. Nearly 65 per cent of the cancer surgeries were completed within clinically recommended wait times. By the end of 2022-23, AHS had cleared all postponed surgeries due to COVID-19, and continues to work on reducing wait times. The main focus remains on those patients that are waiting the longest out of clinically recommended targets, and the most acute cases. As of March 31, 2023, AHS reduced the adult surgical waitlist by more than 7,000 patients, and the total number of cases on the adult surgical waitlist is 67,186 which is less than before the pandemic. In 2022-23, there were 38 existing CSFs and three new CSF contracts were implemented to expand publicly funded surgical capacity in these facilities. CSFs are an extension of existing capacity in hospitals and used in many other Canadian health systems. Under the Health Facilities Act, CSFs providing publicly funded insured services must be accredited by the College of Physicians and Surgeons of Alberta, and have a signed service contract with AHS. In 2022-23, accredited CSFs in Alberta provided approximately 47,400 surgeries, which is equivalent to 16.2 per cent of publicly funded scheduled surgeries. In Alberta and other provinces, wait times for three common surgical procedures (hip replacement, knee replacement and cataract surgeries) continue to be impacted by delays due to the COVID-19 pandemic and workforce shortages. The 2022-23 results for hip, knee and cataract surgical procedures showed a decline, meaning that fewer Albertans received these surgical procedures within national benchmark wait times when compared to 2021-22 results. The chart below shows quarterly trends for the three common surgical procedures completed within national benchmarks in 2022-23. There were improvements in the number of cases completed for hip and knee replacements over the course of 2022-23, showing increases of 13 per cent and 15 per cent (respectively), and demonstrating significant improvements with the appointment of the Official Administrator and the implementation of the HCAP in November 2022. While the quarterly results for cataract surgery declined in the second quarter, the number has stabilized in the third quarter since the implementation of HCAP and is beginning an upward trend in the fourth quarter, although it is slightly below the first quarter result. Since 2019-20, there has been a 20 per cent improvement in cases completed within national benchmarks for cataract surgeries, ranking Alberta as a top performer nationally. As part of ASI, Alberta Health has worked with AHS to implement additional measures aimed at improving access and wait times for surgery. Work is ongoing to increase the use of Rapid Access Clinics to reduce wait times for the assessment of orthopedic issues, reducing unnecessary consultations and decreasing wait times for consultations. The Facilitated Access to Specialized Treatment (FAST) program accelerates implementation of central intake for orthopedic and urology surgery to allow patients to see the first available surgeon. Work has begun on the implementation of the Electronic Referral System (ERS), which will expedite referrals for Albertans requiring assessment by surgical specialists. In addition, consultants have been contracted to enhance surgical capacity by improving inpatient surgeries scheduling, monitoring operating room capacity, and reducing patient flow variation. With the added capacity of additional CSFs offering surgeries and implementation of FAST and ERS, Albertans will experience a streamlined surgical journey from referral to consultation to surgery. More Albertans will get their surgery within the clinically recommended wait time targets, thereby reducing the amount of time they must live with pain and other inconveniences. Reducing wait times for medically necessary diagnostic tests is also a top priority for government. Each year, Alberta spends about $1 billion on diagnostic imaging, which includes ultrasounds, Xrays, mammography, MRI and CT scans. About 46 per cent of the $1 billion is allocated to AHS, while 54 per cent is allocated to community diagnostic imaging providers. Approximately one-third of all CT and MRI scans are emergency scans and are completed within clinically appropriate timelines (under 24 hours). In 2022-23, a total of 520,504 CT scans and 231,030 MRI scans were completed across the province. The wait time for both types of scans increased due to a sharp increase in demand and staffing issues. Alberta Health and AHS continue to implement the Diagnostic Imaging Action Plan developed in 2019 to facilitate timely access to CT and MRI scans. As part of the plan, there is a significant focus on triaging patients to ensure that those who need urgent scans can get one as soon as possible. In addition, the Clinical Decision Support (CDS) within Connect Care aims to improve appropriateness of referrals and triage decisions. AHS has reached a five-year agreement with radiologist groups in Edmonton and Calgary to reduce wait times, and signed a memorandum of understanding with the remaining three largest radiology providers in Alberta North, Central, and South Zones. In total, 83 per cent of provincial radiologists have signed agreements with AHS. As part of the HCAP, the Government of Alberta is working with AHS to improve emergency medical services (EMS) response times. Improved ambulance times means that Albertans are receiving the urgent care they need from highly skilled paramedics more quickly. The Alberta Emergency Medical Services Provincial Advisory Committee (AEPAC) was established and tasked with providing immediate and long-term recommendations that will better support staff and ensure a strengthened and sustainable EMS system for Albertans needing services now and into the future. AEPAC focused on the issues facing EMS, such as system pressures that may cause service gaps, staffing issues, and hours of work. This included issues related to ground ambulance, air ambulance, and dispatch. Furthermore, Alberta conducted an independent review of EMS dispatch (the Dispatch Review) to inform improvements that can be made to dispatch services overall. The Dispatch Review and full report from AEPAC were submitted to the Minister of Health in the fall of 2022 and released to the public in January 2023. The Government of Alberta accepted the final AEPAC report and Dispatch Review recommendations in full. The recommendations were focused on accountability, capacity, efficiencies, operations, performance, and workforce support. Adjustments are being made to improve EMS response times and get paramedics out of hospital waiting rooms and back into their communities. Implementation of recommendations on a priority basis has supported ongoing reduction in EMS response times and red alerts, and improvements in community coverage. In 2022-23, Alberta Health initiated several actions to address these recommendations and strengthen the EMS system across the province. Examples of projects include: • Implemented measures to improve the central dispatch system to better deal with lowacuity calls and prioritize emergent/urgent 911 calls for EMS and made workforcescheduling changes as part of the Fatigue Management Strategy. • Initiated pilot projects using an integrated Fire-EMS model to maximize the use of paramedics and increase ambulance capacity to the health care system. Examples of the projects included: using inbound EMS resources only when they are clinically required; staffing spare ambulances to support the EMS system during times of stress; and, expanding single member advanced care paramedic response units that provide immediate advanced life support care in anticipation of, or in the absence of, an available ambulance. • Introduced new provincial guidelines, including a 45-minute EMS emergency department (ED) wait time target for 911, to get ambulances back on the road more quickly. The new provincial guidelines enable fast-tracking ambulance transfers at EDs by moving less urgent patients to hospital waiting areas. • Put procedures in place to contract appropriately trained resources for non-emergency transfers between facilities in Calgary and Edmonton, freeing up paramedics. Instead of using highly trained paramedics for non-medical patient transfers to patients’ homes from a facility or acute care, alternative resources are now arranged by hospitals, also freeing up paramedics. • Granted an exemption to the minimum staffing requirements defined in the Ground Ambulance Regulation, significantly expanding the instances where an emergency medical responder can meet the staffing requirements for all classes of ambulance, to alleviate staffing challenges across the province. • Empowered paramedics to assess a patient's condition at the scene to decide if they need ambulance transport to the hospital. In 2022-23, a total of $590 million was spent on EMS. Capacity increases were laid out in the AHS’ EMS 10-Point Plan and recommendations by AEPAC, including increases in paramedic workforce and adding ambulances to the system. As of March 31, 2023, there are 8,417 regulated members in the province registered with the Alberta College of Paramedics, including 1,383 emergency medical responders, 4,050 primary care paramedics, and 2,984 advanced care paramedics. AHS added 19 new ambulances in Calgary and Edmonton and more ambulance coverage in Chestermere and Okotoks, and hired 457 new staff members, including 341 paramedics. Increased capacity helps reduce EMS response times and red alerts and improves working conditions for frontline practitioners and community coverage, especially for life-threatening conditions. Measures to address staffing issues include AHS’ Fatigue Management Strategy, a recruitment campaign aimed at other provinces and Australia, development of a Provincial Service Plan, and interim AEPAC recommendations brought forward in June 2022, granting an exemption to expand use of emergency medical responders and pilot projects to give greater autonomy to ambulance operators using an integrated fire-EMS model. In addition, keeping paramedics out of hospital waiting rooms and in communities has contributed to decreased EMS response times and red alerts, improved community coverage, and quicker access to EMS. The HCAP 90-day Report released in February 2023 (https://www.albertahealthservices.ca/assets/about/aop/ahs-aop-90-report.pdf ) shows an early reduction in response times and red alerts, and greater focus on urgent/emergent 911 calls through low-acuity diversion measures and non-clinical patient transport programs across Alberta, particularly in Calgary and Edmonton. Comparing November 2022 to March 2023, EMS response time for the most urgent calls in metro and urban areas was reduced from 21.8 minutes to 15 minutes. Improving access to EMS enables timely patient care and entry into the health care system. The government also launched the EMS/811 Shared Response program to ensure patients receive the level of care they need and reduce unnecessary ambulance responses. Calls that have been assessed as not experiencing a medical emergency that requires an ambulance are transferred to Health Link 811, where registered nurses provide further triage, assessment and care. Since the launch in January 2023, more than 2000 911-callers with non-urgent conditions were transferred and helped by Health Link 811, keeping more ambulances available for emergency calls. In October 2022, government appointed a Parliamentary Secretary of EMS Reform to work with health partners to set priorities for service improvement based on AEPAC and Dispatch Review report recommendations. Remaining AEPAC and Dispatch Review recommendations have been incorporated into the AHS Operations Plan and are being prioritized and monitored by the EMS Reform Parliamentary Secretary. There are almost two million visits to Alberta EDs every year. Alberta Health together with AHS is working to improve patient flow within the health system, in particular to reduce ED wait times. AHS is committed to improving the experience of patients and families from the time they seek emergency care until the time the patient is discharged or admitted. There are 780 more staff in EDs today than in December 2018. AHS is working diligently on several initiatives to improve access to emergency care including improving access to continuing care living options, expanding hospital capacity, and implementing initiatives in hospitals to streamline patient treatment and discharge. In 2022-23, alternate level of care days were reduced by enhancing social work supports in acute care to address barriers for discharge. This included adding a fast-track area at the Alberta Children’s Hospital in Calgary, and deploying additional units of EMS mobile Integrated Health Units in Calgary and Edmonton to provide care for unscheduled needs within the community (i.e., IV antibiotics, rehydration, and transfusions at home). In January 2023, the Bridge Healing Transitional Accommodation Program was launched in Edmonton to support transitioning of patients experiencing homelessness as they are discharged from emergency departments. The initiative aims to reduce hospital readmission rates for Albertans experiencing homelessness by providing wrap-around health and social services. This program provides 36 beds to support this vulnerable population. Over the next three years, $305 million will be provided for additional health care capacity on a permanent basis under the HCAP. This includes approximately $268.6 million in operating funds and $36.4 million for capital projects to increase ICU capacity on a permanent basis. Approximately $61 million was spent in 2022-23 to create 50 permanent new fully equipped and staffed adult ICU beds across the province, which brings the number of ICU beds up to 223 from 173 before the pandemic. The pandemic has shown that more permanent capacity and staff are needed, particularly in rural and remote areas. The ministry continues to address ICU staffing shortages across health care facilities in Alberta. As vacancies are filled, ICU beds are reopened. Temporary bed closures are implemented only as a last resort, and patients continue to receive safe, high-quality care. AHS filled 392 positions, as of the end of fiscal year 2022-23, to support the new beds. These positions included nurses, allied health professionals, pharmacists, and clinical support service positions for diagnostic imaging and service workers. The latest data available at the end of fiscal year 2022-23 indicated that the provincial ICU baseline occupancy rate was 82 per cent, a 29 per cent improvement from being at over capacity (115 per cent) in 2021-22. Increasing ICU capacity ensures that Albertans receive care when they need it most. However, unplanned temporary service disruptions, including bed reductions, are not unusual in any health system, as services and beds are managed based on patient need, staffing levels, acuity of patient health, and other factors. Government works to ensure patients continue to receive safe, high-quality care. Occasionally, however, temporary bed closures are implemented as a last resort. Government is committed to ensuring that any Albertan who needs acute care will receive it. Workforce challenges remain a significant barrier to improving wait times for surgery given the high demand for anesthesiologists in Canada and international jurisdictions. Alberta Health is reviewing and developing options to support continued implementation of the Anesthesia Care Team Model in AHS and CSFs. The implementation of the Anesthesia Care Team Model aims to use anesthesiologists more resourcefully for some ophthalmology and orthopedic surgeries by employing a multidisciplinary team that works under supervision of the anesthesiologist to support anesthesia services in the operating room. Recruitment efforts are underway through AHS to attract more anesthesiologists to Alberta, including in rural areas. In March 2023, government released MAPS Strategy, which sets out a framework for supporting the province’s current health care workers and building the future workforce that can support Albertans getting the health care they need when and where they need it. Alberta has various initiatives underway to attract and retain nurses and increase system capacity. Alberta Health worked with the College of Registered Nurses of Alberta to streamline registration processes for Internationally Educated Nurses (IEN) and developed a grant agreement with the Alberta Association of Nurses for nurse navigators to support IENs going through the assessment, education, and registration processes. Announced in September 2022, the Modernizing Alberta’s Primary Health Care System (MAPS) initiative formed three panels to provide advice to the Minister on ways to improve the primary health care system, thereby improving the overall efficiency of the health care system. On February 21, 2023, the Minister announced an investment into primary health care of $243 million over three years; of this, $125 million is allocated for MAPS recommendations. In addition, the Minister accepted, in principle, early opportunities for investment that could be implemented to enhance Albertans’ access to primary health care immediately. On March 31, 2023, the MAPS Strategic Advisory Panel and Indigenous Primary Health Care Advisory Panel submitted parallel final reports to the Minister, outlining transformative strategic roadmaps for the next 10 years of primary health care in Alberta. These reports address both Indigenous access to primary health care and advice on improving primary health care for all Albertans. The intent of the MAPS initiative will be to reorient the health system around primary health care, thereby improving patient outcomes and reducing costs and decreasing pressures on the acute care system in the long-term. Partnerships and collaboration between primary care providers and specialists will improve patient wait times and health outcomes. The ASI Care Pathways and Specialty Advice, which includes the Provincial Pathways Unit and provincially aligned non-urgent telephone advice service programs, support consistency and quality to ensure continuity of care across the patient journey. The Provincial Primary Care Network provided these projects with conditional endorsement to begin transition to operational shared service programs. Primary Care Networks (PCNs) are also working with other stakeholders on the ASI to improve primary care and specialist linkages and patient navigation of the health care system by building and leveraging PCN specialist linkage programs. Some initiatives include Strong Partnerships and Transitions of Care for the Central Zone; Patient’s Medical Home, including referral navigators; Specialist LINK Tool for the Calgary Zone; Connect MD for the Edmonton and North Zones; FAST General Surgery for the Edmonton Zone; and, Specialist Integration Task Group for the Calgary Zone. Modernize Alberta’s continuing care system, based on Alberta’s facility‐based continuing care and palliative and end‐of‐life care reviews, to improve continuing care services for Albertans living with disabilities and chronic conditions (including people living with dementia). Government continues to be committed to addressing gaps in the continuing care system, and meeting the needs of Albertans by implementing transformative changes within the system. Alberta Health worked with partners to develop a new legislative framework for the continuing care system. The Continuing Care Act (Act), which received Royal Assent on May 31, 2022, will increase clarity regarding services, address gaps and inconsistencies across services and settings, enable improved service delivery for Albertans, and support health system accountability and sustainability. Multiple pieces of legislation will be consolidated into the Act, which establishes clear and consistent oversight and authority over the delivery of continuing care services and settings. The new legislation was proclaimed to be in effect April 1, 2024, except for sections regarding administrative penalties, which will be proclaimed on April 1, 2025. Implementation of the legislative framework will better support Albertans transitioning between care types and settings, including home and community care, supportive living accommodations, and continuing care homes. The continuing care system in Alberta provides a range of services for health, personal care, and housing to ensure the safety, independence, and quality of life for people in Alberta, regardless of age, based on their evaluated need for continuing care assistance. Publicly funded care options include home and community care; continuing care homes, which includes Designated Supportive Living and Long-Term Care; and, Palliative and End-of-Life Care services (PEOLC). In addition, Albertans have the option to access housing support in supportive living settings, such as lodges, group homes, and seniors' complexes. In 2022-23, 871 new continuing care beds/spaces were created at AHS-operated or contracted facilities to meet Albertans’ needs. The government continues to be committed to expanding the number of available continuing care spaces throughout the province and enhancing the continuing care system to effectively meet the needs of Albertans by incorporating recommendations from the Facility-Based Continuing Care (FBCC) Review Final Report, which was released on May 31, 2021. Alberta Health has acted on several recommendations from the FBCC review, including the introduction of self-managed care as a way to provide greater choice regarding locations, types and providers of services. Further, Alberta Health has enhanced client choice by supporting more continuing care clients in the community rather than at FBCC sites. Alberta Health worked with Alberta Blue Cross and AHS to successfully implement the ClientDirected Home Care Invoicing model. This model was implemented in the Edmonton Zone in April 2022, and in the Calgary Zone in the fall of 2022. Expansion to rural areas of the province will move forward over the course of 2023 to provide Albertans with increased choice and flexibility in selecting their home care service provider and the ability to better direct how their care is provided. In June 2022, Alberta Health worked with AHS to initiate a Request for Expression of Interest and Qualification (RFEOIQ) procurement process to explore opportunities to optimize the provision of home care services in Alberta, as well as identify innovative service delivery solutions to support specialized needs and populations. Albertans will begin to see the outcomes and impacts of the RFEOIQ process during fiscal year 2023-24, as the successful proposals are implemented. Another recommendation from the FBCC report was to streamline inspections. Transition of continuing care facility audits from AHS to Alberta Health began in March 2022. A coordinated monitoring approach has reduced duplications of both reviews and site visits. In 2022-23, over 1,100 inspections were completed on accommodation and care in continuing care facilities across the province. Alberta Health also followed up on over 940 reportable incidents of resident safety or care concerns and conducted 103 complaint investigations. These activities continue to provide assurance that residents and clients are receiving safe and quality care and services. Budget 2022 allocated $204 million in capital grant funding over three years to expand capacity for continuing care. The inaugural Indigenous Stream was launched in 2021 to support continuing care facilities on and off reserves/settlements. As of June 2022, seven projects were approved for $67 million to develop 147 continuing care spaces. The inaugural Modernization Stream was launched on September 20, 2022, and concluded on January 6, 2023. This stream focused on refurbishing and/or replacing existing aging continuing care infrastructure at non-AHS owned facilities. The Government of Alberta continues to prioritize quality PEOLC by investing $20 million in over 30 projects since 2019. Progress to date on projects commenced in 2020 include: • Covenant Health continued to work to increase general awareness of PEOLC, increase uptake of advance care planning and develop standardized, competency-based education to support the provision of high-quality PEOLC. • In October 2022, Covenant Health’s Palliative Institute launched the Compassionate Alberta website, (compassionatealberta.ca) which is a resource aimed at increasing awareness around palliative care and to help Albertans have open and honest conversations about death. • Between April 2022 and March 2023, the Alberta Hospice Palliative Care Association successfully launched two programs that addresses the needs of caregivers and those with a life-limiting illness (the Living Every Season Program) as well as grief and bereavement needs for Albertans (the You’re Not Alone Grief Connection Program). In November 2021, Alberta Health released the PEOLC call for grant proposals. The grant program focused on projects that address the four PEOLC priority areas identified in the Advancing Palliative and End‐of‐Life Care in Alberta Report. As a result of this grant call, a total of 25 new PEOLC grants were initiated in April 2022, totaling $11.3 million. The funding and project breakdown is as follows: • Nearly $4.2 million for eight projects to expand community supports and services. • More than $4.1 million for 10 projects to improve health-care provider and caregiver education and training. • More than $1.9 million to support four projects that advance earlier access to palliative and end-of-life care. • More than $1.1 million for three projects for research and innovation. In June 2022, the Pilgrims Hospice Society completed a one-year, grant-funded project that supported care navigation services, which provided Albertans with information on residential support programming and provided staff training on hospice care. Pilgrims Hospice Society also received $2.5 million in October 2022 to support residential hospice care at the Roozen Family Hospice Centre in Edmonton. This demonstration project will provide important information on the standalone hospice model used at the centre, including usage data and service quality, to identify longer-term options for funding and expanding residential hospice services in Alberta. Government continued to invest in supporting the nearly one million Albertans who are caregivers for family and friends. This included approximately $2 million in grant funding since 2022 to Caregivers Alberta to enhance their programs and services; to Norquest College for the Skills Training for caregivers with a focus on rural areas; to the University of Alberta to reduce caregiver distress and support family and friend caregivers to maintain their health and well-being; and, to the Alzheimer Society of Alberta and the Northwest Territories to focus on delivering communitybased programming for persons living with dementia and their caregivers. In 2022-23, the Government of Alberta continued to support innovations in dementia care through the Community-based Innovations for Dementia Care initiative, which supported 15 communitylevel projects, and through multiple projects delivered by the Alzheimer Society of Alberta and the Northwest Territories: • The Alberta Employers Dementia Awareness Project identified the needs of employers to develop best practices to create inclusive workplaces. This included piloting and launch of the Dementia Alberta website (https://www.dementiaalberta.ca) to ensure dementia in the workplace awareness materials are available to Alberta employers. The project also helps to ensure that employers have access to materials describing the importance of brain health and dementia risk reductions, and that employers have access to sample guidance, facts, tips and scenarios applicable to Alberta employers and employees. • The expansion of the First Link® early intervention program by enhancing outreach to and in rural communities. During the project, 113 rural communities received outreach and 91 small cities, specialized municipalities, municipal districts, towns, villages or summer villages received outreach services. • The Community Dementia Ambassador Project, which created a program delivered by volunteers (Ambassadors) who live in or are familiar with the cultural and social values of Alberta communities. This project identified 22 Ambassadors from 16 communities, including Cardston, St. Paul and Peace River. Ambassadors reached more than 1,325 Albertans. To support the continuing care sector and its staffing needs, the government is exploring ways to increase the number of students enrolled in Health Care Aide (HCA) programs at various postsecondary institutions. Government is funding an additional 1,090 seats in HCA programs over three years, and invested $12.8 million to provide bursaries for HCA students to assist with education costs and encourage them to become HCAs. The HCA bursary program, administered by NorQuest College, went live July 1, 2022, and included three streams of funding: the Financial Incentive program, the HCA Tuition Bursary program, and the Workplace Tutor program. Under the Financial Incentive program, students who were enrolled in a licensed HCA program between January 1 and June 30, 2022, are eligible for up to $4,000 if they agree to work a minimum of 1,000 hours with an identified continuing care operator within one year of starting employment. Eligible HCA students may receive up to $9,000 through the HCA Tuition Bursary program. The Workplace Tutor program provides funding for identified continuing care operators to educate and train HCAs at their workplace. Demand for the bursaries is steady with over 600 students applying for the regular bursary and approximately 350 HCA students approved to receive the bursary. These bursaries will remove barriers for students, and pay for schooling and other expenses while they are completing their program. From July 2022 to March 31, 2023, government provided $20.6 million to continuing care operators to partially offset inflationary increases to accommodation charges for continuing care residents. This support made accommodation charges more affordable for residents and shielded them from the full cost of living pressures associated with higher-than-average inflation. The government provided $1 million to improve access to non-medical supports in the community. This included initiatives with United Way Calgary and the Edmonton Seniors Coordinating Council to provide more community supports and navigation assistance for clients seeking this help, expanding caregiver supports. In 2022-23, the percentage of medical patients with an unplanned hospital readmission within 30 days of discharge from hospital was 12.8 per cent. This was one per cent lower compared to last year (2021-22). A lower percentage means fewer patients have been readmitted to hospital within one month of discharge. A high rate of readmissions increases costs and may mean the health system is not performing as well as it could be. Although readmission may involve many factors, lower readmission rates show that Albertans are supported by discharge planning and continuity of services after discharge. Rates may also be impacted by the nature of the population served by a hospital facility, such as elderly patients or patients with complex health needs, or by the accessibility of post-discharge health care services in the community. Coordination of care is also improving with increased access to virtual care services and supports as well as recent enhancements to health information systems that enable electronic notification of primary care doctors when their patient is admitted or discharged from hospital. 1.3 Use digital technology to enable new models of care and reduce manual and paperbased processes. Government continues to enhance the digital health environment to provide Albertans with digital access to their health information and give health care providers more complete digital patient information at the point of care to enhance quality of care for Albertans. Collecting health system data helps support evidence-informed decisions to address changing circumstances and to keep Albertans informed. The digital modernization of the health care system involves several key elements. The MyHealth Records (MHR) portal allows Albertans to access their health information. In 2022-23, over $7.9 million was spent on MHR. Alberta Netcare, the province's Electronic Health Record, is available to health care professionals in the community and AHS. In addition, Connect Care, an integrated system with Alberta Netcare, serves as a common platform for clinical information and stores all medical records, prescriptions, and care history collected from AHS facilities, including doctor's notes. Giving Albertans digital access to their health information via the MHR portal reduces the need for them to manually request that information separately from each health provider. Albertans registered on MHR has grown from 1.25 million users in March of 2022 to just under 1.5 million users at the end of March 2023. MHR portal capabilities have been expanded with the addition of immediate release diagnostic imaging reports including CT and MRI scans. The Apple MHR App is now integrated with Apple Health Kit, allowing Albertans to connect health information from their Apple Health App account to MHR. These information technology components facilitate the shift from paper-based processes to digital processes and support the expansion of virtual care options. In 2022-23, new services to support electronic referral as part of the ASI were planned and developed. A data feed is being tested, paving the way for future referral notifications in MHR and in the Electronic Medical Records (EMR) systems of referring providers. Other improvements also included continuity of care services: • Patient data from the Central Patient Attachment Registry is now integrated with Alberta Netcare, enabling health care providers across Alberta to access information on the patient’s medical home, and who their primary provider is. Design work on Alberta’s version of the International Patient Summary is nearing completion and development work will begin shortly with EMR vendors. A patient summary is a collection of clinical and contextual information about a patient’s health details. The Alberta version of the national standard is being coordinated with Ontario and Canada Health Infoway (a not-for profit funded by the Government of Canada) and includes necessary minimum amount of information to inform patient treatment at point of care. Alberta is hoping to have at least one EMR vendor conformed to Alberta’s Patient Summary in 2023, with additional vendors onboarded in 2024. • The Community Information Integration (CII) project improves Albertans’ access to primary care and community health information by collecting patient data from physician offices and other community-based clinics and making it available to other health care providers through Alberta Netcare. Over $6.5 million was spent on CII in 2022-23. In January 2023, there were 1,764 providers live on CII, taken from 430 clinics across 40 PCNs, and nearly 1.2 million Albertans in the Central Patient Attachment Registry database. More than seven million patient encounters and over 500,000 consult reports have been submitted to Netcare as of March 31, 2023. As the province emerges from the pandemic, the expectations of Albertans have shifted and there is a greater reliance on accessing on-demand virtual government services. In alignment with the Government of Alberta Digital Strategy and Alberta Health’s eHealth Strategy, developed in 202122, Alberta Health will modernize digital service delivery, increase productivity, save tax dollars, and improve user experience by better integrating technologies into the delivery of government services. In 2022-23, $5.7 million was spent through the Health Canada Bilateral Agreement for PanCanadian Virtual Care to address secure messaging, secure video-conferencing technology, remote patient monitoring technologies, patient access to COVID-19 and other lab results, and back-end supports for integration of new platforms. This investment supported Alberta Health’s ongoing initiatives foundational to expanding the virtual health care system. Alberta Health has identified four strategic priorities for virtual care delivery in the province, which are reflected in Alberta’s Virtual Care Action Plan: • establishment of an eHealth Strategy that includes a strategy for virtual care; • expansion of the MyHealth Records patient portal capabilities, including expansion of lab results and addition of diagnostic imaging results; • development of secure messaging services for Alberta, including advanced services for twoway integration between community EMRs and Alberta Netcare; and, • development of a privacy and security framework for virtual care. Access to the MHR portal is free at https://myhealth.alberta.ca/myhealthrecords. Currently, Albertans can view parts of their Netcare record, including their medications dispensed through community pharmacies, lab results and immunization history through MHR. In 2022-23, discussions and approval processes for MHR and Alberta Netcare were underway for implementation. This enables Albertans to be active participants in their own health management. The ministry continues to make progress on a phased roll out of Connect Care within all AHS facilities to support digital modernization of the health system. In 2022-23, five of the nine planned launches for this multi-year project had been completed. Connect Care provides a single source of information in AHS to support team-based, integrated care with a focus on the patient and the efficient and effective provision of services. In 2022-23, over $260 million was spent on Connect Care. The total cost of Connect Care when completed is expected to be $1.45 billion. Although progress was slowed by the pandemic, work continues on the remaining four launches of deployment. All launches are expected to be completed by fall 2024 and approximately 145,400 users are expected with full roll out of the program. The application of modern technologies will support the delivery of innovative care models that empower patients, families and their health care teams to improve quality of care. In 2022-23, eight digital health projects were funded at the Universities of Alberta and Calgary for a total investment of $9.6 million from AHS and Alberta Innovates. These academic-clinical collaborations will help AHS identify and advance solutions that improve health care quality, health outcomes, and overall value for Albertans. Projects include the integration of prevention into Connect Care to improve the health of Albertans; digital tools such as clinical decision support and remote monitoring for people with kidney issues to reduce acute care use; tele monitoring to reduce adverse events for hospitalized patients; and, an integrated digital health approach to diabetes with First Nations in Alberta. Digital technology is also being leveraged to modernize critical capabilities to administer the Alberta Health Care Insurance Plan (AHCIP) and support core business, such as claims processing and payment to health care providers. To better meet the needs of Albertans and care providers, work continued on future models of care and emerging digital technology to replace and redesign mainframe systems to increase functionality and reduce maintenance costs. In 2022-23, over $6.5 million was spent on this initiative and the work towards the replacement and redesign of nine applications used to administer the AHCIP is ongoing. 1.4 Ensure processes for resolving patient concerns are effective, streamlined, and consistent across the province. It is important that Albertans are aware of what resources are available to help them resolve patient concerns, and how their valuable feedback can help improve the quality and safety of health services. The Office of the Alberta Health Advocates empowers Albertans to advocate for their health needs; resolves their concerns and refers individuals to programs and services to address their complaints; educates Albertans about the province’s Health Charter; and, provides health selfadvocacy skills and health literacy education to promote early resolution of issues and remove barriers and gaps in care. In February 2023, government appointed a new Health and Mental Health Advocate to be a strong voice for Albertans when it comes to their health care and to ensure the health system operates effectively for all Albertans. From April 1, 2022, to March 31, 2023, there were 2,589 Albertans served by the Office of the Alberta Health Advocates. More specifically, there were 1,565 under the Health Advocate’s jurisdiction, 742 under the Mental Health Advocate’s jurisdiction, and 175 files that were under both jurisdictions. The Office of the Alberta Health Advocates hears the patient perspective on care experiences and provides feedback to entities in the health system through effective partnership and collaboration to encourage system improvement/change and effective legislative development. The ministry is committed to ensuring the patient complaints process is fair, responsive, and accessible and has processes in place to review and respond to feedback from patients and families. Recommendations to improve the current processes for resolving patient concerns and complaints have been developed, informed by consultation and research led by the Health Quality Council of Alberta. These recommendations were approved by government in the summer of 2022; Alberta Health is working on their implementation which is to expand the role and mandate of the Health Advocate; centralize intake, triage, navigation and standardize follow up with Albertans for all patient complaints; and, require mandatory information exchange between stakeholders to support improved public reporting for health care complaints. Once the recommendations are fully implemented, Albertans will have a simplified process to raise concerns and complaints about health care, and the Health Advocate will help them find the appropriate body to review and investigate the complaints. The Health Advocate will help improve accountability by monitoring the status of the resolution processes for completion and closure. Concerns and complaints will continue to be reviewed and investigated by AHS, health professions and other bodies created under statute to hear concerns. Alberta Health continues working with First Nations and Métis health leaders to better understand their experiences with the current complaints management systems in Alberta, involve them in identifying ways to build Indigenous patient trust in the health care they receive, and to ensure their concerns are addressed appropriately. The outcome of this work will improve the current complaints management system by removing existing red tape and making the system easier to navigate for patients and families. Outcome Two: A modernized, safe, person-centred, high quality and resilient health system that provides the most effective care now and in the future for each tax dollar spent Key Objectives 2.1 Continue to implement strategies to bring Alberta’s health spending and health outcomes more in line with comparator provinces and national norms, including implementation of AHS review recommendations and working with the Alberta Medical Association to reach a fiscally sustainable agreement. Albertans want and deserve a health care system that meets their needs, while also understanding the system needs to be sustainable. Government’s focus on ensuring value for money spent on health care supports this vision through actions and initiatives that make the most of taxpayer dollars. Budget 2022 invested $22.5 billion in Health’s operating budget to keep Albertans safe and healthy. In 2022-23, Alberta received $5.8 billion in Government of Canada transfers, of which $5.5 billion was the Canada Health Transfer (CHT). The CHT included a $232 million one-time funding to address surgery backlog resulting from the COVID-19 pandemic. In February 2023, Alberta reached an agreement with the Government of Canada to invest more than $24 billion in Alberta's health care system over the next 10 years through the CHT. This funding aims to respond to the immediate needs of Albertans under the Health Care Action Plan, as well as improve access to family health services, including in rural and remote areas and in underserved communities; foster a resilient and supported health workforce; improve mental health care and addictions services; and, allow Albertans access to their own electronic health information. The ministry continues to closely monitor provincial per capita spending on health care to quantify progress on government’s broader commitment to get the most value for each dollar and improve access, and make the health system work better for Albertans, while managing cost growth in health care. The Government of Alberta continues to collaborate with health system partners to manage the biggest cost drivers in the health system – namely hospital services, labour and physician compensation, and publicly funded drug benefit programs. In 2022-23, the Government of Alberta spent $4.3 billion on hospital services (i.e., acute care), $6.0 billion on physician compensation and development, and $2.5 billion on drugs and supplemental health benefits. The pandemic caused per capita health care spending for all provinces to increase significantly. The national average increased from $4,835 in 2019-20 to $5,628 in 2021-22. The Alberta provincial per capita spending on health care in 2021-22 is estimated to be $5,384, on par with the Canadian average. Improving efficiency and ensuring more value for tax dollars will improve health outcomes and support fiscal sustainability of the health system. The Alberta Health Services (AHS) Performance Review identified opportunities for AHS to reduce costs and improve health outcomes by using resources more efficiently. The ministry will continue to pursue opportunities to align spending with British Columbia, Ontario and Quebec by implementing efficiencies and reducing drug costs through the work of the pan-Canadian Pharmaceutical Alliance. AHS continues to find ways to improve the health system and access to services to Albertans. Actions implemented as a result of the 2019 AHS Performance Review have had substantial impacts on the health care system and savings have been used to improve front-line care and system sustainability (https://open.alberta.ca/publications/alberta-health-services-performance-reviewsummary-report). Implementation of the AHS Review initiatives was concurrent with a global pandemic, labour negotiations and development of a new agreement between the government and the Alberta Medical Association (AMA). Operating expenditures (excluding COVID-19 costs) increased by 6.1 per cent in 2022-23 when compared to 2021-22. Alberta’s population growth and aging population has resulted in increased demand for healthcare services. The overall increase also reflected implementation of the new agreement with the AMA and recent settlements with various health labour unions. Despite these cost pressures, health spending growth is lower than the combined population growth and inflation increase. Protecting and improving the quality of health care in Alberta also requires capital investments. In 2022-23, a total of $841 million was invested in health-related capital projects across the province, including technology and information systems maintenance and renewal of existing facilities. Alberta continues to expand and modernize hospitals and other facilities to protect quality health care and grow system capacity. Investments in health system infrastructure is fundamental to improving efficiency in the health care system, reducing wait-times, providing additional surgical capacity, and to generally improve patient outcomes. Budget 2022 invested $193 million over three years for the redevelopment and expansion of the Red Deer Regional Hospital Centre to increase critical services and add capacity to one of the busiest hospitals in the province. The Red Deer Regional Hospital Centre redevelopment project functional program was completed in late April. The functional program develops and validates the scope of services and projected workload, staffing, and space to meet current and emerging acute health care needs of all residents of the Red Deer Regional Hospital’s catchment area. The functional program also addresses capacity and quality of space to improve patient and staff safety, support quality of care, manage utilization efficiently and sustainably, and ensure timely access to care. When completed this project will expand inpatient capacity from 370 beds to 570 beds and add three surgical suites, plus space to add three more suites when required in the future. There will be a new cardiac catheterization laboratory, a new medical device reprocessing space, expanded ambulatory care capacity, and expansion of many other clinical programs throughout the hospital. In 2022-23, over $133 million was allocated over three years for Alberta Surgical Initiative capital projects at AHS-owned facilities. This includes the renovation of the Medicine Hat Regional Hospital, the Edson Health Centre, and the Royal Alexandra Hospital in Edmonton. Construction also progressed on the University of Alberta Hospital in Edmonton, which will include a postanesthetic recovery unit and medical device reprocessing area when completed, and the Rocky Mountain House Health Centre, which is undergoing renovations for a new procedure room and the development of a new medical device reprocessing area. Design was completed for redevelopment at the Chinook Regional Hospital that will modernize and increase surgical procedure capacity. Other work also included designing 11 operating suites at the Calgary Foothills Medical Centre. As part of Budget 2022, $2.2 billion was allocated over three years to move forward with a number of capital projects, for example: • The University of Alberta Hospital Brain Centre received $50 million over three years for a Neurosciences Intensive Care Unit. The design development report is nearing completion. • Provincial Pharmacy Central Drug Production and Distribution Centre ($49 million over three years). The design development report is complete. • The Norwood Tower at the Gene Zwozdesky Centre ($142 million over two years) received an occupancy permit in March 2023 and was turned over to AHS for operational commissioning. In 2022-23, $116 million was spent to complete the Calgary Cancer Centre. The Calgary Cancer Centre Construction is complete and AHS is preparing the hospital to open in 2024. The hospital will have 160 new inpatient cancer beds, 100 patient exam rooms, 100 chemotherapy chairs, increased space for clinical trials, 12 radiation vaults, outpatient cancer clinics, and designated areas for clinical and operational support services and research laboratories. The completed project will increase cancer care capacity in Calgary by consolidating and expanding existing services to support integrated and comprehensive cancer care. On October 6, 2022, the government executed a four-year agreement with the AMA to address common interests such as quality of care, health care system sustainability, and stability of physician practices. Implementation of the AMA Agreement is underway and includes over $250 million in new spending over four years on initiatives targeted at communities and physician specialties facing recruitment and retention issues. The agreement included concrete solutions and the financial resources to support Albertans’ health care needs by promoting system stability through competitive compensation and providing targeted funding to address pressures that require immediate and longer-term stabilization. The agreement also allows physicians to provide greater input into longer-term approaches on improving patient care and physician compensation reform initiatives. Physicians received a one per cent lump sum COVID-19 recognition payment in 2022-23. Alberta physicians were at the forefront of the pandemic and the one-time payment for eligible practicing physicians is in recognition of that work during the 2021-22 fiscal year. The lump sum payment is approximately $45 million and was provided to the AMA in December 2022 to distribute to their members. Physicians will receive an average one per cent rate increase to compensation for each of the next three years. As part of implementation of the AMA Agreement, the Business Costs Program premium rate was increased by about 22 per cent. This increase will help physicians deal with inflation and keep practices open. The increase is estimated to cost $20 million annually, providing on average an extra $2,300 annually for each physician. This is in addition to about $80 million the government currently invests in the program each year. Following the ratification of the AMA Agreement, a commitment for collaboration between Alberta Health and the AMA regarding primary health care, including one-time investments of $20 million in Primary Care Networks (PCNs) for two fiscal years, was established. The Provincial PCN Committee provided significant contributions to the work of the Modernizing Alberta’s Primary Health Care System (MAPS) initiative to improve access and quality of primary and community health services. The MAPS initiative goal is to provide recommendations on ways to strengthen primary health care and achieve a primary health care-oriented health system. MAPS is engaging leaders and experts with hands-on experience in primary health care and health systems improvement to examine the current landscape and propose improvements. By March 31, 2023, a final report was delivered proposing a strategic direction for primary health care over the next 10 years, with a parallel report providing strategic directions to improve the delivery of primary health care for Indigenous peoples in Alberta. The $20 million investment in primary health care provides significant relief across the primary health care system, particularly for PCNs that have experienced a decline in their per capita payments from declining numbers of patients. This funding provides stabilization while work is undertaken to review and improve the overall funding model for PCNs, which will consider recommendations from the MAPS initiative. For many Albertans, prescription drugs have tremendous benefits in terms of improving quality of life, managing illnesses, and in some cases, precluding the need for more extensive treatments. Alberta continued to work with the pan-Canadian Pharmaceutical Alliance (pCPA) to reduce prescription drug costs and increase access to clinically effective and cost-effective drug treatment options, including cell and gene therapy. All new drugs and/or new indications for use undergo price negotiations between the pCPA and drug manufacturers. In 2022-23, rebates have increased to an estimated $327 million from $275 million in 2021-22. This is a successful trend that shows the importance of the pCPA and Alberta’s involvement as a member to push health jurisdictions for more value and budgetary protection. In 2022-23, the province spent $2.5 billion on drugs and supplemental health benefits and continued to improve existing drug benefit programs and add innovative and effective therapies through the addition of 320 new products in 2022-23. Of the 320 products added, 48 were brand name drug products and 272 were generic products. Alberta’s Biosimilars Initiative will expand the use of biosimilars by replacing the use of biologic drugs with their biosimilar versions whenever possible. This means patients will continue receiving safe and effective treatment, but at a lower cost. In 2022-23, savings from this initiative increased to an estimated $65.7 million from $48.9 million in 2021-22. 2.2 Increase regulations and oversight to improve safety, while reducing red tape within the health system by restructuring and modernizing health legislation, streamlining processes, and reducing duplication. As of March 31, 2023, the ministry, including AHS, achieved a 36.1 per cent reduction of its regulatory and administrative requirements, exceeding the government target of 33 per cent. AHS will continue to see reductions with the ongoing launches of Connect Care across the organization, continuing through 2024. Connect Care supports digital modernization of more complete central access to patient information related to AHS services. It provides resources, including medication alerts; evidencebased order sets; test and treatment suggestions; and, care paths and best practice advisories, which result in fewer repeated tests and consistent information across the province wherever care is being provided at AHS facilities. This system also reduces the number of forms used by AHS and helps to eliminate data entry duplication. Connect Care also facilitates direct communication between patients and providers through a patient portal, MyAHS Connect, which helps patients better manage their health with online access to their health information, including reports and test results. It also allows for online interaction with their care team, an ability to review and manage appointments and after visit care summaries, and less repeating of their health histories or need to remember complex histories or medication lists. The ministry continues to monitor Alberta’s health system to ensure standards are maintained and to improve safety and quality of health care. As of March 31, 2023, amendments to the Health Professions Act have been proclaimed into force that modernize Alberta’s professional regulatory structure. This included changes to 29 regulatory college regulations and one regulation that enhance professional regulation by health profession regulatory bodies and will make it easier for regulatory colleges to be more agile and adapt faster to changing best practices. The PCN Nurse Practitioner (NP) Support Program was created to enable NPs to work to the full scope of their skills. In 2022-23, $7.6 million was provided and the program facilitated the incorporation of NPs working more than 57 full-time equivalent positions as of March 2023. The program increases access to primary health care, including after hours, weekends, and in rural and remote areas and underserved populations; supports chronic disease management; and, helps meet unmet demand for primary health care services. Challenges for the program include NP compensation, recruitment and retention, and the desire of NPs for an independent practice model. Alberta Health is currently consulting with key stakeholders on a draft NP Compensation Model to address the challenges of the program. Amendments to the Pharmacy and Drug Act and the Pharmacy and Drug Regulation came into effect June 1, 2022. These amendments allow the Alberta College of Pharmacy and pharmacies to better respond to changes in the provision of pharmacy services to Albertans and reduce significant government red tape faced by pharmacy operators. To address the current challenges in continuing care legislation and help to initiate transformative change within continuing care, Alberta Health worked with partners to develop a new legislative framework for the continuing care system to increase clarity regarding services, address gaps and inconsistencies across settings, enable improved service delivery for Albertans, and support health system accountability and sustainability. On May 31, 2022, the Continuing Care Act (Act) received Royal Assent. The Act will come into force on April 1, 2024, after the development and approval of regulations and standards. The ministry is currently working with partners on the development of those regulations and standards. When proclaimed, the Act will regulate the full spectrum of continuing care services and settings in Alberta, including continuing care homes, supportive living accommodations, and home and community care. Consequential amendments to the Act are included in The Red Tape Reduction Statutes Amendment Act, 2023. These amendments ensure alignment of terminology in existing legislation with the Act while maintaining the policies and intent of the current legislation. In May 2022, the Food Regulation under the Public Health Act was amended to eliminate the requirement for food establishments to request an approval from a public health inspector to allow dogs into outdoor eating areas. The amendment reduced red tape for operators and provided them greater flexibility in meeting the needs of their customers. The Food Regulation provides clear requirements to support the change so dogs can stay with their owners on outdoor patios, while maintaining a high degree of food safety. 2.3 Improve measuring, monitoring and reporting of health system performance to drive health care improvements. Measuring performance is the clearest way to show investments in the health care system are leading to better outcomes for Albertans. Alberta Health worked with the Health Quality Council of Alberta (HQCA) to ensure alignment of their plans and priorities with government key priorities and achieve improvements through various initiatives. On July 26, 2022, Alberta Health executed a $23 million operating grant agreement with the HQCA over three years (April 1, 2022 to March 31, 2025) to keep the organization working with patients, families, and partners from across health care and academia to inspire improvement in patient safety, person-centred care, and health service quality. As an example, Alberta Health worked with the HQCA to develop a Primary Care Patient Experience survey to engage Albertans on their experiences within the health care system. Work continued towards transitioning manual surveys to a digital, computer-adaptive testing methodologies format to use digital technology to enable new models of care and reduce manual and paper-based processes. Digital formats for surveys and reports across primary and continuing care increased Albertans’ engagement within the health system and allowed more timely feedback to service providers about care concerns, including patients’ opinions. Alberta Health worked with HQCA to create primary health care panel reports to support planning, quality improvement, health system management for overall purpose of improving primary health care delivery. The panel reports provide family physicians with information on their patients’ continuity, as well as valuable data on screening and vaccination rates, chronic conditions, pharmaceutical use, and emergency and hospital visits. Alberta Health worked with AHS and the HQCA to develop a value-based assessment tool for objectively assessing value from the Government of Alberta annual investment into health outcomes of Albertans and benchmark against other jurisdictions, particularly the comparator provinces of British Columbia, Ontario and Quebec. Alberta Health also worked with the HQCA to complete priority work on identifying emergency medical services key performance indicators. Performance measures were developed and are under ministry review, with a shift in focus to reducing response times measured at the 90th percentile, rather than the 50th percentile. Releasing the results and performance information improves quality and patient safety and assures Albertans of the government’s commitment to increase accountability and transparency in Alberta’s health care system. The adoption of best practices and monitoring of performance measures help to improve health outcomes. Work continued with the HQCA on developing the Patient Experience Awards and Quality Exchange to support excellence in care and sharing of best practices. This included continuing to develop resources and information to support and inform program planning, panel management, quality improvement and policy development in primary health care, as well as patient experience information for designated supportive living and continuing care. Information is published for Albertans in FOCUS, a dynamic online reporting tool which collects information about what patients experience in the provincial health care system, including: emergency departments, primary health care, long-term care, designated supportive living and home care. Outcome Three: The health and well-being of all Albertans is protected, supported and improved, and health inequities among population groups are reduced Key Objectives 3.1 Ensure a continued, effective response to the COVID‐19 pandemic by optimizing access to treatments and vaccine, and reducing vaccine hesitancy. The Government of Alberta remains committed to supporting Albertans as we shift to managing COVID-19 similar to how other endemic respiratory viruses are managed. Alberta’s capacity to treat and clinically manage cases of COVID-19 continues to improve. Immunization, including receiving a booster dose of COVID-19 vaccine, is one of the best choices Albertans can make to protect themselves from severe illness due to COVID-19 infection. In 2022-23, $1.2 billion was spent on COVID-19 response to ensure the health care system had the resources required to address health care pressures resulting from the pandemic. By the end of June 2022, all mandatory public health measures related to COVID-19 were lifted. This was due to increased immunization coverage, attenuation of severity of new circulating variants, and the ability to treat and clinically manage cases of COVID-19. This signaled the beginning of a shift in Alberta’s handling of COVID-19 from an emergency pandemic response to an endemic state. Government supported this transition by working across multiple facets of health care (e.g., primary care, continuing care, workplace health and safety, public health, provincial laboratory, etc.) to align public health recommendations, such as testing and isolation, across all common respiratory viral illnesses. The ministry continued to monitor the impacts and transmission of COVID-19 and other respiratory viruses in the community by working with partners on the implementation of ongoing and new COVID-19 immunization programs, including the introduction of bivalent booster vaccines, and implementing treatment protocols for COVID-19. Alberta Health and the Health Quality Council of Alberta established a COVID-19 Data Task Force, comprised of health professionals, to conduct a data review of the last several years of health information with a view to offering recommendations to the Government of Alberta on how to better manage a future pandemic. The purpose of the review is an opportunity to reflect on Alberta’s pandemic response from a data quality and validity lens to identify opportunities for improvements to manage future pandemics. To minimize the impact of COVID-19 and protect public health, COVID-19 Rapid Antigen Tests were made available across the province to all Albertans free of charge through participating community pharmacies. Initially, supply was limited and this distribution model enabled an equitable distribution of tests across the province. Between March 2021 to March 31, 2023, Alberta distributed 48.5 million rapid antigen tests to acute and continuing care sites, primary care clinics, businesses, K-12 schools, municipalities, First Nations and Métis communities, and the general public. Government developed COVID-19 vaccine strategies to help reduce the spread, minimize severe outcomes and protect vulnerable Albertans. Work continued to support the review of ongoing evidence and recommendations for immunization against COVID-19, including guidance for immunization post-infection (or hybrid immunity), as well as for fall/spring booster programs. In 2022, Alberta continuously achieved key milestones on COVID-19 vaccine administration and roll out for different age groups and populations. In April 2022, 40 per cent of Albertans 12 and older had received their third vaccine dose. In June 2022, 35 per cent of Albertans aged five to 11 had received two doses of COVID-19 vaccine. On November 14, 2022, the Pfizer vaccine was made available for individuals six months to four years of age, and on March 20, 2023, a second bivalent vaccine (spring booster) was made available for residents living in senior congregate living settings. In 2022-23, 1.4 million COVID-19 vaccine doses were administered to Albertans and 26 per cent of the population 12 years of age and older had received a booster dose. While the federal government continued to cover the costs of the vaccines, Alberta Health spent $53 million in 2022-23 to distribute the vaccines to Albertans. The Alberta Vaccine Booking System (AVBS), launched in summer of 2021, continues to provide Albertans with access to book both COVID-19 and influenza vaccine appointments at participating Alberta Health Services (AHS) or pharmacy locations by providing a centralized, province-wide online appointment booking platform. The centralization of all vaccine booking appointments, including from AHS, Public Health, and Community Pharmacy helps Alberta Health forecast vaccine demand and strategically distribute vaccine supply. Vaccine eligibility criteria and system functionality continue to be updated based on direction from provincial immunization programs. In 2022-23, more than 575,000 appointments for COVID-19 and influenza immunization were scheduled using the AVBS. Updates continue to be released to support dynamic vaccine eligibility changes and to continually improve the user experience. Previously, Albertans had to call multiple pharmacies and Health Link in an attempt to find available vaccine supply. The Health Link 811 call centre continues to support Albertans who do not or cannot use the AVBS. To ensure a continued response to COVID-19, Alberta Health together with AHS extended the provision of free personal protective equipment (PPE) to primary care physicians, pediatricians, and their staff to support their operations and enhance safety to May 31, 2022. In 2022-23, inventory consumption expense associated with the COVID-19 response was $365 million; this includes PPE, testing supplies and $88.6 million for rapid test kits. In addition, the government worked with continuing care partners to protect residents of congregate care facilities and home care clients. A total of $286 million was provided in 2022-23 for additional staffing costs and cleaning supplies, PPE and screening of visitors to protect the health and safety of residents. In 2022-23, AHS, in collaboration with the Zone PCN Committees, worked towards the administration of an oral antiviral COVID-19 treatment in respective AHS geographical zones, enhancing capacity for testing and swabbing for respiratory illnesses. In 2021-22, intravenous Sotrovimab was made available on an outpatient basis to Albertans at higher risk of severe illness or death, followed by availability of Paxlovid, the first COVID-19 treatment approved by Health Canada that can be taken orally at home. Efforts were made to recruit sentinels (primary care physicians/nurse volunteers) to increase the effectiveness of the TARRANT Viral Watch Program, which monitors respiratory infections circulating in the community. 3.2 Safeguard Albertans from communicable diseases that can cause severe illness, permanent disability, or death. The ministry works to protect Albertans from a number of communicable diseases, such as influenza, measles, and sexually transmitted and blood borne infections. Over the past year, immunization programs for vaccine-preventable diseases continued to be a primary strategy in preventing disease, disease transmission and severe health outcomes. They are key to the health of a population and to decreasing the strain on the acute care system. Through promoting initiatives that aim to increase childhood and adult immunization rates, Alberta continued to offer immunizations programs, including influenza vaccine, to Albertans six months of age and older, free of charge in collaboration with many partners. Alberta’s 2022-23 influenza season started earlier with a surge of influenza A cases in early October. The highest positivity for influenza A was 31.9 per cent in the week of November 20, 2022, and cases and outbreaks decreased significantly by the end of December 2022. Alberta had sufficient supply of influenza vaccines to immunize 38 per cent of the population. Alberta Health worked with AHS to ensure respiratory outbreak definitions and management guidelines were in place for high-risk settings, including continuing care and acute care facilities, to minimize severe health outcomes and protect the most vulnerable Albertans in these settings. Despite the challenges of fatigued providers and a generally vaccine fatigued population, the overall influenza immunization rate is one per cent higher than in 2021-22. As of March 31, 2023, approximately 28 per cent of Albertans received an influenza vaccine. Budget 2022 included an increase of $14.3 million related to the approval of the high-dose influenza vaccine for Albertans 65 years of age or older. As of March 31, 2023, approximately 64 per cent of Albertans 65 years of age and older, and 75 per cent of Albertans 90 years of age and older received a high-dose influenza vaccine. The Alberta Outreach Program started the week of October 3, 2022, to immunize those at highest risk of severe outcomes from influenza. The 2022-23 Influenza Immunization Program for the general public began on October 17, 2022, and ended on March 31, 2023. Influenza vaccine was available at over 2,500 immunizing sites, including AHS clinics, Indigenous Services Canada clinics, community pharmacies, community medical clinics, and post-secondary institutions. Immunization programs save millions of dollars, helping people of all ages live longer, healthier lives, and decreasing the burden on the health care system. The pandemic did result in some disruptions to the routine school immunization program and overall infant and preschool immunization rates have decreased. However, AHS has hired additional staff to support addressing the school immunization backlog and in-school catch-up programs, and immunization rates for school-aged children are nearing pre-pandemic coverage levels. In 2022, by age two, 71 per cent of Albertans had received immunization with diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b (DTaP-IPV-Hib) vaccine and 82 per cent had received immunization with measles, mumps, rubella (MMR) vaccine. These immunization rates are both lower than the national target of 95 per cent for these vaccines. As a result of the COVID-19 response, childhood immunization rates dropped between 2021 and 2022. AHS has a catch-up program to increase childhood immunization rates to help reach the national target of 95 per cent. This includes actions such as reminder calls for booked appointments, monitoring wait times and adding appointments as needed, and following up using a recall process for children with delayed immunizations. Work is underway with service providers to enhance testing, treatment and prevention strategies, including working with community-based organizations, to improve women’s health, reduce barriers to sexually transmitted and blood borne infections (STBBI) testing and treatment, and increase access to prenatal syphilis screening. Over $8 million annually is provided to organizations to prevent STBBIs and provide wrap-around supports for people living with those infections, including $1.2 million specifically for syphilis outbreak response. In September 2022, Alberta experienced a shigella outbreak in Edmonton, which ended in February 2023 after two weeks without new cases. However, the outbreak was re-opened in March 2023, when seven additional cases were reported and some patients hospitalized. As of March 31, 2023, 214 cases were reported since the outbreak initially started; no deaths were reported. In October 2022, the Shigella Task Force brought together cross-sector partners, including representatives from Alberta Health, AHS, shelters, inner-city agencies, the City of Edmonton, local family physicians, and Alberta Precision Labs to coordinate resources and discuss options for limiting spread. Syphilis has made a drastic resurgence in Alberta since 2019, with rates being the highest in more than 70 years. Alberta Health has resumed a leadership role in the provincial syphilis response, after an interruption due to COVID-19, through work with frontline service providers to support testing, treatment, and prevention strategies. By increasing access to syphilis testing and treatment services in a variety of novel health settings, the Government of Alberta will help create awareness and normalize sexually transmitted infections testing and treatment for all Albertans. The ministry is also leading and supporting a number of provincial outbreak responses and preparedness activities including: • leading the human health response to highly pathogenic avian influenza, including supporting the update of public health disease management guidelines and communication pieces for government websites; • supporting the coordinated provincial response to the international mpox (formally known as monkey pox) outbreak, including guidelines for contact management and guidance on pre and post-exposure vaccine use; and, • working with AHS public health in preparation for response to international communicable disease outbreaks, including Ebola and Polio. In early May 2022, cases of mpox began to occur in countries where mpox was not previously detected. Canada’s first case was reported on May 19, 2022, and Alberta reported its first case on June 2, 2022. By July 2022, mpox was declared a public health emergency of international concern by the World Health Organization. Alberta Health worked in collaboration with public health partners to develop testing criteria, case definitions and public health management guidelines. The Alberta Mpox Public Health Notifiable Disease Guideline was published in June 2022. Alberta began offering post-exposure vaccine on June 7, 2022, and the targeted pre-exposure vaccine campaign began at the end of June. As of March 31, 2023, Alberta recorded 45 cases of mpox. Alberta has administered 2,183 first doses and 1,715 second doses of the vaccine. 3.3 Expand access to a range of in‐person and virtual recovery‐oriented addiction and mental health services. Reporting responsibility for this objective has transferred to the Ministry of Mental Health and Addiction. Performance Measure 3.a Percentage of mental health and addiction‐related emergency department visits with no mental health service in previous two years Reporting responsibility for this performance measure has transferred to the Ministry of Mental Health and Addiction. 3.4 Prevent injuries and chronic diseases and conditions through health and wellness promotion, and environmental and individual initiatives. In 2022-23, $646 million was expensed to support population and public health initiatives to maintain and improve the health of Albertans through services promoting and protecting health and preventing injury and disease. Government provides leadership and support to protect the health and safety of Albertans and improve their health and well-being by setting public policy in a number of areas, such as maternal, infant and early child development; injury prevention; public health matters related to cannabis use; tobacco and vaping control; and, promotion of population wellness and health equity. Government recognizes that Albertans living with diabetes want to access health programs and services that will more effectively support their needs. On July 21, 2022, the Minister announced the establishment of the Diabetes Working Group (DWG) to review Alberta’s entire diabetes care pathway, identify gaps in care, and provide recommendations to improve diabetes prevention, diagnosis, treatment, and management. In addition, Alberta Health expanded the Insulin Pump Therapy Program to include newer pumps and supplies. Albertans enrolled in the pump program now have access to the newest technologies for management of diabetes. Improved access to the newer diabetes management technologies, and the work of the DWG will improve outcomes and quality of life for Albertans living with diabetes. Nearly $7 million was provided to AHS for cancer prevention initiatives supporting comprehensive projects that are reducing the risk of cancer across the province. These projects address healthy lifestyles, smoking cessation, workplace wellness, and partnerships with Indigenous communities. In 2022-23, the Cancer Prevention Screening and Innovation initiative worked with organizations such as Promoting Health, Chronic Disease Prevention and Oral Health, AHS Provincial Population and Public Health, the Alberta First Nations Information Governance Centre, the Métis Nation of Alberta, and the new AHS Indigenous Wellness Core to: • adopt the Alberta Healthy Communities Approach to focus on scaling and spreading successful interventions provincewide; • create a working partnership with the Human Papilloma Virus community innovation for sub-populations and the Provincial Population and Public Health Screening Programs and Communicable Disease Control divisions; • improve the Healthier Together Workplace program and recognition strategy; and, • strengthen work with Indigenous communities to facilitate community action to reduce modifiable factors, raise cancer awareness and improve cancer screening. A community support model was created, and tools were adapted to support the three initial Metis Settlements to create, implement and evaluate cancer prevention action plans. Alberta Health currently funds several health promotion-based initiatives to improve individual and community health and well-being: • Alberta Health continues to support the Injury Prevention Centre to provide unintentional injury prevention programs, research, and education. Through the Injury Prevention Centre, Albertans have access to programs and education that reduce the risk of injury and make communities safer. Injury prevention is a public health priority that directly reduces costs to the health care system. Injury bears an estimated financial cost of $7.1 billion annually in Alberta, $4.6 billion of which is direct health care costs. • Physician prescription to Get Active supports individuals to become more active through physical activity. Prescriptions can be filled at participating recreation facilities for free visits, free one month facility passes and/or free fitness classes. • The Communities ChooseWell program advances healthy eating and active living by supporting communities to create local conditions and environments that enable Albertans to eat well and be active. The program provides resources, education and support to community groups as well as offering small grants for implementing local healthy eating and active living initiatives. Alberta Health provides approximately $2 million in grants annually to five programs that support vulnerable mothers and their babies. From April 2022 to September 2022, programs provided intensive supports to 287 vulnerable women who were pregnant or of child-bearing age, and more vulnerable women were provided outreach supports to address gaps in support specific to the COVID-19 pandemic. Alberta Health and AHS also provided funding to support the University of Alberta’s ENRICH Maskwacîs Kokums and Mosoms Elders Mentoring Program, which creates enhanced support networks for parents-to-be. In addition, elder support helps address a gap in service within the prenatal clinical setting by connecting parents to traditional knowledge and culture. Budget 2021 provided a total of $6.75 million over three years, including $2.25 million in Budget 2022, to establish and operate the AHS Tobacco and Vaping Reduction Act Enforcement Team. As of March 31, 2023, over $2.4 million has been spent, and the team has conducted retail inspections, established a secret shopper program and a public complaint line, and created retailer resources (handbook and signage) that will improve compliance with the Act and regulation. The most current data (from the 2021-22 fiscal year) shows the enforcement team conducted 2,400 retail inspections and provided over 4,000 copies of the retailer handbook and signs to retailers. In 2022-23, Alberta Health established the Alberta Ukrainian Evacuees Health Benefit Program. The total cost of the program was $9.5 million, including physician services. As of March 31, 2023, 24,000 Ukrainians have applied for health coverage in Alberta. In addition, the ministry established a health benefit program that provided Ukrainian evacuees with access to supplemental coverage for prescription and non-prescription drugs, nutritional products, diabetic supplies, and dental, optical and emergency ambulance services. Work continues in partnership with the ministries of Agriculture and Irrigation and Environment and Protected Areas on a One Health approach to antimicrobial resistance (AMR) in the province. This work is critical to address the emerging threat of treatment-resistant microbes in human and animal populations and in the environment. An Antimicrobial Strategic Framework for Action and Implementation plan continues to be developed to help guide collective efforts to address the growing threat of AMR in Alberta. Stakeholders and partners were consulted and supported development of the framework. In 2022-23, the Office of One Health at the University of Calgary was contracted at a cost of $200,000 to support implementation of AMR priority areas for action. As part of the contract, an advisory group on stewardship was created to provide guidance on specific activities, measures, targets, and costs for implementation. Alberta Health worked with AHS, Alberta Environment and Protected Areas, and the Alberta Lake Management Society to quickly set up a water quality (fecal contamination and cyanobacterial blooms) monitoring program for four sites on Lac Ste. Anne to support the 2022 papal visit and annual Lac Ste. Anne pilgrimage. Data from this monitoring program provided the basis for issuance of a cyanobacterial bloom public health advisory for Lac Ste. Anne shortly before the event. Alberta Health regularly assesses the evidence on water fluoridation to help support municipal councils to make evidence-informed decisions regarding community water fluoridation. The ministry worked on updating community water fluoridation position statement with new relevant research, including new local data from Calgary. Alberta Health continues to provide transparent information about environmental public health data, while simultaneously providing risk communication materials to influence modifiable risk factors within the Alberta population. Examples of public health data and information available through the Open Government Portal include: • Routine chemistry and trace element data from domestic well water samples analyzed in 2016–17 and 2017–18 are available. Alberta Health funded routine chemistry and trace elements analysis of 4,842 samples of drinking water from private water wells and 307 samples from small, public, non-municipal drinking water systems. As well, data related to the study of two stormwater ponds in Lacombe, Alberta were released to the open government portal at https://open.alberta.ca/opendata/lacombe-stormwater-ponddataset. This data includes the analysis of contaminants (e.g., mercury, polycyclic aromatic hydrocarbons, trace metals, pesticides and volatile organic compounds) in fish, sediments, and water. • The Alberta Environmental Public Health Information Network, accessible at http://aephin.alberta.ca, supports awareness and provides opportunities for Albertans, academics, and cross-government partners to learn more about environmental hazards and public health in the province. In 2022-23, new visualizations were published for “Human Biomonitoring of Environmental Chemicals in Canada and the Prairies” and a “Search Interface for Environmental Site Assessment Repository”, along with enhancements including the incorporation of new, yearly data on the recreational water bodies and the impacts of poor air quality and heat. In addition, Alberta Health developed the Extreme Heat website and notification protocol at https://www.alberta.ca/extreme-heat.aspx. • Alberta Health continued to provide real-time information to Albertans about hazards and risks associated with recreational water quality at Alberta beaches and waterbodies. In 2022, over 2,300 samples were collected from 85 recreational sites to identify fecal contamination and 436 samples were collected from 50 lakes, reservoirs, and rivers to be assessed for cyanobacterial (blue green algal) blooms and microcystin toxin. This monitoring resulted in the issuing of 47 cyanobacterial bloom advisories and nine fecal contamination advisories to protect the health of Albertans and visitors to the province. Additionally, in May 2022, Alberta Health updated the Alberta Safe Beach Protocol available at https://open.alberta.ca/publications/9781460145395 to reflect new Health Canada Guidelines for cyanobacterial blooms in recreational water. In February 2023, Alberta Health released a position statement around use of stormwater ponds at https://open.alberta.ca/publications/stormwater-ponds-in-alberta-health-guidanceinformation-sheet. • Alberta Health, as part of the Scientific Working Group on Contaminated Sites in Alberta, has published a Site-Specific Risk Assessment guidance document to clarify the specific requirements of conducting a site-specific risk assessment in Alberta, available at: https://open.alberta.ca/publications/supplemental-guidance-on-site-specific-riskassessments-in-alberta. Alberta Health and the Alberta Centre for Toxicology at the University of Calgary have published the report and dataset of “Post-Horse River Wildfire Surface Water Quality Monitoring Using the Water Cytotoxicity Test” available at https://prism.ucalgary.ca/handle/1880/115412. 3.5 Improve access for underserved populations and for First Nations, Métis, and Inuit peoples to quality health services that support improved health outcomes. The most current result available from Statistics Canada’s Canadian Community Health Survey shows that in 2021, 87.3 per cent of Albertans had access to a regular health provider, an improvement from 85.3 per cent in 2020. Having a regular health care provider is important for early screening, prevention through health and wellness advice, diagnosis, and treatment of a health issue, as well as ensuring good continuity of care and connections to other health and social services. The desired result is to increase the percentage of Albertans who have access to a regular health care provider. Increasing access to a regular health care provider is consistent with progress towards the following provincial primary health care goals: • timely access to appropriate primary care services delivered by a regular health care provider or team; • coordinated, seamless delivery of primary care services through a patient’s ‘medical home’ and integration of primary care with other levels of the health care system; • efficient delivery of high-quality, evidence-informed primary care services; and, • involvement of Albertans as active partners in their own health and wellness. Alberta’s Primary Care Networks are involved in a variety of initiatives that support provincial and health zone primary care goals, including adopting a ‘medical home’ approach in their practices. This approach strengthens the connection between a patient and regular health care provider to improve access to care, chronic disease prevention and management, continuity of care, and innovations in primary health care including telemedicine and virtual care. The Government of Alberta is committed to addressing the health needs of First Nations, Métis and Inuit peoples residing in Alberta, including working with First Nations and Métis leaders, the Government of Canada and other partners to streamline how Indigenous peoples access health services, and ensuring that health services are more culturally appropriate. There is a significant gap in equitable access to primary health care for Indigenous peoples. This is evidenced by noting that in Alberta, Indigenous peoples’ life expectancy is 16.4 years below that of all other Albertans, falling below 64 years of age. An Indigenous Primary Health Care Advisory Panel was established in the fall of 2022 under MAPS to provide advice to the Minister on how the existing primary health care system could be improved to ensure First Nation, Métis, and Inuit peoples have access to high-quality, culturally safe primary health care no matter where they live. As part of their work, the Indigenous Panel convened an Indigenous Youth Innovation Forum, Indigenous Primary Health Care Innovation Forum, and participated in the MAPS Forum and Community Care Innovation Forum. These forums, along with engagements with First Nations, the Metis Settlements General Council, the Métis Nation of Alberta, and others ensured that a broad range of perspectives informed the Indigenous Panel’s work. As part of their deliberations, the Indigenous Panel submitted recommendations to the Minister in December 2022 for early opportunities for investment in enhancing Indigenous primary health care. These recommendations were approved in principle by the Minister as a first step to improving access to more culturally safe and integrated care. In 2022-23, Alberta Health provided $8.8 million to the Indigenous Wellness Program Alternative Relationship Plan to support 24 full-time equivalent physician positions to provide care in over 20 Indigenous health care centres throughout Alberta, including the Alberta Indigenous Virtual Care Clinic. Alberta Health has a separate Alternative Relationship Plan arrangement with Siksika Nation, and provides up to $1.1 million to support three full-time equivalent physician positions to provide care in the community. Alberta Health continues to engage Indigenous health care experts through the First Nations Health Advisory Panel and a Metis Settlements Health Advisory Panel. Panel members include Health Directors from across the province, as well as other associated stakeholders. The Panels inform health priorities and strategies and assist in identifying issues or gaps in programs and services, as well as working to identify potential solutions and areas of future collaboration. Alberta Health also continued work on Alberta’s Protocol Agreement Health Sub-Tables to collaborate on addressing the health gaps identified by the members of the Blackfoot Confederacy and the Stoney Nakoda Tsuut’ina Tribal Council. Alberta Health similarly worked with the Métis Nation of Alberta under their Framework Agreement with the Government of Alberta. Alberta upholds the Jordan’s Principle commitments by working with the Government of Canada and the First Nations Health Consortium, an Alberta-wide organization developed to improve access to health, social, and education services and supports to First Nations and Inuit children throughout the province, living both on and off reserve. To ensure compliance, Alberta Health established an Executive Leadership Group (including the ministries of Children’s Services, Seniors, Community and Social Services, Alberta Education, Indigenous Relations, and Alberta Health) to implement Jordan’s Principle in Alberta and to ensure that First Nations children have access to health, social, and educational resources when required, without denial or delay related to jurisdictional dispute over payment. Alberta Health has also established a Technical Cross-Jurisdictional Working Group to address barriers impacting access to programs and services. The working group includes the First Nations Health Consortium, the First Nations Inuit Health Branch, and the Ministries of Children Services, Seniors, Community and Social Services, Education, and Indigenous Relations. On October 24, 2022, government appointed a Parliamentary Secretary for Rural Health, to work with Alberta Health to address rural health challenges, such as access and health care professionals. Budget 2022 introduced a new Rural Capacity Investment Fund, as part of the provincial agreement that impacted more than 30,000 registered nurses and registered psychiatric nurses across the province. The fund supports recruitment and retention strategies in rural and remote areas of the province, including relocation assistance. Almost $4.4 million was spent in 2022-23 to assist nearly 200 employees who chose to relocate to rural Alberta and pay out retention payments to over 8,200 rural health professionals. The benefit to rural Albertans will be realized by improved staff retention rates and fewer vacancies. The Government of Alberta recognizes the importance of rural health facilities and that these health centres provide an essential role for local residents. AHS and Alberta Health have established Zone Health Care Plans based on a framework that guides the development of comprehensive, zone-wide strategic health service plans, including services for Indigenous peoples. These long-range plans address the needs of rural communities with a continued focus on appropriate quality of care, patient safety, and access to services. Conditional approval was provided to seven proponents under the Continuing Care Capital Program–Indigenous Stream in June 2022. The Modernization Stream was launched in September 2022. In 2022-23, the Government of Alberta provided approximately $7 million to the Rural Health Professions Action Plan to attract and retain rural physicians with the appropriate skills to meet the needs of rural Albertans. The program supported physician locums to maintain services when rural physicians need time away from their practice; offered continuing medical education; provided accommodations for 785 rural learners for rural placements so that they can train and choose to practice in rural communities; and, created welcoming environments though 50 attraction and retention committees so that rural communities can attract and retain health professionals. In 2022, the Government of Alberta announced the Rural Education Supplement and Integrated Doctor Experience (RESIDE) program, which allocated $8 million over three years to provide incentives to new family physicians who agree to practice in rural and remote communities in exchange for a multi-year service agreement. The program will help address challenges in patient access to health services in rural and remote areas. Since the start of the program, Alberta Health has approved several changes to the RESIDE program to better meet the needs of physicians and communities and help ensure the program successfully incentivizes more physicians to move to communities of need. As of March 31, 2023, seven physicians had signed return of service agreements in rural communities. The Provincial Primary Care Network Committee provided the Minister with a recommendations report on supporting recruitment and retention of primary care physicians, nurse practitioners, and physician assistants in rural communities. In May 2022, the Minister accepted the seven recommendations that address broader systemic aspects of rural health service challenges, and this report will inform further work within Alberta Health. In July 2022, government announced new funding of $45 million over three years to increase access to pediatric rehabilitation services and programs such as speech-language, as well as occupational and physical therapy for children and youth. A community pediatric services model was developed by AHS to address gaps with implementation of enhanced pediatric rehabilitation supports, including universal and targeted resources and programs and expanded eligibility for specified services. Service delivery is enhanced with clear intake, access and triage to services and strengthened teams to support care. Pediatric rehabilitation professionals work with families and alongside other health care professionals to help children and youth live well, build resiliency and take part in activities meaningful to them and their families. A multi-pronged workforce recruitment, retention, and optimization approach is enabling implementation despite the ongoing challenges with recruitment of health professionals across programs and jurisdictions. Alberta Health Services Provincial Rural Palliative Care In-Home Funding Program provides special, funding that can be accessed by rural palliative clients and families when they require additional support beyond existing services at end-of-life to remain at home instead of being admitted to hospital. Between April 1, 2022 and March 31, 2023, a total of 143 clients were served by the program. Of the clients who have died while accessing the program, 80 per cent were able to pass away in the comfort of their own home.

Answer questions using the information provided in the prompt. Attempt to keep answers concise, while also avoiding or explaining jargon that the masses wouldn't understand.

What does the article suggest General Motors Company has an advantage in?

GENERAL MOTORS COMPANY Item 1A. Risk Factors We have listed below the most material risk factors applicable to us. These risk factors are not necessarily in the order of importance or probability of occurrence: Risks related to our competition and strategy If we do not deliver new products, services, technologies and customer experiences in response to increased competition and changing consumer needs and preferences, our business could suffer. We believe that the automotive industry will continue to experience significant change in the coming years, particularly as traditional automotive original equipment manufacturers (OEMs) continue to shift resources to the development of EVs. In addition to our traditional competitors, we must also be responsive to the entrance of start-ups and other non-traditional competitors in the automotive industry, such as software and ridesharing services supported by large technology companies. These new competitors, as well as established industry participants, are disrupting the historic business model of our industry through the introduction of new technologies, products, services, direct-to-consumer sales channels, methods of transportation and vehicle ownership. To successfully execute our long-term strategy, we must continue to develop and commercialize new products and services, including products and services that are outside of our historically core ICE business, such as EVs and AVs, software-enabled connected services and other new businesses. There can be no assurance that advances in technology will occur in a timely or feasible way, if at all, that others will not acquire similar or superior technologies sooner than we do, or that we will acquire technologies on an exclusive basis or at a significant price advantage. The process of designing and developing new technology, products and services is costly and uncertain and requires extensive capital investment. If our access to capital were to become significantly constrained, if costs of capital increased significantly, or if our ability to raise capital is challenged relative to our peers, our ability to execute on our strategic plans could be adversely affected. Further, if we are unable to prevent or effectively remedy errors, bugs, vulnerabilities or defects in our software and hardware, or fail to deploy updates to our software properly, or if we do not adequately prepare for and respond to new kinds of technological innovations, market developments and changing customer needs and preferences, our sales, profitability and long-term competitiveness may be materially harmed. Our ability to attract and retain talented, diverse and highly skilled employees is critical to our success and competitiveness. Our success depends on our ability to recruit and retain talented and diverse employees who are highly skilled in their areas. In particular, our vehicles and connected services increasingly rely on software and hardware that is highly technical and complex and our success in this area is dependent upon our ability to retain and recruit the best talent. The market for highly skilled workers and leaders in our industry is extremely competitive. In addition to compensation considerations, current and potential employees are increasingly placing a premium on culture and other various intangibles, such as working for companies with a clear purpose and strong brand reputation, flexible work arrangements, and other considerations, such as embracing sustainability and diversity, equity and inclusion initiatives. Failure to attract, hire, develop, motivate and retain highly qualified and diverse employees could disrupt our operations and adversely affect our strategic plans. Our ability to maintain profitability is dependent upon our ability to timely fund and introduce new and improved vehicle models, including EVs, that are able to attract a sufficient number of consumers. We operate in a very competitive industry with market participants routinely introducing new and improved vehicle models and features, at decreasing price points, designed to meet rapidly evolving consumer expectations. Producing new and improved vehicle models, including EVs, that preserve our reputation for designing, building and selling safe, high-quality cars, crossovers, trucks and SUVs is critical to our long-term profitability. Successful launches of our new vehicles are critical to our short-term profitability. The new vehicle development process can take two years or more, and a number of factors may lengthen that time period. Because of this product development cycle and the various elements that may contribute to consumers’ acceptance of new vehicle designs, including competitors’ product introductions, technological innovations, fuel prices, general economic conditions, regulatory developments, including tax credits or other government policies in various countries, transportation infrastructure and changes in quality, safety, reliability and styling demands and preferences, an initial product concept or design may not result in a saleable vehicle or a vehicle that generates sales in sufficient quantities and at high enough prices to be profitable. Our high proportion of fixed costs, both due to our significant investment in property, plant and equipment as well as other requirements of our collective bargaining agreements, which limit our flexibility to adjust personnel costs to changes in demands for our products, may further exacerbate the risks associated with incorrectly assessing demand for our vehicles. Our long-term strategy is dependent upon our ability to profitably deliver a strategic portfolio of EVs. The production and profitable sale of EVs has become increasingly important to our long-term business as we continue our transition to an allelectric future. Our EV strategy is dependent on our ability to deliver a strategic portfolio of high-quality EVs that are competitive and meet consumer demands; scale our EV manufacturing capabilities; reduce the costs associated with the manufacture of EVs, particularly with respect to battery cells and packs; increase vehicle range and the energy density of our batteries; efficiently source sufficient materials for the manufacture of battery cells; license and monetize our proprietary platforms and related innovations; successfully invest in new technologies relative to our peers; develop new software and services; and leverage our scale, manufacturing capabilities and synergies with existing ICE vehicles. Our progress towards these objectives has impacted, and may continue to impact, the need to record losses on our EV-related inventory, including battery cells.In addition, the success of our long-term strategy is dependent on consumer adoption of EVs. Consumer adoption of EVs could be impacted by numerous factors, including the breadth of the portfolio of EVs available; perceptions about EV features, quality, safety, performance and cost relative to ICE vehicles; the range over which EVs may be driven on a given battery charge; the proliferation and speed of charging infrastructure, in particular with respect to public EV charging stations, and the success of the Company's charging infrastructure programs and strategic joint ventures and other relationships; cost and availability of high fuel-economy ICE vehicles; volatility, or a sustained decrease, in the cost of petroleum-based fuel; failure by governments and other third parties to make the investments necessary to make infrastructure improvements, such as greater availability of cleaner energy grids and EV charging stations, and to provide meaningful and fully utilizable economic incentives promoting the adoption of EVs, including production and consumer credits contemplated by the Inflation Reduction Act (IRA); and negative feedback from stakeholders impacting investor and consumer confidence in our company or industry. If we are unable to successfully deliver on our EV strategy, it could materially and adversely affect our results of operations, financial condition and growth prospects, and could negatively impact our brand and reputation. Our near-term profitability is dependent upon the success of our current line of ICE vehicles, particularly our full-size ICE SUVs and full-size ICE pickup trucks. While we offer a broad portfolio of cars, crossovers, SUVs and trucks, and we have announced significant plans to design, build and sell a strategic portfolio of EVs, we currently recognize the highest profit margins on our full-size ICE SUVs and full-size ICE pickup trucks. As a result, our near-term success is dependent upon our ability to sell higher margin vehicles in sufficient volumes. We are also using the cash generated by our ICE vehicles to fund our growth strategy, including with respect to EVs and AVs. Any near-term shift in consumer preferences toward smaller, more fuel-efficient vehicles, whether as a result of increases in the price of oil or any sustained shortage of oil, including as a result of global political instability (such as related to the ongoing conflicts in Ukraine and Gaza), concerns about fuel consumption or GHG emissions, or other reasons, could weaken the demand for our higher margin vehicles. More stringent fuel economy regulations could also impact our ability to sell these vehicles or could result in additional costs associated with these vehicles, which could be material. See “Our operations and products are subject to extensive laws, regulations and policies, including those related to vehicle emissions and fuel economy standards, which can significantly increase our costs and affect how we do business.”

System Instructions: Answer questions using the information provided in the prompt. Attempt to keep answers concise, while also avoiding or explaining jargon that the masses wouldn't understand. Question: What does the article suggest General Motors Company has an advantage in? Context Block: GENERAL MOTORS COMPANY Item 1A. Risk Factors We have listed below the most material risk factors applicable to us. These risk factors are not necessarily in the order of importance or probability of occurrence: Risks related to our competition and strategy If we do not deliver new products, services, technologies and customer experiences in response to increased competition and changing consumer needs and preferences, our business could suffer. We believe that the automotive industry will continue to experience significant change in the coming years, particularly as traditional automotive original equipment manufacturers (OEMs) continue to shift resources to the development of EVs. In addition to our traditional competitors, we must also be responsive to the entrance of start-ups and other non-traditional competitors in the automotive industry, such as software and ridesharing services supported by large technology companies. These new competitors, as well as established industry participants, are disrupting the historic business model of our industry through the introduction of new technologies, products, services, direct-to-consumer sales channels, methods of transportation and vehicle ownership. To successfully execute our long-term strategy, we must continue to develop and commercialize new products and services, including products and services that are outside of our historically core ICE business, such as EVs and AVs, software-enabled connected services and other new businesses. There can be no assurance that advances in technology will occur in a timely or feasible way, if at all, that others will not acquire similar or superior technologies sooner than we do, or that we will acquire technologies on an exclusive basis or at a significant price advantage. The process of designing and developing new technology, products and services is costly and uncertain and requires extensive capital investment. If our access to capital were to become significantly constrained, if costs of capital increased significantly, or if our ability to raise capital is challenged relative to our peers, our ability to execute on our strategic plans could be adversely affected. Further, if we are unable to prevent or effectively remedy errors, bugs, vulnerabilities or defects in our software and hardware, or fail to deploy updates to our software properly, or if we do not adequately prepare for and respond to new kinds of technological innovations, market developments and changing customer needs and preferences, our sales, profitability and long-term competitiveness may be materially harmed. Our ability to attract and retain talented, diverse and highly skilled employees is critical to our success and competitiveness. Our success depends on our ability to recruit and retain talented and diverse employees who are highly skilled in their areas. In particular, our vehicles and connected services increasingly rely on software and hardware that is highly technical and complex and our success in this area is dependent upon our ability to retain and recruit the best talent. The market for highly skilled workers and leaders in our industry is extremely competitive. In addition to compensation considerations, current and potential employees are increasingly placing a premium on culture and other various intangibles, such as working for companies with a clear purpose and strong brand reputation, flexible work arrangements, and other considerations, such as embracing sustainability and diversity, equity and inclusion initiatives. Failure to attract, hire, develop, motivate and retain highly qualified and diverse employees could disrupt our operations and adversely affect our strategic plans. Our ability to maintain profitability is dependent upon our ability to timely fund and introduce new and improved vehicle models, including EVs, that are able to attract a sufficient number of consumers. We operate in a very competitive industry with market participants routinely introducing new and improved vehicle models and features, at decreasing price points, designed to meet rapidly evolving consumer expectations. Producing new and improved vehicle models, including EVs, that preserve our reputation for designing, building and selling safe, high-quality cars, crossovers, trucks and SUVs is critical to our long-term profitability. Successful launches of our new vehicles are critical to our short-term profitability. The new vehicle development process can take two years or more, and a number of factors may lengthen that time period. Because of this product development cycle and the various elements that may contribute to consumers’ acceptance of new vehicle designs, including competitors’ product introductions, technological innovations, fuel prices, general economic conditions, regulatory developments, including tax credits or other government policies in various countries, transportation infrastructure and changes in quality, safety, reliability and styling demands and preferences, an initial product concept or design may not result in a saleable vehicle or a vehicle that generates sales in sufficient quantities and at high enough prices to be profitable. Our high proportion of fixed costs, both due to our significant investment in property, plant and equipment as well as other requirements of our collective bargaining agreements, which limit our flexibility to adjust personnel costs to changes in demands for our products, may further exacerbate the risks associated with incorrectly assessing demand for our vehicles. Our long-term strategy is dependent upon our ability to profitably deliver a strategic portfolio of EVs. The production and profitable sale of EVs has become increasingly important to our long-term business as we continue our transition to an allelectric future. Our EV strategy is dependent on our ability to deliver a strategic portfolio of high-quality EVs that are competitive and meet consumer demands; scale our EV manufacturing capabilities; reduce the costs associated with the manufacture of EVs, particularly with respect to battery cells and packs; increase vehicle range and the energy density of our batteries; efficiently source sufficient materials for the manufacture of battery cells; license and monetize our proprietary platforms and related innovations; successfully invest in new technologies relative to our peers; develop new software and services; and leverage our scale, manufacturing capabilities and synergies with existing ICE vehicles. Our progress towards these objectives has impacted, and may continue to impact, the need to record losses on our EV-related inventory, including battery cells.In addition, the success of our long-term strategy is dependent on consumer adoption of EVs. Consumer adoption of EVs could be impacted by numerous factors, including the breadth of the portfolio of EVs available; perceptions about EV features, quality, safety, performance and cost relative to ICE vehicles; the range over which EVs may be driven on a given battery charge; the proliferation and speed of charging infrastructure, in particular with respect to public EV charging stations, and the success of the Company's charging infrastructure programs and strategic joint ventures and other relationships; cost and availability of high fuel-economy ICE vehicles; volatility, or a sustained decrease, in the cost of petroleum-based fuel; failure by governments and other third parties to make the investments necessary to make infrastructure improvements, such as greater availability of cleaner energy grids and EV charging stations, and to provide meaningful and fully utilizable economic incentives promoting the adoption of EVs, including production and consumer credits contemplated by the Inflation Reduction Act (IRA); and negative feedback from stakeholders impacting investor and consumer confidence in our company or industry. If we are unable to successfully deliver on our EV strategy, it could materially and adversely affect our results of operations, financial condition and growth prospects, and could negatively impact our brand and reputation. Our near-term profitability is dependent upon the success of our current line of ICE vehicles, particularly our full-size ICE SUVs and full-size ICE pickup trucks. While we offer a broad portfolio of cars, crossovers, SUVs and trucks, and we have announced significant plans to design, build and sell a strategic portfolio of EVs, we currently recognize the highest profit margins on our full-size ICE SUVs and full-size ICE pickup trucks. As a result, our near-term success is dependent upon our ability to sell higher margin vehicles in sufficient volumes. We are also using the cash generated by our ICE vehicles to fund our growth strategy, including with respect to EVs and AVs. Any near-term shift in consumer preferences toward smaller, more fuel-efficient vehicles, whether as a result of increases in the price of oil or any sustained shortage of oil, including as a result of global political instability (such as related to the ongoing conflicts in Ukraine and Gaza), concerns about fuel consumption or GHG emissions, or other reasons, could weaken the demand for our higher margin vehicles. More stringent fuel economy regulations could also impact our ability to sell these vehicles or could result in additional costs associated with these vehicles, which could be material. See “Our operations and products are subject to extensive laws, regulations and policies, including those related to vehicle emissions and fuel economy standards, which can significantly increase our costs and affect how we do business.”

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

I've heard some people talk about the constitution and how it has racist traits. What is the three fifths part about in regard to black men and what does it mean? How is this legal and what does it mean to primarily prisons and people in jail through the legal system. I hate reading so can ou limit this to 200 words.

the 13th Amendment officially was ratified, and with it, slavery finally was abolished in America. The New York World hailed it as “one of the most important reforms ever accomplished by voluntary human agency.” The newspaper said the amendment “takes out of politics, and consigns to history, an institution incongruous to our political system, inconsistent with justice and repugnant to the humane sentiments fostered by Christian civilization.” With the passage of the 13th Amendment—which states that “[n]either slavery nor involuntary servitude, except as a punishment for crime whereof the party shall have been duly convicted, shall exist within the United States, or any place subject to their jurisdiction”—the central contradiction at the heart of the Founding was resolved. Eighty-nine years after the Declaration of Independence had proclaimed all men to be free and equal, race-based chattel slavery would be no more in the United States. While all today recognize this momentous accomplishment, many remain confused about the status of slavery under the original Constitution. Textbooks and history books routinely dismiss the Constitution as racist and pro-slavery. The New York Times, among others, continues to casually assert that the Constitution affirmed African-Americans to be worth only three-fifths of a human being. Ironically, many Americans who are resolutely opposed to racism unwittingly agree with Chief Justice Roger Taney’s claim in Dred Scott v. Sandford (1857) that the Founders’ Constitution regarded blacks as “so far inferior that they had no rights which the white man was bound to respect, and that the negro might justly and lawfully be reduced to slavery for his benefit.” In this view, the worst Supreme Court case decision in American history was actually correctly decided. The argument that the Constitution is racist suffers from one fatal flaw: the concept of race does not exist in the Constitution. Such arguments have unsettling implications for the health of our republic. They teach citizens to despise their founding charter and to be ashamed of their country’s origins. They make the Constitution an object of contempt rather than reverence. And they foster alienation and resentment among African-American citizens by excluding them from our Constitution. The received wisdom in this case is wrong. If we turn to the actual text of the Constitution and the debates that gave rise to it, a different picture emerges. The case for a racist, pro-slavery Constitution collapses under closer scrutiny. Race and the Constitution The argument that the Constitution is racist suffers from one fatal flaw: the concept of race does not exist in the Constitution. Nowhere in the Constitution—or in the Declaration of Independence, for that matter—are human beings classified according to race, skin color, or ethnicity (nor, one should add, sex, religion, or any other of the left’s favored groupings). Our founding principles are colorblind (although our history, regrettably, has not been). The Constitution speaks of people, citizens, persons, other persons (a euphemism for slaves) and Indians not taxed (in which case, it is their tax-exempt status, and not their skin color, that matters). The first references to “race” and “color” occur in the 15th Amendment’s guarantee of the right to vote, ratified in 1870. The infamous three-fifths clause, which more nonsense has been written than any other clause, does not declare that a black person is worth 60 percent of a white person. It says that for purposes of determining the number of representatives for each state in the House (and direct taxes), the government would count only three-fifths of the slaves, and not all of them, as the Southern states, who wanted to gain more seats, had insisted. The 60,000 or so free blacks in the North and the South were counted on par with whites. Contrary to a popular misconception, the Constitution also does not say that only white males who owned property could vote. The Constitution defers to the states to determine who shall be eligible to vote (Article I, Section 2, Clause 1). It is a little known fact of American history that black citizens were voting in perhaps as many as 10 states at the time of the founding (the precise number is unclear, but only Georgia, South Carolina, and Virginia explicitly restricted suffrage to whites). Slavery and the Constitution Not only does the Constitution not mention blacks or whites, but it also doesn’t mention slaves or slavery. Throughout the document, slaves are referred to as persons to underscore their humanity. As James Madison remarked during the constitutional convention, it was “wrong to admit in the Constitution the idea that there could be property in men.” The Constitution refers to slaves using three different formulations: “other persons” (Article I, Section 2, Clause 3), “such persons as any of the states now existing shall think proper to admit” (Article I, Section 9, Clause 1), and a “person held to service or labor in one state, under the laws thereof” (Article IV, Section 2, Clause 3). Although these circumlocutions may not have done much to improve the lot of slaves, they are important, as they denied constitutional legitimacy to the institution of slavery. The practice remained legal, but slaveholders could not invoke the supreme law of the land to defend its legitimacy. These formulations make clear that slavery is a state institution that is tolerated—but not sanctioned—by the national government and the Constitution. Reading the original Constitution, a visitor from a foreign land would simply have no way of knowing that race-based slavery existed in America. As Abraham Lincoln would later explain: Thus, the thing is hid away, in the Constitution, just as an afflicted man hides away a wen or a cancer, which he dares not cut out at once, lest he bleed to death.

"================ <TEXT PASSAGE> ======= the 13th Amendment officially was ratified, and with it, slavery finally was abolished in America. The New York World hailed it as “one of the most important reforms ever accomplished by voluntary human agency.” The newspaper said the amendment “takes out of politics, and consigns to history, an institution incongruous to our political system, inconsistent with justice and repugnant to the humane sentiments fostered by Christian civilization.” With the passage of the 13th Amendment—which states that “[n]either slavery nor involuntary servitude, except as a punishment for crime whereof the party shall have been duly convicted, shall exist within the United States, or any place subject to their jurisdiction”—the central contradiction at the heart of the Founding was resolved. Eighty-nine years after the Declaration of Independence had proclaimed all men to be free and equal, race-based chattel slavery would be no more in the United States. While all today recognize this momentous accomplishment, many remain confused about the status of slavery under the original Constitution. Textbooks and history books routinely dismiss the Constitution as racist and pro-slavery. The New York Times, among others, continues to casually assert that the Constitution affirmed African-Americans to be worth only three-fifths of a human being. Ironically, many Americans who are resolutely opposed to racism unwittingly agree with Chief Justice Roger Taney’s claim in Dred Scott v. Sandford (1857) that the Founders’ Constitution regarded blacks as “so far inferior that they had no rights which the white man was bound to respect, and that the negro might justly and lawfully be reduced to slavery for his benefit.” In this view, the worst Supreme Court case decision in American history was actually correctly decided. The argument that the Constitution is racist suffers from one fatal flaw: the concept of race does not exist in the Constitution. Such arguments have unsettling implications for the health of our republic. They teach citizens to despise their founding charter and to be ashamed of their country’s origins. They make the Constitution an object of contempt rather than reverence. And they foster alienation and resentment among African-American citizens by excluding them from our Constitution. The received wisdom in this case is wrong. If we turn to the actual text of the Constitution and the debates that gave rise to it, a different picture emerges. The case for a racist, pro-slavery Constitution collapses under closer scrutiny. Race and the Constitution The argument that the Constitution is racist suffers from one fatal flaw: the concept of race does not exist in the Constitution. Nowhere in the Constitution—or in the Declaration of Independence, for that matter—are human beings classified according to race, skin color, or ethnicity (nor, one should add, sex, religion, or any other of the left’s favored groupings). Our founding principles are colorblind (although our history, regrettably, has not been). The Constitution speaks of people, citizens, persons, other persons (a euphemism for slaves) and Indians not taxed (in which case, it is their tax-exempt status, and not their skin color, that matters). The first references to “race” and “color” occur in the 15th Amendment’s guarantee of the right to vote, ratified in 1870. The infamous three-fifths clause, which more nonsense has been written than any other clause, does not declare that a black person is worth 60 percent of a white person. It says that for purposes of determining the number of representatives for each state in the House (and direct taxes), the government would count only three-fifths of the slaves, and not all of them, as the Southern states, who wanted to gain more seats, had insisted. The 60,000 or so free blacks in the North and the South were counted on par with whites. Contrary to a popular misconception, the Constitution also does not say that only white males who owned property could vote. The Constitution defers to the states to determine who shall be eligible to vote (Article I, Section 2, Clause 1). It is a little known fact of American history that black citizens were voting in perhaps as many as 10 states at the time of the founding (the precise number is unclear, but only Georgia, South Carolina, and Virginia explicitly restricted suffrage to whites). Slavery and the Constitution Not only does the Constitution not mention blacks or whites, but it also doesn’t mention slaves or slavery. Throughout the document, slaves are referred to as persons to underscore their humanity. As James Madison remarked during the constitutional convention, it was “wrong to admit in the Constitution the idea that there could be property in men.” The Constitution refers to slaves using three different formulations: “other persons” (Article I, Section 2, Clause 3), “such persons as any of the states now existing shall think proper to admit” (Article I, Section 9, Clause 1), and a “person held to service or labor in one state, under the laws thereof” (Article IV, Section 2, Clause 3). Although these circumlocutions may not have done much to improve the lot of slaves, they are important, as they denied constitutional legitimacy to the institution of slavery. The practice remained legal, but slaveholders could not invoke the supreme law of the land to defend its legitimacy. These formulations make clear that slavery is a state institution that is tolerated—but not sanctioned—by the national government and the Constitution. Reading the original Constitution, a visitor from a foreign land would simply have no way of knowing that race-based slavery existed in America. As Abraham Lincoln would later explain: Thus, the thing is hid away, in the Constitution, just as an afflicted man hides away a wen or a cancer, which he dares not cut out at once, lest he bleed to death. https://www.heritage.org/the-constitution/commentary/what-the-constitution-really-says-about-race-and-slavery ================ <QUESTION> ======= I've heard some people talk about the constitution and how it has racist traits. What is the three fifths part about in regard to black men and what does it mean? How is this legal and what does it mean to primarily prisons and people in jail through the legal system. I hate reading so can ou limit this to 200 words. ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

You will use only the information presented by the user when answering the user's questions. You will not use external sources or your own stored data to answer these questions.

What are the mentioned pros and cons of using historical precedent to decide the case in the context block?

The Supreme Court’s Opinion The Court, in an opinion by Chief Justice Roberts, held that § 922(g)(8) is consistent with the Second Amendment, reversing the Fifth Circuit and rejecting Rahimi’s challenge to the law.64 The Court emphasized that the scope of the Second Amendment is not limited to those laws that “precisely match . . . historical precursors” or that are “identical” to laws from 1791, as if the Second Amendment were “trapped in amber.”65 Instead, the Court explained that, under Bruen, a court is required to assess whether a challenged law is “relevantly similar” to laws from the country’s regulatory tradition, with “why and how” the challenged law burdens the Second Amendment right being the “central” considerations in this inquiry.66 In the context of § 922(g)(8), the Court determined that sufficient historical support existed for the principle that, “[w]hen an individual poses a clear threat of physical violence to another, the threatening individual may be disarmed.”67 The Court found that surety laws, which were designed to prevent firearm violence by requiring an individual who posed a credible threat of violence to another to post a surety, and “going armed” laws, which punished individuals who had menaced others or disturbed the public order with firearms through imprisonment or disarmament, established a historical tradition of similar firearm regulation.68 In the Court’s view, 57 Id. at 456. “Going armed” laws refer to the ancient criminal offense of “going armed to terrify the King’s subjects.” Id. at 457. Surety laws were common law allowing an individual who could show “just cause to fear” injury from another to “demand surety of the peace against such person.” Id. at 459. The individual causing fear would then be required to post monetary surety or be forbidden from carrying arms. Id. 58 Id. at 460. 59 Id. at 461. 60 Petition for Writ of Certiorari, United States v. Rahimi, No. 22-915 (U.S. Mar. 17, 2023). 61 Rahimi, 143 S. Ct. at 2688–89. 62 Petition for Writ of Certiorari, supra note footnote 60, at I. 63 Rahimi, 61 F.4th at 449 n.2. 64 United States v. Rahimi, 144 S. Ct. 1889, 1898 (2024). 65 Id. at 1897–98. 66 Id. at 1898. 67 Id. at 1901. 68 Id. at 1901–02. Congressional Research Service 6 Supreme Court Term October 2023: A Review of Selected Major Rulings § 922(g)(8), which disarms an individual found by a judge to threaten the physical safety of another, “fits neatly” within this tradition.69 The Court emphasized that § 922(g)(8) is of “limited duration,” prohibiting firearm possession for only as long as the individual is subject to the restraining order, and Rahimi himself was subject to the order for up to two years after his release from prison.70 The Court also explained that, historically, individuals could be imprisoned for threatening others with firearms, so the regulatory burden imposed by § 922(g)(8) was less than the more severe penalty of imprisonment.71 Finally, the Court rejected the government’s argument that Rahimi may be disarmed simply because he is not “responsible,” clarifying that, although the Court’s precedents describe “responsible” individuals as those who enjoy the Second Amendment right, this wording was a vague description rather than a legal line being drawn.72 Concurring and Dissenting Opinions A majority of the Court—six Justices in total—wrote separately to concur or dissent, offering their individual views on how the Second Amendment and the Bruen standard should be properly interpreted both in this case and in future cases. Justice Sotomayor’s concurring opinion, joined by Justice Kagan, expressed her continued view that Bruen was wrongly decided and that a different legal standard should apply to Second Amendment cases.73 She wrote separately to emphasize that when applying the Bruen historical tradition standard, however, the majority’s methodology was the “right one.”74 In Justice Sotomayor’s view, this is an “easy case,” as § 922(g)(8) is “wholly consistent” with historical firearms regulations.75 By contrast, she criticized the dissenting view as too “rigid,” characterizing it as “insist[ing] that the means of addressing that problem cannot be ‘materially different’ from the means that existed in the eighteenth century,” which would unduly hamstring modern policy efforts.76 In his concurring opinion, Justice Gorsuch underscored the difficulty in maintaining a facial challenge to a law, which requires a showing that the law has no constitutional applications.77 He also defended the Bruen historical tradition standard, arguing that the original meaning of the Constitution, while “an imperfect guide,” provides proper constraints on judicial decisionmaking and is better than unbounded alternatives such as an interest-balancing inquiry.78 Justice Gorsuch also cautioned that the Court decided a narrow question—whether § 922(g)(3) “has any lawful scope”—and that future defendants could argue that § 922(g)(3) was unconstitutional under particular facts.79 69 Id. at 1901. 70 Id. at 1902. 71 Id. 72 Id. at 1903. 73 Id. at 1904 (Sotomayor, J., concurring). 74 Id. 75 Id. 76 Id. at 1905. 77 Id. at 1907 (Gorsuch, J., concurring). 78 Id. at 1909. 79 Id. at 1910. Congressional Research Service 7 Supreme Court Term October 2023: A Review of Selected Major Rulings Justice Kavanaugh concurred to expound his view on the roles of text, history, and precedent in constitutional interpretation. He explained that unambiguous text controls and that history, rather than policy, is a more neutral and principled guide for constitutional decisionmaking when the text is unclear.80 Using historical examples, Justice Kavanaugh illustrated his view on how pre- and post-ratification history may inform the meaning of vague constitutional text.81 Next, he argued that balancing tests in constitutional cases are a relatively recent development, generally depart from tests centered on text and history, are inherently subjective, and should not be extended to the Second Amendment arena.82 Finally, he opined that the majority’s opinion was faithful to his perception of the appropriate roles of text, history, and precedent in constitutional adjudication in this particular case.83 Justice Barrett wrote a concurring opinion to explain her understanding of the relationship between Bruen’s historical tradition test and originalism as a method of constitutional interpretation. In her view, historical tradition is a means to understand original meaning, and, accordingly, historical practice around the time of ratification should be the focus of the legal inquiry.84 In her view, history demonstrates that, “[s]ince the founding, our Nation’s firearm laws have included provisions preventing individuals who threaten physical harm to others from misusing firearms.” Justice Barrett agreed with the majority that § 922(g)(8) “fits well within that principle.”85 Justice Jackson also wrote a concurring opinion, agreeing that the majority fairly applied Bruen as precedent.86 She wrote separately to highlight what she perceived as problems with applying the history-and-tradition standard in a workable manner.87 She argued that Rahimi illustrates the “pitfalls of Bruen’s approach” by demonstrating the difficulty of sifting through the historical record and determining whether historical evidence establishes a tradition of sufficiently analogous regulation.88 The numerous unanswered questions that remain even after Rahimi, in her view, result in “the Rule of Law suffer[ing].”89 Stating that legal standards should “foster stability, facilitate consistency, and promote predictability,” Justice Jackson concluded by arguing that “Bruen’s history-focused test ticks none of those boxes.”90 Justice Thomas was the sole dissenter. In his view, the historical examples cited by the majority were not sufficient to establish a tradition of firearm regulation that justified § 922(g)(8).91 According to Justice Thomas, courts should look to two metrics to evaluate whether historical examples of regulation are analogous to modern enactments: “how and why the regulations burden a law-abiding citizen’s right to armed self-defense.”92 In his view, the two categories of evidence proffered by the government—historical laws disarming “dangerous” individuals and historical characterization of the right to bear arms as belonging only to “peaceable” citizens— 80 Id. at 1912 (Kavanaugh, J., concurring). 81 Id. at 1913–19. 82 Id. at 1921. 83 Id. at 1923. 84 Id. at 1924 (Barrett, J., concurring). 85 Id. at 1926 (quoting Rahimi, 144 S. Ct. at 1896 (majority opinion)). 86 Id. (Jackson, J., concurring). 87 Id. at 1928. 88 Id. 89 Id. at 1929. 90 Id. 91 Id. at 1930 (Thomas, J., dissenting). 92 Id. at 1931–32. Congressional Research Service 8 Supreme Court Term October 2023: A Review of Selected Major Rulings did not impose comparable burdens as § 922(g)(8).93 Justice Thomas argued that § 922(g)(8) was enacted in response to “interpersonal violence,” whereas the historical English laws were concerned with insurrection and rebellion.94 Ultimately, Rahimi could have been disarmed, in Justice Thomas’s view, through criminal conviction but not through a restraining order.95

You will use only the information presented by the user when answering the user's questions. You will not use external sources or your own stored data to answer these questions. What are the mentioned pros and cons of using historical precedent to decide the case in the context block? The Supreme Court’s Opinion The Court, in an opinion by Chief Justice Roberts, held that § 922(g)(8) is consistent with the Second Amendment, reversing the Fifth Circuit and rejecting Rahimi’s challenge to the law.64 The Court emphasized that the scope of the Second Amendment is not limited to those laws that “precisely match . . . historical precursors” or that are “identical” to laws from 1791, as if the Second Amendment were “trapped in amber.”65 Instead, the Court explained that, under Bruen, a court is required to assess whether a challenged law is “relevantly similar” to laws from the country’s regulatory tradition, with “why and how” the challenged law burdens the Second Amendment right being the “central” considerations in this inquiry.66 In the context of § 922(g)(8), the Court determined that sufficient historical support existed for the principle that, “[w]hen an individual poses a clear threat of physical violence to another, the threatening individual may be disarmed.”67 The Court found that surety laws, which were designed to prevent firearm violence by requiring an individual who posed a credible threat of violence to another to post a surety, and “going armed” laws, which punished individuals who had menaced others or disturbed the public order with firearms through imprisonment or disarmament, established a historical tradition of similar firearm regulation.68 In the Court’s view, 57 Id. at 456. “Going armed” laws refer to the ancient criminal offense of “going armed to terrify the King’s subjects.” Id. at 457. Surety laws were common law allowing an individual who could show “just cause to fear” injury from another to “demand surety of the peace against such person.” Id. at 459. The individual causing fear would then be required to post monetary surety or be forbidden from carrying arms. Id. 58 Id. at 460. 59 Id. at 461. 60 Petition for Writ of Certiorari, United States v. Rahimi, No. 22-915 (U.S. Mar. 17, 2023). 61 Rahimi, 143 S. Ct. at 2688–89. 62 Petition for Writ of Certiorari, supra note footnote 60, at I. 63 Rahimi, 61 F.4th at 449 n.2. 64 United States v. Rahimi, 144 S. Ct. 1889, 1898 (2024). 65 Id. at 1897–98. 66 Id. at 1898. 67 Id. at 1901. 68 Id. at 1901–02. Congressional Research Service 6 Supreme Court Term October 2023: A Review of Selected Major Rulings § 922(g)(8), which disarms an individual found by a judge to threaten the physical safety of another, “fits neatly” within this tradition.69 The Court emphasized that § 922(g)(8) is of “limited duration,” prohibiting firearm possession for only as long as the individual is subject to the restraining order, and Rahimi himself was subject to the order for up to two years after his release from prison.70 The Court also explained that, historically, individuals could be imprisoned for threatening others with firearms, so the regulatory burden imposed by § 922(g)(8) was less than the more severe penalty of imprisonment.71 Finally, the Court rejected the government’s argument that Rahimi may be disarmed simply because he is not “responsible,” clarifying that, although the Court’s precedents describe “responsible” individuals as those who enjoy the Second Amendment right, this wording was a vague description rather than a legal line being drawn.72 Concurring and Dissenting Opinions A majority of the Court—six Justices in total—wrote separately to concur or dissent, offering their individual views on how the Second Amendment and the Bruen standard should be properly interpreted both in this case and in future cases. Justice Sotomayor’s concurring opinion, joined by Justice Kagan, expressed her continued view that Bruen was wrongly decided and that a different legal standard should apply to Second Amendment cases.73 She wrote separately to emphasize that when applying the Bruen historical tradition standard, however, the majority’s methodology was the “right one.”74 In Justice Sotomayor’s view, this is an “easy case,” as § 922(g)(8) is “wholly consistent” with historical firearms regulations.75 By contrast, she criticized the dissenting view as too “rigid,” characterizing it as “insist[ing] that the means of addressing that problem cannot be ‘materially different’ from the means that existed in the eighteenth century,” which would unduly hamstring modern policy efforts.76 In his concurring opinion, Justice Gorsuch underscored the difficulty in maintaining a facial challenge to a law, which requires a showing that the law has no constitutional applications.77 He also defended the Bruen historical tradition standard, arguing that the original meaning of the Constitution, while “an imperfect guide,” provides proper constraints on judicial decisionmaking and is better than unbounded alternatives such as an interest-balancing inquiry.78 Justice Gorsuch also cautioned that the Court decided a narrow question—whether § 922(g)(3) “has any lawful scope”—and that future defendants could argue that § 922(g)(3) was unconstitutional under particular facts.79 69 Id. at 1901. 70 Id. at 1902. 71 Id. 72 Id. at 1903. 73 Id. at 1904 (Sotomayor, J., concurring). 74 Id. 75 Id. 76 Id. at 1905. 77 Id. at 1907 (Gorsuch, J., concurring). 78 Id. at 1909. 79 Id. at 1910. Congressional Research Service 7 Supreme Court Term October 2023: A Review of Selected Major Rulings Justice Kavanaugh concurred to expound his view on the roles of text, history, and precedent in constitutional interpretation. He explained that unambiguous text controls and that history, rather than policy, is a more neutral and principled guide for constitutional decisionmaking when the text is unclear.80 Using historical examples, Justice Kavanaugh illustrated his view on how pre- and post-ratification history may inform the meaning of vague constitutional text.81 Next, he argued that balancing tests in constitutional cases are a relatively recent development, generally depart from tests centered on text and history, are inherently subjective, and should not be extended to the Second Amendment arena.82 Finally, he opined that the majority’s opinion was faithful to his perception of the appropriate roles of text, history, and precedent in constitutional adjudication in this particular case.83 Justice Barrett wrote a concurring opinion to explain her understanding of the relationship between Bruen’s historical tradition test and originalism as a method of constitutional interpretation. In her view, historical tradition is a means to understand original meaning, and, accordingly, historical practice around the time of ratification should be the focus of the legal inquiry.84 In her view, history demonstrates that, “[s]ince the founding, our Nation’s firearm laws have included provisions preventing individuals who threaten physical harm to others from misusing firearms.” Justice Barrett agreed with the majority that § 922(g)(8) “fits well within that principle.”85 Justice Jackson also wrote a concurring opinion, agreeing that the majority fairly applied Bruen as precedent.86 She wrote separately to highlight what she perceived as problems with applying the history-and-tradition standard in a workable manner.87 She argued that Rahimi illustrates the “pitfalls of Bruen’s approach” by demonstrating the difficulty of sifting through the historical record and determining whether historical evidence establishes a tradition of sufficiently analogous regulation.88 The numerous unanswered questions that remain even after Rahimi, in her view, result in “the Rule of Law suffer[ing].”89 Stating that legal standards should “foster stability, facilitate consistency, and promote predictability,” Justice Jackson concluded by arguing that “Bruen’s history-focused test ticks none of those boxes.”90 Justice Thomas was the sole dissenter. In his view, the historical examples cited by the majority were not sufficient to establish a tradition of firearm regulation that justified § 922(g)(8).91 According to Justice Thomas, courts should look to two metrics to evaluate whether historical examples of regulation are analogous to modern enactments: “how and why the regulations burden a law-abiding citizen’s right to armed self-defense.”92 In his view, the two categories of evidence proffered by the government—historical laws disarming “dangerous” individuals and historical characterization of the right to bear arms as belonging only to “peaceable” citizens— 80 Id. at 1912 (Kavanaugh, J., concurring). 81 Id. at 1913–19. 82 Id. at 1921. 83 Id. at 1923. 84 Id. at 1924 (Barrett, J., concurring). 85 Id. at 1926 (quoting Rahimi, 144 S. Ct. at 1896 (majority opinion)). 86 Id. (Jackson, J., concurring). 87 Id. at 1928. 88 Id. 89 Id. at 1929. 90 Id. 91 Id. at 1930 (Thomas, J., dissenting). 92 Id. at 1931–32. Congressional Research Service 8 Supreme Court Term October 2023: A Review of Selected Major Rulings did not impose comparable burdens as § 922(g)(8).93 Justice Thomas argued that § 922(g)(8) was enacted in response to “interpersonal violence,” whereas the historical English laws were concerned with insurrection and rebellion.94 Ultimately, Rahimi could have been disarmed, in Justice Thomas’s view, through criminal conviction but not through a restraining order.95

Respond using only the information contained within this prompt.

According to this report, can someone vote in the Annual Meeting if they bought shares in Tripadvisor for the first time 3 months before the meeting date?

The 2024 Annual Meeting of Stockholders of Tripadvisor, Inc., a Delaware corporation, will be held on Tuesday, June 11, 2024, at 11:00 a.m. Eastern Time. The Annual Meeting will be held via the Internet and will be a completely virtual meeting. You may attend the Annual Meeting, submit questions, and vote your shares electronically during the meeting via the Internet by visiting www.virtualshareholdermeeting.com/TRIP2024. To enter the Annual Meeting, you will need the 16-digit control number that is printed in the box marked by the arrow on your proxy card. We recommend logging in at least fifteen minutes before the meeting to ensure that you are correctly logged in when the Annual Meeting begins. The online check-in will start shortly before the Annual Meeting on June 11, 2024. At the Annual Meeting, stockholders will be asked to consider and vote on the following proposals: 1. To elect the ten directors named in this Proxy Statement, each to serve for a one-year term from the date of his or her election and until such director’s successor is elected or until such director’s earlier resignation or removal; 2. To ratify the appointment of KPMG LLP as our independent registered public accounting firm for the fiscal year ending December 31, 2024; 3. To approve, on a non-binding advisory basis, the compensation of our named executive officers; 4. To vote, on a non-binding advisory basis, on the frequency of future advisory resolutions to approve the compensation of our named executive officers; 5. To vote on the stockholder proposal requesting a report on implementation of the Global Human Rights Policy concerning operations in CAHRAs; and 6. To consider and act upon any other business that may properly come before the Annual Meeting and any adjournments or postponements thereof. Only holders of record of outstanding shares of Tripadvisor capital stock at the close of business on April 15, 2024 are entitled to notice of and to vote at the Annual Meeting and at any adjournments or postponements thereof. We will furnish the Notice of Annual Meeting of Stockholders, Proxy Statement and Annual Report on Form 10-K for the fiscal year ended December 31, 2023 over the Internet. Whether or not you plan to attend the Annual Meeting, we encourage you to access and read the accompanying Proxy Statement. We will send to our stockholders a Notice of Internet Availability of Proxy Materials on or about April 26, 2024, and provide access to our proxy materials over the Internet to our holders of record and beneficial owners of our capital stock as of the close of business on the record date. You may request paper copies by following the instructions on the Notice of Internet Availability of Proxy Materials.

System instruction: Respond using only the information contained within this prompt. context: The 2024 Annual Meeting of Stockholders of Tripadvisor, Inc., a Delaware corporation, will be held on Tuesday, June 11, 2024, at 11:00 a.m. Eastern Time. The Annual Meeting will be held via the Internet and will be a completely virtual meeting. You may attend the Annual Meeting, submit questions, and vote your shares electronically during the meeting via the Internet by visiting www.virtualshareholdermeeting.com/TRIP2024. To enter the Annual Meeting, you will need the 16-digit control number that is printed in the box marked by the arrow on your proxy card. We recommend logging in at least fifteen minutes before the meeting to ensure that you are correctly logged in when the Annual Meeting begins. The online check-in will start shortly before the Annual Meeting on June 11, 2024. At the Annual Meeting, stockholders will be asked to consider and vote on the following proposals: 1. To elect the ten directors named in this Proxy Statement, each to serve for a one-year term from the date of his or her election and until such director’s successor is elected or until such director’s earlier resignation or removal; 2. To ratify the appointment of KPMG LLP as our independent registered public accounting firm for the fiscal year ending December 31, 2024; 3. To approve, on a non-binding advisory basis, the compensation of our named executive officers; 4. To vote, on a non-binding advisory basis, on the frequency of future advisory resolutions to approve the compensation of our named executive officers; 5. To vote on the stockholder proposal requesting a report on implementation of the Global Human Rights Policy concerning operations in CAHRAs; and 6. To consider and act upon any other business that may properly come before the Annual Meeting and any adjournments or postponements thereof. Only holders of record of outstanding shares of Tripadvisor capital stock at the close of business on April 15, 2024 are entitled to notice of and to vote at the Annual Meeting and at any adjournments or postponements thereof. We will furnish the Notice of Annual Meeting of Stockholders, Proxy Statement and Annual Report on Form 10-K for the fiscal year ended December 31, 2023 over the Internet. Whether or not you plan to attend the Annual Meeting, we encourage you to access and read the accompanying Proxy Statement. We will send to our stockholders a Notice of Internet Availability of Proxy Materials on or about April 26, 2024, and provide access to our proxy materials over the Internet to our holders of record and beneficial owners of our capital stock as of the close of business on the record date. You may request paper copies by following the instructions on the Notice of Internet Availability of Proxy Materials. question: According to this report, can someone vote in the Annual Meeting if they bought shares in Tripadvisor for the first time 3 months before the meeting date?

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According to the author of the preface, who cannot accept that value investing works?

Preface to the Sixth Edition THE TIMELESS WISDOM OF GRAHAM AND DODD BY SETH A. KLARMAN Seventy-five years after Benjamin Graham and David Dodd wrote Security Analysis, a growing coterie of modern-day value investors remain deeply indebted to them. Graham and David were two assiduous and unusually insightful thinkers seeking to give order to the mostly uncharted financial wilderness of their era. They kindled a flame that has illuminated the way for value investors ever since. Today, Security Analysis remains an invaluable roadmap for investors as they navigate through unpredictable, often volatile, and sometimes treacherous finan- cial markets. Frequently referred to as the “bible of value investing,” Secu- rity Analysis is extremely thorough and detailed, teeming with wisdom for the ages. Although many of the examples are obviously dated, their les- sons are timeless. And while the prose may sometimes seem dry, readers can yet discover valuable ideas on nearly every page. The financial mar- kets have morphed since 1934 in almost unimaginable ways, but Graham and Dodd’s approach to investing remains remarkably applicable today. Value investing, today as in the era of Graham and Dodd, is the prac- tice of purchasing securities or assets for less than they are worth—the proverbial dollar for 50 cents. Investing in bargain-priced securities pro- vides a “margin of safety”—room for error, imprecision, bad luck, or the vicissitudes of the economy and stock market. While some might mistak- enly consider value investing a mechanical tool for identifying bargains, it is actually a comprehensive investment philosophy that emphasizes the need to perform in-depth fundamental analysis, pursue long-term investment results, limit risk, and resist crowd psychology. Far too many people approach the stock market with a focus on mak- ing money quickly. Such an orientation involves speculation rather than investment and is based on the hope that share prices will rise irrespec- tive of valuation. Speculators generally regard stocks as pieces of paper to be quickly traded back and forth, foolishly decoupling them from business reality and valuation criteria. Speculative approaches—which pay little or no attention to downside risk—are especially popular in ris- ing markets. In heady times, few are sufficiently disciplined to maintain strict standards of valuation and risk aversion, especially when most of those abandoning such standards are quickly getting rich. After all, it is easy to confuse genius with a bull market. In recent years, some people have attempted to expand the defini- tion of an investment to include any asset that has recently—or might soon—appreciate in price: art, rare stamps, or a wine collection. Because these items have no ascertainable fundamental value, generate no pres- ent or future cash flow, and depend for their value entirely on buyer whim, they clearly constitute speculations rather than investments. In contrast to the speculator’s preoccupation with rapid gain, value investors demonstrate their risk aversion by striving to avoid loss. A risk- averse investor is one for whom the perceived benefit of any gain is out- weighed by the perceived cost of an equivalent loss. Once any of us has accumulated a modicum of capital, the incremental benefit of gaining more is typically eclipsed by the pain of having less.1 Imagine how you would respond to the proposition of a coin flip that would either double your net worth or extinguish it. Being risk averse, nearly all people would respectfully decline such a gamble. Such risk aversion is deeply ingrained in human nature. Yet many unwittingly set aside their risk aversion when the sirens of market speculation call. Value investors regard securities not as speculative instruments but as fractional ownership in, or debt claims on, the underlying businesses. This orientation is key to value investing. When a small slice of a business is offered at a bargain price, it is helpful to evaluate it as if the whole business were offered for sale there. This analytical anchor helps value investors remain focused on the pursuit of long-term results rather than the profitability of their daily trading ledger. At the root of Graham and Dodd’s philosophy is the principle that the financial markets are the ultimate creators of opportunity. Sometimes the markets price securities correctly, other times not. Indeed, in the short run, the market can be quite inefficient, with great deviations between price and underlying value. Unexpected developments, increased uncer- tainty, and capital flows can boost short-term market volatility, with prices overshooting in either direction.2 In the words of Graham and Dodd, “The price [of a security] is frequently an essential element, so that a stock . . . may have investment merit at one price level but not at another.” (p. 106) As Graham has instructed, those who view the market as a weighing machine—a precise and efficient assessor of value—are part of the emo- tionally driven herd. Those who regard the market as a voting machine—a sentiment-driven popularity contest—will be well positioned to take proper advantage of the extremes of market sentiment. While it might seem that anyone can be a value investor, the essential characteristics of this type of investor—patience, discipline, and risk aver- sion—may well be genetically determined. When you first learn of the value approach, it either resonates with you or it doesn’t. Either you are able to remain disciplined and patient, or you aren’t. As Warren Buffett said in his famous article, “The Superinvestors of Graham-and-Doddsville,” “It is extraordinary to me that the idea of buying dollar bills for 40 cents takes immediately with people or it doesn’t take at all. It’s like an inocula- tion. If it doesn’t grab a person right away, I find you can talk to him for years and show him records, and it doesn’t make any difference.” 3,4 If Security Analysis resonates with you—if you can resist speculating and sometimes sit on your hands—perhaps you have a predisposition toward value investing. If not, at least the book will help you understand where you fit into the investing landscape and give you an appreciation for what the value-investing community may be thinking. Just as Relevant Now Perhaps the most exceptional achievement of Security Analysis, first pub- lished in 1934 and revised in the acclaimed 1940 edition, is that its les- sons are timeless. Generations of value investors have adopted the teachings of Graham and Dodd and successfully implemented them across highly varied market environments, countries, and asset classes. 3 “The Superinvestors of Graham-and-Doddsville,” Hermes, the Columbia Business School magazine, 1984. 4 My own experience has been exactly the one that Buffett describes. My 1978 summer job at Mutual Shares, a no-load value-based mutual fund, set the course for my professional career. The planned liquidation of Telecor and spin-off of its Electro Rent subsidiary in 1980 forever imprinted in my mind the merit of fundamental investment analysis. A buyer of Telecor stock was effectively creating an investment in the shares of Electro Rent, a fast-growing equipment rental company, at the giveaway valuation of approximately 1 times the cash flow. You always remember your first value investment.This would delight the authors, who hoped to set forth principles that would “stand the test of the ever enigmatic future.” (p. xliv) In 1992, Tweedy, Browne Company LLC, a well-known value invest- ment firm, published a compilation of 44 research studies entitled, “What Has Worked in Investing.” The study found that what has worked is fairly simple: cheap stocks (measured by price-to-book values, price- to-earnings ratios, or dividend yields) reliably outperform expensive ones, and stocks that have underperformed (over three- and five-year periods) subsequently beat those that have lately performed well. In other words, value investing works! I know of no long-time practitioner who regrets adhering to a value philosophy; few investors who embrace the fundamental principles ever abandon this investment approach for another. Today, when you read Graham and Dodd’s description of how they navigated through the financial markets of the 1930s, it seems as if they were detailing a strange, foreign, and antiquated era of economic depression, extreme risk aversion, and obscure and obsolete businesses. But such an exploration is considerably more valuable than it superfi- cially appears. After all, each new day has the potential to bring with it a strange and foreign environment. Investors tend to assume that tomor- row’s markets will look very much like today’s, and, most of the time, they will. But every once in a while,5 conventional wisdom is turned on its head, circular reasoning is unraveled, prices revert to the mean, and speculative behavior is exposed as such. At those times, when today fails to resemble yesterday, most investors will be paralyzed. In the words of Graham and Dodd, “We have striven throughout to guard the student against overemphasis upon the superficial and the temporary,” which is “at once the delusion and the nemesis of the world of finance.” (p. xliv) It is during periods of tumult that a value-investing philosophy is particu- larly beneficial. In 1934, Graham and Dodd had witnessed over a five-year span the best and the worst of times in the markets—the run-up to the 1929 peak, the October 1929 crash, and the relentless grind of the Great Depression. They laid out a plan for how investors in any environment might sort through hundreds or even thousands of common stocks, pre- ferred shares, and bonds to identify those worthy of investment. Remark- ably, their approach is essentially the same one that value investors employ today. The same principles they applied to the U.S. stock and bond markets of the 1920s and 1930s apply to the global capital markets of the early twenty-first century, to less liquid asset classes like real estate and private equity, and even to derivative instruments that hardly existed when Security Analysis was written. While formulas such as the classic “net working capital” test are nec- essary to support an investment analysis, value investing is not a paint- by-numbers exercise.6 Skepticism and judgment are always required. For one thing, not all elements affecting value are captured in a company’s financial statements—inventories can grow obsolete and receivables uncollectible; liabilities are sometimes unrecorded and property values over- or understated. Second, valuation is an art, not a science. Because the value of a business depends on numerous variables, it can typically be assessed only within a range. Third, the outcomes of all investments depend to some extent on the future, which cannot be predicted with certainty; for this reason, even some carefully analyzed investments fail to achieve profitable outcomes. Sometimes a stock becomes cheap for good reason: a broken business model, hidden liabilities, protracted litigation, or incompetent or corrupt management. Investors must always act with caution and humility, relentlessly searching for additional infor- mation while realizing that they will never know everything about a company. In the end, the most successful value investors combine detailed business research and valuation work with endless discipline and patience, a well-considered sensitivity analysis, intellectual honesty, and years of analytical and investment experience. Interestingly, Graham and Dodd’s value-investing principles apply beyond the financial markets—including, for example, to the market for baseball talent, as eloquently captured in Moneyball, Michael Lewis’s 2003 bestseller. The market for baseball players, like the market for stocks and bonds, is inefficient—and for many of the same reasons. In both investing and baseball, there is no single way to ascertain value, no one metric that tells the whole story. In both, there are mountains of information and no broad consensus on how to assess it. Decision makers in both arenas mis- interpret available data, misdirect their analyses, and reach inaccurate conclusions. In baseball, as in securities, many overpay because they fear standing apart from the crowd and being criticized. They often make decisions for emotional, not rational, reasons. They become exuberant; they panic. Their orientation sometimes becomes overly short term. They fail to understand what is mean reverting and what isn’t. Baseball’s value investors, like financial market value investors, have achieved significant outperformance over time. While Graham and Dodd didn’t apply value principles to baseball, the applicability of their insights to the market for athletic talent attests to the universality and timelessness of this approach. Value Investing Today Amidst the Great Depression, the stock market and the national econ- omy were exceedingly risky. Downward movements in share prices and business activity came suddenly and could be severe and protracted. Optimists were regularly rebuffed by circumstances. Winning, in a sense, was accomplished by not losing. Investors could achieve a margin of safety by buying shares in businesses at a large discount to their under- lying value, and they needed a margin of safety because of all the things that could—and often did—go wrong. Even in the worst of markets, Graham and Dodd remained faithful to their principles, including their view that the economy and markets sometimes go through painful cycles, which must simply be endured. They expressed confidence, in those dark days, that the economy and stock market would eventually rebound: “While we were writing, we had to combat a widespread conviction that financial debacle was to be the permanent order.” (p. xliv) Of course, just as investors must deal with down cycles when busi- ness results deteriorate and cheap stocks become cheaper, they must also endure up cycles when bargains are scarce and investment capital is plentiful. In recent years, the financial markets have performed exceed- ingly well by historic standards, attracting substantial fresh capital in need of managers. Today, a meaningful portion of that capital—likely totaling in the trillions of dollars globally—invests with a value approach. This includes numerous value-based asset management firms and mutual funds, a number of today’s roughly 9,000 hedge funds, and some of the largest and most successful university endowments and family investment offices. It is important to note that not all value investors are alike. In the aforementioned “Superinvestors of Graham-and-Doddsville,” Buffett describes numerous successful value investors who have little portfolio overlap. Some value investors hold obscure, “pink-sheet shares” while others focus on the large-cap universe. Some have gone global, while others focus on a single market sector such as real estate or energy. Some run computer screens to identify statistically inexpensive compa- nies, while others assess “private market value”—the value an industry buyer would pay for the entire company. Some are activists who aggres- sively fight for corporate change, while others seek out undervalued securities with a catalyst already in place—such as a spin-off, asset sale, major share repurchase plan, or new management team—for the partial or full realization of the underlying value. And, of course, as in any pro- fession, some value investors are simply more talented than others. In the aggregate, the value-investing community is no longer the very small group of adherents that it was several decades ago. Competition can have a powerful corrective effect on market inefficiencies and mis- pricings. With today’s many amply capitalized and skilled investors, what are the prospects for a value practitioner? Better than you might expect, for several reasons. First, even with a growing value community, there are far more market participants with little or no value orientation. Most man- agers, including growth and momentum investors and market indexers, pay little or no attention to value criteria. Instead, they concentrate almost single-mindedly on the growth rate of a company’s earnings, the momentum of its share price, or simply its inclusion in a market index. Second, nearly all money managers today, including some hapless value managers, are forced by the (real or imagined) performance pres- sures of the investment business to have an absurdly short investment horizon, sometimes as brief as a calendar quarter, month, or less. A value strategy is of little use to the impatient investor since it usually takes time to pay off. Finally, human nature never changes. Capital market manias regularly occur on a grand scale: Japanese stocks in the late 1980s, Internet and technology stocks in 1999 and 2000, subprime mortgage lending in 2006 and 2007, and alternative investments currently. It is always difficult to take a contrarian approach. Even highly capable investors can wither under the relentless message from the market that they are wrong. The pressures to succumb are enormous; many investment managers fear they’ll lose business if they stand too far apart from the crowd. Some also fail to pursue value because they’ve handcuffed themselves (or been saddled by clients) with constraints preventing them from buying stocks selling at low dollar prices, small-cap stocks, stocks of companies that don’t pay dividends or are losing money, or debt instruments with below investment-grade ratings.7 Many also engage in career manage- ment techniques like “window dressing” their portfolios at the end of cal- endar quarters or selling off losers (even if they are undervalued) while buying more of the winners (even if overvalued). Of course, for those value investors who are truly long term oriented, it is a wonderful thing that many potential competitors are thrown off course by constraints that render them unable or unwilling to effectively compete. Another reason that greater competition may not hinder today’s value investors is the broader and more diverse investment landscape in which they operate. Graham faced a limited lineup of publicly traded U.S. equity and debt securities. Today, there are many thousands of publicly traded stocks in the United States alone, and many tens of thousands worldwide, plus thousands of corporate bonds and asset-backed debt securities. Previously illiquid assets, such as bank loans, now trade regu- larly. Investors may also choose from an almost limitless number of derivative instruments, including customized contracts designed to meet any need or hunch. Nevertheless, 25 years of historically strong stock market perform- ance have left the market far from bargain-priced. High valuations and intensified competition raise the specter of lower returns for value investors generally. Also, some value investment firms have become extremely large, and size can be the enemy of investment performance because decision making is slowed by bureaucracy and smaller opportu- nities cease to move the needle. In addition, because growing numbers of competent buy-side and sell-side analysts are plying their trade with the assistance of sophisti- cated information technology, far fewer securities seem likely to fall through the cracks to become extremely undervalued.8 Today’s value investors are unlikely to find opportunity armed only with a Value Line guide or by thumbing through stock tables. While bargains still occasion- ally hide in plain sight, securities today are most likely to become mis- priced when they are either accidentally overlooked or deliberately avoided. Consequently, value investors have had to become thoughtful about where to focus their analysis. In the early 2000s, for example, investors became so disillusioned with the capital allocation procedures of many South Korean companies that few considered them candidates for worthwhile investment. As a result, the shares of numerous South Korean companies traded at great discounts from prevailing international valuations: at two or three times the cash flow, less than half the underly- ing business value, and, in several cases, less than the cash (net of debt) held on their balance sheets. Bargain issues, such as Posco and SK Tele- com, ultimately attracted many value seekers; Warren Buffett reportedly profited handsomely from a number of South Korean holdings. Today’s value investors also find opportunity in the stocks and bonds of companies stigmatized on Wall Street because of involvement in pro-tracted litigation, scandal, accounting fraud, or financial distress. The securities of such companies sometimes trade down to bargain levels, where they become good investments for those who are able to remain stalwart in the face of bad news. For example, the debt of Enron, per- haps the world’s most stigmatized company after an accounting scandal forced it into bankruptcy in 2001, traded as low as 10 cents on the dollar of claim; ultimate recoveries are expected to be six times that amount. Similarly, companies with tobacco or asbestos exposure have in recent years periodically come under severe selling pressure due to the uncer- tainties surrounding litigation and the resultant risk of corporate finan- cial distress. More generally, companies that disappoint or surprise investors with lower-than-expected results, sudden management changes, accounting problems, or ratings downgrades are more likely than consistently strong performers to be sources of opportunity. When bargains are scarce, value investors must be patient; compro- mising standards is a slippery slope to disaster. New opportunities will emerge, even if we don’t know when or where. In the absence of com- pelling opportunity, holding at least a portion of one’s portfolio in cash equivalents (for example, U.S. Treasury bills) awaiting future deployment will sometimes be the most sensible option. Recently, Warren Buffett stated that he has more cash to invest than he has good investments. As all value investors must do from time to time, Buffett is waiting patiently. Still, value investors are bottom-up analysts, good at assessing securi- ties one at a time based on the fundamentals. They don’t need the entire market to be bargain priced, just 20 or 25 unrelated securities—a num- ber sufficient for diversification of risk. Even in an expensive market, value investors must keep analyzing securities and assessing businesses, gaining knowledge and experience that will be useful in the future. Value investors, therefore, should not try to time the market or guess whether it will rise or fall in the near term. Rather, they should rely on a bottom-up approach, sifting the financial markets for bargains and then buying them, regardless of the level or recent direction of the market or economy. Only when they cannot find bargains should they default to holding cash. A Flexible Approach Because our nation’s founders could not foresee—and knew they could not foresee—technological, social, cultural, and economic changes that the future would bring, they wrote a flexible constitution that still guides us over two centuries later. Similarly, Benjamin Graham and David Dodd acknowledged that they could not anticipate the business, economic, technological, and competitive changes that would sweep through the investment world over the ensuing years. But they, too, wrote a flexible treatise that provides us with the tools to function in an investment landscape that was destined—and remains destined—to undergo pro- found and unpredictable change. For example, companies today sell products that Graham and Dodd could not have imagined. Indeed, there are companies and entire indus- tries that they could not have envisioned. Security Analysis offers no examples of how to value cellular phone carriers, software companies, satellite television providers, or Internet search engines. But the book provides the analytical tools to evaluate almost any company, to assess the value of its marketable securities, and to determine the existence of a margin of safety. Questions of solvency, liquidity, predictability, busi- ness strategy, and risk cut across businesses, nations, and time. Graham and Dodd did not specifically address how to value private businesses or how to determine the value of an entire company rather than the value of a fractional interest through ownership of its shares.9 9 They did consider the relative merits of corporate control enjoyed by a private business owner ver- sus the value of marketability for a listed stock (p. 372). But their analytical principles apply equally well to these different issues. Investors still need to ask, how stable is the enterprise, and what are its future prospects? What are its earnings and cash flow? What is the downside risk of owning it? What is its liquidation value? How capable and honest is its management? What would you pay for the stock of this company if it were public? What factors might cause the owner of this business to sell control at a bargain price? Similarly, the pair never addressed how to analyze the purchase of an office building or apartment complex. Real estate bargains come about for the same reasons as securities bargains—an urgent need for cash, inability to perform proper analysis, a bearish macro view, or investor disfavor or neglect. In a bad real estate climate, tighter lending standards can cause even healthy properties to sell at distressed prices. Graham and Dodd’s principles—such as the stability of cash flow, sufficiency of return, and analysis of downside risk—allow us to identify real estate investments with a margin of safety in any market environment. Even complex derivatives not imagined in an earlier era can be scruti- nized with the value investor’s eye. While traders today typically price put and call options via the Black-Scholes model, one can instead use value-investing precepts—upside potential, downside risk, and the likeli- hood that each of various possible scenarios will occur—to analyze these instruments. An inexpensive option may, in effect, have the favorable risk-return characteristics of a value investment—regardless of what the Black-Scholes model dictates. Institutional Investing Perhaps the most important change in the investment landscape over the past 75 years is the ascendancy of institutional investing. In the 1930s, individual investors dominated the stock market. Today, by contrast, most market activity is driven by institutional investors—large pools of pension, endowment, and aggregated individual capital. While the advent of these large, quasi-permanent capital pools might have resulted in the wide-scale adoption of a long-term value-oriented approach, in fact this has not occurred. Instead, institutional investing has evolved into a short-term performance derby, which makes it diffi- cult for institutional managers to take contrarian or long-term positions. Indeed, rather than standing apart from the crowd and possibly suffering disappointing short-term results that could cause clients to withdraw capital, institutional investors often prefer the safe haven of assured mediocre performance that can be achieved only by closely following the herd. Alternative investments—a catch-all category that includes venture capital, leveraged buyouts, private equity, and hedge funds—are the cur- rent institutional rage. No investment treatise written today could fail to comment on this development. Fueled by performance pressures and a growing expectation of low (and inadequate) returns from traditional equity and debt investments, institutional investors have sought high returns and diversification by allocating a growing portion of their endowments and pension funds to alternatives. Pioneering Portfolio Management, written in 2000 by David Swensen, the groundbreaking head of Yale’s Investment Office, makes a strong case for alternative investments. In it, Swensen points to the historically inefficient pricing of many asset classes,10 the historically high risk-adjusted returns of many alternative managers, and the limited 10 Many investors make the mistake of thinking about returns to asset classes as if they were perma- nent. Returns are not inherent to an asset class; they result from the fundamentals of the underlying businesses and the price paid by investors for the related securities. Capital flowing into an asset class can, reflexively, impair the ability of those investing in that asset class to continue to generate the anticipated, historically attractive returns. He highlights the importance of alternative manager selection by noting the large dispersion of returns achieved between top-quartile and third- quartile performers. A great many endowment managers have emulated Swensen, following him into a large commitment to alternative investments, almost certainly on worse terms and amidst a more competitive environment than when he entered the area. Graham and Dodd would be greatly concerned by the commitment of virtually all major university endowments to one type of alternative investment: venture capital. The authors of the margin-of-safety approach to investing would not find one in the entire venture capital universe.11 While there is often the prospect of substantial upside in ven- ture capital, there is also very high risk of failure. Even with the diversifi- cation provided by a venture fund, it is not clear how to analyze the underlying investments to determine whether the potential return justi- fies the risk. Venture capital investment would, therefore, have to be characterized as pure speculation, with no margin of safety whatsoever. Hedge funds—a burgeoning area of institutional interest with nearly $2 trillion of assets under management—are pools of capital that vary widely in their tactics but have a common fee structure that typically pays the manager 1% to 2% annually of assets under management and 20% (and sometimes more) of any profits generated. They had their start in the 1920s, when Ben Graham himself ran one of the first hedge funds. What would Graham and Dodd say about the hedge funds operating in today’s markets? They would likely disapprove of hedge funds that make investments based on macroeconomic assessments or that pursue 11 Nor would they find one in leveraged buyouts, through which businesses are purchased at lofty prices using mostly debt financing and a thin layer of equity capital. The only value-investing ration- ale for venture capital or leveraged buyouts might be if they were regarded as mispriced call options. Even so, it is not clear that these areas constitute good value. Such funds, by avoiding or even sell- ing undervalued securities to participate in one or another folly, inadver- tently create opportunities for value investors. The illiquidity, lack of transparency, gargantuan size, embedded leverage, and hefty fees of some hedge funds would no doubt raise red flags. But Graham and Dodd would probably approve of hedge funds that practice value-ori- ented investment selection. Importantly, while Graham and Dodd emphasized limiting risk on an investment-by-investment basis, they also believed that diversification and hedging could protect the downside for an entire portfolio. (p. 106) This is what most hedge funds attempt to do. While they hold individual securities that, considered alone, may involve an uncomfortable degree of risk, they attempt to offset the risks for the entire portfolio through the short sale of similar but more highly valued securities, through the purchase of put options on individual securities or market indexes, and through adequate diversification (although many are guilty of overdiver- sification, holding too little of their truly good ideas and too much of their mediocre ones). In this way, a hedge fund portfolio could (in theory, anyway) have characteristics of good potential return with limited risk that its individual components may not have. Modern-day Developments As mentioned, the analysis of businesses and securities has become increasingly sophisticated over the years. Spreadsheet technology, for example, allows for vastly more sophisticated modeling than was possible even one generation ago. Benjamin Graham’s pencil, clearly one of the sharpest of his era, might not be sharp enough today. On the other hand, technology can easily be misused; computer modeling requires making a series of assumptions about the future that can lead to a spurious preci- sion of which Graham would have been quite dubious. While Graham was interested in companies that produced consistent earnings, analysis in his day was less sophisticated regarding why some company’s earnings might be more consistent than others. Analysts today examine businesses but also business models; the bottom-line impact of changes in revenues, profit margins, product mix, and other variables is carefully studied by managements and financial analysts alike. Investors know that businesses do not exist in a vacuum; the actions of competitors, suppliers, and cus- tomers can greatly impact corporate profitability and must be considered.12 Another important change in focus over time is that while Graham looked at corporate earnings and dividend payments as barometers of a company’s health, most value investors today analyze free cash flow. This is the cash generated annually from the operations of a business after all capital expenditures are made and changes in working capital are con- sidered. Investors have increasingly turned to this metric because reported earnings can be an accounting fiction, masking the cash gener- ated by a business or implying positive cash generation when there is none. Today’s investors have rightly concluded that following the cash— as the manager of a business must do—is the most reliable and reveal- ing means of assessing a company. In addition, many value investors today consider balance sheet analy- sis less important than was generally thought a few generations ago. With returns on capital much higher at present than in the past, most stocks trade far above book value; balance sheet analysis is less helpful in understanding upside potential or downside risk of stocks priced at 12 Professor Michael Porter of Harvard Business School, in his seminal book Competitive Strategy (Free Press, 1980), lays out the groundwork for a more intensive, thorough, and dynamic analysis of busi- nesses and industries in the modern economy. A broad industry analysis has become particularly necessary as a result of the passage in 2000 of Regulation FD (Fair Disclosure), which regulates and restricts the communications between a company and its actual or potential shareholders. Wall Street analysts, facing a dearth of information from the companies they cover, have been forced to expand their areas of inquiry. The effects of sustained inflation over time have also wreaked havoc with the accuracy of assets accounted for using historic cost; this means that two companies owning identical assets could report very different book values. Of course, balance sheets must still be carefully scrutinized. Astute observers of corporate balance sheets are often the first to see business deterioration or vulnerability as inventories and receivables build, debt grows, and cash evaporates. And for investors in the equity and debt of underperforming companies, balance sheet analysis remains one generally reliable way of assessing downside protection. Globalization has increasingly affected the investment landscape, with most investors looking beyond their home countries for opportunity and diversification. Graham and Dodd’s principles fully apply to international markets, which are, if anything, even more subject to the vicissitudes of investor sentiment—and thus more inefficiently priced—than the U.S. market is today. Investors must be cognizant of the risks of international investing, including exposure to foreign currencies and the need to consider hedging them. Among the other risks are political instability, different (or absent) securities laws and investor protections, varying accounting standards, and limited availability of information. Oddly enough, despite 75 years of success achieved by value investors, one group of observers largely ignores or dismisses this disci- pline: academics. Academics tend to create elegant theories that purport to explain the real world but in fact oversimplify it. One such theory, the Efficient Market Hypothesis (EMH), holds that security prices always and immediately reflect all available information, an idea deeply at odds with Graham and Dodd’s notion that there is great value to fundamental security analysis. The Capital Asset Pricing Model (CAPM) relates risk to return but always mistakes volatility, or beta, for risk. Modern Portfolio Theory (MPT) applauds the benefits of diversification in constructing an optimal portfolio. But by insisting that higher expected return comes only with greater risk, MPT effectively repudiates the entire value-invest- ing philosophy and its long-term record of risk-adjusted investment out- performance. Value investors have no time for these theories and generally ignore them. The assumptions made by these theories—including continuous markets, perfect information, and low or no transaction costs—are unre- alistic. Academics, broadly speaking, are so entrenched in their theories that they cannot accept that value investing works. Instead of launching a series of studies to understand the remarkable 50-year investment record of Warren Buffett, academics instead explain him away as an aber- ration. Greater attention has been paid recently to behavioral economics, a field recognizing that individuals do not always act rationally and have systematic cognitive biases that contribute to market inefficiencies and security mispricings. These teachings—which would not seem alien to Graham—have not yet entered the academic mainstream, but they are building some momentum. Academics have espoused nuanced permutations of their flawed the- ories for several decades. Countless thousands of their students have been taught that security analysis is worthless, that risk is the same as volatility, and that investors must avoid overconcentration in good ideas (because in efficient markets there can be no good ideas) and thus diver- sify into mediocre or bad ones. Of course, for value investors, the propa- gation of these academic theories has been deeply gratifying: the brainwashing of generations of young investors produces the very ineffi- ciencies that savvy stock pickers can exploit. Another important factor for value investors to take into account is the growing propensity of the Federal Reserve to intervene in financial markets at the first sign of trouble. Amidst severe turbulence, the Fed frequently lowers interest rates to prop up securities prices and restore investor confidence. While the intention of Fed officials is to maintain orderly capital markets, some money managers view Fed intervention as a virtual license to speculate. Aggressive Fed tactics, sometimes referred to as the “Greenspan put” (now the “Bernanke put”), create a moral haz- ard that encourages speculation while prolonging overvaluation. So long as value investors aren’t lured into a false sense of security, so long as they can maintain a long-term horizon and ensure their staying power, market dislocations caused by Fed action (or investor anticipation of it) may ultimately be a source of opportunity. Another modern development of relevance is the ubiquitous cable television coverage of the stock market. This frenetic lunacy exacerbates the already short-term orientation of most investors. It foments the view that it is possible—or even necessary—to have an opinion on everything pertinent to the financial markets, as opposed to the patient and highly selective approach endorsed by Graham and Dodd. This sound-bite cul- ture reinforces the popular impression that investing is easy, not rigorous and painstaking. The daily cheerleading pundits exult at rallies and record highs and commiserate over market reversals; viewers get the impression that up is the only rational market direction and that selling or sitting on the sidelines is almost unpatriotic. The hysterical tenor is exacerbated at every turn. For example, CNBC frequently uses a format- ted screen that constantly updates the level of the major market indexes against a digital clock. Not only is the time displayed in hours, minutes, and seconds but in completely useless hundredths of seconds, the num- bers flashing by so rapidly (like tenths of a cent on the gas pump) as to be completely unreadable. The only conceivable purpose is to grab the viewers’ attention and ratchet their adrenaline to full throttle. Cable business channels bring the herdlike mentality of the crowd into everyone’s living room, thus making it much harder for viewers to stand apart from the masses. Only on financial cable TV would a commentator with a crazed persona become a celebrity whose pronouncements regularly move markets. In a world in which the differences between investing and speculating are frequently blurred, the nonsense on financial cable channels only compounds the problem. Graham would have been appalled. The only saving grace is that value investors prosper at the expense of those who fall under the spell of the cable pundits. Meanwhile, human nature virtually ensures that there will never be a Graham and Dodd channel. Unanswered Questions Today’s investors still wrestle, as Graham and Dodd did in their day, with a number of important investment questions. One is whether to focus on relative or absolute value. Relative value involves the assessment that one security is cheaper than another, that Microsoft is a better bargain than IBM. Relative value is easier to determine than absolute value, the two-dimensional assessment of whether a security is cheaper than other securities and cheap enough to be worth purchasing. The most intrepid investors in relative value manage hedge funds where they purchase the relatively less expensive securities and sell short the relatively more expensive ones. This enables them potentially to profit on both sides of the ledger, long and short. Of course, it also exposes them to double- barreled losses if they are wrong.13 It is harder to think about absolute value than relative value. When is a stock cheap enough to buy and hold without a short sale as a hedge? One standard is to buy when a security trades at an appreciable—say, 30%, 40%, or greater—discount from its underlying value, calculated either as its liquidation value, going-concern value, or private-market 13 Many hedge funds also use significant leverage to goose their returns further, which backfires when analysis is faulty or judgment is flawed. Another standard is to invest when a security offers an acceptably attractive return to a long-term holder, such as a low-risk bond priced to yield 10% or more, or a stock with an 8% to 10% or higher free cash flow yield at a time when “risk-free” U.S. government bonds deliver 4% to 5% nominal and 2% to 3% real returns. Such demanding standards virtually ensure that absolute value will be quite scarce. Another area where investors struggle is trying to define what consti- tutes a good business. Someone once defined the best possible business as a post office box to which people send money. That idea has certainly been eclipsed by the creation of subscription Web sites that accept credit cards. Today’s most profitable businesses are those in which you sell a fixed amount of work product—say, a piece of software or a hit recording—millions and millions of times at very low marginal cost. Good businesses are generally considered those with strong barriers to entry, limited capital requirements, reliable customers, low risk of tech- nological obsolescence, abundant growth possibilities, and thus signifi- cant and growing free cash flow. Businesses are also subject to changes in the technological and com- petitive landscape. Because of the Internet, the competitive moat sur- rounding the newspaper business—which was considered a very good business only a decade ago—has eroded faster than almost anyone anticipated. In an era of rapid technological change, investors must be ever vigilant, even with regard to companies that are not involved in technology but are simply affected by it. In short, today’s good busi- nesses may not be tomorrow’s. Investors also expend considerable effort attempting to assess the quality of a company’s management. Some managers are more capable or scrupulous than others, and some may be able to manage certain businesses and environments better than others. Yet, as Graham and Dodd noted, “Objective tests of managerial ability are few and far from scientific.” (p. 84) Make no mistake about it: a management’s acumen, foresight, integrity, and motivation all make a huge difference in share- holder returns. In the present era of aggressive corporate financial engi- neering, managers have many levers at their disposal to positively impact returns, including share repurchases, prudent use of leverage, and a valuation-based approach to acquisitions. Managers who are unwilling to make shareholder-friendly decisions risk their companies becoming perceived as “value traps”: inexpensively valued, but ulti- mately poor investments, because the assets are underutilized. Such companies often attract activist investors seeking to unlock this trapped value. Even more difficult, investors must decide whether to take the risk of investing—at any price—with management teams that have not always done right by shareholders. Shares of such companies may sell at steeply discounted levels, but perhaps the discount is warranted; value that today belongs to the equity holders may tomorrow have been spir- ited away or squandered. An age-old difficulty for investors is ascertaining the value of future growth. In the preface to the first edition of Security Analysis, the authors said as much: “Some matters of vital significance, e.g., the determination of the future prospects of an enterprise, have received little space, because little of definite value can be said on the subject.” (p. xliii) Clearly, a company that will earn (or have free cash flow of) $1 per share today and $2 per share in five years is worth considerably more than a company with identical current per share earnings and no growth. This is especially true if the growth of the first company is likely to continue and is not subject to great variability. Another complication is that companies can grow in many different ways—for example, selling the same number of units at higher prices; selling more units at the same (or even lower) prices; changing the product mix (selling proportionately more of the higher-profit-margin products); or developing an entirely new product line. Obviously, some forms of growth are worth more than others. There is a significant downside to paying up for growth or, worse, to obsessing over it. Graham and Dodd astutely observed that “analysis is concerned primarily with values which are supported by the facts and not with those which depend largely upon expectations.” (p. 86) Strongly preferring the actual to the possible, they regarded the “future as a haz- ard which his [the analyst’s] conclusions must encounter rather than as the source of his vindication.” (p. 86) Investors should be especially vigi- lant against focusing on growth to the exclusion of all else, including the risk of overpaying. Again, Graham and Dodd were spot on, warning that “carried to its logical extreme, . . . [there is no price] too high for a good stock, and that such an issue was equally ‘safe’ after it had advanced to 200 as it had been at 25.” (p. 105) Precisely this mistake was made when stock prices surged skyward during the Nifty Fifty era of the early 1970s and the dot-com bubble of 1999 to 2000. The flaw in such a growth-at-any-price approach becomes obvious when the anticipated growth fails to materialize. When the future disap- points, what should investors do? Hope growth resumes? Or give up and sell? Indeed, failed growth stocks are often so aggressively dumped by disappointed holders that their price falls to levels at which value investors, who stubbornly pay little or nothing for growth characteristics, become major holders. This was the case with many technology stocks that suffered huge declines after the dot-com bubble burst in the spring of 2000. By 2002, hundreds of fallen tech stocks traded for less than the cash on their balance sheets, a value investor’s dream. One such com- pany was Radvision, an Israeli provider of voice, video, and data products whose stock subsequently rose from under $5 to the mid-$20s after the urgent selling abated and investors refocused on fundamentals. Another conundrum for value investors is knowing when to sell. Buy- ing bargains is the sweet spot of value investors, although how small a discount one might accept can be subject to debate. Selling is more dif- ficult because it involves securities that are closer to fully priced. As with buying, investors need a discipline for selling. First, sell targets, once set, should be regularly adjusted to reflect all currently available information. Second, individual investors must consider tax consequences. Third, whether or not an investor is fully invested may influence the urgency of raising cash from a stockholding as it approaches full valuation. The availability of better bargains might also make one a more eager seller. Finally, value investors should completely exit a security by the time it reaches full value; owning overvalued securities is the realm of specula- tors. Value investors typically begin selling at a 10% to 20% discount to their assessment of underlying value—based on the liquidity of the security, the possible presence of a catalyst for value realization, the quality of management, the riskiness and leverage of the underlying business, and the investors’ confidence level regarding the assumptions underlying the investment. Finally, investors need to deal with the complex subject of risk. As mentioned earlier, academics and many professional investors have come to define risk in terms of the Greek letter beta, which they use as a measure of past share price volatility: a historically more volatile stock is seen as riskier. But value investors, who are inclined to think about risk as the probability and amount of potential loss, find such reasoning absurd. In fact, a volatile stock may become deeply undervalued, rendering it a very low risk investment. One of the most difficult questions for value investors is how much risk to incur. One facet of this question involves position size and its impact on portfolio diversification. How much can you comfortably own of even the most attractive opportunities? Naturally, investors desire to profit fully from their good ideas. Yet this tendency is tempered by the fear of being unlucky or wrong. Nonetheless, value investors should concentrate their holdings in their best ideas; if you can tell a good investment from a bad one, you can also distinguish a great one from a good one. Investors must also ponder the risks of investing in politically unsta- ble countries, as well as the uncertainties involving currency, interest rate, and economic fluctuations. How much of your capital do you want tied up in Argentina or Thailand, or even France or Australia, no matter how undervalued the stocks may be in those markets? Another risk consideration for value investors, as with all investors, is whether or not to use leverage. While some value-oriented hedge funds and even endowments use leverage to enhance their returns, I side with those who are unwilling to incur the added risks that come with margin debt. Just as leverage enhances the return of successful investments, it magnifies the losses from unsuccessful ones. More importantly, nonre- course (margin) debt raises risk to unacceptable levels because it places one’s staying power in jeopardy. One risk-related consideration should be paramount above all others: the ability to sleep well at night, confi- dent that your financial position is secure whatever the future may bring. Final Thoughts In a rising market, everyone makes money and a value philosophy is unnecessary. But because there is no certain way to predict what the market will do, one must follow a value philosophy at all times. By con- trolling risk and limiting loss through extensive fundamental analysis, strict discipline, and endless patience, value investors can expect good results with limited downside. You may not get rich quick, but you will keep what you have, and if the future of value investing resembles its past, you are likely to get rich slowly. As investment strategies go, this is the most that any reasonable investor can hope for. The real secret to investing is that there is no secret to investing. Every important aspect of value investing has been made available to the public many times over, beginning in 1934 with the first edition of Security Analysis. That so many people fail to follow this timeless and almost foolproof approach enables those who adopt it to remain suc- cessful. The foibles of human nature that result in the mass pursuit of instant wealth and effortless gain seem certain to be with us forever. So long as people succumb to this aspect of their natures, value investing will remain, as it has been for 75 years, a sound and low-risk approach to successful long-term investing. SETH A. KLARMAN Boston, Massachusetts, May, 2008 Introduction to the Sixth Edition It was a distracted world before which McGraw-Hill set, with a thud, the first edition of Security Analysis in July 1934. From Berlin dribbled reports of a shake-up at the top of the German government. “It will simplify the Führer’s whole work immensely if he need not first ask some- body if he may do this or that,” the Associated Press quoted an informant on August 1 as saying of Hitler’s ascension from chancellor to dictator. Set against such epochal proceedings, a 727-page textbook on the fine points of value investing must have seemed an unlikely candidate for bestsellerdom, then or later. In his posthumously published autobiography, The Memoirs of the Dean of Wall Street, Graham (1894–1976) thanked his lucky stars that he had entered the investment business when he did. The timing seemed not so propitious in the year of the first edition of Security Analysis, or, indeed, that of the second edition—expanded and revised—six years later. From its 1929 peak to its 1932 trough, the Dow Jones Industrial Average had lost 87% of its value. At cyclical low ebb, in 1933, the national unemployment rate topped 25%. That the Great Depression ended in 1933 was the considered judgment of the timekeepers of the National Bureau of Economic Research. Millions of Americans, however— not least, the relatively few who tried to squeeze a living out of a profit- less Wall Street—had reason to doubt it. The bear market and credit liquidation of the early 1930s gave the institutions of American finance a top-to-bottom scouring. What was left of them presently came in for a rough handling by the first Roosevelt administration. Graham had learned his trade in the Wall Street of the mid–nineteen teens, an era of lightly regulated markets. He began work on Security Analysis as the administration of Herbert Hoover was giving the country its first taste of thoroughgoing federal intervention in a peacetime economy. He was correcting page proofs as the Roosevelt administration was implementing its first radical forays into macroeco- nomic management. By 1934, there were laws to institute federal regula- tion of the securities markets, federal insurance of bank deposits, and federal price controls (not to put a cap on prices, as in later, inflationary times, but rather to put a floor under them). To try to prop up prices, the administration devalued the dollar. It is a testament to the enduring quality of Graham’s thought, not to mention the resiliency of America’s financial markets, that Security Analysis lost none of its relevance even as the economy was being turned upside down and inside out. Five full months elapsed following publication of the first edition before Louis Rich got around to reviewing it in the New York Times. Who knows? Maybe the conscientious critic read every page. In any case, Rich gave the book a rave, albeit a slightly rueful one. “On the assumption,” he wrote, on December 2, 1934, “that despite the debacle of recent history there are still people left whose money burns a hole in their pockets, it is hoped that they will read this book. It is a full-bodied, mature, meticu- lous and wholly meritorious outgrowth of scholarly probing and practi- cal sagacity. Although cast in the form and spirit of a textbook, the presentation is endowed with all the qualities likely to engage the liveli- est interest of the layman.”1 How few laymen seemed to care about investing was brought home to Wall Street more forcefully with every passing year of the unprosperous postcrash era. Just when it seemed that trading volume could get no smaller, or New York Stock Exchange seat prices no lower, or equity valu- ations more absurdly cheap, a new, dispiriting record was set. It required every effort of the editors of the Big Board’s house organ, the Exchange magazine, to keep up a brave face. “Must There Be an End to Progress?” was the inquiring headline over an essay by the Swedish economist Gus- tav Cassel published around the time of the release of Graham and Dodd’s second edition (the professor thought not).2 “Why Do Securities Brokers Stay in Business?” the editors posed and helpfully answered, “Despite wearying lethargy over long periods, confidence abounds that when the public recognizes fully the value of protective measures which lately have been ranged about market procedure, investment interest in securities will increase.” It did not amuse the Exchange that a New York City magistrate, sarcastically addressing in his court a collection of defen- dants hauled in by the police for shooting craps on the sidewalk, had derided the financial profession. “The first thing you know,” the judge had upbraided the suspects, “you’ll wind up as stock brokers in Wall Street with yachts and country homes on Long Island.”3 In ways now difficult to imagine, Murphy’s Law was the order of the day; what could go wrong, did. “Depression” was more than a long-lin- gering state of economic affairs. It had become a worldview. The aca- demic exponents of “secular stagnation,” notably Alvin Hansen and Joseph Schumpeter, each a Harvard economics professor, predicted a long decline in American population growth. This deceleration, Hansen contended in his 1939 essay, “together with the failure of any really important innovations of a magnitude to absorb large capital outlays, weighs very heavily as an explanation for the failure of the recent recov- ery to reach full employment.”4 Neither Hansen nor his readers had any way of knowing that a baby boom was around the corner. Nothing could have seemed more unlikely to a world preoccupied with a new war in Europe and the evident decline and fall of capitalism. Certainly, Hansen’s ideas must have struck a chord with the chronically underemployed brokers and traders in lower Manhat- tan. As a business, the New York Stock Exchange was running at a steady loss. From 1933, the year in which it began to report its financial results, through 1940, the Big Board recorded a profit in only one year, 1935 (and a nominal one, at that). And when, in 1937, Chelcie C. Bosland, an assis- tant professor of economics at Brown University, brought forth a book entitled The Common Stock Theory of Investment, he remarked as if he were repeating a commonplace that the American economy had peaked two decades earlier at about the time of what was not yet called World War I. The professor added, quoting unnamed authorities, that American population growth could be expected to stop in its tracks by 1975.5 Small wonder that Graham was to write that the acid test of a bond issuer was its capacity to meet its obligations not in a time of middling prosperity (which modest test today’s residential mortgage–backed securities strug- gle to meet) but in a depression. Altogether, an investor in those days was well advised to keep up his guard. “The combination of a record high level for bonds,” writes Graham in the 1940 edition, “with a history of two catastrophic price collapses in the preceding 20 years and a major war in progress is not one to justify airy confidence in the future.” (p. 142) Wall Street, not such a big place even during the 1920s’ boom, got considerably smaller in the subsequent bust. Ben Graham, in conjunction with his partner Jerry Newman, made a very small cog of this low-horse- power machine. The two of them conducted a specialty investment busi- ness at 52 Wall Street. Their strong suits were arbitrage, reorganizations, bankruptcies, and other complex matters. A schematic drawing of the financial district published by Fortune in 1937 made no reference to the Graham-Newman offices. Then again, the partnerships and corporate headquarters that did rate a spot on the Wall Street map were them- selves—by the standards of twenty-first-century finance—remarkably compact. One floor at 40 Wall Street was enough to contain the entire office of Merrill Lynch & Co. And a single floor at 2 Wall Street was all the space required to house Morgan Stanley, the hands-down leader in 1936 corporate securities underwriting, with originations of all of $195 million. Compensation was in keeping with the slow pace of business, especially at the bottom of the corporate ladder.6 After a 20% rise in the new fed- eral minimum wage, effective October 1939, brokerage employees could earn no less than 30 cents an hour.7 In March 1940, the Exchange documented in all the detail its readers could want (and possibly then some) the collapse of public participation in the stock market. In the first three decades of the twentieth century, the annual volume of trading had almost invariably exceeded the quantity of listed shares outstanding, sometimes by a wide margin. And in only one year between 1900 and 1930 had annual volume amounted to less than 50% of listed shares—the exception being 1914, the year in which the exchange was closed for 41/2 months to allow for the shock of the out- break of World War I to sink in. Then came the 1930s, and the annual turnover as a percentage of listed shares struggled to reach as high as 50%. In 1939, despite a short-lived surge of trading on the outbreak of World War II in Europe, the turnover ratio had fallen to a shockingly low 18.4%. (For comparison, in 2007, the ratio of trading volume to listed shares amounted to 123%.) “Perhaps,” sighed the author of the study, “it is a fair statement that if the farming industry showed a similar record, government subsidies would have been voted long ago. Unfortunately for Wall Street, it seems to have too little sponsorship in officialdom.”8 If a reader took hope from the idea that things were so bad that they could hardly get worse, he or she was in for yet another disappointment. The second edition of Security Analysis had been published only months earlier when, on August 19, 1940, the stock exchange volume totaled just 129,650 shares. It was one of the sleepiest sessions since the 49,000- share mark set on August 5, 1916. For the entire 1940 calendar year, vol- ume totaled 207,599,749 shares—a not very busy two hours’ turnover at this writing and 18.5% of the turnover of 1929, that year of seemingly irrecoverable prosperity. The cost of a membership, or seat, on the stock exchange sank along with turnover and with the major price indexes. At the nadir in 1942, a seat fetched just $17,000. It was the lowest price since 1897 and 97% below the record high price of $625,000, set—natu- rally—in 1929. “‘The Cleaners,’” quipped Fred Schwed, Jr., in his funny and wise book Where Are the Customers’ Yachts? (which, like Graham’s second edition, appeared in 1940), “was not one of those exclusive clubs; by 1932, every- body who had ever tried speculation had been admitted to membership.”9 And if an investor did, somehow, manage to avoid the cleaner’s during the formally designated Great Depression, he or she was by no means home free. In August 1937, the market began a violent sell-off that would carry the averages down by 50% by March 1938. The nonfinancial portion of the economy fared little better than the financial side. In just nine months, industrial production fell by 34.5%, a sharper contraction even than that in the depression of 1920 to 1921, a slump that, for Graham’s generation, had seemed to set the standard for the most economic damage in the shortest elapsed time.10 The Roosevelt administration insisted that the slump of 1937 to 1938 was no depression but rather a “recession.” The national unemployment rate in 1938 was, on average, 18.8%. In April 1937, four months before the bottom fell out of the stock mar- ket for the second time in 10 years, Robert Lovett, a partner at the invest- ment firm of Brown Brothers Harriman & Co., served warning to the American public in the pages of the weekly Saturday Evening Post. Lovett, a member of the innermost circle of the Wall Street establishment, set out to demonstrate that there is no such thing as financial security—none, at least, to be had in stocks and bonds. The gist of Lovett’s argument was that, in capitalism, capital is consumed and that businesses are just as fragile, and mortal, as the people who own them. He invited his millions of readers to examine the record, as he had done: “If an investor had pur- chased 100 shares of the 20 most popular dividend-paying stocks on December 31, 1901, and held them through 1936, adding, in the mean- time, all the melons in the form of stock dividends, and all the plums in the form of stock split-ups, and had exercised all the valuable rights to subscribe to additional stock, the aggregate market value of his total holdings on December 31, 1936, would have shown a shrinkage of 39% as compared with the cost of his original investment. In plain English, the average investor paid $294,911.90 for things worth $180,072.06 on December 31, 1936. That’s a big disappearance of dollar value in any lan- guage.” In the innocent days before the crash, people had blithely spoken of “permanent investments.” “For our part,” wrote this partner of an emi- nent Wall Street private bank, “we are convinced that the only permanent investment is one which has become a total and irretrievable loss.”11 Lovett turned out to be a prophet. At the nadir of the 1937 to 1938 bear market, one in five NYSE-listed industrial companies was valued in the market for less than its net current assets. Subtract from cash and quick assets all liabilities and the remainder was greater than the company’s market value. That is, business value was negative. The Great Atlantic & Pacific Tea Company (A&P), the Wal-Mart of its day, was one of these corporate castoffs. At the 1938 lows, the market value of the com- mon and preferred shares of A&P at $126 million was less than the value of its cash, inventories, and receivables, conservatively valued at $134 million. In the words of Graham and Dodd, the still-profitable company was selling for “scrap.” (p. 673) A Different Wall Street Few institutional traces of that Wall Street remain. Nowadays, the big broker-dealers keep as much as $1 trillion in securities in inventory; in Graham’s day, they customarily held none. Nowadays, the big broker- dealers are in a perpetual competitive lather to see which can bring the greatest number of initial public offerings (IPOs) to the public market. In Graham’s day, no frontline member firm would stoop to placing an IPO in public hands, the risks and rewards for this kind of offering being reserved for professionals. Federal securities regulation was a new thing in the 1930s. What had preceded the Securities and Exchange Commis- sion (SEC) was a regime of tribal sanction. Some things were simply beyond the pale. Both during and immediately after World War I, no self- respecting NYSE member firm facilitated a client’s switch from Liberty bonds into potentially more lucrative, if less patriotic, alternatives. There was no law against such a business development overture. Rather, according to Graham, it just wasn’t done. A great many things weren’t done in the Wall Street of the 1930s. Newly empowered regulators were resistant to financial innovation, trans- action costs were high, technology was (at least by today’s digital stan- dards) primitive, and investors were demoralized. After the vicious bear market of 1937 to 1938, not a few decided they’d had enough. What was the point of it all? “In June 1939,” writes Graham in a note to a discussion about corporate finance in the second edition, “the S.E.C. set a salutary precedent by refusing to authorize the issuance of ‘Capital Income Debentures’ in the reorganization of the Griess-Pfleger Tanning Company, on the ground that the devising of new types of hybrid issues had gone far enough.” (p. 115, fn. 4) In the same conservative vein, he expresses his approval of the institution of the “legal list,” a document compiled by state banking departments to stipulate which bonds the regulated sav- ings banks could safely own. The very idea of such a list flies in the face of nearly every millennial notion about good regulatory practice. But Gra- ham defends it thus: “Since the selection of high-grade bonds has been shown to be in good part a process of exclusion, it lends itself reasonably well to the application of definite rules and standards designed to dis- qualify unsuitable issues.” (p. 169) No collateralized debt obligations stocked with subprime mortgages for the father of value investing! The 1930s ushered in a revolution in financial disclosure. The new federal securities acts directed investor-owned companies to brief their stockholders once a quarter as well as at year-end. But the new stan- dards were not immediately applicable to all public companies, and more than a few continued doing business the old-fashioned way, with their cards to their chests. One of these informational holdouts was none other than Dun & Bradstreet (D&B), the financial information company. Graham seemed to relish the irony of D&B not revealing “its own earn- ings to its own stockholders.” (p. 92, fn. 4) On the whole, by twenty-first- century standards, information in Graham’s time was as slow moving as it was sparse. There were no conference calls, no automated spread- sheets, and no nonstop news from distant markets—indeed, not much truck with the world outside the 48 states. Security Analysis barely acknowledges the existence of foreign markets. Such an institutional setting was hardly conducive to the develop- ment of “efficient markets,” as the economists today call them—markets in which information is disseminated rapidly, human beings process it flawlessly, and prices incorporate it instantaneously. Graham would have scoffed at such an idea. Equally, he would have smiled at the discovery— so late in the evolution of the human species—that there was a place in economics for a subdiscipline called “behavioral finance.” Reading Security Analysis, one is led to wonder what facet of investing is not behavioral. The stock market, Graham saw, is a source of entertainment value as well as investment value: “Even when the underlying motive of purchase is mere speculative greed, human nature desires to conceal this unlovely impulse behind a screen of apparent logic and good sense. To adapt the aphorism of Voltaire, it may be said that if there were no such thing as common-stock analysis, it would be necessary to counterfeit it.” (p. 348) Anomalies of undervaluation and overvaluation—of underdoing it and overdoing it—fill these pages. It bemused Graham, but did not shock him, that so many businesses could be valued in the stock market for less than their net current assets, even during the late 1920s’ boom, or that, in the dislocations to the bond market immediately following World War I, investors became disoriented enough to assign a higher price and a lower yield to the Union Pacific First Mortgage 4s than they did to the U.S. Treasury’s own Fourth Liberty 41⁄4s. Graham writes of the “inveterate tendency of the stock market to exaggerate.” (p. 679) He would not have exaggerated much if he had written, instead, “all markets.” Though he did not dwell long on the cycles in finance, Graham was certainly aware of them. He could see that ideas, no less than prices and categories of investment assets, had their seasons. The discussion in Security Analysis of the flame-out of the mortgage guarantee business in the early 1930s is a perfect miniature of the often-ruinous competition in which financial institutions periodically engage. “The rise of the newer and more aggressive real estate bond organizations had a most unfortu- nate effect upon the policies of the older concerns,” Graham writes of his time and also of ours. “By force of competition they were led to relax their standards of making loans. New mortgages were granted on an increasingly liberal basis, and when old mortgages matured, they were frequently renewed in a larger sum. Furthermore, the face amount of the mortgages guaranteed rose to so high a multiple of the capital of the guarantor companies that it should have been obvious that the guaranty would afford only the flimsiest of protection in the event of a general decline in values.” (p. 217) Security analysis itself is a cyclical phenomenon; it, too, goes in and out of fashion, Graham observed. It holds a strong, intuitive appeal for the kind of businessperson who thinks about stocks the way he or she thinks about his or her own family business. What would such a fount of com- mon sense care about earnings momentum or Wall Street’s pseudo-scien- tific guesses about the economic future? Such an investor, appraising a common stock, would much rather know what the company behind it is worth. That is, he or she would want to study its balance sheet. Well, Gra- ham relates here, that kind of analysis went out of style when stocks started levitating without reference to anything except hope and prophecy. So, by about 1927, fortune-telling and chart-reading had dis- placed the value discipline by which he and his partner were earning a very good living. It is characteristic of Graham that his critique of the “new era” method of investing is measured and not derisory. The old, conserva- tive approach—his own—had been rather backward looking, Graham admits. It had laid more emphasis on the past than on the future, on sta- ble earning power rather than tomorrow’s earnings prospects. But new technologies, new methods, and new forms of corporate organization had introduced new risks into the post–World War I economy. This fact— “the increasing instability of the typical business”—had blown a small hole in the older analytical approach that emphasized stable earnings power over forecast earnings growth. Beyond that mitigating considera- tion, however, Graham does not go. The new era approach, “which turned upon the earnings trend as the sole criterion of value, . . . was certain to end in an appalling debacle.” (p. 366) Which, of course, it did, and—in the CNBC-driven markets of the twenty-first century—continues to do at intervals today. A Man of Many Talents Benjamin Graham was born Benjamin Grossbaum on May 9, 1894, in London, and sailed to New York with his family before he was two. Young Benjamin was a prodigy in mathematics, classical languages, modern languages, expository writing (as readers of this volume will see for themselves), and anything else that the public schools had to offer. He had a tenacious memory and a love of reading—a certain ticket to aca- demic success, then or later. His father’s death at the age of 35 left him, his two brothers, and their mother in the social and financial lurch. Ben- jamin early learned to work and to do without. No need here for a biographical profile of the principal author of Security Analysis: Graham’s own memoir delightfully covers that ground. Suffice it to say that the high school brainiac entered Columbia College as an Alumni Scholar in September 1911 at the age of 17. So much material had he already absorbed that he began with a semester’s head start, “the highest possible advanced standing.”12 He mixed his academic studies with a grab bag of jobs, part-time and full-time alike. Upon his graduation in 1914, he started work as a runner and board-boy at the New York Stock Exchange member firm of Newberger, Henderson & Loeb. Within a year, the board-boy was playing the liquidation of the Guggenheim Exploration Company by astutely going long the shares of Guggenheim and short the stocks of the companies in which Guggen- heim had made a minority investment, as his no-doubt bemused elders looked on: “The profit was realized exactly as calculated; and everyone was happy, not least myself.”13 Security Analysis did not come out of the blue. Graham had supple- mented his modest salary by contributing articles to the Magazine of Wall Street. His productions are unmistakably those of a self-assured and superbly educated Wall Street moneymaker. There was no need to quote expert opinion. He and the documents he interpreted were all the authority he needed. His favorite topics were the ones that he subse- quently developed in the book you hold in your hands. He was partial to the special situations in which Graham-Newman was to become so suc- cessful. Thus, when a high-flying, and highly complex, American Interna- tional Corp. fell from the sky in 1920, Graham was able to show that the stock was cheap in relation to the evident value of its portfolio of miscel- laneous (and not especially well disclosed) investment assets.14 The shocking insolvency of Goodyear Tire and Rubber attracted his attention in 1921. “The downfall of Goodyear is a remarkable incident even in the present plenitude of business disasters,” he wrote, in a characteristic Gra- ham sentence (how many financial journalists, then or later, had “pleni- tude” on the tips of their tongues?). He shrewdly judged that Goodyear would be a survivor.15 In the summer of 1924, he hit on a theme that would echo through Security Analysis: it was the evident non sequitor of stocks valued in the market at less than the liquidating value of the com- panies that issued them. “Eight Stock Bargains Off the Beaten Track,” said the headline over the Benjamin Graham byline: “Stocks that Are Covered Chiefly by Cash or the Equivalent—No Bonds or Preferred Stock Ahead of These Issues—An Unusually Interesting Group of Securities.” In one case, that of Tonopah Mining, liquid assets of $4.31 per share towered over a market price of just $1.38 a share.16 For Graham, an era of sweet reasonableness in investment thinking seemed to end around 1914. Before that time, the typical investor was a businessman who analyzed a stock or a bond much as he might a claim on a private business. He—it was usually a he—would naturally try to determine what the security-issuing company owned, free and clear of any encumbrances. If the prospective investment was a bond—and it usually was—the businessman-investor would seek assurances that the borrowing company had the financial strength to weather a depression. “It’s not undue modesty,” Graham wrote in his memoir, “to say that I had become something of a smart cookie in my particular field.” His spe- cialty was the carefully analyzed out-of-the-way investment: castaway stocks or bonds, liquidations, bankruptcies, arbitrage. Since at least the early 1920s, Graham had preached the sermon of the “margin of safety.” As the future is a closed book, he urged in his writings, an investor, as a matter of self-defense against the unknown, should contrive to pay less than “intrinsic” value. Intrinsic value, as defined in Security Analysis, is “that value which is justified by the facts, e.g., the assets, earnings, divi- dends, definite prospects, as distinct, let us say, from market quotations established by artificial manipulation or distorted by psychological excesses.” (p. 64) He himself had gone from the ridiculous to the sublime (and some- times back again) in the conduct of his own investment career. His quick and easy grasp of mathematics made him a natural arbitrageur. He would sell one stock and simultaneously buy another. Or he would buy or sell shares of stock against the convertible bonds of the identical issu- ing company. So doing, he would lock in a profit that, if not certain, was as close to guaranteed as the vicissitudes of finance allowed. In one instance, in the early 1920s, he exploited an inefficiency in the relation- ship between DuPont and the then red-hot General Motors (GM). DuPont held a sizable stake in GM. And it was for that interest alone which the market valued the big chemical company. By implication, the rest of the business was worth nothing. To exploit this anomaly, Graham bought shares in DuPont and sold short the hedge-appropriate number of shares in GM. And when the market came to its senses, and the price gap between DuPont and GM widened in the expected direction, Gra- ham took his profit.17 However, Graham, like many another value investors after him, some- times veered from the austere precepts of safe-and-cheap investing. A Graham only slightly younger than the master who sold GM and bought DuPont allowed himself to be hoodwinked by a crooked promoter of a company that seems not actually to have existed—at least, in anything like the state of glowing prosperity described by the manager of the pool to which Graham entrusted his money. An electric sign in Colum- bus Circle, on the upper West Side of Manhattan, did bear the name of the object of Graham’s misplaced confidence, Savold Tire. But, as the author of Security Analysis confessed in his memoir, that could have been the only tangible marker of the company’s existence. “Also, as far as I knew,” Graham added, “nobody complained to the district attorney’s office about the promoter’s bare-faced theft of the public’s money.” Cer- tainly, by his own telling, Graham didn’t.18 By 1929, when he was 35, Graham was well on his way to fame and fortune. His wife and he kept a squadron of servants, including—for the first and only time in his life—a manservant for himself. With JerryNewman, Graham had compiled an investment record so enviable that the great Bernard M. Baruch sought him out. Would Graham wind up his busi- ness to manage Baruch’s money? “I replied,” Graham writes, “that I was highly flattered—flabbergasted, in fact—by his proposal, but I could not end so abruptly the close and highly satisfactory relations I had with my friends and clients.”19 Those relations soon became much less satisfactory. Graham relates that, though he was worried at the top of the market, he failed to act on his bearish hunch. The Graham-Newman partnership went into the 1929 break with $2.5 million of capital. And they con- trolled about $2.5 million in hedged positions—stocks owned long offset by stocks sold short. They had, besides, about $4.5 million in outright long positions. It was bad enough that they were leveraged, as Graham later came to realize. Compounding that tactical error was a deeply rooted conviction that the stocks they owned were cheap enough to withstand any imaginable blow. They came through the crash creditably: down by only 20% was, for the final quarter of 1929, almost heroic. But they gave up 50% in 1930, 16% in 1931, and 3% in 1932 (another relatively excellent showing), for a cumulative loss of 70%.20 “I blamed myself not so much for my failure to protect myself against the disaster I had been predicting,” Graham writes, “as for having slipped into an extravagant way of life which I hadn’t the temperament or capacity to enjoy. I quickly convinced myself that the true key to material happiness lay in a modest standard of living which could be achieved with little difficulty under almost all economic condi- tions”—the margin-of-safety idea applied to personal finance.21 It can’t be said that the academic world immediately clasped Security Analysis to its breast as the definitive elucidation of value investing, or of anything else. The aforementioned survey of the field in which Graham and Dodd made their signal contribution, The Common Stock Theory of Investment, by Chelcie C. Bosland, published three years after the appear- ance of the first edition of Security Analysis, cited 53 different sources and 43 different authors. Not one of them was named Graham or Dodd. Edgar Lawrence Smith, however, did receive Bosland’s full and respectful attention. Smith’s Common Stocks as Long Term Investments, published in 1924, had challenged the long-held view that bonds were innately superior to equities. For one thing, Smith argued, the dollar (even the gold-backed 1924 edition) was inflation-prone, which meant that creditors were inherently disadvantaged. Not so the owners of com- mon stock. If the companies in which they invested earned a profit, and if the managements of those companies retained a portion of that profit in the business, and if those retained earnings, in turn, produced future earnings, the principal value of an investor’s portfolio would tend “to increase in accordance with the operation of compound interest.”22 Smith’s timing was impeccable. Not a year after he published, the great Coolidge bull market erupted. Common Stocks as Long Term Investments, only 129 pages long, provided a handy rationale for chasing the market higher. That stocks do, in fact, tend to excel in the long run has entered the canon of American investment thought as a revealed truth (it looked any- thing but obvious in the 1930s). For his part, Graham entered a strong dis- sent to Smith’s thesis, or, more exactly, its uncritical bullish application. It was one thing to pay 10 times earnings for an equity investment, he notes, quite another to pay 20 to 40 times earnings. Besides, the Smith analysis skirted the important question of what asset values lay behind the stock certificates that people so feverishly and uncritically traded back and forth. Finally, embedded in Smith’s argument was the assumption that common stocks could be counted on to deliver in the future what they had done in the past. Graham was not a believer. (pp. 362–363) If Graham was a hard critic, however, he was also a generous one. In 1939 he was given John Burr Williams’s The Theory of Investment Value to review for the Journal of Political Economy (no small honor for a Wall Street author-practitioner). Williams’s thesis was as important as it was concise. The investment value of a common stock is the present value of all future dividends, he proposed. Williams did not underestimate the significance of these loaded words. Armed with that critical knowledge, the author ventured to hope, investors might restrain themselves from bidding stocks back up to the moon again. Graham, in whose capacious brain dwelled the talents both of the quant and behavioral financier, voiced his doubts about that forecast. The rub, as he pointed out, was that, in order to apply Williams’s method, one needed to make some very large assumptions about the future course of interest rates, the growth of profit, and the terminal value of the shares when growth stops. “One wonders,” Graham mused, “whether there may not be too great a discrepancy between the necessarily hit-or-miss character of these assumptions and the highly refined mathematical treatment to which they are subjected.” Graham closed his essay on a characteristi- cally generous and witty note, commending Williams for the refreshing level-headedness of his approach and adding: “This conservatism is not really implicit in the author’s formulas; but if the investor can be per- suaded by higher algebra to take a sane attitude toward common-stock prices, the reviewer will cast a loud vote for higher algebra.”23 Graham’s technical accomplishments in securities analysis, by them- selves, could hardly have carried Security Analysis through its five edi- tions. It’s the book’s humanity and good humor that, to me, explain its long life and the adoring loyalty of a certain remnant of Graham readers, myself included. Was there ever a Wall Street moneymaker better steeped than Graham in classical languages and literature and in the financial history of his own time? I would bet “no” with all the confidence of a value investor laying down money to buy an especially cheap stock. Yet this great investment philosopher was, to a degree, a prisoner of his own times. He could see that the experiences through which he lived were unique, that the Great Depression was, in fact, a great anomaly. If anyone understood the folly of projecting current experience into the unpredictable future, it was Graham. Yet this investment-philosopher king, having spent 727 pages (not including the gold mine of an appendix) describing how a careful and risk-averse investor could prosper in every kind of macroeconomic conditions, arrives at a remarkable conclusion. What of the institutional investor, he asks. How should he invest? At first, Graham diffidently ducks the question—who is he to prescribe for the experienced financiers at the head of America’s philanthropic and educational institutions? But then he takes the astonishing plunge. “An institution,” he writes, “that can manage to get along on the low income provided by high-grade fixed-value issues should, in our opinion, confine its holdings to this field. We doubt if the better performance of common- stock indexes over past periods will, in itself, warrant the heavy responsi- bilities and the recurring uncertainties that are inseparable from a common-stock investment program.” (pp. 709–710) Could the greatest value investor have meant that? Did the man who stuck it out through ruinous losses in the Depression years and went on to compile a remarkable long-term investment record really mean that common stocks were not worth the bother? In 1940, with a new world war fanning the Roosevelt administration’s fiscal and monetary policies, high-grade corporate bonds yielded just 2.75%, while blue-chip equities yielded 5.1%. Did Graham mean to say that bonds were a safer proposi- tion than stocks? Well, he did say it. If Homer could nod, so could Gra- ham—and so can the rest of us, whoever we are. Let it be a lesson.

You will be provided with a user prompt and a context block. Only respond to prompts using information that has been provided in the context block. Do not use any outside knowledge to answer prompts. If you cannot answer a prompt based on the information in the context block alone, please state "I unable to determine that without additional context" and do not add anything further. According to the author of the preface, who cannot accept that value investing works? Preface to the Sixth Edition THE TIMELESS WISDOM OF GRAHAM AND DODD BY SETH A. KLARMAN Seventy-five years after Benjamin Graham and David Dodd wrote Security Analysis, a growing coterie of modern-day value investors remain deeply indebted to them. Graham and David were two assiduous and unusually insightful thinkers seeking to give order to the mostly uncharted financial wilderness of their era. They kindled a flame that has illuminated the way for value investors ever since. Today, Security Analysis remains an invaluable roadmap for investors as they navigate through unpredictable, often volatile, and sometimes treacherous finan- cial markets. Frequently referred to as the “bible of value investing,” Secu- rity Analysis is extremely thorough and detailed, teeming with wisdom for the ages. Although many of the examples are obviously dated, their les- sons are timeless. And while the prose may sometimes seem dry, readers can yet discover valuable ideas on nearly every page. The financial mar- kets have morphed since 1934 in almost unimaginable ways, but Graham and Dodd’s approach to investing remains remarkably applicable today. Value investing, today as in the era of Graham and Dodd, is the prac- tice of purchasing securities or assets for less than they are worth—the proverbial dollar for 50 cents. Investing in bargain-priced securities pro- vides a “margin of safety”—room for error, imprecision, bad luck, or the vicissitudes of the economy and stock market. While some might mistak- enly consider value investing a mechanical tool for identifying bargains, it is actually a comprehensive investment philosophy that emphasizes the need to perform in-depth fundamental analysis, pursue long-term investment results, limit risk, and resist crowd psychology. Far too many people approach the stock market with a focus on mak- ing money quickly. Such an orientation involves speculation rather than investment and is based on the hope that share prices will rise irrespec- tive of valuation. Speculators generally regard stocks as pieces of paper to be quickly traded back and forth, foolishly decoupling them from business reality and valuation criteria. Speculative approaches—which pay little or no attention to downside risk—are especially popular in ris- ing markets. In heady times, few are sufficiently disciplined to maintain strict standards of valuation and risk aversion, especially when most of those abandoning such standards are quickly getting rich. After all, it is easy to confuse genius with a bull market. In recent years, some people have attempted to expand the defini- tion of an investment to include any asset that has recently—or might soon—appreciate in price: art, rare stamps, or a wine collection. Because these items have no ascertainable fundamental value, generate no pres- ent or future cash flow, and depend for their value entirely on buyer whim, they clearly constitute speculations rather than investments. In contrast to the speculator’s preoccupation with rapid gain, value investors demonstrate their risk aversion by striving to avoid loss. A risk- averse investor is one for whom the perceived benefit of any gain is out- weighed by the perceived cost of an equivalent loss. Once any of us has accumulated a modicum of capital, the incremental benefit of gaining more is typically eclipsed by the pain of having less.1 Imagine how you would respond to the proposition of a coin flip that would either double your net worth or extinguish it. Being risk averse, nearly all people would respectfully decline such a gamble. Such risk aversion is deeply ingrained in human nature. Yet many unwittingly set aside their risk aversion when the sirens of market speculation call. Value investors regard securities not as speculative instruments but as fractional ownership in, or debt claims on, the underlying businesses. This orientation is key to value investing. When a small slice of a business is offered at a bargain price, it is helpful to evaluate it as if the whole business were offered for sale there. This analytical anchor helps value investors remain focused on the pursuit of long-term results rather than the profitability of their daily trading ledger. At the root of Graham and Dodd’s philosophy is the principle that the financial markets are the ultimate creators of opportunity. Sometimes the markets price securities correctly, other times not. Indeed, in the short run, the market can be quite inefficient, with great deviations between price and underlying value. Unexpected developments, increased uncer- tainty, and capital flows can boost short-term market volatility, with prices overshooting in either direction.2 In the words of Graham and Dodd, “The price [of a security] is frequently an essential element, so that a stock . . . may have investment merit at one price level but not at another.” (p. 106) As Graham has instructed, those who view the market as a weighing machine—a precise and efficient assessor of value—are part of the emo- tionally driven herd. Those who regard the market as a voting machine—a sentiment-driven popularity contest—will be well positioned to take proper advantage of the extremes of market sentiment. While it might seem that anyone can be a value investor, the essential characteristics of this type of investor—patience, discipline, and risk aver- sion—may well be genetically determined. When you first learn of the value approach, it either resonates with you or it doesn’t. Either you are able to remain disciplined and patient, or you aren’t. As Warren Buffett said in his famous article, “The Superinvestors of Graham-and-Doddsville,” “It is extraordinary to me that the idea of buying dollar bills for 40 cents takes immediately with people or it doesn’t take at all. It’s like an inocula- tion. If it doesn’t grab a person right away, I find you can talk to him for years and show him records, and it doesn’t make any difference.” 3,4 If Security Analysis resonates with you—if you can resist speculating and sometimes sit on your hands—perhaps you have a predisposition toward value investing. If not, at least the book will help you understand where you fit into the investing landscape and give you an appreciation for what the value-investing community may be thinking. Just as Relevant Now Perhaps the most exceptional achievement of Security Analysis, first pub- lished in 1934 and revised in the acclaimed 1940 edition, is that its les- sons are timeless. Generations of value investors have adopted the teachings of Graham and Dodd and successfully implemented them across highly varied market environments, countries, and asset classes. 3 “The Superinvestors of Graham-and-Doddsville,” Hermes, the Columbia Business School magazine, 1984. 4 My own experience has been exactly the one that Buffett describes. My 1978 summer job at Mutual Shares, a no-load value-based mutual fund, set the course for my professional career. The planned liquidation of Telecor and spin-off of its Electro Rent subsidiary in 1980 forever imprinted in my mind the merit of fundamental investment analysis. A buyer of Telecor stock was effectively creating an investment in the shares of Electro Rent, a fast-growing equipment rental company, at the giveaway valuation of approximately 1 times the cash flow. You always remember your first value investment.This would delight the authors, who hoped to set forth principles that would “stand the test of the ever enigmatic future.” (p. xliv) In 1992, Tweedy, Browne Company LLC, a well-known value invest- ment firm, published a compilation of 44 research studies entitled, “What Has Worked in Investing.” The study found that what has worked is fairly simple: cheap stocks (measured by price-to-book values, price- to-earnings ratios, or dividend yields) reliably outperform expensive ones, and stocks that have underperformed (over three- and five-year periods) subsequently beat those that have lately performed well. In other words, value investing works! I know of no long-time practitioner who regrets adhering to a value philosophy; few investors who embrace the fundamental principles ever abandon this investment approach for another. Today, when you read Graham and Dodd’s description of how they navigated through the financial markets of the 1930s, it seems as if they were detailing a strange, foreign, and antiquated era of economic depression, extreme risk aversion, and obscure and obsolete businesses. But such an exploration is considerably more valuable than it superfi- cially appears. After all, each new day has the potential to bring with it a strange and foreign environment. Investors tend to assume that tomor- row’s markets will look very much like today’s, and, most of the time, they will. But every once in a while,5 conventional wisdom is turned on its head, circular reasoning is unraveled, prices revert to the mean, and speculative behavior is exposed as such. At those times, when today fails to resemble yesterday, most investors will be paralyzed. In the words of Graham and Dodd, “We have striven throughout to guard the student against overemphasis upon the superficial and the temporary,” which is “at once the delusion and the nemesis of the world of finance.” (p. xliv) It is during periods of tumult that a value-investing philosophy is particu- larly beneficial. In 1934, Graham and Dodd had witnessed over a five-year span the best and the worst of times in the markets—the run-up to the 1929 peak, the October 1929 crash, and the relentless grind of the Great Depression. They laid out a plan for how investors in any environment might sort through hundreds or even thousands of common stocks, pre- ferred shares, and bonds to identify those worthy of investment. Remark- ably, their approach is essentially the same one that value investors employ today. The same principles they applied to the U.S. stock and bond markets of the 1920s and 1930s apply to the global capital markets of the early twenty-first century, to less liquid asset classes like real estate and private equity, and even to derivative instruments that hardly existed when Security Analysis was written. While formulas such as the classic “net working capital” test are nec- essary to support an investment analysis, value investing is not a paint- by-numbers exercise.6 Skepticism and judgment are always required. For one thing, not all elements affecting value are captured in a company’s financial statements—inventories can grow obsolete and receivables uncollectible; liabilities are sometimes unrecorded and property values over- or understated. Second, valuation is an art, not a science. Because the value of a business depends on numerous variables, it can typically be assessed only within a range. Third, the outcomes of all investments depend to some extent on the future, which cannot be predicted with certainty; for this reason, even some carefully analyzed investments fail to achieve profitable outcomes. Sometimes a stock becomes cheap for good reason: a broken business model, hidden liabilities, protracted litigation, or incompetent or corrupt management. Investors must always act with caution and humility, relentlessly searching for additional infor- mation while realizing that they will never know everything about a company. In the end, the most successful value investors combine detailed business research and valuation work with endless discipline and patience, a well-considered sensitivity analysis, intellectual honesty, and years of analytical and investment experience. Interestingly, Graham and Dodd’s value-investing principles apply beyond the financial markets—including, for example, to the market for baseball talent, as eloquently captured in Moneyball, Michael Lewis’s 2003 bestseller. The market for baseball players, like the market for stocks and bonds, is inefficient—and for many of the same reasons. In both investing and baseball, there is no single way to ascertain value, no one metric that tells the whole story. In both, there are mountains of information and no broad consensus on how to assess it. Decision makers in both arenas mis- interpret available data, misdirect their analyses, and reach inaccurate conclusions. In baseball, as in securities, many overpay because they fear standing apart from the crowd and being criticized. They often make decisions for emotional, not rational, reasons. They become exuberant; they panic. Their orientation sometimes becomes overly short term. They fail to understand what is mean reverting and what isn’t. Baseball’s value investors, like financial market value investors, have achieved significant outperformance over time. While Graham and Dodd didn’t apply value principles to baseball, the applicability of their insights to the market for athletic talent attests to the universality and timelessness of this approach. Value Investing Today Amidst the Great Depression, the stock market and the national econ- omy were exceedingly risky. Downward movements in share prices and business activity came suddenly and could be severe and protracted. Optimists were regularly rebuffed by circumstances. Winning, in a sense, was accomplished by not losing. Investors could achieve a margin of safety by buying shares in businesses at a large discount to their under- lying value, and they needed a margin of safety because of all the things that could—and often did—go wrong. Even in the worst of markets, Graham and Dodd remained faithful to their principles, including their view that the economy and markets sometimes go through painful cycles, which must simply be endured. They expressed confidence, in those dark days, that the economy and stock market would eventually rebound: “While we were writing, we had to combat a widespread conviction that financial debacle was to be the permanent order.” (p. xliv) Of course, just as investors must deal with down cycles when busi- ness results deteriorate and cheap stocks become cheaper, they must also endure up cycles when bargains are scarce and investment capital is plentiful. In recent years, the financial markets have performed exceed- ingly well by historic standards, attracting substantial fresh capital in need of managers. Today, a meaningful portion of that capital—likely totaling in the trillions of dollars globally—invests with a value approach. This includes numerous value-based asset management firms and mutual funds, a number of today’s roughly 9,000 hedge funds, and some of the largest and most successful university endowments and family investment offices. It is important to note that not all value investors are alike. In the aforementioned “Superinvestors of Graham-and-Doddsville,” Buffett describes numerous successful value investors who have little portfolio overlap. Some value investors hold obscure, “pink-sheet shares” while others focus on the large-cap universe. Some have gone global, while others focus on a single market sector such as real estate or energy. Some run computer screens to identify statistically inexpensive compa- nies, while others assess “private market value”—the value an industry buyer would pay for the entire company. Some are activists who aggres- sively fight for corporate change, while others seek out undervalued securities with a catalyst already in place—such as a spin-off, asset sale, major share repurchase plan, or new management team—for the partial or full realization of the underlying value. And, of course, as in any pro- fession, some value investors are simply more talented than others. In the aggregate, the value-investing community is no longer the very small group of adherents that it was several decades ago. Competition can have a powerful corrective effect on market inefficiencies and mis- pricings. With today’s many amply capitalized and skilled investors, what are the prospects for a value practitioner? Better than you might expect, for several reasons. First, even with a growing value community, there are far more market participants with little or no value orientation. Most man- agers, including growth and momentum investors and market indexers, pay little or no attention to value criteria. Instead, they concentrate almost single-mindedly on the growth rate of a company’s earnings, the momentum of its share price, or simply its inclusion in a market index. Second, nearly all money managers today, including some hapless value managers, are forced by the (real or imagined) performance pres- sures of the investment business to have an absurdly short investment horizon, sometimes as brief as a calendar quarter, month, or less. A value strategy is of little use to the impatient investor since it usually takes time to pay off. Finally, human nature never changes. Capital market manias regularly occur on a grand scale: Japanese stocks in the late 1980s, Internet and technology stocks in 1999 and 2000, subprime mortgage lending in 2006 and 2007, and alternative investments currently. It is always difficult to take a contrarian approach. Even highly capable investors can wither under the relentless message from the market that they are wrong. The pressures to succumb are enormous; many investment managers fear they’ll lose business if they stand too far apart from the crowd. Some also fail to pursue value because they’ve handcuffed themselves (or been saddled by clients) with constraints preventing them from buying stocks selling at low dollar prices, small-cap stocks, stocks of companies that don’t pay dividends or are losing money, or debt instruments with below investment-grade ratings.7 Many also engage in career manage- ment techniques like “window dressing” their portfolios at the end of cal- endar quarters or selling off losers (even if they are undervalued) while buying more of the winners (even if overvalued). Of course, for those value investors who are truly long term oriented, it is a wonderful thing that many potential competitors are thrown off course by constraints that render them unable or unwilling to effectively compete. Another reason that greater competition may not hinder today’s value investors is the broader and more diverse investment landscape in which they operate. Graham faced a limited lineup of publicly traded U.S. equity and debt securities. Today, there are many thousands of publicly traded stocks in the United States alone, and many tens of thousands worldwide, plus thousands of corporate bonds and asset-backed debt securities. Previously illiquid assets, such as bank loans, now trade regu- larly. Investors may also choose from an almost limitless number of derivative instruments, including customized contracts designed to meet any need or hunch. Nevertheless, 25 years of historically strong stock market perform- ance have left the market far from bargain-priced. High valuations and intensified competition raise the specter of lower returns for value investors generally. Also, some value investment firms have become extremely large, and size can be the enemy of investment performance because decision making is slowed by bureaucracy and smaller opportu- nities cease to move the needle. In addition, because growing numbers of competent buy-side and sell-side analysts are plying their trade with the assistance of sophisti- cated information technology, far fewer securities seem likely to fall through the cracks to become extremely undervalued.8 Today’s value investors are unlikely to find opportunity armed only with a Value Line guide or by thumbing through stock tables. While bargains still occasion- ally hide in plain sight, securities today are most likely to become mis- priced when they are either accidentally overlooked or deliberately avoided. Consequently, value investors have had to become thoughtful about where to focus their analysis. In the early 2000s, for example, investors became so disillusioned with the capital allocation procedures of many South Korean companies that few considered them candidates for worthwhile investment. As a result, the shares of numerous South Korean companies traded at great discounts from prevailing international valuations: at two or three times the cash flow, less than half the underly- ing business value, and, in several cases, less than the cash (net of debt) held on their balance sheets. Bargain issues, such as Posco and SK Tele- com, ultimately attracted many value seekers; Warren Buffett reportedly profited handsomely from a number of South Korean holdings. Today’s value investors also find opportunity in the stocks and bonds of companies stigmatized on Wall Street because of involvement in pro-tracted litigation, scandal, accounting fraud, or financial distress. The securities of such companies sometimes trade down to bargain levels, where they become good investments for those who are able to remain stalwart in the face of bad news. For example, the debt of Enron, per- haps the world’s most stigmatized company after an accounting scandal forced it into bankruptcy in 2001, traded as low as 10 cents on the dollar of claim; ultimate recoveries are expected to be six times that amount. Similarly, companies with tobacco or asbestos exposure have in recent years periodically come under severe selling pressure due to the uncer- tainties surrounding litigation and the resultant risk of corporate finan- cial distress. More generally, companies that disappoint or surprise investors with lower-than-expected results, sudden management changes, accounting problems, or ratings downgrades are more likely than consistently strong performers to be sources of opportunity. When bargains are scarce, value investors must be patient; compro- mising standards is a slippery slope to disaster. New opportunities will emerge, even if we don’t know when or where. In the absence of com- pelling opportunity, holding at least a portion of one’s portfolio in cash equivalents (for example, U.S. Treasury bills) awaiting future deployment will sometimes be the most sensible option. Recently, Warren Buffett stated that he has more cash to invest than he has good investments. As all value investors must do from time to time, Buffett is waiting patiently. Still, value investors are bottom-up analysts, good at assessing securi- ties one at a time based on the fundamentals. They don’t need the entire market to be bargain priced, just 20 or 25 unrelated securities—a num- ber sufficient for diversification of risk. Even in an expensive market, value investors must keep analyzing securities and assessing businesses, gaining knowledge and experience that will be useful in the future. Value investors, therefore, should not try to time the market or guess whether it will rise or fall in the near term. Rather, they should rely on a bottom-up approach, sifting the financial markets for bargains and then buying them, regardless of the level or recent direction of the market or economy. Only when they cannot find bargains should they default to holding cash. A Flexible Approach Because our nation’s founders could not foresee—and knew they could not foresee—technological, social, cultural, and economic changes that the future would bring, they wrote a flexible constitution that still guides us over two centuries later. Similarly, Benjamin Graham and David Dodd acknowledged that they could not anticipate the business, economic, technological, and competitive changes that would sweep through the investment world over the ensuing years. But they, too, wrote a flexible treatise that provides us with the tools to function in an investment landscape that was destined—and remains destined—to undergo pro- found and unpredictable change. For example, companies today sell products that Graham and Dodd could not have imagined. Indeed, there are companies and entire indus- tries that they could not have envisioned. Security Analysis offers no examples of how to value cellular phone carriers, software companies, satellite television providers, or Internet search engines. But the book provides the analytical tools to evaluate almost any company, to assess the value of its marketable securities, and to determine the existence of a margin of safety. Questions of solvency, liquidity, predictability, busi- ness strategy, and risk cut across businesses, nations, and time. Graham and Dodd did not specifically address how to value private businesses or how to determine the value of an entire company rather than the value of a fractional interest through ownership of its shares.9 9 They did consider the relative merits of corporate control enjoyed by a private business owner ver- sus the value of marketability for a listed stock (p. 372). But their analytical principles apply equally well to these different issues. Investors still need to ask, how stable is the enterprise, and what are its future prospects? What are its earnings and cash flow? What is the downside risk of owning it? What is its liquidation value? How capable and honest is its management? What would you pay for the stock of this company if it were public? What factors might cause the owner of this business to sell control at a bargain price? Similarly, the pair never addressed how to analyze the purchase of an office building or apartment complex. Real estate bargains come about for the same reasons as securities bargains—an urgent need for cash, inability to perform proper analysis, a bearish macro view, or investor disfavor or neglect. In a bad real estate climate, tighter lending standards can cause even healthy properties to sell at distressed prices. Graham and Dodd’s principles—such as the stability of cash flow, sufficiency of return, and analysis of downside risk—allow us to identify real estate investments with a margin of safety in any market environment. Even complex derivatives not imagined in an earlier era can be scruti- nized with the value investor’s eye. While traders today typically price put and call options via the Black-Scholes model, one can instead use value-investing precepts—upside potential, downside risk, and the likeli- hood that each of various possible scenarios will occur—to analyze these instruments. An inexpensive option may, in effect, have the favorable risk-return characteristics of a value investment—regardless of what the Black-Scholes model dictates. Institutional Investing Perhaps the most important change in the investment landscape over the past 75 years is the ascendancy of institutional investing. In the 1930s, individual investors dominated the stock market. Today, by contrast, most market activity is driven by institutional investors—large pools of pension, endowment, and aggregated individual capital. While the advent of these large, quasi-permanent capital pools might have resulted in the wide-scale adoption of a long-term value-oriented approach, in fact this has not occurred. Instead, institutional investing has evolved into a short-term performance derby, which makes it diffi- cult for institutional managers to take contrarian or long-term positions. Indeed, rather than standing apart from the crowd and possibly suffering disappointing short-term results that could cause clients to withdraw capital, institutional investors often prefer the safe haven of assured mediocre performance that can be achieved only by closely following the herd. Alternative investments—a catch-all category that includes venture capital, leveraged buyouts, private equity, and hedge funds—are the cur- rent institutional rage. No investment treatise written today could fail to comment on this development. Fueled by performance pressures and a growing expectation of low (and inadequate) returns from traditional equity and debt investments, institutional investors have sought high returns and diversification by allocating a growing portion of their endowments and pension funds to alternatives. Pioneering Portfolio Management, written in 2000 by David Swensen, the groundbreaking head of Yale’s Investment Office, makes a strong case for alternative investments. In it, Swensen points to the historically inefficient pricing of many asset classes,10 the historically high risk-adjusted returns of many alternative managers, and the limited 10 Many investors make the mistake of thinking about returns to asset classes as if they were perma- nent. Returns are not inherent to an asset class; they result from the fundamentals of the underlying businesses and the price paid by investors for the related securities. Capital flowing into an asset class can, reflexively, impair the ability of those investing in that asset class to continue to generate the anticipated, historically attractive returns. He highlights the importance of alternative manager selection by noting the large dispersion of returns achieved between top-quartile and third- quartile performers. A great many endowment managers have emulated Swensen, following him into a large commitment to alternative investments, almost certainly on worse terms and amidst a more competitive environment than when he entered the area. Graham and Dodd would be greatly concerned by the commitment of virtually all major university endowments to one type of alternative investment: venture capital. The authors of the margin-of-safety approach to investing would not find one in the entire venture capital universe.11 While there is often the prospect of substantial upside in ven- ture capital, there is also very high risk of failure. Even with the diversifi- cation provided by a venture fund, it is not clear how to analyze the underlying investments to determine whether the potential return justi- fies the risk. Venture capital investment would, therefore, have to be characterized as pure speculation, with no margin of safety whatsoever. Hedge funds—a burgeoning area of institutional interest with nearly $2 trillion of assets under management—are pools of capital that vary widely in their tactics but have a common fee structure that typically pays the manager 1% to 2% annually of assets under management and 20% (and sometimes more) of any profits generated. They had their start in the 1920s, when Ben Graham himself ran one of the first hedge funds. What would Graham and Dodd say about the hedge funds operating in today’s markets? They would likely disapprove of hedge funds that make investments based on macroeconomic assessments or that pursue 11 Nor would they find one in leveraged buyouts, through which businesses are purchased at lofty prices using mostly debt financing and a thin layer of equity capital. The only value-investing ration- ale for venture capital or leveraged buyouts might be if they were regarded as mispriced call options. Even so, it is not clear that these areas constitute good value. Such funds, by avoiding or even sell- ing undervalued securities to participate in one or another folly, inadver- tently create opportunities for value investors. The illiquidity, lack of transparency, gargantuan size, embedded leverage, and hefty fees of some hedge funds would no doubt raise red flags. But Graham and Dodd would probably approve of hedge funds that practice value-ori- ented investment selection. Importantly, while Graham and Dodd emphasized limiting risk on an investment-by-investment basis, they also believed that diversification and hedging could protect the downside for an entire portfolio. (p. 106) This is what most hedge funds attempt to do. While they hold individual securities that, considered alone, may involve an uncomfortable degree of risk, they attempt to offset the risks for the entire portfolio through the short sale of similar but more highly valued securities, through the purchase of put options on individual securities or market indexes, and through adequate diversification (although many are guilty of overdiver- sification, holding too little of their truly good ideas and too much of their mediocre ones). In this way, a hedge fund portfolio could (in theory, anyway) have characteristics of good potential return with limited risk that its individual components may not have. Modern-day Developments As mentioned, the analysis of businesses and securities has become increasingly sophisticated over the years. Spreadsheet technology, for example, allows for vastly more sophisticated modeling than was possible even one generation ago. Benjamin Graham’s pencil, clearly one of the sharpest of his era, might not be sharp enough today. On the other hand, technology can easily be misused; computer modeling requires making a series of assumptions about the future that can lead to a spurious preci- sion of which Graham would have been quite dubious. While Graham was interested in companies that produced consistent earnings, analysis in his day was less sophisticated regarding why some company’s earnings might be more consistent than others. Analysts today examine businesses but also business models; the bottom-line impact of changes in revenues, profit margins, product mix, and other variables is carefully studied by managements and financial analysts alike. Investors know that businesses do not exist in a vacuum; the actions of competitors, suppliers, and cus- tomers can greatly impact corporate profitability and must be considered.12 Another important change in focus over time is that while Graham looked at corporate earnings and dividend payments as barometers of a company’s health, most value investors today analyze free cash flow. This is the cash generated annually from the operations of a business after all capital expenditures are made and changes in working capital are con- sidered. Investors have increasingly turned to this metric because reported earnings can be an accounting fiction, masking the cash gener- ated by a business or implying positive cash generation when there is none. Today’s investors have rightly concluded that following the cash— as the manager of a business must do—is the most reliable and reveal- ing means of assessing a company. In addition, many value investors today consider balance sheet analy- sis less important than was generally thought a few generations ago. With returns on capital much higher at present than in the past, most stocks trade far above book value; balance sheet analysis is less helpful in understanding upside potential or downside risk of stocks priced at 12 Professor Michael Porter of Harvard Business School, in his seminal book Competitive Strategy (Free Press, 1980), lays out the groundwork for a more intensive, thorough, and dynamic analysis of busi- nesses and industries in the modern economy. A broad industry analysis has become particularly necessary as a result of the passage in 2000 of Regulation FD (Fair Disclosure), which regulates and restricts the communications between a company and its actual or potential shareholders. Wall Street analysts, facing a dearth of information from the companies they cover, have been forced to expand their areas of inquiry. The effects of sustained inflation over time have also wreaked havoc with the accuracy of assets accounted for using historic cost; this means that two companies owning identical assets could report very different book values. Of course, balance sheets must still be carefully scrutinized. Astute observers of corporate balance sheets are often the first to see business deterioration or vulnerability as inventories and receivables build, debt grows, and cash evaporates. And for investors in the equity and debt of underperforming companies, balance sheet analysis remains one generally reliable way of assessing downside protection. Globalization has increasingly affected the investment landscape, with most investors looking beyond their home countries for opportunity and diversification. Graham and Dodd’s principles fully apply to international markets, which are, if anything, even more subject to the vicissitudes of investor sentiment—and thus more inefficiently priced—than the U.S. market is today. Investors must be cognizant of the risks of international investing, including exposure to foreign currencies and the need to consider hedging them. Among the other risks are political instability, different (or absent) securities laws and investor protections, varying accounting standards, and limited availability of information. Oddly enough, despite 75 years of success achieved by value investors, one group of observers largely ignores or dismisses this disci- pline: academics. Academics tend to create elegant theories that purport to explain the real world but in fact oversimplify it. One such theory, the Efficient Market Hypothesis (EMH), holds that security prices always and immediately reflect all available information, an idea deeply at odds with Graham and Dodd’s notion that there is great value to fundamental security analysis. The Capital Asset Pricing Model (CAPM) relates risk to return but always mistakes volatility, or beta, for risk. Modern Portfolio Theory (MPT) applauds the benefits of diversification in constructing an optimal portfolio. But by insisting that higher expected return comes only with greater risk, MPT effectively repudiates the entire value-invest- ing philosophy and its long-term record of risk-adjusted investment out- performance. Value investors have no time for these theories and generally ignore them. The assumptions made by these theories—including continuous markets, perfect information, and low or no transaction costs—are unre- alistic. Academics, broadly speaking, are so entrenched in their theories that they cannot accept that value investing works. Instead of launching a series of studies to understand the remarkable 50-year investment record of Warren Buffett, academics instead explain him away as an aber- ration. Greater attention has been paid recently to behavioral economics, a field recognizing that individuals do not always act rationally and have systematic cognitive biases that contribute to market inefficiencies and security mispricings. These teachings—which would not seem alien to Graham—have not yet entered the academic mainstream, but they are building some momentum. Academics have espoused nuanced permutations of their flawed the- ories for several decades. Countless thousands of their students have been taught that security analysis is worthless, that risk is the same as volatility, and that investors must avoid overconcentration in good ideas (because in efficient markets there can be no good ideas) and thus diver- sify into mediocre or bad ones. Of course, for value investors, the propa- gation of these academic theories has been deeply gratifying: the brainwashing of generations of young investors produces the very ineffi- ciencies that savvy stock pickers can exploit. Another important factor for value investors to take into account is the growing propensity of the Federal Reserve to intervene in financial markets at the first sign of trouble. Amidst severe turbulence, the Fed frequently lowers interest rates to prop up securities prices and restore investor confidence. While the intention of Fed officials is to maintain orderly capital markets, some money managers view Fed intervention as a virtual license to speculate. Aggressive Fed tactics, sometimes referred to as the “Greenspan put” (now the “Bernanke put”), create a moral haz- ard that encourages speculation while prolonging overvaluation. So long as value investors aren’t lured into a false sense of security, so long as they can maintain a long-term horizon and ensure their staying power, market dislocations caused by Fed action (or investor anticipation of it) may ultimately be a source of opportunity. Another modern development of relevance is the ubiquitous cable television coverage of the stock market. This frenetic lunacy exacerbates the already short-term orientation of most investors. It foments the view that it is possible—or even necessary—to have an opinion on everything pertinent to the financial markets, as opposed to the patient and highly selective approach endorsed by Graham and Dodd. This sound-bite cul- ture reinforces the popular impression that investing is easy, not rigorous and painstaking. The daily cheerleading pundits exult at rallies and record highs and commiserate over market reversals; viewers get the impression that up is the only rational market direction and that selling or sitting on the sidelines is almost unpatriotic. The hysterical tenor is exacerbated at every turn. For example, CNBC frequently uses a format- ted screen that constantly updates the level of the major market indexes against a digital clock. Not only is the time displayed in hours, minutes, and seconds but in completely useless hundredths of seconds, the num- bers flashing by so rapidly (like tenths of a cent on the gas pump) as to be completely unreadable. The only conceivable purpose is to grab the viewers’ attention and ratchet their adrenaline to full throttle. Cable business channels bring the herdlike mentality of the crowd into everyone’s living room, thus making it much harder for viewers to stand apart from the masses. Only on financial cable TV would a commentator with a crazed persona become a celebrity whose pronouncements regularly move markets. In a world in which the differences between investing and speculating are frequently blurred, the nonsense on financial cable channels only compounds the problem. Graham would have been appalled. The only saving grace is that value investors prosper at the expense of those who fall under the spell of the cable pundits. Meanwhile, human nature virtually ensures that there will never be a Graham and Dodd channel. Unanswered Questions Today’s investors still wrestle, as Graham and Dodd did in their day, with a number of important investment questions. One is whether to focus on relative or absolute value. Relative value involves the assessment that one security is cheaper than another, that Microsoft is a better bargain than IBM. Relative value is easier to determine than absolute value, the two-dimensional assessment of whether a security is cheaper than other securities and cheap enough to be worth purchasing. The most intrepid investors in relative value manage hedge funds where they purchase the relatively less expensive securities and sell short the relatively more expensive ones. This enables them potentially to profit on both sides of the ledger, long and short. Of course, it also exposes them to double- barreled losses if they are wrong.13 It is harder to think about absolute value than relative value. When is a stock cheap enough to buy and hold without a short sale as a hedge? One standard is to buy when a security trades at an appreciable—say, 30%, 40%, or greater—discount from its underlying value, calculated either as its liquidation value, going-concern value, or private-market 13 Many hedge funds also use significant leverage to goose their returns further, which backfires when analysis is faulty or judgment is flawed. Another standard is to invest when a security offers an acceptably attractive return to a long-term holder, such as a low-risk bond priced to yield 10% or more, or a stock with an 8% to 10% or higher free cash flow yield at a time when “risk-free” U.S. government bonds deliver 4% to 5% nominal and 2% to 3% real returns. Such demanding standards virtually ensure that absolute value will be quite scarce. Another area where investors struggle is trying to define what consti- tutes a good business. Someone once defined the best possible business as a post office box to which people send money. That idea has certainly been eclipsed by the creation of subscription Web sites that accept credit cards. Today’s most profitable businesses are those in which you sell a fixed amount of work product—say, a piece of software or a hit recording—millions and millions of times at very low marginal cost. Good businesses are generally considered those with strong barriers to entry, limited capital requirements, reliable customers, low risk of tech- nological obsolescence, abundant growth possibilities, and thus signifi- cant and growing free cash flow. Businesses are also subject to changes in the technological and com- petitive landscape. Because of the Internet, the competitive moat sur- rounding the newspaper business—which was considered a very good business only a decade ago—has eroded faster than almost anyone anticipated. In an era of rapid technological change, investors must be ever vigilant, even with regard to companies that are not involved in technology but are simply affected by it. In short, today’s good busi- nesses may not be tomorrow’s. Investors also expend considerable effort attempting to assess the quality of a company’s management. Some managers are more capable or scrupulous than others, and some may be able to manage certain businesses and environments better than others. Yet, as Graham and Dodd noted, “Objective tests of managerial ability are few and far from scientific.” (p. 84) Make no mistake about it: a management’s acumen, foresight, integrity, and motivation all make a huge difference in share- holder returns. In the present era of aggressive corporate financial engi- neering, managers have many levers at their disposal to positively impact returns, including share repurchases, prudent use of leverage, and a valuation-based approach to acquisitions. Managers who are unwilling to make shareholder-friendly decisions risk their companies becoming perceived as “value traps”: inexpensively valued, but ulti- mately poor investments, because the assets are underutilized. Such companies often attract activist investors seeking to unlock this trapped value. Even more difficult, investors must decide whether to take the risk of investing—at any price—with management teams that have not always done right by shareholders. Shares of such companies may sell at steeply discounted levels, but perhaps the discount is warranted; value that today belongs to the equity holders may tomorrow have been spir- ited away or squandered. An age-old difficulty for investors is ascertaining the value of future growth. In the preface to the first edition of Security Analysis, the authors said as much: “Some matters of vital significance, e.g., the determination of the future prospects of an enterprise, have received little space, because little of definite value can be said on the subject.” (p. xliii) Clearly, a company that will earn (or have free cash flow of) $1 per share today and $2 per share in five years is worth considerably more than a company with identical current per share earnings and no growth. This is especially true if the growth of the first company is likely to continue and is not subject to great variability. Another complication is that companies can grow in many different ways—for example, selling the same number of units at higher prices; selling more units at the same (or even lower) prices; changing the product mix (selling proportionately more of the higher-profit-margin products); or developing an entirely new product line. Obviously, some forms of growth are worth more than others. There is a significant downside to paying up for growth or, worse, to obsessing over it. Graham and Dodd astutely observed that “analysis is concerned primarily with values which are supported by the facts and not with those which depend largely upon expectations.” (p. 86) Strongly preferring the actual to the possible, they regarded the “future as a haz- ard which his [the analyst’s] conclusions must encounter rather than as the source of his vindication.” (p. 86) Investors should be especially vigi- lant against focusing on growth to the exclusion of all else, including the risk of overpaying. Again, Graham and Dodd were spot on, warning that “carried to its logical extreme, . . . [there is no price] too high for a good stock, and that such an issue was equally ‘safe’ after it had advanced to 200 as it had been at 25.” (p. 105) Precisely this mistake was made when stock prices surged skyward during the Nifty Fifty era of the early 1970s and the dot-com bubble of 1999 to 2000. The flaw in such a growth-at-any-price approach becomes obvious when the anticipated growth fails to materialize. When the future disap- points, what should investors do? Hope growth resumes? Or give up and sell? Indeed, failed growth stocks are often so aggressively dumped by disappointed holders that their price falls to levels at which value investors, who stubbornly pay little or nothing for growth characteristics, become major holders. This was the case with many technology stocks that suffered huge declines after the dot-com bubble burst in the spring of 2000. By 2002, hundreds of fallen tech stocks traded for less than the cash on their balance sheets, a value investor’s dream. One such com- pany was Radvision, an Israeli provider of voice, video, and data products whose stock subsequently rose from under $5 to the mid-$20s after the urgent selling abated and investors refocused on fundamentals. Another conundrum for value investors is knowing when to sell. Buy- ing bargains is the sweet spot of value investors, although how small a discount one might accept can be subject to debate. Selling is more dif- ficult because it involves securities that are closer to fully priced. As with buying, investors need a discipline for selling. First, sell targets, once set, should be regularly adjusted to reflect all currently available information. Second, individual investors must consider tax consequences. Third, whether or not an investor is fully invested may influence the urgency of raising cash from a stockholding as it approaches full valuation. The availability of better bargains might also make one a more eager seller. Finally, value investors should completely exit a security by the time it reaches full value; owning overvalued securities is the realm of specula- tors. Value investors typically begin selling at a 10% to 20% discount to their assessment of underlying value—based on the liquidity of the security, the possible presence of a catalyst for value realization, the quality of management, the riskiness and leverage of the underlying business, and the investors’ confidence level regarding the assumptions underlying the investment. Finally, investors need to deal with the complex subject of risk. As mentioned earlier, academics and many professional investors have come to define risk in terms of the Greek letter beta, which they use as a measure of past share price volatility: a historically more volatile stock is seen as riskier. But value investors, who are inclined to think about risk as the probability and amount of potential loss, find such reasoning absurd. In fact, a volatile stock may become deeply undervalued, rendering it a very low risk investment. One of the most difficult questions for value investors is how much risk to incur. One facet of this question involves position size and its impact on portfolio diversification. How much can you comfortably own of even the most attractive opportunities? Naturally, investors desire to profit fully from their good ideas. Yet this tendency is tempered by the fear of being unlucky or wrong. Nonetheless, value investors should concentrate their holdings in their best ideas; if you can tell a good investment from a bad one, you can also distinguish a great one from a good one. Investors must also ponder the risks of investing in politically unsta- ble countries, as well as the uncertainties involving currency, interest rate, and economic fluctuations. How much of your capital do you want tied up in Argentina or Thailand, or even France or Australia, no matter how undervalued the stocks may be in those markets? Another risk consideration for value investors, as with all investors, is whether or not to use leverage. While some value-oriented hedge funds and even endowments use leverage to enhance their returns, I side with those who are unwilling to incur the added risks that come with margin debt. Just as leverage enhances the return of successful investments, it magnifies the losses from unsuccessful ones. More importantly, nonre- course (margin) debt raises risk to unacceptable levels because it places one’s staying power in jeopardy. One risk-related consideration should be paramount above all others: the ability to sleep well at night, confi- dent that your financial position is secure whatever the future may bring. Final Thoughts In a rising market, everyone makes money and a value philosophy is unnecessary. But because there is no certain way to predict what the market will do, one must follow a value philosophy at all times. By con- trolling risk and limiting loss through extensive fundamental analysis, strict discipline, and endless patience, value investors can expect good results with limited downside. You may not get rich quick, but you will keep what you have, and if the future of value investing resembles its past, you are likely to get rich slowly. As investment strategies go, this is the most that any reasonable investor can hope for. The real secret to investing is that there is no secret to investing. Every important aspect of value investing has been made available to the public many times over, beginning in 1934 with the first edition of Security Analysis. That so many people fail to follow this timeless and almost foolproof approach enables those who adopt it to remain suc- cessful. The foibles of human nature that result in the mass pursuit of instant wealth and effortless gain seem certain to be with us forever. So long as people succumb to this aspect of their natures, value investing will remain, as it has been for 75 years, a sound and low-risk approach to successful long-term investing. SETH A. KLARMAN Boston, Massachusetts, May, 2008 Introduction to the Sixth Edition It was a distracted world before which McGraw-Hill set, with a thud, the first edition of Security Analysis in July 1934. From Berlin dribbled reports of a shake-up at the top of the German government. “It will simplify the Führer’s whole work immensely if he need not first ask some- body if he may do this or that,” the Associated Press quoted an informant on August 1 as saying of Hitler’s ascension from chancellor to dictator. Set against such epochal proceedings, a 727-page textbook on the fine points of value investing must have seemed an unlikely candidate for bestsellerdom, then or later. In his posthumously published autobiography, The Memoirs of the Dean of Wall Street, Graham (1894–1976) thanked his lucky stars that he had entered the investment business when he did. The timing seemed not so propitious in the year of the first edition of Security Analysis, or, indeed, that of the second edition—expanded and revised—six years later. From its 1929 peak to its 1932 trough, the Dow Jones Industrial Average had lost 87% of its value. At cyclical low ebb, in 1933, the national unemployment rate topped 25%. That the Great Depression ended in 1933 was the considered judgment of the timekeepers of the National Bureau of Economic Research. Millions of Americans, however— not least, the relatively few who tried to squeeze a living out of a profit- less Wall Street—had reason to doubt it. The bear market and credit liquidation of the early 1930s gave the institutions of American finance a top-to-bottom scouring. What was left of them presently came in for a rough handling by the first Roosevelt administration. Graham had learned his trade in the Wall Street of the mid–nineteen teens, an era of lightly regulated markets. He began work on Security Analysis as the administration of Herbert Hoover was giving the country its first taste of thoroughgoing federal intervention in a peacetime economy. He was correcting page proofs as the Roosevelt administration was implementing its first radical forays into macroeco- nomic management. By 1934, there were laws to institute federal regula- tion of the securities markets, federal insurance of bank deposits, and federal price controls (not to put a cap on prices, as in later, inflationary times, but rather to put a floor under them). To try to prop up prices, the administration devalued the dollar. It is a testament to the enduring quality of Graham’s thought, not to mention the resiliency of America’s financial markets, that Security Analysis lost none of its relevance even as the economy was being turned upside down and inside out. Five full months elapsed following publication of the first edition before Louis Rich got around to reviewing it in the New York Times. Who knows? Maybe the conscientious critic read every page. In any case, Rich gave the book a rave, albeit a slightly rueful one. “On the assumption,” he wrote, on December 2, 1934, “that despite the debacle of recent history there are still people left whose money burns a hole in their pockets, it is hoped that they will read this book. It is a full-bodied, mature, meticu- lous and wholly meritorious outgrowth of scholarly probing and practi- cal sagacity. Although cast in the form and spirit of a textbook, the presentation is endowed with all the qualities likely to engage the liveli- est interest of the layman.”1 How few laymen seemed to care about investing was brought home to Wall Street more forcefully with every passing year of the unprosperous postcrash era. Just when it seemed that trading volume could get no smaller, or New York Stock Exchange seat prices no lower, or equity valu- ations more absurdly cheap, a new, dispiriting record was set. It required every effort of the editors of the Big Board’s house organ, the Exchange magazine, to keep up a brave face. “Must There Be an End to Progress?” was the inquiring headline over an essay by the Swedish economist Gus- tav Cassel published around the time of the release of Graham and Dodd’s second edition (the professor thought not).2 “Why Do Securities Brokers Stay in Business?” the editors posed and helpfully answered, “Despite wearying lethargy over long periods, confidence abounds that when the public recognizes fully the value of protective measures which lately have been ranged about market procedure, investment interest in securities will increase.” It did not amuse the Exchange that a New York City magistrate, sarcastically addressing in his court a collection of defen- dants hauled in by the police for shooting craps on the sidewalk, had derided the financial profession. “The first thing you know,” the judge had upbraided the suspects, “you’ll wind up as stock brokers in Wall Street with yachts and country homes on Long Island.”3 In ways now difficult to imagine, Murphy’s Law was the order of the day; what could go wrong, did. “Depression” was more than a long-lin- gering state of economic affairs. It had become a worldview. The aca- demic exponents of “secular stagnation,” notably Alvin Hansen and Joseph Schumpeter, each a Harvard economics professor, predicted a long decline in American population growth. This deceleration, Hansen contended in his 1939 essay, “together with the failure of any really important innovations of a magnitude to absorb large capital outlays, weighs very heavily as an explanation for the failure of the recent recov- ery to reach full employment.”4 Neither Hansen nor his readers had any way of knowing that a baby boom was around the corner. Nothing could have seemed more unlikely to a world preoccupied with a new war in Europe and the evident decline and fall of capitalism. Certainly, Hansen’s ideas must have struck a chord with the chronically underemployed brokers and traders in lower Manhat- tan. As a business, the New York Stock Exchange was running at a steady loss. From 1933, the year in which it began to report its financial results, through 1940, the Big Board recorded a profit in only one year, 1935 (and a nominal one, at that). And when, in 1937, Chelcie C. Bosland, an assis- tant professor of economics at Brown University, brought forth a book entitled The Common Stock Theory of Investment, he remarked as if he were repeating a commonplace that the American economy had peaked two decades earlier at about the time of what was not yet called World War I. The professor added, quoting unnamed authorities, that American population growth could be expected to stop in its tracks by 1975.5 Small wonder that Graham was to write that the acid test of a bond issuer was its capacity to meet its obligations not in a time of middling prosperity (which modest test today’s residential mortgage–backed securities strug- gle to meet) but in a depression. Altogether, an investor in those days was well advised to keep up his guard. “The combination of a record high level for bonds,” writes Graham in the 1940 edition, “with a history of two catastrophic price collapses in the preceding 20 years and a major war in progress is not one to justify airy confidence in the future.” (p. 142) Wall Street, not such a big place even during the 1920s’ boom, got considerably smaller in the subsequent bust. Ben Graham, in conjunction with his partner Jerry Newman, made a very small cog of this low-horse- power machine. The two of them conducted a specialty investment busi- ness at 52 Wall Street. Their strong suits were arbitrage, reorganizations, bankruptcies, and other complex matters. A schematic drawing of the financial district published by Fortune in 1937 made no reference to the Graham-Newman offices. Then again, the partnerships and corporate headquarters that did rate a spot on the Wall Street map were them- selves—by the standards of twenty-first-century finance—remarkably compact. One floor at 40 Wall Street was enough to contain the entire office of Merrill Lynch & Co. And a single floor at 2 Wall Street was all the space required to house Morgan Stanley, the hands-down leader in 1936 corporate securities underwriting, with originations of all of $195 million. Compensation was in keeping with the slow pace of business, especially at the bottom of the corporate ladder.6 After a 20% rise in the new fed- eral minimum wage, effective October 1939, brokerage employees could earn no less than 30 cents an hour.7 In March 1940, the Exchange documented in all the detail its readers could want (and possibly then some) the collapse of public participation in the stock market. In the first three decades of the twentieth century, the annual volume of trading had almost invariably exceeded the quantity of listed shares outstanding, sometimes by a wide margin. And in only one year between 1900 and 1930 had annual volume amounted to less than 50% of listed shares—the exception being 1914, the year in which the exchange was closed for 41/2 months to allow for the shock of the out- break of World War I to sink in. Then came the 1930s, and the annual turnover as a percentage of listed shares struggled to reach as high as 50%. In 1939, despite a short-lived surge of trading on the outbreak of World War II in Europe, the turnover ratio had fallen to a shockingly low 18.4%. (For comparison, in 2007, the ratio of trading volume to listed shares amounted to 123%.) “Perhaps,” sighed the author of the study, “it is a fair statement that if the farming industry showed a similar record, government subsidies would have been voted long ago. Unfortunately for Wall Street, it seems to have too little sponsorship in officialdom.”8 If a reader took hope from the idea that things were so bad that they could hardly get worse, he or she was in for yet another disappointment. The second edition of Security Analysis had been published only months earlier when, on August 19, 1940, the stock exchange volume totaled just 129,650 shares. It was one of the sleepiest sessions since the 49,000- share mark set on August 5, 1916. For the entire 1940 calendar year, vol- ume totaled 207,599,749 shares—a not very busy two hours’ turnover at this writing and 18.5% of the turnover of 1929, that year of seemingly irrecoverable prosperity. The cost of a membership, or seat, on the stock exchange sank along with turnover and with the major price indexes. At the nadir in 1942, a seat fetched just $17,000. It was the lowest price since 1897 and 97% below the record high price of $625,000, set—natu- rally—in 1929. “‘The Cleaners,’” quipped Fred Schwed, Jr., in his funny and wise book Where Are the Customers’ Yachts? (which, like Graham’s second edition, appeared in 1940), “was not one of those exclusive clubs; by 1932, every- body who had ever tried speculation had been admitted to membership.”9 And if an investor did, somehow, manage to avoid the cleaner’s during the formally designated Great Depression, he or she was by no means home free. In August 1937, the market began a violent sell-off that would carry the averages down by 50% by March 1938. The nonfinancial portion of the economy fared little better than the financial side. In just nine months, industrial production fell by 34.5%, a sharper contraction even than that in the depression of 1920 to 1921, a slump that, for Graham’s generation, had seemed to set the standard for the most economic damage in the shortest elapsed time.10 The Roosevelt administration insisted that the slump of 1937 to 1938 was no depression but rather a “recession.” The national unemployment rate in 1938 was, on average, 18.8%. In April 1937, four months before the bottom fell out of the stock mar- ket for the second time in 10 years, Robert Lovett, a partner at the invest- ment firm of Brown Brothers Harriman & Co., served warning to the American public in the pages of the weekly Saturday Evening Post. Lovett, a member of the innermost circle of the Wall Street establishment, set out to demonstrate that there is no such thing as financial security—none, at least, to be had in stocks and bonds. The gist of Lovett’s argument was that, in capitalism, capital is consumed and that businesses are just as fragile, and mortal, as the people who own them. He invited his millions of readers to examine the record, as he had done: “If an investor had pur- chased 100 shares of the 20 most popular dividend-paying stocks on December 31, 1901, and held them through 1936, adding, in the mean- time, all the melons in the form of stock dividends, and all the plums in the form of stock split-ups, and had exercised all the valuable rights to subscribe to additional stock, the aggregate market value of his total holdings on December 31, 1936, would have shown a shrinkage of 39% as compared with the cost of his original investment. In plain English, the average investor paid $294,911.90 for things worth $180,072.06 on December 31, 1936. That’s a big disappearance of dollar value in any lan- guage.” In the innocent days before the crash, people had blithely spoken of “permanent investments.” “For our part,” wrote this partner of an emi- nent Wall Street private bank, “we are convinced that the only permanent investment is one which has become a total and irretrievable loss.”11 Lovett turned out to be a prophet. At the nadir of the 1937 to 1938 bear market, one in five NYSE-listed industrial companies was valued in the market for less than its net current assets. Subtract from cash and quick assets all liabilities and the remainder was greater than the company’s market value. That is, business value was negative. The Great Atlantic & Pacific Tea Company (A&P), the Wal-Mart of its day, was one of these corporate castoffs. At the 1938 lows, the market value of the com- mon and preferred shares of A&P at $126 million was less than the value of its cash, inventories, and receivables, conservatively valued at $134 million. In the words of Graham and Dodd, the still-profitable company was selling for “scrap.” (p. 673) A Different Wall Street Few institutional traces of that Wall Street remain. Nowadays, the big broker-dealers keep as much as $1 trillion in securities in inventory; in Graham’s day, they customarily held none. Nowadays, the big broker- dealers are in a perpetual competitive lather to see which can bring the greatest number of initial public offerings (IPOs) to the public market. In Graham’s day, no frontline member firm would stoop to placing an IPO in public hands, the risks and rewards for this kind of offering being reserved for professionals. Federal securities regulation was a new thing in the 1930s. What had preceded the Securities and Exchange Commis- sion (SEC) was a regime of tribal sanction. Some things were simply beyond the pale. Both during and immediately after World War I, no self- respecting NYSE member firm facilitated a client’s switch from Liberty bonds into potentially more lucrative, if less patriotic, alternatives. There was no law against such a business development overture. Rather, according to Graham, it just wasn’t done. A great many things weren’t done in the Wall Street of the 1930s. Newly empowered regulators were resistant to financial innovation, trans- action costs were high, technology was (at least by today’s digital stan- dards) primitive, and investors were demoralized. After the vicious bear market of 1937 to 1938, not a few decided they’d had enough. What was the point of it all? “In June 1939,” writes Graham in a note to a discussion about corporate finance in the second edition, “the S.E.C. set a salutary precedent by refusing to authorize the issuance of ‘Capital Income Debentures’ in the reorganization of the Griess-Pfleger Tanning Company, on the ground that the devising of new types of hybrid issues had gone far enough.” (p. 115, fn. 4) In the same conservative vein, he expresses his approval of the institution of the “legal list,” a document compiled by state banking departments to stipulate which bonds the regulated sav- ings banks could safely own. The very idea of such a list flies in the face of nearly every millennial notion about good regulatory practice. But Gra- ham defends it thus: “Since the selection of high-grade bonds has been shown to be in good part a process of exclusion, it lends itself reasonably well to the application of definite rules and standards designed to dis- qualify unsuitable issues.” (p. 169) No collateralized debt obligations stocked with subprime mortgages for the father of value investing! The 1930s ushered in a revolution in financial disclosure. The new federal securities acts directed investor-owned companies to brief their stockholders once a quarter as well as at year-end. But the new stan- dards were not immediately applicable to all public companies, and more than a few continued doing business the old-fashioned way, with their cards to their chests. One of these informational holdouts was none other than Dun & Bradstreet (D&B), the financial information company. Graham seemed to relish the irony of D&B not revealing “its own earn- ings to its own stockholders.” (p. 92, fn. 4) On the whole, by twenty-first- century standards, information in Graham’s time was as slow moving as it was sparse. There were no conference calls, no automated spread- sheets, and no nonstop news from distant markets—indeed, not much truck with the world outside the 48 states. Security Analysis barely acknowledges the existence of foreign markets. Such an institutional setting was hardly conducive to the develop- ment of “efficient markets,” as the economists today call them—markets in which information is disseminated rapidly, human beings process it flawlessly, and prices incorporate it instantaneously. Graham would have scoffed at such an idea. Equally, he would have smiled at the discovery— so late in the evolution of the human species—that there was a place in economics for a subdiscipline called “behavioral finance.” Reading Security Analysis, one is led to wonder what facet of investing is not behavioral. The stock market, Graham saw, is a source of entertainment value as well as investment value: “Even when the underlying motive of purchase is mere speculative greed, human nature desires to conceal this unlovely impulse behind a screen of apparent logic and good sense. To adapt the aphorism of Voltaire, it may be said that if there were no such thing as common-stock analysis, it would be necessary to counterfeit it.” (p. 348) Anomalies of undervaluation and overvaluation—of underdoing it and overdoing it—fill these pages. It bemused Graham, but did not shock him, that so many businesses could be valued in the stock market for less than their net current assets, even during the late 1920s’ boom, or that, in the dislocations to the bond market immediately following World War I, investors became disoriented enough to assign a higher price and a lower yield to the Union Pacific First Mortgage 4s than they did to the U.S. Treasury’s own Fourth Liberty 41⁄4s. Graham writes of the “inveterate tendency of the stock market to exaggerate.” (p. 679) He would not have exaggerated much if he had written, instead, “all markets.” Though he did not dwell long on the cycles in finance, Graham was certainly aware of them. He could see that ideas, no less than prices and categories of investment assets, had their seasons. The discussion in Security Analysis of the flame-out of the mortgage guarantee business in the early 1930s is a perfect miniature of the often-ruinous competition in which financial institutions periodically engage. “The rise of the newer and more aggressive real estate bond organizations had a most unfortu- nate effect upon the policies of the older concerns,” Graham writes of his time and also of ours. “By force of competition they were led to relax their standards of making loans. New mortgages were granted on an increasingly liberal basis, and when old mortgages matured, they were frequently renewed in a larger sum. Furthermore, the face amount of the mortgages guaranteed rose to so high a multiple of the capital of the guarantor companies that it should have been obvious that the guaranty would afford only the flimsiest of protection in the event of a general decline in values.” (p. 217) Security analysis itself is a cyclical phenomenon; it, too, goes in and out of fashion, Graham observed. It holds a strong, intuitive appeal for the kind of businessperson who thinks about stocks the way he or she thinks about his or her own family business. What would such a fount of com- mon sense care about earnings momentum or Wall Street’s pseudo-scien- tific guesses about the economic future? Such an investor, appraising a common stock, would much rather know what the company behind it is worth. That is, he or she would want to study its balance sheet. Well, Gra- ham relates here, that kind of analysis went out of style when stocks started levitating without reference to anything except hope and prophecy. So, by about 1927, fortune-telling and chart-reading had dis- placed the value discipline by which he and his partner were earning a very good living. It is characteristic of Graham that his critique of the “new era” method of investing is measured and not derisory. The old, conserva- tive approach—his own—had been rather backward looking, Graham admits. It had laid more emphasis on the past than on the future, on sta- ble earning power rather than tomorrow’s earnings prospects. But new technologies, new methods, and new forms of corporate organization had introduced new risks into the post–World War I economy. This fact— “the increasing instability of the typical business”—had blown a small hole in the older analytical approach that emphasized stable earnings power over forecast earnings growth. Beyond that mitigating considera- tion, however, Graham does not go. The new era approach, “which turned upon the earnings trend as the sole criterion of value, . . . was certain to end in an appalling debacle.” (p. 366) Which, of course, it did, and—in the CNBC-driven markets of the twenty-first century—continues to do at intervals today. A Man of Many Talents Benjamin Graham was born Benjamin Grossbaum on May 9, 1894, in London, and sailed to New York with his family before he was two. Young Benjamin was a prodigy in mathematics, classical languages, modern languages, expository writing (as readers of this volume will see for themselves), and anything else that the public schools had to offer. He had a tenacious memory and a love of reading—a certain ticket to aca- demic success, then or later. His father’s death at the age of 35 left him, his two brothers, and their mother in the social and financial lurch. Ben- jamin early learned to work and to do without. No need here for a biographical profile of the principal author of Security Analysis: Graham’s own memoir delightfully covers that ground. Suffice it to say that the high school brainiac entered Columbia College as an Alumni Scholar in September 1911 at the age of 17. So much material had he already absorbed that he began with a semester’s head start, “the highest possible advanced standing.”12 He mixed his academic studies with a grab bag of jobs, part-time and full-time alike. Upon his graduation in 1914, he started work as a runner and board-boy at the New York Stock Exchange member firm of Newberger, Henderson & Loeb. Within a year, the board-boy was playing the liquidation of the Guggenheim Exploration Company by astutely going long the shares of Guggenheim and short the stocks of the companies in which Guggen- heim had made a minority investment, as his no-doubt bemused elders looked on: “The profit was realized exactly as calculated; and everyone was happy, not least myself.”13 Security Analysis did not come out of the blue. Graham had supple- mented his modest salary by contributing articles to the Magazine of Wall Street. His productions are unmistakably those of a self-assured and superbly educated Wall Street moneymaker. There was no need to quote expert opinion. He and the documents he interpreted were all the authority he needed. His favorite topics were the ones that he subse- quently developed in the book you hold in your hands. He was partial to the special situations in which Graham-Newman was to become so suc- cessful. Thus, when a high-flying, and highly complex, American Interna- tional Corp. fell from the sky in 1920, Graham was able to show that the stock was cheap in relation to the evident value of its portfolio of miscel- laneous (and not especially well disclosed) investment assets.14 The shocking insolvency of Goodyear Tire and Rubber attracted his attention in 1921. “The downfall of Goodyear is a remarkable incident even in the present plenitude of business disasters,” he wrote, in a characteristic Gra- ham sentence (how many financial journalists, then or later, had “pleni- tude” on the tips of their tongues?). He shrewdly judged that Goodyear would be a survivor.15 In the summer of 1924, he hit on a theme that would echo through Security Analysis: it was the evident non sequitor of stocks valued in the market at less than the liquidating value of the com- panies that issued them. “Eight Stock Bargains Off the Beaten Track,” said the headline over the Benjamin Graham byline: “Stocks that Are Covered Chiefly by Cash or the Equivalent—No Bonds or Preferred Stock Ahead of These Issues—An Unusually Interesting Group of Securities.” In one case, that of Tonopah Mining, liquid assets of $4.31 per share towered over a market price of just $1.38 a share.16 For Graham, an era of sweet reasonableness in investment thinking seemed to end around 1914. Before that time, the typical investor was a businessman who analyzed a stock or a bond much as he might a claim on a private business. He—it was usually a he—would naturally try to determine what the security-issuing company owned, free and clear of any encumbrances. If the prospective investment was a bond—and it usually was—the businessman-investor would seek assurances that the borrowing company had the financial strength to weather a depression. “It’s not undue modesty,” Graham wrote in his memoir, “to say that I had become something of a smart cookie in my particular field.” His spe- cialty was the carefully analyzed out-of-the-way investment: castaway stocks or bonds, liquidations, bankruptcies, arbitrage. Since at least the early 1920s, Graham had preached the sermon of the “margin of safety.” As the future is a closed book, he urged in his writings, an investor, as a matter of self-defense against the unknown, should contrive to pay less than “intrinsic” value. Intrinsic value, as defined in Security Analysis, is “that value which is justified by the facts, e.g., the assets, earnings, divi- dends, definite prospects, as distinct, let us say, from market quotations established by artificial manipulation or distorted by psychological excesses.” (p. 64) He himself had gone from the ridiculous to the sublime (and some- times back again) in the conduct of his own investment career. His quick and easy grasp of mathematics made him a natural arbitrageur. He would sell one stock and simultaneously buy another. Or he would buy or sell shares of stock against the convertible bonds of the identical issu- ing company. So doing, he would lock in a profit that, if not certain, was as close to guaranteed as the vicissitudes of finance allowed. In one instance, in the early 1920s, he exploited an inefficiency in the relation- ship between DuPont and the then red-hot General Motors (GM). DuPont held a sizable stake in GM. And it was for that interest alone which the market valued the big chemical company. By implication, the rest of the business was worth nothing. To exploit this anomaly, Graham bought shares in DuPont and sold short the hedge-appropriate number of shares in GM. And when the market came to its senses, and the price gap between DuPont and GM widened in the expected direction, Gra- ham took his profit.17 However, Graham, like many another value investors after him, some- times veered from the austere precepts of safe-and-cheap investing. A Graham only slightly younger than the master who sold GM and bought DuPont allowed himself to be hoodwinked by a crooked promoter of a company that seems not actually to have existed—at least, in anything like the state of glowing prosperity described by the manager of the pool to which Graham entrusted his money. An electric sign in Colum- bus Circle, on the upper West Side of Manhattan, did bear the name of the object of Graham’s misplaced confidence, Savold Tire. But, as the author of Security Analysis confessed in his memoir, that could have been the only tangible marker of the company’s existence. “Also, as far as I knew,” Graham added, “nobody complained to the district attorney’s office about the promoter’s bare-faced theft of the public’s money.” Cer- tainly, by his own telling, Graham didn’t.18 By 1929, when he was 35, Graham was well on his way to fame and fortune. His wife and he kept a squadron of servants, including—for the first and only time in his life—a manservant for himself. With JerryNewman, Graham had compiled an investment record so enviable that the great Bernard M. Baruch sought him out. Would Graham wind up his busi- ness to manage Baruch’s money? “I replied,” Graham writes, “that I was highly flattered—flabbergasted, in fact—by his proposal, but I could not end so abruptly the close and highly satisfactory relations I had with my friends and clients.”19 Those relations soon became much less satisfactory. Graham relates that, though he was worried at the top of the market, he failed to act on his bearish hunch. The Graham-Newman partnership went into the 1929 break with $2.5 million of capital. And they con- trolled about $2.5 million in hedged positions—stocks owned long offset by stocks sold short. They had, besides, about $4.5 million in outright long positions. It was bad enough that they were leveraged, as Graham later came to realize. Compounding that tactical error was a deeply rooted conviction that the stocks they owned were cheap enough to withstand any imaginable blow. They came through the crash creditably: down by only 20% was, for the final quarter of 1929, almost heroic. But they gave up 50% in 1930, 16% in 1931, and 3% in 1932 (another relatively excellent showing), for a cumulative loss of 70%.20 “I blamed myself not so much for my failure to protect myself against the disaster I had been predicting,” Graham writes, “as for having slipped into an extravagant way of life which I hadn’t the temperament or capacity to enjoy. I quickly convinced myself that the true key to material happiness lay in a modest standard of living which could be achieved with little difficulty under almost all economic condi- tions”—the margin-of-safety idea applied to personal finance.21 It can’t be said that the academic world immediately clasped Security Analysis to its breast as the definitive elucidation of value investing, or of anything else. The aforementioned survey of the field in which Graham and Dodd made their signal contribution, The Common Stock Theory of Investment, by Chelcie C. Bosland, published three years after the appear- ance of the first edition of Security Analysis, cited 53 different sources and 43 different authors. Not one of them was named Graham or Dodd. Edgar Lawrence Smith, however, did receive Bosland’s full and respectful attention. Smith’s Common Stocks as Long Term Investments, published in 1924, had challenged the long-held view that bonds were innately superior to equities. For one thing, Smith argued, the dollar (even the gold-backed 1924 edition) was inflation-prone, which meant that creditors were inherently disadvantaged. Not so the owners of com- mon stock. If the companies in which they invested earned a profit, and if the managements of those companies retained a portion of that profit in the business, and if those retained earnings, in turn, produced future earnings, the principal value of an investor’s portfolio would tend “to increase in accordance with the operation of compound interest.”22 Smith’s timing was impeccable. Not a year after he published, the great Coolidge bull market erupted. Common Stocks as Long Term Investments, only 129 pages long, provided a handy rationale for chasing the market higher. That stocks do, in fact, tend to excel in the long run has entered the canon of American investment thought as a revealed truth (it looked any- thing but obvious in the 1930s). For his part, Graham entered a strong dis- sent to Smith’s thesis, or, more exactly, its uncritical bullish application. It was one thing to pay 10 times earnings for an equity investment, he notes, quite another to pay 20 to 40 times earnings. Besides, the Smith analysis skirted the important question of what asset values lay behind the stock certificates that people so feverishly and uncritically traded back and forth. Finally, embedded in Smith’s argument was the assumption that common stocks could be counted on to deliver in the future what they had done in the past. Graham was not a believer. (pp. 362–363) If Graham was a hard critic, however, he was also a generous one. In 1939 he was given John Burr Williams’s The Theory of Investment Value to review for the Journal of Political Economy (no small honor for a Wall Street author-practitioner). Williams’s thesis was as important as it was concise. The investment value of a common stock is the present value of all future dividends, he proposed. Williams did not underestimate the significance of these loaded words. Armed with that critical knowledge, the author ventured to hope, investors might restrain themselves from bidding stocks back up to the moon again. Graham, in whose capacious brain dwelled the talents both of the quant and behavioral financier, voiced his doubts about that forecast. The rub, as he pointed out, was that, in order to apply Williams’s method, one needed to make some very large assumptions about the future course of interest rates, the growth of profit, and the terminal value of the shares when growth stops. “One wonders,” Graham mused, “whether there may not be too great a discrepancy between the necessarily hit-or-miss character of these assumptions and the highly refined mathematical treatment to which they are subjected.” Graham closed his essay on a characteristi- cally generous and witty note, commending Williams for the refreshing level-headedness of his approach and adding: “This conservatism is not really implicit in the author’s formulas; but if the investor can be per- suaded by higher algebra to take a sane attitude toward common-stock prices, the reviewer will cast a loud vote for higher algebra.”23 Graham’s technical accomplishments in securities analysis, by them- selves, could hardly have carried Security Analysis through its five edi- tions. It’s the book’s humanity and good humor that, to me, explain its long life and the adoring loyalty of a certain remnant of Graham readers, myself included. Was there ever a Wall Street moneymaker better steeped than Graham in classical languages and literature and in the financial history of his own time? I would bet “no” with all the confidence of a value investor laying down money to buy an especially cheap stock. Yet this great investment philosopher was, to a degree, a prisoner of his own times. He could see that the experiences through which he lived were unique, that the Great Depression was, in fact, a great anomaly. If anyone understood the folly of projecting current experience into the unpredictable future, it was Graham. Yet this investment-philosopher king, having spent 727 pages (not including the gold mine of an appendix) describing how a careful and risk-averse investor could prosper in every kind of macroeconomic conditions, arrives at a remarkable conclusion. What of the institutional investor, he asks. How should he invest? At first, Graham diffidently ducks the question—who is he to prescribe for the experienced financiers at the head of America’s philanthropic and educational institutions? But then he takes the astonishing plunge. “An institution,” he writes, “that can manage to get along on the low income provided by high-grade fixed-value issues should, in our opinion, confine its holdings to this field. We doubt if the better performance of common- stock indexes over past periods will, in itself, warrant the heavy responsi- bilities and the recurring uncertainties that are inseparable from a common-stock investment program.” (pp. 709–710) Could the greatest value investor have meant that? Did the man who stuck it out through ruinous losses in the Depression years and went on to compile a remarkable long-term investment record really mean that common stocks were not worth the bother? In 1940, with a new world war fanning the Roosevelt administration’s fiscal and monetary policies, high-grade corporate bonds yielded just 2.75%, while blue-chip equities yielded 5.1%. Did Graham mean to say that bonds were a safer proposi- tion than stocks? Well, he did say it. If Homer could nod, so could Gra- ham—and so can the rest of us, whoever we are. Let it be a lesson.

Answer questions based only on information provided in the context block. Do not use external resources or any prior knowledge. Give your answer in bullet points, with a brief explanation following each one.

What do I need to be on the lookout for if I'm worried about pre-eclampsia?

1 Preeclampsia - Topic of the Month J U LY 6 , 2022 What is preeclampsia? Preeclampsia is a life-threatening disorder that most often occurs during pregnancy, although ten percent of cases occur in the postpartum period. The disorder is defined by two major symptoms found after 20 weeks of pregnancy, the most significant is a rapid rise in blood pressure (hypertension) combined with the presence of protein in the urine (proteinuria). For some women, proteinuria does not occur; for these women, preeclampsia is diagnosed as hypertension with thrombocytopenia (low platelet count), impaired liver function, renal insufficiency (poor kidney function), pulmonary edema (excess fluid in the lungs), and/or cerebral or visual disturbances (brain and vision problems). Preeclampsia is just one of the hypertensive disorders that may occur during pregnancy, others include chronic hypertension, gestational hypertension, HELLP syndrome, and eclampsia. Hypertensive disorders during pregnancy result in one of the leading causes of maternal and perinatal mortality worldwide.4 Historically, women and infants of color and American Indian women and their infants are disproportionately affected.3 Shocking statistics3: ▪ Hypertensive disorders affect 4-10% of pregnancies in the US. ▪ Severe hypertension contributes to 9% of maternal deaths in the US. ▪ One-third of severe childbirth complications result from preeclampsia/eclampsia. What are the maternal risks? PREECLAMPSIA - TO PIC O F THE MONTH 2 Preeclampsia puts great stress on the heart and can impair liver and kidney function. There is also a risk of suffering a stroke, seizures, hemorrhaging, multiple organ failure, placenta abruption (placenta separates from wall of uterus), and even maternal and/or infant death. What are the risks to the infant? Preeclampsia may restrict the flow of blood to the placenta, decreasing the oxygen and nutrients the fetus needs to thrive. Lack of these essential components can contribute to low infant birth weight, preterm delivery, and a chance of experiencing a stillbirth. Prematurity is the second leading cause of infant death in Minnesota.3 Infants that are born premature have a higher risk of long-term health and development difficulties. The prevention of preterm birth is critical to supporting infant health, promoting health equity, and controlling healthcare costs.3 WIC Pregnancy Related Risk Codes – refer to Implications for WIC Services 304 History of Preeclampsia 345 Hypertension and Prehypertension What are the warning signs? Preeclampsia typically occurs during the third trimester of pregnancy (after 28 weeks). For the postpartum parent, preeclampsia can occur within 48 hours of delivery or up to six weeks later. Parents who recognize any of these symptoms below should immediately contact their healthcare provider. Common warning signs of preeclampsia: ▪ Persistent headache that gets worse overtime ▪ Any changes in vision such as seeing spots or blurred vision ▪ Sudden and severe swelling in hands or face ▪ Sudden weight gain ▪ Nausea and vomiting in second half of pregnancy ▪ Pain in right upper abdomen or shoulder ▪ Shortness of breath or heavy chest Is preeclampsia preventable? It is not widely understood what causes preeclampsia. For this reason, doctors recommend parents maintain regular prenatal and postnatal visits with their healthcare providers and be vigilant of the signs and symptoms of the condition. Preventative care is the best defense against any pregnancy related hypertensive disorders. Preventative tips: PREECLAMPSIA - TO PIC O F THE MONTH 3 ▪ Attend regular healthcare visits and all prenatal visits ▪ Follow a healthy dietary pattern with regular daily meals and snacks ▪ Aim for an adequate calcium intake. While it is not yet conclusive, when dietary calcium is inadequate, research suggests that adequate calcium intake may help prevent preeclampsia. ▪ Maintain a healthy pre-pregnancy weight and gain appropriately during pregnancy ▪ Stay active with 150 minutes of moderate activity each week ▪ Reduce intake of tobacco products or consider smoking cessation A history of preeclampsia increases the risk of future hypertension, cardiovascular disease, and stroke. The above healthy lifestyle habits can help reduce the risk. Postpartum nutrition education contacts can provide an opportune time to follow up on this. For more information about Hypertensive Disorders of pregnancy: Blood Pressure During Pregnancy- December 14, 2021, Bay State Health Training Opportunity Section 5.3: Nutrition Risk Assessment policy explains the importance for WIC staff to obtain and synthesize information about a participant medical/health/nutrition status to most appropriately individualize WIC services. This includes asking questions that allow for education based on the participant’s concerns and offering referrals when necessary. Using the Pregnant Woman complete question format during the assessment may help you to most accurately determine if there are concerns the participant or their healthcare provider have regarding their medical, health, and/or nutrition. Exercise: 1. Read through the Pregnant Woman complete question format alone or as a group. 2. Discuss with a co-worker or as a group what questions would help identify some of the risk factors for preeclampsia. (HINT: Read through the risk factors above.) 3. What education can you offer to support the health of the at-risk participant? (HINT: Read through the preventative tips above.) Resources 1. Preeclampsia Foundation 2. HEAR HER Campaign -Centerfor Disease Control and Prevention (CDC) 3. Hypertension in Pregnancy -Minnesota Perinatal Quality Collaborative (MNPQC) 4. Hypertension and Preeclampsia in Pregnancy -The American College of Obstetricians and Gynecologists (ACOG) Topic ideas? Share yourfuture topic suggestion with [email protected]. PREECLAMPSIA - TO PIC O F THE MONTH 4 Reference – Complete Listing of Hyperlinks 304 History of Preeclampsia (https://www.health.state.mn.us/docs/people/wic/localagency/nutrition/riskcodes/bioclinmed /304mn.pdf) 345 Hypertension and Prehypertension (https://www.health.state.mn.us/docs/people/wic/localagency/nutrition/riskcodes/bioclinmed /345mn.pdf) Blood Pressure During Pregnancy (https://www.youtube.com/watch?v=Ff061nIXPx0&t=537s) Preeclampsia Foundation (https://www.preeclampsia.org/) HEAR HER Campaign (https://www.cdc.gov/hearher/index.html) Hypertension in Pregnancy (https://minnesotaperinatal.org/hypertension-in-pregnancy/) Hypertension and Preeclampsia in Pregnancy (https://www.acog.org/topics/hypertension-andpreeclampsia-in-pregnancy) Minnesota Department of Health - WIC Program, 85 E 7th Place, PO BOX 64882, ST PAUL MN 55164-0882; 1-800-657-3942, [email protected], www.health.state.mn.us; to obtain this information in a different format, call: 1-800-657-3942.

System instruction: [Answer questions based only on information provided in the context block. Do not use external resources or any prior knowledge. Give your answer in bullet points, with a brief explanation following each one.] Question: [What do I need to be on the lookout for if I'm worried about pre-eclampsia?] Context block: [1 Preeclampsia - Topic of the Month J U LY 6 , 2022 What is preeclampsia? Preeclampsia is a life-threatening disorder that most often occurs during pregnancy, although ten percent of cases occur in the postpartum period. The disorder is defined by two major symptoms found after 20 weeks of pregnancy, the most significant is a rapid rise in blood pressure (hypertension) combined with the presence of protein in the urine (proteinuria). For some women, proteinuria does not occur; for these women, preeclampsia is diagnosed as hypertension with thrombocytopenia (low platelet count), impaired liver function, renal insufficiency (poor kidney function), pulmonary edema (excess fluid in the lungs), and/or cerebral or visual disturbances (brain and vision problems). Preeclampsia is just one of the hypertensive disorders that may occur during pregnancy, others include chronic hypertension, gestational hypertension, HELLP syndrome, and eclampsia. Hypertensive disorders during pregnancy result in one of the leading causes of maternal and perinatal mortality worldwide.4 Historically, women and infants of color and American Indian women and their infants are disproportionately affected.3 Shocking statistics3: ▪ Hypertensive disorders affect 4-10% of pregnancies in the US. ▪ Severe hypertension contributes to 9% of maternal deaths in the US. ▪ One-third of severe childbirth complications result from preeclampsia/eclampsia. What are the maternal risks? PREECLAMPSIA - TO PIC O F THE MONTH 2 Preeclampsia puts great stress on the heart and can impair liver and kidney function. There is also a risk of suffering a stroke, seizures, hemorrhaging, multiple organ failure, placenta abruption (placenta separates from wall of uterus), and even maternal and/or infant death. What are the risks to the infant? Preeclampsia may restrict the flow of blood to the placenta, decreasing the oxygen and nutrients the fetus needs to thrive. Lack of these essential components can contribute to low infant birth weight, preterm delivery, and a chance of experiencing a stillbirth. Prematurity is the second leading cause of infant death in Minnesota.3 Infants that are born premature have a higher risk of long-term health and development difficulties. The prevention of preterm birth is critical to supporting infant health, promoting health equity, and controlling healthcare costs.3 WIC Pregnancy Related Risk Codes – refer to Implications for WIC Services 304 History of Preeclampsia 345 Hypertension and Prehypertension What are the warning signs? Preeclampsia typically occurs during the third trimester of pregnancy (after 28 weeks). For the postpartum parent, preeclampsia can occur within 48 hours of delivery or up to six weeks later. Parents who recognize any of these symptoms below should immediately contact their healthcare provider. Common warning signs of preeclampsia: ▪ Persistent headache that gets worse overtime ▪ Any changes in vision such as seeing spots or blurred vision ▪ Sudden and severe swelling in hands or face ▪ Sudden weight gain ▪ Nausea and vomiting in second half of pregnancy ▪ Pain in right upper abdomen or shoulder ▪ Shortness of breath or heavy chest Is preeclampsia preventable? It is not widely understood what causes preeclampsia. For this reason, doctors recommend parents maintain regular prenatal and postnatal visits with their healthcare providers and be vigilant of the signs and symptoms of the condition. Preventative care is the best defense against any pregnancy related hypertensive disorders. Preventative tips: PREECLAMPSIA - TO PIC O F THE MONTH 3 ▪ Attend regular healthcare visits and all prenatal visits ▪ Follow a healthy dietary pattern with regular daily meals and snacks ▪ Aim for an adequate calcium intake. While it is not yet conclusive, when dietary calcium is inadequate, research suggests that adequate calcium intake may help prevent preeclampsia. ▪ Maintain a healthy pre-pregnancy weight and gain appropriately during pregnancy ▪ Stay active with 150 minutes of moderate activity each week ▪ Reduce intake of tobacco products or consider smoking cessation A history of preeclampsia increases the risk of future hypertension, cardiovascular disease, and stroke. The above healthy lifestyle habits can help reduce the risk. Postpartum nutrition education contacts can provide an opportune time to follow up on this. For more information about Hypertensive Disorders of pregnancy: Blood Pressure During Pregnancy- December 14, 2021, Bay State Health Training Opportunity Section 5.3: Nutrition Risk Assessment policy explains the importance for WIC staff to obtain and synthesize information about a participant medical/health/nutrition status to most appropriately individualize WIC services. This includes asking questions that allow for education based on the participant’s concerns and offering referrals when necessary. Using the Pregnant Woman complete question format during the assessment may help you to most accurately determine if there are concerns the participant or their healthcare provider have regarding their medical, health, and/or nutrition. Exercise: 1. Read through the Pregnant Woman complete question format alone or as a group. 2. Discuss with a co-worker or as a group what questions would help identify some of the risk factors for preeclampsia. (HINT: Read through the risk factors above.) 3. What education can you offer to support the health of the at-risk participant? (HINT: Read through the preventative tips above.) Resources 1. Preeclampsia Foundation 2. HEAR HER Campaign -Centerfor Disease Control and Prevention (CDC) 3. Hypertension in Pregnancy -Minnesota Perinatal Quality Collaborative (MNPQC) 4. Hypertension and Preeclampsia in Pregnancy -The American College of Obstetricians and Gynecologists (ACOG) Topic ideas? Share yourfuture topic suggestion with [email protected]. PREECLAMPSIA - TO PIC O F THE MONTH 4 Reference – Complete Listing of Hyperlinks 304 History of Preeclampsia (https://www.health.state.mn.us/docs/people/wic/localagency/nutrition/riskcodes/bioclinmed /304mn.pdf) 345 Hypertension and Prehypertension (https://www.health.state.mn.us/docs/people/wic/localagency/nutrition/riskcodes/bioclinmed /345mn.pdf) Blood Pressure During Pregnancy (https://www.youtube.com/watch?v=Ff061nIXPx0&t=537s) Preeclampsia Foundation (https://www.preeclampsia.org/) HEAR HER Campaign (https://www.cdc.gov/hearher/index.html) Hypertension in Pregnancy (https://minnesotaperinatal.org/hypertension-in-pregnancy/) Hypertension and Preeclampsia in Pregnancy (https://www.acog.org/topics/hypertension-andpreeclampsia-in-pregnancy) Minnesota Department of Health - WIC Program, 85 E 7th Place, PO BOX 64882, ST PAUL MN 55164-0882; 1-800-657-3942, [email protected], www.health.state.mn.us; to obtain this information in a different format, call: 1-800-657-3942.]

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. [user request] [context document]

I am 50 years old, I live in Louisiana, I am married, and I have a 700 credit score. I am applying for an FHA mortgage loan on a house in a flood zone in Louisiana. I want to apply without my husband since his credit isn't good, he owes a lot debts from before we were married and he doesn't have much of a work history. The loan officer says he has to run a credit report on my husband even if he isn't on the loan. Do we have to have his credit checked too?

II. ORIGINATION THROUGH POST-CLOSING/ENDORSEMENT A. Title II Insured Housing Programs Forward Mortgages 4. Underwriting the Borrower Using the TOTAL Mortgage Scorecard (TOTAL) Handbook 4000.1 215 Last Revised: 05/20/2024 (2) Standard The Mortgagee must include the debt. The amount of the required payment must be included in the calculation of the Borrower’s total debt to income. (3) Required Documentation The Mortgagee must include documentation from the federal agency evidencing the repayment agreement and verification of payments made, if applicable. (E) Alimony, Child Support, and Maintenance (TOTAL) (1) Definition Alimony, Child Support, and Maintenance are court-ordered or otherwise agreed upon payments. (2) Standard For Alimony, if the Borrower’s income was not reduced by the amount of the monthly alimony obligation in the Mortgagee’s calculation of the Borrower’s gross income, the Mortgagee must include the monthly obligation in the calculation of the Borrower’s debt. Child Support and Maintenance are to be treated as a recurring liability and the Mortgagee must include the monthly obligation in the Borrower’s liabilities and debt. (3) Required Documentation The Mortgagee must verify and document the monthly obligation by obtaining the official signed divorce decree, separation agreement, maintenance agreement, or other legal order. The Mortgagee must also obtain the Borrower’s pay stubs covering no less than 28 consecutive Days to verify whether the Borrower is subject to any order of garnishment relating to the Alimony, Child Support, and Maintenance. (4) Calculation of Monthly Obligation The Mortgagee must calculate the Borrower’s monthly obligation from the greater of: • the amount shown on the most recent decree or agreement establishing the Borrower’s payment obligation; or • the monthly amount of the garnishment. II. ORIGINATION THROUGH POST-CLOSING/ENDORSEMENT A. Title II Insured Housing Programs Forward Mortgages 4. Underwriting the Borrower Using the TOTAL Mortgage Scorecard (TOTAL) Handbook 4000.1 216 Last Revised: 05/20/2024 (F) Non-Borrowing Spouse Debt in Community Property States (TOTAL) (1) Definition Non-Borrowing Spouse Debt refers to debts owed by a spouse that are not owed by, or in the name of the Borrower. (2) Standard If the Borrower resides in a community property state or the Property being insured is located in a community property state, debts of the non-borrowing spouse must be included in the Borrower’s qualifying ratios, except for obligations specifically excluded by state law. The non-borrowing spouse’s credit history is not considered a reason to deny a mortgage application. (3) Required Documentation The Mortgagee must verify and document the debt of the non-borrowing spouse. The Mortgagee must make a note in the file referencing the specific state law that justifies the exclusion of any debt from consideration. The Mortgagee must obtain a credit report for the non-borrowing spouse in order to determine the debts that must be included in the liabilities. The credit report for the non-borrowing spouse is for the purpose of establishing debt only, and is not submitted to TOTAL Mortgage Scorecard for the purpose of credit evaluation. The credit report for the non-borrowing spouse may be traditional or non- traditional. (G) Deferred Obligations (TOTAL) (1) Definition Deferred Obligations (excluding Student Loans) refer to liabilities that have been incurred but where payment is deferred or has not yet commenced, including accounts in forbearance. (2) Standard The Mortgagee must include deferred obligations in the Borrower’s liabilities. (3) Required Documentation The Mortgagee must obtain written documentation of the deferral of the liability from the creditor and evidence of the outstanding balance and terms of the II. ORIGINATION THROUGH POST-CLOSING/ENDORSEMENT A. Title II Insured Housing Programs Forward Mortgages 4. Underwriting the Borrower Using the TOTAL Mortgage Scorecard (TOTAL) Handbook 4000.1 217 Last Revised: 05/20/2024 deferred liability. The Mortgagee must obtain evidence of the actual monthly payment obligation, if available. (4) Calculation of Monthly Obligation The Mortgagee must use the actual monthly payment to be paid on a deferred liability, whenever available. If the actual monthly payment is not available for installment debt, the Mortgagee must utilize the terms of the debt or 5 percent of the outstanding balance to establish the monthly payment. (H) Student Loans (TOTAL) (1) Definition Student Loan refers to liabilities incurred for educational purposes. (2) Standard The Mortgagee must include all Student Loans in the Borrower’s liabilities, regardless of the payment type or status of payments. (3) Required Documentation If the payment used for the monthly obligation is less than the monthly payment reported on the Borrower’s credit report, the Mortgagee must obtain written documentation of the actual monthly payment, the payment status, and evidence of the outstanding balance and terms from the creditor or student loan servicer. The Mortgagee may exclude the payment from the Borrower’s monthly debt calculation where written documentation from the student loan program, creditor, or student loan servicer indicates that the loan balance has been forgi

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. I am 50 years old, I live in Louisiana, I am married, and I have a 700 credit score. I am applying for an FHA mortgage loan on a house in a flood zone in Louisiana. I want to apply without my husband since his credit isn't good, he owes a lot debts from before we were married and he doesn't have much of a work history. The loan officer says he has to run a credit report on my husband even if he isn't on the loan. Do we have to have his credit checked too? II. ORIGINATION THROUGH POST-CLOSING/ENDORSEMENT A. Title II Insured Housing Programs Forward Mortgages 4. Underwriting the Borrower Using the TOTAL Mortgage Scorecard (TOTAL) Handbook 4000.1 215 Last Revised: 05/20/2024 (2) Standard The Mortgagee must include the debt. The amount of the required payment must be included in the calculation of the Borrower’s total debt to income. (3) Required Documentation The Mortgagee must include documentation from the federal agency evidencing the repayment agreement and verification of payments made, if applicable. (E) Alimony, Child Support, and Maintenance (TOTAL) (1) Definition Alimony, Child Support, and Maintenance are court-ordered or otherwise agreed upon payments. (2) Standard For Alimony, if the Borrower’s income was not reduced by the amount of the monthly alimony obligation in the Mortgagee’s calculation of the Borrower’s gross income, the Mortgagee must include the monthly obligation in the calculation of the Borrower’s debt. Child Support and Maintenance are to be treated as a recurring liability and the Mortgagee must include the monthly obligation in the Borrower’s liabilities and debt. (3) Required Documentation The Mortgagee must verify and document the monthly obligation by obtaining the official signed divorce decree, separation agreement, maintenance agreement, or other legal order. The Mortgagee must also obtain the Borrower’s pay stubs covering no less than 28 consecutive Days to verify whether the Borrower is subject to any order of garnishment relating to the Alimony, Child Support, and Maintenance. (4) Calculation of Monthly Obligation The Mortgagee must calculate the Borrower’s monthly obligation from the greater of: • the amount shown on the most recent decree or agreement establishing the Borrower’s payment obligation; or • the monthly amount of the garnishment. II. ORIGINATION THROUGH POST-CLOSING/ENDORSEMENT A. Title II Insured Housing Programs Forward Mortgages 4. Underwriting the Borrower Using the TOTAL Mortgage Scorecard (TOTAL) Handbook 4000.1 216 Last Revised: 05/20/2024 (F) Non-Borrowing Spouse Debt in Community Property States (TOTAL) (1) Definition Non-Borrowing Spouse Debt refers to debts owed by a spouse that are not owed by, or in the name of the Borrower. (2) Standard If the Borrower resides in a community property state or the Property being insured is located in a community property state, debts of the non-borrowing spouse must be included in the Borrower’s qualifying ratios, except for obligations specifically excluded by state law. The non-borrowing spouse’s credit history is not considered a reason to deny a mortgage application. (3) Required Documentation The Mortgagee must verify and document the debt of the non-borrowing spouse. The Mortgagee must make a note in the file referencing the specific state law that justifies the exclusion of any debt from consideration. The Mortgagee must obtain a credit report for the non-borrowing spouse in order to determine the debts that must be included in the liabilities. The credit report for the non-borrowing spouse is for the purpose of establishing debt only, and is not submitted to TOTAL Mortgage Scorecard for the purpose of credit evaluation. The credit report for the non-borrowing spouse may be traditional or non- traditional. (G) Deferred Obligations (TOTAL) (1) Definition Deferred Obligations (excluding Student Loans) refer to liabilities that have been incurred but where payment is deferred or has not yet commenced, including accounts in forbearance. (2) Standard The Mortgagee must include deferred obligations in the Borrower’s liabilities. (3) Required Documentation The Mortgagee must obtain written documentation of the deferral of the liability from the creditor and evidence of the outstanding balance and terms of the II. ORIGINATION THROUGH POST-CLOSING/ENDORSEMENT A. Title II Insured Housing Programs Forward Mortgages 4. Underwriting the Borrower Using the TOTAL Mortgage Scorecard (TOTAL) Handbook 4000.1 217 Last Revised: 05/20/2024 deferred liability. The Mortgagee must obtain evidence of the actual monthly payment obligation, if available. (4) Calculation of Monthly Obligation The Mortgagee must use the actual monthly payment to be paid on a deferred liability, whenever available. If the actual monthly payment is not available for installment debt, the Mortgagee must utilize the terms of the debt or 5 percent of the outstanding balance to establish the monthly payment. (H) Student Loans (TOTAL) (1) Definition Student Loan refers to liabilities incurred for educational purposes. (2) Standard The Mortgagee must include all Student Loans in the Borrower’s liabilities, regardless of the payment type or status of payments. (3) Required Documentation If the payment used for the monthly obligation is less than the monthly payment reported on the Borrower’s credit report, the Mortgagee must obtain written documentation of the actual monthly payment, the payment status, and evidence of the outstanding balance and terms from the creditor or student loan servicer. The Mortgagee may exclude the payment from the Borrower’s monthly debt calculation where written documentation from the student loan program, creditor, or student loan servicer indicates that the loan balance has been forgi https://www.hud.gov/sites/dfiles/OCHCO/documents/40001-hsgh-update15-052024.pdf

Use only context block information. write the answer in bullet points only. Less than 100 words.

Write a cost-benefit analysis of 1983 Act.

After the 1973 Act, in fulfilling the objective of controlling pollution, each Water Authority had created a water quality advisory panel to monitor its performance in meeting water quality requirements. The objective of the advisory panels was to achieve some independence between the water authority’s functions of public supply, pollution control and monitoring of environmental performance. In a move to address the problem of poor surface water quality, the National Water Council published a classification of river quality objectives in 1977. The classification system related to the purposes for which water was to be used based on five basic classes of river waters: 1A High quality waters suitable for all abstraction purposes with only modest treatment. Capable of supporting high class fisheries. High amenity value. 1B Good quality waters usable for substantially the same purposes as 1A though not as high quality. 2 Fair quality waters viable as coarse (freshwater) fisheries and capable of use for drinking water provided advanced treatment is given. Moderate amenity value. 3 Poor waters polluted to the extent that fish were absent or only sporadically present. Suitable only for low grade industrial abstractions. 4 Bad quality waters which were grossly polluted and likely to cause a nuisance. This classification was adopted by each water authority in setting informal river quality objectives and to define the permits for treated sewage discharges. The suitability of this classification system was later questioned as it introduced the concept of high river quality being a lower priority unless specific uses compel it. With significant scope for discretion in the setting of standards by the water authorities and no imposed national standards, it ultimately led to a review of the number of discharge permits, which led to a relaxation of their requirements36. It further masked the problems of declining water quality and was clearly insufficient to satisfy EC law. With little political acceptance of the dramatic increases required to customer bills to address the problems of under-investment and declining infrastructure, the government continued to delay implementation of the condition from the 1974 Act that required the water authorities to publish pollution registers against the performance of discharge permits. This was contrary to the openness required once the authorities were given the conflicting roles of sewage works operators and river quality regulators37, conflicted with the water authorities’ role to prevent pollution and led the water quality advisory panels to be largely ineffective. With the water authorities unwilling to selfregulate and self-prosecute there was a sharp increase in the number of incidents of river pollution38. Lack of public access to information on discharge permits and pollution incidents further compounded the problem. 3.4 WATER ACT 1983 In response to the problems created by the increasing capital investment requirements of the water authorities and the requirement to address the problems of environmental pollution, the government introduced the Water Act 1983. The assumption underlying the 1983 Act was that water customers were best served by an efficiently run water utility providing prescribed service standards at least cost. The 1983 Act changed the organisational structure of the water authorities, reduced the role of local government, and, by allowing companies to operate in a more commercial manner, paved the way for privatisation. 3.4.1 Constitutional changes Until 1983, the water authorities were run by large boards with a majority of local authority representatives (see section 3.1.4). The 1983 Act reduced the size of the board structures with the intention of making these smaller and more business like by reducing the number of representatives from local authorities. Although all members continued to be appointed by central government, a series of chairmen vacancies were filled by people with experience in the industry rather than experience of public affairs. The 1983 Act provided for Consumer Consultative Committees to represent the interests of customers following the abolishment of locally elected councillors as water authority members, and as a result of restrictions in public access to management meetings of the authorities.

Write a cost-benefit analysis of 1983 Act. Use only context block information. write the answer in bullet points only. Less than 100 words. After the 1973 Act, in fulfilling the objective of controlling pollution, each Water Authority had created a water quality advisory panel to monitor its performance in meeting water quality requirements. The objective of the advisory panels was to achieve some independence between the water authority’s functions of public supply, pollution control and monitoring of environmental performance. In a move to address the problem of poor surface water quality, the National Water Council published a classification of river quality objectives in 1977. The classification system related to the purposes for which water was to be used based on five basic classes of river waters: 1A High quality waters suitable for all abstraction purposes with only modest treatment. Capable of supporting high class fisheries. High amenity value. 1B Good quality waters usable for substantially the same purposes as 1A though not as high quality. 2 Fair quality waters viable as coarse (freshwater) fisheries and capable of use for drinking water provided advanced treatment is given. Moderate amenity value. 3 Poor waters polluted to the extent that fish were absent or only sporadically present. Suitable only for low grade industrial abstractions. 4 Bad quality waters which were grossly polluted and likely to cause a nuisance. This classification was adopted by each water authority in setting informal river quality objectives and to define the permits for treated sewage discharges. The suitability of this classification system was later questioned as it introduced the concept of high river quality being a lower priority unless specific uses compel it. With significant scope for discretion in the setting of standards by the water authorities and no imposed national standards, it ultimately led to a review of the number of discharge permits, which led to a relaxation of their requirements36. It further masked the problems of declining water quality and was clearly insufficient to satisfy EC law. With little political acceptance of the dramatic increases required to customer bills to address the problems of under-investment and declining infrastructure, the government continued to delay implementation of the condition from the 1974 Act that required the water authorities to publish pollution registers against the performance of discharge permits. This was contrary to the openness required once the authorities were given the conflicting roles of sewage works operators and river quality regulators37, conflicted with the water authorities’ role to prevent pollution and led the water quality advisory panels to be largely ineffective. With the water authorities unwilling to selfregulate and self-prosecute there was a sharp increase in the number of incidents of river pollution38. Lack of public access to information on discharge permits and pollution incidents further compounded the problem. 3.4 WATER ACT 1983 In response to the problems created by the increasing capital investment requirements of the water authorities and the requirement to address the problems of environmental pollution, the government introduced the Water Act 1983. The assumption underlying the 1983 Act was that water customers were best served by an efficiently run water utility providing prescribed service standards at least cost. The 1983 Act changed the organisational structure of the water authorities, reduced the role of local government, and, by allowing companies to operate in a more commercial manner, paved the way for privatisation. 3.4.1 Constitutional changes Until 1983, the water authorities were run by large boards with a majority of local authority representatives (see section 3.1.4). The 1983 Act reduced the size of the board structures with the intention of making these smaller and more business like by reducing the number of representatives from local authorities. Although all members continued to be appointed by central government, a series of chairmen vacancies were filled by people with experience in the industry rather than experience of public affairs. The 1983 Act provided for Consumer Consultative Committees to represent the interests of customers following the abolishment of locally elected councillors as water authority members, and as a result of restrictions in public access to management meetings of the authorities. Local authorities were left to propose how the committees were set up, but the government published guidelines indicating how this should be done. The guidelines were criticised for a number of reasons including (i) the committees had wide terms of reference that covered national issues, but were intended to be set up on a regional basis and deal with regional issues, and (ii) they had little independence from the water authorities. In addition, the 1983 Act abolished the National Water Council which had done little to promote the views of the water industry to central government since its implementation40. 3.4.2 Financial changes The 1983 Act initiated many of the financing changes that were ultimately required at privatisation and started the process of transforming the water industry from a public service to a business organisation. The 1983 Act made express provision for water authorities to borrow directly from the private capital markets rather than solely from central government. However, in practice central government continued to exercise control over the authorities’ borrowing and this acted to prevent the authorities from private borrowing. The 1983 Act introduced the principle of cost-benefit to the industry for assessing capital investment requirements and attempts were made to introduce long-run marginal cost pricing for determination of water tariffs41. THE NEED FOR CHANGE Section II of the Control of Pollution Act 1974 (COPA II), finally became effective from 1985 and required publication of discharge permit standards. However, in practice, the changes brought about by COPA II or the 1983 Act did little to improve the environmental performance of the water authorities, measured by improvements in river water quality. Despite the above inflation price rises from the early 1980’s onwards (Figure 3.3.1b), the 1985 River Quality Survey showed, for the first time since surveys were undertaken in 1958, that the length of river quality deterioration had overtaken that of river water quality improvement. In total, 903km out of 40,000km rivers surveyed showed a net deterioration over the period42. And in 1988, for example, 742 out of 6407 sewage treatment works failed their discharge permit requirements. The continued lack of investment meant that a significant number of incidents of pollution continued to occur and the United Kingdom continued to be in breach of a number of EC Directives. The decision by the EC to start prosecution proceedings against the government for non-compliance with two EC Directives in the mid-1980’s was a major factor in the government recognising the requirement for further significant capital investment and control of pollution. With government unwilling to fund the increased investment requirements either from increases in taxes or increasing borrowing and with its broader programme of privatisation of utilities underway, the government started to consider the privatisation of the industry. The next section describes the process of privatisation. 4. PRIVATISATION 4.1 INTRODUCTION The proposals for privatisation of the water industry were in response to the need for more investment in the industry than the government was prepared to fund from public finance. There was also a prevailing policy which favoured privatisation as a means of securing efficiency; British Telecom and British Gas had been privatised in 1984 and 1986 respectively. The government first published its proposals in a discussion paper on water privatisation in 198643. 4.2 INITIAL PROPOSALS The 1986 discussion paper proposed privatisation of the water authorities as they existed. This would have simply transferred the water authorities to private ownership, without changes to their powers or responsibilities. It would have required the authorities, as private companies, to have responsibility for providing water and sewerage services and to have responsibility for flood control, river water quality and control of abstraction. The 1986 discussion paper included the concept of comparative competition, such that the privatised undertakers would be competing in the financial markets for access to finance and the performance of each company could be compared. The government considered profit would be a more effective incentive for improved management performance than government controls. However, to protect customers’ interests, a system of regulatory controls would be required to prevent privatised water authorities from overcharging customers or providing poor standards of service. The paper proposed that a Director General of Water Services would set price limits and performance standards for each licensed company.44 4.2.1 Economic Regulation The proposals for privatisation of the water industry differed in three fundamental respects from those of the gas and telecoms industries:
privatisation would involve not one (as in gas and telecoms), but ten Water Authorities;
the water and sewerage industries are distinctive in that they have duties concerning the protection of the environment; and
natural monopoly conditions were more prevalent in the water and sewerage industry because it consisted of local and regional monopolies with no national distribution network. Alongside its plans for sale and restructuring of the water and sewerage services, the government commissioned a report to discuss the proposals for economic regulation of the industry45.

[question] [user request] ===================== [text] [context document] ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

The state is trying to introduce some study about how sex offenders keep reoffending, but it has ot been properly peer reviewed., According tho this article, will it be admissible or what should i do to get it thrown out of evidence? I need to know the reasoning behind why eividence gets thrown out.

2. The Frye ruling refers only to the character of the “scientific principle” proffered as evidence. Frye makes no mention of subject-matter expertise (27), except in the sense implied by the “general acceptance” clause, which refers to the consensual expertise held by the scientific community. This concept of consensual expertise as the basis for establishing trustworthiness became eroded through establishment of the Federal Rules of Evidence, which turned the focus toward opinions of individual experts. Rule 702: Testimony by Experts By the 1970s, a sense had emerged that the inflexible Frye requirement for general acceptance was difficult to establish and perhaps insufficient, in that it was mainly relevant to criminal cases in which an invented instrument was proposed to establish fact.# Partly in response to this concern, standards for admissibility of scientific evidence began to change. They did so initially, at least in a formal sense, following recommendations of a federal advisory committee of the United States Judicial Conference, which was established for the broader purpose of normalizing and codifying rules for the use of evidence in US Courts. The Federal Rules of Evidence became law in 1975 by act of Congress. The particular rule that bears on admissibility of expert testimony is known as Rule 702 (28). While Frye selectively targets the use of scientific evidence, Rule 702 applies more generally to expert testimony on “scientific, technical, or other specialized knowledge,” meaning that the same standards apply to evidence drawn from the well of scientific knowledge and to subject-matter experts in nonscience knowledge domains, such as tugboat captaining. In its original form, Rule 702–1975 merely formalized and made into law standards for “helpfulness” and “expert” qualifications, both of which had been less formally applied since the 19th century: “If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise.” As a notably limp standard for judging the evidentiary nuances of modern science, Rule 702-1975 was subsequently interpreted and clarified by the Supreme Court’s transformative 1993 ruling on scientific evidence in Daubert v. Merrell Dow Pharmaceuticals, Inc. (8). The Daubert Standard Unlike the forensic instrument that motivated the Frye standard, in which the question before the court concerned the scientific validity of measured quantities, the Daubert ruling emerged from a toxic tort case, in which scientific evidence attempted to establish cause and effect. Daubert’s civil action was filed against the drug company Merrell Dow Pharmaceuticals in 1984, on behalf of two children born with serious birth defects. The mothers had taken the drug Bendectin [doxylamine succinate and pyridoxine hydrochloride (vitamin B6)], which was manufactured by Merrell Dow and widely used for decades to quell nausea and vomiting during first-trimester pregnancy. The plaintiff alleged that Bendectin had caused deformities during gestation. Merrell Dow maintained that there was no scientific evidence of a link between their drug and birth defects, but Daubert recruited an expert in the form of obstetrician William McBride, who was prepared to testify on the teratogenic effects of Bendectin. Noting that McBride’s assertions failed to meet the Frye standard of general acceptance by the scientific community, the District Court for the Southern District of California issued summary judgement in favor of Merrell Dow (29). Daubert appealed to the Ninth Circuit, which upheld the lower court’s ruling (30). In response, Daubert went on to argue before the Supreme Court that the common law Frye standard for admissibility of scientific evidence was inapplicable in their case, because it had been replaced in 1975 by the legislatively enacted Rule 702. The Court agreed and upheld Rule 702–1975 as the modern legal standard for admissibility in federal court, superseding the Frye standard.‖ In its ruling (8), the Court provided an interpretation of Rule 702–1975, which is known today as the Daubert standard. This standard consists of a set of clear and useful criteria for assessing the trustworthiness of scientific evidence: • whether the theory or technique in question can be (and has been) tested, • whether it has been subjected to peer review and publication, • its known or potential error rate, and • the existence and maintenance of standards controlling its operation, and • whether it has attracted widespread acceptance within a relevant scientific community Unlike the uncompromising Frye standard, these criteria are intended to be flexibly applied at the discretion of the trial judge. With these brief considerations, Daubert strengthened the application of evidence law in several ways that conform to the nature of scientific investigation. Perhaps most importantly, Daubert returned the focus to the body of scientific knowledge (27), highlighting the importance of empirically demonstrating [“can be (and has been) tested”] that a scientific instrument or principle is a valid predictor of the probability that a courtroom hypothesis is correct (“known or potential error rate”). To that end, the focus on widespread or general acceptance of scientific evidence – consistent with Frye but absent from Rule 702 – is notable here, as the scientific consensus at any moment is the rational basis for decision under the unyielding demands of courtroom litigation. Also consistent with Frye and contrary to the letter of Rule 702, Daubert emphasizes the need for evidence to reflect the consensus of the “relevant scientific community.” As highlighted below, the definition of relevance has become a battleground in efforts to reform the use of forensic evidence. Rule 702 Evolves Rule 702 was substantially amended in 2000 to conform with Daubert and to promote a “more rigorous and structured approach” (31), in which the gatekeeping role was formally handed to judges. The Rule’s emphasis on the expert remained, but three “reliability” requirements were included in Rule 702–2000 (provisions b-d), which place constraints on the data, methods, principles, and their application by the expert: A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if: the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue; the testimony is based on sufficient facts or data; (c) the testimony is the product of reliable principles and methods; and (d) the expert has reliably applied the principles and methods to the facts of the case. Rule 702 was revised again in 2022 (to take effect December 2023) through amendments proposed by the Advisory Committee on Evidence Rules and subsequently approved by the US Judicial Conference and the Supreme Court (32). For these efforts, Rule 702–2022 differs from the previous by two small text additions. One defines a preponderance of evidence (“more likely than not”) standard for demonstrating that the four provisions [702(a-d)] have been satisfied, which offers the gatekeeping judge a quantitative criterion for decisions about admissibility. The other clarifies that it is not the expert’s reliable application that matters, but rather that “the expert’s opinion reflects a reliable application,” which grants the trial judge the ability to bar opinions that exceed what can be reasonably concluded from the methods and principles applied.

[question] The state is trying to introduce some study about how sex offenders keep reoffending, but it has ot been properly peer reviewed., According tho this article, will it be admissible or what should i do to get it thrown out of evidence? I need to know the reasoning behind why eividence gets thrown out. ===================== [text] 2. The Frye ruling refers only to the character of the “scientific principle” proffered as evidence. Frye makes no mention of subject-matter expertise (27), except in the sense implied by the “general acceptance” clause, which refers to the consensual expertise held by the scientific community. This concept of consensual expertise as the basis for establishing trustworthiness became eroded through establishment of the Federal Rules of Evidence, which turned the focus toward opinions of individual experts. Rule 702: Testimony by Experts By the 1970s, a sense had emerged that the inflexible Frye requirement for general acceptance was difficult to establish and perhaps insufficient, in that it was mainly relevant to criminal cases in which an invented instrument was proposed to establish fact.# Partly in response to this concern, standards for admissibility of scientific evidence began to change. They did so initially, at least in a formal sense, following recommendations of a federal advisory committee of the United States Judicial Conference, which was established for the broader purpose of normalizing and codifying rules for the use of evidence in US Courts. The Federal Rules of Evidence became law in 1975 by act of Congress. The particular rule that bears on admissibility of expert testimony is known as Rule 702 (28). While Frye selectively targets the use of scientific evidence, Rule 702 applies more generally to expert testimony on “scientific, technical, or other specialized knowledge,” meaning that the same standards apply to evidence drawn from the well of scientific knowledge and to subject-matter experts in nonscience knowledge domains, such as tugboat captaining. In its original form, Rule 702–1975 merely formalized and made into law standards for “helpfulness” and “expert” qualifications, both of which had been less formally applied since the 19th century: “If scientific, technical, or other specialized knowledge will assist the trier of fact to understand the evidence or to determine a fact in issue, a witness qualified as an expert by knowledge, skill, experience, training, or education, may testify thereto in the form of an opinion or otherwise.” As a notably limp standard for judging the evidentiary nuances of modern science, Rule 702-1975 was subsequently interpreted and clarified by the Supreme Court’s transformative 1993 ruling on scientific evidence in Daubert v. Merrell Dow Pharmaceuticals, Inc. (8). The Daubert Standard Unlike the forensic instrument that motivated the Frye standard, in which the question before the court concerned the scientific validity of measured quantities, the Daubert ruling emerged from a toxic tort case, in which scientific evidence attempted to establish cause and effect. Daubert’s civil action was filed against the drug company Merrell Dow Pharmaceuticals in 1984, on behalf of two children born with serious birth defects. The mothers had taken the drug Bendectin [doxylamine succinate and pyridoxine hydrochloride (vitamin B6)], which was manufactured by Merrell Dow and widely used for decades to quell nausea and vomiting during first-trimester pregnancy. The plaintiff alleged that Bendectin had caused deformities during gestation. Merrell Dow maintained that there was no scientific evidence of a link between their drug and birth defects, but Daubert recruited an expert in the form of obstetrician William McBride, who was prepared to testify on the teratogenic effects of Bendectin. Noting that McBride’s assertions failed to meet the Frye standard of general acceptance by the scientific community, the District Court for the Southern District of California issued summary judgement in favor of Merrell Dow (29). Daubert appealed to the Ninth Circuit, which upheld the lower court’s ruling (30). In response, Daubert went on to argue before the Supreme Court that the common law Frye standard for admissibility of scientific evidence was inapplicable in their case, because it had been replaced in 1975 by the legislatively enacted Rule 702. The Court agreed and upheld Rule 702–1975 as the modern legal standard for admissibility in federal court, superseding the Frye standard.‖ In its ruling (8), the Court provided an interpretation of Rule 702–1975, which is known today as the Daubert standard. This standard consists of a set of clear and useful criteria for assessing the trustworthiness of scientific evidence: • whether the theory or technique in question can be (and has been) tested, • whether it has been subjected to peer review and publication, • its known or potential error rate, and • the existence and maintenance of standards controlling its operation, and • whether it has attracted widespread acceptance within a relevant scientific community Unlike the uncompromising Frye standard, these criteria are intended to be flexibly applied at the discretion of the trial judge. With these brief considerations, Daubert strengthened the application of evidence law in several ways that conform to the nature of scientific investigation. Perhaps most importantly, Daubert returned the focus to the body of scientific knowledge (27), highlighting the importance of empirically demonstrating [“can be (and has been) tested”] that a scientific instrument or principle is a valid predictor of the probability that a courtroom hypothesis is correct (“known or potential error rate”). To that end, the focus on widespread or general acceptance of scientific evidence – consistent with Frye but absent from Rule 702 – is notable here, as the scientific consensus at any moment is the rational basis for decision under the unyielding demands of courtroom litigation. Also consistent with Frye and contrary to the letter of Rule 702, Daubert emphasizes the need for evidence to reflect the consensus of the “relevant scientific community.” As highlighted below, the definition of relevance has become a battleground in efforts to reform the use of forensic evidence. Rule 702 Evolves Rule 702 was substantially amended in 2000 to conform with Daubert and to promote a “more rigorous and structured approach” (31), in which the gatekeeping role was formally handed to judges. The Rule’s emphasis on the expert remained, but three “reliability” requirements were included in Rule 702–2000 (provisions b-d), which place constraints on the data, methods, principles, and their application by the expert: A witness who is qualified as an expert by knowledge, skill, experience, training, or education may testify in the form of an opinion or otherwise if: the expert’s scientific, technical, or other specialized knowledge will help the trier of fact to understand the evidence or to determine a fact in issue; the testimony is based on sufficient facts or data; (c) the testimony is the product of reliable principles and methods; and (d) the expert has reliably applied the principles and methods to the facts of the case. Rule 702 was revised again in 2022 (to take effect December 2023) through amendments proposed by the Advisory Committee on Evidence Rules and subsequently approved by the US Judicial Conference and the Supreme Court (32). For these efforts, Rule 702–2022 differs from the previous by two small text additions. One defines a preponderance of evidence (“more likely than not”) standard for demonstrating that the four provisions [702(a-d)] have been satisfied, which offers the gatekeeping judge a quantitative criterion for decisions about admissibility. The other clarifies that it is not the expert’s reliable application that matters, but rather that “the expert’s opinion reflects a reliable application,” which grants the trial judge the ability to bar opinions that exceed what can be reasonably concluded from the methods and principles applied. https://www.pnas.org/doi/full/10.1073/pnas.2301839120 ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. [user request] [context document]

What are V2G batteries and how do they work in Oakland Unified School District's new bussing system? What are the pros and are there any cons?

The wheels on this bus do indeed go round and round. Its wipers swish. And its horn beeps. Hidden in its innards, though, is something special — a motor that doesn’t vroom but pairs with a burgeoning technology that could help the grid proliferate with renewable energy. These new buses, developed by a company called Zum, ride clean and quiet because they’re fully electric. With them, California’s Oakland Unified School District just became the first major district in the United States to transition to 100 percent electrified buses. The vehicles are now transporting 1,300 students to and from school, replacing diesel-chugging buses that pollute the kids’ lungs and the neighborhoods with particulate matter. Like in other American cities, Oakland’s underserved areas tend to be closer to freeways and industrial activity, so air quality in those areas is already terrible compared to the city’s richer parts. Pollution from buses and other vehicles contributes to chronic asthma among students, which leads to chronic absenteeism. Since Oakland Unified only provides bus services for its special-need students, the problem of missing school for preventable health issues is particularly acute for them. “We have already seen the data — more kids riding the buses, that means more of our most vulnerable who are not missing school,” said Kyla Johnson-Trammell, superintendent of Oakland Unified School District, during a press conference Tuesday. “That, over time, means they’re having more learning and achievement goes up.” What’s more, a core challenge of weaning our society off fossil fuels is that utilities will need to produce more electricity, not less of it. “In some places, you’re talking about doubling the amount of energy needed,” said Kevin Schneider, an expert in power systems at Pacific Northwest National Laboratory, who isn’t involved in the Oakland project. Counterintuitively enough, the buses’ massive batteries aren’t straining the grid; they’re benefiting it. Like a growing number of consumer EV models, the buses are equipped with vehicle-to-grid technology, or V2G. That allows them to charge their batteries by plugging into the grid, but also send energy back to the grid if the electrical utility needs extra power. “School buses play a very important role in the community as a transportation provider, but now also as an energy provider,” said Vivek Garg, co-founder and chief operating officer of Zum. And provide the buses must. Demand on the grid tends to spike in the late afternoon, when everyone’s returning home and switching on appliances like air conditioners. Historically, utilities could just spin up more generation at a fossil fuel power plant to meet that demand. But as the grid is loaded with more renewable energy sources, intermittency becomes a challenge: You can’t crank up power in the system if the sun isn’t shining or the wind isn’t blowing. If every EV has V2G capability, that creates a distributed network of batteries for a utility to draw on when demand spikes. The nature of the school bus suits it perfectly for this, because it’s on a fixed schedule, making it a predictable resource for the utility. In the afternoon, Zum’s buses take kids home, then plug back into the grid. “They have more energy in each bus than they need to do their route, so there’s always an ample amount left over,” said Rudi Halbright, product manager of V2G integration at Pacific Gas and Electric Company, the utility that’s partnered with Zum and Oakland Unified for the new system. As the night goes on and demand wanes, the buses charge again to be ready for their morning routes. Then during the day, they charge again, when there’s plentiful solar power on the grid. On weekends or holidays, the buses would be available all day as backup power for the grid. “Sure, they’re going to take a very large amount of charge,” said Kevin Schneider, an expert in power systems at Pacific Northwest National Laboratory, who isn’t involved in the Oakland project. “But things like school buses don’t run that often, so they have a great potential to be a resource.” That resource ain’t free: Utilities pay owners of V2G vehicles to provide power to the grid. (Because V2G is so new, utilities are still experimenting with what this rate structure looks like.) Zum says that that revenue helps bring down the transportation costs of its buses to be on par with cheaper diesel-powered buses. Oakland Unified and other districts can get still more money from the EPA’s Clean School Bus Program, which is handing out $5 billion between 2022 and 2026 to make the switch. The potential of V2G is that there are so many different kinds of electric vehicles (or vehicle types left to electrify). Garbage trucks run early in the day, while delivery trucks and city vehicles do more of a nine-to-five. Passenger vehicles are kind of all over the place, with some people taking them to work, while others sit in garages all day. Basically, lots of batteries — big and small — parked idle at different times to send power back to the grid. All the while, fiercer heat waves will require more energy-hungry air conditioning to keep people healthy. (Though ideally, everyone would get a heat pump instead.) “We’re still going to need more generation, more power lines, but energy storage is going to give us the flexibility so we can deploy it quicker,” Schneider said. In the near future, you may get home on a sweltering day and still be able to switch on your AC — thanks to an electric school bus sitting in a lot.

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. What are V2G batteries and how do they work in Oakland Unified School District's new bussing system? What are the pros and are there any cons? The wheels on this bus do indeed go round and round. Its wipers swish. And its horn beeps. Hidden in its innards, though, is something special — a motor that doesn’t vroom but pairs with a burgeoning technology that could help the grid proliferate with renewable energy. These new buses, developed by a company called Zum, ride clean and quiet because they’re fully electric. With them, California’s Oakland Unified School District just became the first major district in the United States to transition to 100 percent electrified buses. The vehicles are now transporting 1,300 students to and from school, replacing diesel-chugging buses that pollute the kids’ lungs and the neighborhoods with particulate matter. Like in other American cities, Oakland’s underserved areas tend to be closer to freeways and industrial activity, so air quality in those areas is already terrible compared to the city’s richer parts. Pollution from buses and other vehicles contributes to chronic asthma among students, which leads to chronic absenteeism. Since Oakland Unified only provides bus services for its special-need students, the problem of missing school for preventable health issues is particularly acute for them. “We have already seen the data — more kids riding the buses, that means more of our most vulnerable who are not missing school,” said Kyla Johnson-Trammell, superintendent of Oakland Unified School District, during a press conference Tuesday. “That, over time, means they’re having more learning and achievement goes up.” What’s more, a core challenge of weaning our society off fossil fuels is that utilities will need to produce more electricity, not less of it. “In some places, you’re talking about doubling the amount of energy needed,” said Kevin Schneider, an expert in power systems at Pacific Northwest National Laboratory, who isn’t involved in the Oakland project. Counterintuitively enough, the buses’ massive batteries aren’t straining the grid; they’re benefiting it. Like a growing number of consumer EV models, the buses are equipped with vehicle-to-grid technology, or V2G. That allows them to charge their batteries by plugging into the grid, but also send energy back to the grid if the electrical utility needs extra power. “School buses play a very important role in the community as a transportation provider, but now also as an energy provider,” said Vivek Garg, co-founder and chief operating officer of Zum. And provide the buses must. Demand on the grid tends to spike in the late afternoon, when everyone’s returning home and switching on appliances like air conditioners. Historically, utilities could just spin up more generation at a fossil fuel power plant to meet that demand. But as the grid is loaded with more renewable energy sources, intermittency becomes a challenge: You can’t crank up power in the system if the sun isn’t shining or the wind isn’t blowing. If every EV has V2G capability, that creates a distributed network of batteries for a utility to draw on when demand spikes. The nature of the school bus suits it perfectly for this, because it’s on a fixed schedule, making it a predictable resource for the utility. In the afternoon, Zum’s buses take kids home, then plug back into the grid. “They have more energy in each bus than they need to do their route, so there’s always an ample amount left over,” said Rudi Halbright, product manager of V2G integration at Pacific Gas and Electric Company, the utility that’s partnered with Zum and Oakland Unified for the new system. As the night goes on and demand wanes, the buses charge again to be ready for their morning routes. Then during the day, they charge again, when there’s plentiful solar power on the grid. On weekends or holidays, the buses would be available all day as backup power for the grid. “Sure, they’re going to take a very large amount of charge,” said Kevin Schneider, an expert in power systems at Pacific Northwest National Laboratory, who isn’t involved in the Oakland project. “But things like school buses don’t run that often, so they have a great potential to be a resource.” That resource ain’t free: Utilities pay owners of V2G vehicles to provide power to the grid. (Because V2G is so new, utilities are still experimenting with what this rate structure looks like.) Zum says that that revenue helps bring down the transportation costs of its buses to be on par with cheaper diesel-powered buses. Oakland Unified and other districts can get still more money from the EPA’s Clean School Bus Program, which is handing out $5 billion between 2022 and 2026 to make the switch. The potential of V2G is that there are so many different kinds of electric vehicles (or vehicle types left to electrify). Garbage trucks run early in the day, while delivery trucks and city vehicles do more of a nine-to-five. Passenger vehicles are kind of all over the place, with some people taking them to work, while others sit in garages all day. Basically, lots of batteries — big and small — parked idle at different times to send power back to the grid. All the while, fiercer heat waves will require more energy-hungry air conditioning to keep people healthy. (Though ideally, everyone would get a heat pump instead.) “We’re still going to need more generation, more power lines, but energy storage is going to give us the flexibility so we can deploy it quicker,” Schneider said. In the near future, you may get home on a sweltering day and still be able to switch on your AC — thanks to an electric school bus sitting in a lot. https://grist.org/transportation/oakland-electric-school-buses-battery-storage/

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== [user request] {passage 0} ========== [context document]

In what ways does the implementation of Zero-Trust architecture transform an organization's cybersecurity strategy, specifically with regard to tackling the obstacles presented by antiquated technologies, societal opposition, and the requirement for expandability? Talk about how the fundamental elements of Zero-Trust, such network segmentation, device security, and identity verification, improve security resilience while taking into account how difficult it is to apply this paradigm in contemporary digital contexts.

Globally, today’s organizations are increasingly vulnerable to a wide array of cybersecurity threats. These range from sophisticated phishing schemes to aggressive ransomware attacks, underscoring the urgent need for more effective security frameworks. Among the most promising of these frameworks is Zero-Trust Architecture (ZTA), a cybersecurity strategy that fundamentally abandons the traditional assumption that everything inside an organization’s network should be trusted. Instead, Zero-Trust operates on a foundational principle of “never trust, always verify,” applying strict access controls and continuous verification to every access request, regardless of origin. This approach challenges the conventional perimeter-centric model of security, which relies on defending the boundary between ‘safe’ internal networks and ‘unsafe’ external ones. In the Zero-Trust model, trust is neither location-dependent nor static; it is contingent on dynamic, context-based policies that evaluate each request for network access on its own merits, incorporating user identity, device security posture, and other behavioral analytics. The importance of Zero-Trust Architecture in modern cybersecurity cannot be overstated. As digital transformation accelerates and organizations adopt cloud technologies and mobile workforces, the traditional security perimeter has dissolved, creating new vulnerabilities and attack surfaces. Zero-Trust addresses these challenges by securing an environment where users, devices, applications, and data are distributed globally, thus necessitating robust mechanisms for protecting data not just at the perimeter, but at every point of digital interaction. By verifying all entities and enforcing strict access controls, Zero-Trust helps prevent unauthorized access and contains lateral movement within the network, significantly enhancing the organization’s overall security posture and resilience against cyber threats. Core Components of Zero-Trust Architecture Zero-Trust Architecture dismantles the old network security model that relies on a secure perimeter and instead uses several core components that enforce its strict security protocols. These components work in unison to ensure that security is maintained not just at the edges, but throughout the network by continuously verifying and limiting access. Identity Verification: At the heart of Zero-Trust is robust identity and access management (IAM), which ensures that only verified users and devices can access network resources. IAM systems utilize advanced authentication methods, such as multi-factor authentication (MFA), to verify identities reliably before granting access. Device Security: Each device attempting to access the network must be secured and compliant with the organization’s security policies. Zero-Trust frameworks often employ device security enforcement mechanisms like endpoint security solutions, which assess devices for compliance before allowing connection to the network. Network Segmentation: This involves dividing the network into smaller, manageable segments, each with its own strict access controls. Network segmentation limits the potential damage in case of a breach by isolating segments from one another, thereby preventing an attacker from moving laterally across the network. Least Privilege Access: This principle ensures that users and devices are granted the minimum level of access necessary to perform their functions. Access rights are strictly controlled and regularly reviewed to ensure they are appropriate, reducing the risk of insider threats and data breaches. Real-Time Threat Detection and Response: Zero-Trust architectures utilize advanced monitoring tools to detect and respond to threats in real-time. These systems analyze network traffic and user behavior to identify suspicious activities, enabling immediate response to potential security incidents. Implementation Strategy Implementing Zero-Trust Architecture requires a strategic approach that encompasses assessing existing infrastructures, designing appropriate security frameworks, and integrating advanced technologies. This section outlines a clear path for organizations to follow, ensuring a comprehensive and secure transition to a Zero-Trust environment. Assessing Current Security Posture and Infrastructure: Begin by conducting a thorough audit of your current security measures and network architecture. This assessment should identify vulnerabilities, outdated systems, and areas lacking sufficient protection, providing a baseline for the Zero-Trust implementation. Identifying Sensitive Data and Systems: Determine which data and systems are critical to the organization’s operations and require higher levels of security. This step involves mapping out data flows and understanding where sensitive information resides and how it is accessed. Designing a Zero-Trust Network Architecture: Based on the assessments, design a network architecture that incorporates Zero-Trust principles such as micro-segmentation and least privilege. This design should ensure that security is enforceable and effective at every layer of the network. Deploying Zero-Trust Policies and Controls: Implement policies that enforce strict identity verification, device compliance, and access controls based on the least privilege principle. These policies should be dynamically applied and capable of adapting to changes in the threat landscape and organizational needs. Continuous Evaluation and Adaptation of Security Measures: Zero-Trust is not a set-and-forget solution; it requires ongoing evaluation and adaptation. Regularly review and update security policies, controls, and system configurations to keep up with evolving security threats and technological advances. Challenges in Adopting Zero-Trust Architecture Adopting Zero-Trust Architecture presents several challenges that organizations must navigate to ensure a successful transition. One of the primary hurdles is cultural resistance within the organization. Zero-Trust necessitates a shift from the traditional security mindset, which can be substantial as it changes fundamental aspects of how employees access systems and data. Employees and management alike may be wary of the increased security measures, viewing them as obstacles to productivity rather than enhancements to security. Overcoming this cultural barrier requires thorough training and clear communication to demonstrate the benefits and necessity of a Zero-Trust approach, emphasizing its role in safeguarding both personal and organizational data. Another significant challenge is the complexity and cost associated with implementing a Zero-Trust model, particularly when integrating with legacy systems. Many organizations operate on outdated infrastructure that is not readily compatible with Zero-Trust principles, making the transition technically challenging and financially demanding. Upgrading these systems or finding workarounds often involves substantial time and resource investment. Additionally, scalability can pose difficulties as organizations grow and their network environments become more complex. Ensuring that the Zero-Trust architecture can scale effectively without compromising security or performance requires continuous adaptation and possibly significant changes to the network and security infrastructure. These challenges demand a committed, strategic approach to ensure that the security architecture can evolve in tandem with the organization. ​​Zero-Trust Architecture stands as a transformative approach in the realm of cybersecurity, shifting the traditional security paradigm to effectively combat the increasing frequency and sophistication of cyber threats. By fundamentally rejecting the notion of inherent trust within the network, ZTA introduces a rigorous framework of continuous verification and strict access controls that adapt to the complexities of modern digital environments. Implementing this architecture involves a comprehensive redesign of security systems—from identity verification and device security to network segmentation and real-time threat detection. Despite its challenges, the strategic adoption of Zero-Trust principles significantly strengthens an organization’s defense mechanisms. It not only prevents unauthorized access but also minimizes the impact of potential breaches, thereby enhancing overall security resilience. Thus, as organizations continue to evolve and expand their digital footprints, embracing Zero-Trust Architecture becomes crucial for maintaining robust and dynamic cybersecurity defenses in an increasingly vulnerable global landscape.

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== In what ways does the implementation of Zero-Trust architecture transform an organization's cybersecurity strategy, specifically with regard to tackling the obstacles presented by antiquated technologies, societal opposition, and the requirement for expandability? Talk about how the fundamental elements of Zero-Trust, such network segmentation, device security, and identity verification, improve security resilience while taking into account how difficult it is to apply this paradigm in contemporary digital contexts. {passage 0} ========== Globally, today’s organizations are increasingly vulnerable to a wide array of cybersecurity threats. These range from sophisticated phishing schemes to aggressive ransomware attacks, underscoring the urgent need for more effective security frameworks. Among the most promising of these frameworks is Zero-Trust Architecture (ZTA), a cybersecurity strategy that fundamentally abandons the traditional assumption that everything inside an organization’s network should be trusted. Instead, Zero-Trust operates on a foundational principle of “never trust, always verify,” applying strict access controls and continuous verification to every access request, regardless of origin. This approach challenges the conventional perimeter-centric model of security, which relies on defending the boundary between ‘safe’ internal networks and ‘unsafe’ external ones. In the Zero-Trust model, trust is neither location-dependent nor static; it is contingent on dynamic, context-based policies that evaluate each request for network access on its own merits, incorporating user identity, device security posture, and other behavioral analytics. The importance of Zero-Trust Architecture in modern cybersecurity cannot be overstated. As digital transformation accelerates and organizations adopt cloud technologies and mobile workforces, the traditional security perimeter has dissolved, creating new vulnerabilities and attack surfaces. Zero-Trust addresses these challenges by securing an environment where users, devices, applications, and data are distributed globally, thus necessitating robust mechanisms for protecting data not just at the perimeter, but at every point of digital interaction. By verifying all entities and enforcing strict access controls, Zero-Trust helps prevent unauthorized access and contains lateral movement within the network, significantly enhancing the organization’s overall security posture and resilience against cyber threats. Core Components of Zero-Trust Architecture Zero-Trust Architecture dismantles the old network security model that relies on a secure perimeter and instead uses several core components that enforce its strict security protocols. These components work in unison to ensure that security is maintained not just at the edges, but throughout the network by continuously verifying and limiting access. Identity Verification: At the heart of Zero-Trust is robust identity and access management (IAM), which ensures that only verified users and devices can access network resources. IAM systems utilize advanced authentication methods, such as multi-factor authentication (MFA), to verify identities reliably before granting access. Device Security: Each device attempting to access the network must be secured and compliant with the organization’s security policies. Zero-Trust frameworks often employ device security enforcement mechanisms like endpoint security solutions, which assess devices for compliance before allowing connection to the network. Network Segmentation: This involves dividing the network into smaller, manageable segments, each with its own strict access controls. Network segmentation limits the potential damage in case of a breach by isolating segments from one another, thereby preventing an attacker from moving laterally across the network. Least Privilege Access: This principle ensures that users and devices are granted the minimum level of access necessary to perform their functions. Access rights are strictly controlled and regularly reviewed to ensure they are appropriate, reducing the risk of insider threats and data breaches. Real-Time Threat Detection and Response: Zero-Trust architectures utilize advanced monitoring tools to detect and respond to threats in real-time. These systems analyze network traffic and user behavior to identify suspicious activities, enabling immediate response to potential security incidents. Implementation Strategy Implementing Zero-Trust Architecture requires a strategic approach that encompasses assessing existing infrastructures, designing appropriate security frameworks, and integrating advanced technologies. This section outlines a clear path for organizations to follow, ensuring a comprehensive and secure transition to a Zero-Trust environment. Assessing Current Security Posture and Infrastructure: Begin by conducting a thorough audit of your current security measures and network architecture. This assessment should identify vulnerabilities, outdated systems, and areas lacking sufficient protection, providing a baseline for the Zero-Trust implementation. Identifying Sensitive Data and Systems: Determine which data and systems are critical to the organization’s operations and require higher levels of security. This step involves mapping out data flows and understanding where sensitive information resides and how it is accessed. Designing a Zero-Trust Network Architecture: Based on the assessments, design a network architecture that incorporates Zero-Trust principles such as micro-segmentation and least privilege. This design should ensure that security is enforceable and effective at every layer of the network. Deploying Zero-Trust Policies and Controls: Implement policies that enforce strict identity verification, device compliance, and access controls based on the least privilege principle. These policies should be dynamically applied and capable of adapting to changes in the threat landscape and organizational needs. Continuous Evaluation and Adaptation of Security Measures: Zero-Trust is not a set-and-forget solution; it requires ongoing evaluation and adaptation. Regularly review and update security policies, controls, and system configurations to keep up with evolving security threats and technological advances. Challenges in Adopting Zero-Trust Architecture Adopting Zero-Trust Architecture presents several challenges that organizations must navigate to ensure a successful transition. One of the primary hurdles is cultural resistance within the organization. Zero-Trust necessitates a shift from the traditional security mindset, which can be substantial as it changes fundamental aspects of how employees access systems and data. Employees and management alike may be wary of the increased security measures, viewing them as obstacles to productivity rather than enhancements to security. Overcoming this cultural barrier requires thorough training and clear communication to demonstrate the benefits and necessity of a Zero-Trust approach, emphasizing its role in safeguarding both personal and organizational data. Another significant challenge is the complexity and cost associated with implementing a Zero-Trust model, particularly when integrating with legacy systems. Many organizations operate on outdated infrastructure that is not readily compatible with Zero-Trust principles, making the transition technically challenging and financially demanding. Upgrading these systems or finding workarounds often involves substantial time and resource investment. Additionally, scalability can pose difficulties as organizations grow and their network environments become more complex. Ensuring that the Zero-Trust architecture can scale effectively without compromising security or performance requires continuous adaptation and possibly significant changes to the network and security infrastructure. These challenges demand a committed, strategic approach to ensure that the security architecture can evolve in tandem with the organization. ​​Zero-Trust Architecture stands as a transformative approach in the realm of cybersecurity, shifting the traditional security paradigm to effectively combat the increasing frequency and sophistication of cyber threats. By fundamentally rejecting the notion of inherent trust within the network, ZTA introduces a rigorous framework of continuous verification and strict access controls that adapt to the complexities of modern digital environments. Implementing this architecture involves a comprehensive redesign of security systems—from identity verification and device security to network segmentation and real-time threat detection. Despite its challenges, the strategic adoption of Zero-Trust principles significantly strengthens an organization’s defense mechanisms. It not only prevents unauthorized access but also minimizes the impact of potential breaches, thereby enhancing overall security resilience. Thus, as organizations continue to evolve and expand their digital footprints, embracing Zero-Trust Architecture becomes crucial for maintaining robust and dynamic cybersecurity defenses in an increasingly vulnerable global landscape. https://agileblue.com/zero-trust-architecture-implementation-and-challenges/

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> [user request] <TEXT> [context document]

I'm tired of wearing eye-sight glasses now and planning laser surgery for my eyes. The issue is I have a very thin cornea, so will I be considered an unsuitable candidate for laser eye surgery, and what other factors could disqualify a person from undergoing the procedure?

The eye has an outer layer called the cornea. Some people’s corneas can undergo changes in their shape, leading to vision issues, such as astigmatism and myopia. Laser eye surgery is a medical procedure that reshapes this layer. Precisely how laser eye surgery reshapes the cornea depends on the vision condition that the treatment aims to correct. Laser eye surgery can fix vision issues, such as nearsightedness and farsightedness. The surgery is quick, and people remain awake throughout the procedure. It is also usually painless — if a person experiences pain, it usually indicates there have been complications. This article discusses what laser eye surgery is, who it can help, costs, duration of the surgery, recovery time, and any associated short- and long-term risks. What is laser eye surgery (LASIK or PRK) SCIENCE PHOTO LIBRARY/Getty Images LASIK stands for laser-assisted in situ keratomileusis and is the most common type of refractive eye surgery. LASIK was first patented in 1989 and has become the most commonTrusted Source treatment for refractive eye errors. The procedure involves lasers to reshape the cornea. Who may it help? According to the American Academy of Ophthalmology, over 150 million Americans use corrective eyewear, such as glasses or contact lenses, to compensate for refractive errors. Refractive errors occur when the eye does not bend — or refract — the light to properly focus on the retina in the back of the eye. This is usually due to the shape of the cornea. Farsightedness The clinical name for farsightedness is hyperopia. People with this condition can see objects in the distance clearly, but other things can appear blurry at close distance. Farsightedness is due to the curvature of the cornea being too flat. Laser eye surgery can correct this by reshaping the cornea to have a steeper curve. Nearsightedness Nearsightedness, known as myopia or short-sightedness, is where a person can see objects close to them clearly. However, distant objects can appear blurred. This is due to the curvature of the cornea being too steep. Healthcare professionals can correct this through laser eye surgery by reshaping the cornea. Astigmatism People with astigmatism have a differently-shaped eye that characterizes this condition. The eye of someone without the condition is round, like a soccer ball, while with astigmatism, the eye may have more of a football-like shape. It is possible to correct this irregular curvature of the cornea with laser eye surgery in some cases. Get our Eye Health Newsletter Receive expert advice, tips to manage your symptoms, and the latest on condition breakthroughs delivered straight to your inbox. Enter your email Also sign up for our popular Heart Health newsletter Your privacy is important to us People who are not suitableTrusted Source candidates for laser eye surgery include those who: have had a change in their eye prescription in the last 12 months take medications that may cause changes in vision are in their 20s or younger, although some experts recommend not being under 18 years have thin corneas, which may not be stable following laser surgery are pregnant or nursing Benefits The main benefit of laser eye surgery is that mostTrusted Source people no longer have to wear corrective eyewear to see clearly. Individuals may choose to undergo the procedure for several reasons, including: being unable to wear contact lenses but preferring not to wear glasses, perhaps for cosmetic reasons wishing to undertake activities, such as sports, that require a person not to wear glasses or contact lenses having the convenience of not having to wear corrective eyewear A person is more at riskTrusted Source of developing complications if they have the followingTrusted Source eye conditions: eye infections, such as keratitis or ocular herpes significant cataracts — people with this condition will not have corrected vision after laser surgery glaucoma large pupils keratoconus, a disease that makes the cornea thinner and unstable over time As with all surgeries, a person may experience complications, including: Dry eyes: Up to 95%Trusted Source of people who have laser eye surgery may experience dry eyes after the procedure, where the eyes produce fewer tears. Lubricating eye drops can help with this symptom. Glare or halo: 20% of people undergoing laser eye surgery may experience visual changes such as glare, halo, or sensitivity to light. Double or blurry vision: As many as 1 in 50 people may report blurriness and feel there is something in their eyes. Diffuse lamellar keratitis — also called “sands of Sahara” syndrome — may be the cause. Other complications a person may experience include: eye infection corneal flap complications red or bloodshot whites of the eye Most symptoms should resolve after the first few days, so an individual experiencing any symptoms after this time should consult with a medical professional. The Food & Drug Administration (FDA) suggests laser eye surgery usually takes less than 30 minutesTrusted Source. Others estimate the procedure will take around 5 minutes per eye. People undergoing laser eye surgery should expect the following: They will sit in a chair and recline, so they are flat on their back underneath a laser device and computer screen. The surgical team will clean the area around the eye and place numbing drops in the eye. Surgeons will use a lid speculum, a medical instrument, to hold the eyelids open. A laser will cut a flap in the cornea, and the surgeon will then lift this open. People will need to stare at a light to keep their eyes still while the laser works. The laser will then reshape the surface of the cornea. The surgeon will then place the flap back into position and apply a shield to protect the eye. Recovery time The FDATrusted Source notes that after surgery, a person may feel as though their eye is burning, itchy, or that there is a foreign object present. The surgeon may recommend a mild pain reliever, such as acetaminophen, to help with these sensations. Surgeons will provide people with an eye shield to protect their eyes, as there will be no stitches holding the flap in place. The guard helps prevent rubbing the eye or accidentally applying pressure, such as during sleep. Individuals will usually take a few days off from work so they can recover. They should schedule an appointment to see their eye doctor within the first 24–48 hours after surgery to undergo an eye examination. The doctor will make sure the eyes are healing as they should. After this, a person will need several additional appointments over the first 6 months. Results It may take up to 6 monthsTrusted Source for a person’s vision to stabilize after laser eye surgery. They may notice their vision fluctuates for a while after the procedure, but this should not be a cause for concern. However, it is common for vision to vary for the initial few months following surgery. Additionally, sometimes laser eye surgery may accidentally over- or under-correct a person’s sight. This might require further surgery to rectify, which healthcare professionals usually called enhancement. It is also important to remember that corrected vision can regress years after the procedure. The cost of LASIK surgery will be different depending on where the person lives. Other surgeons may use various equipment or techniques, which the price may reflect. Health insurance companies usually categorize LASIK as an elective or cosmetic procedure and do not typically cover these treatments. In 2020, the American Refractive Surgery Council estimated that LASIK surgery might cost around $4,200 per eye, on average. Although laser eye surgery can be expensive, it is crucial that people thoroughly do their research before undergoing treatment at reduced prices. There may be a reason the price is so low, which may increase the risk of complications.

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> I'm tired of wearing eye-sight glasses now and planning laser surgery for my eyes. The issue is I have a very thin cornea, so will I be considered an unsuitable candidate for laser eye surgery, and what other factors could disqualify a person from undergoing the procedure? <TEXT> The eye has an outer layer called the cornea. Some people’s corneas can undergo changes in their shape, leading to vision issues, such as astigmatism and myopia. Laser eye surgery is a medical procedure that reshapes this layer. Precisely how laser eye surgery reshapes the cornea depends on the vision condition that the treatment aims to correct. Laser eye surgery can fix vision issues, such as nearsightedness and farsightedness. The surgery is quick, and people remain awake throughout the procedure. It is also usually painless — if a person experiences pain, it usually indicates there have been complications. This article discusses what laser eye surgery is, who it can help, costs, duration of the surgery, recovery time, and any associated short- and long-term risks. What is laser eye surgery (LASIK or PRK) SCIENCE PHOTO LIBRARY/Getty Images LASIK stands for laser-assisted in situ keratomileusis and is the most common type of refractive eye surgery. LASIK was first patented in 1989 and has become the most commonTrusted Source treatment for refractive eye errors. The procedure involves lasers to reshape the cornea. Who may it help? According to the American Academy of Ophthalmology, over 150 million Americans use corrective eyewear, such as glasses or contact lenses, to compensate for refractive errors. Refractive errors occur when the eye does not bend — or refract — the light to properly focus on the retina in the back of the eye. This is usually due to the shape of the cornea. Farsightedness The clinical name for farsightedness is hyperopia. People with this condition can see objects in the distance clearly, but other things can appear blurry at close distance. Farsightedness is due to the curvature of the cornea being too flat. Laser eye surgery can correct this by reshaping the cornea to have a steeper curve. Nearsightedness Nearsightedness, known as myopia or short-sightedness, is where a person can see objects close to them clearly. However, distant objects can appear blurred. This is due to the curvature of the cornea being too steep. Healthcare professionals can correct this through laser eye surgery by reshaping the cornea. Astigmatism People with astigmatism have a differently-shaped eye that characterizes this condition. The eye of someone without the condition is round, like a soccer ball, while with astigmatism, the eye may have more of a football-like shape. It is possible to correct this irregular curvature of the cornea with laser eye surgery in some cases. Get our Eye Health Newsletter Receive expert advice, tips to manage your symptoms, and the latest on condition breakthroughs delivered straight to your inbox. Enter your email Also sign up for our popular Heart Health newsletter Your privacy is important to us People who are not suitableTrusted Source candidates for laser eye surgery include those who: have had a change in their eye prescription in the last 12 months take medications that may cause changes in vision are in their 20s or younger, although some experts recommend not being under 18 years have thin corneas, which may not be stable following laser surgery are pregnant or nursing Benefits The main benefit of laser eye surgery is that mostTrusted Source people no longer have to wear corrective eyewear to see clearly. Individuals may choose to undergo the procedure for several reasons, including: being unable to wear contact lenses but preferring not to wear glasses, perhaps for cosmetic reasons wishing to undertake activities, such as sports, that require a person not to wear glasses or contact lenses having the convenience of not having to wear corrective eyewear A person is more at riskTrusted Source of developing complications if they have the followingTrusted Source eye conditions: eye infections, such as keratitis or ocular herpes significant cataracts — people with this condition will not have corrected vision after laser surgery glaucoma large pupils keratoconus, a disease that makes the cornea thinner and unstable over time As with all surgeries, a person may experience complications, including: Dry eyes: Up to 95%Trusted Source of people who have laser eye surgery may experience dry eyes after the procedure, where the eyes produce fewer tears. Lubricating eye drops can help with this symptom. Glare or halo: 20% of people undergoing laser eye surgery may experience visual changes such as glare, halo, or sensitivity to light. Double or blurry vision: As many as 1 in 50 people may report blurriness and feel there is something in their eyes. Diffuse lamellar keratitis — also called “sands of Sahara” syndrome — may be the cause. Other complications a person may experience include: eye infection corneal flap complications red or bloodshot whites of the eye Most symptoms should resolve after the first few days, so an individual experiencing any symptoms after this time should consult with a medical professional. The Food & Drug Administration (FDA) suggests laser eye surgery usually takes less than 30 minutesTrusted Source. Others estimate the procedure will take around 5 minutes per eye. People undergoing laser eye surgery should expect the following: They will sit in a chair and recline, so they are flat on their back underneath a laser device and computer screen. The surgical team will clean the area around the eye and place numbing drops in the eye. Surgeons will use a lid speculum, a medical instrument, to hold the eyelids open. A laser will cut a flap in the cornea, and the surgeon will then lift this open. People will need to stare at a light to keep their eyes still while the laser works. The laser will then reshape the surface of the cornea. The surgeon will then place the flap back into position and apply a shield to protect the eye. Recovery time The FDATrusted Source notes that after surgery, a person may feel as though their eye is burning, itchy, or that there is a foreign object present. The surgeon may recommend a mild pain reliever, such as acetaminophen, to help with these sensations. Surgeons will provide people with an eye shield to protect their eyes, as there will be no stitches holding the flap in place. The guard helps prevent rubbing the eye or accidentally applying pressure, such as during sleep. Individuals will usually take a few days off from work so they can recover. They should schedule an appointment to see their eye doctor within the first 24–48 hours after surgery to undergo an eye examination. The doctor will make sure the eyes are healing as they should. After this, a person will need several additional appointments over the first 6 months. Results It may take up to 6 monthsTrusted Source for a person’s vision to stabilize after laser eye surgery. They may notice their vision fluctuates for a while after the procedure, but this should not be a cause for concern. However, it is common for vision to vary for the initial few months following surgery. Additionally, sometimes laser eye surgery may accidentally over- or under-correct a person’s sight. This might require further surgery to rectify, which healthcare professionals usually called enhancement. It is also important to remember that corrected vision can regress years after the procedure. The cost of LASIK surgery will be different depending on where the person lives. Other surgeons may use various equipment or techniques, which the price may reflect. Health insurance companies usually categorize LASIK as an elective or cosmetic procedure and do not typically cover these treatments. In 2020, the American Refractive Surgery Council estimated that LASIK surgery might cost around $4,200 per eye, on average. Although laser eye surgery can be expensive, it is crucial that people thoroughly do their research before undergoing treatment at reduced prices. There may be a reason the price is so low, which may increase the risk of complications. https://www.medicalnewstoday.com/articles/laser-eye-surgery#summary

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

I have sleep apnea and just found out I am pregnant. I want to know what effect my sleep apnea will have on my pregnancy. Using this article, please explain the symptoms, risks, and treatments. Use at least 400 words.

What to Do About Sleep Apnea During Pregnancy Suddenly snoring all the time in pregnancy? It could be a symptom of sleep apnea. Here are the major signs to have on your radar, plus what to do next. save article Save this article to view it later on your Bump dashboard . It’s free! profile picture of Korin Miller By Korin Miller Updated May 3, 2024 Medically Reviewed by Kendra Segura, MD|Fact Checked by Denise Porretto pregnant woman sleeping in bed at night Image: PR Image Factory | Shutterstock Getting plenty of rest is crucial during pregnancy, but unfortunately you might also notice more sleep disturbances while you’re expecting. If you’ve been snoring or you’re suddenly dealing with morning headaches, you could be dealing with sleep apnea during pregnancy. While sleep apnea is a common condition outside of pregnancy, being an expectant mom raises your risk of developing it. Research has found that anywhere from 3 to 27 percent of pregnant women experience obstructive sleep apnea, depending on gestational age (it’s more common toward the third trimester) and method of diagnosis. So what’s the connection between sleep apnea and pregnancy, and what should you do if you suspect you have it? Ahead, experts explain risk factors, treatment and more. In this article: What is obstructive sleep apnea? Can pregnancy cause sleep apnea? Risk factors for sleep apnea in pregnancy Symptoms of sleep apnea in pregnancy How to treat sleep apnea during pregnancy When to see your doctor What Is Obstructive Sleep Apnea? Sleep apnea is a common condition in which your breathing stops and starts several times while you sleep, preventing your body from getting enough oxygen, the National Heart, Lung, and Blood Institute (NHLBI) explains. Sleep apnea is classified into two categories: obstructive sleep apnea and central sleep apnea. Obstructive sleep apnea, the more common type, is when your upper airway becomes blocked several times while you sleep, reducing or completely stopping airflow, the NHLBI says. Central sleep apnea happens when your brain doesn’t send the signals you need to breathe, which can be caused by another health condition. Obstructive sleep apnea “increases the carbon dioxide level in your blood, which makes your brain force you to wake up—briefly—to breathe,” says Jade Wu, PhD, a board-certified behavioral sleep medicine specialist and author of Hello Sleep: The Science and Art of Overcoming Insomnia without Medications. This can happen multiple times an hour or even as often as every two minutes or more during the night, she says. “Most people who have it don’t realize it because they don’t become fully awake each time they have an apnea,” Wu adds. Related Video Pregnancy Symptoms 101: Pregnancy Gas Obstructive sleep apnea “fragments sleep and reduces sleep quality,” says Christopher Winter, MD, a neurologist and sleep medicine physician with Charlottesville Neurology and Sleep Medicine and host of the Sleep Unplugged podcast. Can Pregnancy Cause Sleep Apnea? While sleep apnea is fairly common outside of pregnancy, pregnancy can “absolutely” increase the risk of developing the condition, Winter says. The main reasons there’s a connection between sleep apnea and pregnancy are: Weight gain. The risk of developing obstructive sleep apnea increases as you gain weight in pregnancy, Winter says. In addition to your body weight increasing, your breast tissue may grow and add more weight to your chest, increasing the risk of sleep apnea, Wu says. Anatomical factors. “Just the presence of baby pushing up into the chest cavity can change breathing dynamics,” Winter says. Hormonal changes. Pregnancy hormones are no joke. “Estrogen increases can cause nasal congestion, which makes it harder to breathe,” Wu says. Risk Factors for Sleep Apnea in Pregnancy A few factors can raise your risk of developing sleep apnea in pregnancy. “The biggest risk factor is having a history of sleep apnea or snoring before pregnancy,” Wu says. Having obesity before you become pregnant also raises your risk, Winter says. Other risk factors, according to the NHLBI, include: A family history of obstructive sleep apnea Having heart or kidney failure Being older Having large tonsils and a thick neck Symptoms of Sleep Apnea in Pregnancy The biggest symptom of sleep apnea during pregnancy is snoring, Wu says. (Of course, most people don’t know they snore, so you might just hear about this from your partner or another person you live with.) But snoring doesn’t necessarily mean that you have obstructive sleep apnea, Wu says. There are a few other symptoms to have on your radar, according to Winter: Feeling especially tired during the day Waking up with a headache Atypical weight gain for pregnancy Peeing a lot Snoring or choking during your sleep Elevated blood pressure Fragmented sleep How to Treat Sleep Apnea During Pregnancy There’s a range of treatment options when it comes to sleep apnea during pregnancy. Wu says doctors usually treat milder cases of obstructive sleep apnea with the following: Having you sleep on your side Suggesting using a wedge pillow to help keep your airway open when you sleep Suggesting using a dental device to help keep your jaw forward when you sleep If you have moderate to severe sleep apnea, your doctor will likely recommend that you use a continuous positive airway pressure machine (CPAP), Winter says. This provides continuous air pressure throughout your airways while you sleep to keep them open and help you breathe, the NHLBI says. Wu says that this form of therapy “has gotten so advanced that they can be quite comfortable and unobtrusive.” She adds, “I’ve had plenty of patients say they feel soothed by their CPAP and can’t settle down to sleep without it now.” When to See Your Doctor If you think you have symptoms of obstructive sleep apnea, Wu says it’s time to reach out to your provider. “One major problem with obstructive sleep apnea is that it can take a long time to get in to see a sleep specialist and to get the testing required to be diagnosed and treated,” she says. There’s not a lot of data on whether obstructive sleep apnea in pregnancy will continue after baby’s born. “Risk for obstructive sleep apnea should go down after baby’s born, but it’s very possible that once you’ve had it, you continue to have elevated risk,” Wu says. “It’s important to keep follow-ups with your sleep doctor to continue to monitor symptoms.” Please note: The Bump and the materials and information it contains are not intended to, and do not constitute, medical or other health advice or diagnosis and should not be used as such. You should always consult with a qualified physician or health professional about your specific circumstances. Plus, more from The Bump: These Are the Safest Pregnancy Sleeping Positions Natural Remedies to Help You Sleep Better During Pregnancy The 13 Best Pregnancy Pillows, According to Pregnant Moms Sources save article Was this article helpful? Already a member? Log In

"================ <TEXT PASSAGE> ======= What to Do About Sleep Apnea During Pregnancy Suddenly snoring all the time in pregnancy? It could be a symptom of sleep apnea. Here are the major signs to have on your radar, plus what to do next. save article Save this article to view it later on your Bump dashboard . It’s free! profile picture of Korin Miller By Korin Miller Updated May 3, 2024 Medically Reviewed by Kendra Segura, MD|Fact Checked by Denise Porretto pregnant woman sleeping in bed at night Image: PR Image Factory | Shutterstock Getting plenty of rest is crucial during pregnancy, but unfortunately you might also notice more sleep disturbances while you’re expecting. If you’ve been snoring or you’re suddenly dealing with morning headaches, you could be dealing with sleep apnea during pregnancy. While sleep apnea is a common condition outside of pregnancy, being an expectant mom raises your risk of developing it. Research has found that anywhere from 3 to 27 percent of pregnant women experience obstructive sleep apnea, depending on gestational age (it’s more common toward the third trimester) and method of diagnosis. So what’s the connection between sleep apnea and pregnancy, and what should you do if you suspect you have it? Ahead, experts explain risk factors, treatment and more. In this article: What is obstructive sleep apnea? Can pregnancy cause sleep apnea? Risk factors for sleep apnea in pregnancy Symptoms of sleep apnea in pregnancy How to treat sleep apnea during pregnancy When to see your doctor What Is Obstructive Sleep Apnea? Sleep apnea is a common condition in which your breathing stops and starts several times while you sleep, preventing your body from getting enough oxygen, the National Heart, Lung, and Blood Institute (NHLBI) explains. Sleep apnea is classified into two categories: obstructive sleep apnea and central sleep apnea. Obstructive sleep apnea, the more common type, is when your upper airway becomes blocked several times while you sleep, reducing or completely stopping airflow, the NHLBI says. Central sleep apnea happens when your brain doesn’t send the signals you need to breathe, which can be caused by another health condition. Obstructive sleep apnea “increases the carbon dioxide level in your blood, which makes your brain force you to wake up—briefly—to breathe,” says Jade Wu, PhD, a board-certified behavioral sleep medicine specialist and author of Hello Sleep: The Science and Art of Overcoming Insomnia without Medications. This can happen multiple times an hour or even as often as every two minutes or more during the night, she says. “Most people who have it don’t realize it because they don’t become fully awake each time they have an apnea,” Wu adds. Related Video Pregnancy Symptoms 101: Pregnancy Gas Obstructive sleep apnea “fragments sleep and reduces sleep quality,” says Christopher Winter, MD, a neurologist and sleep medicine physician with Charlottesville Neurology and Sleep Medicine and host of the Sleep Unplugged podcast. Can Pregnancy Cause Sleep Apnea? While sleep apnea is fairly common outside of pregnancy, pregnancy can “absolutely” increase the risk of developing the condition, Winter says. The main reasons there’s a connection between sleep apnea and pregnancy are: Weight gain. The risk of developing obstructive sleep apnea increases as you gain weight in pregnancy, Winter says. In addition to your body weight increasing, your breast tissue may grow and add more weight to your chest, increasing the risk of sleep apnea, Wu says. Anatomical factors. “Just the presence of baby pushing up into the chest cavity can change breathing dynamics,” Winter says. Hormonal changes. Pregnancy hormones are no joke. “Estrogen increases can cause nasal congestion, which makes it harder to breathe,” Wu says. Risk Factors for Sleep Apnea in Pregnancy A few factors can raise your risk of developing sleep apnea in pregnancy. “The biggest risk factor is having a history of sleep apnea or snoring before pregnancy,” Wu says. Having obesity before you become pregnant also raises your risk, Winter says. Other risk factors, according to the NHLBI, include: A family history of obstructive sleep apnea Having heart or kidney failure Being older Having large tonsils and a thick neck Symptoms of Sleep Apnea in Pregnancy The biggest symptom of sleep apnea during pregnancy is snoring, Wu says. (Of course, most people don’t know they snore, so you might just hear about this from your partner or another person you live with.) But snoring doesn’t necessarily mean that you have obstructive sleep apnea, Wu says. There are a few other symptoms to have on your radar, according to Winter: Feeling especially tired during the day Waking up with a headache Atypical weight gain for pregnancy Peeing a lot Snoring or choking during your sleep Elevated blood pressure Fragmented sleep How to Treat Sleep Apnea During Pregnancy There’s a range of treatment options when it comes to sleep apnea during pregnancy. Wu says doctors usually treat milder cases of obstructive sleep apnea with the following: Having you sleep on your side Suggesting using a wedge pillow to help keep your airway open when you sleep Suggesting using a dental device to help keep your jaw forward when you sleep If you have moderate to severe sleep apnea, your doctor will likely recommend that you use a continuous positive airway pressure machine (CPAP), Winter says. This provides continuous air pressure throughout your airways while you sleep to keep them open and help you breathe, the NHLBI says. Wu says that this form of therapy “has gotten so advanced that they can be quite comfortable and unobtrusive.” She adds, “I’ve had plenty of patients say they feel soothed by their CPAP and can’t settle down to sleep without it now.” When to See Your Doctor If you think you have symptoms of obstructive sleep apnea, Wu says it’s time to reach out to your provider. “One major problem with obstructive sleep apnea is that it can take a long time to get in to see a sleep specialist and to get the testing required to be diagnosed and treated,” she says. There’s not a lot of data on whether obstructive sleep apnea in pregnancy will continue after baby’s born. “Risk for obstructive sleep apnea should go down after baby’s born, but it’s very possible that once you’ve had it, you continue to have elevated risk,” Wu says. “It’s important to keep follow-ups with your sleep doctor to continue to monitor symptoms.” Please note: The Bump and the materials and information it contains are not intended to, and do not constitute, medical or other health advice or diagnosis and should not be used as such. You should always consult with a qualified physician or health professional about your specific circumstances. Plus, more from The Bump: These Are the Safest Pregnancy Sleeping Positions Natural Remedies to Help You Sleep Better During Pregnancy The 13 Best Pregnancy Pillows, According to Pregnant Moms Sources save article Was this article helpful? Already a member? Log In https://www.thebump.com/a/sleep-apnea-during-pregnancy ================ <QUESTION> ======= I have sleep apnea and just found out I am pregnant. I want to know what effect my sleep apnea will have on my pregnancy. Using this article, please explain the symptoms, risks, and treatments. Use at least 400 words. ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> [user request] <TEXT> [context document]

I have the Iphone 15, but the 16 is coming out, and I need to decide if I want to upgrade again. please list the features only the 16 has that the 15 doesn't have, make sure to list any drawbacks the new features may have. Highlight camera features, but I don't care about the size. I need a summary of the features at the end. Do not mention the other phone in the summary.

While Apple's latest models bring a variety of enhancements, the most significant change is support for Apple Intelligence, a new AI system that transforms how you interact with your device by offering smarter notifications, text summarization, and contextual information. The ‌iPhone 16‌ also features the Action Button and Camera Control button, which provide more intuitive ways to access key functions. Design and Displays The ‌iPhone 16‌ introduces several design and display upgrades over the ‌iPhone 15‌. The shift to vertically arranged cameras facilitates spatial video capture and looks more modern. Durability is also improved with the next-generation Ceramic Shield, which is twice as strong as the previous version. Additionally, the customizable Action Button replaces the traditional Ring/Silent switch and a new Camera Control button streamlines photography. ‌iPhone 15‌ ‌iPhone 16‌ Diagonally arranged rear cameras Vertically arranged rear cameras ~2–4 nits minimum brightness 1 nit minimum brightness Ceramic Shield front glass Next-generation Ceramic Shield front glass (2x stronger) Improved thermal design for better heat dissipation Easier battery service Ring/Silent switch Action Button Camera Control capacitive button with sapphire crystal cover Available in Green, Blue, Pink, Black, and Yellow finishes Available in Teal, Ultramarine, Pink, Black, and White finishes Artificial Intelligence The ‌iPhone 16‌ includes support for Apple Intelligence, a significant upgrade absent in the ‌iPhone 15‌. This artificial intelligence system enhances the iPhone's ability to understand and process personal context, offering features like Visual Intelligence, which can recognize objects and scenes through the camera and provide relevant information, such as restaurant or product details. ‌iPhone 16‌ Apple Intelligence (including priority notifications, text summarization, system-wide writing tools, audio transcription, Genmoji creation, personalized suggestions, and more) Visual Intelligence, allowing users to pull up contextual information about objects or scenes in front of the camera (such as restaurant details or product info) Apple Intelligence features like priority notifications, text summarization, and system-wide writing tools can significantly enhance the experience of using the device, making the ‌iPhone 16‌ a substantial upgrade over the ‌iPhone 15‌ in this area. Chip, Memory, and Connectivity The ‌iPhone 16‌ brings notable improvements in performance and connectivity over the ‌iPhone 15‌, driven by the A18 chip built with TSMC's 3nm process, which is more efficient and powerful than the ‌iPhone 15‌'s A16 chip. The 6-core CPU is up to 30% faster, while the upgraded 16-core Neural Engine is optimized for running generative models, doubling the speed of machine learning tasks. In terms of graphics, the ‌iPhone 16‌'s 5-core GPU delivers a 40% boost in performance and introduces hardware-accelerated ray tracing, enhancing gaming and visual effects. Memory and connectivity also see significant upgrades, with the ‌iPhone 16‌ offering 8GB of RAM, a 33% increase over the ‌iPhone 15‌, and the introduction of Wi-Fi 7 and Thread networking for better wireless performance and smart home integration. ‌iPhone 15‌ ‌iPhone 16‌ A16 Bionic chip (TSMC's "N4P" enhanced 5nm process) A18 chip (TSMC's "N3E" enhanced ‌3nm‌ process) 6-core CPU 6-core CPU (up to 30% faster) 16-core Neural Engine Upgraded 16-core Neural Engine optimized for generative models (runs ML models 2x faster) 5-core GPU 5-core GPU (up to 40% faster) Hardware-accelerated ray tracing 6GB memory 8GB memory (+33%) Wi-Fi 6 Wi‑Fi 7 (802.11be) with 2x2 MIMO Thread networking technology The performance gains with the A18 chip and enhanced GPU are particularly meaningful for users who engage in gaming, video editing, or other graphics-heavy tasks. The hardware-accelerated ray tracing will greatly benefit gamers, making the ‌iPhone 16‌ capable of rendering more realistic lighting and shadows. Meanwhile, the Neural Engine upgrade doubles the speed of machine learning tasks such as Apple Intelligence. For everyday users, the jump from 6GB to 8GB of memory ensures better multitasking and future-proofing, while Wi-Fi 7 and Thread networking will improve connectivity speeds and compatibility with smart home devices. The ‌iPhone 16‌'s improvements are substantial for users who demand higher performance and future-ready wireless tech, though those who use their devices more casually might notice less immediate impact. The ‌iPhone 16‌ enhances the already impressive camera setup from the ‌iPhone 15‌. The Ultra Wide camera has been upgraded with an ƒ/2.2 aperture, providing better low-light performance compared to the ƒ/2.4 aperture on the ‌iPhone 15‌. The ‌iPhone 16‌ also introduces Macro photography and Macro video recording, enabling users to capture detailed close-up shots, while the Camera Control button brings new levels of ease and precision to shooting photos and videos. ‌iPhone 15‌ ‌iPhone 16‌ 48-megapixel Main camera with ƒ/1.6 aperture 48-megapixel Fusion camera with ƒ/1.6 aperture 12-megapixel Ultra Wide camera with ƒ/2.4 aperture 12-megapixel Ultra Wide camera with ƒ/2.2 aperture for improved-low light performance Anti-reflective coating on Fusion camera lens Macro photography and Macro video recording, including slo‑mo and time‑lapse Photo­graphic Styles Next-generation Photo­graphic Styles Spatial video recording at 1080p at 30 fps 4K video recording at 24 fps, 25 fps, 30 fps or 60 fps 4K Dolby Vision video recording at 24 fps, 25 fps, 30 fps or 60 fps 1080p HD video recording at 25 fps, 30 fps or 60 fps 1080p Dolby Vision video recording at 25 fps, 30 fps or 60 fps Cinematic mode up to 4K HDR at 30 fps Cinematic mode up to 4K Dolby Vision at 30 fps QuickTake video QuickTake video (up to 4K at 60 fps in Dolby Vision HDR) Launch the Camera App: Pressing the Camera Control button immediately opens the camera app. Capture Photos: A single press of the button captures a photo, providing a quick and tactile way to take pictures. Record Videos: A press and hold action allows you to start recording a video. Half-Press for Focus and Exposure (upcoming feature): A light, half-press will lock focus and exposure, allowing you to reframe the shot without losing focus. Trackpad-Like Control: The capacitive sensor on the button acts like a trackpad, enabling gestures to control zoom, cycle through filters, or switch between lenses by sliding your finger across the button. Third-Party App Integration: The Camera Control button can also be used to trigger third-party camera apps, giving more flexibility to users who prefer other photography tools. Camera Function Overlay: A light touch gesture reveals a clean preview and quick access to key camera controls like zoom or exposure settings. Visual Intelligence Activation: The Camera Control button is integrated with Visual Intelligence, allowing users to pull up contextual information about objects or scenes in front of the camera. The ‌iPhone 16‌ brings several enhancements to audio recording over the ‌iPhone 15‌. While the ‌iPhone 15‌ offers stereo recording, the ‌iPhone 16‌ introduces Spatial Audio recording, providing a more immersive sound experience, particularly with playback on the Apple Vision Pro headset. Additional features like wind noise reduction and the new Audio Mix function further improve the quality and flexibility of recorded audio, making the ‌iPhone 16‌ a more capable device for capturing high-quality sound. ‌iPhone 15‌ ‌iPhone 16‌ Stereo recording Spatial Audio and stereo recording Wind noise reduction Audio Mix Battery Life and Charging The ‌iPhone 16‌ brings noticeable improvements in battery life and charging efficiency compared to the ‌iPhone 15‌. With up to 22 hours of battery life on the ‌iPhone 16‌ and 27 hours on the ‌iPhone 16‌ Plus, the new models offer a modest boost. In addition, MagSafe wireless charging is now significantly faster, supporting up to 25W with a 30W adapter, a 66.67% increase over the ‌iPhone 15‌'s 15W limit. iPhone 15: Up to 20 hours of battery life iPhone 15 Plus: Up to 26 hours of battery life iPhone 16: Up to 22 hours of battery life iPhone 16 Plus: Up to 27 hours of battery life ‌MagSafe‌ wireless charging up to 15W with 20W adapter or higher ‌MagSafe‌ wireless charging up to 25W with 30W adapter or higher (+66.67%)

<TASK DESCRIPTION> Only use the provided text to answer the question, no outside sources. <QUESTION> I have the Iphone 15, but the 16 is coming out, and I need to decide if I want to upgrade again. please list the features only the 16 has that the 15 doesn't have, make sure to list any drawbacks the new features may have. Highlight camera features, but I don't care about the size. I need a summary of the features at the end. Do not mention the other phone in the summary. <TEXT> While Apple's latest models bring a variety of enhancements, the most significant change is support for Apple Intelligence, a new AI system that transforms how you interact with your device by offering smarter notifications, text summarization, and contextual information. The ‌iPhone 16‌ also features the Action Button and Camera Control button, which provide more intuitive ways to access key functions. Design and Displays The ‌iPhone 16‌ introduces several design and display upgrades over the ‌iPhone 15‌. The shift to vertically arranged cameras facilitates spatial video capture and looks more modern. Durability is also improved with the next-generation Ceramic Shield, which is twice as strong as the previous version. Additionally, the customizable Action Button replaces the traditional Ring/Silent switch and a new Camera Control button streamlines photography. ‌iPhone 15‌ ‌iPhone 16‌ Diagonally arranged rear cameras Vertically arranged rear cameras ~2–4 nits minimum brightness 1 nit minimum brightness Ceramic Shield front glass Next-generation Ceramic Shield front glass (2x stronger) Improved thermal design for better heat dissipation Easier battery service Ring/Silent switch Action Button Camera Control capacitive button with sapphire crystal cover Available in Green, Blue, Pink, Black, and Yellow finishes Available in Teal, Ultramarine, Pink, Black, and White finishes Artificial Intelligence The ‌iPhone 16‌ includes support for Apple Intelligence, a significant upgrade absent in the ‌iPhone 15‌. This artificial intelligence system enhances the iPhone's ability to understand and process personal context, offering features like Visual Intelligence, which can recognize objects and scenes through the camera and provide relevant information, such as restaurant or product details. ‌iPhone 16‌ Apple Intelligence (including priority notifications, text summarization, system-wide writing tools, audio transcription, Genmoji creation, personalized suggestions, and more) Visual Intelligence, allowing users to pull up contextual information about objects or scenes in front of the camera (such as restaurant details or product info) Apple Intelligence features like priority notifications, text summarization, and system-wide writing tools can significantly enhance the experience of using the device, making the ‌iPhone 16‌ a substantial upgrade over the ‌iPhone 15‌ in this area. Chip, Memory, and Connectivity The ‌iPhone 16‌ brings notable improvements in performance and connectivity over the ‌iPhone 15‌, driven by the A18 chip built with TSMC's 3nm process, which is more efficient and powerful than the ‌iPhone 15‌'s A16 chip. The 6-core CPU is up to 30% faster, while the upgraded 16-core Neural Engine is optimized for running generative models, doubling the speed of machine learning tasks. In terms of graphics, the ‌iPhone 16‌'s 5-core GPU delivers a 40% boost in performance and introduces hardware-accelerated ray tracing, enhancing gaming and visual effects. Memory and connectivity also see significant upgrades, with the ‌iPhone 16‌ offering 8GB of RAM, a 33% increase over the ‌iPhone 15‌, and the introduction of Wi-Fi 7 and Thread networking for better wireless performance and smart home integration. ‌iPhone 15‌ ‌iPhone 16‌ A16 Bionic chip (TSMC's "N4P" enhanced 5nm process) A18 chip (TSMC's "N3E" enhanced ‌3nm‌ process) 6-core CPU 6-core CPU (up to 30% faster) 16-core Neural Engine Upgraded 16-core Neural Engine optimized for generative models (runs ML models 2x faster) 5-core GPU 5-core GPU (up to 40% faster) Hardware-accelerated ray tracing 6GB memory 8GB memory (+33%) Wi-Fi 6 Wi‑Fi 7 (802.11be) with 2x2 MIMO Thread networking technology The performance gains with the A18 chip and enhanced GPU are particularly meaningful for users who engage in gaming, video editing, or other graphics-heavy tasks. The hardware-accelerated ray tracing will greatly benefit gamers, making the ‌iPhone 16‌ capable of rendering more realistic lighting and shadows. Meanwhile, the Neural Engine upgrade doubles the speed of machine learning tasks such as Apple Intelligence. For everyday users, the jump from 6GB to 8GB of memory ensures better multitasking and future-proofing, while Wi-Fi 7 and Thread networking will improve connectivity speeds and compatibility with smart home devices. The ‌iPhone 16‌'s improvements are substantial for users who demand higher performance and future-ready wireless tech, though those who use their devices more casually might notice less immediate impact. The ‌iPhone 16‌ enhances the already impressive camera setup from the ‌iPhone 15‌. The Ultra Wide camera has been upgraded with an ƒ/2.2 aperture, providing better low-light performance compared to the ƒ/2.4 aperture on the ‌iPhone 15‌. The ‌iPhone 16‌ also introduces Macro photography and Macro video recording, enabling users to capture detailed close-up shots, while the Camera Control button brings new levels of ease and precision to shooting photos and videos. ‌iPhone 15‌ ‌iPhone 16‌ 48-megapixel Main camera with ƒ/1.6 aperture 48-megapixel Fusion camera with ƒ/1.6 aperture 12-megapixel Ultra Wide camera with ƒ/2.4 aperture 12-megapixel Ultra Wide camera with ƒ/2.2 aperture for improved-low light performance Anti-reflective coating on Fusion camera lens Macro photography and Macro video recording, including slo‑mo and time‑lapse Photo­graphic Styles Next-generation Photo­graphic Styles Spatial video recording at 1080p at 30 fps 4K video recording at 24 fps, 25 fps, 30 fps or 60 fps 4K Dolby Vision video recording at 24 fps, 25 fps, 30 fps or 60 fps 1080p HD video recording at 25 fps, 30 fps or 60 fps 1080p Dolby Vision video recording at 25 fps, 30 fps or 60 fps Cinematic mode up to 4K HDR at 30 fps Cinematic mode up to 4K Dolby Vision at 30 fps QuickTake video QuickTake video (up to 4K at 60 fps in Dolby Vision HDR) Launch the Camera App: Pressing the Camera Control button immediately opens the camera app. Capture Photos: A single press of the button captures a photo, providing a quick and tactile way to take pictures. Record Videos: A press and hold action allows you to start recording a video. Half-Press for Focus and Exposure (upcoming feature): A light, half-press will lock focus and exposure, allowing you to reframe the shot without losing focus. Trackpad-Like Control: The capacitive sensor on the button acts like a trackpad, enabling gestures to control zoom, cycle through filters, or switch between lenses by sliding your finger across the button. Third-Party App Integration: The Camera Control button can also be used to trigger third-party camera apps, giving more flexibility to users who prefer other photography tools. Camera Function Overlay: A light touch gesture reveals a clean preview and quick access to key camera controls like zoom or exposure settings. Visual Intelligence Activation: The Camera Control button is integrated with Visual Intelligence, allowing users to pull up contextual information about objects or scenes in front of the camera. The ‌iPhone 16‌ brings several enhancements to audio recording over the ‌iPhone 15‌. While the ‌iPhone 15‌ offers stereo recording, the ‌iPhone 16‌ introduces Spatial Audio recording, providing a more immersive sound experience, particularly with playback on the Apple Vision Pro headset. Additional features like wind noise reduction and the new Audio Mix function further improve the quality and flexibility of recorded audio, making the ‌iPhone 16‌ a more capable device for capturing high-quality sound. ‌iPhone 15‌ ‌iPhone 16‌ Stereo recording Spatial Audio and stereo recording Wind noise reduction Audio Mix Battery Life and Charging The ‌iPhone 16‌ brings noticeable improvements in battery life and charging efficiency compared to the ‌iPhone 15‌. With up to 22 hours of battery life on the ‌iPhone 16‌ and 27 hours on the ‌iPhone 16‌ Plus, the new models offer a modest boost. In addition, MagSafe wireless charging is now significantly faster, supporting up to 25W with a 30W adapter, a 66.67% increase over the ‌iPhone 15‌'s 15W limit. iPhone 15: Up to 20 hours of battery life iPhone 15 Plus: Up to 26 hours of battery life iPhone 16: Up to 22 hours of battery life iPhone 16 Plus: Up to 27 hours of battery life ‌MagSafe‌ wireless charging up to 15W with 20W adapter or higher ‌MagSafe‌ wireless charging up to 25W with 30W adapter or higher (+66.67%) https://www.macrumors.com/guide/iphone-15-vs-iphone-16/

Only refer to the attached document in providing your response.

Summarize the benefits of maternity leave for a mother and for a child.

Having a baby is no small feat. Fortunately, taking time off work for maternity leave can give a new mother the chance to heal both physically and emotionally, as well as sufficient time to bond with and care for her newborn baby. Countless studies and research show that adequate paid maternity leave has a host of benefits for mother, baby and the entire family, such as decreased rehospitalization rates for both mother and baby, improved stress management and more consistent exercise. However, paid maternity leave is lacking in the U.S., which affects mothers, children and families. Read on to learn more about maternity leave, including the landscape of maternity leave in the U.S. and how maternity leave affects a person’s mental and physical health after childbirth. What Is Maternity Leave? Maternity leave is the time a mother takes off from work after having a baby. It’s generally a time for them to recover from childbirth and adjust to life with a newborn baby. However, maternity leave in the U.S. isn’t standardized, which can make it difficult to define. “The definition and scope of maternity leave and the mechanics of taking leave vary from organization to organization,” says Shayla Thurlow, vice president of people and talent acquisition at The Muse who has developed and administered parental leave programs for large and small organizations across various industries. How Does Maternity Leave Work? The U.S. is one of the few industrialized countries worldwide that doesn’t mandate paid parental leave. Maternity leave is meant to be a time for a mother to give all her focus and attention to her newborn baby, her health and her family, but the length of leave— and whether it’s paid and to what extent—varies based on a number of factors, including where you work, how long you’ve worked for your employer the number of employees they have. The Family and Medical Leave Act (FMLA) guarantees coverage for 12 workweeks of unpaid leave per year for qualifying family and medical reasons, including the birth of a baby, adoption or foster care placement, or when you or an immediate family member are seriously ill and in need of care. However, FMLA doesn’t cover all employees. Employers with at least 50 employees must allow parents 12 weeks of job-protected leave to care for their newborn, but pay during this time is not guaranteed, according to the International Labour Organization. To qualify for FMLA coverage: • You must work for a covered employer, including any public agency, any public or private elementary or secondary school, or a private employer with at least 50 employees within a 75-mile radius. • You must have worked at the company for at least 12 months. • You must have worked at least 1,250 hours for the company in the 12 months before your leave. Many new mothers take less than 12 weeks of maternity leave for various reasons, including (but not limited to) working for a company that doesn’t offer FMLA coverage and/or being unable to afford being out of work for that long. A 2014 analysis in Maternal and Child Health Journal found 41% of employed women in the U.S. received paid maternity leave for an average of three weeks, with only a 31% wage replacement. The research also noted that, on average, new mothers took 10 weeks of maternity leave, and the majority of women didn’t receive any compensation for that time away from work[1]. As Thurlow points out, some states require paid maternity leave, but it’s usually up to the employer to decide whether to provide paid maternity leave for its employees. “Though 12 weeks of unpaid leave is covered by federal law [in certain cases], many families are not in a financial position to use that time [without pay] and may be unable to have a long maternity leave,” she says. Maternity Leave Trends in the U.S. The U.S. is lacking when it comes to maternity leave benefits. Most adults don’t have access to paid family leave through their employers, according to a 2021 survey conducted by the U.S. Bureau of Labor Statistics. Furthermore, a 2019 Pew Research Center study of 41 nations found the U.S. is the only country that doesn’t mandate any paid leave for new parents. Among the other 40 nations, the smallest amount of paid maternity leave is two months in Ireland while Estonia offers more than a year and a half of paid parental leave[2]. Worldwide, very few countries don’t guarantee paid maternity leave; instead, more than 120 countries offer paid maternity leave and health benefits by law. At the lower end of the spectrum, only 33 countries mandate maternity leave that lasts less than 12 weeks. Meanwhile, as of 2021 in the U.S., only nine states and the District of Columbia have instituted some degree of paid parental leave. How Can Maternity Leave Impact Your Health? Taking maternity leave is essential not only for the health of the newborn, but also for the health of the mother. “Maternity leave [or the 12 weeks after birth] is often referred to as the fourth trimester,” says Suzanne Bovone, M.D., an OBGYN at Obstetrics and Gynecology of San Jose, part of the Pediatrix Medical Group in Campbell, California. “As each trimester of pregnancy brought changes for the woman and baby, the period after delivery is a continuation of change. Inadequate maternity leave can lead not only to anxiety and depression, but also relationship issues and the inability to return to work.” More than 12 weeks is needed for an adequate maternity leave, according to Dr. Bovone. “Many issues that need assistance are not even apparent until three to four months after delivery,” she says. “It almost becomes impossible to juggle the demands of self-care, childcare, relationships and work obligations.” According to Dr. Bovone, some complications of the side effects of the postpartum period may include: • Sleep deprivation • Increased stress levels • Loss of coping mechanisms • Inability to think clearly and ask for help • Negative thoughts and feelings • Pelvic floor issues • Impact on urinary and bowel function • Negative impact on sexual health “It may take months for one to recognize areas that need work,” she adds. “Unfortunately, with limited maternity leave, many [parents] cannot find the time to provide adequate self-care when they’re back at work.” Physical Health The body goes through major physical changes after having a baby, from pelvic floor disruption to urinary and bowel dysfunction. “Just as pregnancy physically changes one’s body over [more than] nine months, [recovery during] the postpartum period takes just as long,” says Dr. Bovone. “Maternity leave is a time for the woman to rest and recover.” Research shows the positive effect maternity leave has on physical health. For instance, a study in the American Economic Journal: Economic Policy observing health data on mothers in Norway both before and after paid maternity leave became mandated by law in 1977 found women who gave birth after 1977 experienced better overall health as they approached middle age. This improvement was particularly noticeable among women who worked low-income jobs and wouldn’t have taken unpaid leave previously—they were less likely to smoke or experience high blood pressure, had lower BMIs and were more likely to exercise regularly[3]. Paid maternity leave can also contribute to decreased infant mortality, as well as mother and infant rehospitalizations, according to a 2020 review in the Harvard Review of Psychiatry, which also found paid maternity leave to be associated with an increase in pediatric visit attendance and timely administration of infant immunizations[4]. A 2018 study in Maternal and Child Health Journal found similar results: Women who took paid maternity leave experienced a 47% decrease in the odds of rehospitalization for their infants and a 51% decrease in the odds of being rehospitalized themselves at 21 months postpartum[5]. The 2020 review in the Harvard Review of Psychiatry also found paid maternity leave can lead to an increase in the initiation and duration of breastfeeding. Paid maternity leave may lead to healthier habits as well. The 2018 study in Maternal and Child Health Journalalso found women who took paid maternity leave were nearly twice as likely to exercise and were able to better manage their stress levels compared to those who didn’t take paid maternity leave. Mental Health Maternity leave has a significant impact on mental health as well. “There are huge adjustments that come with a new baby,” says Thurlow. “Changes in family dynamics, sleep deprivation and bonding with a new baby create mental and emotional strains for new parents. The ability to take time off to adjust and create a new normal has proven beneficial for parents’ overall mental and emotional well-being.” Research shows a positive correlation between mental health and paid maternity leave as well. According to the same 2020 review in the Harvard Review of Psychology, paid maternity leave is associated with a decrease in postpartum maternal depression. Meanwhile, a 2012 study in the Journal of Mental Health Policies and Economicsfound having fewer than 12 weeks of maternity leave and fewer than eight weeks of paid maternity leave to be associated with increases in depressive symptoms[6]. And the longer the leave, the better: Longer paid maternity leaves are associated with decreased depressive symptoms until six months postpartum, according to a 2014 study in the Journal of Health Politics, Policy and Law[7]. Maternity leave can also mean less stress for postpartum mothers, which can trickle down in a positive way to affect family dynamics and relationships as well. A 2013 study in the Journal of Family Issues observed Australian two-parent families and found the length of maternity leave affected a mother’s mental health, quality of parenting and the couple’s relationship. What’s more, mothers who took more than 13 weeks of paid leave experienced significantly less psychological distress[8]. The positive effects of maternity leave aren’t just apparent immediately after a baby is born: Maternity leave can lead to better mental health later in life as well. A 2015 study in Social Science and Medicine using European data found longer maternity leaves to be associated with improved mental health in old age[9]. Emotional Health A mother’s emotional health can be influenced by maternity leave as well. Postpartum emotional health involves identity changes that go along with becoming a parent, says Dr. Bovone. “Our self-identity changes, as well as our relationships and interactions with our partners, families and friends,” she adds. New mothers may find it difficult to ask for help, and some may find being a parent isn’t what they thought it would be. “Priorities may change as well, and some struggle with this new perspective,” says Dr. Bovone. Fortunately, maternity leave can lead to better bonding experiences between mother and child. A 2018 study of 3,850 mothers in the U.S. found a significant correlation between the duration of paid maternity leave and positive mother-child interactions, such as secure attachment and empathy[10]. A decreased chance of domestic violence is also associated with paid parental leave. A 2019 study in Preventive Medicine found paid parental leave can be an effective strategy to prevent future instances of intimate partner violence. This connection could exist because paid leaves maintains household income and prevents financial stressors, increases gender equity (which is associated with less intimate partner violence against women) and gives parents time to bond with a child without having to worry about work[11]. What Experts Say About Maternity Leave Dr. Bovone and Thurlow both agree that adequate paid maternity leave is a necessity for the health and well-being of mothers, children and families as a whole. What’s more, maternity leave should be longer than what’s typically offered, according to Dr. Bovone. “Ideally, a year to care for oneself and the newborn is needed,” she says. “Coverage for breastfeeding issues, mental and emotional health, pelvic floor health and sexual health should be the norm and accessible to all. The American College of Obstetricians and Gynecologists supports the expansion of postpartum services, but the current medical system at OBGYN offices doesn’t allow adequate time nor payment for these services.” She stresses the importance of improved maternity leave, saying that not only is it beneficial to mothers, but also to families, communities and, ultimately, work environments. Thurlow believes maternity leave should be a minimum of 12 weeks, paid and federally mandated for all employers. “Maternity leave is good, but organizations should provide paid parental leave to truly support parents,” she says. She adds that maternity leave needs to be expanded. “Providing paid leave to a birthing parent shouldn’t be a discussion, but the issue is much larger. Only providing paid leave to a birthing parent doesn’t take into account families that are made whole by adoption, surrogacy or the placement of a child. Additionally, only offering maternity leave places a burden of childcare on one parent.”

Only refer to the attached document in providing your response. Summarize the benefits of maternity leave for a mother and for a child. Having a baby is no small feat. Fortunately, taking time off work for maternity leave can give a new mother the chance to heal both physically and emotionally, as well as sufficient time to bond with and care for her newborn baby. Countless studies and research show that adequate paid maternity leave has a host of benefits for mother, baby and the entire family, such as decreased rehospitalization rates for both mother and baby, improved stress management and more consistent exercise. However, paid maternity leave is lacking in the U.S., which affects mothers, children and families. Read on to learn more about maternity leave, including the landscape of maternity leave in the U.S. and how maternity leave affects a person’s mental and physical health after childbirth. What Is Maternity Leave? Maternity leave is the time a mother takes off from work after having a baby. It’s generally a time for them to recover from childbirth and adjust to life with a newborn baby. However, maternity leave in the U.S. isn’t standardized, which can make it difficult to define. “The definition and scope of maternity leave and the mechanics of taking leave vary from organization to organization,” says Shayla Thurlow, vice president of people and talent acquisition at The Muse who has developed and administered parental leave programs for large and small organizations across various industries. How Does Maternity Leave Work? The U.S. is one of the few industrialized countries worldwide that doesn’t mandate paid parental leave. Maternity leave is meant to be a time for a mother to give all her focus and attention to her newborn baby, her health and her family, but the length of leave— and whether it’s paid and to what extent—varies based on a number of factors, including where you work, how long you’ve worked for your employer the number of employees they have. The Family and Medical Leave Act (FMLA) guarantees coverage for 12 workweeks of unpaid leave per year for qualifying family and medical reasons, including the birth of a baby, adoption or foster care placement, or when you or an immediate family member are seriously ill and in need of care. However, FMLA doesn’t cover all employees. Employers with at least 50 employees must allow parents 12 weeks of job-protected leave to care for their newborn, but pay during this time is not guaranteed, according to the International Labour Organization. To qualify for FMLA coverage: • You must work for a covered employer, including any public agency, any public or private elementary or secondary school, or a private employer with at least 50 employees within a 75-mile radius. • You must have worked at the company for at least 12 months. • You must have worked at least 1,250 hours for the company in the 12 months before your leave. Many new mothers take less than 12 weeks of maternity leave for various reasons, including (but not limited to) working for a company that doesn’t offer FMLA coverage and/or being unable to afford being out of work for that long. A 2014 analysis in Maternal and Child Health Journal found 41% of employed women in the U.S. received paid maternity leave for an average of three weeks, with only a 31% wage replacement. The research also noted that, on average, new mothers took 10 weeks of maternity leave, and the majority of women didn’t receive any compensation for that time away from work[1]. As Thurlow points out, some states require paid maternity leave, but it’s usually up to the employer to decide whether to provide paid maternity leave for its employees. “Though 12 weeks of unpaid leave is covered by federal law [in certain cases], many families are not in a financial position to use that time [without pay] and may be unable to have a long maternity leave,” she says. Maternity Leave Trends in the U.S. The U.S. is lacking when it comes to maternity leave benefits. Most adults don’t have access to paid family leave through their employers, according to a 2021 survey conducted by the U.S. Bureau of Labor Statistics. Furthermore, a 2019 Pew Research Center study of 41 nations found the U.S. is the only country that doesn’t mandate any paid leave for new parents. Among the other 40 nations, the smallest amount of paid maternity leave is two months in Ireland while Estonia offers more than a year and a half of paid parental leave[2]. Worldwide, very few countries don’t guarantee paid maternity leave; instead, more than 120 countries offer paid maternity leave and health benefits by law. At the lower end of the spectrum, only 33 countries mandate maternity leave that lasts less than 12 weeks. Meanwhile, as of 2021 in the U.S., only nine states and the District of Columbia have instituted some degree of paid parental leave. How Can Maternity Leave Impact Your Health? Taking maternity leave is essential not only for the health of the newborn, but also for the health of the mother. “Maternity leave [or the 12 weeks after birth] is often referred to as the fourth trimester,” says Suzanne Bovone, M.D., an OBGYN at Obstetrics and Gynecology of San Jose, part of the Pediatrix Medical Group in Campbell, California. “As each trimester of pregnancy brought changes for the woman and baby, the period after delivery is a continuation of change. Inadequate maternity leave can lead not only to anxiety and depression, but also relationship issues and the inability to return to work.” More than 12 weeks is needed for an adequate maternity leave, according to Dr. Bovone. “Many issues that need assistance are not even apparent until three to four months after delivery,” she says. “It almost becomes impossible to juggle the demands of self-care, childcare, relationships and work obligations.” According to Dr. Bovone, some complications of the side effects of the postpartum period may include: • Sleep deprivation • Increased stress levels • Loss of coping mechanisms • Inability to think clearly and ask for help • Negative thoughts and feelings • Pelvic floor issues • Impact on urinary and bowel function • Negative impact on sexual health “It may take months for one to recognize areas that need work,” she adds. “Unfortunately, with limited maternity leave, many [parents] cannot find the time to provide adequate self-care when they’re back at work.” Physical Health The body goes through major physical changes after having a baby, from pelvic floor disruption to urinary and bowel dysfunction. “Just as pregnancy physically changes one’s body over [more than] nine months, [recovery during] the postpartum period takes just as long,” says Dr. Bovone. “Maternity leave is a time for the woman to rest and recover.” Research shows the positive effect maternity leave has on physical health. For instance, a study in the American Economic Journal: Economic Policy observing health data on mothers in Norway both before and after paid maternity leave became mandated by law in 1977 found women who gave birth after 1977 experienced better overall health as they approached middle age. This improvement was particularly noticeable among women who worked low-income jobs and wouldn’t have taken unpaid leave previously—they were less likely to smoke or experience high blood pressure, had lower BMIs and were more likely to exercise regularly[3]. Paid maternity leave can also contribute to decreased infant mortality, as well as mother and infant rehospitalizations, according to a 2020 review in the Harvard Review of Psychiatry, which also found paid maternity leave to be associated with an increase in pediatric visit attendance and timely administration of infant immunizations[4]. A 2018 study in Maternal and Child Health Journal found similar results: Women who took paid maternity leave experienced a 47% decrease in the odds of rehospitalization for their infants and a 51% decrease in the odds of being rehospitalized themselves at 21 months postpartum[5]. The 2020 review in the Harvard Review of Psychiatry also found paid maternity leave can lead to an increase in the initiation and duration of breastfeeding. Paid maternity leave may lead to healthier habits as well. The 2018 study in Maternal and Child Health Journalalso found women who took paid maternity leave were nearly twice as likely to exercise and were able to better manage their stress levels compared to those who didn’t take paid maternity leave. Mental Health Maternity leave has a significant impact on mental health as well. “There are huge adjustments that come with a new baby,” says Thurlow. “Changes in family dynamics, sleep deprivation and bonding with a new baby create mental and emotional strains for new parents. The ability to take time off to adjust and create a new normal has proven beneficial for parents’ overall mental and emotional well-being.” Research shows a positive correlation between mental health and paid maternity leave as well. According to the same 2020 review in the Harvard Review of Psychology, paid maternity leave is associated with a decrease in postpartum maternal depression. Meanwhile, a 2012 study in the Journal of Mental Health Policies and Economicsfound having fewer than 12 weeks of maternity leave and fewer than eight weeks of paid maternity leave to be associated with increases in depressive symptoms[6]. And the longer the leave, the better: Longer paid maternity leaves are associated with decreased depressive symptoms until six months postpartum, according to a 2014 study in the Journal of Health Politics, Policy and Law[7]. Maternity leave can also mean less stress for postpartum mothers, which can trickle down in a positive way to affect family dynamics and relationships as well. A 2013 study in the Journal of Family Issues observed Australian two-parent families and found the length of maternity leave affected a mother’s mental health, quality of parenting and the couple’s relationship. What’s more, mothers who took more than 13 weeks of paid leave experienced significantly less psychological distress[8]. The positive effects of maternity leave aren’t just apparent immediately after a baby is born: Maternity leave can lead to better mental health later in life as well. A 2015 study in Social Science and Medicine using European data found longer maternity leaves to be associated with improved mental health in old age[9]. Emotional Health A mother’s emotional health can be influenced by maternity leave as well. Postpartum emotional health involves identity changes that go along with becoming a parent, says Dr. Bovone. “Our self-identity changes, as well as our relationships and interactions with our partners, families and friends,” she adds. New mothers may find it difficult to ask for help, and some may find being a parent isn’t what they thought it would be. “Priorities may change as well, and some struggle with this new perspective,” says Dr. Bovone. Fortunately, maternity leave can lead to better bonding experiences between mother and child. A 2018 study of 3,850 mothers in the U.S. found a significant correlation between the duration of paid maternity leave and positive mother-child interactions, such as secure attachment and empathy[10]. A decreased chance of domestic violence is also associated with paid parental leave. A 2019 study in Preventive Medicine found paid parental leave can be an effective strategy to prevent future instances of intimate partner violence. This connection could exist because paid leaves maintains household income and prevents financial stressors, increases gender equity (which is associated with less intimate partner violence against women) and gives parents time to bond with a child without having to worry about work[11]. What Experts Say About Maternity Leave Dr. Bovone and Thurlow both agree that adequate paid maternity leave is a necessity for the health and well-being of mothers, children and families as a whole. What’s more, maternity leave should be longer than what’s typically offered, according to Dr. Bovone. “Ideally, a year to care for oneself and the newborn is needed,” she says. “Coverage for breastfeeding issues, mental and emotional health, pelvic floor health and sexual health should be the norm and accessible to all. The American College of Obstetricians and Gynecologists supports the expansion of postpartum services, but the current medical system at OBGYN offices doesn’t allow adequate time nor payment for these services.” She stresses the importance of improved maternity leave, saying that not only is it beneficial to mothers, but also to families, communities and, ultimately, work environments. Thurlow believes maternity leave should be a minimum of 12 weeks, paid and federally mandated for all employers. “Maternity leave is good, but organizations should provide paid parental leave to truly support parents,” she says. She adds that maternity leave needs to be expanded. “Providing paid leave to a birthing parent shouldn’t be a discussion, but the issue is much larger. Only providing paid leave to a birthing parent doesn’t take into account families that are made whole by adoption, surrogacy or the placement of a child. Additionally, only offering maternity leave places a burden of childcare on one parent.”

Respond using only the text provided. Do not use prior training data or external knowledge to form your response. Structure your output in bullet point format, but if the user question asks for information related to a process, use a numbered list format.

Describe the protocol for dealing with clothing prior to beginning an autopsy.

Introduction, Concepts and Principles It is assumed that all pathologists know the construction and requirements for reporting the findings of a complete postmortem examination. The following is a guide for use in converting the standard autopsy protocol into the report of a medicolegal autopsy. All of the usual descriptive technics should be maintained. Greater attention to detail, accurate description of abnormal findings, and the addition of final conclusions and interpretations, will bring about this transformation. The hospital autopsy is an examination performed with the consent of the deceased person's relatives for the purposes of: (1) determining the cause of death; (2) providing correlation of clinical diagnosis and clinical symptoms; (3) determining the effectiveness of therapy; (4) studying the natural course of disease processes; and (5) educating students and physicians. The medicolegal autopsy is an examination performed under the law, usually ordered by the Medical Examiner and Coroner 1 for the purposes of: (1) determining the cause, manner, 2 and time of death; (2) recovering, identifying, and preserving evidentiary material; (3) providing interpretation and correlation of facts and circumstances related to death; (4) providing a factual, objective medical report for law enforcement, prosecution, and defense agencies; and (5) separating death due to disease from death due to external causes for protection of the innocent. The essential features of a medicolegal autopsy are: (1) to perform a complete autopsy; (2) to personally perform the examination and observe all findings so that interpretation may be sound; (3) to perform a thorough examination and overlook nothing which could later prove of importance; (4) to preserve all information by written and photographic records; and (5) to provide a professional report without bias. Preliminary Procedures Before the clothing is removed, the body should be examined to determine the condition of the clothing, and to correlate tears and other defects with obvious injuries to the body, and to record the findings. The clothing, body, and hands should be protected from possible contamination prior to specific examination of each. A record of the general condition of the body and of the clothing should be made and the extent of rigo r and lividity, the temperature of the body and the environment, and any other data pertinent to the subsequent determination of the time of death also should be recorded. After the preliminary examination the clothing may be carefully removed by unbuttoning, unzippering, or unhooking to remove without tearing or cutting. If the clothing is wet or bloody, it must be hung up to dry in the air to prevent putrefaction and disintegration. Record and label each item of clothing. Preserve with proper identification for subsequent examination. Clothing may be examined in the laboratory with soft tissue x-ray and infrared photographs in addition to various chemical analyses and immunohematologic analyses. Autopsy Procedure -The..date, time and place of autopsy should be succinctly noted, and where and by whom it was performed, and any observers or participants should be named. The body should be identified, and all physical characteristics should be described. These include age, height, weight, sex, color of hair and eyes, state of nutrition and muscular development, scars,, and tattoos. Description of the teeth, the number present and absent, :and the general condition should be detailed noting any' abnormalities or deformities, or evidence of fracture, old or recent. In a separate paragraph or paragraphs describe all injuries, noting the number and characteristics of each including size, shape, pattern, and location in relation to anatomic landmarks. Describe the course, direction, and depth.of injuries and enumerate structures involved by the injury. Identify and label any'foreign object recovered ,and specify its relation to a given injury~ : ~, . ~:At' least one photograph should be taken to identify the body. Photograph injuries to document their location and be certain to, include a 'scale to show their size. Photographs can be used to demonstrate and correlate, external injuries with internal injuries and to demonstrate pathologic processes other than those of traumatic origin. ' Roentgenographic and fluoroscopic examinations tan be used to locate bullets or other radio-opaque objects, to identify the victim, and tO document fractures, anatomic deformities, and surgical procedures when such metallic.foreign bodies as plates, nails, screws, and wire sutures have been used. .. A general description of the head, neck, cervical spine., thorax, abdo2 men, genitalia, and extremities should be given in logical sequence. The course of wounds through various structures should be detailed remembering variations of position in relationships during life versus relationships after death and when supine on the autopsy table. Evidentiary items such as bullets, knives, or portions thereof, pellets or foreign materials, should be preserved and the point of recovery should be noted. Each should be labelled for proper identification. Each organ should be dissected and described, noting relationships and conditions.

Respond using only the text provided. Do not use prior training data or external knowledge to form your response. Structure your output in bullet point format, but if the user question asks for information related to a process, use a numbered list format. Introduction, Concepts and Principles It is assumed that all pathologists know the construction and requirements for reporting the findings of a complete postmortem examination. The following is a guide for use in converting the standard autopsy protocol into the report of a medicolegal autopsy. All of the usual descriptive technics should be maintained. Greater attention to detail, accurate description of abnormal findings, and the addition of final conclusions and interpretations, will bring about this transformation. The hospital autopsy is an examination performed with the consent of the deceased person's relatives for the purposes of: (1) determining the cause of death; (2) providing correlation of clinical diagnosis and clinical symptoms; (3) determining the effectiveness of therapy; (4) studying the natural course of disease processes; and (5) educating students and physicians. The medicolegal autopsy is an examination performed under the law, usually ordered by the Medical Examiner and Coroner 1 for the purposes of: (1) determining the cause, manner, 2 and time of death; (2) recovering, identifying, and preserving evidentiary material; (3) providing interpretation and correlation of facts and circumstances related to death; (4) providing a factual, objective medical report for law enforcement, prosecution, and defense agencies; and (5) separating death due to disease from death due to external causes for protection of the innocent. The essential features of a medicolegal autopsy are: (1) to perform a complete autopsy; (2) to personally perform the examination and observe all findings so that interpretation may be sound; (3) to perform a thorough examination and overlook nothing which could later prove of importance; (4) to preserve all information by written and photographic records; and (5) to provide a professional report without bias. Preliminary Procedures Before the clothing is removed, the body should be examined to determine the condition of the clothing, and to correlate tears and other defects with obvious injuries to the body, and to record the findings. The clothing, body, and hands should be protected from possible contamination prior to specific examination of each. A record of the general condition of the body and of the clothing should be made and the extent of rigo r and lividity, the temperature of the body and the environment, and any other data pertinent to the subsequent determination of the time of death also should be recorded. After the preliminary examination the clothing may be carefully removed by unbuttoning, unzippering, or unhooking to remove without tearing or cutting. If the clothing is wet or bloody, it must be hung up to dry in the air to prevent putrefaction and disintegration. Record and label each item of clothing. Preserve with proper identification for subsequent examination. Clothing may be examined in the laboratory with soft tissue x-ray and infrared photographs in addition to various chemical analyses and immunohematologic analyses. Autopsy Procedure -The..date, time and place of autopsy should be succinctly noted, and where and by whom it was performed, and any observers or participants should be named. The body should be identified, and all physical characteristics should be described. These include age, height, weight, sex, color of hair and eyes, state of nutrition and muscular development, scars,, and tattoos. Description of the teeth, the number present and absent, :and the general condition should be detailed noting any' abnormalities or deformities, or evidence of fracture, old or recent. In a separate paragraph or paragraphs describe all injuries, noting the number and characteristics of each including size, shape, pattern, and location in relation to anatomic landmarks. Describe the course, direction, and depth.of injuries and enumerate structures involved by the injury. Identify and label any'foreign object recovered ,and specify its relation to a given injury~ : ~, . ~:At' least one photograph should be taken to identify the body. Photograph injuries to document their location and be certain to, include a 'scale to show their size. Photographs can be used to demonstrate and correlate, external injuries with internal injuries and to demonstrate pathologic processes other than those of traumatic origin. ' Roentgenographic and fluoroscopic examinations tan be used to locate bullets or other radio-opaque objects, to identify the victim, and tO document fractures, anatomic deformities, and surgical procedures when such metallic.foreign bodies as plates, nails, screws, and wire sutures have been used. .. A general description of the head, neck, cervical spine., thorax, abdo2 men, genitalia, and extremities should be given in logical sequence. The course of wounds through various structures should be detailed remembering variations of position in relationships during life versus relationships after death and when supine on the autopsy table. Evidentiary items such as bullets, knives, or portions thereof, pellets or foreign materials, should be preserved and the point of recovery should be noted. Each should be labelled for proper identification. Each organ should be dissected and described, noting relationships and conditions. Describe the protocol for dealing with clothing prior to beginning an autopsy.

Provide a response based solely on the information provided in the prompt. External sources and prior knowledge must not be used.

What did the first circuit conclude?

In the 2016 case United States v. McIntosh, the U.S. Court of Appeals for the Ninth Circuit considered the circumstances in which the appropriations rider bars CSA prosecution of marijuana-related activities. The court held that the rider prohibits the federal government only from preventing the implementation of those specific rules of state law that authorize the use, distribution, possession, or cultivation of medical marijuana. DOJ does not prevent the implementation of [such rules] when it prosecutes individuals who engage in conduct unauthorized under state medical marijuana laws. Individuals who do not strictly comply with all state-law conditions regarding the use, distribution, possession, and cultivation of medical marijuana have engaged in conduct that is unauthorized, and prosecuting such individuals does not violate [the rider]. Relying on McIntosh, the Ninth Circuit has issued several decisions allowing federal prosecution of individuals who did not “strictly comply” with state medical marijuana laws, notwithstanding the appropriations rider, and several district courts have followed that reasoning. As one example, in United States v. Evans, the Ninth Circuit upheld the prosecution of two individuals involved in the production of medical marijuana who smoked marijuana as they processed plants for sale. Although state law permitted medical marijuana use by “qualifying patients,” the court concluded that the defendants failed to show they were qualifying patients, and thus they could be prosecuted because their personal marijuana use did not strictly comply with state medical marijuana law. In the 2022 case United States v. Bilodeau, the U.S. Court of Appeals for the First Circuit also considered the scope of the appropriations rider. The defendants in Bilodeau were registered with the State of Maine to produce medical marijuana, but DOJ alleged that they distributed large quantities of marijuana to individuals who were not qualifying patients under Maine law, including recipients in other states. Following indictment for criminal CSA violations, the defendants sought to invoke the appropriations rider to bar their prosecutions. They argued that the rider “must be read to preclude the DOJ, under most circumstances, from prosecuting persons who possess state licenses to partake in medical marijuana activity.” DOJ instead urged the court to apply the Ninth Circuit’s standard, allowing prosecution unless the defendants could show that they acted in strict compliance with state medical marijuana laws. The First Circuit declined to adopt either of the proposed tests. As an initial matter, the court agreed with the Ninth Circuit that the rider means “DOJ may not spend funds to bring prosecutions if doing so prevents a state from giving practical effect to its medical marijuana laws.” However, the panel declined to adopt the Ninth Circuit’s holding that the rider bars prosecution only in cases where defendants strictly complied with state law. The court noted that the text of the rider does not explicitly require strict compliance with state law and that, given the complexity of state marijuana regulations, “the potential for technical noncompliance [with state law] is real enough that no person through any reasonable effort could always assure strict compliance.” Thus, the First Circuit concluded that requiring strict compliance with state law would likely chill state-legal medical marijuana activities and prevent the states from giving effect to their medical marijuana laws. On the other hand, the court also rejected the defendants’ more expansive reading of the rider, reasoning that “Congress surely did not intend for the rider to provide a safe harbor to all caregivers with facially valid documents without regard for blatantly illegitimate activity.” Ultimately, while the First Circuit held that the rider bars CSA prosecution in at least some cases where the defendant has committed minor technical violations of state medical marijuana laws, it declined to Congressional Research Service 4 “fully define [the] precise boundaries” of its alternative standard. On the record before it, the court concluded that “the defendants’ cultivation, possession, and distribution of marijuana aimed at supplying persons whom no defendant ever thought were qualifying patients under Maine law” and that a CSA conviction in those circumstances would not “prevent Maine’s medical marijuana laws from having their intended practical effect.” Considerations for Congress It remains to be seen whether and how the difference in reasoning between the Ninth Circuit and the First Circuit will make a practical difference in federal marijuana prosecutions. In theory, the First Circuit’s analysis could make it easier for defendants to invoke the appropriations rider to bar federal prosecutions, because they could do so even if they had not been in strict compliance with state law. In practice, however, resource limitations and enforcement priorities have historically meant that federal marijuana prosecutions target only individuals and organizations that have clearly not complied with state law. Thus, one of the First Circuit judges who considered Bilodeau agreed with the panel’s interpretation of the rider but wrote a concurrence noting that, in practice, the First Circuit’s standard might not be “materially different from the one that the Ninth Circuit applied.” While the medical marijuana appropriations rider restricts DOJ’s ability to bring some marijuana prosecutions, its effect is limited in several ways. First, marijuana-related activities that fall outside the scope of the appropriations rider remain subject to prosecution under the CSA. By its terms, the rider applies only to state laws related to medical marijuana; it does not bar prosecution of any activities related to recreational marijuana, even if those activities are permitted under state law. Second, as the Ninth Circuit has explained, even where the rider does apply, it “does not provide immunity from prosecution for federal marijuana offenses”—it simply restricts DOJ’s ability to expend funds to enforce federal law for as long as it remains in effect. If Congress instead opted to repeal the rider or allow it to lapse, DOJ would be able to prosecute future CSA violations as well as past violations that occurred while the rider was in effect, subject to the applicable statute of limitations. Third, participants in the cannabis industry may face numerous collateral consequences arising from the federal prohibition of marijuana in areas including bankruptcy, taxation, and immigration. Many of those legal consequences attach regardless of whether a person is charged with or convicted of a CSA offense, meaning the rider would not affect them. Because the medical marijuana appropriations rider applies to marijuana specifically, regardless of how the substance is classified under the CSA, rescheduling marijuana would not affect the rider. Congress has the authority to enact legislation to clarify or alter the scope of the appropriations rider, repeal the rider, or decline to include it in future appropriations laws. For instance, Congress could amend the rider to specify whether strict compliance with state medical marijuana law is required in order to bar prosecution under the CSA or provide a different standard that DOJ and the courts should apply. Congress could also expand the scope of the rider to bar the expenditure of funds on prosecutions related to recreational marijuana or other controlled substances. Beyond the appropriations context, Congress could also consider other changes to federal marijuana law that would affect its interaction with state law. Such changes could take the form of more stringent marijuana regulation—for instance, through increased DOJ funding to prosecute CSA violations or limiting federal funds for states that legalize marijuana. In contrast, most recent proposals before Congress seek to relax federal restrictions on marijuana or mitigate the disparity between federal and state marijuana regulation. Some proposals would remove marijuana from regulation under the CSA entirely or move it to a less restrictive schedule. Other proposed legislation would limit enforcement of federal marijuana law in states that elect to legalize marijuana. Additional proposals from the past few years would seek to address specific legal consequences of marijuana’s Schedule I status by, for example, Congressional Research Service 5 LSB10694 · VERSION 4 · UPDATED enabling marijuana businesses to access banking services or removing collateral consequences for individuals in areas such as immigration, federally assisted housing, and gun ownership.

Provide a response based solely on the information provided in the prompt. External sources and prior knowledge must not be used. What did the first circuit conclude? In the 2016 case United States v. McIntosh, the U.S. Court of Appeals for the Ninth Circuit considered the circumstances in which the appropriations rider bars CSA prosecution of marijuana-related activities. The court held that the rider prohibits the federal government only from preventing the implementation of those specific rules of state law that authorize the use, distribution, possession, or cultivation of medical marijuana. DOJ does not prevent the implementation of [such rules] when it prosecutes individuals who engage in conduct unauthorized under state medical marijuana laws. Individuals who do not strictly comply with all state-law conditions regarding the use, distribution, possession, and cultivation of medical marijuana have engaged in conduct that is unauthorized, and prosecuting such individuals does not violate [the rider]. Relying on McIntosh, the Ninth Circuit has issued several decisions allowing federal prosecution of individuals who did not “strictly comply” with state medical marijuana laws, notwithstanding the appropriations rider, and several district courts have followed that reasoning. As one example, in United States v. Evans, the Ninth Circuit upheld the prosecution of two individuals involved in the production of medical marijuana who smoked marijuana as they processed plants for sale. Although state law permitted medical marijuana use by “qualifying patients,” the court concluded that the defendants failed to show they were qualifying patients, and thus they could be prosecuted because their personal marijuana use did not strictly comply with state medical marijuana law. In the 2022 case United States v. Bilodeau, the U.S. Court of Appeals for the First Circuit also considered the scope of the appropriations rider. The defendants in Bilodeau were registered with the State of Maine to produce medical marijuana, but DOJ alleged that they distributed large quantities of marijuana to individuals who were not qualifying patients under Maine law, including recipients in other states. Following indictment for criminal CSA violations, the defendants sought to invoke the appropriations rider to bar their prosecutions. They argued that the rider “must be read to preclude the DOJ, under most circumstances, from prosecuting persons who possess state licenses to partake in medical marijuana activity.” DOJ instead urged the court to apply the Ninth Circuit’s standard, allowing prosecution unless the defendants could show that they acted in strict compliance with state medical marijuana laws. The First Circuit declined to adopt either of the proposed tests. As an initial matter, the court agreed with the Ninth Circuit that the rider means “DOJ may not spend funds to bring prosecutions if doing so prevents a state from giving practical effect to its medical marijuana laws.” However, the panel declined to adopt the Ninth Circuit’s holding that the rider bars prosecution only in cases where defendants strictly complied with state law. The court noted that the text of the rider does not explicitly require strict compliance with state law and that, given the complexity of state marijuana regulations, “the potential for technical noncompliance [with state law] is real enough that no person through any reasonable effort could always assure strict compliance.” Thus, the First Circuit concluded that requiring strict compliance with state law would likely chill state-legal medical marijuana activities and prevent the states from giving effect to their medical marijuana laws. On the other hand, the court also rejected the defendants’ more expansive reading of the rider, reasoning that “Congress surely did not intend for the rider to provide a safe harbor to all caregivers with facially valid documents without regard for blatantly illegitimate activity.” Ultimately, while the First Circuit held that the rider bars CSA prosecution in at least some cases where the defendant has committed minor technical violations of state medical marijuana laws, it declined to Congressional Research Service 4 “fully define [the] precise boundaries” of its alternative standard. On the record before it, the court concluded that “the defendants’ cultivation, possession, and distribution of marijuana aimed at supplying persons whom no defendant ever thought were qualifying patients under Maine law” and that a CSA conviction in those circumstances would not “prevent Maine’s medical marijuana laws from having their intended practical effect.” Considerations for Congress It remains to be seen whether and how the difference in reasoning between the Ninth Circuit and the First Circuit will make a practical difference in federal marijuana prosecutions. In theory, the First Circuit’s analysis could make it easier for defendants to invoke the appropriations rider to bar federal prosecutions, because they could do so even if they had not been in strict compliance with state law. In practice, however, resource limitations and enforcement priorities have historically meant that federal marijuana prosecutions target only individuals and organizations that have clearly not complied with state law. Thus, one of the First Circuit judges who considered Bilodeau agreed with the panel’s interpretation of the rider but wrote a concurrence noting that, in practice, the First Circuit’s standard might not be “materially different from the one that the Ninth Circuit applied.” While the medical marijuana appropriations rider restricts DOJ’s ability to bring some marijuana prosecutions, its effect is limited in several ways. First, marijuana-related activities that fall outside the scope of the appropriations rider remain subject to prosecution under the CSA. By its terms, the rider applies only to state laws related to medical marijuana; it does not bar prosecution of any activities related to recreational marijuana, even if those activities are permitted under state law. Second, as the Ninth Circuit has explained, even where the rider does apply, it “does not provide immunity from prosecution for federal marijuana offenses”—it simply restricts DOJ’s ability to expend funds to enforce federal law for as long as it remains in effect. If Congress instead opted to repeal the rider or allow it to lapse, DOJ would be able to prosecute future CSA violations as well as past violations that occurred while the rider was in effect, subject to the applicable statute of limitations. Third, participants in the cannabis industry may face numerous collateral consequences arising from the federal prohibition of marijuana in areas including bankruptcy, taxation, and immigration. Many of those legal consequences attach regardless of whether a person is charged with or convicted of a CSA offense, meaning the rider would not affect them. Because the medical marijuana appropriations rider applies to marijuana specifically, regardless of how the substance is classified under the CSA, rescheduling marijuana would not affect the rider. Congress has the authority to enact legislation to clarify or alter the scope of the appropriations rider, repeal the rider, or decline to include it in future appropriations laws. For instance, Congress could amend the rider to specify whether strict compliance with state medical marijuana law is required in order to bar prosecution under the CSA or provide a different standard that DOJ and the courts should apply. Congress could also expand the scope of the rider to bar the expenditure of funds on prosecutions related to recreational marijuana or other controlled substances. Beyond the appropriations context, Congress could also consider other changes to federal marijuana law that would affect its interaction with state law. Such changes could take the form of more stringent marijuana regulation—for instance, through increased DOJ funding to prosecute CSA violations or limiting federal funds for states that legalize marijuana. In contrast, most recent proposals before Congress seek to relax federal restrictions on marijuana or mitigate the disparity between federal and state marijuana regulation. Some proposals would remove marijuana from regulation under the CSA entirely or move it to a less restrictive schedule. Other proposed legislation would limit enforcement of federal marijuana law in states that elect to legalize marijuana. Additional proposals from the past few years would seek to address specific legal consequences of marijuana’s Schedule I status by, for example, Congressional Research Service 5 LSB10694 · VERSION 4 · UPDATED enabling marijuana businesses to access banking services or removing collateral consequences for individuals in areas such as immigration, federally assisted housing, and gun ownership.

[question] [user request] ===================== [text] [context document] ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

My sister and her dog live in NYC. I've visited there and have always been fascinated with their tall buildings. Then I thought...someone has to clean those! Then next thing you know, window washing robotos popped up on my feed. How do these robots work? Also what does this mean for the people who do those jobs?

The skyscraper window-washing robots are here Skyline Robotics claims its autonomous robot Ozmo can clean windows three times faster than humans alone. By Mack DeGeurin Posted on Aug 28, 2024 10:06 AM EDT Share Tourists and workers alike jostling their way through New York’s bustling midtown may notice an odd sight next time they look up. Dozens of floors above ground, the world’s first commercial window-cleaning-robot will be thrusting its two white mechanical arms back and forth, soapy squeegees in hand. Skyline Robotics, the New York-based company behind the “Ozmo” cleaning robot, believe machines like theirs are faster and safer than traditional cleaning methods and could help address the potential shortage of human skyscraper window washers in coming years. It’s just the latest example of artificial intelligence and robotics merging together to perform real-word tasks once confined to people. Caption: The Ozmo robot uses a combination of computer vision, Lidar, and force sensors to determine when and how to clean windows. Credit: Skyline Robotics Starting this week, Skyline’s Ozmo robot will get to work cleaning windows at 1133 Avenue of the Americas, a 45-story Class A skyscraper owned and managed by the Durst Organization near New York’s Bryant Park. Ozmo was previously beta tested across several buildings in the city and Tel Aviv, Israel, but Skyline tells Popular Science this marks the first full-time deployment on an autonomous window-cleaning robot. Early prototypes of window-cleaning robots have been around for years, with some even tested on the original World Trade Center buildings. But those predecessors were imprecise and required a human reviewer to follow up and clean up messy spots the machine missed. Since then, modern skyscrapers have been built with sharper angles and more artistic designs, which can make cleaning them even more skill intensive. Ozmo uses Lidar and computer vision to ‘see’ what it’s cleaning Ozmo improves on older robot designs thanks to recent advances in robotics and artificial intelligence. The robot cleaner uses a combination of Lidar and computer vision, similar to what’s used in some autonomous vehicles, to scan a building’s surface and its particular curve and edge areas. Onboard force sensors let the robot determine how much pressure it needs to apply to clean a particular window most effectively. AI software, meanwhile, helps Ozmo stabilize itself even when presented with heavy gusts of wind. Since its initial beta tests, a Skyline spokesperson says they have equipped Ozmo with additional ultrasonic sensors and increased its robustness in order to properly handle taller buildings. And while the robot operates autonomously, Skyline says a team of human supervisors located on the building’s roof will still remotely monitor it. “We’re delivering the future of façade maintenance as Ozmo and human window cleaners work in unison to protect the health of buildings faster and safer than existing solutions,” Skyline Robotics CEO Michael Brown said. A Skyline spokesperson told Popular Science their product is a “robot as a service platform” and that total pricing will depend on the overall size of the surface’s being cleaned. Robots could make window cleaning even safer Window washing, especially amongst Manhattan’s concrete behemoths, isn’t for the faint of heart. Cleaners often operate hundreds of feet in the air supported by harness and working in tight corridors. Strong winds and other environmental factors can make an already nerve-racking job even more stress inducing. But even though harrowing videos occasionally surface showing workers dangerously dangling from rooftops or falling, window-washing is actually statistically safer than some might expect. Data compiled by the Occupational Safety and Health Administration (OSHA) lists only 20 fatalities involving window washers nationally between 2019 and 2023. Still, Skyline argues its robotics solution can make the industry even faster and more efficient. The company claims its human-aided robotic approach can clean windows three times faster than traditional window cleaning methods. Aside from pure speed, robots might one-day need to help fill in gaps in the aging window-asking workforce. A recent analysis of census and Department of Labor data compiled by the online job resource firm Zippia estimates around 70% of US-based window cleaners are over 40 years old. Just 9% of workers were reportedly between the ages of 20 and 30. At the same time, the appetite for new towers doesn’t seem to be subsiding. There are currently five towers over 980 feet currently under construction in Manhattan and many more smaller ones. Ozmo arrives during a time of increased automation nationwide, both in white collar service jobs and physical labor. Advanced large language models like those created by OpenAI and Google are already disrupting work and contributing to layoffs in the tech industry and beyond. Larger humanoid-style robots, though still nascent, may increasingly take on work once left to humans in manufacturing sectors. How human workers and labor groups respond to those impending changes could dictate how advancements in robotics evolve in the coming years. Skyline isn’t necessarily waiting for the dust to settle. The company says it has plans to expand Ozmo to buildings in Japan, Singapore, and London, moving forward.

[question] My sister and her dog live in NYC. I've visited there and have always been fascinated with their tall buildings. Then I thought...someone has to clean those! Then next thing you know, window washing robotos popped up on my feed. How do these robots work? Also what does this mean for the people who do those jobs? ===================== [text] The skyscraper window-washing robots are here Skyline Robotics claims its autonomous robot Ozmo can clean windows three times faster than humans alone. By Mack DeGeurin Posted on Aug 28, 2024 10:06 AM EDT Share Tourists and workers alike jostling their way through New York’s bustling midtown may notice an odd sight next time they look up. Dozens of floors above ground, the world’s first commercial window-cleaning-robot will be thrusting its two white mechanical arms back and forth, soapy squeegees in hand. Skyline Robotics, the New York-based company behind the “Ozmo” cleaning robot, believe machines like theirs are faster and safer than traditional cleaning methods and could help address the potential shortage of human skyscraper window washers in coming years. It’s just the latest example of artificial intelligence and robotics merging together to perform real-word tasks once confined to people. Caption: The Ozmo robot uses a combination of computer vision, Lidar, and force sensors to determine when and how to clean windows. Credit: Skyline Robotics Starting this week, Skyline’s Ozmo robot will get to work cleaning windows at 1133 Avenue of the Americas, a 45-story Class A skyscraper owned and managed by the Durst Organization near New York’s Bryant Park. Ozmo was previously beta tested across several buildings in the city and Tel Aviv, Israel, but Skyline tells Popular Science this marks the first full-time deployment on an autonomous window-cleaning robot. Early prototypes of window-cleaning robots have been around for years, with some even tested on the original World Trade Center buildings. But those predecessors were imprecise and required a human reviewer to follow up and clean up messy spots the machine missed. Since then, modern skyscrapers have been built with sharper angles and more artistic designs, which can make cleaning them even more skill intensive. Ozmo uses Lidar and computer vision to ‘see’ what it’s cleaning Ozmo improves on older robot designs thanks to recent advances in robotics and artificial intelligence. The robot cleaner uses a combination of Lidar and computer vision, similar to what’s used in some autonomous vehicles, to scan a building’s surface and its particular curve and edge areas. Onboard force sensors let the robot determine how much pressure it needs to apply to clean a particular window most effectively. AI software, meanwhile, helps Ozmo stabilize itself even when presented with heavy gusts of wind. Since its initial beta tests, a Skyline spokesperson says they have equipped Ozmo with additional ultrasonic sensors and increased its robustness in order to properly handle taller buildings. And while the robot operates autonomously, Skyline says a team of human supervisors located on the building’s roof will still remotely monitor it. “We’re delivering the future of façade maintenance as Ozmo and human window cleaners work in unison to protect the health of buildings faster and safer than existing solutions,” Skyline Robotics CEO Michael Brown said. A Skyline spokesperson told Popular Science their product is a “robot as a service platform” and that total pricing will depend on the overall size of the surface’s being cleaned. Robots could make window cleaning even safer Window washing, especially amongst Manhattan’s concrete behemoths, isn’t for the faint of heart. Cleaners often operate hundreds of feet in the air supported by harness and working in tight corridors. Strong winds and other environmental factors can make an already nerve-racking job even more stress inducing. But even though harrowing videos occasionally surface showing workers dangerously dangling from rooftops or falling, window-washing is actually statistically safer than some might expect. Data compiled by the Occupational Safety and Health Administration (OSHA) lists only 20 fatalities involving window washers nationally between 2019 and 2023. Still, Skyline argues its robotics solution can make the industry even faster and more efficient. The company claims its human-aided robotic approach can clean windows three times faster than traditional window cleaning methods. Aside from pure speed, robots might one-day need to help fill in gaps in the aging window-asking workforce. A recent analysis of census and Department of Labor data compiled by the online job resource firm Zippia estimates around 70% of US-based window cleaners are over 40 years old. Just 9% of workers were reportedly between the ages of 20 and 30. At the same time, the appetite for new towers doesn’t seem to be subsiding. There are currently five towers over 980 feet currently under construction in Manhattan and many more smaller ones. Ozmo arrives during a time of increased automation nationwide, both in white collar service jobs and physical labor. Advanced large language models like those created by OpenAI and Google are already disrupting work and contributing to layoffs in the tech industry and beyond. Larger humanoid-style robots, though still nascent, may increasingly take on work once left to humans in manufacturing sectors. How human workers and labor groups respond to those impending changes could dictate how advancements in robotics evolve in the coming years. Skyline isn’t necessarily waiting for the dust to settle. The company says it has plans to expand Ozmo to buildings in Japan, Singapore, and London, moving forward. https://www.popsci.com/technology/window-washing-robot-skyscrapers/ ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

system instruction: [This task requires you to answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. Present your answer in headed sections with an explanation for each section. Each explanation should be in bullet points with exactly three bullet points.]

question: [which famous economists are mentioned?]

Free market economies: o Also known as laissez-faire economies, where governments leave markets to their own devices, so the market forces of supply and demand allocate scarce resources. o Economic decisions are taken by private individuals and firms, and private individuals own everything. There is no government intervention. o In reality, governments usually intervene by implementing laws and public services, such as property rights and national defence. o Adam Smith and Friedrich Hayek were famous free market economists. Adam Smith’s famous theory of the invisible hand of the market can be applied to free market economies and the price mechanism, which describes how prices are determined by the ‘spending votes’ of consumers and businesses. Smith recognised some of the issues with monopoly power that could arise from a free market, however. Hayek argued that government intervention makes the market worse. For example, shortly after the 1930s crash, he argued that the Fed caused the crash by keeping interest rates low, and encouraging investments which were not economically worthwhile: ‘malinvestments’. o What to produce: determined by what the consumer prefers o How to produce it: producers seek profits o For whom to produce it: whoever has the greatest purchasing power in the economy, and is therefore able to buy the good o Advantages: o Firms are likely to be efficient because they have to provide goods and services demanded by consumers. They are also likely to lower their average costs and make better use of scarce resources. Therefore, overall output of the economy increases. o The bureaucracy from government intervention is avoided. o Some economists might argue the freedom gained from having a free economy leads to more personal freedom. o Disadvantages: o The free market ignores inequality, and tends to benefit those who hold most of the wealth. There are no social security payments for those on low incomes. www.pmt.education o There could be monopolies, which could exploit the market by charging higher prices. o There could be the overconsumption of demerit goods, which have large negative externalities, such as tobacco. o Public goods are not provided in a free market, such as national defence. Merit goods, such as education, are underprovided. Command economy: o This is where the government allocates all of the scarce resources in an economy to where they think there is a greater need. It is also referred to as central planning. o Karl Marx saw the free market as unstable. He saw profits created in the free market as coming from the exploitation of labour, and by not paying workers to cover the value of their work. He argued for the “common ownership of the means of production”. o What to produce: determined by what the government prefers o How to produce it: governments and their employees o For whom to produce it: who the government prefers o Advantages: o It might be easier to coordinate resources in times of crises, such as wars. o The government can compensate for market failure, by reallocating resources. They might ensure everyone can access basic necessities. o Inequality in society could be reduced, and society might maximise welfare rather than profit. o The abuse of monopoly power could be prevented. o Disadvantages: o Governments fail, as do markets, and they may not be fully informed for what to produce. o They may not necessarily meet consumer preferences. o It limits democracy and personal freedom. Mixed economy: o This has features of both command and free economies and is the most common economic system today. There are different balances between command and free economies in reality, though. The UK is generally www.pmt.education considered quite central, whilst the US is slightly more free (although the government spends around 35% of GDP) and Cuba is more centrally planned. o The market is controlled by both the government and the forces of supply and demand. o Governments often provide public goods such as street lights, roads and the police, and merit goods, such as healthcare and education. o What to produce: determined by both consumer and government preferences o How to produce it: determined by producers making profits and the government o For whom to produce it: both who the government prefers and the purchasing power of private individuals.

system instruction: [This task requires you to answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. Present your answer in headed sections with an explanation for each section. Each explanation should be in bullet points with exactly three bullet points.] question: [which famous economists are mentioned?] context block: [Free market economies: o Also known as laissez-faire economies, where governments leave markets to their own devices, so the market forces of supply and demand allocate scarce resources. o Economic decisions are taken by private individuals and firms, and private individuals own everything. There is no government intervention. o In reality, governments usually intervene by implementing laws and public services, such as property rights and national defence. o Adam Smith and Friedrich Hayek were famous free market economists. Adam Smith’s famous theory of the invisible hand of the market can be applied to free market economies and the price mechanism, which describes how prices are determined by the ‘spending votes’ of consumers and businesses. Smith recognised some of the issues with monopoly power that could arise from a free market, however. Hayek argued that government intervention makes the market worse. For example, shortly after the 1930s crash, he argued that the Fed caused the crash by keeping interest rates low, and encouraging investments which were not economically worthwhile: ‘malinvestments’. o What to produce: determined by what the consumer prefers o How to produce it: producers seek profits o For whom to produce it: whoever has the greatest purchasing power in the economy, and is therefore able to buy the good o Advantages: o Firms are likely to be efficient because they have to provide goods and services demanded by consumers. They are also likely to lower their average costs and make better use of scarce resources. Therefore, overall output of the economy increases. o The bureaucracy from government intervention is avoided. o Some economists might argue the freedom gained from having a free economy leads to more personal freedom. o Disadvantages: o The free market ignores inequality, and tends to benefit those who hold most of the wealth. There are no social security payments for those on low incomes. www.pmt.education o There could be monopolies, which could exploit the market by charging higher prices. o There could be the overconsumption of demerit goods, which have large negative externalities, such as tobacco. o Public goods are not provided in a free market, such as national defence. Merit goods, such as education, are underprovided. Command economy: o This is where the government allocates all of the scarce resources in an economy to where they think there is a greater need. It is also referred to as central planning. o Karl Marx saw the free market as unstable. He saw profits created in the free market as coming from the exploitation of labour, and by not paying workers to cover the value of their work. He argued for the “common ownership of the means of production”. o What to produce: determined by what the government prefers o How to produce it: governments and their employees o For whom to produce it: who the government prefers o Advantages: o It might be easier to coordinate resources in times of crises, such as wars. o The government can compensate for market failure, by reallocating resources. They might ensure everyone can access basic necessities. o Inequality in society could be reduced, and society might maximise welfare rather than profit. o The abuse of monopoly power could be prevented. o Disadvantages: o Governments fail, as do markets, and they may not be fully informed for what to produce. o They may not necessarily meet consumer preferences. o It limits democracy and personal freedom. Mixed economy: o This has features of both command and free economies and is the most common economic system today. There are different balances between command and free economies in reality, though. The UK is generally www.pmt.education considered quite central, whilst the US is slightly more free (although the government spends around 35% of GDP) and Cuba is more centrally planned. o The market is controlled by both the government and the forces of supply and demand. o Governments often provide public goods such as street lights, roads and the police, and merit goods, such as healthcare and education. o What to produce: determined by both consumer and government preferences o How to produce it: determined by producers making profits and the government o For whom to produce it: both who the government prefers and the purchasing power of private individuals.]

Do not use any knowledge other than the provided document. After answering the question, quote in parentheses the section of the document that you referred to for your answer. Use capital letters for this quotation.

Summarize the reviews from the provided text.

**Oben VH-R2 Reviews** Great product By Freddy 2/14/2023 Verified Buyer Community Member Excellent product Handy Easy Great price Was this review helpful to you? 0 0 Report Great Simple Monopod Mount By Brian 1/22/2023 Verified Buyer Community Member Works great. Love the quick mount locking action. Makes it really easy and quick to mount and remove camera. Just slide one side in and it flips to lock down securely. Was this review helpful to you? 0 0 Report Nice add on for the Oben ATM-2600 By Sam 8/2/2022 Verified Buyer This head works well with the Oben ATM-2600 6-Section Aluminum Monopod. good combo, camera mounts securely and no movement at all. I do use it often and have seen no problem with it so far. Was this review helpful to you? 1 0 Report great monopod accessary. By Mike 1/31/2022 Verified Buyer Community Member works really well, Especially like being able to tilt the head to shoot vertically. The quick attachment piece is proprietary,I wish a had a second one. Other ones I have don't work with it. So i need to remember when I move the piece from a lens to a camera body. No big deal. The quick release works really well. Was this review helpful to you? 1 0 Report Nice Tilt Head for Monopod By Katie 1/5/2022 Verified Buyer Community Member I'm using this tilt head with my Manfrotto monopod. It's very sturdy and doesn't move when locked down. I used it quite a bit on a trip to Yellowstone recently with my Sigma 150-500 lens and it worked perfectly. Really well priced- very pleased with it!

{Context} ================== **Oben VH-R2 Reviews** Great product By Freddy 2/14/2023 Verified Buyer Community Member Excellent product Handy Easy Great price Was this review helpful to you? 0 0 Report Great Simple Monopod Mount By Brian 1/22/2023 Verified Buyer Community Member Works great. Love the quick mount locking action. Makes it really easy and quick to mount and remove camera. Just slide one side in and it flips to lock down securely. Was this review helpful to you? 0 0 Report Nice add on for the Oben ATM-2600 By Sam 8/2/2022 Verified Buyer This head works well with the Oben ATM-2600 6-Section Aluminum Monopod. good combo, camera mounts securely and no movement at all. I do use it often and have seen no problem with it so far. Was this review helpful to you? 1 0 Report great monopod accessary. By Mike 1/31/2022 Verified Buyer Community Member works really well, Especially like being able to tilt the head to shoot vertically. The quick attachment piece is proprietary,I wish a had a second one. Other ones I have don't work with it. So i need to remember when I move the piece from a lens to a camera body. No big deal. The quick release works really well. Was this review helpful to you? 1 0 Report Nice Tilt Head for Monopod By Katie 1/5/2022 Verified Buyer Community Member I'm using this tilt head with my Manfrotto monopod. It's very sturdy and doesn't move when locked down. I used it quite a bit on a trip to Yellowstone recently with my Sigma 150-500 lens and it worked perfectly. Really well priced- very pleased with it! ================ {Query} ================== Summarize the reviews from the provided text. ================ {Task} ================== Do not use any knowledge other than the provided document. After answering the question, quote in parentheses the section of the document that you referred to for your answer. Use capital letters for this quotation.

Answer in one complete sentence. Add the relevant quoted piece of text from the context document in italics, at the end of your response.

As per this Technology Transfer Agreement between Merck KGaA and Nitec Pharma, what responsibilities regarding clinical and technical development in Germany and Austria does Nitec Pharma agree to?

** TECHNOLOGY TRANSFER AGREEMENT ** Technology Transfer Agreement between Merck KGaA (“Merck”), Frankfurter Strasse 250, 64271 Darmstadt and Nitec Pharma AG (“Nitec Pharma”) Switzerland Preamble Merck has been marketing corticoids (Fortecortin, Decortin, Decortin H, Solu Decortin H) successfully – primarily in Germany – for many years. In order to support the corticoid business Merck started developing Prednison Night Time Release in 1998, which is a novel galenic formulation using the active agent prednison. For the treatment of rheumatoid arthritis (“RA”) the Project (as defined hereinafter) has not yet entered phase 3 of clinical testing. Merck due to limited resources and its focus on other business areas is unable to develop the Project until it is ready for marketing or to obtain a legal pharmaceutical licence for the Project. Merck therefore internally has decided to discontinue the Project. It now appears that Nitec Pharma may be able to resume the Project at its own cost and risk, see it through phase III clinical testing and obtain a license to market the Merchandise (as defined below) in Germany, Austria and other countries. In light of this development Merck is willing to transfer the Project to Nitec Pharma by turning over to Nitec Pharma all know-how acquired within the framework of and in connection with the Project and all pertinent industrial property rights. In particular Merck is willing to grant Nitec Pharma access to all data, which have accrued within the framework of the Project development and which are still to accrue pending the conclusion of the successful “Mutual Recognition Procedure”. As provided herein Nitec Pharma is willing to undertake to use all of its Commercially Reasonable Efforts (as defined below) to continue the clinical and technical development of the Project on its own, in particular using its own financial resources and at its own company risk and to obtain legal pharmaceutical approvals for relevant markets that have been identified by Nitec Pharma as promising markets and to confirm that Merck shall, under the terms specified in greater detail in section 6 hereof retain the right to market the Merchandise on an exclusive or non-exclusive basis in Germany and Austria and that such right shall only pass to Nitec Pharma as set forth in section 6 hereof. For this purpose the parties stipulate as follows: 1. Definitions “Technology Transfer Agreement” or “TTA” refers to this Agreement between Merck and Nitec Pharma. “Clinical Development” refers to the implementation of all clinical trials aimed at obtaining licences to market the Merchandise in Germany, Austria and other countries. “Commercially Reasonable Efforts” means those efforts and resources that Nitec Pharma would use were it developing, manufacturing, promoting and detailing the Active Agents as its own pharmaceutical products but taking into account clinical development results (including all safety, efficacy and cost issues), product labeling, regulatory review and approval issues, market potential, past performance, market potential, economic return, the general regulatory environment and competitive market conditions in the therapeutic area, all as measured by the facts and circumstances at the time such efforts are due. “Technical Development” refers to the implementation of all technical activities aimed at obtaining licences to market the Merchandise in Germany, Austria and other countries. “Approval” refers to the date on which an approval to market the Merchandise is granted in Germany and/or Austria. “Launch” refers to the day on which the Merchandise is brought onto the market in Germany and/or Austria. “Access to Data” refers to access to all data within Merck or affiliated enterprises of Merck within the meaning of § 15 of the German Stock Corporation Act (“Merck Group”) concerning the Project as well as concerning the Project periphery (e.g. Decortin, Decortin H), which are required or useful within the framework of Nitec Pharma’s activities described in this Agreement. “Initial Application” is the date on which the first application for a legal pharmaceutical licence for the Project is filed in a country, which is a member of the European Union. “Ex-factory Price” is the list price of the product without discounts by Merck Group to each independent customer. “Production Costs” are all costs incurred by Nitec Pharma in the complete provision of Merchandise to one of Merck’s supply depots. “Patents” refer to all of Merck Group’s patents and/or applications and utility models with respect to the Project. “Project” refers to the galenic formulation containing Active Agents and which releases the latter in a delayed manner as more specifically described in Annex I. “Merchandise” refers to the primary and secondary project packed and released for marketing. “Bulk-Ware” refers to the galenic formulation approved for marketing, which still needs to undergo primary and secondary packing. 2 “Packing Instruments” comprises primary and secondary packing for Merchandise. “Rheumatoid Arthritis” refers to the indication for which Nitec Pharma initially endeavours to obtain Approval. “Active Agents” refer to Prednison, Prednisolon and Methylprednisolon. “Skye Pharma” shall mean Skye Pharma AG with its head office in Muttenz, Switzerland, is the company, which has participated in the development of the Project from the technical aspect and which is meant to undertake production of the bulk-ware at its Lyon production site. “Jagotec” shall mean Jagotec AG, a Swiss corporation having its head office at Eptingerstr. 51 in CH-6052 Hergiswil, Switzerland. “Option Area” are the national territories of Germany and Austria. 2. Third Party Contracts 2.1. Merck, subject only to the restriction set forth specifically in section 6 hereof, hereby assigns to Nitec Pharma the agreement attached hereto as Appendix 2.1 “Skye/Jagotec DLA”) between Merck and SkyePharma/Jagotec concerning the development and production of the Project, on the precondition that SkyePharma /Jagotec shall give its required consent thereto. For the purpose of said assignment, Merck shall continue the agreement until then. 2.2. The content of the agreement with SkyePharma/Jagotec is known to Nitec Pharma. All documents pertaining thereto, including correspondence concerning the agreement as well as other documents, which are useful for the implementation and interpretation thereof, shall be delivered to Nitec Pharma following the signing hereof. 3. Transfer of Rights and Know-How 3.1. Merck hereby sells, assigns and promises to otherwise transfer to and Nitec Pharma hereby purchases, accepts assignment and promises to accept delivery and/or transfer of the entire know-how obtained within the framework of the development of the Project to date, including all clinical test and stability patterns, experimental charges and all (also electronic) documents, including the correspondence to date (“Know-How”). Upon conclusion hereof the Know-How becomes the property of Nitec Pharma and shall be transferred promptly to Nitec Pharma after the signature of this Agreement to the extent that such transfer requires action beyond the signature of this Agreement. Insofar as it is set out in documents, on data carriers or represented in another manner (“Represented Know-How”), Merck shall store the Know-How in safe keeping for Nitec Pharma pending delivery thereof to the latter. In addition, Merck shall grant Nitec Pharma access to all of its know-how obtained with respect to the Active Agent. 3 3.2. Nitec Pharma shall assemble the Represented Know-How by 31st December 2004 at the latest at Merck’s premises, submit such know-how for Merck’s approval, and Merck shall thereupon deliver the same to Nitec Pharma promptly. 3.3. If the results of the development work performed hitherto are protected by copyrights or other industrial property rights, said rights are hereby assigned to Nitec Pharma and Nitec Pharma accepts such assignment. In the same manner, and subject to the condition precedent of the conferral of the required approval pursuant to section 13.4 of the Skye/Jagotec DLA, all of the industrial property rights acquired by Merck from Skye Pharma or from Jagotec on the basis of the Skye/Jagotec DLA within the framework of or in connection with the Skye/Jagotec DLA, are hereby assigned to Nitec Pharma and Nitec Pharma accepts such assignment. 3.4. The purchase price for such Know-How, Represented Know-How and the property rights as defined hereinabove shall be […***…]. Payment shall become due upon signature of this Agreement. 3.5. Should an assignment pursuant to section 3.1 and 3.3 hereof be impossible for legal reasons, Nitec Pharma is hereby granted […***…] a worldwide, exclusive, unlimited and unrestricted perpetual license to use these property rights (with the right to sublicense but subject to the following sentence). Said right of use shall not be transferable in connection with marketing and distributing Merchandise in the Option Area, but shall be transformed into a transferable right of use for such purpose as soon as Nitec Pharma becomes entitled to market and distribute or have marketed and distributed Merchandise in the Option Area in accordance with the provisions set forth in sec. 6 hereof. 3.6. Should the results of the development performed hitherto contain inventions or ideas capable of being protected, Nitec Pharma shall be entitled hereupon to apply for relevant protections in its own name and at its own costs – and where required by law, by naming the inventors pursuant to the statutory provisions in force from time to time - in any countries. 3.7. Should it be reasonably necessary or beneficial for the development and production of the Project to allow access to know-how and/or copyrights and/or industrial property rights from outside the development of the Project, whether owned or licensed or otherwise available to Merck or any other company within the Merck Group, Merck hereby grants Nitec Pharma and undertakes to use its best efforts to procure that Nitec Pharma is granted by any other company within the Merck Group a non-exclusive, […***…] license to use such know-how and/or copyrights and/or industrial property rights. The right to transfer such right shall be limited to affiliates of Nitec Pharma within the meaning of § 15 German Stock Corporation Act. Transfers to any other persons shall be limited to the following purposes:

Query: As per this Technology Transfer Agreement between Merck KGaA and Nitec Pharma, what responsibilities regarding clinical and technical development in Germany and Austria does Nitec Pharma agree to? Instruction: Answer in one complete sentence. Add the relevant quoted piece of text from the context document in italics, at the end of your response. Context: ** TECHNOLOGY TRANSFER AGREEMENT ** Technology Transfer Agreement between Merck KGaA (“Merck”), Frankfurter Strasse 250, 64271 Darmstadt and Nitec Pharma AG (“Nitec Pharma”) Switzerland Preamble Merck has been marketing corticoids (Fortecortin, Decortin, Decortin H, Solu Decortin H) successfully – primarily in Germany – for many years. In order to support the corticoid business Merck started developing Prednison Night Time Release in 1998, which is a novel galenic formulation using the active agent prednison. For the treatment of rheumatoid arthritis (“RA”) the Project (as defined hereinafter) has not yet entered phase 3 of clinical testing. Merck due to limited resources and its focus on other business areas is unable to develop the Project until it is ready for marketing or to obtain a legal pharmaceutical licence for the Project. Merck therefore internally has decided to discontinue the Project. It now appears that Nitec Pharma may be able to resume the Project at its own cost and risk, see it through phase III clinical testing and obtain a license to market the Merchandise (as defined below) in Germany, Austria and other countries. In light of this development Merck is willing to transfer the Project to Nitec Pharma by turning over to Nitec Pharma all know-how acquired within the framework of and in connection with the Project and all pertinent industrial property rights. In particular Merck is willing to grant Nitec Pharma access to all data, which have accrued within the framework of the Project development and which are still to accrue pending the conclusion of the successful “Mutual Recognition Procedure”. As provided herein Nitec Pharma is willing to undertake to use all of its Commercially Reasonable Efforts (as defined below) to continue the clinical and technical development of the Project on its own, in particular using its own financial resources and at its own company risk and to obtain legal pharmaceutical approvals for relevant markets that have been identified by Nitec Pharma as promising markets and to confirm that Merck shall, under the terms specified in greater detail in section 6 hereof retain the right to market the Merchandise on an exclusive or non-exclusive basis in Germany and Austria and that such right shall only pass to Nitec Pharma as set forth in section 6 hereof. For this purpose the parties stipulate as follows: 1. Definitions “Technology Transfer Agreement” or “TTA” refers to this Agreement between Merck and Nitec Pharma. “Clinical Development” refers to the implementation of all clinical trials aimed at obtaining licences to market the Merchandise in Germany, Austria and other countries. “Commercially Reasonable Efforts” means those efforts and resources that Nitec Pharma would use were it developing, manufacturing, promoting and detailing the Active Agents as its own pharmaceutical products but taking into account clinical development results (including all safety, efficacy and cost issues), product labeling, regulatory review and approval issues, market potential, past performance, market potential, economic return, the general regulatory environment and competitive market conditions in the therapeutic area, all as measured by the facts and circumstances at the time such efforts are due. “Technical Development” refers to the implementation of all technical activities aimed at obtaining licences to market the Merchandise in Germany, Austria and other countries. “Approval” refers to the date on which an approval to market the Merchandise is granted in Germany and/or Austria. “Launch” refers to the day on which the Merchandise is brought onto the market in Germany and/or Austria. “Access to Data” refers to access to all data within Merck or affiliated enterprises of Merck within the meaning of § 15 of the German Stock Corporation Act (“Merck Group”) concerning the Project as well as concerning the Project periphery (e.g. Decortin, Decortin H), which are required or useful within the framework of Nitec Pharma’s activities described in this Agreement. “Initial Application” is the date on which the first application for a legal pharmaceutical licence for the Project is filed in a country, which is a member of the European Union. “Ex-factory Price” is the list price of the product without discounts by Merck Group to each independent customer. “Production Costs” are all costs incurred by Nitec Pharma in the complete provision of Merchandise to one of Merck’s supply depots. “Patents” refer to all of Merck Group’s patents and/or applications and utility models with respect to the Project. “Project” refers to the galenic formulation containing Active Agents and which releases the latter in a delayed manner as more specifically described in Annex I. “Merchandise” refers to the primary and secondary project packed and released for marketing. “Bulk-Ware” refers to the galenic formulation approved for marketing, which still needs to undergo primary and secondary packing. 2 “Packing Instruments” comprises primary and secondary packing for Merchandise. “Rheumatoid Arthritis” refers to the indication for which Nitec Pharma initially endeavours to obtain Approval. “Active Agents” refer to Prednison, Prednisolon and Methylprednisolon. “Skye Pharma” shall mean Skye Pharma AG with its head office in Muttenz, Switzerland, is the company, which has participated in the development of the Project from the technical aspect and which is meant to undertake production of the bulk-ware at its Lyon production site. “Jagotec” shall mean Jagotec AG, a Swiss corporation having its head office at Eptingerstr. 51 in CH-6052 Hergiswil, Switzerland. “Option Area” are the national territories of Germany and Austria. 2. Third Party Contracts 2.1. Merck, subject only to the restriction set forth specifically in section 6 hereof, hereby assigns to Nitec Pharma the agreement attached hereto as Appendix 2.1 “Skye/Jagotec DLA”) between Merck and SkyePharma/Jagotec concerning the development and production of the Project, on the precondition that SkyePharma /Jagotec shall give its required consent thereto. For the purpose of said assignment, Merck shall continue the agreement until then. 2.2. The content of the agreement with SkyePharma/Jagotec is known to Nitec Pharma. All documents pertaining thereto, including correspondence concerning the agreement as well as other documents, which are useful for the implementation and interpretation thereof, shall be delivered to Nitec Pharma following the signing hereof. 3. Transfer of Rights and Know-How 3.1. Merck hereby sells, assigns and promises to otherwise transfer to and Nitec Pharma hereby purchases, accepts assignment and promises to accept delivery and/or transfer of the entire know-how obtained within the framework of the development of the Project to date, including all clinical test and stability patterns, experimental charges and all (also electronic) documents, including the correspondence to date (“Know-How”). Upon conclusion hereof the Know-How becomes the property of Nitec Pharma and shall be transferred promptly to Nitec Pharma after the signature of this Agreement to the extent that such transfer requires action beyond the signature of this Agreement. Insofar as it is set out in documents, on data carriers or represented in another manner (“Represented Know-How”), Merck shall store the Know-How in safe keeping for Nitec Pharma pending delivery thereof to the latter. In addition, Merck shall grant Nitec Pharma access to all of its know-how obtained with respect to the Active Agent. 3 3.2. Nitec Pharma shall assemble the Represented Know-How by 31st December 2004 at the latest at Merck’s premises, submit such know-how for Merck’s approval, and Merck shall thereupon deliver the same to Nitec Pharma promptly. 3.3. If the results of the development work performed hitherto are protected by copyrights or other industrial property rights, said rights are hereby assigned to Nitec Pharma and Nitec Pharma accepts such assignment. In the same manner, and subject to the condition precedent of the conferral of the required approval pursuant to section 13.4 of the Skye/Jagotec DLA, all of the industrial property rights acquired by Merck from Skye Pharma or from Jagotec on the basis of the Skye/Jagotec DLA within the framework of or in connection with the Skye/Jagotec DLA, are hereby assigned to Nitec Pharma and Nitec Pharma accepts such assignment. 3.4. The purchase price for such Know-How, Represented Know-How and the property rights as defined hereinabove shall be […***…]. Payment shall become due upon signature of this Agreement. 3.5. Should an assignment pursuant to section 3.1 and 3.3 hereof be impossible for legal reasons, Nitec Pharma is hereby granted […***…] a worldwide, exclusive, unlimited and unrestricted perpetual license to use these property rights (with the right to sublicense but subject to the following sentence). Said right of use shall not be transferable in connection with marketing and distributing Merchandise in the Option Area, but shall be transformed into a transferable right of use for such purpose as soon as Nitec Pharma becomes entitled to market and distribute or have marketed and distributed Merchandise in the Option Area in accordance with the provisions set forth in sec. 6 hereof. 3.6. Should the results of the development performed hitherto contain inventions or ideas capable of being protected, Nitec Pharma shall be entitled hereupon to apply for relevant protections in its own name and at its own costs – and where required by law, by naming the inventors pursuant to the statutory provisions in force from time to time - in any countries. 3.7. Should it be reasonably necessary or beneficial for the development and production of the Project to allow access to know-how and/or copyrights and/or industrial property rights from outside the development of the Project, whether owned or licensed or otherwise available to Merck or any other company within the Merck Group, Merck hereby grants Nitec Pharma and undertakes to use its best efforts to procure that Nitec Pharma is granted by any other company within the Merck Group a non-exclusive, […***…] license to use such know-how and/or copyrights and/or industrial property rights. The right to transfer such right shall be limited to affiliates of Nitec Pharma within the meaning of § 15 German Stock Corporation Act. Transfers to any other persons shall be limited to the following purposes:

You must respond to the prompt using only information provided in the context block. Please limit your response to about 150 words.

What is the relationship between operating flexibility and the amount of cash a firm holds?

2.2.3. How does D&I affect financial policies? The previous section argues that diversity and inclusion (D&I) could affect a firm’s operating flexibility. In addition, a literature in financial economics indicates that a firm’s operating flexibility affects its financial policies. Thus, D&I could affect a firm’s financial policies as well. A literature in finance theorizes and documents that more operating flexibility allows a firm to hold less cash. Opler et al. (1999) argue that firms hold cash for precautionary motive, e.g., in case of an unexpected loss or an unexpected opportunity to invest (see Almeida et al. (2014) for a review). Since operating flexibility could help a firm mitigate losses from negative shocks and expand more easily following positive shocks, more operating flexibility would imply less of a precautionary motive to hold cash. Empirically, Gu and Li (2021) document that flexible firms hold less cash, and Ghaly, Anh Dang, and Stathopoulos (2017) show that firms with more inflexibility due to a dependence on skilled labor hold more cash. Another literature in finance argues that more operating flexibility could affect a firm’s debt policies. Kraus and Litzenberger (1973) theorize that a firm chooses its optimal debt ratio by trading off the tax shield benefit of debt and the cost of financial distress related to debt, both of which Gu, Hackbarth, and Li (2020) argue could be affected by operating flexibility. The argument is that a firm’s flexibility to downsize mitigates its losses in bad times, leading to a lower expected cost of financial distress. In addition, a firm’s flexibility to scale up in good times results in a higher taxable income, which increases the value of the debt tax shield. In other words, operating flexibility could both decrease the cost and increase the benefit of using debt, so a more flexible firm would optimally use more debt in its capital structure. This prediction holds in many empirical studies across different dimensions of operating flexibility, including production flexibility (Reinartz and Schmid (2016)), pricing flexibility (D’Acunto et al. (2018)), and workforce flexibility (Simintzi, Vig, and Volpin (2015), Serfling (2016), Bates, Du, and Wang (2020)). Because D&I can affect operating flexibility, and operating flexibility can affect cash holdings and debt usage, D&I can affect these financial policies. If D&I increases a firm’s operating flexibility, then a diverse and inclusive firm (D&I firm) would hold less cash and use more debt. If D&I decreases a firm’s operating flexibility, then I would expect the opposite. Beyond an indirect channel, D&I considerations could directly affect a firm’s cash and debt holdings as well. On the one hand, direct spending on D&I practices, such as the costs of sexual harassment training or diversity hiring, could reduce a firm’s financial resources, e.g., less cash. On the other hand, because building a D&I culture is likely costly (Gorton and Zentefis (2020)), a firm could have an incentive to hold more cash and use less debt to keep the financial flexibility needed to maintain such a culture. Overall, it is an empirical question how a firm’s D&I affects its financial policies. I formally state these hypotheses below in their null forms below: H2a: a D&I firm on average does not use more debt in its capital structure than a nonD&I firm. H2b: a D&I firm on average does not hold more cash on its balance sheet than a non-D&I firm.

You must respond to the prompt using only information provided in the context block. Please limit your response to about 150 words. What is the relationship between operating flexibility and the amount of cash a firm holds? 2.2.3. How does D&I affect financial policies? The previous section argues that diversity and inclusion (D&I) could affect a firm’s operating flexibility. In addition, a literature in financial economics indicates that a firm’s operating flexibility affects its financial policies. Thus, D&I could affect a firm’s financial policies as well. A literature in finance theorizes and documents that more operating flexibility allows a firm to hold less cash. Opler et al. (1999) argue that firms hold cash for precautionary motive, e.g., in case of an unexpected loss or an unexpected opportunity to invest (see Almeida et al. (2014) for a review). Since operating flexibility could help a firm mitigate losses from negative shocks and expand more easily following positive shocks, more operating flexibility would imply less of a precautionary motive to hold cash. Empirically, Gu and Li (2021) document that flexible firms hold less cash, and Ghaly, Anh Dang, and Stathopoulos (2017) show that firms with more inflexibility due to a dependence on skilled labor hold more cash. Another literature in finance argues that more operating flexibility could affect a firm’s debt policies. Kraus and Litzenberger (1973) theorize that a firm chooses its optimal debt ratio by trading off the tax shield benefit of debt and the cost of financial distress related to debt, both of which Gu, Hackbarth, and Li (2020) argue could be affected by operating flexibility. The argument is that a firm’s flexibility to downsize mitigates its losses in bad times, leading to a lower expected cost of financial distress. In addition, a firm’s flexibility to scale up in good times results in a higher taxable income, which increases the value of the debt tax shield. In other words, operating flexibility could both decrease the cost and increase the benefit of using debt, so a more flexible firm would optimally use more debt in its capital structure. This prediction holds in many empirical studies across different dimensions of operating flexibility, including production flexibility (Reinartz and Schmid (2016)), pricing flexibility (D’Acunto et al. (2018)), and workforce flexibility (Simintzi, Vig, and Volpin (2015), Serfling (2016), Bates, Du, and Wang (2020)). Because D&I can affect operating flexibility, and operating flexibility can affect cash holdings and debt usage, D&I can affect these financial policies. If D&I increases a firm’s operating flexibility, then a diverse and inclusive firm (D&I firm) would hold less cash and use more debt. If D&I decreases a firm’s operating flexibility, then I would expect the opposite. Beyond an indirect channel, D&I considerations could directly affect a firm’s cash and debt holdings as well. On the one hand, direct spending on D&I practices, such as the costs of sexual harassment training or diversity hiring, could reduce a firm’s financial resources, e.g., less cash. On the other hand, because building a D&I culture is likely costly (Gorton and Zentefis (2020)), a firm could have an incentive to hold more cash and use less debt to keep the financial flexibility needed to maintain such a culture. Overall, it is an empirical question how a firm’s D&I affects its financial policies. I formally state these hypotheses below in their null forms below: H2a: a D&I firm on average does not use more debt in its capital structure than a nonD&I firm. H2b: a D&I firm on average does not hold more cash on its balance sheet than a non-D&I firm.

Provide your response in a professional and formal tone. Use the information given in the document without referring to external sources or requiring additional context. Avoid using technical jargon or acronyms that are not explained within the document.

What is Open AI doing to make sure AI doesn't threaten human existence.

3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 1/5 Our Charter describes the principles we use to execute on OpenAI’s mission. OpenAI Charter 3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 2/5 Published April 9, 2018 This document reflects the strategy we’ve refined over the past two years, including feedback from many people internal and external to OpenAI. The timeline to AGI remains uncertain, but our Charter will guide us in acting in the best interests of humanity throughout its development. 3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 3/5 OpenAI’s mission is to ensure that artificial general intelligence (AGI)—by which we mean highly autonomous systems that outperform humans at most economically valuable work—benefits all of humanity. We will attempt to directly build safe and beneficial AGI, but will also consider our mission fulfilled if our work aids others to achieve this outcome. To that end, we commit to the following principles: Broadly distributed benefits We commit to use any influence we obtain over AGI’s deployment to ensure it is used for the benefit of all, and to avoid enabling uses of AI or AGI that harm humanity or unduly concentrate power. Our primary fiduciary duty is to humanity. We anticipate needing to marshal substantial resources to fulfill our mission, but will always diligently act to minimize conflicts of interest among our employees and stakeholders that could compromise broad benefit. Long-term safety We are committed to doing the research required to make AGI safe, and to driving the broad adoption of such research across the AI community. We are concerned about late-stage AGI development becoming a competitive race without time for adequate safety precautions. Therefore, if a value-aligned, safety-conscious project comes close to building AGI before we do, we commit to stop competing with and start assisting this project. We will work out specifics in case-by-case agreements, but a typical triggering condition might be “a better-than-even chance of success in the next two years.” Technical leadership To be effective at addressing AGI’s impact on society, OpenAI must be on the cutting edge of AI capabilities— policy and safety advocacy alone would be insufficient. We believe that AI will have broad societal impact before AGI, and we’ll strive to lead in those areas that are directly aligned with our mission and expertise. Cooperative orientation We will actively cooperate with other research and policy institutions; we seek to create a global community working together to address AGI’s global challenges. We are committed to providing public goods that help society navigate the path to AGI. Today this includes publishing most of our AI research, but we expect that safety and security concerns will reduce our traditional publishing in the future, while increasing the importance of sharing safety, policy, and standards research. Menu 3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 4/5 Research API ChatGPT Company OpenAI © 2015 – 2024 Social Overview Index GPT-4 DALL·E 3 Sora Overview Pricing Docs Overview Team Enterprise Pricing Try ChatGPT About Blog Careers Charter Security Customer stories Safety Terms & policies Privacy policy Brand guidelines Twitter YouTube GitHub SoundCloud LinkedIn Back to top 3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 5/5

Provide your response in a professional and formal tone. Use the information given in the document without referring to external sources or requiring additional context. Avoid using technical jargon or acronyms that are not explained within the document. What is Open AI doing to make sure AI doesn't threaten human existence. 3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 1/5 Our Charter describes the principles we use to execute on OpenAI’s mission. OpenAI Charter 3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 2/5 Published April 9, 2018 This document reflects the strategy we’ve refined over the past two years, including feedback from many people internal and external to OpenAI. The timeline to AGI remains uncertain, but our Charter will guide us in acting in the best interests of humanity throughout its development. 3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 3/5 OpenAI’s mission is to ensure that artificial general intelligence (AGI)—by which we mean highly autonomous systems that outperform humans at most economically valuable work—benefits all of humanity. We will attempt to directly build safe and beneficial AGI, but will also consider our mission fulfilled if our work aids others to achieve this outcome. To that end, we commit to the following principles: Broadly distributed benefits We commit to use any influence we obtain over AGI’s deployment to ensure it is used for the benefit of all, and to avoid enabling uses of AI or AGI that harm humanity or unduly concentrate power. Our primary fiduciary duty is to humanity. We anticipate needing to marshal substantial resources to fulfill our mission, but will always diligently act to minimize conflicts of interest among our employees and stakeholders that could compromise broad benefit. Long-term safety We are committed to doing the research required to make AGI safe, and to driving the broad adoption of such research across the AI community. We are concerned about late-stage AGI development becoming a competitive race without time for adequate safety precautions. Therefore, if a value-aligned, safety-conscious project comes close to building AGI before we do, we commit to stop competing with and start assisting this project. We will work out specifics in case-by-case agreements, but a typical triggering condition might be “a better-than-even chance of success in the next two years.” Technical leadership To be effective at addressing AGI’s impact on society, OpenAI must be on the cutting edge of AI capabilities— policy and safety advocacy alone would be insufficient. We believe that AI will have broad societal impact before AGI, and we’ll strive to lead in those areas that are directly aligned with our mission and expertise. Cooperative orientation We will actively cooperate with other research and policy institutions; we seek to create a global community working together to address AGI’s global challenges. We are committed to providing public goods that help society navigate the path to AGI. Today this includes publishing most of our AI research, but we expect that safety and security concerns will reduce our traditional publishing in the future, while increasing the importance of sharing safety, policy, and standards research. Menu 3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 4/5 Research API ChatGPT Company OpenAI © 2015 – 2024 Social Overview Index GPT-4 DALL·E 3 Sora Overview Pricing Docs Overview Team Enterprise Pricing Try ChatGPT About Blog Careers Charter Security Customer stories Safety Terms & policies Privacy policy Brand guidelines Twitter YouTube GitHub SoundCloud LinkedIn Back to top 3/8/24, 11:07 AM OpenAI Charter https://openai.com/charter 5/5

[question] [user request] ===================== [text] [context document] ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

Discuss the similarities and differences between a simple installment loan and a mortgage. Explain in what situations one option should be chosen over the other. Limit the discussion to 250 words.

Installment Loans A loan is something that is borrowed. In the case where this is a sum of money the amount that will be paid by the borrower will include the original amount plus interest. Some loans require full payment on the maturity date of the loan. The maturity date is when all principal and/or interest must be repaid to the the lender. Consider a one year loan of $1000 at a simple interest rate of 5%. At the end of one year (the maturity date) the borrower will pay back the original $1000 plus the interest of $50 for a total of $1050. For major purchases such as vehicles or furniture there is a different type of loan, called the installment loan. The average consumer cannot afford to pay $25000 or more for a new vehicle and they may not want to wait three or four years until they have saved enough money to do so. The qualifying consumer has the option of paying for the item with an installment loan. Installment loans do not require full repayment of the loan on a specific date. With an installment loan the borrower is required to make regular (installment) payments until the loan is paid off. Each installment payment will include an interest charge. An installment loan can vary in length from a few years to perhaps twenty years or more (in the case of real estate). Consider an installment loan for a $4000 television. The purchaser takes out a $4000 loan with a four-year term at an interest rate of 4.5%. The monthly installment payments will be $91.21. Although the television has a purchase price of $4000, the total cost to the purchaser will be more than $4000. The total of the installment payments will be: Total Installment Payments = Number of Installment Payments x Payment Amount = 4 years x 12 payments/year x $91.21/mth = $4378.08 The $4000 television ends up costing $4378.08 because the consumer is charged interest. Each payment includes an interest component that adds to the overall cost of the item. The total of the interest charges is referred to as the finance charge on the loan. Finance Charge The finance charge is the sum of the interest charges on a loan. These interest charges are embedded in the installment payments. To calculate the finance charge: Finance Charge = Total Installment Payments – Loan Amount = (Number of Installment Payments x Payment Amount) – Loan Amount For the $4000 television the finance charge will be calculated as follows: Finance charge = Total Installment Payments – Loan Amount = (4 years x 12 payments/year x $91.21/payment) – $4000 = $4378.08 – $4000 = $378.08 Over the 4-year term of the loan the purchaser will have paid the $4000 loan amount plus an additional $378.08 in interest (the finance charge). Sometimes the borrower will make an initial payment at the time of purchase. This is called a down payment. When a down payment is made the remaining amount is the amount financed or the loan amount. Amount Financed The amount financed or loan amount is the purchase price of the item less any down payment: Amount Financed = Purchase Price – Down Payment Consider the $4000 television. Assume the purchaser makes a down payment of $1500. The amount financed is: Purchase Price – Down Payment = $4000 – $1500 = $2500. In this case the purchaser borrows $2500 rather than $4000. The amount financed is therefore $2500. Assuming the same 4-year term and an interest rate of 4.5%, the installment payments on the $2500 will be reduced to $57.01 per month. In this case the finance charge will be calculated as follows: Finance charge = Total Installment Payments – Loan Amount = (4 years x 12 payments/year x $57.01/payment) – $2500 = $2736.48 – $2500 = $236.48 With the down payment of $2500 the total finance charges will be reduced to $236.48 from $378.08. The total cost of the television to the purchaser will be: Purchase Price + Finance Charge = $4000 + $236.48 = $4236.48 Alternatively we can calculate: Total Installment Payment + Down Payment = $2736.48 + $1500 = $4236.48 As one can see, the finance charges are a hidden but added cost. This cost will become more pronounced with more expensive purchases such as with real estate. Loan Payments When consumers obtain installment loans they often just trust the lender to determine the installment (periodic) loan payments. In Example1 Paul purchased a home entertainment system at a total cost of $6000. He obtained a three year loan at an interest rate of 7.5%. If Paul attempts to calculate his monthly payment by simply dividing the loan amount by the number of payments he will underestimate his monthly payment as he has ignored the interest component: $6000 ÷ 36 = $166.67 Paul’s actual monthly payment of $186.64 is slightly higher than Paul’s estimate because of the interest component. The actual amount of a periodic loan payment can be determined using a formula, a table or technology. In this section we will illustrate the use of a formula. Amortization Amortization is the process of spreading out a loan into a series of fixed payments. A portion of each payment will be applied to the interest charge and a portion will be applied to the principal amount of the loan. Although each payment is equal, the amount that applies to the interest versus the prinipal will change with each payment period. We can get a better sense of the impact that a loan payment has by examining the amortization schedule for a loan. Consider the amortization table for the installment loan in Example 5. Recall that the loan amount is $5000 at 6% for 5 years and annual payments are $1186.98. Note then that for each year the sum of the interest and principal is equivalent to the payment of $1186.98. Refer to Figure 1 for the amortization schedule of this loan. Mortgages A long term loan that is used for the purchase of a house is called a mortgage. It is called a mortgage because the lending agency requires that the house be used as collateral for the loan. This means that if the mortgage holder is unable to make the payments the lender can take possession of the house. Mortgages generally tend to be for longer time periods than an installment loan and the terms of the mortgage will often change over the course of the mortgage. Take for example the purchase of a house with a twenty year mortgage. The purchaser might sign a mortgage agreement for a five year term. The mortgage agreement will include the interest rate, the frequency of payments and additional rules which may allow the mortgage holder to make lump sum payments or change the payment amount. At the end of the five year term a new agreement will be required and the conditions of the mortgage usually change. Although it is possible to do the calculations manually, that is beyond the scope of this book. We will use technology to calculate the periodic payments and interest charges and to generate an amortization schedule. Example 8 will illustrate that amortizing a mortgage is similar to amortizing other loans except that the mortgage amortization generally involves many more payment periods.

[question] Discuss the similarities and differences between a simple installment loan and a mortgage. Explain in what situations one option should be chosen over the other. Limit the discussion to 250 words. ===================== [text] Installment Loans A loan is something that is borrowed. In the case where this is a sum of money the amount that will be paid by the borrower will include the original amount plus interest. Some loans require full payment on the maturity date of the loan. The maturity date is when all principal and/or interest must be repaid to the the lender. Consider a one year loan of $1000 at a simple interest rate of 5%. At the end of one year (the maturity date) the borrower will pay back the original $1000 plus the interest of $50 for a total of $1050. For major purchases such as vehicles or furniture there is a different type of loan, called the installment loan. The average consumer cannot afford to pay $25000 or more for a new vehicle and they may not want to wait three or four years until they have saved enough money to do so. The qualifying consumer has the option of paying for the item with an installment loan. Installment loans do not require full repayment of the loan on a specific date. With an installment loan the borrower is required to make regular (installment) payments until the loan is paid off. Each installment payment will include an interest charge. An installment loan can vary in length from a few years to perhaps twenty years or more (in the case of real estate). Consider an installment loan for a $4000 television. The purchaser takes out a $4000 loan with a four-year term at an interest rate of 4.5%. The monthly installment payments will be $91.21. Although the television has a purchase price of $4000, the total cost to the purchaser will be more than $4000. The total of the installment payments will be: Total Installment Payments = Number of Installment Payments x Payment Amount = 4 years x 12 payments/year x $91.21/mth = $4378.08 The $4000 television ends up costing $4378.08 because the consumer is charged interest. Each payment includes an interest component that adds to the overall cost of the item. The total of the interest charges is referred to as the finance charge on the loan. Finance Charge The finance charge is the sum of the interest charges on a loan. These interest charges are embedded in the installment payments. To calculate the finance charge: Finance Charge = Total Installment Payments – Loan Amount = (Number of Installment Payments x Payment Amount) – Loan Amount For the $4000 television the finance charge will be calculated as follows: Finance charge = Total Installment Payments – Loan Amount = (4 years x 12 payments/year x $91.21/payment) – $4000 = $4378.08 – $4000 = $378.08 Over the 4-year term of the loan the purchaser will have paid the $4000 loan amount plus an additional $378.08 in interest (the finance charge). Sometimes the borrower will make an initial payment at the time of purchase. This is called a down payment. When a down payment is made the remaining amount is the amount financed or the loan amount. Amount Financed The amount financed or loan amount is the purchase price of the item less any down payment: Amount Financed = Purchase Price – Down Payment Consider the $4000 television. Assume the purchaser makes a down payment of $1500. The amount financed is: Purchase Price – Down Payment = $4000 – $1500 = $2500. In this case the purchaser borrows $2500 rather than $4000. The amount financed is therefore $2500. Assuming the same 4-year term and an interest rate of 4.5%, the installment payments on the $2500 will be reduced to $57.01 per month. In this case the finance charge will be calculated as follows: Finance charge = Total Installment Payments – Loan Amount = (4 years x 12 payments/year x $57.01/payment) – $2500 = $2736.48 – $2500 = $236.48 With the down payment of $2500 the total finance charges will be reduced to $236.48 from $378.08. The total cost of the television to the purchaser will be: Purchase Price + Finance Charge = $4000 + $236.48 = $4236.48 Alternatively we can calculate: Total Installment Payment + Down Payment = $2736.48 + $1500 = $4236.48 As one can see, the finance charges are a hidden but added cost. This cost will become more pronounced with more expensive purchases such as with real estate. Loan Payments When consumers obtain installment loans they often just trust the lender to determine the installment (periodic) loan payments. In Example1 Paul purchased a home entertainment system at a total cost of $6000. He obtained a three year loan at an interest rate of 7.5%. If Paul attempts to calculate his monthly payment by simply dividing the loan amount by the number of payments he will underestimate his monthly payment as he has ignored the interest component: $6000 ÷ 36 = $166.67 Paul’s actual monthly payment of $186.64 is slightly higher than Paul’s estimate because of the interest component. The actual amount of a periodic loan payment can be determined using a formula, a table or technology. In this section we will illustrate the use of a formula. Amortization Amortization is the process of spreading out a loan into a series of fixed payments. A portion of each payment will be applied to the interest charge and a portion will be applied to the principal amount of the loan. Although each payment is equal, the amount that applies to the interest versus the prinipal will change with each payment period. We can get a better sense of the impact that a loan payment has by examining the amortization schedule for a loan. Consider the amortization table for the installment loan in Example 5. Recall that the loan amount is $5000 at 6% for 5 years and annual payments are $1186.98. Note then that for each year the sum of the interest and principal is equivalent to the payment of $1186.98. Refer to Figure 1 for the amortization schedule of this loan. Mortgages A long term loan that is used for the purchase of a house is called a mortgage. It is called a mortgage because the lending agency requires that the house be used as collateral for the loan. This means that if the mortgage holder is unable to make the payments the lender can take possession of the house. Mortgages generally tend to be for longer time periods than an installment loan and the terms of the mortgage will often change over the course of the mortgage. Take for example the purchase of a house with a twenty year mortgage. The purchaser might sign a mortgage agreement for a five year term. The mortgage agreement will include the interest rate, the frequency of payments and additional rules which may allow the mortgage holder to make lump sum payments or change the payment amount. At the end of the five year term a new agreement will be required and the conditions of the mortgage usually change. Although it is possible to do the calculations manually, that is beyond the scope of this book. We will use technology to calculate the periodic payments and interest charges and to generate an amortization schedule. Example 8 will illustrate that amortizing a mortgage is similar to amortizing other loans except that the mortgage amortization generally involves many more payment periods. https://opentextbc.ca/businesstechnicalmath/chapter/9-5-loans-mortgages/ ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.

use only the context you are provided to answer. include every isp mentioned. use bullet points, then no more than 25 words to explain. focus on direct actions made.

what have isps done to transition into edge providers?

Examples of ISPs Becoming Edge Providers AT&T. AT&T owns part of the internet backbone and is considered a Tier 1 ISP, meaning it has free access to the entire U.S. internet region.10 It is also a mobile carrier and provides voice services and video programming.11 In 2018, AT&T acquired Time Warner, a content creator that owns HBO and its affiliated edge provider HBO NOW, as well as other cable channels.12 The DOJ unsuccessfully attempted to block the merger.13 AT&T has announced plans to introduce a new edge provider—HBO Max—to stream video programming for no extra charge to AT&T customers who are also HBO subscribers; other customers will reportedly be charged a subscription fee.14 10 DrPeering.net. “Who Are the Tier 1 ISPs?” accessed on December 4, 2019, https://drpeering.net/FAQ/Who-are-the- Tier-1-ISPs.php. Edge providers associated with Tier 1 ISPs may have additional competitive advantages through the ISPs’ ability to send content to any part of the internet for free. Edge providers associated with other ISPs may have to pay or barter with Tier 1 or other ISPs to access certain destinations. Details on how Tier 1 ISPs compete with other ISPs are beyond the scope of this report. 11 See https://www.att.com/gen/general?pid=7462 for more information on the digital and communications infrastructure owned by AT&T. AT&T has stated that it considers its television subscription service to be a “video service” under the Communications Act of 1934, as amended, rather than a cable service. See AT&T Inc., SEC Form 10-K for the year ending December 31, 2014, p. 3. 12 Edmund Lee and Cecilia King, “U.S. Loses Appeal Seeking to Block AT&T-Time Warner Merger,” New York Times, February 26, 2019, https://www.nytimes.com/2019/02/26/business/media/att-time-warner-appeal.html. 13 Ibid; see CRS In Focus IF10526, AT&T-Time Warner Merger Overview, by Dana A. Scherer, for more information on the merger and the court case. 14 Helen Coster and Kenneth Li, “Behind AT&T’s Plan to Take on Netflix, Apple, and Disney with HBO Max,” Competition on the Edge of the Internet Congressional Research Service 5 Comcast. Comcast is an ISP, a cable television service, and a voice service provider. In 2011, Comcast became the majority owner of NBCUniversal, which owns television networks and broadcast stations, and thus obtained minority ownership of Hulu, an edge provider that streams video programming to subscribers.15 In 2019, Walt Disney Company obtained “full operational control” of Hulu, but Comcast retained its 33% financial stake.16 Comcast also announced plans to launch its own video streaming service, Peacock. Comcast reportedly plans to offer three subscription options for Peacock: a free option supported by ads, a premium version with more programming for a fee, and the premium version with no ads for a higher fee.17 The premium version is to be offered for free to subscribers of Comcast and Cox Communications. Verizon. Verizon owns part of the internet backbone and is considered a Tier 1 ISP.18 It is also a mobile carrier, and offers video, voice, and ISP services. In 2015, Verizon acquired AOL, an ISP and edge provider, and in 2016, it acquired the core business of Yahoo, an edge provider.19 It combined the edge provider products from these acquisitions—such as Yahoo Finance, Huffington Post, TechCrunch, and Engadget—in 2017 to create Oath.20 Examples of Edge Providers Becoming ISPs Google. Google is the largest subsidiary of the company Alphabet.21 It offers multiple products, including a search engine, email server, word processing, video streaming, and mapping/navigation system.22 Google generally relies on other ISPs to deliver its content, but entered the ISP market in 2010 when it announced Google Fiber. Google Fiber provides broadband internet service and video programming.23 Beginning in 2016, it suspended or ended some of its projects; as of October 2019, it had installed fiber optic cables in 18 cities.24 Reuters, October 25, 2019, https://www.reuters.com/article/us-media-at-t-hbo-max-focus/behind-atts-plan-to-take-on- netflix-apple-and-disney-with-hbo-max-idUSKBN1X4163. 15 Yinka Adegoke and Dan Levine, “Comcast Completes NBC Universal Merger,” Reuters, January 29, 2011, https://www.reuters.com/article/us-comcast-nbc/comcast-completes-nbc-universal-merger- idUSTRE70S2WZ20110129. 16 Lauren Feiner, Christine Wang, and Alex Sherman, “Disney to Take Full Control over Hulu, Comcast Has Option to Sell Its Stake in 5 years,” CNBC, May 14, 2019, https://www.cnbc.com/2019/05/14/comcast-has-agreed-to-sell-its- stake-in-hulu-in-5-years.html. 17 Gerry Smith, “NBC’s Peacock Bets Viewers Will Watch Ads to Stream for Free,” Bloomberg, January 16, 2020, https://www.bloomberg.com/news/articles/2020-01-16/nbc-s-peacock-bets-consumers-will-watch-ads-to-stream-for- free. 18 DrPeering.net. “Who Are the Tier 1 ISPs?” accessed on December 4, 2019, https://drpeering.net/FAQ/Who-are-the- Tier-1-ISPs.php. 19 Verizon, “Mergers & Acquisitions,” accessed on October 28, 2019, https://www.verizon.com/about/timeline- categories/mergers-acquisitions. 20 Tracey Lien, “Verizon Buys Yahoo for $4.8 Billion, and It’s Giving Yahoo’s Brand Another Chance,” Los Angeles Times, July 25, 2016, https://www.latimes.com/business/technology/la-fi-verizon-buys-yahoo-20160725-snap- story.html. 21 Larry Page, “G Is for Google,” Google Official Blog, August 10, 2015, https://googleblog.blogspot.com/2015/08/google-alphabet.html. 22 Google, “Our Products,” accessed on November 16, 2019, https://about.google/products. 23 Google, “Think Big with a Gig: Our Experimental Fiber Network,” February 10, 2010, https://googleblog.blogspot.com/2010/02/think-big-with-gig-our-experimental.html. 24 Jack Nicas, “Google’s High-Speed Web Plans Hit Snags,” Wall Street Journal, August 15, 2016, https://www.wsj.com/articles/googles-high-speed-web-plans-hit-snags-1471193165; Lauren Feiner, “Google Fiber’s High-Speed Internet Service Is Leaving Louisville After Ripping up Roads and Leaving Cables Exposed,” CNBC, February 7, 2019, https://www.cnbc.com/2019/02/07/google-fiber-pulls-out-of-louisville.html; Google, “Our Cities,” Competition on the Edge of the Internet Congressional Research Service 6 Facebook. As it attracted more users, Facebook expanded from providing an online platform that connects users to an online platform suitable for various activities, including fundraising, messaging, and commerce. In 2018, a spokesman confirmed that Facebook was pursuing another project, dubbed Athena.25 Athena is an experimental satellite that would beam internet access through radio signals. If successful, Athena would enable Facebook to become an ISP. Amazon. In addition to being a major online retailer, Amazon offers information technology infrastructure services through Amazon Web Services.26 In 2019, Amazon confirmed plans— dubbed Project Kuiper—to launch 3,236 satellites into low-Earth orbit to provide broadband internet across the world. If successful, Project Kuiper would enable Amazon to become an ISP.27

use only the context you are provided to answer. include every isp mentioned. use bullet points, then no more than 25 words to explain. focus on direct actions made. what have isps done to transition into edge providers? Examples of ISPs Becoming Edge Providers AT&T. AT&T owns part of the internet backbone and is considered a Tier 1 ISP, meaning it has free access to the entire U.S. internet region.10 It is also a mobile carrier and provides voice services and video programming.11 In 2018, AT&T acquired Time Warner, a content creator that owns HBO and its affiliated edge provider HBO NOW, as well as other cable channels.12 The DOJ unsuccessfully attempted to block the merger.13 AT&T has announced plans to introduce a new edge provider—HBO Max—to stream video programming for no extra charge to AT&T customers who are also HBO subscribers; other customers will reportedly be charged a subscription fee.14 10 DrPeering.net. “Who Are the Tier 1 ISPs?” accessed on December 4, 2019, https://drpeering.net/FAQ/Who-are-the- Tier-1-ISPs.php. Edge providers associated with Tier 1 ISPs may have additional competitive advantages through the ISPs’ ability to send content to any part of the internet for free. Edge providers associated with other ISPs may have to pay or barter with Tier 1 or other ISPs to access certain destinations. Details on how Tier 1 ISPs compete with other ISPs are beyond the scope of this report. 11 See https://www.att.com/gen/general?pid=7462 for more information on the digital and communications infrastructure owned by AT&T. AT&T has stated that it considers its television subscription service to be a “video service” under the Communications Act of 1934, as amended, rather than a cable service. See AT&T Inc., SEC Form 10-K for the year ending December 31, 2014, p. 3. 12 Edmund Lee and Cecilia King, “U.S. Loses Appeal Seeking to Block AT&T-Time Warner Merger,” New York Times, February 26, 2019, https://www.nytimes.com/2019/02/26/business/media/att-time-warner-appeal.html. 13 Ibid; see CRS In Focus IF10526, AT&T-Time Warner Merger Overview, by Dana A. Scherer, for more information on the merger and the court case. 14 Helen Coster and Kenneth Li, “Behind AT&T’s Plan to Take on Netflix, Apple, and Disney with HBO Max,” Competition on the Edge of the Internet Congressional Research Service 5 Comcast. Comcast is an ISP, a cable television service, and a voice service provider. In 2011, Comcast became the majority owner of NBCUniversal, which owns television networks and broadcast stations, and thus obtained minority ownership of Hulu, an edge provider that streams video programming to subscribers.15 In 2019, Walt Disney Company obtained “full operational control” of Hulu, but Comcast retained its 33% financial stake.16 Comcast also announced plans to launch its own video streaming service, Peacock. Comcast reportedly plans to offer three subscription options for Peacock: a free option supported by ads, a premium version with more programming for a fee, and the premium version with no ads for a higher fee.17 The premium version is to be offered for free to subscribers of Comcast and Cox Communications. Verizon. Verizon owns part of the internet backbone and is considered a Tier 1 ISP.18 It is also a mobile carrier, and offers video, voice, and ISP services. In 2015, Verizon acquired AOL, an ISP and edge provider, and in 2016, it acquired the core business of Yahoo, an edge provider.19 It combined the edge provider products from these acquisitions—such as Yahoo Finance, Huffington Post, TechCrunch, and Engadget—in 2017 to create Oath.20 Examples of Edge Providers Becoming ISPs Google. Google is the largest subsidiary of the company Alphabet.21 It offers multiple products, including a search engine, email server, word processing, video streaming, and mapping/navigation system.22 Google generally relies on other ISPs to deliver its content, but entered the ISP market in 2010 when it announced Google Fiber. Google Fiber provides broadband internet service and video programming.23 Beginning in 2016, it suspended or ended some of its projects; as of October 2019, it had installed fiber optic cables in 18 cities.24 Reuters, October 25, 2019, https://www.reuters.com/article/us-media-at-t-hbo-max-focus/behind-atts-plan-to-take-on- netflix-apple-and-disney-with-hbo-max-idUSKBN1X4163. 15 Yinka Adegoke and Dan Levine, “Comcast Completes NBC Universal Merger,” Reuters, January 29, 2011, https://www.reuters.com/article/us-comcast-nbc/comcast-completes-nbc-universal-merger- idUSTRE70S2WZ20110129. 16 Lauren Feiner, Christine Wang, and Alex Sherman, “Disney to Take Full Control over Hulu, Comcast Has Option to Sell Its Stake in 5 years,” CNBC, May 14, 2019, https://www.cnbc.com/2019/05/14/comcast-has-agreed-to-sell-its- stake-in-hulu-in-5-years.html. 17 Gerry Smith, “NBC’s Peacock Bets Viewers Will Watch Ads to Stream for Free,” Bloomberg, January 16, 2020, https://www.bloomberg.com/news/articles/2020-01-16/nbc-s-peacock-bets-consumers-will-watch-ads-to-stream-for- free. 18 DrPeering.net. “Who Are the Tier 1 ISPs?” accessed on December 4, 2019, https://drpeering.net/FAQ/Who-are-the- Tier-1-ISPs.php. 19 Verizon, “Mergers & Acquisitions,” accessed on October 28, 2019, https://www.verizon.com/about/timeline- categories/mergers-acquisitions. 20 Tracey Lien, “Verizon Buys Yahoo for $4.8 Billion, and It’s Giving Yahoo’s Brand Another Chance,” Los Angeles Times, July 25, 2016, https://www.latimes.com/business/technology/la-fi-verizon-buys-yahoo-20160725-snap- story.html. 21 Larry Page, “G Is for Google,” Google Official Blog, August 10, 2015, https://googleblog.blogspot.com/2015/08/google-alphabet.html. 22 Google, “Our Products,” accessed on November 16, 2019, https://about.google/products. 23 Google, “Think Big with a Gig: Our Experimental Fiber Network,” February 10, 2010, https://googleblog.blogspot.com/2010/02/think-big-with-gig-our-experimental.html. 24 Jack Nicas, “Google’s High-Speed Web Plans Hit Snags,” Wall Street Journal, August 15, 2016, https://www.wsj.com/articles/googles-high-speed-web-plans-hit-snags-1471193165; Lauren Feiner, “Google Fiber’s High-Speed Internet Service Is Leaving Louisville After Ripping up Roads and Leaving Cables Exposed,” CNBC, February 7, 2019, https://www.cnbc.com/2019/02/07/google-fiber-pulls-out-of-louisville.html; Google, “Our Cities,” Competition on the Edge of the Internet Congressional Research Service 6 Facebook. As it attracted more users, Facebook expanded from providing an online platform that connects users to an online platform suitable for various activities, including fundraising, messaging, and commerce. In 2018, a spokesman confirmed that Facebook was pursuing another project, dubbed Athena.25 Athena is an experimental satellite that would beam internet access through radio signals. If successful, Athena would enable Facebook to become an ISP. Amazon. In addition to being a major online retailer, Amazon offers information technology infrastructure services through Amazon Web Services.26 In 2019, Amazon confirmed plans— dubbed Project Kuiper—to launch 3,236 satellites into low-Earth orbit to provide broadband internet across the world. If successful, Project Kuiper would enable Amazon to become an ISP.27

Only use the text provided in the context block to answer the question.

Why would "hard" science-fiction writers struggle to conceptualize the future?

Abstract Within thirty years, we will have the technological means to create superhuman intelligence. Shortly after, the human era will be ended. Is such progress avoidable? If not to be avoided, can events be guided so that we may survive? These questions are investigated. Some possible answers (and some further dangers) are presented. _What is The Singularity?_ The acceleration of technological progress has been the central feature of this century. I argue in this paper that we are on the edge of change comparable to the rise of human life on Earth. The precise cause of this change is the imminent creation by technology of entities with greater than human intelligence. There are several means by which science may achieve this breakthrough (and this is another reason for having confidence that the event will occur): o The development of computers that are "awake" and superhumanly intelligent. (To date, most controversy in the area of AI relates to whether we can create human equivalence in a machine. But if the answer is "yes, we can", then there is little doubt that beings more intelligent can be constructed shortly thereafter. o Large computer networks (and their associated users) may "wake up" as a superhumanly intelligent entity. o Computer/human interfaces may become so intimate that users may reasonably be considered superhumanly intelligent. o Biological science may find ways to improve upon the natural human intellect. The first three possibilities depend in large part on improvements in computer hardware. Progress in computer hardware has followed an amazingly steady curve in the last few decades [16]. Based largely on this trend, I believe that the creation of greater than human intelligence will occur during the next thirty years. (Charles Platt [19] has pointed out the AI enthusiasts have been making claims like this for the last thirty years. Just so I'm not guilty of a relative-time ambiguity, let me more specific: I'll be surprised if this event occurs before 2005 or after 2030.) What are the consequences of this event? When greater-than-human intelligence drives progress, that progress will be much more rapid. In fact, there seems no reason why progress itself would not involve the creation of still more intelligent entities -- on a still-shorter time scale. The best analogy that I see is with the evolutionary past: Animals can adapt to problems and make inventions, but often no faster than natural selection can do its work -- the world acts as its own simulator in the case of natural selection. We humans have the ability to internalize the world and conduct "what if's" in our heads; we can solve many problems thousands of times faster than natural selection. Now, by creating the means to execute those simulations at much higher speeds, we are entering a regime as radically different from our human past as we humans are from the lower animals. From the human point of view this change will be a throwing away of all the previous rules, perhaps in the blink of an eye, an exponential runaway beyond any hope of control. Developments that before were thought might only happen in "a million years" (if ever) will likely happen in the next century. (In [4], Greg Bear paints a picture of the major changes happening in a matter of hours.) I think it's fair to call this event a singularity ("the Singularity" for the purposes of this paper). It is a point where our models must be discarded and a new reality rules. As we move closer and closer to this point, it will loom vaster and vaster over human affairs till the notion becomes a commonplace. Yet when it finally happens it may still be a great surprise and a greater unknown. In the 1950s there were very few who saw it: Stan Ulam [27] paraphrased John von Neumann as saying: One conversation centered on the ever accelerating progress of technology and changes in the mode of human life, which gives the appearance of approaching some essential singularity in the history of the race beyond which human affairs, as we know them, could not continue. Von Neumann even uses the term singularity, though it appears he is still thinking of normal progress, not the creation of superhuman intellect. (For me, the superhumanity is the essence of the Singularity. Without that we would get a glut of technical riches, never properly absorbed (see [24]).) In the 1960s there was recognition of some of the implications of superhuman intelligence. I. J. Good wrote [10]: Let an ultraintelligent machine be defined as a machine that can far surpass all the intellectual activities of any any man however clever. Since the design of machines is one of these intellectual activities, an ultraintelligent machine could design even better machines; there would then unquestionably be an "intelligence explosion," and the intelligence of man would be left far behind. Thus the first ultraintelligent machine is the _last_ invention that man need ever make, provided that the machine is docile enough to tell us how to keep it under control. ... It is more probable than not that, within the twentieth century, an ultraintelligent machine will be built and that it will be the last invention that man need make. Good has captured the essence of the runaway, but does not pursue its most disturbing consequences. Any intelligent machine of the sort he describes would not be humankind's "tool" -- any more than humans are the tools of rabbits or robins or chimpanzees. Through the '60s and '70s and '80s, recognition of the cataclysm spread [28] [1] [30] [4]. Perhaps it was the science-fiction writers who felt the first concrete impact. After all, the "hard" science-fiction writers are the ones who try to write specific stories about all that technology may do for us. More and more, these writers felt an opaque wall across the future. Once, they could put such fantasies millions of years in the future [23]. Now they saw that their most diligent extrapolations resulted in the unknowable ... soon. Once, galactic empires might have seemed a Post-Human domain. Now, sadly, even interplanetary ones are. What about the '90s and the '00s and the '10s, as we slide toward the edge? How will the approach of the Singularity spread across the human world view? For a while yet, the general critics of machine sapience will have good press. After all, till we have hardware as powerful as a human brain it is probably foolish to think we'll be able to create human equivalent (or greater) intelligence. (There is the far-fetched possibility that we could make a human equivalent out of less powerful hardware, if were willing to give up speed, if we were willing to settle for an artificial being who was literally slow [29]. But it's much more likely that devising the software will be a tricky process, involving lots of false starts and experimentation. If so, then the arrival of self-aware machines will not happen till after the development of hardware that is substantially more powerful than humans' natural equipment.) But as time passes, we should see more symptoms. The dilemma felt by science fiction writers will be perceived in other creative endeavors. (I have heard thoughtful comic book writers worry about how to have spectacular effects when everything visible can be produced by the technically commonplace.) We will see automation replacing higher and higher level jobs. We have tools right now (symbolic math programs, cad/cam) that release us from most low-level drudgery. Or put another way: The work that is truly productive is the domain of a steadily smaller and more elite fraction of humanity. In the coming of the Singularity, we are seeing the predictions of _true_ technological unemployment finally come true. Another symptom of progress toward the Singularity: ideas themselves should spread ever faster, and even the most radical will quickly become commonplace. When I began writing, it seemed very easy to come up with ideas that took decades to percolate into the cultural consciousness; now the lead time seems more like eighteen months. (Of course, this could just be me losing my imagination as I get old, but I see the effect in others too.) Like the shock in a compressible flow, the Singularity moves closer as we accelerate through the critical speed.

Only use the text provided in the context block to answer the question. Why would "hard" science-fiction writers struggle to conceptualize the future? Abstract Within thirty years, we will have the technological means to create superhuman intelligence. Shortly after, the human era will be ended. Is such progress avoidable? If not to be avoided, can events be guided so that we may survive? These questions are investigated. Some possible answers (and some further dangers) are presented. _What is The Singularity?_ The acceleration of technological progress has been the central feature of this century. I argue in this paper that we are on the edge of change comparable to the rise of human life on Earth. The precise cause of this change is the imminent creation by technology of entities with greater than human intelligence. There are several means by which science may achieve this breakthrough (and this is another reason for having confidence that the event will occur): o The development of computers that are "awake" and superhumanly intelligent. (To date, most controversy in the area of AI relates to whether we can create human equivalence in a machine. But if the answer is "yes, we can", then there is little doubt that beings more intelligent can be constructed shortly thereafter. o Large computer networks (and their associated users) may "wake up" as a superhumanly intelligent entity. o Computer/human interfaces may become so intimate that users may reasonably be considered superhumanly intelligent. o Biological science may find ways to improve upon the natural human intellect. The first three possibilities depend in large part on improvements in computer hardware. Progress in computer hardware has followed an amazingly steady curve in the last few decades [16]. Based largely on this trend, I believe that the creation of greater than human intelligence will occur during the next thirty years. (Charles Platt [19] has pointed out the AI enthusiasts have been making claims like this for the last thirty years. Just so I'm not guilty of a relative-time ambiguity, let me more specific: I'll be surprised if this event occurs before 2005 or after 2030.) What are the consequences of this event? When greater-than-human intelligence drives progress, that progress will be much more rapid. In fact, there seems no reason why progress itself would not involve the creation of still more intelligent entities -- on a still-shorter time scale. The best analogy that I see is with the evolutionary past: Animals can adapt to problems and make inventions, but often no faster than natural selection can do its work -- the world acts as its own simulator in the case of natural selection. We humans have the ability to internalize the world and conduct "what if's" in our heads; we can solve many problems thousands of times faster than natural selection. Now, by creating the means to execute those simulations at much higher speeds, we are entering a regime as radically different from our human past as we humans are from the lower animals. From the human point of view this change will be a throwing away of all the previous rules, perhaps in the blink of an eye, an exponential runaway beyond any hope of control. Developments that before were thought might only happen in "a million years" (if ever) will likely happen in the next century. (In [4], Greg Bear paints a picture of the major changes happening in a matter of hours.) I think it's fair to call this event a singularity ("the Singularity" for the purposes of this paper). It is a point where our models must be discarded and a new reality rules. As we move closer and closer to this point, it will loom vaster and vaster over human affairs till the notion becomes a commonplace. Yet when it finally happens it may still be a great surprise and a greater unknown. In the 1950s there were very few who saw it: Stan Ulam [27] paraphrased John von Neumann as saying: One conversation centered on the ever accelerating progress of technology and changes in the mode of human life, which gives the appearance of approaching some essential singularity in the history of the race beyond which human affairs, as we know them, could not continue. Von Neumann even uses the term singularity, though it appears he is still thinking of normal progress, not the creation of superhuman intellect. (For me, the superhumanity is the essence of the Singularity. Without that we would get a glut of technical riches, never properly absorbed (see [24]).) In the 1960s there was recognition of some of the implications of superhuman intelligence. I. J. Good wrote [10]: Let an ultraintelligent machine be defined as a machine that can far surpass all the intellectual activities of any any man however clever. Since the design of machines is one of these intellectual activities, an ultraintelligent machine could design even better machines; there would then unquestionably be an "intelligence explosion," and the intelligence of man would be left far behind. Thus the first ultraintelligent machine is the _last_ invention that man need ever make, provided that the machine is docile enough to tell us how to keep it under control. ... It is more probable than not that, within the twentieth century, an ultraintelligent machine will be built and that it will be the last invention that man need make. Good has captured the essence of the runaway, but does not pursue its most disturbing consequences. Any intelligent machine of the sort he describes would not be humankind's "tool" -- any more than humans are the tools of rabbits or robins or chimpanzees. Through the '60s and '70s and '80s, recognition of the cataclysm spread [28] [1] [30] [4]. Perhaps it was the science-fiction writers who felt the first concrete impact. After all, the "hard" science-fiction writers are the ones who try to write specific stories about all that technology may do for us. More and more, these writers felt an opaque wall across the future. Once, they could put such fantasies millions of years in the future [23]. Now they saw that their most diligent extrapolations resulted in the unknowable ... soon. Once, galactic empires might have seemed a Post-Human domain. Now, sadly, even interplanetary ones are. What about the '90s and the '00s and the '10s, as we slide toward the edge? How will the approach of the Singularity spread across the human world view? For a while yet, the general critics of machine sapience will have good press. After all, till we have hardware as powerful as a human brain it is probably foolish to think we'll be able to create human equivalent (or greater) intelligence. (There is the far-fetched possibility that we could make a human equivalent out of less powerful hardware, if were willing to give up speed, if we were willing to settle for an artificial being who was literally slow [29]. But it's much more likely that devising the software will be a tricky process, involving lots of false starts and experimentation. If so, then the arrival of self-aware machines will not happen till after the development of hardware that is substantially more powerful than humans' natural equipment.) But as time passes, we should see more symptoms. The dilemma felt by science fiction writers will be perceived in other creative endeavors. (I have heard thoughtful comic book writers worry about how to have spectacular effects when everything visible can be produced by the technically commonplace.) We will see automation replacing higher and higher level jobs. We have tools right now (symbolic math programs, cad/cam) that release us from most low-level drudgery. Or put another way: The work that is truly productive is the domain of a steadily smaller and more elite fraction of humanity. In the coming of the Singularity, we are seeing the predictions of _true_ technological unemployment finally come true. Another symptom of progress toward the Singularity: ideas themselves should spread ever faster, and even the most radical will quickly become commonplace. When I began writing, it seemed very easy to come up with ideas that took decades to percolate into the cultural consciousness; now the lead time seems more like eighteen months. (Of course, this could just be me losing my imagination as I get old, but I see the effect in others too.) Like the shock in a compressible flow, the Singularity moves closer as we accelerate through the critical speed.

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

I remember vaguely hearing about the Glass-Steagall Act while I was in college and that it was removed. What is the act exactly, and what are some of the pros and cons of the act being repealed?

The Glass-Steagall Act was passed under FDR as a response to the stock market crash of 1929. It effected a wall between commercial banking and investment banking, only to be partially repealed in 1999. While there exists consensus around what the Glass-Steagall Act pertains to, there’s disagreement around its influence on the financial markets. In particular, the debate has centered around the repeal’s effects on the 2008 financial crisis and whether it was a principal cause of the crisis. Notably, it remains relevant despite the introduction of recent legislation. In 2010, the Obama administration enacted the Dodd-Frank Act in response to the financial crisis. Similar to Glass-Steagall, it attempted to promote financial stability and protect the consumer, but Dodd-Frank did not reinstate the repealed provisions of Glass-Steagall. In the aftermath of the 1929 stock market crash, the Pecora Commission was tasked with investigating its causes. The Commission identified issues including risky securities investments that endangered bank deposits, unsound loans made to companies in which banks were invested, and conflicts of interest. Other issues included a blurring of the distinction between uninsured and insured practices, or an abusive practice of requiring joint purchases of multiple products. Congress attempted to address these issues with the Banking Act of 1933 and other legislation. While the effects of the Glass-Steagall Act were wide-ranging, it is equally important to note what the Glass-Steagall Act did not do. Beyond limiting the scope of activities for commercial and investment banks, the Act was not intended to limit the size or volume of such activities. Therefore, returning to the example of J.P. Morgan & Co., while the Act prohibited the bank from conducting all the same activities within a single organization, it did not prohibit the same activities (type and volume) if carried out separately through JPMorgan and Morgan Stanley. So when was the Glass-Steagall Act repealed? By the late 1990s, the Glass-Steagall Act had essentially become ineffective. In November 1999, then-President Bill Clinton signed the Gramm-Leach-Bliley Act (GLBA) into effect. GLBA repealed Sections 20 and 32 of the Glass-Steagall Act, which had prohibited the interlocking of commercial and investment activities. The partial repeal allowed for universal banking, which combines commercial and investment banking services under one roof. Many experts view GLBA as “ratifying, rather than revolutionizing” in that it simply formalized a change that was already ongoing. However, GLBA left intact Sections 16 and 21, which are still in place today. These continue to have practical effects on the industry today. For instance, they limit investment management firms such as Bridgewater Associates from offering checking accounts and prohibit commercial banks such as Wells Fargo from dealing in risky securities such as cattle futures. Between 1998 and 2006, the housing market and housing prices rose to previously unseen highs. As many readers already know, the market’s later crash was a primary cause of the Financial Crisis. A major determinant of the housing boom was the utilization of imprudent lending standards and subsequent growth of subprime mortgage loans. Most of these loans were made to homebuyers with factors that prevented them from qualifying for a prime loan. Many subprime loans also included tricky features that kept the initial payments low but subjected borrowers to risk if interest rates rose or house prices declined. Unfortunately, when housing prices started to fall, many borrowers found that they owed more on their houses than they were worth. According to the Financial Crisis Inquiry Commission (FCIC), which conducted the official government investigation into the crisis, the percentage of borrowers who defaulted on their mortgages months after the loan nearly doubled from 2006 to late 2007. Suspicious activity reports related to mortgage fraud grew 20-fold between 1996 and 2005, more than doubling between 2005 and 2009 (Chart 4). The losses from this fraud have been estimated at $112 billion. Did the Glass-Steagall Act’s repeal contribute to the deterioration in underwriting standards that fueled the housing boom and eventual collapse? Predictably, opinions are divided. On the one hand, those who believe the absence of Glass-Steagall did not cause the crisis highlight that offering mortgages has always been a core business for commercial banks, and so the banking system has always been exposed to high default rates in residential mortgages. Glass-Steagall was never intended to address or regulate loan qualification standards. In addition, while the Glass-Steagall Act limited the investment activities of commercial banks, it did not prevent non-depositories from extending mortgages that competed with commercial banks, or from selling these mortgages to investment banks. It also did not prevent investment banks from securitizing the mortgages to then sell to institutional investors. Nor did it address the incentives of the institutions that originated mortgages or sold mortgage-related securities. Because it did not directly address these issues, it’s unlikely the Glass-Steagall Act could have prevented the decline in mortgage underwriting standards that led to the housing boom of the 2000s. On the other hand, those who argue that the absence of Glass-Steagall did cause the crisis believe that the decline in underwriting standards was in fact partially, or indirectly, caused by the Act’s absence. Readers will recall from the beginning of the article that Glass-Steagall’s provisions addressed the conflicts of interest and other potential abuses of universal banks. After Glass-Steagall’s repeal, it is feasible that universal banks aimed to establish an initial market share in the securities market by lowering underwriting standards. Separately, universal banks might also self-deal and favor their own interests over those of their customers. Both of these incentives could have led to or exacerbated the decline in underwriting standards. While these results are not entirely conclusive, it does suggest that Glass-Steagall’s absence could have worsened underwriting standards. Had Glass-Steagall been in place, these universal banking institutions would not have been created. Nevertheless, the regulation would not have prevented new, investment-only entrants also looking to gain market share. And as we’ve already mentioned, the Glass-Steagall Act never directly addressed loan qualification standards or prevented non-depositors from extending, repackaging, and selling mortgages. It’s therefore unlikely that the Glass-Steagall Act could have prevented the decline in mortgage underwriting standards, but its absence could have aggravated the situation. The second major topic of discussion related to Glass-Steagall and the financial crisis surrounds the issue of “too big to fail” and systemic risks. When the failure of an institution could result in systemic risks, whereby there would be contagious, widespread harm to financial institutions, it was deemed too big to fail (TBTF). TBTF institutions are so large, interconnected, and important that their failure would be disastrous to the greater economic system. Should they fail, the associated costs are absorbed by government and taxpayers. If one accepts that systemic risk and TBTF institutions were major contributors to the 2008 crisis, then the debate turns to whether the absence of Glass-Steagall contributed to the creation of TBTF institutions and their disastrous effects. After all, the repeal of Glass-Steagall in 1999 set in motion the wave of mega-mergers that created huge financial conglomerates, many of which fall firmly within the TBTF camp. Ironically, Glass-Steagall’s repeal actually allowed for the rescue of many large institutions after the crisis: After all, JPMorgan Chase rescued Bear Stearns and Bank of America rescued Merrill Lynch, which would have been impermissible prior to the 1999 repeal. Both were already involved in commercial and investment banking when they saved the two failing investment banks. On balance, therefore, the evidence does not seem to support the view that Glass-Steagall’s absence was a cause of the financial crisis. Overall, while the general consensus is that Glass-Steagall's absence was not a principal cause of the crisis, the underlying culture of excessive risk-taking and short-term profit was real.

"================ <TEXT PASSAGE> ======= The Glass-Steagall Act was passed under FDR as a response to the stock market crash of 1929. It effected a wall between commercial banking and investment banking, only to be partially repealed in 1999. While there exists consensus around what the Glass-Steagall Act pertains to, there’s disagreement around its influence on the financial markets. In particular, the debate has centered around the repeal’s effects on the 2008 financial crisis and whether it was a principal cause of the crisis. Notably, it remains relevant despite the introduction of recent legislation. In 2010, the Obama administration enacted the Dodd-Frank Act in response to the financial crisis. Similar to Glass-Steagall, it attempted to promote financial stability and protect the consumer, but Dodd-Frank did not reinstate the repealed provisions of Glass-Steagall. In the aftermath of the 1929 stock market crash, the Pecora Commission was tasked with investigating its causes. The Commission identified issues including risky securities investments that endangered bank deposits, unsound loans made to companies in which banks were invested, and conflicts of interest. Other issues included a blurring of the distinction between uninsured and insured practices, or an abusive practice of requiring joint purchases of multiple products. Congress attempted to address these issues with the Banking Act of 1933 and other legislation. While the effects of the Glass-Steagall Act were wide-ranging, it is equally important to note what the Glass-Steagall Act did not do. Beyond limiting the scope of activities for commercial and investment banks, the Act was not intended to limit the size or volume of such activities. Therefore, returning to the example of J.P. Morgan & Co., while the Act prohibited the bank from conducting all the same activities within a single organization, it did not prohibit the same activities (type and volume) if carried out separately through JPMorgan and Morgan Stanley. So when was the Glass-Steagall Act repealed? By the late 1990s, the Glass-Steagall Act had essentially become ineffective. In November 1999, then-President Bill Clinton signed the Gramm-Leach-Bliley Act (GLBA) into effect. GLBA repealed Sections 20 and 32 of the Glass-Steagall Act, which had prohibited the interlocking of commercial and investment activities. The partial repeal allowed for universal banking, which combines commercial and investment banking services under one roof. Many experts view GLBA as “ratifying, rather than revolutionizing” in that it simply formalized a change that was already ongoing. However, GLBA left intact Sections 16 and 21, which are still in place today. These continue to have practical effects on the industry today. For instance, they limit investment management firms such as Bridgewater Associates from offering checking accounts and prohibit commercial banks such as Wells Fargo from dealing in risky securities such as cattle futures. Between 1998 and 2006, the housing market and housing prices rose to previously unseen highs. As many readers already know, the market’s later crash was a primary cause of the Financial Crisis. A major determinant of the housing boom was the utilization of imprudent lending standards and subsequent growth of subprime mortgage loans. Most of these loans were made to homebuyers with factors that prevented them from qualifying for a prime loan. Many subprime loans also included tricky features that kept the initial payments low but subjected borrowers to risk if interest rates rose or house prices declined. Unfortunately, when housing prices started to fall, many borrowers found that they owed more on their houses than they were worth. According to the Financial Crisis Inquiry Commission (FCIC), which conducted the official government investigation into the crisis, the percentage of borrowers who defaulted on their mortgages months after the loan nearly doubled from 2006 to late 2007. Suspicious activity reports related to mortgage fraud grew 20-fold between 1996 and 2005, more than doubling between 2005 and 2009 (Chart 4). The losses from this fraud have been estimated at $112 billion. Did the Glass-Steagall Act’s repeal contribute to the deterioration in underwriting standards that fueled the housing boom and eventual collapse? Predictably, opinions are divided. On the one hand, those who believe the absence of Glass-Steagall did not cause the crisis highlight that offering mortgages has always been a core business for commercial banks, and so the banking system has always been exposed to high default rates in residential mortgages. Glass-Steagall was never intended to address or regulate loan qualification standards. In addition, while the Glass-Steagall Act limited the investment activities of commercial banks, it did not prevent non-depositories from extending mortgages that competed with commercial banks, or from selling these mortgages to investment banks. It also did not prevent investment banks from securitizing the mortgages to then sell to institutional investors. Nor did it address the incentives of the institutions that originated mortgages or sold mortgage-related securities. Because it did not directly address these issues, it’s unlikely the Glass-Steagall Act could have prevented the decline in mortgage underwriting standards that led to the housing boom of the 2000s. On the other hand, those who argue that the absence of Glass-Steagall did cause the crisis believe that the decline in underwriting standards was in fact partially, or indirectly, caused by the Act’s absence. Readers will recall from the beginning of the article that Glass-Steagall’s provisions addressed the conflicts of interest and other potential abuses of universal banks. After Glass-Steagall’s repeal, it is feasible that universal banks aimed to establish an initial market share in the securities market by lowering underwriting standards. Separately, universal banks might also self-deal and favor their own interests over those of their customers. Both of these incentives could have led to or exacerbated the decline in underwriting standards. While these results are not entirely conclusive, it does suggest that Glass-Steagall’s absence could have worsened underwriting standards. Had Glass-Steagall been in place, these universal banking institutions would not have been created. Nevertheless, the regulation would not have prevented new, investment-only entrants also looking to gain market share. And as we’ve already mentioned, the Glass-Steagall Act never directly addressed loan qualification standards or prevented non-depositors from extending, repackaging, and selling mortgages. It’s therefore unlikely that the Glass-Steagall Act could have prevented the decline in mortgage underwriting standards, but its absence could have aggravated the situation. The second major topic of discussion related to Glass-Steagall and the financial crisis surrounds the issue of “too big to fail” and systemic risks. When the failure of an institution could result in systemic risks, whereby there would be contagious, widespread harm to financial institutions, it was deemed too big to fail (TBTF). TBTF institutions are so large, interconnected, and important that their failure would be disastrous to the greater economic system. Should they fail, the associated costs are absorbed by government and taxpayers. If one accepts that systemic risk and TBTF institutions were major contributors to the 2008 crisis, then the debate turns to whether the absence of Glass-Steagall contributed to the creation of TBTF institutions and their disastrous effects. After all, the repeal of Glass-Steagall in 1999 set in motion the wave of mega-mergers that created huge financial conglomerates, many of which fall firmly within the TBTF camp. Ironically, Glass-Steagall’s repeal actually allowed for the rescue of many large institutions after the crisis: After all, JPMorgan Chase rescued Bear Stearns and Bank of America rescued Merrill Lynch, which would have been impermissible prior to the 1999 repeal. Both were already involved in commercial and investment banking when they saved the two failing investment banks. On balance, therefore, the evidence does not seem to support the view that Glass-Steagall’s absence was a cause of the financial crisis. Overall, while the general consensus is that Glass-Steagall's absence was not a principal cause of the crisis, the underlying culture of excessive risk-taking and short-term profit was real. https://www.toptal.com/finance/investment-banking-freelancer/glass-steagall-act ================ <QUESTION> ======= I remember vaguely hearing about the Glass-Steagall Act while I was in college and that it was removed. What is the act exactly, and what are some of the pros and cons of the act being repealed? ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

Use only the given sources to complete your responses. Do not use outside sources or any previous knowledge of the topic that you may have.

Can you list all of the ancient people mentioned by name in a bullet point list along with a brief description of their beliefs regarding the brain?

1) A BRIEF HISTORY OF NEUROSCIENCE Humans have long been interested in exploring the nature of mind. The long history of their enquiry into the relationship between mind and body is particularly marked by several twists and turns. However, brain is the last of the human organs to be studied in all seriousness, more particularly its relation with human mind. Around 2000 BC and for long since that time the Egyptians did not think highly of the brain. They would take out the brain via the nostrils and discarded it away before mummifying the dead body. Instead, they would take great care of the heart and other internal organs. However, a few Egyptian physicians seemed to appreciate the significance of the brain early on. Certain written records have been found where Egyptian physicians had even identified parts and areas in the brain. Besides, Egyptian papyrus, believed to have been written around 1700 BC, carried careful description of the brain, suggesting the possibility of addressing mental disorders through treatment of the brain. That is the first record of its kind in the human history (Figure 1). The Greek mathematician and philosopher, Plato (427-347) believed that the brain was the seat of mental processes such as memory and feelings (Figure 2). Later, another Greek physician and writer on medicine, Galen (130-200 AD) too, believed that brain disorders were responsible for mental illnesses. He also followed Plato in concluding that the mind or soul resided in the brain. However, Aristotle (384-322 BC), the great philosopher of Greece at that time, restated the ancient belief that the heart was the superior organ over the brain (Figure 3). In support of his belief, he stated that the brain was just like a radiator which stopped the body from becoming overheated, whereas the heart served as the seat of human intelligence, thought, and imagination, etc. Medieval philosophers felt that the brain was constituted of fluid-filled spaces called ventricles where the ‘animal spirits’ circulated to form sensations, emotions, and memories. This viewpoint brought about a shift in the previously held views and also provided the scientists with the new idea of actually looking into the brains of the humans and animals. However, no such ventricles as claimed by them were found upon examination nor did the scientists find any specific location for the self or the soul in the brain. In the seventeenth century, the French philosopher Rene Descartes (1596-1650) described mind and body as separate entities (Figure 4) yet they interacted with each other via the pineal gland, the only structure not duplicated on both sides of the brain. He maintained that the mind begins its journey from the pineal gland and circulates the rest of the body via the nerve vessels. His dualist view influenced the mind-body debate for Page 4 of 35 the next two centuries. However, through the numerous experiments undertaken in the 19th century, the scientists gathered evidences and findings which all emboldened the scientists to claim that the brain is the center of feelings, thoughts, self and behaviors. Just to give an example of the kind of experiments performed on a particular physical activity which pointed to the brain as the regulator of bodily actions, imagine activating a particular area of the brain through electrical stimulus, you would actually see it effectively impacting a corresponding body-part, say the legs by making them move. Through findings such as these as well as others, we have come of know also of the special activities of the electrical impulses and chemicals in the brain. Explorations continued into the later centuries and, by the middle of 20th century, human understanding of the brain and its activities have increased manifold. Particularly, towards the end of twentieth century, with further improvement in imaging technologies enabling the researchers to undertake investigation on functioning brains, the scientists were deeply convinced that the brain and the rest of the nervous systems monitored and regulated emotions and bodily behaviors (Figures 5 & 6). Since then, the brain together with the nervous system have become the center of attention as the basis of mental activities as well as physical behaviors, and gradually a separate branch of science called neuroscience focusing specifically on the nervous systems of the body has evolved in the last 40 so years. To better understand modern neuroscience in its historical context, including why the brain and nervous system have become the center of attention in the scientific pursuit of understanding the mind, it is useful to first review some preliminary topics in the philosophy of science. Science is a method of inquiry that is grounded in empirical evidence. Questions about the unknown direct the path of science as a method. Each newly discovered answer opens the door to many new questions, and the curiosity of scientists motivates them to answer those unfolding questions. When a scientist encounters a question, she or he develops an explanatory hypothesis that has the potential to answer it. But it is not enough to simply invent an explanation. To know if an explanation is valid or not, a scientist must test the hypothesis by identifying and observing relevant, objectively measurable phenomena. Any hypothesis that cannot be tested in this way is not useful for science. A useful hypothesis must be falsifiable, meaning that it must be possible to ascertain, based on objective observations, whether the hypothesis is wrong and does not explain the phenomena in question. If a hypothesis is not falsifiable, it is impossible to know whether it is the correct explanation of a phenomenon because we cannot test the validity of the claim. Why does the scientific method rely only on objective observations? Science is a team effort, conducted across communities and generations over space and time. For a hypothesis to be accepted as valid, it must be possible for any interested scientist to test it. For example, if we want to repeat an experiment that our colleague conducted last year, we need to test the hypothesis under the same conditions as the original experiment. This means it must be possible to recreate those conditions. The only way to do this in a precise and controlled manner is if the scientific method relies on empirical evidence. Page 5 of 35 Furthermore, conclusions in science are subject to peer review. This means that any scientist’s colleagues must be able to review and even re-create the procedures, analyses, and conclusions made by that scientist before deciding if the evidence supports the conclusions. Because we don’t have access to the subjective experiences of others, it is not possible to replicate experiments that are grounded in subjectivity because we cannot recreate the conditions of such an experiment, nor can we perform identical analyses of subjective phenomena across people. No matter how many words we use, we cannot describe a single subjective experience accurately enough to allow another person to experience it the same way. Consequently, we cannot have a replicable experiment if the evidence is not objective. Therefore, two necessary features of a scientific hypothesis are the potentials to falsify and replicate it. And both of these requirements are dependent on objectively measurable evidence. This is why we began with the claim that science is a method of inquiry that is grounded in empirical evidence. Neuroscience is a scientific discipline like any other, in that the focus of investigation is on objectively measurable phenomena. But unlike most other sciences, this poses a particularly challenging problem for neuroscience. How do we investigate the mind, which is subjective by nature, if empirical evidence is the only valid form of data to support a conclusion in science? The relationship between the mind and the body has become known as the “mind-body problem” in modern neuroscience and Western philosophy of mind, because there is a fundamental challenge to explain the mind in objective terms. Scientists view this relationship as a problem because their method of inquiry investigates phenomena from a third-person (he, she, it, they) perspective, while the subjective experience of the mind has a first-person (I, we) perspective. The mindbody problem has been a central, unresolved topic in Western philosophy of mind for centuries, and is a topic we will discuss in more detail in a later chapter of this textbook when we explore the neuroscience of consciousness. For now we can start simply by stating that the majority of scientists, including neuroscientists, hold the philosophical view that all phenomena are caused by physical processes, including consciousness and its related mental phenomena. This view might be proven wrong as inquiry proceeds, but is taken as the most simple (or parsimonious) starting point. Science uses the principle of parsimony, of starting with simple rather than complex explanations, as a way to facilitate production of falsifiable hypotheses: more complex explanations are built up as evidence accumulates and more simple explanations are excluded. Modern neuroscience investigates the brain and nervous system based on the working assumption that the objective physical states of those biological systems are the cause of the subjective mental states of the organism that has those biological systems. In other words, when you smell a fresh flower, taste a cup of chai, listen to the birds, feel the wind on your cheek, and see the clouds in the sky, those subjective experiences are caused by the momentary physical processes in your body, nervous system, and brain interacting with the physical environment. Under this philosophical view, then, mental states correlate with physical states of the organism, and by investigating those physical states scientists can understand the nature of those mental Page 6 of 35 states. So while this might seem counterintuitive based on the Buddhist method of inquiry, for a neuroscientist it is obvious to begin the investigation by focusing on physical phenomena; on the empirical evidence. Neuroscientists often equate the “neural correlates” of consciousness as consciousness itself. We will explore in more depth the relationship between form and function between the body and mind later in the textbook, as well as the philosophical view of materialism in neuroscience. It will also be helpful to introduce some basic concepts in neuroscience before exploring topics in more detail. The primary goal in this year of the neuroscience curriculum is that you become familiar with the brain and nervous system. The human brain is the most complex and extraordinary object known to all of modern science. Because of this immense complexity, it can be very challenging to encounter neuroscience in an introductory course such as this one. So patience is an important part of the learning process. First, neuroscience is still very much in its infancy as a scientific discipline, and there are vastly more questions than there are answers. Second, it can be a challenge for new students of neuroscience to simultaneously learn the details of the basic concepts while understanding and appreciating the broader conclusions. It’s like learning a language while also reading the literature of that language! Neuroscience is a scientific discipline with many different levels of exploration and explanation. Therefore, it is important for you to pay attention to the level at which are we speaking when you learn new concepts. For example, the brain and nervous system are made up of cells called neurons or nerve cells, which we will discuss in detail in Chapter 4. Neurons connect with each other to form complex networks, and from those different patterns of connection emerge different phenomena (such as a thought or a sensation) in the brain and ultimately in the mind. This may sound confusing at the moment, but we will explore these topics in more detail in later chapters. In neuroscience, levels of explanation can span from very low levels such as the molecular mechanisms involved in the neuron cells, to middle levels such as particular networks of neurons in the brain, to very high levels such as how humans engage in thoughts, speech, and purposeful actions. The brain is the bodily organ that is the center of the nervous system. But it might surprise you to learn that not all animals that have neurons have a brain! For example, jellyfish have neurons, but they don’t have a brain. Jellyfish are very simple organisms that live in the ocean, and their neurons allow them to sense some basic information about their environment. But because they don’t have a brain to process that environmental information, they can only react to their immediate environment. Without a brain, jellyfish cannot think, make plans for the future, have memories of the past, or make decisions. Their behavior is limited to reactions and reflexes. Complex networks of neurons in the human brain are the physiological substrates that support what we experience as human beings. But we are not the only species with a brain. Later in this textbook we will explore the relationship between brain complexity and behavior across species. For organisms that have a brain, information can flow along the complex networks of neurons in different ways. Some networks, also called pathways or systems, flow from the sensory organs to the brain, while others flow from the brain to the muscles of the Page 7 of 35 body. Afferent neurons, also called sensory neurons or receptor neurons, communicate information from the sensory organs to the brain. Efferent neurons, also called motor neurons, communicate information from the brain to the muscles of the body. Interneurons, also called association neurons, communicate information between neurons in the central nervous system and brain. This allows for the sensory and motor systems to interact, facilitating complex behaviors and integrating across the different sensory modalities. For example, to be able to reach for an object such as a teacup, your brain needs to link together your ability to sense the presence and location of the cup with your ability to control the muscles in your arm to grasp the cup. Interneurons perform this function. Finally, before starting your journey in learning about neuroscience, pause to contemplate some of the big questions and insights as they pertain to the Western science of the mind. As you go through this textbook and learn new concepts, it will be useful to think about them within the context of these big questions. For example, what is sentience? Is a brain required for sentience? The jellyfish we mentioned earlier can have basic sensations and react to the environment without a brain, but it cannot think or have memory. What are the necessary conditions to be sentient? What is the relationship between the mind and body? As a method of inquiry, can science directly investigate subjective experience? Or must we use alternative, and perhaps complementary methods of inquiry to achieve that? Do we perceive the physical world directly, or are our perceptions constructed? If the latter, how does that happen? 2) WHAT IS NEUROSCIENCE AND WHAT ARE ITS BRANCH SCIENCES? In the case of humans, it is the branch of science that studies the brain, the spinal cord, the nerves extending from them, and the rest of the nervous systems including the synapses, etc. Recall that neurons, or nerve cells, are the biological cells that make up the nervous system, and the nervous system is the complex network of connections between those cells. In this connection, it may involve itself with the cellular and molecular bases of the nervous system as well as the systems responsible for sensory and motor activities of the body. It also deals with the physical bases of mental processes of all levels, including emotions and cognitive elements. Thus, it concerns itself with issues such as thoughts, mental activities, behaviors, the brain and the spinal cord, functions of nerves, neural disorders, etc. It wrestles with questions such as What is consciousness?, How and why do beings have mental activities?, What are the physical bases for the variety of neural and mental illnesses, etc. In identifying the sub-branches within neuroscience, there are quite a few ways of doing so. However, here we will follow the lead of the Society for Neuroscience which identifies the following five branches: Neuro-anatomy, Developmental Neuroscience, Cognitive Neuroscience, Behavioral Neuroscience, and Neurology. Of these, Page 8 of 35 neuroanatomy concerns itself mainly with the issue of structures and parts of the nervous system. In this discipline, the scientists employ special dyeing techniques in identifying neurotransmitters and in understanding the specific functions of the nerves and nerve centers. Neurotransmitters are chemicals released between neurons for transmission of signals. When a neuron communicates with its neighboring cells, it releases neurotransmitters and its neighbors receive them. In developmental neuroscience, the scientists look into the phases and processes of development of nervous system, the changes they undergo after they have matured, and their eventual degeneration. In this regard, the scientists also investigate the ways neurons go about seeking connection with other neurons, how they establish the connection, and how they maintain the connection and what chemical changes and processes they have to undergo for these activities. Neurons make connections to form networks, and the different patterns of connectivity support different functions. Patterns of connectivity can change over different time scales, such as developmental changes over a lifetime from infancy to old age, but also in the short term such as learning a new concept. Neuroplasticity is the term that describes the capacity of the brain to change in response to stimulation or even damage: it is not a static organ, but is highly adaptable. In cognitive neuroscience, they study the functions of behaviors, perceptions, and memories, etc. By making use of non-invasive methods such as the PTE and MRI technologies that allow us to take detailed pictures of the brain without opening the skull, they look into the neural pathways activated during engagement in language, solutions, and other activities. Cognitive neuroscience studies the mind-body relationship by discovering the neural correlates to mental and behavioral phenomena. Behavioral neuroscience looks into the underpinning processes of human and animal behaviors. Using electrodes, they measure the neural electrical activities occurring alongside our actions such as visual perception, language use, and generating memories. Through fMRI scan techniques, another technology that allows us to take detailed motion pictures of brain activity over time without opening the skull, they strive to arrive at closer understanding of the brain parts in real time. Finally, neurology makes use of the fundamental research findings of the other disciplines in understanding the neural and neuronal disorders and strives to explore new innovative ways of detecting, preventing, and treating these disorders. 3) THE SUBJECT MATTER OF NEUROSCIENCE: THE MAIN SYSTEMS AND THEIR PARTS The field of neuroscience is the nervous system of animals in general and of humans in particular. In the case of humans, its nervous system has two main components: the central nervous system (CNS) and the peripheral nervous system (PNS) (Figure 7). The CNS comprises of the brain and the spinal cord. Their functions involve processing and interpreting the information received the senses, skin, muscles, etc. and giving responses Page 9 of 35 that direct and dictate specific actions such as particular movements by different parts of the body. The peripheral nervous system (PNS) includes all the rest of the nervous system aside from the central nervous system. This means that it comprises the 12 pairs of cranial nerves that originate directly from the brain and spread to different parts of the body bypassing the spinal cord, and the 31 pairs of spinal nerves that pass through the spinal cord and spread to different parts of the body. Thus, the PNS is mainly constituted of nerve. PNS is sometimes further classified into voluntary nervous system and the autonomic nervous system. This is based on the fact that the nerves in the former system are involved in making conscious movements, whereas those in the latter system make movements over which the person does not have control. Obviously, the former category of nerves includes those associated with the muscles of touch, smell, vision, and skeleton. The latter includes nerves spread over muscles attached with heart beats, blood pressure, glands, and smooth muscles. 4) AN EXCLUSIVE LOOK AT ‘NEURONS’, A FUNDAMENTAL UNIT OF THE BRAIN AND THE NERVOUS SYSTEM Neurons Neurons are the cellular units of the brain and nervous system, and are otherwise called nerve cells (Figure 8). Estimates of the number of brain neurons range from 50 billion to 500 billion, and they are not even the most numerous cells in the brain. Like hepatocyte cells in the liver, osteocytes in bone, or erythrocytes in blood, each neuron is a selfcontained functioning unit. Its internal components, the organelles, include a nucleus harboring the genetic material (DNA), energy-providing mitochondria, and proteinmaking ribosomes. As in most other types of cells, the organelles are concentrated in the main cell body. In addition, characteristic features of neurons are neurites—long, thin, finger-like or threadlike extensions from the cell body (soma). The two main types are dendrites and axons. Usually, dendrites receive nerve signals, while axons send them onward. The cell body of a neuron is about 10-100 micrometers across, that is 1/100th to 1/10th of one millimeter. Also, the axon is 0.2-20 micrometers in diameter, dendrites are usually slimmer. In terms of length, dendrites are typically 10-50 micrometers long, while axons can be up a few centimeters (inches). This is mostly the case in the central nervous system (Figure 9). Classification of neurons Page 10 of 35 There are numerous ways of classifying neurons among themselves. One of them is by the direction that they send information. On this basis, we can classify all neurons into the three: sensory neurons, motor neurons, and interneurons. The sensory neurons are those that send information received from sensory receptors toward the central nervous system, whereas the motor neurons send information away from the central nervous system to muscles or glands. The interneurons are those neurons that send information between sensory neurons and motor neurons. Here, the sensory neurons receive information from sensory receptors (e.g., in skin, eyes, nose, tongue, ears) and send them toward the central nervous system. Because of this, these neurons are also called afferent neurons as they bring informational input towards the central nervous system. Likewise, the motor neurons bring motor information away from the central nervous system to muscles or glands, and are thus called efferent neurons as they bring the output from the central nervous system to the muscles or glands. Since the interneurons send information between sensory neurons and motor neurons, thus serving as connecting links between them, they are sometimes called internuncial neurons. This third type of neurons is mostly found in the central nervous system. Another way of classifying the neurons is by the number of extensions that extend from the neuron’s cell body (soma) (Figure 10). In accordance with this system, we have unipolar, bipolar, and multipolar neurons. This classification takes into account the number of extensions extending initially from the cell body of the neuron, not the overall number of extensions. This is because there can be unipolar neurons which have more than one extensions in total. However, what the difference here is from the other two types of neurons is that these unipolar neurons shall have only one initial extension from the cell body. Most of the neurons are multipolar in nature. Synapses Synapses are communication sites where neurons pass nerve impulses among themselves. The cells are not usually in actual physical contact, but are separated by an incredibly thin gap, called the synaptic cleft. Microanatomically, synapses are divided into types according to the sites where the neurons almost touch. These sites include the soma, the dendrites, the axons, and tiny narrow projections called dendritic spines found on certain kinds of dendrites. Axospinodendrittic synapses form more than 50 percent of all synapses in the brain; axodendritic synapses constitute about 30 percent (Figure 11). How signals are passed among neurons Page 11 of 35 Neurons send signals to each other across the synapses. Initially, signals enter into the cell body of a neuron through their dendrites, and they pass down the axon until their arrival at the axon terminals. From there, the signal is sent across to the next neuron. Starting from the time the signal passes along the dendrites and axon, eventually reaching the axon terminal, it consists of moving electrically charges ions, but at a synapse while making that transition, it relies more on the structural shape of the chemical neurotransmitters. Every two neurons are separated by a gap, called synaptic cleft, at their synaptic site. The neuron preceding the synapse is known as pre-synaptic neuron and the one following the synapse is known as post-synaptic neuron. When the action potential of the pre-synaptic neuron is passed along its axon and reaches the other end of it, it causes synaptic vesicles to fuse or merge with the membrane. This releases the neurotransmitter molecules to pass or diffuse across the synaptic cleft to the post-synaptic membrane and slot into receptor sites (Figure 12). Neurotransmitter molecules slot into the same-shaped receptor sites in the postsynaptic membrane. A particular neurotransmitter can either excite a receiving nerve cell and continue a nerve impulse, or inhibit it. Which of these occurs depends on the type of membrane channel on the receiving cell. The interaction among neurons or between a neuron and another type of body cell, all occur due to the transfer of neurotransmitters. Thus, our body movements, mental thought processes, as well as feelings, etc. are all dependent on the transfer of neurotransmitters. In particular, let’s take a look into how the muscle movements happen due to the transfer of neurotransmitter. The axons of motor neurons extend from the spinal cord to the muscle fibers. For intending to perform any action, either of the speech or body, the command has to originate from the brain to the spinal cord. From the spinal cord, the command has to pass through motor neurons to the specific body parts, upon which the respective actions will be performed. The electrical impulse released along the axon of the motor neuron arrives at the axon terminal. Once they are there, then the neurotransmitters are secreted to carry the signals across the synapse. The receptors in the membrane of the muscles cells attach to the neurotransmitters and stimulate the electrically charged ions within the muscle cells. This leads to the contraction or extension of the respective muscles. Page 12 of 35 5) FACTS ABOUT HUMAN BRAIN Brain is a complex organ generally found in vertebrates. Of all the brains, human brain is even more complex. On average, a human brain weighs about one and a half kilogram, and has over 100 billion neurons. Each of these neurons is connected with several other neurons and thus, just the number of synapses (nerve cell connections) exceeds 100 trillion. The sustenance required to keep these neurons alive is supplied by different parts of the body. For example, 25 percent of the body total oxygen consumption is used up by the brain. Likewise, 25 percent of the glucose produced by our food is used up by it. Of the total amount of blood pumped out by our heart, 15 percent goes to the brain. Thus, from among the different parts of the body, the brain is the single part that uses the most amount of energy. The reason for this is because the brain engages itself in unceasing activity, day and night, of interpreting data form the internal and external environment, and respond to them. To protect this important organ from harm, it is naturally enclosed in three layers of protection, with an additional cushioning fluid in between. These layers are, in turn, protected with the hard covering, the skull, which is once again wound around by the skin of the scalp (Figure 13). The main function of the brain is to enhance the chance of survival of the person by proper regulation of the body conditions based on the brain’s reading of the internal and external environment. The way it carries out this function is by first registering the information received and responding to them by undertaking several activities. The brain also gives rise to inner conscious awareness alongside performing those processes. When the data, released by the different body senses, in the form of electrical impulses uninterruptedly arrive at the brain, the brain first of all checks their importance. When it finds them to be either irrelevant or commonplace, then it makes them dissolve by themselves and the concerned person doesn’t even generate an awareness of them. This is how only around 5 percent of the overall information received by the brain ever reaches our consciousness. For the rest of the information, the brain may process them, but they never become the subject of our consciousness. If, on the other hand, the information at hand is important or novel, the brain increases it impulses and allows it to active all over its parts. Remaining active for over a period of time, a conscious awareness unto this impulse is generated. Sometimes, in the wake of generating a conscious awareness, the brain sends commands to relevant muscles for either contraction or extension, thus making the body parts in question to engage in certain actions. Page 13 of 35 6) MAJOR PARTS OF HUMAN BRAIN Human brain is enclosed within its natural enclosures. In its normal form, it is found to be composed of three major parts (Figure 14). Cerebrum Of the three parts mentioned above, cerebrum is located in the uppermost position and is also the largest in size. It takes up ¾ of the entire brain size. It is itself composed of two brain hemispheres—the right and the left hemispheres. The two hemispheres are held together by a bridge like part called corpus callosum, a large bundle of neurons. The covering layer of the hemispheres is constituted of the cortex of which the average thickness is between 2 to 4 millimeters. The higher centers of coordinating and regulating human physical activities are located in the cortex areas, such as the motor center, proprioception center (proprioception is the sense of the relative position of the body in space, for example being aware that your arm is extended when reaching for the doorknob), language center, visual center, and auditory center. The outer surface of the cortex is formed of grooves and bulges because of which, despite being quite expansive, the cortex is able to be contained in the relatively small area. In terms of its basic composition, the outer layer of cortex is mostly made of gray matter, which is mainly comprised of cell bodies and nerve tissues formed out of nerve fibers. This matter is gray with a slight reddish shade in color. In the layer below, the cortex is formed of the white matter, which is, as the name suggests, white in color and mainly comprised of nerve tissues formed out of nerve fibers wrapped around with myelin sheath. Some nerve fibers wrapped in myelin sheath bind together the right and left hemispheres of the cerebrum, while others connect it with cerebellum, brainstem, and the spinal cord. Most of the brain parts belong to cerebrum, such as amygdala and hippocampus, as well as thalamus, hypothalamus, and other associated regions. In short, of the division into forebrain, midbrain, and hindbrain—in which the entirety of brain is accounted for, the cerebrum contains the whole of forebrain (Figure 15). The surface area of the cerebral cortex is actually quite large, and described above, it becomes folded to fit inside the skull. Humans are highly intelligent and creative animals not just because of the size of our brains, but also because of the complexity of the connections among our neurons. The folded nature of the human cortex promotes more complex connections between areas. For example, take a piece of blank paper, and draw five dots, one on each corner and one in the middle. Now draw lines from each dot to the other four dots. Imagine if these five dots were buildings, and the lines you drew were roads, then it would require more time to traverse from one corner to another corner than from one corner to the center. But what if you fold the four corners of the paper on top of Page 14 of 35 the center of the page? Suddenly all five of those dots become immediate neighbors, and it becomes very easy to walk from one “building” to another. The folding of the cortex has a similar effect. Neurons make connections with their neighbors, and if folding the cortex increases the number of neighbors each neuron has, then it also increases the complexity of the networks that can be formed among those neurons. Cerebellum Cerebellum is located below the cerebrum and at the upper back of the brainstem. Its name connotes its small size. Its mass is 1/10 of the whole brain. However, in terms of the number of neurons it contains, it exceeds that of the remaining parts of the central nervous system combined. This lump of nerve tissues, bearing the look of something cut in half, covers most of the back of brainstem. With the help of three pairs of fibers, collectively called cerebral peduncles, the brainstem is bound to the cerebellum. Like the cerebrum, it also has a wrinkled surface, but its grooves and bulges are finer and organized into more regular patterns. In terms of its physical structure, this too has a long groove in the center, with two large lateral lobes, one on each side. These lobes are reminiscent of the two hemispheres of the cerebrum and are sometimes termed cerebellar hemispheres. The cerebellum has a similar layered microstructure to the cerebrum. The outer layer, or cerebellar cortex, is gray matter composed of nerve-cell bodies and their dendrite projections. Beneath this is a medullary area of white matter consisting largely of nerve fibers. As of now, it has been established that cerebellum’s main function is in coordinating the body movement. Although, it may not initiate the movements, however it helps in the coordination and timely performance of movements, ensuring their integrated control. It receives data from spinal cord and other parts of the brain, and these data undergo integration and modification, contributing to the balance and smooth functioning of the movements, and thus helps in maintaining the equilibrium. Therefore, whenever this part of the brain is plagued by a disorder, the person may not lose total movement, but their ability of performing measured and steady movements is affected as also their ability to learn new movements. Within the division of entire brain into forebrain, midbrain, and hindbrain—cerebellum forms part of the hindbrain (Figure 16). Brainstem Brainstem is located below the cerebrum and in front of cerebellum. Its lower end connects with the spinal cord. It is perhaps misnamed. It is not a stem leading to a separate brain above, but an integral part of the brain itself. Its uppermost region is the midbrain comprising an upper “roof” incorporating the superior and inferior colliculi or Page 15 of 35 bulges at the rear, and the tegmentum to the front. Below the midbrain is the hindbrain. At its front is the large bulge of the pons. Behind and below this is the medulla which narrows to merge with the uppermost end of the body’s main nerve, the spinal cord. This part of the brain in associated with the middle and lower levels of consciousness. The eye movement involved in following a moving object in front of the eye is an example. The brainstem is highly involved in mid-to low-order mental activities, for example, the almost “automatic” scanning movements of the eyes as we watch something pass by. The gray and white matter composites of the brainstem are not as well defined as in other parts of the brain. The gray matter in this part of the brain possesses some of the crucial centers responsible for basic life functions. For example, the medulla houses groups of nuclei that are centers for respiratory (breathing), cardiac (heartbeat), and vasomotor (blood pressure) monitoring and control, as well as for vomiting, sneezing, swallowing, and coughing. When brainstem is damaged, that will immediately trigger danger to life by hindering heartbeat and respiratory processes (Figures 17 & 18). 7) WAYS OF ZONING AND SECTIONING THE HUMAN BRAIN FOR STUDY PURPOSES The two hemispheres Of the obviously so many different ways of zoning the human brain for study purposes, we will take up only a few of them as samples. As briefly mentioned before, a fully matured brain has three major parts. Of these the largest is the cerebrum. It covers around ¾ of the brain size. In terms of its outer structure, it is covered with numerous folds, and has a color of purple and gray blended. The cerebrum is formed by two cerebral hemispheres, accordingly called the right and the left hemisphere, that are separated by a groove, the medial longitudinal fissure. Between the two hemispheres, there is a bundle of nerve fibers that connects the two sides, almost serving like connecting rope holding the two in place. Called corpus callosum, if this were to be cut into two, the two hemispheres would virtually become two separate entities. Just as there are two hemispheres, that look broadly like mirror images to each other, on the two sides, likewise many of the brain parts exist in pairs, one on each side. However, due to the technological advances in general, and that of the MRI, in particular, it has been shown that, on average, brains are not as symmetrical in their left-right structure as was once believed to be , almost like mirror images (Figure 19). The two apparently symmetrical hemispheres and, within them, their other paired structures are also functionally not mirror images to each other. For example, for most Page 16 of 35 people, speech and language, and stepwise reasoning and analysis and so on are based mainly on the left side. Meanwhile, the right hemisphere is more concerned with sensory inputs, auditory and visual awareness, creative abilities and spatial-temporal awareness (Figure 20). The four or the six lobes Cerebrum is covered with bulges and grooves on its surface. Based on these formations, the cerebrum is divided into the four lobes, using the anatomical system. The main and the deepest groove is the longitudinal fissure that separates the cerebral hemispheres. However, the division into the lobes is made overlooking this fissure, and thus each lobe is spread on both the hemispheres. Due to this, we often speak of the four pairs of lobes. These lobes are frontal lobes, parietal lobes, occipital lobes, and temporal lobes (Figure 21). The names of the lobes are partly related to the overlying bones of the skull such as frontal and occipital bones. In some naming systems, the limbic lobe and the insula, or central lobe, are distinguished as separate from other lobes. Frontal lobes Frontal lobes are located at the front of the two hemispheres. Of all the lobes, these are the biggest in size as well as the last to develop. In relation to the other lobes, this pair of lobes is at the front of the parietal lobes, and above the temporal lobes. Between these lobes and the parietal lobes lies the central sulcus, and between these lobes and the temporal lobes lies the lateral sulcus. Towards the end of these lobes, i. e. the site where the pre-central gyrus is located also happens to be the area of the primary motor cortex. Thus, this pair of lobes is clearly responsible for regulating the conscious movement of certain parts of the body. Besides, it is known that the cortex areas within these lobes hold the largest number of neurons that are very sensitive to the dopamine neurotransmitters. Granting this, these lobes should also be related with such mental activities as intention, short-term memory, attention, and hope. When the frontal lobes are damaged, the person lacks in ability to exercise counter measures against lapses and tend to engage in untoward behaviors. These days, neurologist can detect these disorders quite easily. Parietal lobes Parietal lobes are positioned behind (posterior to) the frontal lobes, and above (superior to) the occipital lobes. Using the anatomical system, the central sulcus divides the frontal and parietal lobes, as mentioned before. Between the parietal and the occipital lobes lies Page 17 of 35 the parieto-occipital sulcus, whereas the lateral sulcus marks the dividing line between the parietal and temporal lobes. This pair of lobes integrates sensory information from different modalities, particularly determining spatial sense and navigation, and thus is significant for the acts of touching and holding objects. For example, it comprises somatosensory cortex, which is the area of the brain that processes the sense of touch, and the dorsal stream of the visual system, which supports knowing where objects are in space and guiding the body’s actions in space. Several portions of the parietal lobe are important in language processing. Occipital lobes The two occipital lobes are the smallest of four paired lobes in the human cerebral cortex. They are located in the lower, rearmost portion of the skull. Included within the region of this pair of lobes are many areas especially associated with vision. Thus, this lobe holds special significance for vision. There are many extrastriate regions within this lobe. These regions are specialized for different visual tasks, such as visual, spatial processing, color discrimination, and motion perception. When this lobe is damaged, the patient may not be able to see part of their visual field, or may be subjected to visual illusions, or even go partial or full blind. Temporal lobes Temporal lobe is situated below the frontal and parietal lobes. It contains the hippocampus and plays a key role in the formation of explicit long-term memory modulated by the amygdala. This means that it is involved in attaching emotions to all the data received from all senses. Adjacent areas in the superior, posterior, and lateral part of the temporal lobes are involved in high-level auditory processing. The temporal lobe is involved in primary auditory perception, such as hearing, and holds the primary auditory cortex. The primary auditory cortex receives sensory information from the ears and secondary areas process the information into meaningful units such as speech and words. The ventral part of the temporal cortices appears to be involved in high-level visual processing of complex stimuli such as faces and scenes. Anterior parts of this ventral stream for visual processing are involved in object perception and recognition. Limbic System The structures of the limbic system are surrounded by an area of the cortex referred to as the limbic lobe. The lobe forms a collarlike or ringlike shape on the inner surfaces of the cerebral hemispheres, both above and below the corpus callosum. As such, the limbic lobe comprises the inward-facing parts of other cortical lobes, including the temporal, parietal, and frontal, where the left and right lobes curve around to face each other. Page 18 of 35 Important anatomical parts of this lobe are hippocampus and amygdala, associated with memory and emotions respectively. Insular cortex (or insula) Insular lobe is located between the frontal, parietal, and temporal lobes. As suggested by its name, it is almost hidden within the lateral sulcus, deep inside the core of the brain. It is believed to be associated with consciousness. Since data indicative of the inner status of the body, such as the heartbeat, body temperature, and pain assemble here, it is believed to impact the equilibrium of the body. Besides, it is also believed to be related with several aspects of the mind, such as the emotions. Among these are perception, motor regulation, self-awareness, cognition, and inter-personal emotions. Thus, insular lobe is considered to be highly related with mental instability. The forebrain, the midbrain, and the hindbrain The divisions of the brain so far, either into the two hemispheres or the four or six lobes are solely based on the cerebrum alone. None of the above divisions included any portion either of the cerebellum or the brainstem. Yet another way of dividing the portions of the brain is into the forebrain, the midbrain, and the hindbrain (Figure 22. This is the most comprehensive division of the brain, leaving no parts of it outside. There are two systems of presenting this division: one, on the basis of the portions of the brain during early development of the central nervous system, and the other, based on the full maturation of those early parts into their respective regions of an adult brain. Here, we follow the latter system. The forebrain The forebrain is so called because of its extension to the forefront of the brain. It is the largest among the three divisions. It even spreads to the top and back part of the brain. It houses both the hemispheres, as well as the entire portion of the part known as the diencephalon. Diencephalon comprises of the hippocampus, which is associated with memory, and the amygdala, which is associated with emotions. Besides them, the forebrain also includes both the thalamus and the hypothalamus, of which the former is the part of the brain that processes information received from other parts of the central nervous system and the peripheral nervous system into the brain, and the latter which is involved is several activities such as appetite, sexuality, body temperature, and hormones. Page 19 of 35 The midbrain The midbrain is located below the forebrain and above the hindbrain. It resides in the core of the brain, almost like a link between the forebrain and the midbrain. It regulates several sensory processes such as that of the visual and auditory ones, as well as motor processes. This is also the region where several visual and auditory reflexive responses take place. These are involuntary reflexes in response to the external stimuli. Several of the masses of gray matter, composed mainly of the cell bodies, such as the basal ganglia linked with movement are also present in the midbrain. Of the above three major divisions of the brain, the midbrain belongs to the brainstem, and of the two main systems within the nervous system, it belongs to the central nervous system. The hindbrain The hindbrain is located below the end-tip of the forebrain, and at the exact back of the midbrain. It includes cerebellum, the pons, and the medulla, among others. Of these, the cerebellum has influence over body movement, equilibrium, and balance. The pons not only brings the motor information to the cerebellum, but is also related with the control over sleep and wakeful states. Finally, the medulla is responsible for involuntary processes of the nervous system associated with such activities as respiration and digestion. In terms of anatomy, pons is uppermost part, and beneath it the cerebellum and the medullae, which tapers to merge with the spinal cord. Vertical organization of the brain The organization of the brain layers can be said to represent a certain gradation of mental processes (Figure 23). The uppermost brain region, the cerebral cortex, is mostly involved in conscious sensations, abstract thought processes, reasoning, planning, working memory, and similar higher mental processes. The limbic areas on the brain’s innermost sides, around the brainstem, deal largely with more emotional and instinctive behaviors and reactions, as well as long-term memory. The thalamus is a preprocessing and relay center, primarily for sensory information coming from lower in the brainstem, bound for the cerebral hemispheres above. Moving down the brainstem into the medulla are the so-called ‘vegetative’ centers of the brain, which sustain life even if the person has lost consciousness. Anatomical directions and reference planes of the brain To enable us to identify the precise location in the brain, both vertically and horizontally, it is important to be familiar with certain technical terms used by the neuroscientists. In Page 20 of 35 terms of anatomy, the front of the brain, nearest the face, is referred to as the anterior end, and polar opposite to the anterior end is the posterior end, referring to the back of the head. Superior (sometimes called dorsal) refers to the direction toward the top of the head, and inferior (sometimes called ventral) refers to the direction toward the neck/body. In terms of reference planes, the sagittal plane divides the brain into left and right portions, the coronal plane divides the brain into anterior and posterior portions, and the axial (sometimes called horizontal) plane divides the brain into superior and inferior portions (Figure 24). In both the above contexts, we can further specify the location of a particular portion or plane in terms of its position, direction, and depth in relation to the whole brain. Likewise, for each of the planes themselves, we can further speak in terms of position, direction, and depth in relation to the whole brain as well as in relation to the individual planes. Also, when representing brain parts and structures, a lateral view illustrates the section or lobes, etc. from the perspective of a whole brain, whereas a medial view illustrates the section in the dissected manner. 8) DIFFERENT TYPES OF BRAINS In general, the number of living beings who possess brain is numerous. Their brains vary both in size and function. However, if you ask whether all brains completely differ from each other. Definitely not. There are features that are common to almost all brains, such as that all brains are composed mainly of neurons, and that they all have the function of protecting the individual being from internal and external dangers. So, although there are various types of brains, here we shall focus mainly on the differences in brain types between vertebrates and invertebrates in general, and the differences within the vertebrates in particular. As you know, vertebrates are those animals who have backbone, and invertebrates do not have backbone. Most of the invertebrates do not have brain. However, those, among them, who do possess brain, theirs is usually a simple brain, composed of very few neurons. Note that majority of the animals on this earth are invertebrates. The vertebrates make up only two percent of the entire animal population. The unicellular organisms, because of practical existential reason, usually tend to be very sensitive to light. Organisms such as sea-urchins are slightly more complex and are multi-cellular. They have a few nerve cells that regulate the function of looking for sustenance and providing protection from possible dangers. Slightly more complex than the types of sea-urchins are earthworm and jellyfish, which have neurons that assist them in fighting hostile external Page 21 of 35 environment (Figure 25). It is interesting to know that the neurons these simple organisms have are similar to the human neurons in terms of structure, function, as well as their neurotransmitters. If you ask, what is the difference then? There hardly is any connection between the nerves in the invertebrates. Besides that, the nerves almost cover their entire bodies. For example, among the invertebrates, earthworms (Figure 26) have one of the simplest types of brains, possessing only a few neurons. Their brains regulate only a few simple tasks such as eating food and doing a few simple body movements, not any higher actions. The network of neurons that process and interpret the information received from the earthworm’s body parts is present in the earthworm’s head. However, even if that network were to be removed from its body, no noticeable changes would be observe in its behavior. Still, among the invertebrates, grasshoppers and bees have slightly more complex brains. Scientists have begun to understand the relation between their brains and the corresponding behaviors (Figure 27). The ants, also an invertebrate, have more complex behavior, but have a very tiny brain. Likewise, the mosquitoes perform the function of flying in the space, suck blood from others, etc. However, their brain size is still no more than a small dot. Among the vertebrates, the mice are generally quite smart, yet have brains weighing no more than 2 grams. Their entire brain size is equivalent to that of the human hypothalamus. Though generally it is said the bigger the brain, the greater the intellect. However, in actuality it is the overall area of cortices, not just the overall bulk that determines the level of intellect. Among the vertebrates, there are mammals and non-mammals. Birds and fish are examples of non-mammals. It is known that the brains of mammals and non-mammals differ greatly in terms of complexity in the areas of composition, neurons, synapses, etc. Though they still have the same basic parts and structures, they differ in the overall brain size in relation to their bodies. Besides that, depending on which parts play out more in their life, they differ in the relative size of specific parts of the brain and body. For example, birds and fish have relatively very small olfactory bulb. Also, these nonmammalian animals lack brain cortex. Cerebral cortex is a special brain part, quite prominent in primates including the humans. Not only this, human beings are known to have a disproportionately large cortex (Figures 28 & 29). The average weight of human brain amounts to only one and a half percent of their body weight. However, it consumes 20 percent of the food required by the whole body. So, the larger the brain is the greater the amount of energy consumption. Therefore, bigger brain Page 22 of 35 is not always a sign of boon to the individual species. This may be the reason why there are no many species with larger brains in the history of evolution. Social animals that depend on their social community for survival are said to have larger brains. For example, dolphins, who hunt in groups, have fairly large brain. Although, the brains of elephants and whales are much bigger in size than that of the humans, but humans have the largest brains in proportionate to their body sizes. 9) FACTS ABOUT HUMAN SPINAL CORD Spinal cord is located within the vertebrae of the backbone. It extends from brainstem down to the first lumbar vertebra. It is roughly the width of a conventional pencil, tapering at it base even thinner. It is comprised of a bundle of fibers, and the fibers are long projections of nerve cells, extending from the base of the brain to the lower region of the spine. The spinal cord carries information to and from the brain and all parts of the body except the head, which is served by the cranial nerves. The signals that travel along the spinal cord are known as nerve impulses. Data from the sensory organs in different parts of the body is collected via the spinal nerves and transmitted along the spinal cord to the brain. The spinal cord also sends motor information, such as movement commands, from the brain out to the body, again transmitted via the spinal nerve network. In terms of its anatomy, the spinal cord (Figure 30) is constituted of what is known as white matter and gray matter. The gray matter, which forms the core of the spinal cord, is composed mainly of nerve cell bodies and forms an external look of a butterfly. The white matter surrounds the gray matter and its nerve fibers play a significant role of establishing connection between different parts of the spinal cord as well as between the brain and the spinal cord. The outer regions of white matter insulate the long projecting nerve fibers (axons) coming out from the neurons. In the gray matter of the spinal cord, there are numerous low-key nerve centers that can perform certain fundamental movement responses. However, the nerve centers within the spinal cord are regulated by the brain. The ability of the humans in consciously controlling the bowl movement is an example in this regard. The fact that infants frequent to toilets more often than the adults and that many have bedwetting problem is due to the brain being not fully developed as well as lacking in control over urine. Thus, the spinal cord serves as a pathway of connection between the brain, the rest of the body, and internal organs. The spinal cord stays in contact with the majority of body organs through the medium of nerves. Page 23 of 35 10) PERIPHERAL NERVOUS SYSTEM As discussed above, the whole of nervous system is divided into the central nervous system (CNS) and the peripheral nervous system (PNS). Of these two, we have already discussed the central nervous system constituted by the brain and the spinal cord. So here, we will take up the remaining part, i.e. the peripheral nervous system. The peripheral nervous system is a complex network of nerves extending across the body, branching out from 12 pairs of cranial nerves originating in the brain and 31 pairs of spinal nerves emanating from the spinal cord. It relays information between the body and the brain in the form of nerve impulses. It has an afferent division (through which messages are sent to the brain) and an efferent division (which carries messages from the brain to the body). Finally, there is the autonomic nervous system, which shares some nerve structures with both the CNS and PNS. It functions ‘automatically’ without conscious awareness, controlling basic functions, such as body temperature, blood pressure, and heart rate. Sensory input travels quickly from receptor points throughout the body via the afferent networks of the PNS to the brain, which processes, coordinates, and interprets the data in just fractions of a second. The brain makes an executive decision that is conveyed via the efferent division of the PNS to muscles, which take the needed action. The twelve pairs of cranial nerves There are 12 pairs of cranial nerves (Figure 31). They are all linked directly to the brain and do not enter the spinal cord. They allow sensory information to pass from the organs of the head, such as the eyes and ears, to the brain and also convey motor information from the brain to these organs—for example, directions for moving the mouth and lips in speech. The cranial nerves are named for the body part they serve, such as the optic nerve for the eyes, and are also assigned Roman numerical, following anatomical convention. Of these, some are associated with sensory information and others with motor information, while some are associated with both the kinds of information. How cranial nerves attach The cranial nerves I and II connect to the cerebrum, while cranial nerves III to XII connect to the brainstem. The fibers of sensory cranial nerves each project from a cell body that is located outside the brain itself, in sensory ganglia or elsewhere along the trunks of sensory nerves. The thirty-one pairs of spinal nerves Page 24 of 35 There are 31 pairs of spinal nerves (Figure 32). These branch out from the spinal cord, dividing and subdividing to form a network connecting the spinal cord to every part of the body. The spinal nerves carry information from receptors around the body to the spinal cord. From here the information passes to the brain for processing. Spinal nerves also transmit motor information from the brain to the body’s muscles and glands so that the brain’s instructions can be carried out swiftly. Each of the 31 pairs of spinal nerves belongs to one of the four spinal regions--- cervical, thoracic, lumbar, and sacral. Of them, the cervical region has eight pairs, the thoracic has twelve pairs, the lumbar has five, and finally, the sacral has six pairs. How spinal nerves attach As mentioned above, human spinal cord is located within the vertebrae of the backbone. So, one may wonder how the spinal nerves attach to the spinal cord. There are gaps in the vertebrae of the backbone through which spinal nerves enter the spinal cord (Figure 33). The nerves divide into spinal nerve roots, each made up of tiny rootlets that enter the back and front parts of the cord. 11) A SLIGHTLY DETAILED LOOK AT THE SENSES How do our brain and the environment interact? Here is how. First the senses come in contact with the external stimuli such as light, sound wave, pressure, etc. to which the corresponding senses respond. Then those sense data are sent along the respective sensory nerves in the form of electrical signals which eventually reach their respective sites on the brain cortices. That is when we shall have the perception of the respective objects. SEEING Let’s now take up each of the senses, one by one. First, we discuss the sense of vision. We shall look into the following topics surrounding the sense of vision: the structure of eye, its receptor cells, the visual pathway, and the range of light frequency different animals, including humans, have access to. Page 25 of 35 STRUCTURE OF EYE The eyeball is a fluid-filled orb. It has a hole in the front called pupil. At the back of the eyeball, there is retina which is a sheet of nerve cells. Some of the retinal cells are lightsensitive (photoreceptive). In the center of the retina, there is a tiny pitted area called fovea, densely packed with cones which are color-picking, light-sensitive cells and are significant in detecting detailed, sensitive image of the object. Between the pupil and the retina is a lens that adjusts to help the light passing through pupil to focus on the surface of the retina. The pupil is surrounded by a muscular ring of pigmented fibers called iris. The iris is responsible for people having different eye colors, and it also controls the amount of light entering into the eye. The pupil is covered by a transparent layer of clear tissue called cornea which merges with the tough outer surface or the ‘white’ of the eye called sclera. In the back of the eye, there is a hole (optic disk) through which the optic nerves pass through to enter the brain (Figure 34). LIGHT-RECEPTIVE CELLS As mentioned before, retina is located at the back of the eye, and is composed of lightreceptive cells (photoreceptors). There are, in the main, two types of photoreceptors in the retina: cone cells and rod cells. The cone cells detect the color components from amongst the visible light spectrum, and are also responsible for detecting fine detail. However, cone photoreceptors require a huge amount of light to perform its function well. Cone cells in the humans are of three types: red-, blue-, and green-sensing cones, each detecting the respective colors. They are all formed on the surface and around the fovea. On the other hand, the rod cells are formed on the periphery of retina. These cells can detect images even in dim light. However, these cells mainly detect shape and motion, not so much the color. Of these two types of photoreceptors, the rods are much more sensitive to light, so much so that even with just a few light particles, they can at least generate a faint image. Besides, the manner of concentration of these cells in and around fovea impacts greatly the sensitivity of the sensation of the object. The majority of the 6 million cone cells are concentrated in the fovea, whereas all of the more than 120 million rod cells are spread around the fovea. Since the rods are spread over a larger area of the retina, they are relatively less concentrated, and thus, when one sees objects, they are not seen that clearly and detailed. Page 26 of 35 VISUAL PATHWAYS The light reflected from the visual objects first enters the pupil through cornea, and through pupil it enters deeper into the eyes. The iris that surrounds the pupil controls the amount of light entering the eyes by changing its shapes, due to which the pupil appears to contract when the light is bright and sharp, and expands when it is less bright. Afterwards, the light passes through the lens which bends (refracts) the light, making the light to converge on the retina. If focusing on a near object, the lens thickens to increase refraction, but if the object is distant, the lens needs to flatten. The light then hits the photoreceptors in the retina, some of which fire, sending electrical signals to the brain via the optic nerve. Information received from the outer environment upon coming in contact with eyes has to travel right to the back of the brain where the relevant cortex (visual cortex) is, and only there it is turned into a conscious vision. Here is the pathway through which the information passes from the eyes to the optic nerves to the visual cortex: the signals from the eyes passes through the two optic nerves and converge at a crossover junction called the optic chiasm. The fibers carrying the signals continue on to form the optic tracts, one on each side, which end at the lateral geniculate nucleus, part of the thalamus. However, the signals continue to the visual cortex via bands of nerve fibers, called the optic radiation (Figure 35). RANGE OF LIGHT WAVELENGTH THAT DIFFERENT ANIMALS, INCLUDING HUMANS, HAVE ACCESS TO In the course of evolution, by means of natural selection, different species of organisms, including the humans, have evolved eyes with varying structures and functions. That range of electromagnetic spectrum visible to the human eyes is called the visible light, which range from 400 to 700 nanometers on the wavelength. That is, from the violet, with the shorter wavelengths, to red, with longer wavelengths. Lights with wavelengths outside of the above range are normally not visible to humans. This illustrates the difference in the structure of eyes among different species of organisms. For example, the vultures and rabbits have different eye from each other. Due to that, vultures can see much farther than the rabbits do, yet cannot see as widely as the rabbits do. Likewise, the infrared light that the humans cannot see is visible to some types of fish and birds. Some birds can tell a male bird from a female bird just by looking at the infrared light reflected from their wings. Likewise, there are two main features distinct in the eyes of the bees that the humans do not have. First, their eyes can detect infrared light that the humans cannot. Second, their Page 27 of 35 visual processing is five-fold speedier than that of the humans. For example, when the bees observe a normal moving object, they do not see that as moving. Rather, they are said to see that in the form of a series of distinct temporal instances. What accounts for such a unique feature of the bees’ eyes? Their eyes are composed of six-sided lens, covered with about 4500 circular discs. These lens let in just the lights reflected from the object they focus on and not from around it. Besides that, unlike human eyes, the eyes of the bees are said to have nine types of light receptors. Because of the speed of the visual processing that the bees possess, they have a advantage of being able to negotiate their movement so well even while moving with so much speed with the least incidents of ever bumping against objects, etc. Also, often we wonder about the sharp lights reflected back from the eyes of cats and other animals of that family. That is now understood to be due to the fact that all the lights entering their eyes fail to be absorbed in the retina, and are thus reflected back by the membrane called the reflective white. HEARING The ear is divided into three sections: the outer ear, the middle ear, and the inner ear. The outer ear has three further sections: the visible part of the ear called the pinna, the auditory canal, and the eardrum. The middle ear has three tiny bone structures that help in our hearing process: malleus (hammer), incus (anvil), and stapes (stirrup). The inner ear has several parts, of which the important ones are oval window, cochlea, and auditory nerve. The outer ear funnels sound waves along the auditory canal to the eardrum which is situated towards the inner end of the air canal. Immediate after the eardrum, the three tiny bones of the middle ear are attached one after the other. The sound waves cause the eardrum to vibrate, which in turn causes this chain of bones to vibrate. The vibration eventually reaches a membrane known as the oval window, the start of the inner ear. The oval window is slightly smaller than the ear drum in diameter. Because of this, when the vibration enters from the middle ear into the inner ear, the vibration becomes more consolidated. Inner ear is situated deep under the skull. Commensurate with the force of sound waves striking the ear drum, the stapes will accordingly cause the oval window to vibrate. Due to this, the fluids filling the chambers of cochlea will move, causing basilar membrane to vibrate. This stimulates the sensory hair cells on the organ of corti transforming the pressure waves into electrical impulses. These impulses pass through auditory nerve to the temporal lobe and from there to the auditory cortex (Figure 36). Page 28 of 35 Because of the way human ear is structured, it has access to a limited range of sound frequency. That is between 20 and 20000 Hertz. Sounds beyond that range are not audible to the humans. Sounds vary in terms of their pitch, and the receptors corresponding to them are found in the various parts of the cochlea. The receptors for low pitch sounds are located in the front part of cochlea, whereas receptors for the higher and the highest pitch sounds are found in the middle and inner end, respectively, of the cochlea. SMELL The area within each nasal cavity that contains the olfactory receptor cells is known as the olfactory epithelium. A small amount of the air entering the nostrils will pass over the epithelium, which is covered in mucus. Smell molecules in the air dissolve in this mucus, bringing receptors into direct contact with the smell molecules. Three cell types are within the epithelium: in addition to the receptor cells, there are supporting cells which produce a constant supply of mucus and, basal cells, which produce new receptor cells every few weeks. The larger the epithelium is, the keener the sense of smell. Dogs, for example, have a considerably larger olfactory epithelium than humans. Like the sense of taste, smell is a chemical sense. Specialized receptors in the nasal cavity detect incoming molecules, which enter the nose on air currents and bind to receptor cells. Sniffing sucks up more odor molecules into the nose, allowing you to ‘sample’ a smell. Olfactory receptors located high up in the nasal cavity send electrical impulses to the olfactory bulb, in the limbic area of the brain, for processing. Odors are initially registered by receptor cells in the nasal cavity. These send electrical impulses along dedicated pathways to the olfactory bulb (each nostril connects to one olfactory bulb). The olfactory bulb is the smell gateway to the brain. It is part of the brain’s limbic system, the seat of our emotions, desires, and instincts, which is why smell can trigger strong emotional reactions. Once processed by the olfactory bulb, data is then sent to various areas of the brain, including the olfactory cortex adjacent to the hippocampus. Unlike data gathered by the other sense organs, odors are processed on the same side, not opposite, side of the brain as the nostril the sensory data was sent from (Figure 37). How do the olfactory receptors detect the different odors? Different smells are produced from different molecular structures of smell. Research shows that each receptor has zones on it. Therefore, when a specific smell enters the nose, only the receptors forming a conforming pattern, not every receptor, is activated. That is how the specific smell is Page 29 of 35 detected. So far the scientists have identified eight primary odors: camphorous, fishy, malty, minty, musky, spermatic, sweaty, and urinous. TASTE Taste and smell are both chemical senses. Therefore, tongue can detect taste only when the receptors in it bind to incoming molecules, generating electrical signals that pass through the related cranial nerves to the specific brain areas. Thus, the pathway of gustatory electrical impulses begins with mouth, going to medulla, continues to the thalamus, then to primary gustatory areas of the cerebral cortex. A person can experience the basic five flavors (sweet, sour, salty, bitter, and umami) by merely activating the taste receptors on the tongue. However, the flavors produced from the combination of these can be detected by tongue only in interaction with the sense of smell. Compared with cold food, we experience the hot food to produce greater taste. This is because, during such time, smell particles rising from the hot food bind to and excite the smell receptors inside the nose, making us also to sense their smell. Before the smell particles and taste particles are detected by the smell receptors and taste receptors respectively, these particles have to dissolve in the liquid solvents in the nose and mouth respectively. So they are similar on that front. However, what is different between the two is that while the taste receptors are not actual neurons, but a special type of cells, the smell receptors are actual neurons. Due to this difference, we see a marked difference in the degree of sensitivity towards the chemical particles. The smell receptors are 300 hundred times more sensitive (Figure 38). The tongue is the main sensory organ for taste detection. It is the body’s most flexible muscular organ. It has three interior muscles and three pairs of muscles connecting it to the mouth and throat. Its surface is dotted with tiny, pimplelike structures called papillae. Papillae are easily visible to naked eyes. Within each papilla are hundreds of taste buds and they are distributed across the tongue. Four types of papillae have been distinguished---vallate, filiform, foliate, and fungiform. Each type bears a different amount of taste buds. A taste bud is composed of a group of about 25 receptor cells alongside supporting cells layered together. In general, humans have 5000 to 10,000 taste buds, and each bud may carry 25 to 100 taste receptor cells within it. At the tip of each cell, there is a hole through which taste chemical particles enter and come in contact with the receptor molecules. The tiny hair-like receptors inside these receptor cells can hold only particular taste particles. Earlier, scientists believed that different parts of the tongue are dedicated to detecting specific tastes. However, according to recent researches, all tastes are detected equally across the tongue, and the tongue is well supplied with nerves Page 30 of 35 that carry taste-related data to the brain. Other parts of the mouth such as the palate, pharynx, and epiglottis can also detect taste stimuli. TOUCH There are many kinds of touch sensations. These include light touch, pressure, vibration, and temperature as well as pain, and awareness of the body position in space. The skin is the body’s main sense organ for touch. There are around 20 types of touch receptor that respond to various types of stimuli. For instance, light touch, a general category that covers sensations ranging from a tap on the arm to stroking a cat’s fur, is detected by four different types of receptor cells: free nerve endings, found in the epidermis; Merkel’s disks, found in deeper layers of the skin; Meissner’s corpuscles, which are common in the palms, soles of the feet, eyelids, genitals, and nipples; and, finally, the root hair plexus, which responds when the hair moves. Pacinian and Ruffini corpuscles respond to more pressure. The sensation of itching is produced by repetitive low-level stimulation of nerve fibers in the skin, while feeling ticklish involves more intense stimulation of the same nerve endings when the stimulus moves over the skin (Figure 39). As for the manner in which touch information finally makes its way to the brain, a sense receptor, when activated, sends information about touch stimuli as electrical impulses along a nerve fiber of the sensory nerve network to the nerve root on the spinal cord. The data enters the spinal cord and continues upward to the brain. The processing of sensory data is begun by the nuclei in the upper (dorsal) column of the spinal cord. From the brainstem, sensory data enters the thalamus, where processing continues. The data then travels to the postcentral gyrus of the cerebral cortex, the location of the somatosensory cortex. Here, it is finally translated into a touch perception. Somatosensory cerebral cortex curls around the brain like a horseshoe. Data from the right side of the body ends on the left side of the brain, and vice versa. THE SIXTH SENSE Proprioception is sometimes referred to as the sixth sense. It is our sense of how our bodies are positioned and moving in space. This ‘awareness’ is produced by part of the somatic sensing system, and involves structures called proprioceptors in the muscles, tendons, joints, and ligaments that monitor changes in their length, tension, and pressure linked to changes in position. Proprioceptors send impulses to the brain. Upon processing this information, a decision can be made—to change position or to stop moving. The brain then sends signals back to the muscles based on the input from the proprioceptors— Page 31 of 35 completing the feedback cycle. This information is not always made conscious. For example, keeping and adjusting balance is generally an unconscious process. Conscious proprioception uses the dorsal column-medial lemniscus pathway, which passes through the thalamus, and ends in the parietal lobe of the cortex. Unconscious proprioception involves spinocerebellar tracts, and ends in the cerebellum. Proprioception is impaired when people are under the influence of alcohol or certain drugs. The degree of impairment can be tested by field sobriety tests, which have long been used by the police in cases of suspected drunk-driving. Typical tests include asking someone to touch their index finger to their nose with eyes closed, to stand on one leg for 30 seconds, or to walk heel-to-toe in a straight line for nine steps. MIXED SENSES Sensory neurons respond to data from specific sense organs. Visual cortical neurons, for example, are most sensitive to signals from the eyes. But this specialization is not rigid. Visual neurons have been found to respond more strongly to weak light signals if accompanied by sound, suggesting that they are activated by data from the ears as well as the eyes. Other studies show that in people who are blind or deaf, some neurons that would normally process visual or auditory stimuli are “hijacked” by the other senses. Hence, blind people hear better and deaf people see better. SYNESTHESIA Most people are aware of only a single sensation in response to one type of stimulus. For example, sound waves make noise. But some people experience more than one sensation in response to a single stimulus. They may “see” sounds as well as hear them, or “taste” images. Called synesthesia, this sensory duplication occurs when the neural pathway from a sense organ diverges and carries data on one type of stimulus to a part of the brain that normally processes another type (Figure 40). PERCEPTION AS A CONSTRUCT Do we perceive the external world directly, or do we perceive a constructed reality? Neuroscience finds that the latter is a more accurate description. When our sensory organs detect something in the environment, they are responding to a physical stimulus. For example, the photoreceptor cells in the retina of the eye respond to photon particles traveling through space. These photons stimulate the receptor neurons, and start a chain reaction of neural signals to the primary visual cortex in the brain, where it becomes a perception. While the visual perception correlates with the physical stimulus, they are not Page 32 of 35 one and the same. It was described earlier that photons have a wavelength, and the wavelength can vary among photons. Each numerical difference in the wavelength of a photon correlates with a difference in the perception of color. That is, photons with a wavelength of around 500 nanometers correlate with perceiving the color blue, while a wavelength of around 700 nanometers correlates with perceiving the color red. While the physical property of wavelength exists objectively in the world, the perceived color only exists subjectively and depends on our ability to detect it. The colors we perceive are not physical properties, but rather the psychological correlates of the physical property of wavelength of light. Moreover, there are many wavelengths that we cannot detect, so our perceptions selectively represent the physical world. The same principle applies to the other senses. Each sensory modality we have has two components: the physical stimulus that is detected by the sensory organ, and the psychological perception that results from it. We do not directly perceive the wavelength of light, rather we perceive the result of how the photon particles stimulate the visual pathway. Therefore, we can say that perception is a construction that is grounded in detecting physical phenomena, but we do not directly perceive those phenomena. Nor do we perceive all objective phenomena, only those that we are capable of detecting. If perception is a construction and a limited representation of objective phenomena, why did it evolve that way? We need to be able to react to environmental circumstances to survive. To find food, to avoid predators, to meet mates, to care for offspring, to engage in social behavior, all of these actions require the ability to detect and respond to changes in the physical environment. But sensory systems can evolve to be simply good enough for survival. It is not necessary to have complete, direct perception to survive. In fact, recall the facts we discussed earlier about how the human brain is very demanding for the body’s resources. More sophisticated sensory systems require more resources, and if those resource requirements are not of great utility to the organism, then evolution likely will not favor increasing the level of sophistication. In addition, there is often a trade-off between speed and accuracy in neural systems and resulting behaviors. When it comes to visual perception, seeing a danger with less accuracy and surviving is more important than seeing a danger directly and not surviving! Page 33 of 35 12)CONSCIOUSNESS AND THE BRAIN WHAT IS CONSCIOUSNESS? Consciousness is important as well as essential. Without it, life would have no meaning. However, once we embark on identifying its nature, it is certain to find it to be like nothing else. A thought, feeling, or idea seems to be a different kind of thing from the physical objects that make up the rest of the universe. The contents of our minds cannot be located in space or time. Although to the neuroscientists the contents of our minds appear to be produced by particular types of physical activity in the brain, it is not known if this activity itself forms consciousness or if brain activity correlates with a different thing altogether that we call “the mind” or consciousness (Figure 41). If consciousness is not simply brain activity, this suggests that the material universe is just one aspect of reality and that consciousness is part of a parallel reality in which entirely different rules apply. MONISM AND DUALISM The philosophical stands of those positing the relation between mind and body can be broadly brought under two divisions: monism and dualism. According to the former, every phenomenon in the universe can be ultimately reduced to a material thing. Consciousness too is identical to the brain activity that correlates with it. However, the fact that not every physical thing has consciousness is because only in those physical bodies where complex physical processes evolved over a long period of time did cognitive mechanism develop. Thus, consciousness never existed in parallel with the material universe as an independent entity of its own. According to the latter, consciousness is not physical but exists in another dimension to the material universe. Certain brain processes are associated with the consciousness, but they are not identical to each other. Some dualists believe consciousness may even exist without the brain processes associated with it. LOCATING CONSCIOUSNESS Human consciousness arises from the interaction of every part of a person with their environment. We know that the brain plays the major role in producing conscious awareness but we do not know exactly how. Certain processes within the brain, and neuronal activity in particular areas, correlate reliably with conscious states, while others do not. Page 34 of 35 Different types of neuronal activity in the brain are associated with the emergence of conscious awareness. Neuronal activity in the cortex, and particularly in the frontal lobes, is associated with the arousal of conscious experience. It takes up to half a second for a stimulus to become conscious after it has first been registered in the brain. Initially, the neuronal activity triggered by the stimulus occurs in the “lower” areas of the brain, such as the amygdala and thalamus, and then in the “higher” brain, in the parts of the cortex that process sensations. The frontal cortex is activated usually only when an experience becomes conscious, suggesting that the involvement of this part of the brain may be an essential component of consciousness. REQUIREMENTS OF CONSCIOUSNESS Every state of conscious awareness has a specific pattern of brain activity associated with it. These are commonly referred to as the neural correlates of consciousness. For example, seeing a patch of yellow produces one pattern of brain activity, seeing grandparents, another. If the brain state changes from one pattern to another, so does the experience of consciousness. Consciousness arises only when brain cells fire at fairly high rates. So, neural activity must be complex for consciousness to occur, but not too complex. If all the neurons are firing, such as in an epileptic seizure, consciousness is lost. The processes relevant to consciousness are generally assumed to be found at the level of brain cells rather than at the level of individual molecules or atoms. Yet it is also possible that consciousness does arise at the far smaller atomic (quantum) level, and if so it may be subject to very different laws. Many neuroscientists hold the philosophical view of materialism; that there is only one fundamental substance in the universe and that is physical material. How, then, is subjective experience of the mind explained? Through a process known as emergence. Emergence is a process described as the production of a phenomenon from the interactions or processes of several other phenomena. For example, the molecule that is water is composed of two hydrogen atoms and one oxygen atom. The hydrogen and oxygen atoms on their own do not have the quality of wetness that water has. But when you combine them to form the molecule, and you have enough water molecules, then the property of wetness emerges from those interactions. Neuroscientists use this as an analogy, and argue that when many neurons are combined, consciousness emerges from those interactions. This analogy serves as a useful description within the viewpoint of materialism, but it is not an explanation, as we have yet to demonstrate the mechanisms involved in such an emergence.

Can you list all of the ancient people mentioned by name in a bullet point list along with a brief description of their beliefs regarding the brain? Use only the given sources to complete your responses. Do not use outside sources or any previous knowledge of the topic that you may have. 1) A BRIEF HISTORY OF NEUROSCIENCE Humans have long been interested in exploring the nature of mind. The long history of their enquiry into the relationship between mind and body is particularly marked by several twists and turns. However, brain is the last of the human organs to be studied in all seriousness, more particularly its relation with human mind. Around 2000 BC and for long since that time the Egyptians did not think highly of the brain. They would take out the brain via the nostrils and discarded it away before mummifying the dead body. Instead, they would take great care of the heart and other internal organs. However, a few Egyptian physicians seemed to appreciate the significance of the brain early on. Certain written records have been found where Egyptian physicians had even identified parts and areas in the brain. Besides, Egyptian papyrus, believed to have been written around 1700 BC, carried careful description of the brain, suggesting the possibility of addressing mental disorders through treatment of the brain. That is the first record of its kind in the human history (Figure 1). The Greek mathematician and philosopher, Plato (427-347) believed that the brain was the seat of mental processes such as memory and feelings (Figure 2). Later, another Greek physician and writer on medicine, Galen (130-200 AD) too, believed that brain disorders were responsible for mental illnesses. He also followed Plato in concluding that the mind or soul resided in the brain. However, Aristotle (384-322 BC), the great philosopher of Greece at that time, restated the ancient belief that the heart was the superior organ over the brain (Figure 3). In support of his belief, he stated that the brain was just like a radiator which stopped the body from becoming overheated, whereas the heart served as the seat of human intelligence, thought, and imagination, etc. Medieval philosophers felt that the brain was constituted of fluid-filled spaces called ventricles where the ‘animal spirits’ circulated to form sensations, emotions, and memories. This viewpoint brought about a shift in the previously held views and also provided the scientists with the new idea of actually looking into the brains of the humans and animals. However, no such ventricles as claimed by them were found upon examination nor did the scientists find any specific location for the self or the soul in the brain. In the seventeenth century, the French philosopher Rene Descartes (1596-1650) described mind and body as separate entities (Figure 4) yet they interacted with each other via the pineal gland, the only structure not duplicated on both sides of the brain. He maintained that the mind begins its journey from the pineal gland and circulates the rest of the body via the nerve vessels. His dualist view influenced the mind-body debate for Page 4 of 35 the next two centuries. However, through the numerous experiments undertaken in the 19th century, the scientists gathered evidences and findings which all emboldened the scientists to claim that the brain is the center of feelings, thoughts, self and behaviors. Just to give an example of the kind of experiments performed on a particular physical activity which pointed to the brain as the regulator of bodily actions, imagine activating a particular area of the brain through electrical stimulus, you would actually see it effectively impacting a corresponding body-part, say the legs by making them move. Through findings such as these as well as others, we have come of know also of the special activities of the electrical impulses and chemicals in the brain. Explorations continued into the later centuries and, by the middle of 20th century, human understanding of the brain and its activities have increased manifold. Particularly, towards the end of twentieth century, with further improvement in imaging technologies enabling the researchers to undertake investigation on functioning brains, the scientists were deeply convinced that the brain and the rest of the nervous systems monitored and regulated emotions and bodily behaviors (Figures 5 & 6). Since then, the brain together with the nervous system have become the center of attention as the basis of mental activities as well as physical behaviors, and gradually a separate branch of science called neuroscience focusing specifically on the nervous systems of the body has evolved in the last 40 so years. To better understand modern neuroscience in its historical context, including why the brain and nervous system have become the center of attention in the scientific pursuit of understanding the mind, it is useful to first review some preliminary topics in the philosophy of science. Science is a method of inquiry that is grounded in empirical evidence. Questions about the unknown direct the path of science as a method. Each newly discovered answer opens the door to many new questions, and the curiosity of scientists motivates them to answer those unfolding questions. When a scientist encounters a question, she or he develops an explanatory hypothesis that has the potential to answer it. But it is not enough to simply invent an explanation. To know if an explanation is valid or not, a scientist must test the hypothesis by identifying and observing relevant, objectively measurable phenomena. Any hypothesis that cannot be tested in this way is not useful for science. A useful hypothesis must be falsifiable, meaning that it must be possible to ascertain, based on objective observations, whether the hypothesis is wrong and does not explain the phenomena in question. If a hypothesis is not falsifiable, it is impossible to know whether it is the correct explanation of a phenomenon because we cannot test the validity of the claim. Why does the scientific method rely only on objective observations? Science is a team effort, conducted across communities and generations over space and time. For a hypothesis to be accepted as valid, it must be possible for any interested scientist to test it. For example, if we want to repeat an experiment that our colleague conducted last year, we need to test the hypothesis under the same conditions as the original experiment. This means it must be possible to recreate those conditions. The only way to do this in a precise and controlled manner is if the scientific method relies on empirical evidence. Page 5 of 35 Furthermore, conclusions in science are subject to peer review. This means that any scientist’s colleagues must be able to review and even re-create the procedures, analyses, and conclusions made by that scientist before deciding if the evidence supports the conclusions. Because we don’t have access to the subjective experiences of others, it is not possible to replicate experiments that are grounded in subjectivity because we cannot recreate the conditions of such an experiment, nor can we perform identical analyses of subjective phenomena across people. No matter how many words we use, we cannot describe a single subjective experience accurately enough to allow another person to experience it the same way. Consequently, we cannot have a replicable experiment if the evidence is not objective. Therefore, two necessary features of a scientific hypothesis are the potentials to falsify and replicate it. And both of these requirements are dependent on objectively measurable evidence. This is why we began with the claim that science is a method of inquiry that is grounded in empirical evidence. Neuroscience is a scientific discipline like any other, in that the focus of investigation is on objectively measurable phenomena. But unlike most other sciences, this poses a particularly challenging problem for neuroscience. How do we investigate the mind, which is subjective by nature, if empirical evidence is the only valid form of data to support a conclusion in science? The relationship between the mind and the body has become known as the “mind-body problem” in modern neuroscience and Western philosophy of mind, because there is a fundamental challenge to explain the mind in objective terms. Scientists view this relationship as a problem because their method of inquiry investigates phenomena from a third-person (he, she, it, they) perspective, while the subjective experience of the mind has a first-person (I, we) perspective. The mindbody problem has been a central, unresolved topic in Western philosophy of mind for centuries, and is a topic we will discuss in more detail in a later chapter of this textbook when we explore the neuroscience of consciousness. For now we can start simply by stating that the majority of scientists, including neuroscientists, hold the philosophical view that all phenomena are caused by physical processes, including consciousness and its related mental phenomena. This view might be proven wrong as inquiry proceeds, but is taken as the most simple (or parsimonious) starting point. Science uses the principle of parsimony, of starting with simple rather than complex explanations, as a way to facilitate production of falsifiable hypotheses: more complex explanations are built up as evidence accumulates and more simple explanations are excluded. Modern neuroscience investigates the brain and nervous system based on the working assumption that the objective physical states of those biological systems are the cause of the subjective mental states of the organism that has those biological systems. In other words, when you smell a fresh flower, taste a cup of chai, listen to the birds, feel the wind on your cheek, and see the clouds in the sky, those subjective experiences are caused by the momentary physical processes in your body, nervous system, and brain interacting with the physical environment. Under this philosophical view, then, mental states correlate with physical states of the organism, and by investigating those physical states scientists can understand the nature of those mental Page 6 of 35 states. So while this might seem counterintuitive based on the Buddhist method of inquiry, for a neuroscientist it is obvious to begin the investigation by focusing on physical phenomena; on the empirical evidence. Neuroscientists often equate the “neural correlates” of consciousness as consciousness itself. We will explore in more depth the relationship between form and function between the body and mind later in the textbook, as well as the philosophical view of materialism in neuroscience. It will also be helpful to introduce some basic concepts in neuroscience before exploring topics in more detail. The primary goal in this year of the neuroscience curriculum is that you become familiar with the brain and nervous system. The human brain is the most complex and extraordinary object known to all of modern science. Because of this immense complexity, it can be very challenging to encounter neuroscience in an introductory course such as this one. So patience is an important part of the learning process. First, neuroscience is still very much in its infancy as a scientific discipline, and there are vastly more questions than there are answers. Second, it can be a challenge for new students of neuroscience to simultaneously learn the details of the basic concepts while understanding and appreciating the broader conclusions. It’s like learning a language while also reading the literature of that language! Neuroscience is a scientific discipline with many different levels of exploration and explanation. Therefore, it is important for you to pay attention to the level at which are we speaking when you learn new concepts. For example, the brain and nervous system are made up of cells called neurons or nerve cells, which we will discuss in detail in Chapter 4. Neurons connect with each other to form complex networks, and from those different patterns of connection emerge different phenomena (such as a thought or a sensation) in the brain and ultimately in the mind. This may sound confusing at the moment, but we will explore these topics in more detail in later chapters. In neuroscience, levels of explanation can span from very low levels such as the molecular mechanisms involved in the neuron cells, to middle levels such as particular networks of neurons in the brain, to very high levels such as how humans engage in thoughts, speech, and purposeful actions. The brain is the bodily organ that is the center of the nervous system. But it might surprise you to learn that not all animals that have neurons have a brain! For example, jellyfish have neurons, but they don’t have a brain. Jellyfish are very simple organisms that live in the ocean, and their neurons allow them to sense some basic information about their environment. But because they don’t have a brain to process that environmental information, they can only react to their immediate environment. Without a brain, jellyfish cannot think, make plans for the future, have memories of the past, or make decisions. Their behavior is limited to reactions and reflexes. Complex networks of neurons in the human brain are the physiological substrates that support what we experience as human beings. But we are not the only species with a brain. Later in this textbook we will explore the relationship between brain complexity and behavior across species. For organisms that have a brain, information can flow along the complex networks of neurons in different ways. Some networks, also called pathways or systems, flow from the sensory organs to the brain, while others flow from the brain to the muscles of the Page 7 of 35 body. Afferent neurons, also called sensory neurons or receptor neurons, communicate information from the sensory organs to the brain. Efferent neurons, also called motor neurons, communicate information from the brain to the muscles of the body. Interneurons, also called association neurons, communicate information between neurons in the central nervous system and brain. This allows for the sensory and motor systems to interact, facilitating complex behaviors and integrating across the different sensory modalities. For example, to be able to reach for an object such as a teacup, your brain needs to link together your ability to sense the presence and location of the cup with your ability to control the muscles in your arm to grasp the cup. Interneurons perform this function. Finally, before starting your journey in learning about neuroscience, pause to contemplate some of the big questions and insights as they pertain to the Western science of the mind. As you go through this textbook and learn new concepts, it will be useful to think about them within the context of these big questions. For example, what is sentience? Is a brain required for sentience? The jellyfish we mentioned earlier can have basic sensations and react to the environment without a brain, but it cannot think or have memory. What are the necessary conditions to be sentient? What is the relationship between the mind and body? As a method of inquiry, can science directly investigate subjective experience? Or must we use alternative, and perhaps complementary methods of inquiry to achieve that? Do we perceive the physical world directly, or are our perceptions constructed? If the latter, how does that happen? 2) WHAT IS NEUROSCIENCE AND WHAT ARE ITS BRANCH SCIENCES? In the case of humans, it is the branch of science that studies the brain, the spinal cord, the nerves extending from them, and the rest of the nervous systems including the synapses, etc. Recall that neurons, or nerve cells, are the biological cells that make up the nervous system, and the nervous system is the complex network of connections between those cells. In this connection, it may involve itself with the cellular and molecular bases of the nervous system as well as the systems responsible for sensory and motor activities of the body. It also deals with the physical bases of mental processes of all levels, including emotions and cognitive elements. Thus, it concerns itself with issues such as thoughts, mental activities, behaviors, the brain and the spinal cord, functions of nerves, neural disorders, etc. It wrestles with questions such as What is consciousness?, How and why do beings have mental activities?, What are the physical bases for the variety of neural and mental illnesses, etc. In identifying the sub-branches within neuroscience, there are quite a few ways of doing so. However, here we will follow the lead of the Society for Neuroscience which identifies the following five branches: Neuro-anatomy, Developmental Neuroscience, Cognitive Neuroscience, Behavioral Neuroscience, and Neurology. Of these, Page 8 of 35 neuroanatomy concerns itself mainly with the issue of structures and parts of the nervous system. In this discipline, the scientists employ special dyeing techniques in identifying neurotransmitters and in understanding the specific functions of the nerves and nerve centers. Neurotransmitters are chemicals released between neurons for transmission of signals. When a neuron communicates with its neighboring cells, it releases neurotransmitters and its neighbors receive them. In developmental neuroscience, the scientists look into the phases and processes of development of nervous system, the changes they undergo after they have matured, and their eventual degeneration. In this regard, the scientists also investigate the ways neurons go about seeking connection with other neurons, how they establish the connection, and how they maintain the connection and what chemical changes and processes they have to undergo for these activities. Neurons make connections to form networks, and the different patterns of connectivity support different functions. Patterns of connectivity can change over different time scales, such as developmental changes over a lifetime from infancy to old age, but also in the short term such as learning a new concept. Neuroplasticity is the term that describes the capacity of the brain to change in response to stimulation or even damage: it is not a static organ, but is highly adaptable. In cognitive neuroscience, they study the functions of behaviors, perceptions, and memories, etc. By making use of non-invasive methods such as the PTE and MRI technologies that allow us to take detailed pictures of the brain without opening the skull, they look into the neural pathways activated during engagement in language, solutions, and other activities. Cognitive neuroscience studies the mind-body relationship by discovering the neural correlates to mental and behavioral phenomena. Behavioral neuroscience looks into the underpinning processes of human and animal behaviors. Using electrodes, they measure the neural electrical activities occurring alongside our actions such as visual perception, language use, and generating memories. Through fMRI scan techniques, another technology that allows us to take detailed motion pictures of brain activity over time without opening the skull, they strive to arrive at closer understanding of the brain parts in real time. Finally, neurology makes use of the fundamental research findings of the other disciplines in understanding the neural and neuronal disorders and strives to explore new innovative ways of detecting, preventing, and treating these disorders. 3) THE SUBJECT MATTER OF NEUROSCIENCE: THE MAIN SYSTEMS AND THEIR PARTS The field of neuroscience is the nervous system of animals in general and of humans in particular. In the case of humans, its nervous system has two main components: the central nervous system (CNS) and the peripheral nervous system (PNS) (Figure 7). The CNS comprises of the brain and the spinal cord. Their functions involve processing and interpreting the information received the senses, skin, muscles, etc. and giving responses Page 9 of 35 that direct and dictate specific actions such as particular movements by different parts of the body. The peripheral nervous system (PNS) includes all the rest of the nervous system aside from the central nervous system. This means that it comprises the 12 pairs of cranial nerves that originate directly from the brain and spread to different parts of the body bypassing the spinal cord, and the 31 pairs of spinal nerves that pass through the spinal cord and spread to different parts of the body. Thus, the PNS is mainly constituted of nerve. PNS is sometimes further classified into voluntary nervous system and the autonomic nervous system. This is based on the fact that the nerves in the former system are involved in making conscious movements, whereas those in the latter system make movements over which the person does not have control. Obviously, the former category of nerves includes those associated with the muscles of touch, smell, vision, and skeleton. The latter includes nerves spread over muscles attached with heart beats, blood pressure, glands, and smooth muscles. 4) AN EXCLUSIVE LOOK AT ‘NEURONS’, A FUNDAMENTAL UNIT OF THE BRAIN AND THE NERVOUS SYSTEM Neurons Neurons are the cellular units of the brain and nervous system, and are otherwise called nerve cells (Figure 8). Estimates of the number of brain neurons range from 50 billion to 500 billion, and they are not even the most numerous cells in the brain. Like hepatocyte cells in the liver, osteocytes in bone, or erythrocytes in blood, each neuron is a selfcontained functioning unit. Its internal components, the organelles, include a nucleus harboring the genetic material (DNA), energy-providing mitochondria, and proteinmaking ribosomes. As in most other types of cells, the organelles are concentrated in the main cell body. In addition, characteristic features of neurons are neurites—long, thin, finger-like or threadlike extensions from the cell body (soma). The two main types are dendrites and axons. Usually, dendrites receive nerve signals, while axons send them onward. The cell body of a neuron is about 10-100 micrometers across, that is 1/100th to 1/10th of one millimeter. Also, the axon is 0.2-20 micrometers in diameter, dendrites are usually slimmer. In terms of length, dendrites are typically 10-50 micrometers long, while axons can be up a few centimeters (inches). This is mostly the case in the central nervous system (Figure 9). Classification of neurons Page 10 of 35 There are numerous ways of classifying neurons among themselves. One of them is by the direction that they send information. On this basis, we can classify all neurons into the three: sensory neurons, motor neurons, and interneurons. The sensory neurons are those that send information received from sensory receptors toward the central nervous system, whereas the motor neurons send information away from the central nervous system to muscles or glands. The interneurons are those neurons that send information between sensory neurons and motor neurons. Here, the sensory neurons receive information from sensory receptors (e.g., in skin, eyes, nose, tongue, ears) and send them toward the central nervous system. Because of this, these neurons are also called afferent neurons as they bring informational input towards the central nervous system. Likewise, the motor neurons bring motor information away from the central nervous system to muscles or glands, and are thus called efferent neurons as they bring the output from the central nervous system to the muscles or glands. Since the interneurons send information between sensory neurons and motor neurons, thus serving as connecting links between them, they are sometimes called internuncial neurons. This third type of neurons is mostly found in the central nervous system. Another way of classifying the neurons is by the number of extensions that extend from the neuron’s cell body (soma) (Figure 10). In accordance with this system, we have unipolar, bipolar, and multipolar neurons. This classification takes into account the number of extensions extending initially from the cell body of the neuron, not the overall number of extensions. This is because there can be unipolar neurons which have more than one extensions in total. However, what the difference here is from the other two types of neurons is that these unipolar neurons shall have only one initial extension from the cell body. Most of the neurons are multipolar in nature. Synapses Synapses are communication sites where neurons pass nerve impulses among themselves. The cells are not usually in actual physical contact, but are separated by an incredibly thin gap, called the synaptic cleft. Microanatomically, synapses are divided into types according to the sites where the neurons almost touch. These sites include the soma, the dendrites, the axons, and tiny narrow projections called dendritic spines found on certain kinds of dendrites. Axospinodendrittic synapses form more than 50 percent of all synapses in the brain; axodendritic synapses constitute about 30 percent (Figure 11). How signals are passed among neurons Page 11 of 35 Neurons send signals to each other across the synapses. Initially, signals enter into the cell body of a neuron through their dendrites, and they pass down the axon until their arrival at the axon terminals. From there, the signal is sent across to the next neuron. Starting from the time the signal passes along the dendrites and axon, eventually reaching the axon terminal, it consists of moving electrically charges ions, but at a synapse while making that transition, it relies more on the structural shape of the chemical neurotransmitters. Every two neurons are separated by a gap, called synaptic cleft, at their synaptic site. The neuron preceding the synapse is known as pre-synaptic neuron and the one following the synapse is known as post-synaptic neuron. When the action potential of the pre-synaptic neuron is passed along its axon and reaches the other end of it, it causes synaptic vesicles to fuse or merge with the membrane. This releases the neurotransmitter molecules to pass or diffuse across the synaptic cleft to the post-synaptic membrane and slot into receptor sites (Figure 12). Neurotransmitter molecules slot into the same-shaped receptor sites in the postsynaptic membrane. A particular neurotransmitter can either excite a receiving nerve cell and continue a nerve impulse, or inhibit it. Which of these occurs depends on the type of membrane channel on the receiving cell. The interaction among neurons or between a neuron and another type of body cell, all occur due to the transfer of neurotransmitters. Thus, our body movements, mental thought processes, as well as feelings, etc. are all dependent on the transfer of neurotransmitters. In particular, let’s take a look into how the muscle movements happen due to the transfer of neurotransmitter. The axons of motor neurons extend from the spinal cord to the muscle fibers. For intending to perform any action, either of the speech or body, the command has to originate from the brain to the spinal cord. From the spinal cord, the command has to pass through motor neurons to the specific body parts, upon which the respective actions will be performed. The electrical impulse released along the axon of the motor neuron arrives at the axon terminal. Once they are there, then the neurotransmitters are secreted to carry the signals across the synapse. The receptors in the membrane of the muscles cells attach to the neurotransmitters and stimulate the electrically charged ions within the muscle cells. This leads to the contraction or extension of the respective muscles. Page 12 of 35 5) FACTS ABOUT HUMAN BRAIN Brain is a complex organ generally found in vertebrates. Of all the brains, human brain is even more complex. On average, a human brain weighs about one and a half kilogram, and has over 100 billion neurons. Each of these neurons is connected with several other neurons and thus, just the number of synapses (nerve cell connections) exceeds 100 trillion. The sustenance required to keep these neurons alive is supplied by different parts of the body. For example, 25 percent of the body total oxygen consumption is used up by the brain. Likewise, 25 percent of the glucose produced by our food is used up by it. Of the total amount of blood pumped out by our heart, 15 percent goes to the brain. Thus, from among the different parts of the body, the brain is the single part that uses the most amount of energy. The reason for this is because the brain engages itself in unceasing activity, day and night, of interpreting data form the internal and external environment, and respond to them. To protect this important organ from harm, it is naturally enclosed in three layers of protection, with an additional cushioning fluid in between. These layers are, in turn, protected with the hard covering, the skull, which is once again wound around by the skin of the scalp (Figure 13). The main function of the brain is to enhance the chance of survival of the person by proper regulation of the body conditions based on the brain’s reading of the internal and external environment. The way it carries out this function is by first registering the information received and responding to them by undertaking several activities. The brain also gives rise to inner conscious awareness alongside performing those processes. When the data, released by the different body senses, in the form of electrical impulses uninterruptedly arrive at the brain, the brain first of all checks their importance. When it finds them to be either irrelevant or commonplace, then it makes them dissolve by themselves and the concerned person doesn’t even generate an awareness of them. This is how only around 5 percent of the overall information received by the brain ever reaches our consciousness. For the rest of the information, the brain may process them, but they never become the subject of our consciousness. If, on the other hand, the information at hand is important or novel, the brain increases it impulses and allows it to active all over its parts. Remaining active for over a period of time, a conscious awareness unto this impulse is generated. Sometimes, in the wake of generating a conscious awareness, the brain sends commands to relevant muscles for either contraction or extension, thus making the body parts in question to engage in certain actions. Page 13 of 35 6) MAJOR PARTS OF HUMAN BRAIN Human brain is enclosed within its natural enclosures. In its normal form, it is found to be composed of three major parts (Figure 14). Cerebrum Of the three parts mentioned above, cerebrum is located in the uppermost position and is also the largest in size. It takes up ¾ of the entire brain size. It is itself composed of two brain hemispheres—the right and the left hemispheres. The two hemispheres are held together by a bridge like part called corpus callosum, a large bundle of neurons. The covering layer of the hemispheres is constituted of the cortex of which the average thickness is between 2 to 4 millimeters. The higher centers of coordinating and regulating human physical activities are located in the cortex areas, such as the motor center, proprioception center (proprioception is the sense of the relative position of the body in space, for example being aware that your arm is extended when reaching for the doorknob), language center, visual center, and auditory center. The outer surface of the cortex is formed of grooves and bulges because of which, despite being quite expansive, the cortex is able to be contained in the relatively small area. In terms of its basic composition, the outer layer of cortex is mostly made of gray matter, which is mainly comprised of cell bodies and nerve tissues formed out of nerve fibers. This matter is gray with a slight reddish shade in color. In the layer below, the cortex is formed of the white matter, which is, as the name suggests, white in color and mainly comprised of nerve tissues formed out of nerve fibers wrapped around with myelin sheath. Some nerve fibers wrapped in myelin sheath bind together the right and left hemispheres of the cerebrum, while others connect it with cerebellum, brainstem, and the spinal cord. Most of the brain parts belong to cerebrum, such as amygdala and hippocampus, as well as thalamus, hypothalamus, and other associated regions. In short, of the division into forebrain, midbrain, and hindbrain—in which the entirety of brain is accounted for, the cerebrum contains the whole of forebrain (Figure 15). The surface area of the cerebral cortex is actually quite large, and described above, it becomes folded to fit inside the skull. Humans are highly intelligent and creative animals not just because of the size of our brains, but also because of the complexity of the connections among our neurons. The folded nature of the human cortex promotes more complex connections between areas. For example, take a piece of blank paper, and draw five dots, one on each corner and one in the middle. Now draw lines from each dot to the other four dots. Imagine if these five dots were buildings, and the lines you drew were roads, then it would require more time to traverse from one corner to another corner than from one corner to the center. But what if you fold the four corners of the paper on top of Page 14 of 35 the center of the page? Suddenly all five of those dots become immediate neighbors, and it becomes very easy to walk from one “building” to another. The folding of the cortex has a similar effect. Neurons make connections with their neighbors, and if folding the cortex increases the number of neighbors each neuron has, then it also increases the complexity of the networks that can be formed among those neurons. Cerebellum Cerebellum is located below the cerebrum and at the upper back of the brainstem. Its name connotes its small size. Its mass is 1/10 of the whole brain. However, in terms of the number of neurons it contains, it exceeds that of the remaining parts of the central nervous system combined. This lump of nerve tissues, bearing the look of something cut in half, covers most of the back of brainstem. With the help of three pairs of fibers, collectively called cerebral peduncles, the brainstem is bound to the cerebellum. Like the cerebrum, it also has a wrinkled surface, but its grooves and bulges are finer and organized into more regular patterns. In terms of its physical structure, this too has a long groove in the center, with two large lateral lobes, one on each side. These lobes are reminiscent of the two hemispheres of the cerebrum and are sometimes termed cerebellar hemispheres. The cerebellum has a similar layered microstructure to the cerebrum. The outer layer, or cerebellar cortex, is gray matter composed of nerve-cell bodies and their dendrite projections. Beneath this is a medullary area of white matter consisting largely of nerve fibers. As of now, it has been established that cerebellum’s main function is in coordinating the body movement. Although, it may not initiate the movements, however it helps in the coordination and timely performance of movements, ensuring their integrated control. It receives data from spinal cord and other parts of the brain, and these data undergo integration and modification, contributing to the balance and smooth functioning of the movements, and thus helps in maintaining the equilibrium. Therefore, whenever this part of the brain is plagued by a disorder, the person may not lose total movement, but their ability of performing measured and steady movements is affected as also their ability to learn new movements. Within the division of entire brain into forebrain, midbrain, and hindbrain—cerebellum forms part of the hindbrain (Figure 16). Brainstem Brainstem is located below the cerebrum and in front of cerebellum. Its lower end connects with the spinal cord. It is perhaps misnamed. It is not a stem leading to a separate brain above, but an integral part of the brain itself. Its uppermost region is the midbrain comprising an upper “roof” incorporating the superior and inferior colliculi or Page 15 of 35 bulges at the rear, and the tegmentum to the front. Below the midbrain is the hindbrain. At its front is the large bulge of the pons. Behind and below this is the medulla which narrows to merge with the uppermost end of the body’s main nerve, the spinal cord. This part of the brain in associated with the middle and lower levels of consciousness. The eye movement involved in following a moving object in front of the eye is an example. The brainstem is highly involved in mid-to low-order mental activities, for example, the almost “automatic” scanning movements of the eyes as we watch something pass by. The gray and white matter composites of the brainstem are not as well defined as in other parts of the brain. The gray matter in this part of the brain possesses some of the crucial centers responsible for basic life functions. For example, the medulla houses groups of nuclei that are centers for respiratory (breathing), cardiac (heartbeat), and vasomotor (blood pressure) monitoring and control, as well as for vomiting, sneezing, swallowing, and coughing. When brainstem is damaged, that will immediately trigger danger to life by hindering heartbeat and respiratory processes (Figures 17 & 18). 7) WAYS OF ZONING AND SECTIONING THE HUMAN BRAIN FOR STUDY PURPOSES The two hemispheres Of the obviously so many different ways of zoning the human brain for study purposes, we will take up only a few of them as samples. As briefly mentioned before, a fully matured brain has three major parts. Of these the largest is the cerebrum. It covers around ¾ of the brain size. In terms of its outer structure, it is covered with numerous folds, and has a color of purple and gray blended. The cerebrum is formed by two cerebral hemispheres, accordingly called the right and the left hemisphere, that are separated by a groove, the medial longitudinal fissure. Between the two hemispheres, there is a bundle of nerve fibers that connects the two sides, almost serving like connecting rope holding the two in place. Called corpus callosum, if this were to be cut into two, the two hemispheres would virtually become two separate entities. Just as there are two hemispheres, that look broadly like mirror images to each other, on the two sides, likewise many of the brain parts exist in pairs, one on each side. However, due to the technological advances in general, and that of the MRI, in particular, it has been shown that, on average, brains are not as symmetrical in their left-right structure as was once believed to be , almost like mirror images (Figure 19). The two apparently symmetrical hemispheres and, within them, their other paired structures are also functionally not mirror images to each other. For example, for most Page 16 of 35 people, speech and language, and stepwise reasoning and analysis and so on are based mainly on the left side. Meanwhile, the right hemisphere is more concerned with sensory inputs, auditory and visual awareness, creative abilities and spatial-temporal awareness (Figure 20). The four or the six lobes Cerebrum is covered with bulges and grooves on its surface. Based on these formations, the cerebrum is divided into the four lobes, using the anatomical system. The main and the deepest groove is the longitudinal fissure that separates the cerebral hemispheres. However, the division into the lobes is made overlooking this fissure, and thus each lobe is spread on both the hemispheres. Due to this, we often speak of the four pairs of lobes. These lobes are frontal lobes, parietal lobes, occipital lobes, and temporal lobes (Figure 21). The names of the lobes are partly related to the overlying bones of the skull such as frontal and occipital bones. In some naming systems, the limbic lobe and the insula, or central lobe, are distinguished as separate from other lobes. Frontal lobes Frontal lobes are located at the front of the two hemispheres. Of all the lobes, these are the biggest in size as well as the last to develop. In relation to the other lobes, this pair of lobes is at the front of the parietal lobes, and above the temporal lobes. Between these lobes and the parietal lobes lies the central sulcus, and between these lobes and the temporal lobes lies the lateral sulcus. Towards the end of these lobes, i. e. the site where the pre-central gyrus is located also happens to be the area of the primary motor cortex. Thus, this pair of lobes is clearly responsible for regulating the conscious movement of certain parts of the body. Besides, it is known that the cortex areas within these lobes hold the largest number of neurons that are very sensitive to the dopamine neurotransmitters. Granting this, these lobes should also be related with such mental activities as intention, short-term memory, attention, and hope. When the frontal lobes are damaged, the person lacks in ability to exercise counter measures against lapses and tend to engage in untoward behaviors. These days, neurologist can detect these disorders quite easily. Parietal lobes Parietal lobes are positioned behind (posterior to) the frontal lobes, and above (superior to) the occipital lobes. Using the anatomical system, the central sulcus divides the frontal and parietal lobes, as mentioned before. Between the parietal and the occipital lobes lies Page 17 of 35 the parieto-occipital sulcus, whereas the lateral sulcus marks the dividing line between the parietal and temporal lobes. This pair of lobes integrates sensory information from different modalities, particularly determining spatial sense and navigation, and thus is significant for the acts of touching and holding objects. For example, it comprises somatosensory cortex, which is the area of the brain that processes the sense of touch, and the dorsal stream of the visual system, which supports knowing where objects are in space and guiding the body’s actions in space. Several portions of the parietal lobe are important in language processing. Occipital lobes The two occipital lobes are the smallest of four paired lobes in the human cerebral cortex. They are located in the lower, rearmost portion of the skull. Included within the region of this pair of lobes are many areas especially associated with vision. Thus, this lobe holds special significance for vision. There are many extrastriate regions within this lobe. These regions are specialized for different visual tasks, such as visual, spatial processing, color discrimination, and motion perception. When this lobe is damaged, the patient may not be able to see part of their visual field, or may be subjected to visual illusions, or even go partial or full blind. Temporal lobes Temporal lobe is situated below the frontal and parietal lobes. It contains the hippocampus and plays a key role in the formation of explicit long-term memory modulated by the amygdala. This means that it is involved in attaching emotions to all the data received from all senses. Adjacent areas in the superior, posterior, and lateral part of the temporal lobes are involved in high-level auditory processing. The temporal lobe is involved in primary auditory perception, such as hearing, and holds the primary auditory cortex. The primary auditory cortex receives sensory information from the ears and secondary areas process the information into meaningful units such as speech and words. The ventral part of the temporal cortices appears to be involved in high-level visual processing of complex stimuli such as faces and scenes. Anterior parts of this ventral stream for visual processing are involved in object perception and recognition. Limbic System The structures of the limbic system are surrounded by an area of the cortex referred to as the limbic lobe. The lobe forms a collarlike or ringlike shape on the inner surfaces of the cerebral hemispheres, both above and below the corpus callosum. As such, the limbic lobe comprises the inward-facing parts of other cortical lobes, including the temporal, parietal, and frontal, where the left and right lobes curve around to face each other. Page 18 of 35 Important anatomical parts of this lobe are hippocampus and amygdala, associated with memory and emotions respectively. Insular cortex (or insula) Insular lobe is located between the frontal, parietal, and temporal lobes. As suggested by its name, it is almost hidden within the lateral sulcus, deep inside the core of the brain. It is believed to be associated with consciousness. Since data indicative of the inner status of the body, such as the heartbeat, body temperature, and pain assemble here, it is believed to impact the equilibrium of the body. Besides, it is also believed to be related with several aspects of the mind, such as the emotions. Among these are perception, motor regulation, self-awareness, cognition, and inter-personal emotions. Thus, insular lobe is considered to be highly related with mental instability. The forebrain, the midbrain, and the hindbrain The divisions of the brain so far, either into the two hemispheres or the four or six lobes are solely based on the cerebrum alone. None of the above divisions included any portion either of the cerebellum or the brainstem. Yet another way of dividing the portions of the brain is into the forebrain, the midbrain, and the hindbrain (Figure 22. This is the most comprehensive division of the brain, leaving no parts of it outside. There are two systems of presenting this division: one, on the basis of the portions of the brain during early development of the central nervous system, and the other, based on the full maturation of those early parts into their respective regions of an adult brain. Here, we follow the latter system. The forebrain The forebrain is so called because of its extension to the forefront of the brain. It is the largest among the three divisions. It even spreads to the top and back part of the brain. It houses both the hemispheres, as well as the entire portion of the part known as the diencephalon. Diencephalon comprises of the hippocampus, which is associated with memory, and the amygdala, which is associated with emotions. Besides them, the forebrain also includes both the thalamus and the hypothalamus, of which the former is the part of the brain that processes information received from other parts of the central nervous system and the peripheral nervous system into the brain, and the latter which is involved is several activities such as appetite, sexuality, body temperature, and hormones. Page 19 of 35 The midbrain The midbrain is located below the forebrain and above the hindbrain. It resides in the core of the brain, almost like a link between the forebrain and the midbrain. It regulates several sensory processes such as that of the visual and auditory ones, as well as motor processes. This is also the region where several visual and auditory reflexive responses take place. These are involuntary reflexes in response to the external stimuli. Several of the masses of gray matter, composed mainly of the cell bodies, such as the basal ganglia linked with movement are also present in the midbrain. Of the above three major divisions of the brain, the midbrain belongs to the brainstem, and of the two main systems within the nervous system, it belongs to the central nervous system. The hindbrain The hindbrain is located below the end-tip of the forebrain, and at the exact back of the midbrain. It includes cerebellum, the pons, and the medulla, among others. Of these, the cerebellum has influence over body movement, equilibrium, and balance. The pons not only brings the motor information to the cerebellum, but is also related with the control over sleep and wakeful states. Finally, the medulla is responsible for involuntary processes of the nervous system associated with such activities as respiration and digestion. In terms of anatomy, pons is uppermost part, and beneath it the cerebellum and the medullae, which tapers to merge with the spinal cord. Vertical organization of the brain The organization of the brain layers can be said to represent a certain gradation of mental processes (Figure 23). The uppermost brain region, the cerebral cortex, is mostly involved in conscious sensations, abstract thought processes, reasoning, planning, working memory, and similar higher mental processes. The limbic areas on the brain’s innermost sides, around the brainstem, deal largely with more emotional and instinctive behaviors and reactions, as well as long-term memory. The thalamus is a preprocessing and relay center, primarily for sensory information coming from lower in the brainstem, bound for the cerebral hemispheres above. Moving down the brainstem into the medulla are the so-called ‘vegetative’ centers of the brain, which sustain life even if the person has lost consciousness. Anatomical directions and reference planes of the brain To enable us to identify the precise location in the brain, both vertically and horizontally, it is important to be familiar with certain technical terms used by the neuroscientists. In Page 20 of 35 terms of anatomy, the front of the brain, nearest the face, is referred to as the anterior end, and polar opposite to the anterior end is the posterior end, referring to the back of the head. Superior (sometimes called dorsal) refers to the direction toward the top of the head, and inferior (sometimes called ventral) refers to the direction toward the neck/body. In terms of reference planes, the sagittal plane divides the brain into left and right portions, the coronal plane divides the brain into anterior and posterior portions, and the axial (sometimes called horizontal) plane divides the brain into superior and inferior portions (Figure 24). In both the above contexts, we can further specify the location of a particular portion or plane in terms of its position, direction, and depth in relation to the whole brain. Likewise, for each of the planes themselves, we can further speak in terms of position, direction, and depth in relation to the whole brain as well as in relation to the individual planes. Also, when representing brain parts and structures, a lateral view illustrates the section or lobes, etc. from the perspective of a whole brain, whereas a medial view illustrates the section in the dissected manner. 8) DIFFERENT TYPES OF BRAINS In general, the number of living beings who possess brain is numerous. Their brains vary both in size and function. However, if you ask whether all brains completely differ from each other. Definitely not. There are features that are common to almost all brains, such as that all brains are composed mainly of neurons, and that they all have the function of protecting the individual being from internal and external dangers. So, although there are various types of brains, here we shall focus mainly on the differences in brain types between vertebrates and invertebrates in general, and the differences within the vertebrates in particular. As you know, vertebrates are those animals who have backbone, and invertebrates do not have backbone. Most of the invertebrates do not have brain. However, those, among them, who do possess brain, theirs is usually a simple brain, composed of very few neurons. Note that majority of the animals on this earth are invertebrates. The vertebrates make up only two percent of the entire animal population. The unicellular organisms, because of practical existential reason, usually tend to be very sensitive to light. Organisms such as sea-urchins are slightly more complex and are multi-cellular. They have a few nerve cells that regulate the function of looking for sustenance and providing protection from possible dangers. Slightly more complex than the types of sea-urchins are earthworm and jellyfish, which have neurons that assist them in fighting hostile external Page 21 of 35 environment (Figure 25). It is interesting to know that the neurons these simple organisms have are similar to the human neurons in terms of structure, function, as well as their neurotransmitters. If you ask, what is the difference then? There hardly is any connection between the nerves in the invertebrates. Besides that, the nerves almost cover their entire bodies. For example, among the invertebrates, earthworms (Figure 26) have one of the simplest types of brains, possessing only a few neurons. Their brains regulate only a few simple tasks such as eating food and doing a few simple body movements, not any higher actions. The network of neurons that process and interpret the information received from the earthworm’s body parts is present in the earthworm’s head. However, even if that network were to be removed from its body, no noticeable changes would be observe in its behavior. Still, among the invertebrates, grasshoppers and bees have slightly more complex brains. Scientists have begun to understand the relation between their brains and the corresponding behaviors (Figure 27). The ants, also an invertebrate, have more complex behavior, but have a very tiny brain. Likewise, the mosquitoes perform the function of flying in the space, suck blood from others, etc. However, their brain size is still no more than a small dot. Among the vertebrates, the mice are generally quite smart, yet have brains weighing no more than 2 grams. Their entire brain size is equivalent to that of the human hypothalamus. Though generally it is said the bigger the brain, the greater the intellect. However, in actuality it is the overall area of cortices, not just the overall bulk that determines the level of intellect. Among the vertebrates, there are mammals and non-mammals. Birds and fish are examples of non-mammals. It is known that the brains of mammals and non-mammals differ greatly in terms of complexity in the areas of composition, neurons, synapses, etc. Though they still have the same basic parts and structures, they differ in the overall brain size in relation to their bodies. Besides that, depending on which parts play out more in their life, they differ in the relative size of specific parts of the brain and body. For example, birds and fish have relatively very small olfactory bulb. Also, these nonmammalian animals lack brain cortex. Cerebral cortex is a special brain part, quite prominent in primates including the humans. Not only this, human beings are known to have a disproportionately large cortex (Figures 28 & 29). The average weight of human brain amounts to only one and a half percent of their body weight. However, it consumes 20 percent of the food required by the whole body. So, the larger the brain is the greater the amount of energy consumption. Therefore, bigger brain Page 22 of 35 is not always a sign of boon to the individual species. This may be the reason why there are no many species with larger brains in the history of evolution. Social animals that depend on their social community for survival are said to have larger brains. For example, dolphins, who hunt in groups, have fairly large brain. Although, the brains of elephants and whales are much bigger in size than that of the humans, but humans have the largest brains in proportionate to their body sizes. 9) FACTS ABOUT HUMAN SPINAL CORD Spinal cord is located within the vertebrae of the backbone. It extends from brainstem down to the first lumbar vertebra. It is roughly the width of a conventional pencil, tapering at it base even thinner. It is comprised of a bundle of fibers, and the fibers are long projections of nerve cells, extending from the base of the brain to the lower region of the spine. The spinal cord carries information to and from the brain and all parts of the body except the head, which is served by the cranial nerves. The signals that travel along the spinal cord are known as nerve impulses. Data from the sensory organs in different parts of the body is collected via the spinal nerves and transmitted along the spinal cord to the brain. The spinal cord also sends motor information, such as movement commands, from the brain out to the body, again transmitted via the spinal nerve network. In terms of its anatomy, the spinal cord (Figure 30) is constituted of what is known as white matter and gray matter. The gray matter, which forms the core of the spinal cord, is composed mainly of nerve cell bodies and forms an external look of a butterfly. The white matter surrounds the gray matter and its nerve fibers play a significant role of establishing connection between different parts of the spinal cord as well as between the brain and the spinal cord. The outer regions of white matter insulate the long projecting nerve fibers (axons) coming out from the neurons. In the gray matter of the spinal cord, there are numerous low-key nerve centers that can perform certain fundamental movement responses. However, the nerve centers within the spinal cord are regulated by the brain. The ability of the humans in consciously controlling the bowl movement is an example in this regard. The fact that infants frequent to toilets more often than the adults and that many have bedwetting problem is due to the brain being not fully developed as well as lacking in control over urine. Thus, the spinal cord serves as a pathway of connection between the brain, the rest of the body, and internal organs. The spinal cord stays in contact with the majority of body organs through the medium of nerves. Page 23 of 35 10) PERIPHERAL NERVOUS SYSTEM As discussed above, the whole of nervous system is divided into the central nervous system (CNS) and the peripheral nervous system (PNS). Of these two, we have already discussed the central nervous system constituted by the brain and the spinal cord. So here, we will take up the remaining part, i.e. the peripheral nervous system. The peripheral nervous system is a complex network of nerves extending across the body, branching out from 12 pairs of cranial nerves originating in the brain and 31 pairs of spinal nerves emanating from the spinal cord. It relays information between the body and the brain in the form of nerve impulses. It has an afferent division (through which messages are sent to the brain) and an efferent division (which carries messages from the brain to the body). Finally, there is the autonomic nervous system, which shares some nerve structures with both the CNS and PNS. It functions ‘automatically’ without conscious awareness, controlling basic functions, such as body temperature, blood pressure, and heart rate. Sensory input travels quickly from receptor points throughout the body via the afferent networks of the PNS to the brain, which processes, coordinates, and interprets the data in just fractions of a second. The brain makes an executive decision that is conveyed via the efferent division of the PNS to muscles, which take the needed action. The twelve pairs of cranial nerves There are 12 pairs of cranial nerves (Figure 31). They are all linked directly to the brain and do not enter the spinal cord. They allow sensory information to pass from the organs of the head, such as the eyes and ears, to the brain and also convey motor information from the brain to these organs—for example, directions for moving the mouth and lips in speech. The cranial nerves are named for the body part they serve, such as the optic nerve for the eyes, and are also assigned Roman numerical, following anatomical convention. Of these, some are associated with sensory information and others with motor information, while some are associated with both the kinds of information. How cranial nerves attach The cranial nerves I and II connect to the cerebrum, while cranial nerves III to XII connect to the brainstem. The fibers of sensory cranial nerves each project from a cell body that is located outside the brain itself, in sensory ganglia or elsewhere along the trunks of sensory nerves. The thirty-one pairs of spinal nerves Page 24 of 35 There are 31 pairs of spinal nerves (Figure 32). These branch out from the spinal cord, dividing and subdividing to form a network connecting the spinal cord to every part of the body. The spinal nerves carry information from receptors around the body to the spinal cord. From here the information passes to the brain for processing. Spinal nerves also transmit motor information from the brain to the body’s muscles and glands so that the brain’s instructions can be carried out swiftly. Each of the 31 pairs of spinal nerves belongs to one of the four spinal regions--- cervical, thoracic, lumbar, and sacral. Of them, the cervical region has eight pairs, the thoracic has twelve pairs, the lumbar has five, and finally, the sacral has six pairs. How spinal nerves attach As mentioned above, human spinal cord is located within the vertebrae of the backbone. So, one may wonder how the spinal nerves attach to the spinal cord. There are gaps in the vertebrae of the backbone through which spinal nerves enter the spinal cord (Figure 33). The nerves divide into spinal nerve roots, each made up of tiny rootlets that enter the back and front parts of the cord. 11) A SLIGHTLY DETAILED LOOK AT THE SENSES How do our brain and the environment interact? Here is how. First the senses come in contact with the external stimuli such as light, sound wave, pressure, etc. to which the corresponding senses respond. Then those sense data are sent along the respective sensory nerves in the form of electrical signals which eventually reach their respective sites on the brain cortices. That is when we shall have the perception of the respective objects. SEEING Let’s now take up each of the senses, one by one. First, we discuss the sense of vision. We shall look into the following topics surrounding the sense of vision: the structure of eye, its receptor cells, the visual pathway, and the range of light frequency different animals, including humans, have access to. Page 25 of 35 STRUCTURE OF EYE The eyeball is a fluid-filled orb. It has a hole in the front called pupil. At the back of the eyeball, there is retina which is a sheet of nerve cells. Some of the retinal cells are lightsensitive (photoreceptive). In the center of the retina, there is a tiny pitted area called fovea, densely packed with cones which are color-picking, light-sensitive cells and are significant in detecting detailed, sensitive image of the object. Between the pupil and the retina is a lens that adjusts to help the light passing through pupil to focus on the surface of the retina. The pupil is surrounded by a muscular ring of pigmented fibers called iris. The iris is responsible for people having different eye colors, and it also controls the amount of light entering into the eye. The pupil is covered by a transparent layer of clear tissue called cornea which merges with the tough outer surface or the ‘white’ of the eye called sclera. In the back of the eye, there is a hole (optic disk) through which the optic nerves pass through to enter the brain (Figure 34). LIGHT-RECEPTIVE CELLS As mentioned before, retina is located at the back of the eye, and is composed of lightreceptive cells (photoreceptors). There are, in the main, two types of photoreceptors in the retina: cone cells and rod cells. The cone cells detect the color components from amongst the visible light spectrum, and are also responsible for detecting fine detail. However, cone photoreceptors require a huge amount of light to perform its function well. Cone cells in the humans are of three types: red-, blue-, and green-sensing cones, each detecting the respective colors. They are all formed on the surface and around the fovea. On the other hand, the rod cells are formed on the periphery of retina. These cells can detect images even in dim light. However, these cells mainly detect shape and motion, not so much the color. Of these two types of photoreceptors, the rods are much more sensitive to light, so much so that even with just a few light particles, they can at least generate a faint image. Besides, the manner of concentration of these cells in and around fovea impacts greatly the sensitivity of the sensation of the object. The majority of the 6 million cone cells are concentrated in the fovea, whereas all of the more than 120 million rod cells are spread around the fovea. Since the rods are spread over a larger area of the retina, they are relatively less concentrated, and thus, when one sees objects, they are not seen that clearly and detailed. Page 26 of 35 VISUAL PATHWAYS The light reflected from the visual objects first enters the pupil through cornea, and through pupil it enters deeper into the eyes. The iris that surrounds the pupil controls the amount of light entering the eyes by changing its shapes, due to which the pupil appears to contract when the light is bright and sharp, and expands when it is less bright. Afterwards, the light passes through the lens which bends (refracts) the light, making the light to converge on the retina. If focusing on a near object, the lens thickens to increase refraction, but if the object is distant, the lens needs to flatten. The light then hits the photoreceptors in the retina, some of which fire, sending electrical signals to the brain via the optic nerve. Information received from the outer environment upon coming in contact with eyes has to travel right to the back of the brain where the relevant cortex (visual cortex) is, and only there it is turned into a conscious vision. Here is the pathway through which the information passes from the eyes to the optic nerves to the visual cortex: the signals from the eyes passes through the two optic nerves and converge at a crossover junction called the optic chiasm. The fibers carrying the signals continue on to form the optic tracts, one on each side, which end at the lateral geniculate nucleus, part of the thalamus. However, the signals continue to the visual cortex via bands of nerve fibers, called the optic radiation (Figure 35). RANGE OF LIGHT WAVELENGTH THAT DIFFERENT ANIMALS, INCLUDING HUMANS, HAVE ACCESS TO In the course of evolution, by means of natural selection, different species of organisms, including the humans, have evolved eyes with varying structures and functions. That range of electromagnetic spectrum visible to the human eyes is called the visible light, which range from 400 to 700 nanometers on the wavelength. That is, from the violet, with the shorter wavelengths, to red, with longer wavelengths. Lights with wavelengths outside of the above range are normally not visible to humans. This illustrates the difference in the structure of eyes among different species of organisms. For example, the vultures and rabbits have different eye from each other. Due to that, vultures can see much farther than the rabbits do, yet cannot see as widely as the rabbits do. Likewise, the infrared light that the humans cannot see is visible to some types of fish and birds. Some birds can tell a male bird from a female bird just by looking at the infrared light reflected from their wings. Likewise, there are two main features distinct in the eyes of the bees that the humans do not have. First, their eyes can detect infrared light that the humans cannot. Second, their Page 27 of 35 visual processing is five-fold speedier than that of the humans. For example, when the bees observe a normal moving object, they do not see that as moving. Rather, they are said to see that in the form of a series of distinct temporal instances. What accounts for such a unique feature of the bees’ eyes? Their eyes are composed of six-sided lens, covered with about 4500 circular discs. These lens let in just the lights reflected from the object they focus on and not from around it. Besides that, unlike human eyes, the eyes of the bees are said to have nine types of light receptors. Because of the speed of the visual processing that the bees possess, they have a advantage of being able to negotiate their movement so well even while moving with so much speed with the least incidents of ever bumping against objects, etc. Also, often we wonder about the sharp lights reflected back from the eyes of cats and other animals of that family. That is now understood to be due to the fact that all the lights entering their eyes fail to be absorbed in the retina, and are thus reflected back by the membrane called the reflective white. HEARING The ear is divided into three sections: the outer ear, the middle ear, and the inner ear. The outer ear has three further sections: the visible part of the ear called the pinna, the auditory canal, and the eardrum. The middle ear has three tiny bone structures that help in our hearing process: malleus (hammer), incus (anvil), and stapes (stirrup). The inner ear has several parts, of which the important ones are oval window, cochlea, and auditory nerve. The outer ear funnels sound waves along the auditory canal to the eardrum which is situated towards the inner end of the air canal. Immediate after the eardrum, the three tiny bones of the middle ear are attached one after the other. The sound waves cause the eardrum to vibrate, which in turn causes this chain of bones to vibrate. The vibration eventually reaches a membrane known as the oval window, the start of the inner ear. The oval window is slightly smaller than the ear drum in diameter. Because of this, when the vibration enters from the middle ear into the inner ear, the vibration becomes more consolidated. Inner ear is situated deep under the skull. Commensurate with the force of sound waves striking the ear drum, the stapes will accordingly cause the oval window to vibrate. Due to this, the fluids filling the chambers of cochlea will move, causing basilar membrane to vibrate. This stimulates the sensory hair cells on the organ of corti transforming the pressure waves into electrical impulses. These impulses pass through auditory nerve to the temporal lobe and from there to the auditory cortex (Figure 36). Page 28 of 35 Because of the way human ear is structured, it has access to a limited range of sound frequency. That is between 20 and 20000 Hertz. Sounds beyond that range are not audible to the humans. Sounds vary in terms of their pitch, and the receptors corresponding to them are found in the various parts of the cochlea. The receptors for low pitch sounds are located in the front part of cochlea, whereas receptors for the higher and the highest pitch sounds are found in the middle and inner end, respectively, of the cochlea. SMELL The area within each nasal cavity that contains the olfactory receptor cells is known as the olfactory epithelium. A small amount of the air entering the nostrils will pass over the epithelium, which is covered in mucus. Smell molecules in the air dissolve in this mucus, bringing receptors into direct contact with the smell molecules. Three cell types are within the epithelium: in addition to the receptor cells, there are supporting cells which produce a constant supply of mucus and, basal cells, which produce new receptor cells every few weeks. The larger the epithelium is, the keener the sense of smell. Dogs, for example, have a considerably larger olfactory epithelium than humans. Like the sense of taste, smell is a chemical sense. Specialized receptors in the nasal cavity detect incoming molecules, which enter the nose on air currents and bind to receptor cells. Sniffing sucks up more odor molecules into the nose, allowing you to ‘sample’ a smell. Olfactory receptors located high up in the nasal cavity send electrical impulses to the olfactory bulb, in the limbic area of the brain, for processing. Odors are initially registered by receptor cells in the nasal cavity. These send electrical impulses along dedicated pathways to the olfactory bulb (each nostril connects to one olfactory bulb). The olfactory bulb is the smell gateway to the brain. It is part of the brain’s limbic system, the seat of our emotions, desires, and instincts, which is why smell can trigger strong emotional reactions. Once processed by the olfactory bulb, data is then sent to various areas of the brain, including the olfactory cortex adjacent to the hippocampus. Unlike data gathered by the other sense organs, odors are processed on the same side, not opposite, side of the brain as the nostril the sensory data was sent from (Figure 37). How do the olfactory receptors detect the different odors? Different smells are produced from different molecular structures of smell. Research shows that each receptor has zones on it. Therefore, when a specific smell enters the nose, only the receptors forming a conforming pattern, not every receptor, is activated. That is how the specific smell is Page 29 of 35 detected. So far the scientists have identified eight primary odors: camphorous, fishy, malty, minty, musky, spermatic, sweaty, and urinous. TASTE Taste and smell are both chemical senses. Therefore, tongue can detect taste only when the receptors in it bind to incoming molecules, generating electrical signals that pass through the related cranial nerves to the specific brain areas. Thus, the pathway of gustatory electrical impulses begins with mouth, going to medulla, continues to the thalamus, then to primary gustatory areas of the cerebral cortex. A person can experience the basic five flavors (sweet, sour, salty, bitter, and umami) by merely activating the taste receptors on the tongue. However, the flavors produced from the combination of these can be detected by tongue only in interaction with the sense of smell. Compared with cold food, we experience the hot food to produce greater taste. This is because, during such time, smell particles rising from the hot food bind to and excite the smell receptors inside the nose, making us also to sense their smell. Before the smell particles and taste particles are detected by the smell receptors and taste receptors respectively, these particles have to dissolve in the liquid solvents in the nose and mouth respectively. So they are similar on that front. However, what is different between the two is that while the taste receptors are not actual neurons, but a special type of cells, the smell receptors are actual neurons. Due to this difference, we see a marked difference in the degree of sensitivity towards the chemical particles. The smell receptors are 300 hundred times more sensitive (Figure 38). The tongue is the main sensory organ for taste detection. It is the body’s most flexible muscular organ. It has three interior muscles and three pairs of muscles connecting it to the mouth and throat. Its surface is dotted with tiny, pimplelike structures called papillae. Papillae are easily visible to naked eyes. Within each papilla are hundreds of taste buds and they are distributed across the tongue. Four types of papillae have been distinguished---vallate, filiform, foliate, and fungiform. Each type bears a different amount of taste buds. A taste bud is composed of a group of about 25 receptor cells alongside supporting cells layered together. In general, humans have 5000 to 10,000 taste buds, and each bud may carry 25 to 100 taste receptor cells within it. At the tip of each cell, there is a hole through which taste chemical particles enter and come in contact with the receptor molecules. The tiny hair-like receptors inside these receptor cells can hold only particular taste particles. Earlier, scientists believed that different parts of the tongue are dedicated to detecting specific tastes. However, according to recent researches, all tastes are detected equally across the tongue, and the tongue is well supplied with nerves Page 30 of 35 that carry taste-related data to the brain. Other parts of the mouth such as the palate, pharynx, and epiglottis can also detect taste stimuli. TOUCH There are many kinds of touch sensations. These include light touch, pressure, vibration, and temperature as well as pain, and awareness of the body position in space. The skin is the body’s main sense organ for touch. There are around 20 types of touch receptor that respond to various types of stimuli. For instance, light touch, a general category that covers sensations ranging from a tap on the arm to stroking a cat’s fur, is detected by four different types of receptor cells: free nerve endings, found in the epidermis; Merkel’s disks, found in deeper layers of the skin; Meissner’s corpuscles, which are common in the palms, soles of the feet, eyelids, genitals, and nipples; and, finally, the root hair plexus, which responds when the hair moves. Pacinian and Ruffini corpuscles respond to more pressure. The sensation of itching is produced by repetitive low-level stimulation of nerve fibers in the skin, while feeling ticklish involves more intense stimulation of the same nerve endings when the stimulus moves over the skin (Figure 39). As for the manner in which touch information finally makes its way to the brain, a sense receptor, when activated, sends information about touch stimuli as electrical impulses along a nerve fiber of the sensory nerve network to the nerve root on the spinal cord. The data enters the spinal cord and continues upward to the brain. The processing of sensory data is begun by the nuclei in the upper (dorsal) column of the spinal cord. From the brainstem, sensory data enters the thalamus, where processing continues. The data then travels to the postcentral gyrus of the cerebral cortex, the location of the somatosensory cortex. Here, it is finally translated into a touch perception. Somatosensory cerebral cortex curls around the brain like a horseshoe. Data from the right side of the body ends on the left side of the brain, and vice versa. THE SIXTH SENSE Proprioception is sometimes referred to as the sixth sense. It is our sense of how our bodies are positioned and moving in space. This ‘awareness’ is produced by part of the somatic sensing system, and involves structures called proprioceptors in the muscles, tendons, joints, and ligaments that monitor changes in their length, tension, and pressure linked to changes in position. Proprioceptors send impulses to the brain. Upon processing this information, a decision can be made—to change position or to stop moving. The brain then sends signals back to the muscles based on the input from the proprioceptors— Page 31 of 35 completing the feedback cycle. This information is not always made conscious. For example, keeping and adjusting balance is generally an unconscious process. Conscious proprioception uses the dorsal column-medial lemniscus pathway, which passes through the thalamus, and ends in the parietal lobe of the cortex. Unconscious proprioception involves spinocerebellar tracts, and ends in the cerebellum. Proprioception is impaired when people are under the influence of alcohol or certain drugs. The degree of impairment can be tested by field sobriety tests, which have long been used by the police in cases of suspected drunk-driving. Typical tests include asking someone to touch their index finger to their nose with eyes closed, to stand on one leg for 30 seconds, or to walk heel-to-toe in a straight line for nine steps. MIXED SENSES Sensory neurons respond to data from specific sense organs. Visual cortical neurons, for example, are most sensitive to signals from the eyes. But this specialization is not rigid. Visual neurons have been found to respond more strongly to weak light signals if accompanied by sound, suggesting that they are activated by data from the ears as well as the eyes. Other studies show that in people who are blind or deaf, some neurons that would normally process visual or auditory stimuli are “hijacked” by the other senses. Hence, blind people hear better and deaf people see better. SYNESTHESIA Most people are aware of only a single sensation in response to one type of stimulus. For example, sound waves make noise. But some people experience more than one sensation in response to a single stimulus. They may “see” sounds as well as hear them, or “taste” images. Called synesthesia, this sensory duplication occurs when the neural pathway from a sense organ diverges and carries data on one type of stimulus to a part of the brain that normally processes another type (Figure 40). PERCEPTION AS A CONSTRUCT Do we perceive the external world directly, or do we perceive a constructed reality? Neuroscience finds that the latter is a more accurate description. When our sensory organs detect something in the environment, they are responding to a physical stimulus. For example, the photoreceptor cells in the retina of the eye respond to photon particles traveling through space. These photons stimulate the receptor neurons, and start a chain reaction of neural signals to the primary visual cortex in the brain, where it becomes a perception. While the visual perception correlates with the physical stimulus, they are not Page 32 of 35 one and the same. It was described earlier that photons have a wavelength, and the wavelength can vary among photons. Each numerical difference in the wavelength of a photon correlates with a difference in the perception of color. That is, photons with a wavelength of around 500 nanometers correlate with perceiving the color blue, while a wavelength of around 700 nanometers correlates with perceiving the color red. While the physical property of wavelength exists objectively in the world, the perceived color only exists subjectively and depends on our ability to detect it. The colors we perceive are not physical properties, but rather the psychological correlates of the physical property of wavelength of light. Moreover, there are many wavelengths that we cannot detect, so our perceptions selectively represent the physical world. The same principle applies to the other senses. Each sensory modality we have has two components: the physical stimulus that is detected by the sensory organ, and the psychological perception that results from it. We do not directly perceive the wavelength of light, rather we perceive the result of how the photon particles stimulate the visual pathway. Therefore, we can say that perception is a construction that is grounded in detecting physical phenomena, but we do not directly perceive those phenomena. Nor do we perceive all objective phenomena, only those that we are capable of detecting. If perception is a construction and a limited representation of objective phenomena, why did it evolve that way? We need to be able to react to environmental circumstances to survive. To find food, to avoid predators, to meet mates, to care for offspring, to engage in social behavior, all of these actions require the ability to detect and respond to changes in the physical environment. But sensory systems can evolve to be simply good enough for survival. It is not necessary to have complete, direct perception to survive. In fact, recall the facts we discussed earlier about how the human brain is very demanding for the body’s resources. More sophisticated sensory systems require more resources, and if those resource requirements are not of great utility to the organism, then evolution likely will not favor increasing the level of sophistication. In addition, there is often a trade-off between speed and accuracy in neural systems and resulting behaviors. When it comes to visual perception, seeing a danger with less accuracy and surviving is more important than seeing a danger directly and not surviving! Page 33 of 35 12)CONSCIOUSNESS AND THE BRAIN WHAT IS CONSCIOUSNESS? Consciousness is important as well as essential. Without it, life would have no meaning. However, once we embark on identifying its nature, it is certain to find it to be like nothing else. A thought, feeling, or idea seems to be a different kind of thing from the physical objects that make up the rest of the universe. The contents of our minds cannot be located in space or time. Although to the neuroscientists the contents of our minds appear to be produced by particular types of physical activity in the brain, it is not known if this activity itself forms consciousness or if brain activity correlates with a different thing altogether that we call “the mind” or consciousness (Figure 41). If consciousness is not simply brain activity, this suggests that the material universe is just one aspect of reality and that consciousness is part of a parallel reality in which entirely different rules apply. MONISM AND DUALISM The philosophical stands of those positing the relation between mind and body can be broadly brought under two divisions: monism and dualism. According to the former, every phenomenon in the universe can be ultimately reduced to a material thing. Consciousness too is identical to the brain activity that correlates with it. However, the fact that not every physical thing has consciousness is because only in those physical bodies where complex physical processes evolved over a long period of time did cognitive mechanism develop. Thus, consciousness never existed in parallel with the material universe as an independent entity of its own. According to the latter, consciousness is not physical but exists in another dimension to the material universe. Certain brain processes are associated with the consciousness, but they are not identical to each other. Some dualists believe consciousness may even exist without the brain processes associated with it. LOCATING CONSCIOUSNESS Human consciousness arises from the interaction of every part of a person with their environment. We know that the brain plays the major role in producing conscious awareness but we do not know exactly how. Certain processes within the brain, and neuronal activity in particular areas, correlate reliably with conscious states, while others do not. Page 34 of 35 Different types of neuronal activity in the brain are associated with the emergence of conscious awareness. Neuronal activity in the cortex, and particularly in the frontal lobes, is associated with the arousal of conscious experience. It takes up to half a second for a stimulus to become conscious after it has first been registered in the brain. Initially, the neuronal activity triggered by the stimulus occurs in the “lower” areas of the brain, such as the amygdala and thalamus, and then in the “higher” brain, in the parts of the cortex that process sensations. The frontal cortex is activated usually only when an experience becomes conscious, suggesting that the involvement of this part of the brain may be an essential component of consciousness. REQUIREMENTS OF CONSCIOUSNESS Every state of conscious awareness has a specific pattern of brain activity associated with it. These are commonly referred to as the neural correlates of consciousness. For example, seeing a patch of yellow produces one pattern of brain activity, seeing grandparents, another. If the brain state changes from one pattern to another, so does the experience of consciousness. Consciousness arises only when brain cells fire at fairly high rates. So, neural activity must be complex for consciousness to occur, but not too complex. If all the neurons are firing, such as in an epileptic seizure, consciousness is lost. The processes relevant to consciousness are generally assumed to be found at the level of brain cells rather than at the level of individual molecules or atoms. Yet it is also possible that consciousness does arise at the far smaller atomic (quantum) level, and if so it may be subject to very different laws. Many neuroscientists hold the philosophical view of materialism; that there is only one fundamental substance in the universe and that is physical material. How, then, is subjective experience of the mind explained? Through a process known as emergence. Emergence is a process described as the production of a phenomenon from the interactions or processes of several other phenomena. For example, the molecule that is water is composed of two hydrogen atoms and one oxygen atom. The hydrogen and oxygen atoms on their own do not have the quality of wetness that water has. But when you combine them to form the molecule, and you have enough water molecules, then the property of wetness emerges from those interactions. Neuroscientists use this as an analogy, and argue that when many neurons are combined, consciousness emerges from those interactions. This analogy serves as a useful description within the viewpoint of materialism, but it is not an explanation, as we have yet to demonstrate the mechanisms involved in such an emergence.

Only use the information provided to you in the prompt question and context block that has been included, NEVER use external resources or prior knowledge. Responses should be exactly two paragraphs in length. If you don't know something because it's not provided in the document, say "Don't know - information not found." Bullet points or sentence fragments should never be used unless specifically requested. Focus on common-sense, obvious conclusions with specific factual support from the prompt.

When an inventor is granted a United States Patent what has the inventor given up or surrendered and what has the inventor received in exchange?

What Are Patents? Patents are a form of intellectual property that give their holders the exclusive right to practice their inventions (i.e., make, use, sell, offer to sell, or import them) for a limited period of time. The Constitution gives Congress the power to grant patent rights to inventors by authorizing Congress to “promote the Progress of Science and useful Arts, by securing for limited Times to . . . Inventors the exclusive Right to their respective . . . Discoveries.”13 Since 1790, Congress has enacted patent laws granting inventors certain exclusive rights in their inventions for a period of time.14 (Currently, patents expire 20 years after the date that the patent application that gave rise to the patent was filed.15) Patents represent a “quid pro quo” by which the inventor publicly discloses an invention in exchange for time-limited, exclusive rights to practice it. 16 In the United States, USPTO is responsible for evaluating patent applications and granting patents on qualifying inventions, as explained below.17 11 See, e.g., id.; ALLIANCE OF U.S. STARTUPS AND INVENTORS FOR JOBS, Why Patents Matter, https://www.usij.org/whypatents-matter/ (last visited Mar. 28, 2024). 12 See, e.g., Gene Quinn, A Kinder, Gentler ‘Death Squad’: Ten Years in, Despite Some Reforms, the USPTO Is Still Killing U.S. Patents, IP WATCHDOG (Sept. 19, 2021, 12:15 PM), https://ipwatchdog.com/2021/09/19/kinder-gentlerdeath-squad-ten-years-despite-reforms-uspto-still-killing-u-s-patents/id=137765/; Oil States Energy Servs. v. Greene’s Energy Grp., 584 U.S. 325, 345–47 (2018) (Gorsuch, J., dissenting). 13 U.S. CONST. art. I, § 8, cl. 8. 14 See, e.g., 35 U.S.C. § 271 (setting forth how patents may be infringed). 15 Id. § 154(a)(2). Patent terms can be extended in some circumstances, such as delays by USPTO in reviewing a patent application. See id. §§ 154(b), 156. 16 J.E.M. Ag Supply, Inc. v. Pioneer Hi-Bred Int’l, Inc., 534 U.S. 124, 142 (2001) (“The disclosure required by the Patent Act is ‘the quid pro quo of the right to exclude.’” (quoting Kewanee Oil Co. v. Bicron Corp., 416 U.S. 470, 484 (1974))); see also Universal Oil Prods. Co. v. Globe Oil & Refin. Co., 322 U.S. 471, 484 (1944) (“As a reward for inventions and to encourage their disclosure, the United States offers a . . . monopoly to an inventor who refrains from keeping his invention a trade secret. But the quid pro quo is disclosure of a process or device in sufficient detail . . . .”). 17 See infra “How Do Inventors Obtain a Patent?”. Once granted, the holder of a valid patent has the exclusive right to make, use, sell, or import the invention in the United States until the patent expires.18 Any other person who practices the invention without permission from the patent holder infringes the patent and is liable for monetary damages, and possibly subject to injunctive relief, if sued by the patentee. 19 Patents have the attributes of personal property, and the patentee may sell or assign the patent to another person.20 A patentee may also license other persons to practice the invention, granting them permission to make, use, sell, or import the invention, usually in exchange for consideration (such as monetary royalties).21 What Inventions Can Be Patented? In order to be patented, an invention must meet four substantive requirements: The invention must be (1) directed to patentable (or “eligible”) subject matter, (2) new, (3) nonobvious, and (4) useful.22 In addition to these four substantive patentability requirements, the Patent Act imposes minimum requirements for the technical disclosure of the invention in the patent application, which must adequately describe and distinctly claim the invention.23 As discussed in this report, PTAB administers certain proceedings in which petitioners may seek to invalidate a patent previously granted by USPTO on the grounds that the patent fails to satisfy certain of these requirements. This section briefly surveys these patentability requirements. Eligible Subject Matter Requirement The Patent Act allows inventors to obtain patents on any new and useful “process, machine, manufacture, or composition of matter, or . . . improvement thereof.”24 Examples of technological areas for patentable inventions include pharmaceuticals, biotechnology, chemistry, computer hardware and software, electrical engineering, mechanical engineering, and manufacturing processes.25 By contrast, the Supreme Court has long held that “laws of nature, natural phenomena, and abstract ideas” are not patentable.26 The Court has reasoned that to permit a monopoly on the “‘basic tools of scientific and technological work’ . . . might tend to impede innovation more than it would tend to promote it.”27 In a series of cases in the 2010s, the Supreme Court established a two-step test for patentable subject matter, sometimes called the Alice test or the Alice/Mayo framework.28 The first step 18 35 U.S.C. § 271(a). 19 Id. §§ 271, 281, 283–285. 20 Id. § 261. 21 License, BLACK’S LAW DICTIONARY (10th ed. 2014); 35 U.S.C. § 271(a). 22 See 35 U.S.C. §§ 101–103. 23 Id. § 112; see generally Hickey, supra note 4, at 12–14. 24 35 U.S.C. § 101. 25 See USPTO, PATENT TECHNOLOGY CENTERS MANAGEMENT, https://www.uspto.gov/patent/contact-patents/patenttechnology-centers-management (last visited Mar. 28, 2024) (listing technological divisions for USPTO examiners). 26 Diamond v. Diehr, 450 U.S. 175, 185 (1981); see generally Hickey, supra note 4, at 10–20 (overviewing development of the law of patent-eligible subject matter). 27 Mayo Collaborative Servs. v. Prometheus Lab’ys, Inc., 566 U.S. 66, 71 (2012) (quoting Gottschalk v. Benson, 409 U.S. 63, 67 (1972)). 28 See Alice Corp. Pty. Ltd. v. CLS Bank Int’l, 573 U.S. 208 (2014); Ass’n for Molecular Pathology v. Myriad Genetics, Inc., 569 U.S. 576 (2013); Mayo Collaborative Servs., 566 U.S. at 66. USPTO has issued guidelines for its patent examiners to determine whether a patent application seeks to claim ineligible subject matter. See 2019 Revised Patent Subject Matter Eligibility Guidance, 84 Fed. Reg. 50 (Jan. 7, 2019).

Instructions: Only use the information provided to you in the prompt question and context block that has been included, NEVER use external resources or prior knowledge. Responses should be exactly two paragraphs in length. If you don't know something because it's not provided in the document, say "Don't know - information not found." Bullet points or sentence fragments should never be used unless specifically requested. Focus on common-sense, obvious conclusions with specific factual support from the prompt. Context: What Are Patents? Patents are a form of intellectual property that give their holders the exclusive right to practice their inventions (i.e., make, use, sell, offer to sell, or import them) for a limited period of time. The Constitution gives Congress the power to grant patent rights to inventors by authorizing Congress to “promote the Progress of Science and useful Arts, by securing for limited Times to . . . Inventors the exclusive Right to their respective . . . Discoveries.”13 Since 1790, Congress has enacted patent laws granting inventors certain exclusive rights in their inventions for a period of time.14 (Currently, patents expire 20 years after the date that the patent application that gave rise to the patent was filed.15) Patents represent a “quid pro quo” by which the inventor publicly discloses an invention in exchange for time-limited, exclusive rights to practice it. 16 In the United States, USPTO is responsible for evaluating patent applications and granting patents on qualifying inventions, as explained below.17 11 See, e.g., id.; ALLIANCE OF U.S. STARTUPS AND INVENTORS FOR JOBS, Why Patents Matter, https://www.usij.org/whypatents-matter/ (last visited Mar. 28, 2024). 12 See, e.g., Gene Quinn, A Kinder, Gentler ‘Death Squad’: Ten Years in, Despite Some Reforms, the USPTO Is Still Killing U.S. Patents, IP WATCHDOG (Sept. 19, 2021, 12:15 PM), https://ipwatchdog.com/2021/09/19/kinder-gentlerdeath-squad-ten-years-despite-reforms-uspto-still-killing-u-s-patents/id=137765/; Oil States Energy Servs. v. Greene’s Energy Grp., 584 U.S. 325, 345–47 (2018) (Gorsuch, J., dissenting). 13 U.S. CONST. art. I, § 8, cl. 8. 14 See, e.g., 35 U.S.C. § 271 (setting forth how patents may be infringed). 15 Id. § 154(a)(2). Patent terms can be extended in some circumstances, such as delays by USPTO in reviewing a patent application. See id. §§ 154(b), 156. 16 J.E.M. Ag Supply, Inc. v. Pioneer Hi-Bred Int’l, Inc., 534 U.S. 124, 142 (2001) (“The disclosure required by the Patent Act is ‘the quid pro quo of the right to exclude.’” (quoting Kewanee Oil Co. v. Bicron Corp., 416 U.S. 470, 484 (1974))); see also Universal Oil Prods. Co. v. Globe Oil & Refin. Co., 322 U.S. 471, 484 (1944) (“As a reward for inventions and to encourage their disclosure, the United States offers a . . . monopoly to an inventor who refrains from keeping his invention a trade secret. But the quid pro quo is disclosure of a process or device in sufficient detail . . . .”). 17 See infra “How Do Inventors Obtain a Patent?”. Once granted, the holder of a valid patent has the exclusive right to make, use, sell, or import the invention in the United States until the patent expires.18 Any other person who practices the invention without permission from the patent holder infringes the patent and is liable for monetary damages, and possibly subject to injunctive relief, if sued by the patentee. 19 Patents have the attributes of personal property, and the patentee may sell or assign the patent to another person.20 A patentee may also license other persons to practice the invention, granting them permission to make, use, sell, or import the invention, usually in exchange for consideration (such as monetary royalties).21 What Inventions Can Be Patented? In order to be patented, an invention must meet four substantive requirements: The invention must be (1) directed to patentable (or “eligible”) subject matter, (2) new, (3) nonobvious, and (4) useful.22 In addition to these four substantive patentability requirements, the Patent Act imposes minimum requirements for the technical disclosure of the invention in the patent application, which must adequately describe and distinctly claim the invention.23 As discussed in this report, PTAB administers certain proceedings in which petitioners may seek to invalidate a patent previously granted by USPTO on the grounds that the patent fails to satisfy certain of these requirements. This section briefly surveys these patentability requirements. Eligible Subject Matter Requirement The Patent Act allows inventors to obtain patents on any new and useful “process, machine, manufacture, or composition of matter, or . . . improvement thereof.”24 Examples of technological areas for patentable inventions include pharmaceuticals, biotechnology, chemistry, computer hardware and software, electrical engineering, mechanical engineering, and manufacturing processes.25 By contrast, the Supreme Court has long held that “laws of nature, natural phenomena, and abstract ideas” are not patentable.26 The Court has reasoned that to permit a monopoly on the “‘basic tools of scientific and technological work’ . . . might tend to impede innovation more than it would tend to promote it.”27 In a series of cases in the 2010s, the Supreme Court established a two-step test for patentable subject matter, sometimes called the Alice test or the Alice/Mayo framework.28 The first step 18 35 U.S.C. § 271(a). 19 Id. §§ 271, 281, 283–285. 20 Id. § 261. 21 License, BLACK’S LAW DICTIONARY (10th ed. 2014); 35 U.S.C. § 271(a). 22 See 35 U.S.C. §§ 101–103. 23 Id. § 112; see generally Hickey, supra note 4, at 12–14. 24 35 U.S.C. § 101. 25 See USPTO, PATENT TECHNOLOGY CENTERS MANAGEMENT, https://www.uspto.gov/patent/contact-patents/patenttechnology-centers-management (last visited Mar. 28, 2024) (listing technological divisions for USPTO examiners). 26 Diamond v. Diehr, 450 U.S. 175, 185 (1981); see generally Hickey, supra note 4, at 10–20 (overviewing development of the law of patent-eligible subject matter). 27 Mayo Collaborative Servs. v. Prometheus Lab’ys, Inc., 566 U.S. 66, 71 (2012) (quoting Gottschalk v. Benson, 409 U.S. 63, 67 (1972)). 28 See Alice Corp. Pty. Ltd. v. CLS Bank Int’l, 573 U.S. 208 (2014); Ass’n for Molecular Pathology v. Myriad Genetics, Inc., 569 U.S. 576 (2013); Mayo Collaborative Servs., 566 U.S. at 66. USPTO has issued guidelines for its patent examiners to determine whether a patent application seeks to claim ineligible subject matter. See 2019 Revised Patent Subject Matter Eligibility Guidance, 84 Fed. Reg. 50 (Jan. 7, 2019). Question: When an inventor is granted a United States Patent what has the inventor given up or surrendered and what has the inventor received in exchange?

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== [user request] {passage 0} ========== [context document]

I have sleep apnea. My friend sent me this article that contains a promising medication that could help me with sleep apnea and weight loss. Explain the connection between the mentioned medication and sleep apnea and the benefits it may include. Use at least 400 words.

Tirzepatide Significantly Reduces Sleep Disruptions Alicia Ault June 22, 2024 Add to Email Alerts 28 2407 ORLANDO, Fla. — The diabetes and weight loss drug tirzepatide (Mounjaro for type 2 diabetes; Zepbound for obesity) was so effective at reducing sleep disruptions in patients with obesity and obstructive sleep apnea (OSA) that 40% to 50% no longer needed to use a continuous pressure airway positive (CPAP) device, according to two new studies. Tirzepatide, a long-acting glucose-dependent insulinotropic polypeptide (GIP) receptor agonist and glucagon-like peptide-1 (GLP-1) receptor agonist, also lowered C-reactive protein levels and systolic blood pressure. And patients taking the medication lost 18% to 20% of their body weight. The SURMOUNT-OSA studies "mark a significant milestone in the treatment of OSA, offering a promising new therapeutic option that addresses both respiratory and metabolic complications," said lead author Atul Malhotra, MD, professor of medicine at University of California San Diego School of Medicine and director of sleep medicine at UC San Diego Health. The two double-blind randomized controlled trials in patients with obesity and moderate-to-severe OSA were conducted at 60 sites in nine countries. The results were presented here at the American Diabetes Association (ADA) 84th Scientific Sessions and simultaneously published online in the New England Journal of Medicine. OSA affects 1 billion people worldwide and 30 million American adults, many of whom are undiagnosed. Obesity is a common risk factor. According to the ADA, 40% of those with obesity have OSA and 70% of those with OSA have obesity. CPAP is an effective and the most-used intervention for OSA, but many patients refuse to use the device, stop using it, or cannot use it. Should tirzepatide eventually gain US Food and Drug Administration (FDA) approval for OSA, it would be the first drug approved for the condition. "This new drug treatment offers a more accessible alternative for individuals who cannot tolerate or adhere to existing therapies," said Malhotra. Huge Reduction in Episodes, Severity For the two studies, patients were enrolled who had moderate-to-severe OSA, defined as more than 15 events per hour (using the apnea–hypopnea index [AHI]) and a body mass index of 30 kg/m2 or greater. Those not using a CPAP device were enrolled in study 1, and those using a CPAP device were enrolled in study 2. Participants received either the maximum tolerated dose of tirzepatide (10 or 15 mg by once-weekly injection) or placebo for 1 year. In study 1, 114 individuals received tirzepatide and 120 received placebo. For study 2, 119 patients received tirzepatide and 114 received placebo. All participants received regular lifestyle counseling sessions about nutrition and were instructed to reduce food intake by 500 kcal/day and to engage in at least 150 min/week of physical activity. Enrollment was limited to 70% men to ensure adequate representation of women. At baseline, 65% to 70% of participants had severe OSA, with more than 30 events/hour on the AHI scale and a mean of 51.5 events/hour By 1 year, patients taking tirzepatide had 27 to 30 fewer events/hour compared with 4 to 6 fewer events/hour for those taking placebo. Up to half of those who received tirzepatide in both trials had less than 5 events/hour or 5 to 14 AHI events/hour and an Epworth Sleepiness Scale score of 10 or less. Those thresholds "represent a level at which CPAP therapy may not be recommended," write the authors. Patients in the tirzepatide group also had a decrease in systolic blood pressure from baseline of 9.7 mm Hg in study 1 and 7.6 mm Hg in study 2 at Week 48. The most common adverse events were diarrhea, nausea, and vomiting, which occurred in approximately a quarter of patients taking tirzepatide. There were two adjudicated-confirmed cases of acute pancreatitis in those taking tirzepatide in study 2. Patients who received tirzepatide also reported fewer daytime and nighttime disturbances, as measured using the Patient-Reported Outcomes Measurement Information System Short Form scale for Sleep-Related Impairment and Sleep Disturbance. Tirzepatide Plus CPAP Are Best Writing in an accompanying editorial, Sanjay R. Patel, MD, noted that although clinical guidelines have recommended that weight loss strategies be incorporated as part of OSA treatment, "the integration of obesity management into the approaches to care for obstructive sleep apnea has lagged." As many as half of patients abandon CPAP therapy within 3 years, writes Patel, who is professor of medicine and epidemiology at the University of Pittsburgh, and medical director of the UPMC Comprehensive Sleep Disorders program. "An effective medication to treat obesity is thus an obvious avenue to pursue," he writes. Patel noted the large reductions in the number of events on the AHI scale. He writes that the improvement in systolic blood pressure "was substantially larger than effects seen with CPAP therapy alone and indicate that tirzepatide may be an attractive option for those patients who seek to reduce their cardiovascular risk." Patel raised concerns about whether patients outside of a trial would stick with therapy, noting studies have shown high rates of discontinuation of GLP-1 receptor agonists. And, he writes, "Racial disparities in the use of GLP-1 receptor agonists among patients with diabetes arouse concern that the addition of tirzepatide as a treatment option for obstructive sleep apnea without directly addressing policies relative to coverage of care will only further exacerbate already pervasive disparities in clinical care for obstructive sleep apnea." Commenting on the study during the presentation of the results, Louis Aronne, MD, said he believes the trials demonstrate "the treatment of obesity with tirzepatide plus CPAP is really the optimal treatment for obstructive sleep apnea and obesity-related cardiometabolic risks." Aronne is the Sanford I. Weill professor of metabolic research at Weill Cornell Medical College, New York. Aronne added there is still much to learn. It is still not clear whether tirzepatide had an independent effect in the OSA trial — as has been seen in other studies where the drug clearly reduced cardiovascular risk — or whether the positive results were primarily due to weight loss. "I believe that over time we'll see that this particular effect in sleep apnea is related to weight," he said.

{instruction} ========== In your answer, refer only to the context document. Do not employ any outside knowledge {question} ========== I have sleep apnea. My friend sent me this article that contains a promising medication that could help me with sleep apnea and weight loss. Explain the connection between the mentioned medication and sleep apnea and the benefits it may include. Use at least 400 words. {passage 0} ========== Tirzepatide Significantly Reduces Sleep Disruptions Alicia Ault June 22, 2024 Add to Email Alerts 28 2407 ORLANDO, Fla. — The diabetes and weight loss drug tirzepatide (Mounjaro for type 2 diabetes; Zepbound for obesity) was so effective at reducing sleep disruptions in patients with obesity and obstructive sleep apnea (OSA) that 40% to 50% no longer needed to use a continuous pressure airway positive (CPAP) device, according to two new studies. Tirzepatide, a long-acting glucose-dependent insulinotropic polypeptide (GIP) receptor agonist and glucagon-like peptide-1 (GLP-1) receptor agonist, also lowered C-reactive protein levels and systolic blood pressure. And patients taking the medication lost 18% to 20% of their body weight. The SURMOUNT-OSA studies "mark a significant milestone in the treatment of OSA, offering a promising new therapeutic option that addresses both respiratory and metabolic complications," said lead author Atul Malhotra, MD, professor of medicine at University of California San Diego School of Medicine and director of sleep medicine at UC San Diego Health. The two double-blind randomized controlled trials in patients with obesity and moderate-to-severe OSA were conducted at 60 sites in nine countries. The results were presented here at the American Diabetes Association (ADA) 84th Scientific Sessions and simultaneously published online in the New England Journal of Medicine. OSA affects 1 billion people worldwide and 30 million American adults, many of whom are undiagnosed. Obesity is a common risk factor. According to the ADA, 40% of those with obesity have OSA and 70% of those with OSA have obesity. CPAP is an effective and the most-used intervention for OSA, but many patients refuse to use the device, stop using it, or cannot use it. Should tirzepatide eventually gain US Food and Drug Administration (FDA) approval for OSA, it would be the first drug approved for the condition. "This new drug treatment offers a more accessible alternative for individuals who cannot tolerate or adhere to existing therapies," said Malhotra. Huge Reduction in Episodes, Severity For the two studies, patients were enrolled who had moderate-to-severe OSA, defined as more than 15 events per hour (using the apnea–hypopnea index [AHI]) and a body mass index of 30 kg/m2 or greater. Those not using a CPAP device were enrolled in study 1, and those using a CPAP device were enrolled in study 2. Participants received either the maximum tolerated dose of tirzepatide (10 or 15 mg by once-weekly injection) or placebo for 1 year. In study 1, 114 individuals received tirzepatide and 120 received placebo. For study 2, 119 patients received tirzepatide and 114 received placebo. All participants received regular lifestyle counseling sessions about nutrition and were instructed to reduce food intake by 500 kcal/day and to engage in at least 150 min/week of physical activity. Enrollment was limited to 70% men to ensure adequate representation of women. At baseline, 65% to 70% of participants had severe OSA, with more than 30 events/hour on the AHI scale and a mean of 51.5 events/hour By 1 year, patients taking tirzepatide had 27 to 30 fewer events/hour compared with 4 to 6 fewer events/hour for those taking placebo. Up to half of those who received tirzepatide in both trials had less than 5 events/hour or 5 to 14 AHI events/hour and an Epworth Sleepiness Scale score of 10 or less. Those thresholds "represent a level at which CPAP therapy may not be recommended," write the authors. Patients in the tirzepatide group also had a decrease in systolic blood pressure from baseline of 9.7 mm Hg in study 1 and 7.6 mm Hg in study 2 at Week 48. The most common adverse events were diarrhea, nausea, and vomiting, which occurred in approximately a quarter of patients taking tirzepatide. There were two adjudicated-confirmed cases of acute pancreatitis in those taking tirzepatide in study 2. Patients who received tirzepatide also reported fewer daytime and nighttime disturbances, as measured using the Patient-Reported Outcomes Measurement Information System Short Form scale for Sleep-Related Impairment and Sleep Disturbance. Tirzepatide Plus CPAP Are Best Writing in an accompanying editorial, Sanjay R. Patel, MD, noted that although clinical guidelines have recommended that weight loss strategies be incorporated as part of OSA treatment, "the integration of obesity management into the approaches to care for obstructive sleep apnea has lagged." As many as half of patients abandon CPAP therapy within 3 years, writes Patel, who is professor of medicine and epidemiology at the University of Pittsburgh, and medical director of the UPMC Comprehensive Sleep Disorders program. "An effective medication to treat obesity is thus an obvious avenue to pursue," he writes. Patel noted the large reductions in the number of events on the AHI scale. He writes that the improvement in systolic blood pressure "was substantially larger than effects seen with CPAP therapy alone and indicate that tirzepatide may be an attractive option for those patients who seek to reduce their cardiovascular risk." Patel raised concerns about whether patients outside of a trial would stick with therapy, noting studies have shown high rates of discontinuation of GLP-1 receptor agonists. And, he writes, "Racial disparities in the use of GLP-1 receptor agonists among patients with diabetes arouse concern that the addition of tirzepatide as a treatment option for obstructive sleep apnea without directly addressing policies relative to coverage of care will only further exacerbate already pervasive disparities in clinical care for obstructive sleep apnea." Commenting on the study during the presentation of the results, Louis Aronne, MD, said he believes the trials demonstrate "the treatment of obesity with tirzepatide plus CPAP is really the optimal treatment for obstructive sleep apnea and obesity-related cardiometabolic risks." Aronne is the Sanford I. Weill professor of metabolic research at Weill Cornell Medical College, New York. Aronne added there is still much to learn. It is still not clear whether tirzepatide had an independent effect in the OSA trial — as has been seen in other studies where the drug clearly reduced cardiovascular risk — or whether the positive results were primarily due to weight loss. "I believe that over time we'll see that this particular effect in sleep apnea is related to weight," he said. https://www.medscape.com/viewarticle/tirzepatide-significantly-reduces-sleep-disruptions-2024a1000bm1

Using only the information provided in the context block, provide the answer in a bullet point list, bolding the reasoning keyword and following it with a description in unbolded text like this: * **Reasoning Keyword**: Explanation....

How should I handle credit card debt?

Your First Step—Making a Financial Plan What are the things you want to save and invest for? • a home • a car • an education • a comfortable retirement • your children • medical or other emergencies • periods of unemployment • caring for parents Make your own list and then think about which goals are the most important to you. List your most important goals first. Decide how many years you have to meet each specific goal, because when you save or invest you’ll need to find a savings or investment option that fits your time frame for meeting each goal. Many tools exist to help you put your financial plan together. You’ll find a wealth of information, including calculators and links to non-commercial resources at Investor.gov. KNOW YOUR CURRENT FINANCIAL SITUATION Sit down and take an honest look at your entire financial situation. You can never take a journey without knowing where you’re starting from, and a journey to financial security is no different. You’ll need to figure out on paper your current situation—what you own and what you owe. You’ll be creating a “net worth statement.” On one side of the page, list what you own. These are your “assets.” And on the other side list what you owe other people, your “liabilities” or debts. Subtract your liabilities from your assets. If your assets are larger than your liabilities, you have a “positive” net worth. If your liabilities are greater than your assets, you have a “negative” net worth. You’ll want to update your “net worth statement” every year to keep track of how you are doing. Don’t be discouraged if you have a negative net worth. If you follow a plan to get into a positive position, you’re doing the right thing. KNOW YOUR INCOME AND EXPENSES The next step is to keep track of your income and your expenses for every month. Write down what you and others in your family earn, and then your monthly expenses. PAY YOURSELF OR YOUR FAMILY FIRST Include a category for savings and investing. What are you paying yourself every month? Many people get into the habit of saving and investing by following this advice: always pay yourself or your family first. Many people find it easier to pay themselves first if they allow their bank to automatically remove money from their paycheck and deposit it into a savings or investment account. Likely even better, for tax purposes, is to participate in an employer-sponsored retirement plan such as a 401(k), 403(b), or 457(b). These plans will typically not only automatically deduct money from your paycheck, but will immediately reduce the taxes you are paying. Additionally, in many plans the employer matches some or all of your contribution. When your employer does that, it’s offering “free money.” Any time you have automatic deductions made from your paycheck or bank account, you’ll increase the chances of being able to stick to your plan and to realize your goals. FINDING MONEY TO SAVE OR INVEST If you are spending all your income, and never have money to save or invest, you’ll need to look for ways to cut back on your expenses. When you watch where you spend your money, you will be surprised how small everyday expenses that you can do without add up over a year. Small Savings Add Up to Big Money How much does a cup of coffee cost you? If you buy a cup of coffee every day for $1.00 (an awfully good price for a decent cup of coffee, nowadays), that adds up to $365.00 a year. If you saved that $365.00 for just one year, and put it into a savings account or investment that earns 5% a year, it would grow to $465.84 by the end of 5 years, and by the end of 30 years, to $1,577.50. That’s the power of “compounding.” With compound interest, you earn interest on the money you save and on the interest that money earns. Over time, even a small amount saved can add up to big money. If you are willing to watch what you spend and look for little ways to save on a regular schedule, you can make money grow. You just did it with one cup of coffee. If a small cup of coffee can make such a huge difference, start looking at how you could make your money grow if you decided to spend less on other things and save those extra dollars. If you buy on impulse, make a rule that you’ll always wait 24 hours to buy anything. You may lose your desire to buy it after a day. And try emptying your pockets and wallet of spare change at the end of each day. You’ll be surprised how quickly those nickels and dimes add up! PAY OFF CREDIT CARD OR OTHER HIGH INTEREST DEBT Speaking of things adding up, few investment strategies pay off as well as, or with less risk than, merely paying off all high interest debt you may have. Many people have wallets filled with credit cards, some of which they’ve “maxed out” (meaning they’ve spent up to their credit limit). Credit cards can make it seem easy to buy expensive things when you don’t have the cash in your pocket—or in the bank. But credit cards aren’t free money. Most credit cards charge high interest rates—as much as 18 percent or more—if you don’t pay off your balance in full each month. If you owe money on your credit cards, the wisest thing you can do is pay off the balance in full as quickly as possible. Virtually no investment will give you the high returns you’ll need to keep pace with an 18 percent interest charge. That’s why you’re better off eliminating all credit card debt before investing savings. Once you’ve paid off your credit cards, you can budget your money and begin to save and invest. Here are some tips for avoiding credit card debt: Put Away the Plastic Don’t use a credit card unless your debt is at a manageable level and you know you’ll have the money to pay the bill when it arrives. Know What You Owe It’s easy to forget how much you’ve charged on your credit card. Every time you use a credit card, write down how much you have spent and figure out how much you’ll have to pay that month. If you know you won’t be able to pay your balance in full, try to figure out how much you can pay each month and how long it’ll take to pay the balance in full. Pay Off the Card with the Highest Rate If you’ve got unpaid balances on several credit cards, you should first pay down the card that charges the highest rate. Pay as much as you can toward that debt each month until your balance is once again zero, while still paying the minimum on your other cards. The same advice goes for any other high interest debt (about 8% or above) which does not offer the tax advantages of, for example, a mortgage. Now, once you have paid off those credit cards and begun to set aside some money to save and invest, what are your choices?

How should I handle credit card debt? Using only the information provided in the context block, provide the answer in a bullet point list, bolding the reasoning keyword and following it with a description in unbolded text like this: * **Reasoning Keyword**: Explanation.... Your First Step—Making a Financial Plan What are the things you want to save and invest for? • a home • a car • an education • a comfortable retirement • your children • medical or other emergencies • periods of unemployment • caring for parents Make your own list and then think about which goals are the most important to you. List your most important goals first. Decide how many years you have to meet each specific goal, because when you save or invest you’ll need to find a savings or investment option that fits your time frame for meeting each goal. Many tools exist to help you put your financial plan together. You’ll find a wealth of information, including calculators and links to non-commercial resources at Investor.gov. KNOW YOUR CURRENT FINANCIAL SITUATION Sit down and take an honest look at your entire financial situation. You can never take a journey without knowing where you’re starting from, and a journey to financial security is no different. You’ll need to figure out on paper your current situation—what you own and what you owe. You’ll be creating a “net worth statement.” On one side of the page, list what you own. These are your “assets.” And on the other side list what you owe other people, your “liabilities” or debts. Subtract your liabilities from your assets. If your assets are larger than your liabilities, you have a “positive” net worth. If your liabilities are greater than your assets, you have a “negative” net worth. You’ll want to update your “net worth statement” every year to keep track of how you are doing. Don’t be discouraged if you have a negative net worth. If you follow a plan to get into a positive position, you’re doing the right thing. KNOW YOUR INCOME AND EXPENSES The next step is to keep track of your income and your expenses for every month. Write down what you and others in your family earn, and then your monthly expenses. PAY YOURSELF OR YOUR FAMILY FIRST Include a category for savings and investing. What are you paying yourself every month? Many people get into the habit of saving and investing by following this advice: always pay yourself or your family first. Many people find it easier to pay themselves first if they allow their bank to automatically remove money from their paycheck and deposit it into a savings or investment account. Likely even better, for tax purposes, is to participate in an employer-sponsored retirement plan such as a 401(k), 403(b), or 457(b). These plans will typically not only automatically deduct money from your paycheck, but will immediately reduce the taxes you are paying. Additionally, in many plans the employer matches some or all of your contribution. When your employer does that, it’s offering “free money.” Any time you have automatic deductions made from your paycheck or bank account, you’ll increase the chances of being able to stick to your plan and to realize your goals. FINDING MONEY TO SAVE OR INVEST If you are spending all your income, and never have money to save or invest, you’ll need to look for ways to cut back on your expenses. When you watch where you spend your money, you will be surprised how small everyday expenses that you can do without add up over a year. Small Savings Add Up to Big Money How much does a cup of coffee cost you? If you buy a cup of coffee every day for $1.00 (an awfully good price for a decent cup of coffee, nowadays), that adds up to $365.00 a year. If you saved that $365.00 for just one year, and put it into a savings account or investment that earns 5% a year, it would grow to $465.84 by the end of 5 years, and by the end of 30 years, to $1,577.50. That’s the power of “compounding.” With compound interest, you earn interest on the money you save and on the interest that money earns. Over time, even a small amount saved can add up to big money. If you are willing to watch what you spend and look for little ways to save on a regular schedule, you can make money grow. You just did it with one cup of coffee. If a small cup of coffee can make such a huge difference, start looking at how you could make your money grow if you decided to spend less on other things and save those extra dollars. If you buy on impulse, make a rule that you’ll always wait 24 hours to buy anything. You may lose your desire to buy it after a day. And try emptying your pockets and wallet of spare change at the end of each day. You’ll be surprised how quickly those nickels and dimes add up! PAY OFF CREDIT CARD OR OTHER HIGH INTEREST DEBT Speaking of things adding up, few investment strategies pay off as well as, or with less risk than, merely paying off all high interest debt you may have. Many people have wallets filled with credit cards, some of which they’ve “maxed out” (meaning they’ve spent up to their credit limit). Credit cards can make it seem easy to buy expensive things when you don’t have the cash in your pocket—or in the bank. But credit cards aren’t free money. Most credit cards charge high interest rates—as much as 18 percent or more—if you don’t pay off your balance in full each month. If you owe money on your credit cards, the wisest thing you can do is pay off the balance in full as quickly as possible. Virtually no investment will give you the high returns you’ll need to keep pace with an 18 percent interest charge. That’s why you’re better off eliminating all credit card debt before investing savings. Once you’ve paid off your credit cards, you can budget your money and begin to save and invest. Here are some tips for avoiding credit card debt: Put Away the Plastic Don’t use a credit card unless your debt is at a manageable level and you know you’ll have the money to pay the bill when it arrives. Know What You Owe It’s easy to forget how much you’ve charged on your credit card. Every time you use a credit card, write down how much you have spent and figure out how much you’ll have to pay that month. If you know you won’t be able to pay your balance in full, try to figure out how much you can pay each month and how long it’ll take to pay the balance in full. Pay Off the Card with the Highest Rate If you’ve got unpaid balances on several credit cards, you should first pay down the card that charges the highest rate. Pay as much as you can toward that debt each month until your balance is once again zero, while still paying the minimum on your other cards. The same advice goes for any other high interest debt (about 8% or above) which does not offer the tax advantages of, for example, a mortgage. Now, once you have paid off those credit cards and begun to set aside some money to save and invest, what are your choices?

Only use information from the context in your response. Focus on things someone can do without help from a professional.

How can I mitigate the risks of investing?

What about risk? All investments involve taking on risk. It’s important that you go into any investment in stocks, bonds or mutual funds with a full understanding that you could lose some or all of your money in any one investment. While over the long term the stock market has historically provided around 10% annual returns (closer to 6% or 7% “real” returns when you subtract for the effects of inflation), the long term does sometimes take a rather long, long time to play out. Those who invested all of their money in the stock market at its peak in 1929 (before the stock market crash) would wait over 20 years to see the stock market return to the same level. However, those that kept adding money to the market throughout that time would have done very well for themselves, as the lower cost of stocks in the 1930s made for some hefty gains for those who bought and held over the course of the next twenty years or more. It is often said that the greater the risk, the greater the potential reward in investing, but taking on unnecessary risk is often avoidable. Investors best protect themselves against risk by spreading their money among various investments, hoping that if one investment loses money, the other investments will more than make up for those losses. This strategy, called “diversification,” can be neatly summed up as, “Don’t put all your eggs in one basket.” Investors also protect themselves from the risk of investing all their money at the wrong time (think 1929) by following a consistent pattern of adding new money to their investments over long periods of time. Once you’ve saved money for investing, consider carefully all your options and think about what diversification strategy makes sense for you. While the SEC cannot recommend any particular investment product, you should know that a vast array of investment products exists—including stocks and stock mutual funds, corporate and municipal bonds, bond mutual funds, certificates of deposit, money market funds, and U.S. Treasury securities. Diversification can’t guarantee that your investments won’t suffer if the market drops. But it can improve the chances that you won’t lose money, or that if you do, it won’t be as much as if you weren’t diversified. What are the best investments for me? The answer depends on when you will need the money, your goals, and if you will be able to sleep at night if you purchase a risky investment where you could lose your principal. For instance, if you are saving for retirement, and you have 35 years before you retire, you may want to consider riskier investment products, knowing that if you stick to only the “savings” products or to less risky investment products, your money will grow too slowly—or, given inflation and taxes, you may lose the purchasing power of your money. A frequent mistake people make is putting money they will not need for a very long time in investments that pay a low amount of interest. On the other hand, if you are saving for a short-term goal, five years or less, you don’t want to choose risky investments, because when it’s time to sell, you may have to take a loss. Since investments often move up and down in value rapidly, you want to make sure that you can wait and sell at the best possible time. How Can I Protect Myself? ASK QUESTIONS! You can never ask a dumb question about your investments and the people who help you choose them, especially when it comes to how much you will be paying for any investment, both in upfront costs and ongoing management fees. Here are some questions you should ask when choosing an investment professional or someone to help you: • What training and experience do you have? How long have you been in business? • What is your investment philosophy? Do you take a lot of risks or are you more concerned about the safety of my money? • Describe your typical client. Can you provide me with references, the names of people who have invested with you for a long time? • How do you get paid? By commission? Based on a percentage of assets you manage? Another method? Do you get paid more for selling your own firm’s products? • How much will it cost me in total to do business with you? Your investment professional should understand your investment goals, whether you’re saving to buy a home, paying for your children’s education, or enjoying a comfortable retirement. Your investment professional should also understand your tolerance for risk. That is, how much money can you afford to lose if the value of one of your investments declines? An investment professional has a duty to make sure that he or she only recommends investments that are suitable for you. That is, that the investment makes sense for you based on your other securities holdings, your financial situation, your means, and any other information that your investment professional thinks is important. The best investment professional is one who fully understands your objectives and matches investment recommendations to your goals. You’ll want someone you can understand, because your investment professional should teach you about investing and the investment products. How Should I Monitor My Investments? Investing makes it possible for your money to work for you. In a sense, your money has become your employee, and that makes you the boss. You’ll want to keep a close watch on how your employee, your money, is doing. Some people like to look at the stock quotations every day to see how their investments have done. That’s probably too often. You may get too caught up in the ups and downs of the “trading” value of your investment, and sell when its value goes down temporarily—even though the performance of the company is still stellar. Remember, you’re in for the long haul. Some people prefer to see how they’re doing once a year. That’s probably not often enough. What’s best for you will most likely be somewhere in between, based on your goals and your investments. But it’s not enough to simply check an investment’s performance. You should compare that performance against an index of similar investments over the same period of time to see if you are getting the proper returns for the amount of risk that you are assuming. You should also compare the fees and commissions that you’re paying to what other investment professionals charge. While you should monitor performance regularly, you should pay close attention every time you send your money somewhere else to work. Every time you buy or sell an investment you will receive a confirmation slip from your broker. Make sure each trade was completed according to your instructions. Make sure the buying or selling price was what your broker quoted. And make sure the commissions or fees are what your broker said they would be. Watch out for unauthorized trades in your account. If you get a confirmation slip for a transaction that you didn’t approve beforehand, call your broker. It may have been a mistake. If your broker refuses to correct it, put your complaint in writing and send it to the firm’s compliance officer. Serious complaints should always be made in writing. Remember, too, that if you rely on your investment professional for advice, he or she has an obligation to recommend investments that match your investment goals and tolerance for risk. Your investment professional should not be recommending trades simply to generate commissions. That’s called “churning,” and it’s illegal. How Can I Avoid Problems? Choosing someone to help you with your investments is one of the most important investment decisions you will ever make. While most investment professionals are honest and hardworking, you must watch out for those few unscrupulous individuals. They can make your life’s savings disappear in an instant. Securities regulators and law enforcement officials can and do catch these criminals. But putting them in jail doesn’t always get your money back. Too often, the money is gone. The good news is you can avoid potential problems by protecting yourself. Let’s say you’ve already met with several investment professionals based on recommendations from friends and others you trust, and you’ve found someone who clearly understands your investment objectives. Before you hire this person, you still have more homework. Make sure the investment professional and her firm are registered with the SEC and licensed to do business in your state. And find out from your state’s securities regulator whether the investment professional or her firm have ever been disciplined, or whether they have any complaints against them. You’ll find contact information for securities regulators in the U.S. by visiting the website of the North American Securities Administrators Association (NASAA) at www.nasaa.org or by calling (202) 737-0900. You should also find out as much as you can about any investments that your investment professional recommends. First, make sure the investments are registered. Keep in mind, however, the mere fact that a company has registered and files reports with the SEC doesn’t guarantee that the company will be a good investment. Likewise, the fact that a company hasn’t registered and doesn’t file reports with the SEC doesn’t mean the company is a fraud. Still, you may be asking for serious losses if, for instance, you invest in a small, thinly traded company that isn’t widely known solely on the basis of what you may have read online. One simple phone call to your state regulator could prevent you from squandering your money on a scam. Be wary of promises of quick profits, offers to share “inside information,” and pressure to invest before you have an opportunity to investigate. These are all warning signs of fraud. Ask your investment professional for written materials and prospectuses, and read them before you invest. If you have questions, now is the time to ask.• How will the investment make money? • How is this investment consistent with my investment goals? • What must happen for the investment to increase in value? • What are the risks? • Where can I get more information? Finally, it’s always a good idea to write down everything your investment professional tells you. Accurate notes will come in handy if ever there’s a problem. Some investments make money. Others lose money. That’s natural, and that’s why you need a diversified portfolio to minimize your risk. But if you lose money because you’ve been cheated, that’s not natural, that’s a problem. Sometimes all it takes is a simple phone call to your investment professional to resolve a problem. Maybe there was an honest mistake that can be corrected. If talking to the investment professional doesn’t resolve the problem, talk to the firm’s manager, and write a letter to confirm your conversation. If that doesn’t lead to a resolution, you may have to initiate private legal action. You may need to take action quickly because legal time limits for doing so vary. Your local bar association can provide referrals for attorneys who specialize in securities law. At the same time, call or write to us and let us know what the problem was. Investor complaints are very important to the SEC. You may think you’re the only one experiencing a problem, but typically, you’re not alone. Sometimes it takes only one investor’s complaint to trigger an investigation that exposes a bad broker or an illegal scheme. Complaints can be filed online with us by going to www.sec.gov/complaint.shtml.

Only use information from the context in your response. Focus on things someone can do without help from a professional. How can I mitigate the risks of investing? What about risk? All investments involve taking on risk. It’s important that you go into any investment in stocks, bonds or mutual funds with a full understanding that you could lose some or all of your money in any one investment. While over the long term the stock market has historically provided around 10% annual returns (closer to 6% or 7% “real” returns when you subtract for the effects of inflation), the long term does sometimes take a rather long, long time to play out. Those who invested all of their money in the stock market at its peak in 1929 (before the stock market crash) would wait over 20 years to see the stock market return to the same level. However, those that kept adding money to the market throughout that time would have done very well for themselves, as the lower cost of stocks in the 1930s made for some hefty gains for those who bought and held over the course of the next twenty years or more. It is often said that the greater the risk, the greater the potential reward in investing, but taking on unnecessary risk is often avoidable. Investors best protect themselves against risk by spreading their money among various investments, hoping that if one investment loses money, the other investments will more than make up for those losses. This strategy, called “diversification,” can be neatly summed up as, “Don’t put all your eggs in one basket.” Investors also protect themselves from the risk of investing all their money at the wrong time (think 1929) by following a consistent pattern of adding new money to their investments over long periods of time. Once you’ve saved money for investing, consider carefully all your options and think about what diversification strategy makes sense for you. While the SEC cannot recommend any particular investment product, you should know that a vast array of investment products exists—including stocks and stock mutual funds, corporate and municipal bonds, bond mutual funds, certificates of deposit, money market funds, and U.S. Treasury securities. Diversification can’t guarantee that your investments won’t suffer if the market drops. But it can improve the chances that you won’t lose money, or that if you do, it won’t be as much as if you weren’t diversified. What are the best investments for me? The answer depends on when you will need the money, your goals, and if you will be able to sleep at night if you purchase a risky investment where you could lose your principal. For instance, if you are saving for retirement, and you have 35 years before you retire, you may want to consider riskier investment products, knowing that if you stick to only the “savings” products or to less risky investment products, your money will grow too slowly—or, given inflation and taxes, you may lose the purchasing power of your money. A frequent mistake people make is putting money they will not need for a very long time in investments that pay a low amount of interest. On the other hand, if you are saving for a short-term goal, five years or less, you don’t want to choose risky investments, because when it’s time to sell, you may have to take a loss. Since investments often move up and down in value rapidly, you want to make sure that you can wait and sell at the best possible time. How Can I Protect Myself? ASK QUESTIONS! You can never ask a dumb question about your investments and the people who help you choose them, especially when it comes to how much you will be paying for any investment, both in upfront costs and ongoing management fees. Here are some questions you should ask when choosing an investment professional or someone to help you: • What training and experience do you have? How long have you been in business? • What is your investment philosophy? Do you take a lot of risks or are you more concerned about the safety of my money? • Describe your typical client. Can you provide me with references, the names of people who have invested with you for a long time? • How do you get paid? By commission? Based on a percentage of assets you manage? Another method? Do you get paid more for selling your own firm’s products? • How much will it cost me in total to do business with you? Your investment professional should understand your investment goals, whether you’re saving to buy a home, paying for your children’s education, or enjoying a comfortable retirement. Your investment professional should also understand your tolerance for risk. That is, how much money can you afford to lose if the value of one of your investments declines? An investment professional has a duty to make sure that he or she only recommends investments that are suitable for you. That is, that the investment makes sense for you based on your other securities holdings, your financial situation, your means, and any other information that your investment professional thinks is important. The best investment professional is one who fully understands your objectives and matches investment recommendations to your goals. You’ll want someone you can understand, because your investment professional should teach you about investing and the investment products. How Should I Monitor My Investments? Investing makes it possible for your money to work for you. In a sense, your money has become your employee, and that makes you the boss. You’ll want to keep a close watch on how your employee, your money, is doing. Some people like to look at the stock quotations every day to see how their investments have done. That’s probably too often. You may get too caught up in the ups and downs of the “trading” value of your investment, and sell when its value goes down temporarily—even though the performance of the company is still stellar. Remember, you’re in for the long haul. Some people prefer to see how they’re doing once a year. That’s probably not often enough. What’s best for you will most likely be somewhere in between, based on your goals and your investments. But it’s not enough to simply check an investment’s performance. You should compare that performance against an index of similar investments over the same period of time to see if you are getting the proper returns for the amount of risk that you are assuming. You should also compare the fees and commissions that you’re paying to what other investment professionals charge. While you should monitor performance regularly, you should pay close attention every time you send your money somewhere else to work. Every time you buy or sell an investment you will receive a confirmation slip from your broker. Make sure each trade was completed according to your instructions. Make sure the buying or selling price was what your broker quoted. And make sure the commissions or fees are what your broker said they would be. Watch out for unauthorized trades in your account. If you get a confirmation slip for a transaction that you didn’t approve beforehand, call your broker. It may have been a mistake. If your broker refuses to correct it, put your complaint in writing and send it to the firm’s compliance officer. Serious complaints should always be made in writing. Remember, too, that if you rely on your investment professional for advice, he or she has an obligation to recommend investments that match your investment goals and tolerance for risk. Your investment professional should not be recommending trades simply to generate commissions. That’s called “churning,” and it’s illegal. How Can I Avoid Problems? Choosing someone to help you with your investments is one of the most important investment decisions you will ever make. While most investment professionals are honest and hardworking, you must watch out for those few unscrupulous individuals. They can make your life’s savings disappear in an instant. Securities regulators and law enforcement officials can and do catch these criminals. But putting them in jail doesn’t always get your money back. Too often, the money is gone. The good news is you can avoid potential problems by protecting yourself. Let’s say you’ve already met with several investment professionals based on recommendations from friends and others you trust, and you’ve found someone who clearly understands your investment objectives. Before you hire this person, you still have more homework. Make sure the investment professional and her firm are registered with the SEC and licensed to do business in your state. And find out from your state’s securities regulator whether the investment professional or her firm have ever been disciplined, or whether they have any complaints against them. You’ll find contact information for securities regulators in the U.S. by visiting the website of the North American Securities Administrators Association (NASAA) at www.nasaa.org or by calling (202) 737-0900. You should also find out as much as you can about any investments that your investment professional recommends. First, make sure the investments are registered. Keep in mind, however, the mere fact that a company has registered and files reports with the SEC doesn’t guarantee that the company will be a good investment. Likewise, the fact that a company hasn’t registered and doesn’t file reports with the SEC doesn’t mean the company is a fraud. Still, you may be asking for serious losses if, for instance, you invest in a small, thinly traded company that isn’t widely known solely on the basis of what you may have read online. One simple phone call to your state regulator could prevent you from squandering your money on a scam. Be wary of promises of quick profits, offers to share “inside information,” and pressure to invest before you have an opportunity to investigate. These are all warning signs of fraud. Ask your investment professional for written materials and prospectuses, and read them before you invest. If you have questions, now is the time to ask.• How will the investment make money? • How is this investment consistent with my investment goals? • What must happen for the investment to increase in value? • What are the risks? • Where can I get more information? Finally, it’s always a good idea to write down everything your investment professional tells you. Accurate notes will come in handy if ever there’s a problem. Some investments make money. Others lose money. That’s natural, and that’s why you need a diversified portfolio to minimize your risk. But if you lose money because you’ve been cheated, that’s not natural, that’s a problem. Sometimes all it takes is a simple phone call to your investment professional to resolve a problem. Maybe there was an honest mistake that can be corrected. If talking to the investment professional doesn’t resolve the problem, talk to the firm’s manager, and write a letter to confirm your conversation. If that doesn’t lead to a resolution, you may have to initiate private legal action. You may need to take action quickly because legal time limits for doing so vary. Your local bar association can provide referrals for attorneys who specialize in securities law. At the same time, call or write to us and let us know what the problem was. Investor complaints are very important to the SEC. You may think you’re the only one experiencing a problem, but typically, you’re not alone. Sometimes it takes only one investor’s complaint to trigger an investigation that exposes a bad broker or an illegal scheme. Complaints can be filed online with us by going to www.sec.gov/complaint.shtml.

Instructions: * Respond using only the information contained in the prompt or context * Use bullet points when the answer has more than one item or explanation.

What is the difference between the medicinal treatments for gouty arthritis and pseudogout?

GOUT A. GOALS 1. Understand pathogenesis of gouty arthritis 2. Learn pharmacologic treatment for gout B. CASE • 55-year-old man with history of episodic pain and swelling in the 1st MTP joints • Started allopurinol one week earlier • Physical examination showed rock-hard lump on right pina and hot, tender purplish-blue swelling in the knee and the left midfoot. • Serum uric acid concentration 7.8 mg/dl • Synovial fluid aspirate contained intracellular needle-shaped crystals with strong negative birefringence THE FOUR PHASES OF GOUT 1. Asymptomatic hyperuricemia Serum urate is typically raised (>7 mg/dl for men and >6 mg/dl for women) for 20 years before the first attack of gouty arthritis or urolithiasis 2. Acute gouty arthritis The first attach usually occurs between the 4th and 6th decades. Onset before the age of 30 years raises the question of an unusual form of gout, perhaps related to an enzymatic defect that causes purine overproduction. Precipitating factors are antihyperuricemic therapy (probenecid, allopurinol), diuretics, IV heparin, cyclosporine, trauma, surgery, alcohol (beer), chronic lead poisoning, dietary excess, hemorrhage, foreign protein therapy, and infections. Medical conditions associated with gout are obesity, diabetes mellitus, hypertriglyceridemia, hypertension, atherosclerosis, syndrome X (resistance to insulin-stimulated glucose uptake, hyperinsulinemia, hypertension, and dyslipoproteinemia with high levels of plasma triglycerides and high-density lipoprotein cholesterol). Usually a single joint is affected, and the first metatarsophalangeal joint is the most commonly affected site. The attack begins suddenly and is common at night. Involvement is usually in the lower extremities. The involved joint becomes dusky, red, and swollen. Pain is intense and “the night is passed in torture”. The pathogenesis of acute gouty arthritis is centered about the monosodium urate crystal, which is always present. Of interest, hyperuricemia is often present but is not necessary for the reaction to occur. Urate crystals, which were likely deposited in synovium, are thought to “flake off” and initiate an intense inflammatory response. The crystals become heavily coated with IgG and iron, both of which increase their inflammatory potential. Leukocytes are necessary for the reaction; almost all of the crystals in an affected joint have been ingested at the height of the reaction. The release of lysosomal mediators and the release of superoxide anion contribute to the local inflammation. Many serum factors mediate the inflammatory response, including complement, fibronectin, IgG, and a number of cytokines among which is transforming growth factor-beta. Leukocytosis, fever, and high erythrocyte sedimentation rate may accompany the acute attack. Radiographs are normal in the acute phase. 3. Intercritical gout. Most patients will have a second attack 6 – 24 months after the first attack. The period between attacks is known as the intercritical period. Joints appear normal during this time. 4. Chronic tophaceous gout. Eventually, patients may enter a phase of chronic polyarticular gout without painfree periods. This may occur 3-42 years after the first attack; the average period is about 12 years. Tophi are a manifestation of the inability to eliminate urate as rapidly as it is produced. Urate deposits appear in the cartilage, synovium, tendons, and soft tissues. A favored location is extensor surfaces and pressure points, and the lesions may resemble rheumatoid nodules. In untreated disease, massive destruction of joints may occur. Tophi have been reported to resolve over periods of years in patients who receive probenecid or allopurinol. E. PRINCIPLES OF THERAPY 1. Asymptomatic hyperuricemia First, consider the multiple causes of secondary hyperuricemia: consider drugs, renal insufficiency, myeloproliferative and lymphoproliferative diseases, hemolytic anemia, anemias associate with ineffective erythropoiesis, psoriasis, Paget’s disease of bone, and enzyme defects (see below). Treatment is not recommended for asymptomatic hyperuricemia. Exceptions to this rule are enzyme defects that lead to lifelong hyperuricemia. Exceptions to this rule are enzyme defects that lead to lifelong hyperuricemia (examples: deficiency of hypoxanthine-guanine phosphoribosyltransferase in the Lesch-Nyhan syndrome, partial deficiency of HGPRT, superactivity of 5-phosphoribosyl – 1- pyrophosphate) and the hyperuricemia associated with tumor chemotherapy. 2. Acute gouty arthritis Principles of treating acute gout include use of nonsteroidal antiinflammatory drugs, colchicines, and corticosteroids. Do not attempt to reduce plasma urate concentrations in the patient who is experiencing an acute attack. 1. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Treatment of acute gouty arthritis is based upon the judicious use of nonsteroidal anti-inflammatory drugs (NSAIDS). Many of these agents are effective. Maximum-dose NSAID treatment is started at the first sign of an attack and the dose is lowed within a day or two and continued until the arthritis has resolved. NSAIDS are also effective in the well-established attack. Indocin (starting dose 50 mg po TID or QID) is often employed; the dose is tapered to 0 after about 1 week. Renal insufficiency is a contraindication to this therapy so is active peptic ulcer disease. Consider a history of bleeding from the upper gastrointestinal tract when deciding upon therapy for acute gout. Undesirable side effects of traditional NSAIDS: Gastric/esophageal irritation, exacerbations of peptic ulcers, anti-platelet effects, reversible hepatocellular toxicity, decreased creatinine clearance, skin rashes, aspirin-like reactions in the presence of the rhinitis, nasal polyposis, and asthma syndrome, and headaches and confusion in the elderly. Aspirin increases renal retention of uric acid in low doses, whereas high doses (3.5-5.0 gm/day) are uricosuric. It is avoided as an agent to treat an acute attack of gout. 2. COLCHICINE Colchicine can be used to treat acute gout, but should be limited to low oral doses or cautious intravenous use (the latter for the hospitalized patient only). Colchicine should be used in reduced doses or avoided altogether in the patient with renal insufficiency. Some clinicians will give a brief course of oral colchicines, 2-3 tablets a week, in geriatric patients or patients with renal insufficiency. No patient should receive the traditional high-dose treatment in which numerous tablets of colchicines are given by mouth. This therapy can cause very servere diarrhea and dehydration. Intravenous administration should be given according to strict guidelines: (1) Single IV doses should not exceed 1 to 2 mg and the total cumulative dose should not be > 4mg, (2) No additional colchicines should be prescribed for 7 days, (3) the dose of IV colchicines should be halved in those with creatinine clearance < 50 ml/min and in those > 65 years of age in whom the creatinine clearance is not known. Patients with renal insufficiency, especially those who are on dialysis, are at risk of developing colchicine neuromyopathy. This complication is characterized by elevated CPK and muscle weakness. Discontinuation of colchicine leads to improvement in the myopathy over several w3eeks. Associated neuropathy resolves more slowly. 3. CORTICOSTEROIDS Intraarticular corticosteroids are very useful in breaking attacks of acute gout and have special value when other treatments cannot be utilized. In some instances, ACTH injections or oral corticosteroids are required. F. LONGTERM PROPHYLACTIC TREATMENT a. PROPHLAXIS Prophylaxis of the acute attack can be achieved by administering daily low doses of colchicine (0.5 or 0.6 mg tablet by mouth, 1 or 2 times daily; or in the presence of renal insufficiency, one tablet 3 times per week). An alternate prophylactic drug is Indocin, 25 mg by mouth twice a day. ALWAYS USE PROPHYLAXIS WHEN STARTING DRUGS TO LOWER THE SERUM URIC ACID LEVEL. b. URICOSURIG THERAPY Uricosuric agents facilitate urate excretion by the kidney and increase urate clearance and the fractional excretion of filtered urate. Probenecid is the most commonly used drug in this class. It is started at a dose of 0.5 gm/.day, and the dose is increased gradually to 1 – 3 gm/day, given in 2-3 divided doses. Renal insufficiency and a history of nephrolithiasis are contraindications to uricosuric treatment. c. XANTHINE OXIDASE INHIBITION The xanthine oxidase inhibitor, allopurinol, is used long-term to lower serum uric acid. It is indicated in overproduction of urate (examples: 24 hour urine uric acid >0.8 gm while on a normal diet; enzyme defect that leads to lifelong overproduction such as deficiency of hypoxanthine-guanine phosphoribosyltransferase), Tophi, renal insufficiency, nephrolithiasis, or intolerance to uricosuric agents. Allopurinol can paradoxically initiate acute polyarticular gout. For this reason, it should never be used in the patient who is experiencing acute gouty arthritis. Remember to start prophylactic treatment and to continue it for at least 6 weeks when allopurinol is started. The dose of allopurinol should be adjusted according to the patient’s renal function. The nomogram for maintenance allopurinol, adapted from Am J Med 76:43, 1984, is: CCr 0, 100 mg every 3 days; CCr 10, 100 mg every 2 days; CCR 20, 100 mg/day; CCR 40, 150 mg/day; CCr 60, 200 mg/day CCr 80, 250 mg/day; CCr 100, 300 mg/day; CCr 120, 350 mg/day CCr 140, 400 mg/day The risk in using allopurinol in renal insufficiency is the allopurinol hypersensitivity syndrome. Use of diuretics is also a risk factor. The syndrome develops within 2 – 4 weeks of starting allopurinol and mortality is 20%. It is characterized by skin rash, fever hepatocellular injury, Leukocytosis, eosinophilia, and worsening renal function. Also, be aware that allopurinol causes potentiation of azathioprine, which as a purine analogue is metabolized by xanthine oxidase. The use of allopurinol requires a 50 to 75% reduction in the azathioprine dose. Careful monitoring of the leukocyte count is required; the margin between leucopenia and inadequate immunosuppression is narrow. II. PSEUDEOGOUT Pseudogout refers to articular disease associated with calcium pyrophosphate dehydrate crystals in synovial fluid or synovium. It is often associated with chondrocalcinosis, a radiographic finding in which calcium-containing crystals are visualized in fibrocartilage or articular cartilage. It is discussed here because some clinical features resemble gout. Differentiation from grout is important; the Pseudogout patient should not receive allopurinol. Pseudogout can occur as a hereditary disease, as a sporadic disease, or as a condition that is associated with metabolic diseases or trauma. The hereditary disease usually shows an autosomal dominant pattern of inheritance. Pseudogout is clearly associated with OLD AGE, and associations with hyperparathyroidism, hemochromatosis, hypothyroidism, amyloidosis, hypomagnesemia, and hypophosphatasia have been reported. The manifestations of Pseudogout are: 1. Acute inflammation in one or more joints lasting for several days to 2 weeks. Joints commonly involved are: knees (50%), wrists, and shoulders. As with gout, the attacks can occur spontaneously or be provoked by trauma, surgery or severe illness. 2. About one half of these patients have progressive degeneration of numerous joints, and acute flares of arthritis may be superimposed on the degenerative problem. 3. About 50% of patients have pseudo-rheumatoid presentation with multiple joint involvement. Rheumatoid factor is present in 10% of these patients, leading to confusion with rheumatoid arthritis.

GOUT A. GOALS 1. Understand pathogenesis of gouty arthritis 2. Learn pharmacologic treatment for gout B. CASE • 55-year-old man with history of episodic pain and swelling in the 1st MTP joints • Started allopurinol one week earlier • Physical examination showed rock-hard lump on right pina and hot, tender purplish-blue swelling in the knee and the left midfoot. • Serum uric acid concentration 7.8 mg/dl • Synovial fluid aspirate contained intracellular needle-shaped crystals with strong negative birefringence THE FOUR PHASES OF GOUT 1. Asymptomatic hyperuricemia Serum urate is typically raised (>7 mg/dl for men and >6 mg/dl for women) for 20 years before the first attack of gouty arthritis or urolithiasis 2. Acute gouty arthritis The first attach usually occurs between the 4th and 6th decades. Onset before the age of 30 years raises the question of an unusual form of gout, perhaps related to an enzymatic defect that causes purine overproduction. Precipitating factors are antihyperuricemic therapy (probenecid, allopurinol), diuretics, IV heparin, cyclosporine, trauma, surgery, alcohol (beer), chronic lead poisoning, dietary excess, hemorrhage, foreign protein therapy, and infections. Medical conditions associated with gout are obesity, diabetes mellitus, hypertriglyceridemia, hypertension, atherosclerosis, syndrome X (resistance to insulin-stimulated glucose uptake, hyperinsulinemia, hypertension, and dyslipoproteinemia with high levels of plasma triglycerides and high-density lipoprotein cholesterol). Usually a single joint is affected, and the first metatarsophalangeal joint is the most commonly affected site. The attack begins suddenly and is common at night. Involvement is usually in the lower extremities. The involved joint becomes dusky, red, and swollen. Pain is intense and “the night is passed in torture”. The pathogenesis of acute gouty arthritis is centered about the monosodium urate crystal, which is always present. Of interest, hyperuricemia is often present but is not necessary for the reaction to occur. Urate crystals, which were likely deposited in synovium, are thought to “flake off” and initiate an intense inflammatory response. The crystals become heavily coated with IgG and iron, both of which increase their inflammatory potential. Leukocytes are necessary for the reaction; almost all of the crystals in an affected joint have been ingested at the height of the reaction. The release of lysosomal mediators and the release of superoxide anion contribute to the local inflammation. Many serum factors mediate the inflammatory response, including complement, fibronectin, IgG, and a number of cytokines among which is transforming growth factor-beta. Leukocytosis, fever, and high erythrocyte sedimentation rate may accompany the acute attack. Radiographs are normal in the acute phase. 3. Intercritical gout. Most patients will have a second attack 6 – 24 months after the first attack. The period between attacks is known as the intercritical period. Joints appear normal during this time. 4. Chronic tophaceous gout. Eventually, patients may enter a phase of chronic polyarticular gout without painfree periods. This may occur 3-42 years after the first attack; the average period is about 12 years. Tophi are a manifestation of the inability to eliminate urate as rapidly as it is produced. Urate deposits appear in the cartilage, synovium, tendons, and soft tissues. A favored location is extensor surfaces and pressure points, and the lesions may resemble rheumatoid nodules. In untreated disease, massive destruction of joints may occur. Tophi have been reported to resolve over periods of years in patients who receive probenecid or allopurinol. E. PRINCIPLES OF THERAPY 1. Asymptomatic hyperuricemia First, consider the multiple causes of secondary hyperuricemia: consider drugs, renal insufficiency, myeloproliferative and lymphoproliferative diseases, hemolytic anemia, anemias associate with ineffective erythropoiesis, psoriasis, Paget’s disease of bone, and enzyme defects (see below). Treatment is not recommended for asymptomatic hyperuricemia. Exceptions to this rule are enzyme defects that lead to lifelong hyperuricemia. Exceptions to this rule are enzyme defects that lead to lifelong hyperuricemia (examples: deficiency of hypoxanthine-guanine phosphoribosyltransferase in the Lesch-Nyhan syndrome, partial deficiency of HGPRT, superactivity of 5-phosphoribosyl – 1- pyrophosphate) and the hyperuricemia associated with tumor chemotherapy. 2. Acute gouty arthritis Principles of treating acute gout include use of nonsteroidal antiinflammatory drugs, colchicines, and corticosteroids. Do not attempt to reduce plasma urate concentrations in the patient who is experiencing an acute attack. 1. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS Treatment of acute gouty arthritis is based upon the judicious use of nonsteroidal anti-inflammatory drugs (NSAIDS). Many of these agents are effective. Maximum-dose NSAID treatment is started at the first sign of an attack and the dose is lowed within a day or two and continued until the arthritis has resolved. NSAIDS are also effective in the well-established attack. Indocin (starting dose 50 mg po TID or QID) is often employed; the dose is tapered to 0 after about 1 week. Renal insufficiency is a contraindication to this therapy so is active peptic ulcer disease. Consider a history of bleeding from the upper gastrointestinal tract when deciding upon therapy for acute gout. Undesirable side effects of traditional NSAIDS: Gastric/esophageal irritation, exacerbations of peptic ulcers, anti-platelet effects, reversible hepatocellular toxicity, decreased creatinine clearance, skin rashes, aspirin-like reactions in the presence of the rhinitis, nasal polyposis, and asthma syndrome, and headaches and confusion in the elderly. Aspirin increases renal retention of uric acid in low doses, whereas high doses (3.5-5.0 gm/day) are uricosuric. It is avoided as an agent to treat an acute attack of gout. 2. COLCHICINE Colchicine can be used to treat acute gout, but should be limited to low oral doses or cautious intravenous use (the latter for the hospitalized patient only). Colchicine should be used in reduced doses or avoided altogether in the patient with renal insufficiency. Some clinicians will give a brief course of oral colchicines, 2-3 tablets a week, in geriatric patients or patients with renal insufficiency. No patient should receive the traditional high-dose treatment in which numerous tablets of colchicines are given by mouth. This therapy can cause very servere diarrhea and dehydration. Intravenous administration should be given according to strict guidelines: (1) Single IV doses should not exceed 1 to 2 mg and the total cumulative dose should not be > 4mg, (2) No additional colchicines should be prescribed for 7 days, (3) the dose of IV colchicines should be halved in those with creatinine clearance < 50 ml/min and in those > 65 years of age in whom the creatinine clearance is not known. Patients with renal insufficiency, especially those who are on dialysis, are at risk of developing colchicine neuromyopathy. This complication is characterized by elevated CPK and muscle weakness. Discontinuation of colchicine leads to improvement in the myopathy over several w3eeks. Associated neuropathy resolves more slowly. 3. CORTICOSTEROIDS Intraarticular corticosteroids are very useful in breaking attacks of acute gout and have special value when other treatments cannot be utilized. In some instances, ACTH injections or oral corticosteroids are required. F. LONGTERM PROPHYLACTIC TREATMENT a. PROPHLAXIS Prophylaxis of the acute attack can be achieved by administering daily low doses of colchicine (0.5 or 0.6 mg tablet by mouth, 1 or 2 times daily; or in the presence of renal insufficiency, one tablet 3 times per week). An alternate prophylactic drug is Indocin, 25 mg by mouth twice a day. ALWAYS USE PROPHYLAXIS WHEN STARTING DRUGS TO LOWER THE SERUM URIC ACID LEVEL. b. URICOSURIG THERAPY Uricosuric agents facilitate urate excretion by the kidney and increase urate clearance and the fractional excretion of filtered urate. Probenecid is the most commonly used drug in this class. It is started at a dose of 0.5 gm/.day, and the dose is increased gradually to 1 – 3 gm/day, given in 2-3 divided doses. Renal insufficiency and a history of nephrolithiasis are contraindications to uricosuric treatment. c. XANTHINE OXIDASE INHIBITION The xanthine oxidase inhibitor, allopurinol, is used long-term to lower serum uric acid. It is indicated in overproduction of urate (examples: 24 hour urine uric acid >0.8 gm while on a normal diet; enzyme defect that leads to lifelong overproduction such as deficiency of hypoxanthine-guanine phosphoribosyltransferase), Tophi, renal insufficiency, nephrolithiasis, or intolerance to uricosuric agents. Allopurinol can paradoxically initiate acute polyarticular gout. For this reason, it should never be used in the patient who is experiencing acute gouty arthritis. Remember to start prophylactic treatment and to continue it for at least 6 weeks when allopurinol is started. The dose of allopurinol should be adjusted according to the patient’s renal function. The nomogram for maintenance allopurinol, adapted from Am J Med 76:43, 1984, is: CCr 0, 100 mg every 3 days; CCr 10, 100 mg every 2 days; CCR 20, 100 mg/day; CCR 40, 150 mg/day; CCr 60, 200 mg/day CCr 80, 250 mg/day; CCr 100, 300 mg/day; CCr 120, 350 mg/day CCr 140, 400 mg/day The risk in using allopurinol in renal insufficiency is the allopurinol hypersensitivity syndrome. Use of diuretics is also a risk factor. The syndrome develops within 2 – 4 weeks of starting allopurinol and mortality is 20%. It is characterized by skin rash, fever hepatocellular injury, Leukocytosis, eosinophilia, and worsening renal function. Also, be aware that allopurinol causes potentiation of azathioprine, which as a purine analogue is metabolized by xanthine oxidase. The use of allopurinol requires a 50 to 75% reduction in the azathioprine dose. Careful monitoring of the leukocyte count is required; the margin between leucopenia and inadequate immunosuppression is narrow. II. PSEUDEOGOUT Pseudogout refers to articular disease associated with calcium pyrophosphate dehydrate crystals in synovial fluid or synovium. It is often associated with chondrocalcinosis, a radiographic finding in which calcium-containing crystals are visualized in fibrocartilage or articular cartilage. It is discussed here because some clinical features resemble gout. Differentiation from grout is important; the Pseudogout patient should not receive allopurinol. Pseudogout can occur as a hereditary disease, as a sporadic disease, or as a condition that is associated with metabolic diseases or trauma. The hereditary disease usually shows an autosomal dominant pattern of inheritance. Pseudogout is clearly associated with OLD AGE, and associations with hyperparathyroidism, hemochromatosis, hypothyroidism, amyloidosis, hypomagnesemia, and hypophosphatasia have been reported. The manifestations of Pseudogout are: 1. Acute inflammation in one or more joints lasting for several days to 2 weeks. Joints commonly involved are: knees (50%), wrists, and shoulders. As with gout, the attacks can occur spontaneously or be provoked by trauma, surgery or severe illness. 2. About one half of these patients have progressive degeneration of numerous joints, and acute flares of arthritis may be superimposed on the degenerative problem. 3. About 50% of patients have pseudo-rheumatoid presentation with multiple joint involvement. Rheumatoid factor is present in 10% of these patients, leading to confusion with rheumatoid arthritis. Instructions: * Respond using only the information contained in the prompt or context * Use bullet points when the answer has more than one item or explanation. What is the difference between the medicinal treatments for gouty arthritis and pseudogout?

Answer the question based on the below text only. Do not use any external resources or previous knowledge. Give your answer as bullet points with a maximum of two sentences per bullet point.

According to the document, summarize the comments by Avishai Abrahami.

Wix Reports Second Quarter 2024 Results Accelerated bookings growth, driven by key product initiatives, and FCF margin expansion in Q2 builds momentum for 2H ● Meaningful bookings growth acceleration with total bookings of $458.4 million, up 15% y/y, as a result of strong Wix Studio uptake, benefits from growing AI capabilities and commerce platform expansion as well as positive response to the price increase implemented earlier this year ○ Bookings growth accelerated across both Self Creators and Partners ○ Continue to expect bookings growth acceleration to 16% y/y in 2H at the high end of full year guidance range ● Total revenue of $435.7 million exceeded expectations, up 12% y/y, driven by strong Partners growth of 29% y/y ● Record take rate of 1.68%, driven by transaction revenue growth of 21% y/y as we added a new payment partner to Wix Payments ● Continued margin expansion with Q2 FCF 1 margin of 27%, driven by additional operating leverage ○ High end of increased full year FCF 1 outlook positions us to achieve the Rule of 40 milestone this year, one full year ahead of plan NEW YORK, August 7, 2024 -- Wix.com Ltd. (Nasdaq: WIX), the leading SaaS website builder platform globally, 2 today reported financial results for the second quarter of 2024. In addition, the Company provided its outlook for the third quarter and an updated outlook for full year 2024. Please visit the Wix Investor Relations website at https://investors.wix.com/ to view the Q2'24 Shareholder Update and other materials. “Excellent Q2 results capped off a strong first half of 2024, fueled by successful execution of our strategic initiatives, solid business fundamentals and continued product innovation,” said Avishai Abrahami, Wix Co-founder and CEO. “We made incredible strides towards our key growth pillars and drove significant bookings growth acceleration this quarter. First, Wix Studio continued to outperform expectations, as Studio subscription purchases accelerated, retention remained strong and the number of Studio accounts purchasing multiple subscriptions ramped. We also continued to execute against our AI strategy with the release of 17 AI business assistants so far this year. These assistants are improving the user creation experience while minimizing the amount of support resources required from us. With dozens more still slated to launch this year, AI assistants will soon be everywhere on our platform and in nearly every product. Finally, expansion of our commerce platform with the addition of a new Wix Payments partner resulted in record take rate of 1.68% in Q2. We expect these product initiatives to increasingly become more meaningful drivers of growth in the years to come.” “Strong execution of our key growth initiatives and solid business fundamentals drove incredible growth momentum and additional margin expansion this quarter,” added Lior Shemesh, CFO at Wix. “Year-over-year bookings growth accelerated to 15% in Q2 from 10% in Q1 as a result of our growth initiatives as well as the price increase implemented earlier this year. Notably, this growth was underpinned by bookings growth acceleration across both Self Creators and Partners businesses. These key product initiatives paired with solid user behavior are expected to drive continued bookings growth acceleration to 16% in 2H at the high end of our expectations. In addition, we delivered further margin expansion this quarter as our stable cost base drove operating leverage, resulting in Q2 FCF margin of 27%. With continued operating leverage expected for the full year, we are increasing our full year FCF outlook. We are now positioned to achieve the Rule of 40 milestone this year at the high end of our guidance range, one year ahead of our three-year plan.” Q2 2024 Financial Results ● Total revenue in the second quarter of 2024 was $435.7 million, up 12% y/y ○ Creative Subscriptions revenue in the second quarter of 2024 was $312.1 million, up 9% y/y ○ Creative Subscriptions ARR increased to $1.28 billion as of the end of the quarter, up 10% y/y ● Business Solutions revenue in the second quarter of 2024 was $123.6 million, up 20% y/y ○ Transaction revenue 3 was $53.9 million, up 21% y/y ● Partners revenue 4 in the second quarter of 2024 was $148.4 million, up 29% y/y ● Total bookings in the second quarter of 2024 were $458.4 million, up 15% y/y ○ Creative Subscriptions bookings in the second quarter of 2024 were $329.0 million, up 12% y/y ○ Business Solutions bookings in the second quarter of 2024 were $129.4 million, up 24% y/y ● Total gross margin on a GAAP basis in the second quarter of 2024 was 67% ○ Creative Subscriptions gross margin on a GAAP basis was 83% ○ Business Solutions gross margin on a GAAP basis was 28% ● Total non-GAAP gross margin in the second quarter of 2024 was 68% ○ Creative Subscriptions gross margin on a non-GAAP basis was 84% ○ Business Solutions gross margin on a non-GAAP basis was 30% ● GAAP net income in the second quarter of 2024 was $39.5 million, or $0.71 per basic share and $0.68 per diluted share ● Non-GAAP net income in the second quarter of 2024 was $99.6 million, or $1.80 per basic share and $1.67 per diluted share ● Net cash provided by operating activities for the second quarter of 2024 was $120.0 million, while capital expenditures totaled $7.2 million, leading to free cash flow of $112.8 million ● Excluding capital expenditures and other expenses associated with the build out of our new corporate headquarters, free cash flow for the second quarter of 2024 would have been $117.8 million, or 27% of revenue ● Completed $225 million of share repurchases, marking over $1 billion of share repurchases executed since 2021 ● Total employee count at the end of Q2’24 was 5,242, flat q/q ____________________ 1 Free cash flow excluding expenses associated with the buildout of our new corporate headquarters. 2 Based on the number of active live sites as reported by key competitors' figures, independent third-party-data and internal data as of Q1 2024. 3 Transaction revenue is a portion of Business Solutions revenue, and we define transaction revenue as all revenue generated through transaction facilitation, primarily from Wix Payments, as well as Wix POS, shipping solutions and multi-channel commerce and gift card solutions. 4 Partners revenue is defined as revenue generated through agencies and freelancers that build sites or applications for other users (“Agencies”) as well as revenue generated through B2B partnerships, such as LegalZoom or Vistaprint (“Resellers”). We identify Agencies using multiple criteria, including but not limited to, the number of sites built, participation in the Wix Partner Program and/or the Wix Marketplace or Wix products used (incl. Wix Studio). Partners revenue includes revenue from both the Creative Subscriptions and Business Solutions businesses. In Q1 2024, the definition was slightly revised to exclude revenue generated from agreements with enterprise users that, by their nature, are more suitable to be categorized under revenue generated by Self Creators. Such revision had an immaterial impact on prior period amounts. Financial Outlook Our guidance for the second half of the year reflects the momentum built up in the first six months, particularly from the strong traction of our key product initiatives and solid business fundamentals. We are updating our full year bookings outlook to $1,802 - $1,822 million, or 13-14% y/y growth, compared to previous guidance of $1,796 - $1,826 million, or 12-14% y/y growth. This outlook reflects the continued expectation that y/y bookings growth will accelerate to 16% in 2H at the high end of our guidance range, as a result of accelerating growth across both Self Creators and Partners. Acceleration is expected to be driven by continued Wix Studio outperformance, benefits from our AI products and our expanded commerce platform, as well as strong user uptake of the price increase implemented earlier this year. Bookings acceleration in 2024 is expected to translate into y/y revenue growth acceleration in 2025. We are also updating our full year revenue outlook to $1,747 - $1,761 million, or 12-13% y/y, compared to $1,738 - $1,761 million, or 11-13% y/y growth, previously. We expect total revenue growth in Q3’24 of $440 - $445 million, or 12-13% y/y growth.

Answer the question based on the below text only. Do not use any external resources or previous knowledge. Give your answer as bullet points with a maximum of two sentences per bullet point. According to the document, summarize the comments by Avishai Abrahami. Wix Reports Second Quarter 2024 Results Accelerated bookings growth, driven by key product initiatives, and FCF margin expansion in Q2 builds momentum for 2H ● Meaningful bookings growth acceleration with total bookings of $458.4 million, up 15% y/y, as a result of strong Wix Studio uptake, benefits from growing AI capabilities and commerce platform expansion as well as positive response to the price increase implemented earlier this year ○ Bookings growth accelerated across both Self Creators and Partners ○ Continue to expect bookings growth acceleration to 16% y/y in 2H at the high end of full year guidance range ● Total revenue of $435.7 million exceeded expectations, up 12% y/y, driven by strong Partners growth of 29% y/y ● Record take rate of 1.68%, driven by transaction revenue growth of 21% y/y as we added a new payment partner to Wix Payments ● Continued margin expansion with Q2 FCF 1 margin of 27%, driven by additional operating leverage ○ High end of increased full year FCF 1 outlook positions us to achieve the Rule of 40 milestone this year, one full year ahead of plan NEW YORK, August 7, 2024 -- Wix.com Ltd. (Nasdaq: WIX), the leading SaaS website builder platform globally, 2 today reported financial results for the second quarter of 2024. In addition, the Company provided its outlook for the third quarter and an updated outlook for full year 2024. Please visit the Wix Investor Relations website at https://investors.wix.com/ to view the Q2'24 Shareholder Update and other materials. “Excellent Q2 results capped off a strong first half of 2024, fueled by successful execution of our strategic initiatives, solid business fundamentals and continued product innovation,” said Avishai Abrahami, Wix Co-founder and CEO. “We made incredible strides towards our key growth pillars and drove significant bookings growth acceleration this quarter. First, Wix Studio continued to outperform expectations, as Studio subscription purchases accelerated, retention remained strong and the number of Studio accounts purchasing multiple subscriptions ramped. We also continued to execute against our AI strategy with the release of 17 AI business assistants so far this year. These assistants are improving the user creation experience while minimizing the amount of support resources required from us. With dozens more still slated to launch this year, AI assistants will soon be everywhere on our platform and in nearly every product. Finally, expansion of our commerce platform with the addition of a new Wix Payments partner resulted in record take rate of 1.68% in Q2. We expect these product initiatives to increasingly become more meaningful drivers of growth in the years to come.” “Strong execution of our key growth initiatives and solid business fundamentals drove incredible growth momentum and additional margin expansion this quarter,” added Lior Shemesh, CFO at Wix. “Year-over-year bookings growth accelerated to 15% in Q2 from 10% in Q1 as a result of our growth initiatives as well as the price increase implemented earlier this year. Notably, this growth was underpinned by bookings growth acceleration across both Self Creators and Partners businesses. These key product initiatives paired with solid user behavior are expected to drive continued bookings growth acceleration to 16% in 2H at the high end of our expectations. In addition, we delivered further margin expansion this quarter as our stable cost base drove operating leverage, resulting in Q2 FCF margin of 27%. With continued operating leverage expected for the full year, we are increasing our full year FCF outlook. We are now positioned to achieve the Rule of 40 milestone this year at the high end of our guidance range, one year ahead of our three-year plan.” Q2 2024 Financial Results ● Total revenue in the second quarter of 2024 was $435.7 million, up 12% y/y ○ Creative Subscriptions revenue in the second quarter of 2024 was $312.1 million, up 9% y/y ○ Creative Subscriptions ARR increased to $1.28 billion as of the end of the quarter, up 10% y/y ● Business Solutions revenue in the second quarter of 2024 was $123.6 million, up 20% y/y ○ Transaction revenue 3 was $53.9 million, up 21% y/y ● Partners revenue 4 in the second quarter of 2024 was $148.4 million, up 29% y/y ● Total bookings in the second quarter of 2024 were $458.4 million, up 15% y/y ○ Creative Subscriptions bookings in the second quarter of 2024 were $329.0 million, up 12% y/y ○ Business Solutions bookings in the second quarter of 2024 were $129.4 million, up 24% y/y ● Total gross margin on a GAAP basis in the second quarter of 2024 was 67% ○ Creative Subscriptions gross margin on a GAAP basis was 83% ○ Business Solutions gross margin on a GAAP basis was 28% ● Total non-GAAP gross margin in the second quarter of 2024 was 68% ○ Creative Subscriptions gross margin on a non-GAAP basis was 84% ○ Business Solutions gross margin on a non-GAAP basis was 30% ● GAAP net income in the second quarter of 2024 was $39.5 million, or $0.71 per basic share and $0.68 per diluted share ● Non-GAAP net income in the second quarter of 2024 was $99.6 million, or $1.80 per basic share and $1.67 per diluted share ● Net cash provided by operating activities for the second quarter of 2024 was $120.0 million, while capital expenditures totaled $7.2 million, leading to free cash flow of $112.8 million ● Excluding capital expenditures and other expenses associated with the build out of our new corporate headquarters, free cash flow for the second quarter of 2024 would have been $117.8 million, or 27% of revenue ● Completed $225 million of share repurchases, marking over $1 billion of share repurchases executed since 2021 ● Total employee count at the end of Q2’24 was 5,242, flat q/q ____________________ 1 Free cash flow excluding expenses associated with the buildout of our new corporate headquarters. 2 Based on the number of active live sites as reported by key competitors' figures, independent third-party-data and internal data as of Q1 2024. 3 Transaction revenue is a portion of Business Solutions revenue, and we define transaction revenue as all revenue generated through transaction facilitation, primarily from Wix Payments, as well as Wix POS, shipping solutions and multi-channel commerce and gift card solutions. 4 Partners revenue is defined as revenue generated through agencies and freelancers that build sites or applications for other users (“Agencies”) as well as revenue generated through B2B partnerships, such as LegalZoom or Vistaprint (“Resellers”). We identify Agencies using multiple criteria, including but not limited to, the number of sites built, participation in the Wix Partner Program and/or the Wix Marketplace or Wix products used (incl. Wix Studio). Partners revenue includes revenue from both the Creative Subscriptions and Business Solutions businesses. In Q1 2024, the definition was slightly revised to exclude revenue generated from agreements with enterprise users that, by their nature, are more suitable to be categorized under revenue generated by Self Creators. Such revision had an immaterial impact on prior period amounts. Financial Outlook Our guidance for the second half of the year reflects the momentum built up in the first six months, particularly from the strong traction of our key product initiatives and solid business fundamentals. We are updating our full year bookings outlook to $1,802 - $1,822 million, or 13-14% y/y growth, compared to previous guidance of $1,796 - $1,826 million, or 12-14% y/y growth. This outlook reflects the continued expectation that y/y bookings growth will accelerate to 16% in 2H at the high end of our guidance range, as a result of accelerating growth across both Self Creators and Partners. Acceleration is expected to be driven by continued Wix Studio outperformance, benefits from our AI products and our expanded commerce platform, as well as strong user uptake of the price increase implemented earlier this year. Bookings acceleration in 2024 is expected to translate into y/y revenue growth acceleration in 2025. We are also updating our full year revenue outlook to $1,747 - $1,761 million, or 12-13% y/y, compared to $1,738 - $1,761 million, or 11-13% y/y growth, previously. We expect total revenue growth in Q3’24 of $440 - $445 million, or 12-13% y/y growth.

Answer only based on information from the below text. Use a bulleted list.

Find and summarize each instance where the text talks about convenience. Please make it highly detailed.

Smart trams have successfully addressed the problem.The main objective of this initiative is to reduce the length of time that customers have to wait before they can pay their bills [1]. The pricing and billing for the items in the cart are automated. This application comprises an Arduino Uno, an LCD display, a buzzer, RFID tags, and an RFID reader. The Arduino development board used in this system has fully accessible input/output pins to enable communication with the reader. The trolley is outfitted with an RFID reader, and each product is linked to an RFID tag [2]. Once the products have been placed in the shopping cart, the RFID reader quickly deciphers the tags. The relevant information, such as the product's name, price, and quantity, is then shown on the LCD screen. The user will receive a prompt to scan the product using an automated alert system equipped with a buzzer. As a result, a bill is produced immediately on the cart. The eradication of human error is a direct result of the full automation of the process. Every day, a substantial amount of people are attracted to shopping malls in order to participate in shopping, self-improvement, and entertainment [3]. With the increasing popularity of online shopping, traditional retail stores have faced challenges in maintaining their customer base. Shopping malls have been actively seeking innovative methods to offer a customized shopping experience in order to attract and retain customers. An effective approach involves employing intelligent individuals to monitor and oversee the movement of shopping carts. Autonomous shopping carts, which are engineered to replicate human locomotion, possess the capability to autonomously track customers, thereby obviating the necessity for them to manually propel the cart [4]. This technology provides shoppers with simplicity and convenience, enabling them to concentrate on their purchases while deriving pleasure from the experience. While a customer is making purchases, their location is monitored by an intelligent trolley that integrates numerous sensors and cameras. The utilization of intelligent shopping carts that monitor human movements provides the benefit of augmenting a customised shopping experience. Patrons are able ABSTRACT Time is an expensive resource in our fast-paced society, and people frequently lose a good deal of it waiting at supermarket and shopping mall checkout counters. An automated intelligent shopping cart has been designed for supermarkets to solve the shortcomings of the current billing systems. This trolley reduces the amount of time customers spend at the checkout counter, improving convenience and saving time, by scanning products using the Atmega 328 controller and RFID tags. Customers can better their shopping experience by monitoring the amount of items and the overall cost thanks to the digital document shown on an LCD. With electronic bills sent via email and thorough purchase information available through the shop's website, the intelligent cart manages shopping and payment procedures, allowing customers to buy things and leave the store fast. In order to manage product and customer information, this system needs an Arduino board, an RFID reader, an RFID tag, an LCD display, a database manager, and a website. Leveraging the Internet of Things (IoT) for smooth connection with the worldwide network, the administrator can access this information anywhere. Keywords: Arduino UNO; Ultrasonic sensor; IR sensor; DC motors; RFID reader; LCD display; Atmega328 controller; Motor drivers. Irish Interdisciplinary Journal of Science & Research (IIJSR) Volume 8, Issue 2, Pages 113-122, April-June 2024 ISSN: 2582-3981 [114] to effortlessly traverse the establishment, circumventing the necessity to push their shopping cart or be concerned with its misplacement. By effortlessly concentrating on the products they are interested in purchasing, they are able to dedicate more time to perusing [5]. Customers with limited mobility or disabilities get an added level of assistance from intelligent shopping carts that track and follow them. These customers may find it difficult to propel a shopping cart. Nevertheless, the intelligent trolley presents a viable resolution that holds the capacity to augment the ease and pleasure derived from the act of shopping [6]. In addition, the integration of intelligent shopping carts—which possess the capability to independently navigate and accompany customers—substantially augments the shopping experience in terms of convenience and effectiveness. Consumers are able to effortlessly locate the desired products, incorporate them into their shopping carts, and proceed to the subsequent item without the necessity of monitoring their carts. As a result, patrons are able to enhance their shopping experience through time conservation and a reduction in the customary anxiety linked to the procedure [7]. By maintaining a linear trajectory, the robot is capable of traversing the lane of shopping racks with ease. An ultrasonic sensor is additionally affixed to the front of the robotic vehicle. The sensor is utilized to determine the user's proximity to the robot [8]. The customer is monitored by the robot from a predetermined distance as they navigate the shopping lane. The system therefore recommends a sophisticated shopping cart for contemporary shopping malls. A smart shopping cart that makes use of Internet of Things (IoT) technology is the proposed concept [9]. A versatile application and Radio Frequency Identification (RFID) sensors are integrated into it. Additionally, an Arduino microcontroller is also present. RFID sensors operate via wireless transmission. The process consists of two essential elements: an RFID tag affixed to every item and a user-specific RFID reader that efficiently scans the item data. The corresponding data for each item is then displayed within the mobile application. The client effectively oversees the shopping list using the adaptable application in accordance with their personal preferences. The shopping information is subsequently transmitted remotely to the employee, who generates the charges. The primary aim of this testing framework is to eliminate arduous shopping processes and technical administration complications. Subsequently, the proposed framework may be readily deployable and verifiable in an extensive operational setting [10]. This clarifies the rationale behind the proposed model's higher level of stringency in comparison to alternative methodologies. The integration of state-of-the-art technologies into a smart shopping cart is intended to revolutionize the traditional shopping experience in multiple ways. It optimizes operational effectiveness through the provision of user-friendly functionalities that streamline the process of item retrieval and diminish the duration of shopping [11]. Digital shopping lists, automated item scanning, and user-friendly payment methods substantially enhance convenience. By encouraging the use of reusable bags, reducing plastic waste, and informing customers about sustainable products, the cart promotes sustainability. By providing customers with real-time pricing comparisons, discounts, and promotions, cost-effectiveness is achieved and they are able to make more informed decisions. The shopping cart incorporates accessibility features that accommodate a diverse array of customers, including individuals with disabilities. Customer access to recipes, nutritional information, and personalized recommendations, while retailers gain insights into consumer behavior, purchasing patterns, and inventory management that are driven by data. Irish Interdisciplinary Journal of Science & Research (IIJSR) Volume 8, Issue 2, Pages 113-122, April-June 2024 ISSN: 2582-3981 [115] Ensuring safety through the implementation of secure locking mechanisms, RFID technology for item tracking, and hazard alarms, seamless connectivity with mobile devices is provided. Constant advancements in functionality and design ensure that the shopping cart remains at the forefront of market trends, with the ultimate goal of improving the customer experience by providing a seamless, enjoyable, and expedient journey that cultivates loyalty towards the retailer.

Find and summarize each instance where the text talks about convenience. Please make it highly detailed. Answer only based on information from the below text. Use a bulleted list. Smart trams have successfully addressed the problem.The main objective of this initiative is to reduce the length of time that customers have to wait before they can pay their bills [1]. The pricing and billing for the items in the cart are automated. This application comprises an Arduino Uno, an LCD display, a buzzer, RFID tags, and an RFID reader. The Arduino development board used in this system has fully accessible input/output pins to enable communication with the reader. The trolley is outfitted with an RFID reader, and each product is linked to an RFID tag [2]. Once the products have been placed in the shopping cart, the RFID reader quickly deciphers the tags. The relevant information, such as the product's name, price, and quantity, is then shown on the LCD screen. The user will receive a prompt to scan the product using an automated alert system equipped with a buzzer. As a result, a bill is produced immediately on the cart. The eradication of human error is a direct result of the full automation of the process. Every day, a substantial amount of people are attracted to shopping malls in order to participate in shopping, self-improvement, and entertainment [3]. With the increasing popularity of online shopping, traditional retail stores have faced challenges in maintaining their customer base. Shopping malls have been actively seeking innovative methods to offer a customized shopping experience in order to attract and retain customers. An effective approach involves employing intelligent individuals to monitor and oversee the movement of shopping carts. Autonomous shopping carts, which are engineered to replicate human locomotion, possess the capability to autonomously track customers, thereby obviating the necessity for them to manually propel the cart [4]. This technology provides shoppers with simplicity and convenience, enabling them to concentrate on their purchases while deriving pleasure from the experience. While a customer is making purchases, their location is monitored by an intelligent trolley that integrates numerous sensors and cameras. The utilization of intelligent shopping carts that monitor human movements provides the benefit of augmenting a customised shopping experience. Patrons are able ABSTRACT Time is an expensive resource in our fast-paced society, and people frequently lose a good deal of it waiting at supermarket and shopping mall checkout counters. An automated intelligent shopping cart has been designed for supermarkets to solve the shortcomings of the current billing systems. This trolley reduces the amount of time customers spend at the checkout counter, improving convenience and saving time, by scanning products using the Atmega 328 controller and RFID tags. Customers can better their shopping experience by monitoring the amount of items and the overall cost thanks to the digital document shown on an LCD. With electronic bills sent via email and thorough purchase information available through the shop's website, the intelligent cart manages shopping and payment procedures, allowing customers to buy things and leave the store fast. In order to manage product and customer information, this system needs an Arduino board, an RFID reader, an RFID tag, an LCD display, a database manager, and a website. Leveraging the Internet of Things (IoT) for smooth connection with the worldwide network, the administrator can access this information anywhere. Keywords: Arduino UNO; Ultrasonic sensor; IR sensor; DC motors; RFID reader; LCD display; Atmega328 controller; Motor drivers. Irish Interdisciplinary Journal of Science & Research (IIJSR) Volume 8, Issue 2, Pages 113-122, April-June 2024 ISSN: 2582-3981 [114] to effortlessly traverse the establishment, circumventing the necessity to push their shopping cart or be concerned with its misplacement. By effortlessly concentrating on the products they are interested in purchasing, they are able to dedicate more time to perusing [5]. Customers with limited mobility or disabilities get an added level of assistance from intelligent shopping carts that track and follow them. These customers may find it difficult to propel a shopping cart. Nevertheless, the intelligent trolley presents a viable resolution that holds the capacity to augment the ease and pleasure derived from the act of shopping [6]. In addition, the integration of intelligent shopping carts—which possess the capability to independently navigate and accompany customers—substantially augments the shopping experience in terms of convenience and effectiveness. Consumers are able to effortlessly locate the desired products, incorporate them into their shopping carts, and proceed to the subsequent item without the necessity of monitoring their carts. As a result, patrons are able to enhance their shopping experience through time conservation and a reduction in the customary anxiety linked to the procedure [7]. By maintaining a linear trajectory, the robot is capable of traversing the lane of shopping racks with ease. An ultrasonic sensor is additionally affixed to the front of the robotic vehicle. The sensor is utilized to determine the user's proximity to the robot [8]. The customer is monitored by the robot from a predetermined distance as they navigate the shopping lane. The system therefore recommends a sophisticated shopping cart for contemporary shopping malls. A smart shopping cart that makes use of Internet of Things (IoT) technology is the proposed concept [9]. A versatile application and Radio Frequency Identification (RFID) sensors are integrated into it. Additionally, an Arduino microcontroller is also present. RFID sensors operate via wireless transmission. The process consists of two essential elements: an RFID tag affixed to every item and a user-specific RFID reader that efficiently scans the item data. The corresponding data for each item is then displayed within the mobile application. The client effectively oversees the shopping list using the adaptable application in accordance with their personal preferences. The shopping information is subsequently transmitted remotely to the employee, who generates the charges. The primary aim of this testing framework is to eliminate arduous shopping processes and technical administration complications. Subsequently, the proposed framework may be readily deployable and verifiable in an extensive operational setting [10]. This clarifies the rationale behind the proposed model's higher level of stringency in comparison to alternative methodologies. The integration of state-of-the-art technologies into a smart shopping cart is intended to revolutionize the traditional shopping experience in multiple ways. It optimizes operational effectiveness through the provision of user-friendly functionalities that streamline the process of item retrieval and diminish the duration of shopping [11]. Digital shopping lists, automated item scanning, and user-friendly payment methods substantially enhance convenience. By encouraging the use of reusable bags, reducing plastic waste, and informing customers about sustainable products, the cart promotes sustainability. By providing customers with real-time pricing comparisons, discounts, and promotions, cost-effectiveness is achieved and they are able to make more informed decisions. The shopping cart incorporates accessibility features that accommodate a diverse array of customers, including individuals with disabilities. Customer access to recipes, nutritional information, and personalized recommendations, while retailers gain insights into consumer behavior, purchasing patterns, and inventory management that are driven by data. Irish Interdisciplinary Journal of Science & Research (IIJSR) Volume 8, Issue 2, Pages 113-122, April-June 2024 ISSN: 2582-3981 [115] Ensuring safety through the implementation of secure locking mechanisms, RFID technology for item tracking, and hazard alarms, seamless connectivity with mobile devices is provided. Constant advancements in functionality and design ensure that the shopping cart remains at the forefront of market trends, with the ultimate goal of improving the customer experience by providing a seamless, enjoyable, and expedient journey that cultivates loyalty towards the retailer.

Only use the document provided. Limit the response to two sentences. Provide a piece of evidence from the text after your answer.

What do the three elements of the cycle of risk mitigation and and crisis management strategies entail?

**Risk, Crisis and Resilience Services** Global Reach, Rapid Response and Local Expertise Your safety and security are our mission. We provide clear, targeted, flexible pre- and post-incident solutions built around that primary priority. Our expert team has operated in more than 80 countries and across multiple disciplines, including kidnap for ransom, extortion, detention and evacuation as well as security training, risk assessments and business continuity planning. Our team of specialist crisis and risk advisors are strategically located across North America, Europe, Africa, the Middle East and Asia. Constellis’ risk analysts monitor, research and advise on current and emerging threats. This enables us to deliver a global spread of expertise and vital rapid-response capabilities with outstanding local and regional knowledge, contacts and language capabilities. Managing Organizational Risk Organizations need to take risks in order to succeed. Managing that risk allows opportunities to be pursued while reducing the potential for negative impact. Our Risk, Crisis and Resilience services help corporate and governmental institutions, international organizations and small to medium sized businesses disrupt threats and eliminate vulnerabilities to effectively exercise control over the risks taken while enhancing organizational resilience. We work with our customers to employ a full cycle of risk mitigation and crisis management strategies: Avert We help reduce the likelihood of a serious incident. Improved threat and vulnerability awareness Anticipating dangers Comprehensive context & risk assessment Enhanced risk treatment measures Good risk intelligence Reliable travel tracking Effective personal safety & security training Prepare We ready you to protect your business and mitigate negative consequences in worst-case scenarios. Broad scenario development Extensive contingency & continuity planning Crisis management training Respond We ensure timely deployment of appropriate internal and external resources. Manage an incident Provide business continuity Bring the situation under control as quickly as possible Risk, Crisis and Resilience Services We incorporate all the current risk, crisis, business continuity and organizational resilience standards in our methodology including ISO 31000, 22301, 22316, BS 65000, CEN/TS 17091 as well as the principles of Enterprise Security Risk Management. Our bespoke approach is tailored to each customer’s unique needs and concerns. Our risk, crisis and resilience services incorporate the following: Personnel Risk Your people are your greatest asset and ensuring their safety and security is not only an essential part of being a good employer but also a necessary step in meeting your duty of care obligations. Our personnel risk services ensure that you are providing the right information and training for the people who work for you to help them look after themselves and make better decisions and also enable you to properly assist them when they encounter problems. These tailored services include: Personal security training (HEAT) Travel security briefings Travel safety & security planning Travel safety platform through our partner LifeLine Response: Global threat intel Location-based tracking Proactive travel security alerts 2-way mass notification Organizational Risk Organizations face numerous risks not only when operating in complex and fragile environments but also in those places where they least expect to encounter problems. We lead the way for our customers, helping them to develop policies, processes and procedures, allowing them to evaluate and manage risk and succeed in their business endeavors. Good risk management is about facilitating operations and managing risk to an acceptable level, not obstructing business activities. Our organizational risk advisory and management services provide the necessary support to ensure that you have the right system and management in place to meet your needs. These services include: Security risk briefings Threat monitoring Strategic risk assessments Organizational resilience reviews Security management planning Security management training Crisis Management When the worst happens, we deliver rapid, targeted and adaptable crisis management, communications and response solutions to enable our customers to overcome the challenges they face. Constellis’ crisis response consultants are well-versed in providing advice and support in the heat of a crisis as well as before a crisis strikes, helping you to be better prepared to deal with all the problems you may face when a critical incident threatens your business. We cover all kinds of crisis scenarios and have extensive experience in dealing with kidnapping, piracy, extortion and detention. We offer a turnkey solution that comprises training, planning, response and recovery services including: Crisis response for all scenarios Crisis management planning Crisis communications planning Business continuity planning Contingency planning (including evacuation) Crisis management training Crisis simulation exercises Crisis communications training Insight and Analysis Accurate, timely information is an essential component to any risk management program. At Constellis, our insight and analysis services integrate strategic understanding with local and empirical knowledge, enabling our customers to make effective decisions for existing operations and future investments. We draw on a large network of resources to deliver social, economic, political and security intelligence to our customers through bespoke reporting services including: Security Threat Assessments Geographical Risk Analysis & Reporting Kidnap for Ransom Analysis & Reporting Special Assignments

<System Instruction> ======= Only use the document provided. Limit the response to two sentences. Provide a piece of evidence from the text after your answer. ---------- <Context> ======= **Risk, Crisis and Resilience Services** Global Reach, Rapid Response and Local Expertise Your safety and security are our mission. We provide clear, targeted, flexible pre- and post-incident solutions built around that primary priority. Our expert team has operated in more than 80 countries and across multiple disciplines, including kidnap for ransom, extortion, detention and evacuation as well as security training, risk assessments and business continuity planning. Our team of specialist crisis and risk advisors are strategically located across North America, Europe, Africa, the Middle East and Asia. Constellis’ risk analysts monitor, research and advise on current and emerging threats. This enables us to deliver a global spread of expertise and vital rapid-response capabilities with outstanding local and regional knowledge, contacts and language capabilities. Managing Organizational Risk Organizations need to take risks in order to succeed. Managing that risk allows opportunities to be pursued while reducing the potential for negative impact. Our Risk, Crisis and Resilience services help corporate and governmental institutions, international organizations and small to medium sized businesses disrupt threats and eliminate vulnerabilities to effectively exercise control over the risks taken while enhancing organizational resilience. We work with our customers to employ a full cycle of risk mitigation and crisis management strategies: Avert We help reduce the likelihood of a serious incident. Improved threat and vulnerability awareness Anticipating dangers Comprehensive context & risk assessment Enhanced risk treatment measures Good risk intelligence Reliable travel tracking Effective personal safety & security training Prepare We ready you to protect your business and mitigate negative consequences in worst-case scenarios. Broad scenario development Extensive contingency & continuity planning Crisis management training Respond We ensure timely deployment of appropriate internal and external resources. Manage an incident Provide business continuity Bring the situation under control as quickly as possible Risk, Crisis and Resilience Services We incorporate all the current risk, crisis, business continuity and organizational resilience standards in our methodology including ISO 31000, 22301, 22316, BS 65000, CEN/TS 17091 as well as the principles of Enterprise Security Risk Management. Our bespoke approach is tailored to each customer’s unique needs and concerns. Our risk, crisis and resilience services incorporate the following: Personnel Risk Your people are your greatest asset and ensuring their safety and security is not only an essential part of being a good employer but also a necessary step in meeting your duty of care obligations. Our personnel risk services ensure that you are providing the right information and training for the people who work for you to help them look after themselves and make better decisions and also enable you to properly assist them when they encounter problems. These tailored services include: Personal security training (HEAT) Travel security briefings Travel safety & security planning Travel safety platform through our partner LifeLine Response: Global threat intel Location-based tracking Proactive travel security alerts 2-way mass notification Organizational Risk Organizations face numerous risks not only when operating in complex and fragile environments but also in those places where they least expect to encounter problems. We lead the way for our customers, helping them to develop policies, processes and procedures, allowing them to evaluate and manage risk and succeed in their business endeavors. Good risk management is about facilitating operations and managing risk to an acceptable level, not obstructing business activities. Our organizational risk advisory and management services provide the necessary support to ensure that you have the right system and management in place to meet your needs. These services include: Security risk briefings Threat monitoring Strategic risk assessments Organizational resilience reviews Security management planning Security management training Crisis Management When the worst happens, we deliver rapid, targeted and adaptable crisis management, communications and response solutions to enable our customers to overcome the challenges they face. Constellis’ crisis response consultants are well-versed in providing advice and support in the heat of a crisis as well as before a crisis strikes, helping you to be better prepared to deal with all the problems you may face when a critical incident threatens your business. We cover all kinds of crisis scenarios and have extensive experience in dealing with kidnapping, piracy, extortion and detention. We offer a turnkey solution that comprises training, planning, response and recovery services including: Crisis response for all scenarios Crisis management planning Crisis communications planning Business continuity planning Contingency planning (including evacuation) Crisis management training Crisis simulation exercises Crisis communications training Insight and Analysis Accurate, timely information is an essential component to any risk management program. At Constellis, our insight and analysis services integrate strategic understanding with local and empirical knowledge, enabling our customers to make effective decisions for existing operations and future investments. We draw on a large network of resources to deliver social, economic, political and security intelligence to our customers through bespoke reporting services including: Security Threat Assessments Geographical Risk Analysis & Reporting Kidnap for Ransom Analysis & Reporting Special Assignments ---------- <Question> ======= What do the three elements of the cycle of risk mitigation and and crisis management strategies entail?

For this task, answer questions exclusively from the knowledge you gain from the information within the prompt. Head each paragraph of your response with a bolded question pertaining to the information following it.

Summarize the key points of menu labeling into the form of paragraphs.

Research Evaluating the Impact of Menu Labeling It is difficult to predict what effect, if any, mandatory restaurant menu labeling will have on food purchasing and health outcomes. However, changes in behavior following implementation of calorie labeling regulations in other jurisdictions prior to publication of the final federal rule (e.g., New York City, Philadelphia, and King County, WA) may provide some insight. Studies of the Impact of Menu Labeling on Calories Purchased Studies examining the relationship between menu labeling and calorie purchasing behavior have yielded mixed findings. Although consumers often report ordering fewer calories as a result of menu labeling, studies examining restaurant transaction data have not consistently reported a decrease in calories purchased after implementation of menu labeling. This section discusses several studies that have evaluated the impact of menu labeling, using survey and transaction data, on calories purchased. 17 Findings from current research are limited because existing studies often vary in scope and methodology. 18 For example, several of the studies that did not find a post-labeling decrease in calories purchased were conducted by the same group of researchers using samples from lowincome communities in New York, NY and Newark, NJ, 19 and research has shown that there are socioeconomic disparities in calorie label use, with higher-income individuals being more likely to notice calorie labels.20 Another study limited its sample population to one chain of restaurants in King County, WA. 21 An additional factor to consider is the time frame between implementation of menu labeling and an assessment of purchasing behavior, as there needs to be enough time for an effect to take place. One study, for instance, did not find an effect at four to six months postmandatory menu labeling, but it did find a decrease in calories purchased 18 months after implementation.22 Another study that did not find an effect of menu labeling on calories purchased examined outcomes two months after implementation, which may not have been enough time for an effect to take place.23 In addition, most of these studies relied on self-reported data to assess customers’ awareness and use of calorie labels. Such self-reporting may not be accurate, as evidenced by the inconsistencies between reported calories purchased and actual calories purchased as indicated on receipts.24 Finally, these studies analyzed the number of calories purchased but not changes in calories consumed, which may differ in response to menu labeling. For example, in full-service restaurants, customers may be more likely to share a meal or eat half the meal and take the rest home, which would not be captured by transaction data. Similarly, in fast food or carry-out establishments, customers may consume only a portion of their meal, which would not be captured by transaction data. Studies of the Impact of Menu Labeling on Sales and Revenue In 2009, Starbucks commissioned a Stanford University study to determine how the menu labeling mandate in New York City (NYC) affected its overall sales.25 Findings indicate that after the implementation of mandatory calorie labeling, average calories per transaction fell by 6% at Starbucks, an effect that lasted 10 months after the calorie posting commenced. This effect was primarily found for food purchases, as the average food calories per transaction fell by 14% (i.e., approximately 14 calories per transaction), while average beverage calories per transaction did not substantially change. Changes in beverage calories may not be reflected in transaction data. For example, if a customer orders a latte and substitutes skim milk for 2% milk, or asks for one pump of syrup instead of the usual three or four, those substitutions would not be captured by transaction data because the cost of the latte would not change. This study also assessed the impact of calorie posting on Starbucks revenue, reporting no statistically significant change in revenue as a result of calorie labeling. Because cost data associated with the policy was unavailable, profits were not measured directly. The effect on revenue was divided into (1) the effect on the number of transactions and (2) the effect on revenue per transaction. The study found that daily store transactions increased by 1.4% on average, while revenue per transaction decreased by 0.8% on average for all Starbucks in NYC, resulting in a zero net impact of calorie posting on Starbucks revenues. In NYC Starbucks stores located within 100 meters of a Dunkin Donuts, daily revenue increased by 3.3% on average. To determine consumers’ preliminary knowledge of calories in Starbucks food and beverages, surveys were administered before and after the introduction of a calorie-posting law in Seattle.26 Pre-menu labeling survey data indicate that Starbucks customers tended to be inaccurate in predicting the number of calories in their beverage and food orders. Specifically, in this study, consumers overestimated the number of calories in beverages and underestimated the number of calories in food. This is consistent with the study’s finding that calorie posting discouraged individuals from purchasing food but not beverages. Because consumers tended to underestimate the number of calories in food items, seeing the posted caloric value, which was greater than initially expected, may have led consumers to reduce their food purchases. However, because consumers tended to overestimate beverage calories, calorie posting may not have discouraged people from purchasing beverages. Proponents of menu labeling argue that, in addition to affecting consumer purchasing behavior, mandatory menu labeling may incentivize restaurants to offer lower calorie options and provide consumers with healthier choices. A study in the American Journal of Preventive Medicine reported that new menu items in restaurant chains in 2013 contained approximately 60 fewer calories compared with menu items in 2012—a 12% drop in calories.27 This voluntary action by large chain restaurants may have been in anticipation of the ACA’s federal menu-labeling provisions which will be in effect May 7, 2018.

Question: Summarize the key points of menu labeling into the form of paragraphs. Context: Research Evaluating the Impact of Menu Labeling It is difficult to predict what effect, if any, mandatory restaurant menu labeling will have on food purchasing and health outcomes. However, changes in behavior following implementation of calorie labeling regulations in other jurisdictions prior to publication of the final federal rule (e.g., New York City, Philadelphia, and King County, WA) may provide some insight. Studies of the Impact of Menu Labeling on Calories Purchased Studies examining the relationship between menu labeling and calorie purchasing behavior have yielded mixed findings. Although consumers often report ordering fewer calories as a result of menu labeling, studies examining restaurant transaction data have not consistently reported a decrease in calories purchased after implementation of menu labeling. This section discusses several studies that have evaluated the impact of menu labeling, using survey and transaction data, on calories purchased. 17 Findings from current research are limited because existing studies often vary in scope and methodology. 18 For example, several of the studies that did not find a post-labeling decrease in calories purchased were conducted by the same group of researchers using samples from lowincome communities in New York, NY and Newark, NJ, 19 and research has shown that there are socioeconomic disparities in calorie label use, with higher-income individuals being more likely to notice calorie labels.20 Another study limited its sample population to one chain of restaurants in King County, WA. 21 An additional factor to consider is the time frame between implementation of menu labeling and an assessment of purchasing behavior, as there needs to be enough time for an effect to take place. One study, for instance, did not find an effect at four to six months postmandatory menu labeling, but it did find a decrease in calories purchased 18 months after implementation.22 Another study that did not find an effect of menu labeling on calories purchased examined outcomes two months after implementation, which may not have been enough time for an effect to take place.23 In addition, most of these studies relied on self-reported data to assess customers’ awareness and use of calorie labels. Such self-reporting may not be accurate, as evidenced by the inconsistencies between reported calories purchased and actual calories purchased as indicated on receipts.24 Finally, these studies analyzed the number of calories purchased but not changes in calories consumed, which may differ in response to menu labeling. For example, in full-service restaurants, customers may be more likely to share a meal or eat half the meal and take the rest home, which would not be captured by transaction data. Similarly, in fast food or carry-out establishments, customers may consume only a portion of their meal, which would not be captured by transaction data. Studies of the Impact of Menu Labeling on Sales and Revenue In 2009, Starbucks commissioned a Stanford University study to determine how the menu labeling mandate in New York City (NYC) affected its overall sales.25 Findings indicate that after the implementation of mandatory calorie labeling, average calories per transaction fell by 6% at Starbucks, an effect that lasted 10 months after the calorie posting commenced. This effect was primarily found for food purchases, as the average food calories per transaction fell by 14% (i.e., approximately 14 calories per transaction), while average beverage calories per transaction did not substantially change. Changes in beverage calories may not be reflected in transaction data. For example, if a customer orders a latte and substitutes skim milk for 2% milk, or asks for one pump of syrup instead of the usual three or four, those substitutions would not be captured by transaction data because the cost of the latte would not change. This study also assessed the impact of calorie posting on Starbucks revenue, reporting no statistically significant change in revenue as a result of calorie labeling. Because cost data associated with the policy was unavailable, profits were not measured directly. The effect on revenue was divided into (1) the effect on the number of transactions and (2) the effect on revenue per transaction. The study found that daily store transactions increased by 1.4% on average, while revenue per transaction decreased by 0.8% on average for all Starbucks in NYC, resulting in a zero net impact of calorie posting on Starbucks revenues. In NYC Starbucks stores located within 100 meters of a Dunkin Donuts, daily revenue increased by 3.3% on average. To determine consumers’ preliminary knowledge of calories in Starbucks food and beverages, surveys were administered before and after the introduction of a calorie-posting law in Seattle.26 Pre-menu labeling survey data indicate that Starbucks customers tended to be inaccurate in predicting the number of calories in their beverage and food orders. Specifically, in this study, consumers overestimated the number of calories in beverages and underestimated the number of calories in food. This is consistent with the study’s finding that calorie posting discouraged individuals from purchasing food but not beverages. Because consumers tended to underestimate the number of calories in food items, seeing the posted caloric value, which was greater than initially expected, may have led consumers to reduce their food purchases. However, because consumers tended to overestimate beverage calories, calorie posting may not have discouraged people from purchasing beverages. Proponents of menu labeling argue that, in addition to affecting consumer purchasing behavior, mandatory menu labeling may incentivize restaurants to offer lower calorie options and provide consumers with healthier choices. A study in the American Journal of Preventive Medicine reported that new menu items in restaurant chains in 2013 contained approximately 60 fewer calories compared with menu items in 2012—a 12% drop in calories.27 This voluntary action by large chain restaurants may have been in anticipation of the ACA’s federal menu-labeling provisions which will be in effect May 7, 2018. System Instructions: For this task, answer questions exclusively from the knowledge you gain from the information within the prompt. Head each paragraph of your response with a bolded question pertaining to the information following it.

Answer the question by using only information extracted from the context block. Do not use your own knowledge or outside sources of information. If you can't answer the question with information extracted from the context block only, output 'I can't answer due to lack of context'.

How does lowering the search costs in digital markets impact the price competition of online retailers?

Reducing Search Costs For Buyers and Sellers Buyers face search costs in obtaining and processing information about the prices and product features of seller offerings. These costs include the opportunity cost of time spent searching, as well as associated expenditures such as driving, telephone calls, computer fees, and magazine subscriptions. Similarly, sellers face search costs in identifying qualified buyers for their products, such as market research, advertising, and sales calls Several Internet-based technologies lower buyer search costs. Many sites help buyers identify appropriate seller offerings: for example, search engines like Alta Vista, Yahoo!, or Google.com; business directories like the one provided by Yahoo!; or specialized product and price comparison agents for specific markets, such as Pricewatch and Computer ESP for computers and components, Expedia and Travelocity for airline tickets and other travel products, Shopper.com and Yahoo Shopping for electronics, and Dealtime for books and music. Online agents like the one provided by R-U-Sure.com monitor consumer behavior and help buyers identify the most desirable prices and product offerings without requiring them to take specific action. Internet technology can also lower the cost to buyers of acquiring information about the reputations of market participants. Such reputations may be provided as part of the marketplace (for example, on eBay), or through specialized intermediaries, such as Bizrate, which rates retailers on specific attributes (like service, product quality, and delivery promptness) by surveying consumers who have recently purchased products from these retailers. The Internet lowers seller search costs as well, by allowing sellers to communicate product information cost-effectively to potential buyers, and by offering sellers new ways to reach buyers through targeted advertising and one-on-one marketing. By reducing search costs on both sides of the market, it appears likely that buyers will be able to consider more product offerings and will identify and purchase products that better match their needs, with a resulting increase in economic efficiency. But the reduction in search costs combined with new capabilities of information technology can set off more complex market dynamics, too. The Impact of Lower Search and Information Costs on Market Competition It may seem clear that lower search and information costs should push markets toward a greater degree of price competition, and this outcome is certainly plausible, especially for homogeneous goods. On the other hand, online retailers can use Internet technology to provide differentiated and customized products, and thus avoid competing purely on price. I will explore these possibilities in turn. The Benefits to Buyers of Greater Price Competition Lower search costs in digital markets will make it easier for buyers to find low-cost sellers, and thus will promote price competition among sellers. This effect will be most pronounced in commodity markets, where lowering buyers’ search costs may result in intensive price competition, wiping out any extraordinary seller profits. It may also be significant in markets where products are differentiated, reducing the monopoly power enjoyed by sellers and leading to lower seller profits while increasing efficiency and total welfare (Bakos, 1997). Some online markets may have lower barriers to entry or smaller efficient scales, thus leading to a larger number of sellers at equilibrium, and correspondingly lower prices and profits. In particular, certain small-scale sellers may have a brighter future in a wired world if they can identify appropriate niches, because they can more easily be searched for and discovered, as search costs online are less determined by geography. It may thus be expected that online markets will have more intense price competition, resulting in lower profits as well as the passing to consumers of savings from lower cost structures. For instance, online shoppers may expect a 20 to 30 percent discount for items normally priced $30-500 (Tedeschi, 1999).

Answer the question by using only information extracted from the context block. Do not use your own knowledge or outside sources of information. If you can't answer the question with information extracted from the context block only, output 'I can't answer due to lack of context'. Reducing Search Costs For Buyers and Sellers Buyers face search costs in obtaining and processing information about the prices and product features of seller offerings. These costs include the opportunity cost of time spent searching, as well as associated expenditures such as driving, telephone calls, computer fees, and magazine subscriptions. Similarly, sellers face search costs in identifying qualified buyers for their products, such as market research, advertising, and sales calls Several Internet-based technologies lower buyer search costs. Many sites help buyers identify appropriate seller offerings: for example, search engines like Alta Vista, Yahoo!, or Google.com; business directories like the one provided by Yahoo!; or specialized product and price comparison agents for specific markets, such as Pricewatch and Computer ESP for computers and components, Expedia and Travelocity for airline tickets and other travel products, Shopper.com and Yahoo Shopping for electronics, and Dealtime for books and music. Online agents like the one provided by R-U-Sure.com monitor consumer behavior and help buyers identify the most desirable prices and product offerings without requiring them to take specific action. Internet technology can also lower the cost to buyers of acquiring information about the reputations of market participants. Such reputations may be provided as part of the marketplace (for example, on eBay), or through specialized intermediaries, such as Bizrate, which rates retailers on specific attributes (like service, product quality, and delivery promptness) by surveying consumers who have recently purchased products from these retailers. The Internet lowers seller search costs as well, by allowing sellers to communicate product information cost-effectively to potential buyers, and by offering sellers new ways to reach buyers through targeted advertising and one-on-one marketing. By reducing search costs on both sides of the market, it appears likely that buyers will be able to consider more product offerings and will identify and purchase products that better match their needs, with a resulting increase in economic efficiency. But the reduction in search costs combined with new capabilities of information technology can set off more complex market dynamics, too. The Impact of Lower Search and Information Costs on Market Competition It may seem clear that lower search and information costs should push markets toward a greater degree of price competition, and this outcome is certainly plausible, especially for homogeneous goods. On the other hand, online retailers can use Internet technology to provide differentiated and customized products, and thus avoid competing purely on price. I will explore these possibilities in turn. The Benefits to Buyers of Greater Price Competition Lower search costs in digital markets will make it easier for buyers to find low-cost sellers, and thus will promote price competition among sellers. This effect will be most pronounced in commodity markets, where lowering buyers’ search costs may result in intensive price competition, wiping out any extraordinary seller profits. It may also be significant in markets where products are differentiated, reducing the monopoly power enjoyed by sellers and leading to lower seller profits while increasing efficiency and total welfare (Bakos, 1997). Some online markets may have lower barriers to entry or smaller efficient scales, thus leading to a larger number of sellers at equilibrium, and correspondingly lower prices and profits. In particular, certain small-scale sellers may have a brighter future in a wired world if they can identify appropriate niches, because they can more easily be searched for and discovered, as search costs online are less determined by geography. It may thus be expected that online markets will have more intense price competition, resulting in lower profits as well as the passing to consumers of savings from lower cost structures. For instance, online shoppers may expect a 20 to 30 percent discount for items normally priced $30-500 (Tedeschi, 1999). How does lowering the search costs in digital markets impact the price competition of online retailers?

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. [user request] [context document]

I've heard that natural deodorant is better for you than regular deodorant. Based on this article, can you explain why? Please used at least 400 words.

Antiperspirants mostly use aluminum-based salts to block the sweat glands from releasing sweat, while deodorants use ingredients that help neutralize odor. Contrary to popular belief, there is no evidence to prove that aluminum can cause Alzheimer’s disease or breast cancer. Deodorants don't have aluminum, but experts say it's still a good idea to opt for natural options because deodorants often contain additives like artificial fragrances or parabens. Many deodorants on the market are now advertised as “natural” and “aluminum-free” because of consumer fears about the health risks associated with aluminum. But there are a lot of details to unpack. Aluminum is only used in antiperspirants, but not in deodorants. And there’s been no evidence to prove that it causes Alzheimer’s disease or breast cancer, the two main concerns about aluminum. Antiperspirants mostly use aluminum-based salts to temporarily block the opening of the sweat glands from releasing sweat, and they usually also include ingredients that help reduce odor, according to Kristina Collins, MD, FAAD, a board-certified dermatologist based in Austin, TX. Deodorants, on the other hand, use ingredients that help neutralize the odor that occurs as bacteria metabolize sweat. Some people prefer using “natural deodorants” to minimize the risk of coming in contact with harmful ingredients, but do these products work? “Natural deodorant reduces the scent of the sweat, but does not reduce the amount of sweat the body produces,” Collins told Verywell. “So if your main concern is the appearance of sweat in the armpit area of your shirt, deodorant will be completely ineffective in reducing the dreaded armpit sweat marks.” The 13 Best Clinical Strength Deodorants and Antiperspirants, Tested and Reviewed Does Aluminum in Antiperspirants Really Cause Alzheimer’s Disease? The theory about aluminum in antiperspirants causing Alzheimer’s disease came about in the ’60s and ’70s, when researchers found increased levels of aluminum in the brains of Alzheimer’s patients, according to Mark Mapstone, PhD, the vice chair for research in neurology at the University of California, Irvine, School of Medicine. “Because aluminum is toxic to brain cells, scientists speculated that the aluminum present in the brains of these people was acquired from the environment and may be responsible for the death of brain cells,” Mapstone told Verywell. While research has found that exposure to aluminum is associated with neurological symptoms, Mapstone said these studies exposed their subjects to much higher concentrations of the metal than what is found in antiperspirants.1 And, according to Collins, there have been no substantiated or randomized studies demonstrating that antiperspirant use specifically causes Alzheimer’s disease. “There is a small amount of absorption of aluminum into the skin and circulation when applied to the skin as an antiperspirant,” Collins said. “However, because of the limited body surface for topical application of these products, that absorption is incredibly small—much smaller, in fact, than the absorption of aluminum in food products.” Do Aluminum-Based Antiperspirants Cause Breast Cancer? Some studies early in this century suggested that an earlier age of breast cancer diagnosis was associated with frequent use of aluminum-based antiperspirants or deodorants, but other studies found no such association. A 2016 study found an apparent association, but only among women who had used antiperspirants or deodorants several times daily before the age of 30. It didn’t provide clear evidence of causation.2 No studies have successfully found a link between an increased risk of breast cancer and antiperspirant use, according to Jennifer Hartman, NP, a nurse practitioner specializing in surgical breast oncology. “It is often mistakenly associated with breast cancer especially because the location of use is close to the location of most breast cancers—upper outer quadrant of the breasts—but products applied anywhere on the body or ingested could impact breast tissue regardless of location,” she said. Should You Use Natural Deodorants? How Do You Pick the Right One? While the evidence about the health risks associated with antiperspirants and deodorants is lacking, Collins said there’s still good reason to opt for the more natural option. Many antiperspirants and some deodorants contain additives like artificial fragrances or parabens that can cause irritation or skin concerns, such as contact dermatitis, she said. Aerosolized spray antiperspirants also sometimes contain a harmful chemical called benzene. What to Know About the Carcinogen Benzene Found in Some Popular Sunscreens “If a person doesn’t sweat very much and they just want to control their body odor, a natural deodorant would be a great choice,” Collins said. The most effective ingredients to look for when selecting a natural deodorant, according to Collins, are ones that help to reduce bacteria on the skin in the armpit. Alpha hydroxy acids (AHAs), such as glycolic acid or mandelic acid, can be used to reduce the dead skin cells in the armpit that bacteria feed off of and encourage healthy cell turnover, Collins said. Tea tree oil is another useful ingredient thanks to its natural antibacterial capabilities, and some deodorants also include probiotics to help boost “good” bacteria and encourage a healthy microbiome balance. Armpit Rash from Deodorant Does Coconut Oil Work as a Natural Deodorant? Coconut oil is another popular choice for those committed to using natural products on their pits, especially on TikTok. Collins said coconut oil contains natural antibacterial properties and is a common ingredient in a variety of natural deodorants, but it’s unlikely to work as effectively on its own. It would also likely rub off faster or absorb faster than an actual deodorant. “It wouldn’t hurt you, but I think this TikTok trend is probably going to leave a lot of people with some stinky armpits,” Collins said. And no matter what ingredients your deodorant includes, it won’t work for an indefinite amount of time. “As the sweat continues to build up, the product is washed away and odor resumes,” Collins said. “The solution for those who are really committed to use of natural deodorants may be to use antibacterial soap in the arm

Answer the question based solely on the information provided in the passage. Do not use any external knowledge or resources. I've heard that natural deodorant is better for you than regular deodorant. Based on this article, can you explain why? Please used at least 400 words. Antiperspirants mostly use aluminum-based salts to block the sweat glands from releasing sweat, while deodorants use ingredients that help neutralize odor. Contrary to popular belief, there is no evidence to prove that aluminum can cause Alzheimer’s disease or breast cancer. Deodorants don't have aluminum, but experts say it's still a good idea to opt for natural options because deodorants often contain additives like artificial fragrances or parabens. Many deodorants on the market are now advertised as “natural” and “aluminum-free” because of consumer fears about the health risks associated with aluminum. But there are a lot of details to unpack. Aluminum is only used in antiperspirants, but not in deodorants. And there’s been no evidence to prove that it causes Alzheimer’s disease or breast cancer, the two main concerns about aluminum. Antiperspirants mostly use aluminum-based salts to temporarily block the opening of the sweat glands from releasing sweat, and they usually also include ingredients that help reduce odor, according to Kristina Collins, MD, FAAD, a board-certified dermatologist based in Austin, TX. Deodorants, on the other hand, use ingredients that help neutralize the odor that occurs as bacteria metabolize sweat. Some people prefer using “natural deodorants” to minimize the risk of coming in contact with harmful ingredients, but do these products work? “Natural deodorant reduces the scent of the sweat, but does not reduce the amount of sweat the body produces,” Collins told Verywell. “So if your main concern is the appearance of sweat in the armpit area of your shirt, deodorant will be completely ineffective in reducing the dreaded armpit sweat marks.” The 13 Best Clinical Strength Deodorants and Antiperspirants, Tested and Reviewed Does Aluminum in Antiperspirants Really Cause Alzheimer’s Disease? The theory about aluminum in antiperspirants causing Alzheimer’s disease came about in the ’60s and ’70s, when researchers found increased levels of aluminum in the brains of Alzheimer’s patients, according to Mark Mapstone, PhD, the vice chair for research in neurology at the University of California, Irvine, School of Medicine. “Because aluminum is toxic to brain cells, scientists speculated that the aluminum present in the brains of these people was acquired from the environment and may be responsible for the death of brain cells,” Mapstone told Verywell. While research has found that exposure to aluminum is associated with neurological symptoms, Mapstone said these studies exposed their subjects to much higher concentrations of the metal than what is found in antiperspirants.1 And, according to Collins, there have been no substantiated or randomized studies demonstrating that antiperspirant use specifically causes Alzheimer’s disease. “There is a small amount of absorption of aluminum into the skin and circulation when applied to the skin as an antiperspirant,” Collins said. “However, because of the limited body surface for topical application of these products, that absorption is incredibly small—much smaller, in fact, than the absorption of aluminum in food products.” Do Aluminum-Based Antiperspirants Cause Breast Cancer? Some studies early in this century suggested that an earlier age of breast cancer diagnosis was associated with frequent use of aluminum-based antiperspirants or deodorants, but other studies found no such association. A 2016 study found an apparent association, but only among women who had used antiperspirants or deodorants several times daily before the age of 30. It didn’t provide clear evidence of causation.2 No studies have successfully found a link between an increased risk of breast cancer and antiperspirant use, according to Jennifer Hartman, NP, a nurse practitioner specializing in surgical breast oncology. “It is often mistakenly associated with breast cancer especially because the location of use is close to the location of most breast cancers—upper outer quadrant of the breasts—but products applied anywhere on the body or ingested could impact breast tissue regardless of location,” she said. Should You Use Natural Deodorants? How Do You Pick the Right One? While the evidence about the health risks associated with antiperspirants and deodorants is lacking, Collins said there’s still good reason to opt for the more natural option. Many antiperspirants and some deodorants contain additives like artificial fragrances or parabens that can cause irritation or skin concerns, such as contact dermatitis, she said. Aerosolized spray antiperspirants also sometimes contain a harmful chemical called benzene. What to Know About the Carcinogen Benzene Found in Some Popular Sunscreens “If a person doesn’t sweat very much and they just want to control their body odor, a natural deodorant would be a great choice,” Collins said. The most effective ingredients to look for when selecting a natural deodorant, according to Collins, are ones that help to reduce bacteria on the skin in the armpit. Alpha hydroxy acids (AHAs), such as glycolic acid or mandelic acid, can be used to reduce the dead skin cells in the armpit that bacteria feed off of and encourage healthy cell turnover, Collins said. Tea tree oil is another useful ingredient thanks to its natural antibacterial capabilities, and some deodorants also include probiotics to help boost “good” bacteria and encourage a healthy microbiome balance. Armpit Rash from Deodorant Does Coconut Oil Work as a Natural Deodorant? Coconut oil is another popular choice for those committed to using natural products on their pits, especially on TikTok. Collins said coconut oil contains natural antibacterial properties and is a common ingredient in a variety of natural deodorants, but it’s unlikely to work as effectively on its own. It would also likely rub off faster or absorb faster than an actual deodorant. “It wouldn’t hurt you, but I think this TikTok trend is probably going to leave a lot of people with some stinky armpits,” Collins said. And no matter what ingredients your deodorant includes, it won’t work for an indefinite amount of time. “As the sweat continues to build up, the product is washed away and odor resumes,” Collins said. “The solution for those who are really committed to use of natural deodorants may be to use antibacterial soap in the arm https://www.verywellhealth.com/do-natural-deodorants-really-work-7255872

This task requires you to answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. Give your answer in bullet points with the proper noun and key word bolded, followed by a short explanation with no, unasked for information.

What states, mentioned in the text, have enacted some type of prohibition or restriction on price rises during proclaimed emergencies and specifically mention the key word,"fuel", by name.

State Price-Gouging Laws Many states have enacted some type of prohibition or limitation on price increases during declared emergencies. Generally, these state laws take one of two basic forms. Some states prohibit the sale of goods and services at what are deemed to be “unconscionable” or “excessive” prices in the area and during the period of a designated emergency. Other states have established a maximum permissible increase in the prices for retail goods during a designated emergency period. Many statutes of both kinds include an exemption if price increases are the result of increased costs incurred for procuring the goods or services in question. Gasoline Price Increases: Federal and State Authority to Limit “Price Gouging” Congressional Research Service 2 Examples of State Statutes Prohibitions on “Excessive” or “Unconscionable” Pricing One common way that states address price gouging is to ban prices that are considered to be (for example) “excessive” or “unconscionable,” as defined in the statute or left to the discretion of the courts. These statutes generally bar such increases during designated emergency periods. The process for emergency designation is also usually defined in the statute. Frequently, the state’s governor is granted authority to designate an emergency during which the price limitations are in place. For example, the New York statute provides that: During any abnormal disruption of the market for consumer goods and services vital and necessary for the health, safety and welfare of consumers, no party within the chain of distribution of such consumer goods or services or both shall sell or offer to sell any such goods or services or both for an amount which represents an unconscionably excessive price.5 The statute defines abnormal disruption of the market as a real or threatened change to the market “resulting from stress of weather, convulsion of nature, failure or shortage of electric power or other source of energy, strike, civil disorder, war, military action, national or local emergency … which results in the declaration of a state of emergency by the governor.”6 The statute provides only for criminal liability and leaves the ultimate decision as to whether a price is “unconscionably excessive” to prosecutors (for charging purposes) and to the courts, with no separate cause of action created for private parties. As guidance in such cases, the statute notes that if there is a “gross disparity” between the price during the disruption and the price prior to the disruption, or if the price “grossly exceeds” the price at which the same or similar goods are available in the area, such disparity will be considered prima facie evidence that a price is unconscionable.7 Similarly, Florida’s statute bars “unconscionable pricing” during declared states of emergency.8 If the amount being charged represents a “gross disparity” from the average price at which the product or service was sold in the usual course of business (or available in the “trade area”) during the 30 days immediately prior to a declaration of a state of emergency, it is considered prima facie evidence of “unconscionable pricing,” which constitutes an “unlawful act or practice.” 9 However, pricing is not considered unconscionable if the increase is attributable to additional costs incurred by the seller or is the result of national or international market trends.10 As with the New York statute, the Florida statute offers guidance, but the question of whether certain prices during an emergency are deemed “unconscionable” is ultimately left to the courts. Many state price-gouging laws are triggered only by a declaration of emergency in response to localized conditions. Thus, they will generally not apply after a declared emergency ends or in areas not directly affected by a particular emergency or natural disaster. However, at least two Gasoline Price Increases: Federal and State Authority to Limit “Price Gouging” Congressional Research Service 3 states have laws prohibiting excessive pricing that impose liability even without a declaration of any type of emergency. Maine law prohibits “unjust or unreasonable” profits in the sale, exchange, or handling of necessities, defined to include fuel.11 Michigan’s consumer protection act simply prohibits “charging the consumer a price that is grossly in excess of the price at which similar property or services are sold.” 12 Prohibitions of Price Increases Beyond a Certain Percentage In contrast to a general ban on “excessive” or “unconscionable” pricing, some state statutes leave less to the courts’ discretion and instead place limits on price increases of certain goods during emergencies. For example, California’s anti-price-gouging statute states that for a period of 30 days following the proclamation of a state of emergency by the President of the United States or the governor of California or the declaration of a local emergency by the relevant executive officer, it is unlawful to sell or offer certain goods and services (including emergency and medical supplies, building and transportation materials, fuel, etc.) at a price more than 10% higher than the price of the good prior to the proclamation of emergency.13 As a defense, a seller can show that the price increase was directly attributable to additional costs imposed on it by the supplier of the goods or additional costs for the labor and material used to provide the services.14 The prohibition lasts for 30 days from the date of issuance of the emergency proclamation.15 West Virginia has also adopted an anti-price-gouging measure based on caps to percentage increases in price during times of emergency. The West Virginia statute provides that upon a declaration of a state of emergency by the President of the United States, the governor, or the state legislature, it is unlawful to sell or offer to sell certain critical goods and services “for a price greater than ten percent above the price charged by that person for those goods and services on the tenth day immediately preceding the declaration of emergency.” 16 West Virginia also provides an exception for price increases attributable to increased costs on the seller imposed by the supplier or to added costs of providing the goods or services during the emergency.17 Some states use language barring “unconscionable” or “excessive” pricing in a manner similar to the state statutes described in the previous section but define these terms with hard caps instead of leaving their exact definition to the discretion of the courts. For example, the Alabama statute makes it unlawful for anyone to “impose unconscionable prices for the sale or rental of any commodity or rental facility during the period of a declared state of emergency.” 18 However, it provides that prima facie evidence of unconscionable pricing exists “if any person, during a state of emergency declared pursuant to the powers granted to the Governor, charges a price that exceeds, by an amount equal to or in excess of 25%, the average price at which the same or similar commodity or rental facility was obtainable in the affected area during the last 30 days Gasoline Price Increases: Federal and State Authority to Limit “Price Gouging” Congressional Research Service 4 immediately prior to the declared state of emergency.” 19 As with most other state price-gouging statutes, the statute does not apply if the price increase is attributable to reasonable costs incurred by the seller in connection with the rental or sale of the commodity.20 A few other states have imposed caps on price increases during emergencies even tighter than the one imposed by the aforementioned statutes. Some state statutes ban any price increase during periods of emergency. For example, in Georgia, it is considered an “unlawful, unfair and deceptive trade practice” for anyone doing business in an areas where a state of emergency has been declared to sell or offer for sale at retail any goods or services identified by the Governor in the declaration of the state of emergency necessary to preserve, protect, or sustain the life, health, or safety of persons or their property at a price higher than the price at which such goods were sold or offered for sale immediately prior to the declaration of a state of emergency.21 As with other state gouging statutes, the Georgia statute provides an exception for price increases that reflect “an increase in cost of the goods or services to the person selling the goods or services or an increase in the cost of transporting the goods or services into the area.”

This task requires you to answer questions based solely on the information provided in the prompt. You are not allowed to use any external resources or prior knowledge. Give your answer in bullet points with the proper noun and key word bolded, followed by a short explanation with no, unasked for information. What states, mentioned in the text, have enacted some type of prohibition or restriction on price rises during proclaimed emergencies and specifically mention the key word,"fuel", by name. State Price-Gouging Laws Many states have enacted some type of prohibition or limitation on price increases during declared emergencies. Generally, these state laws take one of two basic forms. Some states prohibit the sale of goods and services at what are deemed to be “unconscionable” or “excessive” prices in the area and during the period of a designated emergency. Other states have established a maximum permissible increase in the prices for retail goods during a designated emergency period. Many statutes of both kinds include an exemption if price increases are the result of increased costs incurred for procuring the goods or services in question. Gasoline Price Increases: Federal and State Authority to Limit “Price Gouging” Congressional Research Service 2 Examples of State Statutes Prohibitions on “Excessive” or “Unconscionable” Pricing One common way that states address price gouging is to ban prices that are considered to be (for example) “excessive” or “unconscionable,” as defined in the statute or left to the discretion of the courts. These statutes generally bar such increases during designated emergency periods. The process for emergency designation is also usually defined in the statute. Frequently, the state’s governor is granted authority to designate an emergency during which the price limitations are in place. For example, the New York statute provides that: During any abnormal disruption of the market for consumer goods and services vital and necessary for the health, safety and welfare of consumers, no party within the chain of distribution of such consumer goods or services or both shall sell or offer to sell any such goods or services or both for an amount which represents an unconscionably excessive price.5 The statute defines abnormal disruption of the market as a real or threatened change to the market “resulting from stress of weather, convulsion of nature, failure or shortage of electric power or other source of energy, strike, civil disorder, war, military action, national or local emergency … which results in the declaration of a state of emergency by the governor.”6 The statute provides only for criminal liability and leaves the ultimate decision as to whether a price is “unconscionably excessive” to prosecutors (for charging purposes) and to the courts, with no separate cause of action created for private parties. As guidance in such cases, the statute notes that if there is a “gross disparity” between the price during the disruption and the price prior to the disruption, or if the price “grossly exceeds” the price at which the same or similar goods are available in the area, such disparity will be considered prima facie evidence that a price is unconscionable.7 Similarly, Florida’s statute bars “unconscionable pricing” during declared states of emergency.8 If the amount being charged represents a “gross disparity” from the average price at which the product or service was sold in the usual course of business (or available in the “trade area”) during the 30 days immediately prior to a declaration of a state of emergency, it is considered prima facie evidence of “unconscionable pricing,” which constitutes an “unlawful act or practice.” 9 However, pricing is not considered unconscionable if the increase is attributable to additional costs incurred by the seller or is the result of national or international market trends.10 As with the New York statute, the Florida statute offers guidance, but the question of whether certain prices during an emergency are deemed “unconscionable” is ultimately left to the courts. Many state price-gouging laws are triggered only by a declaration of emergency in response to localized conditions. Thus, they will generally not apply after a declared emergency ends or in areas not directly affected by a particular emergency or natural disaster. However, at least two Gasoline Price Increases: Federal and State Authority to Limit “Price Gouging” Congressional Research Service 3 states have laws prohibiting excessive pricing that impose liability even without a declaration of any type of emergency. Maine law prohibits “unjust or unreasonable” profits in the sale, exchange, or handling of necessities, defined to include fuel.11 Michigan’s consumer protection act simply prohibits “charging the consumer a price that is grossly in excess of the price at which similar property or services are sold.” 12 Prohibitions of Price Increases Beyond a Certain Percentage In contrast to a general ban on “excessive” or “unconscionable” pricing, some state statutes leave less to the courts’ discretion and instead place limits on price increases of certain goods during emergencies. For example, California’s anti-price-gouging statute states that for a period of 30 days following the proclamation of a state of emergency by the President of the United States or the governor of California or the declaration of a local emergency by the relevant executive officer, it is unlawful to sell or offer certain goods and services (including emergency and medical supplies, building and transportation materials, fuel, etc.) at a price more than 10% higher than the price of the good prior to the proclamation of emergency.13 As a defense, a seller can show that the price increase was directly attributable to additional costs imposed on it by the supplier of the goods or additional costs for the labor and material used to provide the services.14 The prohibition lasts for 30 days from the date of issuance of the emergency proclamation.15 West Virginia has also adopted an anti-price-gouging measure based on caps to percentage increases in price during times of emergency. The West Virginia statute provides that upon a declaration of a state of emergency by the President of the United States, the governor, or the state legislature, it is unlawful to sell or offer to sell certain critical goods and services “for a price greater than ten percent above the price charged by that person for those goods and services on the tenth day immediately preceding the declaration of emergency.” 16 West Virginia also provides an exception for price increases attributable to increased costs on the seller imposed by the supplier or to added costs of providing the goods or services during the emergency.17 Some states use language barring “unconscionable” or “excessive” pricing in a manner similar to the state statutes described in the previous section but define these terms with hard caps instead of leaving their exact definition to the discretion of the courts. For example, the Alabama statute makes it unlawful for anyone to “impose unconscionable prices for the sale or rental of any commodity or rental facility during the period of a declared state of emergency.” 18 However, it provides that prima facie evidence of unconscionable pricing exists “if any person, during a state of emergency declared pursuant to the powers granted to the Governor, charges a price that exceeds, by an amount equal to or in excess of 25%, the average price at which the same or similar commodity or rental facility was obtainable in the affected area during the last 30 days Gasoline Price Increases: Federal and State Authority to Limit “Price Gouging” Congressional Research Service 4 immediately prior to the declared state of emergency.” 19 As with most other state price-gouging statutes, the statute does not apply if the price increase is attributable to reasonable costs incurred by the seller in connection with the rental or sale of the commodity.20 A few other states have imposed caps on price increases during emergencies even tighter than the one imposed by the aforementioned statutes. Some state statutes ban any price increase during periods of emergency. For example, in Georgia, it is considered an “unlawful, unfair and deceptive trade practice” for anyone doing business in an areas where a state of emergency has been declared to sell or offer for sale at retail any goods or services identified by the Governor in the declaration of the state of emergency necessary to preserve, protect, or sustain the life, health, or safety of persons or their property at a price higher than the price at which such goods were sold or offered for sale immediately prior to the declaration of a state of emergency.21 As with other state gouging statutes, the Georgia statute provides an exception for price increases that reflect “an increase in cost of the goods or services to the person selling the goods or services or an increase in the cost of transporting the goods or services into the area.”

"================ <TEXT PASSAGE> ======= [context document] ================ <QUESTION> ======= [user request] ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

Give an overview of the MBTI test and explain its connection to Jungian psychology. What are the possible applications of the MBTI in the areas of psychiatry and patient-doctor communications, and what are the best ways to implement this? What are the implied limitations of using the MBTI in a clinical setting?

The Myers-Briggs type indicator (MBTI) is a measure of personality type based on the work of psychologist Carl Jung. Isabel Myers developed the MBTI during the Second World War to facilitate better working relationships between healthcare professionals, particularly nurses.[1] She modeled this questionnaire on Jung's theory of "individual preference," which suggests that seemingly random variation in human behavior is attributable to fundamental individual differences in mental and emotional functioning.[2] Myers described these variations as simply different ways individuals prefer to use their minds. The indicator operationalizes these preferences with questions indicating the individual's propensity towards 1 end of a dipole in 4 categories: Energy Perceiving Judging Orientation Energy Energy encompasses the scale of extraversion to introversion. Those tending towards extraversion direct their attention to external experiences and actions, deriving energy from those around them. Those tending towards introversion direct their attention towards inner thoughts and ideas, acquiring energy from solitude. Perceiving Perceiving describes how individuals prefer to intake information on the sensing scale versus intuitive types. Sensing types prefer to gather information using the 5 senses. They require gathering facts before understanding general ideas and patterns. Intuitive types prefer to rely on instincts and view problems from the "big picture" perspective, realizing general patterns before identifying constituent facts. Judging Judging categorizes how individuals prefer to make decisions from thinking to feeling. Thinkers rely on logic and facts, while feelers seek harmony in resolving an issue. Orientation Orientation applies to the preferred lifestyle on the scale of judging to perceiving. Those preferring judgment tend towards an orderly, decisive, and settled lifestyle, while those who prefer a more flexible, unpredictable existence align with the perceiving type.[1] Sixteen personality types are possible with the combinations of 2 poles in 4 different categories. The representation of these types is with 4 letters indicating the individual's propensity in each category. For example, someone tending towards extraversion in energy, intuition in perceiving, thinking in judging, and perceiving in orientation would have the personality type ENTP. The goal of the Myers-Briggs typology is to increase awareness of oneself and others and advance through Jung's "individuation." This process is describable as the integration, differentiation, and development of one's traits and skills.[2] One can begin analyzing and applying those preferences in work and personal endeavors by understanding one's individual preferences. Issues of Concern Myer's primary intended application of the MBTI was for team building in the healthcare setting. Differences in approach to problem-solving and communication have the potential to create barriers to teamwork. Understanding these different thinking and perceiving preferences through MBTI typology can inform strategic changes to workflow and evaluation techniques.[3] Clinical Significance Although the MBTI was not designed for clinical use, it has had application to some patient populations. In psychology and psychiatry, the MBTI may help understand specific patient populations, such as those suffering from suicidality and unipolar depression. In both populations, greater tendencies towards introversion energy and perception orientation have been identified compared to the normative population. The researchers suggest that with more confirmatory samples, these correlations may be useful in identifying vulnerability in patients with affective disorder.[4][5] Most significantly, the MBTI may have applications to fostering communication between healthcare professionals and patients. It is important to consider possible communication differences between the provider and the patient. For example, some research suggests that there are significantly more introverts, intuitive perceivers, thinking deciders, and judging-oriented individuals among a doctor population compared to a general adult population, which consists of more extroverts, sensing-perceivers, feeling deciders, and perceiving-orientated persons.[6] These potential differences can affect patients' interpretations of their provider encounters. A doctor tending towards intuitive perception and thinking judgment may be inclined to approach communication with the following attitudes: Respect my intelligence and desire to understand Demonstrate your competence Answer my questions honestly Give me options to see a pattern [6] However, a patient tending towards sensing, perceiving, and feeling decisions may approach communication with the following attitudes: Listen carefully to me Give me your complete attention Be warm and friendly Give me facts with a personal touch Provide practical information about my condition [6] Suggested approaches to remedy these differences include applying the MBTI typology in communication skills training for health care professionals.[6][7] Formal and structured approaches to instructing professionalism and communication have demonstrated greater effectiveness than passive observational learning, which is critical as improved patient-physician communication correlates better health outcomes as welanded legal action.[8][9][10] Nursing, Allied Health, and Interprofessional Team Interventions All members of the interprofessional healthcare team would do well to have at least a general understanding of the MBTI grading system, as it can facilitate patient interactions, increase empathy for how a patient views their life and world, facilitate interprofessional team communication and collaboration, and lead to improved communication with patients., leading to improved patient outcomes.

"================ <TEXT PASSAGE> ======= The Myers-Briggs type indicator (MBTI) is a measure of personality type based on the work of psychologist Carl Jung. Isabel Myers developed the MBTI during the Second World War to facilitate better working relationships between healthcare professionals, particularly nurses.[1] She modeled this questionnaire on Jung's theory of "individual preference," which suggests that seemingly random variation in human behavior is attributable to fundamental individual differences in mental and emotional functioning.[2] Myers described these variations as simply different ways individuals prefer to use their minds. The indicator operationalizes these preferences with questions indicating the individual's propensity towards 1 end of a dipole in 4 categories: Energy Perceiving Judging Orientation Energy Energy encompasses the scale of extraversion to introversion. Those tending towards extraversion direct their attention to external experiences and actions, deriving energy from those around them. Those tending towards introversion direct their attention towards inner thoughts and ideas, acquiring energy from solitude. Perceiving Perceiving describes how individuals prefer to intake information on the sensing scale versus intuitive types. Sensing types prefer to gather information using the 5 senses. They require gathering facts before understanding general ideas and patterns. Intuitive types prefer to rely on instincts and view problems from the "big picture" perspective, realizing general patterns before identifying constituent facts. Judging Judging categorizes how individuals prefer to make decisions from thinking to feeling. Thinkers rely on logic and facts, while feelers seek harmony in resolving an issue. Orientation Orientation applies to the preferred lifestyle on the scale of judging to perceiving. Those preferring judgment tend towards an orderly, decisive, and settled lifestyle, while those who prefer a more flexible, unpredictable existence align with the perceiving type.[1] Sixteen personality types are possible with the combinations of 2 poles in 4 different categories. The representation of these types is with 4 letters indicating the individual's propensity in each category. For example, someone tending towards extraversion in energy, intuition in perceiving, thinking in judging, and perceiving in orientation would have the personality type ENTP. The goal of the Myers-Briggs typology is to increase awareness of oneself and others and advance through Jung's "individuation." This process is describable as the integration, differentiation, and development of one's traits and skills.[2] One can begin analyzing and applying those preferences in work and personal endeavors by understanding one's individual preferences. Issues of Concern Myer's primary intended application of the MBTI was for team building in the healthcare setting. Differences in approach to problem-solving and communication have the potential to create barriers to teamwork. Understanding these different thinking and perceiving preferences through MBTI typology can inform strategic changes to workflow and evaluation techniques.[3] Clinical Significance Although the MBTI was not designed for clinical use, it has had application to some patient populations. In psychology and psychiatry, the MBTI may help understand specific patient populations, such as those suffering from suicidality and unipolar depression. In both populations, greater tendencies towards introversion energy and perception orientation have been identified compared to the normative population. The researchers suggest that with more confirmatory samples, these correlations may be useful in identifying vulnerability in patients with affective disorder.[4][5] Most significantly, the MBTI may have applications to fostering communication between healthcare professionals and patients. It is important to consider possible communication differences between the provider and the patient. For example, some research suggests that there are significantly more introverts, intuitive perceivers, thinking deciders, and judging-oriented individuals among a doctor population compared to a general adult population, which consists of more extroverts, sensing-perceivers, feeling deciders, and perceiving-orientated persons.[6] These potential differences can affect patients' interpretations of their provider encounters. A doctor tending towards intuitive perception and thinking judgment may be inclined to approach communication with the following attitudes: Respect my intelligence and desire to understand Demonstrate your competence Answer my questions honestly Give me options to see a pattern [6] However, a patient tending towards sensing, perceiving, and feeling decisions may approach communication with the following attitudes: Listen carefully to me Give me your complete attention Be warm and friendly Give me facts with a personal touch Provide practical information about my condition [6] Suggested approaches to remedy these differences include applying the MBTI typology in communication skills training for health care professionals.[6][7] Formal and structured approaches to instructing professionalism and communication have demonstrated greater effectiveness than passive observational learning, which is critical as improved patient-physician communication correlates better health outcomes as welanded legal action.[8][9][10] Nursing, Allied Health, and Interprofessional Team Interventions All members of the interprofessional healthcare team would do well to have at least a general understanding of the MBTI grading system, as it can facilitate patient interactions, increase empathy for how a patient views their life and world, facilitate interprofessional team communication and collaboration, and lead to improved communication with patients., leading to improved patient outcomes. https://www.ncbi.nlm.nih.gov/books/NBK554596/ ================ <QUESTION> ======= Give an overview of the MBTI test and explain its connection to Jungian psychology. What are the possible applications of the MBTI in the areas of psychiatry and patient-doctor communications, and what are the best ways to implement this? What are the implied limitations of using the MBTI in a clinical setting? ================ <TASK> ======= You are an expert in question answering. Your task is to reply to a query or question, based only on the information provided by the user. It should only use information in the article provided."

You must only respond using information that is found in the provided context block. You must not use any other outside sources when forming an answer to the user's question. You may use markdown to format an answer.

Summarise how the laws are likely to impact these two groups.

Speech Rights of Adults Much of the material targeted by age verification laws is protected speech when accessed by adults. With respect to pornography, sexual content that depicts adults but is not legally obscene is protected speech with respect to adults even if it might qualify as speech “harmful to minors.” With respect to social media, the Supreme Court has recognized that social media enables individuals to “engage in a wide array of protected First Amendment activity.” A law may burden adult speech even if it specifically targets material accessed by minors. The Supreme Court’s decision in Reno struck down the Communications Decency Act (CDA) primarily on the basis that the law would impermissibly burden adult speech. The reasons for believing the CDA would burden adult speech may apply to contemporary age verification laws. The Reno court determined that the CDA’s ban on transmitting indecent material to minors would burden adult speech “in the absence of a viable age verification process,” because distributors of material would fear liability for transmitting material to minors. The Court also observed that a website operator’s decision to adopt age verification may block adults from lawful content if the adults lack material required for verification, such as a credit card. Lower courts have suggested that age verification may further burden adult speech by deterring adult users who are not willing to provide identifying information to access potentially embarrassing content. In a different context, the Supreme Court held that a requirement that cable television operators block sexual programming unless a viewer requests access to the programming in writing would “restrict viewing by [cable] subscribers who fear for their reputations” should their request be made public. Speech Rights of Minors Minors, like adults, possess free speech rights under the First Amendment. The Supreme Court has repeatedly held that, except in “relatively narrow and well-defined circumstances,” government has no more power to restrict speech for minors than it does for adults. Laws that target social media websites may fall outside these “narrow” circumstances. The Supreme Court has struck down other laws that attempted to restrict the dissemination of protected speech to minors, including laws involving violent video games and movies with nudity. Social media allows minors to access a broad array of protected speech, meaning a law restricting minors’ access to social media may have a greater impact on minors’ speech rights than narrower laws the Supreme Court has previously struck down. Pornography age verification laws may also impact minors’ access to constitutionally protected material. State laws that seek to mandate age verification for pornography often apply to “material harmful to minors,” a term that tracks the language used by the Supreme Court in Ginsberg v. New York and Miller v. California. Although the Supreme Court has upheld restrictions on physical distribution of material harmful to minors, federal appellate courts have raised issues with such restrictions as they might apply on the internet. For example, the Third Circuit held in multiple decisions that COPA’s definition of “material that is harmful to minors” was unconstitutionally vague and overbroad. The Miller definition of obscenity depends on whether “the average person, applying contemporary community standards” would find that the material in question “appeals to the prurient interest.” Definitions of material “harmful to minors” incorporate this language and specify that the question is whether someone “applying contemporary community standards” would find the material “appeals to the prurient interest” of minors. In cases that involve physical distribution of offensive material, the relevant “community standards” are those of the material’s recipient. The Third Circuit observed that applying a “contemporary community standards” requirement to internet communications, which are typically available worldwide, would subject all material on the internet to the standards of “the most puritanical communities.” The Supreme Court has not decided how to apply “contemporary community standards” to internet communications, beyond concluding that the use of “contemporary community standards” alone did not render COPA unconstitutional. Some Justices have expressed support for a nationwide Congressional Research Service 4 “community standard,” while other Justices have suggested that the standards should depend on where material is received, as is the case with laws that do not involve the internet.

System instruction: You must only respond using information that is found in the provided context block. You must not use any other outside sources when forming an answer to the user's question. You may use markdown to format an answer. question: Summarise how the laws are likely to impact these two groups. context: Speech Rights of Adults Much of the material targeted by age verification laws is protected speech when accessed by adults. With respect to pornography, sexual content that depicts adults but is not legally obscene is protected speech with respect to adults even if it might qualify as speech “harmful to minors.” With respect to social media, the Supreme Court has recognized that social media enables individuals to “engage in a wide array of protected First Amendment activity.” A law may burden adult speech even if it specifically targets material accessed by minors. The Supreme Court’s decision in Reno struck down the Communications Decency Act (CDA) primarily on the basis that the law would impermissibly burden adult speech. The reasons for believing the CDA would burden adult speech may apply to contemporary age verification laws. The Reno court determined that the CDA’s ban on transmitting indecent material to minors would burden adult speech “in the absence of a viable age verification process,” because distributors of material would fear liability for transmitting material to minors. The Court also observed that a website operator’s decision to adopt age verification may block adults from lawful content if the adults lack material required for verification, such as a credit card. Lower courts have suggested that age verification may further burden adult speech by deterring adult users who are not willing to provide identifying information to access potentially embarrassing content. In a different context, the Supreme Court held that a requirement that cable television operators block sexual programming unless a viewer requests access to the programming in writing would “restrict viewing by [cable] subscribers who fear for their reputations” should their request be made public. Speech Rights of Minors Minors, like adults, possess free speech rights under the First Amendment. The Supreme Court has repeatedly held that, except in “relatively narrow and well-defined circumstances,” government has no more power to restrict speech for minors than it does for adults. Laws that target social media websites may fall outside these “narrow” circumstances. The Supreme Court has struck down other laws that attempted to restrict the dissemination of protected speech to minors, including laws involving violent video games and movies with nudity. Social media allows minors to access a broad array of protected speech, meaning a law restricting minors’ access to social media may have a greater impact on minors’ speech rights than narrower laws the Supreme Court has previously struck down. Pornography age verification laws may also impact minors’ access to constitutionally protected material. State laws that seek to mandate age verification for pornography often apply to “material harmful to minors,” a term that tracks the language used by the Supreme Court in Ginsberg v. New York and Miller v. California. Although the Supreme Court has upheld restrictions on physical distribution of material harmful to minors, federal appellate courts have raised issues with such restrictions as they might apply on the internet. For example, the Third Circuit held in multiple decisions that COPA’s definition of “material that is harmful to minors” was unconstitutionally vague and overbroad. The Miller definition of obscenity depends on whether “the average person, applying contemporary community standards” would find that the material in question “appeals to the prurient interest.” Definitions of material “harmful to minors” incorporate this language and specify that the question is whether someone “applying contemporary community standards” would find the material “appeals to the prurient interest” of minors. In cases that involve physical distribution of offensive material, the relevant “community standards” are those of the material’s recipient. The Third Circuit observed that applying a “contemporary community standards” requirement to internet communications, which are typically available worldwide, would subject all material on the internet to the standards of “the most puritanical communities.” The Supreme Court has not decided how to apply “contemporary community standards” to internet communications, beyond concluding that the use of “contemporary community standards” alone did not render COPA unconstitutional. Some Justices have expressed support for a nationwide Congressional Research Service 4 “community standard,” while other Justices have suggested that the standards should depend on where material is received, as is the case with laws that do not involve the internet.

Formulate your answer using only the provided text; do not draw from any outside sources.

What is HR 4319?

Background on the 2024 Farmworker Protection Rule DOL indicates that the purpose of the Farmworker Protection Rule is to strengthen “protections for agricultural workers,” enhance the agency’s “capabilities to monitor H-2A program compliance and take necessary enforcement actions against program violators,” and ensure that “hiring H-2A workers does not adversely affect the wages and working conditions of similarly employed workers” in the United States. The rule amends existing regulations and includes provisions that encompass six areas: (1) “protections for worker voice and empowerment,” (2) “clarification of termination for cause,” (3) “immediate effective date for updated adverse effect wage rate,” (4) “enhanced transparency for job opportunity and foreign labor recruitment,” (5) “enhanced transparency and protections for agricultural workers,” and (6) “enhanced integrity and enforcement capabilities.” In the pending litigation, the first set of provisions, i.e., “protections for worker voice and empowerment” is most relevant. This set revises 20 C.F.R. § 655.135(h) and adds two new subsections, (m) and (n). DOL has stated that these provisions aim to protect H-2A workers by “explicitly protecting certain activities all workers must be able to engage in without fear of intimidation, threats, and other forms of retaliation”; safeguarding “collective action and concerted activity for mutual aid and protection”; allowing workers to decline to listen to “employer speech regarding protected activities without fear of retaliation”; permitting workers to “designate a representative of their choosing in certain interviews”; and authorizing workers to “invite or accept guests to worker housing.” The rule states that it “does not require employers to recognize labor organizations or to engage in any collective bargaining activities such as those that may be required by the [National Labor Relations Act].” The National Labor Relations Act (NLRA) is a law that gives collective bargaining rights to workers who qualify as “employees” under the definition in the statute. The NLRA explicitly excludes agricultural workers from the definition of “employee.” Kansas v. U.S. Department of Labor On June 10, 2024, Kansas and 16 other states, a trade association of growers, and a private farm filed a complaint against DOL in the U.S. District Court for the Southern District of Georgia, arguing, among other things, that the Farmworker Protection Rule violates the NLRA because it gives H-2A agricultural workers collective bargaining rights when the NLRA explicitly excludes agricultural workers from having those rights. The plaintiffs subsequently filed a motion for a preliminary injunction and temporary restraining order seeking a stay of the effective date of the Farmworker Protection Rule or, in the alternative, a temporary restraining order until the court grants an injunction. The court held a hearing on the motion on August 2, 2024, and on August 26, 2024, the federal district court judge granted the plaintiffs’ motion for a preliminary injunction. Plaintiffs’ Arguments The arguments below were raised in the plaintiffs’ motion for preliminary injunction. This Sidebar does not cover every argument the plaintiffs advanced. The Rule Violates the NLRA The plaintiffs argued that the rule is not in accordance with existing law and that DOL is providing collective bargaining protection to H-2A workers. According to the plaintiffs, parts of the rule are almost a direct copy of certain provisions in the NLRA, such as those regarding unfair labor practices and representatives and elections. The plaintiffs acknowledged that the rule does not expressly declare that H2A workers have a right to unionize and collectively bargain, but they claim that the protections conferred by the rule effectively confer such rights in contravention of the NLRA. The Rule Exceeds DOL’s Authority Under the INA The plaintiffs also argued that DOL has very limited authority to issue regulations under 8 U.S.C. § 1188. Specifically, the plaintiffs state that Section 1188(a), which is the part of the statute DOL relied on to promulgate the rule, is being misinterpreted by the agency. According to the plaintiffs, DOL is supposed to neutralize any adverse effects from an influx of H-2A workers and not necessarily take affirmative steps to improve the working conditions for H-2A workers. In addition, according to the plaintiffs, Section 1188(a) does not explicitly give DOL rulemaking authority. The plaintiffs filed this lawsuit before the Supreme Court’s decision in Loper Bright Enterprises v. Raimondo, which overturned the Chevron doctrine. The Chevron doctrine directed courts to defer to an agency’s reasonable interpretation of ambiguous statutes the agency administers. The plaintiffs argued that because Congress’s intent was clear in 8 U.S.C. § 1188, DOL was not entitled to Chevron deference. Relatedly, the plaintiffs pointed out that DOL relies on caselaw that existed before the Supreme Court overruled the Chevron doctrine rather than on the statute itself. DOL’s Arguments The arguments below were raised in DOL’s response to the plaintiffs’ motion for preliminary injunction. This Sidebar does not cover every argument DOL advanced. The Rule Does Not Violate the NLRA In summary, DOL argued that the rule does not require employers to recognize unions or engage in collective bargaining and is therefore not in violation of the NLRA. According to DOL, the rule expands on existing H-2A anti-discrimination provisions, and individuals who fall outside the NLRA’s definition of “employee” can still be protected by other statutes and regulations. DOL states that the rule does just that by granting protections to those not covered by the NLRA. Finally, DOL argues that the rule and the NLRA do not conflict with one another. The Rule Is a Proper Exercise of DOL’s Statutory Obligation DOL responded to the plaintiffs’ argument that the rule exceeded its authority by stating that the INA grants it rulemaking authority. DOL pointed out that provisions in 8 U.S.C. § 1188 expressly reference DOL regulations and that Congress authorized it to implement the mission of the statute through regulation. Further, DOL argued that H-2A workers will become more attractive to U.S. employers if they receive fewer protections than U.S. workers and that this in turn will “adversely affect” U.S. workers. The goal of the rule, according to DOL, is to place H-2A workers on similar footing as U.S. workers to prevent an adverse effect in the long run. Lastly, DOL maintained that it has historically understood the “adverse effect” requirement “as requiring parity between the terms and conditions of employment provided to H-2A workers ... and as establishing a baseline ‘acceptable’ standard for working conditions below which [U.S. workers] would be adversely affected.” DOL filed its response after the Supreme Court announced the overruling of Chevron in Loper Bright Enterprises. Citing Loper Bright Enterprises in a footnote, DOL argued that the best reading of Section 1188 was that Congress had delegated to DOL broad, discretionary authority to take action to prevent adverse effects to workers in the United States. The agency claimed that the rule is an appropriate exercise of this discretionary authority, including because the rule “ensures that agricultural employers cannot use the H-2A workforce to undermine workers in the United States who seek better wages and working conditions.”

Formulate your answer using only the provided text; do not draw from any outside sources. Provided text: The Court’s Order on the Motion for Preliminary Injunction On August 26, 2024, a federal district court judge granted the plaintiffs’ motion for preliminary injunction. The judge found that the plaintiffs met their burden to show that they were entitled to preliminary relief. First, the judge held that the plaintiffs were likely to succeed on the merits of their case. The judge initially determined that the rule falls within DOL’s rulemaking authority under 8 U.S.C. § 1188 but found that the rule conflicts with the NLRA. Specifically, the judge stated that DOL had “not shown a consequential difference between the rights protected by the [rule] and those given to nonagricultural workers by the NLRA,” that the rule “creates a right not previously bestowed by Congress,” and that DOL failed to show that Congress intended to give agricultural workers a right to participate in collective bargaining. The judge further found that just because DOL has rulemaking authority does not mean it can “create law or protect newly-created rights of agricultural workers.” Therefore, the court held that the plaintiffs were likely to succeed on the merits of their claim. The judge further held that the plaintiffs met their burden with regard to the other factors needed to support a preliminary injunction. The judge also found that, although the plaintiffs were entitled to preliminary relief, that relief should be narrowly tailored and party-specific. According to the court, nationwide relief is generally disfavored, as “national uniformity is not a proper consideration,” and a nationwide injunction in this case is unwarranted. The judge determined that the court is able to provide a tailored preliminary injunction that addresses the plaintiffs’ harms and can offer relief “without issuing a nationwide injunction.” DOL filed a motion for reconsideration of the scope of the judge’s order, but the motion was denied. Considerations for Congress Members of Congress have taken differing views on the Farmworker Protection Rule. Before the rule was finalized, several Members of Congress wrote a letter in November 2023 to Acting DOL Secretary Su and DHS Secretary Mayorkas in support of the rule, stating that the rule represents an opportunity to improve working conditions for H-2A workers and “improve enforcement capabilities of agencies against abusive employers.” Following the rule’s publication in April 2024, Representative Scott Franklin introduced a resolution of disapproval under the Congressional Review Act to rescind the rule, H.J. Res. 135. This resolution would prohibit DOL from any future similar rulemaking. He and the co-sponsors maintain that the rule will increase costs for agricultural producers and allow H-2A workers to unionize. There are other options if Congress chooses to respond to DOL’s Farmworker Protection Rule. First, Congress may consider amending the NLRA’s definition of “employee” to include agricultural workers, thereby allowing H-2A agricultural workers to receive collective bargaining rights. Alternatively, Congress could amend the NLRA and other laws to authorize or prohibit different labor requirements contained in the Farmworker Protection Rule that are not expressly addressed under existing statutes. Congress could also consider making changes to the H-2A visa program itself. For example, the Affordable and Secure Food Act (S. 4069) in the 118th Congress would, among other things, reform the H-2A visa program by adding worker protections and by providing visas for year-round jobs. A similar bill, the Farm Workforce Modernization Act of 2023 (H.R. 4319), has been introduced in the House during this Congress. Earlier versions of this bill introduced in the 116th and 117th Congresses passed the House. What is HR 4319?

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Discuss how Sensory Processing Sensitivity is currently measured and what some of the impacts that Sensory Processing Sensitivity would have on someone's everyday life or activities.

Sensory Processing Sensitivity (SPS) is considered a temperament or personality trait. It refers to a person's sensitivity to subtle environmental stimuli, the depth and intensity with which these stimuli are processed, and the impact this has in terms of emotional and physiological reactivity (e.g., the extent to which a person is easily disturbed by crowds and chaotic situations and the consequent need to withdraw and unwind). A highly sensitive person is characterised by a (greatly) increased degree of SPS. Since the existing limited scientific research suggested that there is a link between high SPS and the development of mental and physical symptoms (such as fatigue), we conducted a number of studies on how the concept is measured, and what the possible link is with (other) personality traits and some clinical outcomes. In a first study, the psychometric properties of the Dutch version of the Highly Sensitive Person Scale (HSPS) developed by Aron and Aron (1997) were explored in a general population sample (N=998), a sample of patients suffering from (chronic) fatigue complaints (N=340), and a sample of chronic pain patients (N=337). Results demonstrated that the scale was a valid and reliable measure of the ‘Sensory Processing Sensitivity’ construct. A bi-factor model, consisting of a general sensitivity factor and three separate factors, provided the best fit to the data in each sample. The three separate factors, capturing different dimensions of sensory processing sensitivity, were labelled ‘Ease of Excitation’, ‘Sensory and Aesthetic Sensitivity’, and ‘Low Sensory Threshold’. Distinct patterns of associations were found between these factors and the Big Five personality traits (De Gucht et al., 2023). During the validation process of the HSPS it became apparent that this scale offers a restricted perspective on the Sensory Processing Sensitivity concept. Based on the current literature, several different dimensions can be distinguished within this concept, namely (1) (heightened) sensitivity to (subtle) sensory stimuli, including neutral perceptual sensitivity to both internal and external stimuli, affective sensitivity, and associative sensitivity, (2) sensory discomfort, and (3) emotional or physiological reactivity. The fact that these dimensions are not adequately covered by the HSPS developed by Aron & Aron (1997) was the starting point for study 2, focusing on the development of a more comprehensive scale, the Sensory Processing Sensitivity Questionnaire (SPSQ). The item pool generated for the development of the SPSQ consisted of 60 items. After exploratory factor analysis, 43 items remained, divided into six specific factors: (1) Sensory Sensitivity to Subtle Internal and External Stimuli, (2) Emotional and Physiological Reactivity, (3) Sensory Discomfort, (4) Sensory Comfort, (5) Social-Affective Sensitivity, and (6) Aesthetic Sensitivity. Confirmatory factor analysis indicated that a higher-order bi-factor model consisting of two higher-order factors (a positive and negative dimension), a general sensitivity factor and six specific factors had the best fit. Strong positive associations were found between Emotional and Physiological Reactivity, the negative higher-order dimension, and Neuroticism; the same holds for the association between Aesthetic Sensitivity, the positive higher-order dimension, and Openness. Emotional and Physiological Reactivity and the negative higher-order dimension showed clear associations with clinical outcomes (i.e., anxiety, depression, somatic complaints, and fatigue) (De Gucht et al., 2022). With 43 items, the SPSQ is an extensive questionnaire. Incorporating such a questionnaire in research including multiple variables may lead to surveys becoming quite long. One of the problems with long surveys is that they often result in lower response rates, which can have an impact on the generalizability of the findings due to non-response bias. For this reason, we decided to develop a short form (study 3), similar in content and structure to the original scale, and possessing strong psychometric qualities. Such an abbreviated version of the SPSQ has the advantage of measuring many both positive and negative characteristics of SPS and doing so using a limited number of items. The Short Form (SPSQ-SF) was developed using a split-sample validation design. Within a large selection sample, items were retained based on impact on internal consistency reliability, fit to the hierarchical structure of the original SPSQ, and information curves based on a Graded Response Model. In the replication sample, the dimensionality and fit to the latent structure of the SPSQ were evaluated. The results of our study indicate a good fit of the SPSQ-SF. It is strongly correlated to the original SPSQ. Convergent, discriminant and concurrent validity was established in relation to other instruments measuring aspects of SPS, Big Five personality traits and clinical outcomes, respectively (De Gucht & Woestenburg, manuscript submitted for publication).

[question] Discuss how Sensory Processing Sensitivity is currently measured and what some of the impacts that Sensory Processing Sensitivity would have on someone's everyday life or activities. ===================== [text] Sensory Processing Sensitivity (SPS) is considered a temperament or personality trait. It refers to a person's sensitivity to subtle environmental stimuli, the depth and intensity with which these stimuli are processed, and the impact this has in terms of emotional and physiological reactivity (e.g., the extent to which a person is easily disturbed by crowds and chaotic situations and the consequent need to withdraw and unwind). A highly sensitive person is characterised by a (greatly) increased degree of SPS. Since the existing limited scientific research suggested that there is a link between high SPS and the development of mental and physical symptoms (such as fatigue), we conducted a number of studies on how the concept is measured, and what the possible link is with (other) personality traits and some clinical outcomes. In a first study, the psychometric properties of the Dutch version of the Highly Sensitive Person Scale (HSPS) developed by Aron and Aron (1997) were explored in a general population sample (N=998), a sample of patients suffering from (chronic) fatigue complaints (N=340), and a sample of chronic pain patients (N=337). Results demonstrated that the scale was a valid and reliable measure of the ‘Sensory Processing Sensitivity’ construct. A bi-factor model, consisting of a general sensitivity factor and three separate factors, provided the best fit to the data in each sample. The three separate factors, capturing different dimensions of sensory processing sensitivity, were labelled ‘Ease of Excitation’, ‘Sensory and Aesthetic Sensitivity’, and ‘Low Sensory Threshold’. Distinct patterns of associations were found between these factors and the Big Five personality traits (De Gucht et al., 2023). During the validation process of the HSPS it became apparent that this scale offers a restricted perspective on the Sensory Processing Sensitivity concept. Based on the current literature, several different dimensions can be distinguished within this concept, namely (1) (heightened) sensitivity to (subtle) sensory stimuli, including neutral perceptual sensitivity to both internal and external stimuli, affective sensitivity, and associative sensitivity, (2) sensory discomfort, and (3) emotional or physiological reactivity. The fact that these dimensions are not adequately covered by the HSPS developed by Aron & Aron (1997) was the starting point for study 2, focusing on the development of a more comprehensive scale, the Sensory Processing Sensitivity Questionnaire (SPSQ). The item pool generated for the development of the SPSQ consisted of 60 items. After exploratory factor analysis, 43 items remained, divided into six specific factors: (1) Sensory Sensitivity to Subtle Internal and External Stimuli, (2) Emotional and Physiological Reactivity, (3) Sensory Discomfort, (4) Sensory Comfort, (5) Social-Affective Sensitivity, and (6) Aesthetic Sensitivity. Confirmatory factor analysis indicated that a higher-order bi-factor model consisting of two higher-order factors (a positive and negative dimension), a general sensitivity factor and six specific factors had the best fit. Strong positive associations were found between Emotional and Physiological Reactivity, the negative higher-order dimension, and Neuroticism; the same holds for the association between Aesthetic Sensitivity, the positive higher-order dimension, and Openness. Emotional and Physiological Reactivity and the negative higher-order dimension showed clear associations with clinical outcomes (i.e., anxiety, depression, somatic complaints, and fatigue) (De Gucht et al., 2022). With 43 items, the SPSQ is an extensive questionnaire. Incorporating such a questionnaire in research including multiple variables may lead to surveys becoming quite long. One of the problems with long surveys is that they often result in lower response rates, which can have an impact on the generalizability of the findings due to non-response bias. For this reason, we decided to develop a short form (study 3), similar in content and structure to the original scale, and possessing strong psychometric qualities. Such an abbreviated version of the SPSQ has the advantage of measuring many both positive and negative characteristics of SPS and doing so using a limited number of items. The Short Form (SPSQ-SF) was developed using a split-sample validation design. Within a large selection sample, items were retained based on impact on internal consistency reliability, fit to the hierarchical structure of the original SPSQ, and information curves based on a Graded Response Model. In the replication sample, the dimensionality and fit to the latent structure of the SPSQ were evaluated. The results of our study indicate a good fit of the SPSQ-SF. It is strongly correlated to the original SPSQ. Convergent, discriminant and concurrent validity was established in relation to other instruments measuring aspects of SPS, Big Five personality traits and clinical outcomes, respectively (De Gucht & Woestenburg, manuscript submitted for publication). https://www.universiteitleiden.nl/en/research/research-projects/social-and-behavioural-sciences/hypersensitivity-stimulus-perception-information-processing-and-reporting-of-emotional-and-somatic-symptoms ===================== [instruction] Answer the question using only the information provided in the context. Do not rely on external knowledge or sources.