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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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Aaron Baggish, MD
Corroborative evidence documenting the source of the gratuities anxiety untreated purchase abilify 15 mg free shipping, including the nature depression symptoms psychology cheap abilify 5 mg fast delivery, purpose depression symptoms in dogs buy abilify 20mg visa, and cost involved should be obtained mood disorder essays cheap abilify 5 mg on line. Legislation pertaining to conflicts of interest anxiety night sweats buy abilify 20mg with mastercard, in effect since 1963 anxiety 6 months after quitting smoking cheap abilify 15mg mastercard, broadened both the conduct prohibited and the personnel covered, and created a class of "special government employees" to whom special conflict of interest rules applied. It expands the class of persons affected the category of proceeding to which the disqualification applies, extends the penalty to the giving as well as the receiving of compensation, and applies a rule to special government employees which is less restrictive than that applied to regular government employees. It corrects the failure of former Section 281 to prohibit preemployment receipt or agreement to receive, or post-employment receipt of compensation with respect to service to be rendered or actually rendered during the period of government employment. If, however, the employee receives a gratuity, share, or interest in any claim in consideration for his assistance in the prosecution of the claim, the employee comes within the prohibition of the statue. If he acts as an agent or attorney for prosecuting a claim against the government, as opposed to merely aiding or assisting in the prosecution, he is within the scope of the statute regardless of whether he receives any compensation for services. By not modifying the term "agent" in Section 205(2) with the phrase "for prosecution," the scope of Section 205(2) is extremely broad, covering nearly every conceivable activity which an employee may perform in a representative capacity for another before the designated government agencies. Sections 281 and 283, insofar as they apply to retired officers, were not repealed. It was amended in 1978 as part of the "Ethics in Government Act of 1978" (Public Law 95-521) and further amended in 1979 (Public Law 96-28). Section 207(a) places a lifetime bar on a former government employee acting as agent or attorney for anyone in connection with any particular matter before the government in which the U. Section 207(b) places a 2-year bar on a former senior Government employee from aiding or assisting in the representation of another person in connection with an appearance before the government only when the former employee is personally present at the appearance and when the particular matter in issue is one in which he personally and substantially participated as an employee of the government. Section 207(b) also imposes a 1-year ban which bars a former senior employee from attempting to influence his former agency on a matter that is pending before, or of substantial interest to , the agency for one year after he ceases being a senior employee. The 1-year bar applies even if the senior employee had no prior involvement in the matter. This prohibition reaches attempts to influence not only "particular matters" but also general rule making. The 1-year ban, as amended, excludes from its prohibitions former senior employees who have become elected state officials, full time employees of state and local governments, employees of accredited institutions of higher learning or employees of hospitals or medical research organizations granted tax exemption by the Internal Revenue Service when acting on behalf of these organizations. The amendments also permit the Director of the Office of Government Ethics to further limit the application of the 1-year ban so that in given cases former senior employees will only be prohibited from contacting specific offices within their former departments or agencies as opposed to being barred from contact with the entire department. Section 208(a) abandons the transaction of business concept and disqualifies the employee from participating personally and substantially on behalf of the Government in a matter, even though his participation does not involve the transaction of business. Section 208(a) goes beyond former Section 434 in that it disqualifies an employee from participating in a matter in which not only he, but, to his knowledge, his spouse, minor child, partner, organization in which he is serving as officer, director, trustee, partner, or employee, or any person or organization with whom he is negotiating or has any arrangement concerning prospective employment, has a financial interest. This would cover nonprofit organizations such as universities, foundations, and nonprofit research entities as well as business organizations. Defective pricing occurs whenever a defense contractor knowingly overprices negotiated government contract prices by quoting performance costs higher than those of actual expenditures or fails to reveal all costs associated with a contract. Performance costs include, but are not limited to: design costs; engineering; prototypes; overhead; labor costs; manufacturing costs; subcontracting; facilities; material costs; tooling; packing, packaging and shipping. The most significant contributing factors in price differences are the varying labor rates throughout the country, the fluctuating costs of raw materials and the ceiling on what the market will bear. A primary issue in determining Defective Pricing for commodities is the application of "fair and reasonable" criteria as determined by price analysts within the buying activities. The "fair and reasonable" cost of a commodity is reckoned mainly by the items past price history, current production costs, varying labor scales, and inflation rates. Cost or Pricing Data should never be required unless the contracting officer concludes that none of the exceptions to the cost or pricing data requirement are appropriate. When no exception is appropriate, in the following circumstances, cost or pricing data would normally be obtained: a. The award of any negotiated contract (except for those actions not defined such as letter contracts) expected to exceed $500,000. The award of a subcontract at any tier, if the contractor and each higher-tier subcontractor have been required to furnish cost or pricing data. The modification of any sealed bid or negotiated contract (whether or not cost or pricing data were initially required). This requirement also applies to subcontracts if the contractor and each higher-tier subcontractor have been required to furnish cost or pricing data. They are all the facts that can be reasonably expected to contribute to the soundness of estimates of future costs and to the validity of determinations of costs already incurred. They include such factors as vendor quotations, nonrecurring costs, and information on changes in production methods and in production or purchasing volume. A contract finalized within the parameters of the Truth in Negotiation Act contains a price-reduction clause in the event of overpricing because of inaccurate, incomplete or non-current data submission by the contractor. Government compensation for overpayment to a contractor who knowingly provided inaccurate cost data is governed by Public Law 99-661, Defense Authorization Act. This statute assesses such a contractor with a penalty amount equivalent to the contract overpayment, plus interest, until final restitution is made. Defective Pricing can be a high-cost fraud offense, either because of numerous inflated small purchase contracts or because of the high dollar cost involved in large acquisitions. A large number of contract line items on a single purchase, where the cost of several, although inordinately high, appear acceptable as part of the order. Contractual actions for obsolete or esoteric components that are long out of manufacture and have no recent price history. Production items requiring special tooling, materials or facilities, where costs are not readily determinable or where market costs have not been established. Expedited first-run manufacture items, where production costs are estimated on a contingency basis. Pay and Allowance investigations are conducted to develop information concerning the validity of payments made by Navy and Marine Corps accounting and finance officers, with the purpose of effecting recoupment of monies erroneously paid. The following glossary of terminology applicable to this case category will be useful to the special agent: a. That portion of the pay and allowance of a member that he authorizes to be paid to an allottee in a manner prescribed by law. An accounting and finance document executed by service members to initiate, terminate, or change an allotment. Funds paid to service members to defray expenses incurred in connection with the performance of official duties. A form executed annually by secondary dependents indicating their financial position to qualify for receipt of an allotment. Examples are basic pay, incentive pay for hazardous duty, sea and foreign duty pay. The fulfillment by the service member of requirements of the basic law, regulation, or order. A written document bearing the signature of the payee and certification that the facts therein concerning the claim are true and correct. The status of the service member, whether single or married, determines the factor of entitlement and substantiation to be established in investigations of housing allowances. The various investigations of this type, together with specific requirements as to each and investigative steps recommended to resolve the issues, are set forth below: a. The issues to resolve in these investigations are whether the authorization was proper and whether the service member resided in government quarters during the period involved. As to the latter, it is necessary to establish that the previous marriages, if any, of both parties were legally dissolved (b)(7)(E) c. Full treatment of entitlements and substantiation will be found under subcategory 4I, Dependency Assistance Investigations. Nor is there any apparent requirement that military members offer proof that they are in fact maintaining their private quarters at the permanent duty station while on temporary duty. A service member is entitled to reimbursement for expenses incurred in the performance of travel in connection with official duties and, under certain circumstances, for travel of dependents. All reimbursement of expenditures for travel is claimed by submission of vouchers. Information relative to this travel can usually be developed through examination of military records, such as sign-out registers, morning reports, passenger manifests, and transient billeting records. Investigation in dependent travel cases should be directed to developing information concerning the following: (1) Complete identity of dependent(s). This information may be developed through personal interviews and examination of official records. Evidence of intent may be established by developing information concerning long-term agreements such as leases and contracts for utility services, as well as representations to others. Such costs where the traveler is not required to submit a receipt are meal expenses, laundry expenses, tips, etc. The Navy Comptroller for Financial Management Systems has determined that an adequate administrative remedy is available to commands in "no-receipt" claims. The truth of the statements to which the service member certified his request to ration separately. If the allegation concerns nonpayment for meals consumed in a government messing facility, ascertain dates, places, and witnesses to the consumption and the fact that payment was not made. Any payments, except for dependent travel, occurring under any law to any member of the uniformed service incident to his release from active duty or active duty for training, or for return home incident to release from active duty, may be paid to the service member before departure from his last duty station, whether or not he actually performs the travel involved. Current Joint Travel Regulations allow a military member being separated from active duty to draw advance travel pay for travel from the last duty to his home of record or a point of lesser distance. If, however, there is reason to suspect the member did not perform the travel for which an advance was received, and a claim submitted, an investigation should result if it meets a prosecutorial threshold. Any service member discharged under honorable conditions having accrued leave not to exceed 60 days at the time of separation will be paid for such leave. Investigations in this area are usually requested to ascertain the reason the allotment was not stopped and who was responsible for its continuance. When and what steps were taken by the member or responsible administrative personnel to effect a discontinuance of the allotment; b. The reason the allotment was not discontinued and the responsibility therefore; c. Whether the continuance of the allotment resulted from any collusive action, and the extent to which participant was involved. Investigations in this area are usually based on allegations that accounting and finance documents have been altered to enable a service member to obtain funds to which there was no entitlement. It is not always the service member whose particular record is involved who is guilty of altering or causing the document to be altered. Alterations may be accomplished by erasure or other deletion or addition of erroneous information on the document. The facts to be established in these cases are the type of alteration, by whom it was made, what individuals profited and whether there was any collusion in accomplishing the act. Most investigations in this area are conducted as a result of allegations that accounting and finance personnel unlawfully have converted Federal funds to their own use. The misappropriation may be accomplished in numerous ways, but always involved is documentation which may be fictitious, altered, or destroyed. Again the investigative steps closely follow those set forth in Separation Payment Investigations. This irregularity involves Reserve personnel not on extended active duty receiving pay for periods of training that they either did not attend or did not attend for the required number of hours to be eligible for such payment. This situation usually arises where a member of a Reserve unit signs the name of an absent member to an attendance roll, thereby enabling the latter to collect payment. The investigation should develop information to establish whether the person in question did in fact receive training and, if not, the circumstances surrounding the falsity of the attendance roll and responsibility therefore. A bigamy occurs when a marriage is contracted at a time when one of the contracting parties has a lawful spouse, then living. The terms "enlistment" and "appointment" include any means of entry, except induction, into the military. The term "separation," unless otherwise specified, includes discharge or any other means of discontinuing military duty. Misrepresentation or concealment may involve matters that, if truthfully stated or revealed, would induce an inquiry by the recruiting, appointing or separating officer concerning the qualifications or disqualifications for enlistment, appointment or separation. Such misrepresented facts usually pertain to previous service, arrest records, dependents, etc. Acceptance of food, clothing, shelter, pay or transportation from the government constitutes receipt of pay or allowances. On the other hand, whatever is furnished an accused while in custody, confinement, arrest or restraint pending trial for fraudulent enlistment or appointment is not considered an allowance. An enlistment procured by means of either knowingly making a false representation in regard to any of the qualifications prescribed by law, regulation, or order, or a deliberate concealment in regard to such disqualification. The false representation or concealment is made by the person being enlisted, appointed, or separated. That the accused enlisted in, was appointed to , or separated from the armed forces; b. That the accused knowingly misrepresented, or deliberately concealed, a certain material fact(s) regarding his qualifications for enlistment, appointment, or separation; c. That the enlistment, appointment, or separation was procured by such false representation or deliberated concealment; and d. That under the fraudulent enlistment or appointment, the accused received either pay or allowances, or both, as alleged. That the accused affected the enlistment, appointment, or separation of the person named as alleged; b. That the person was ineligible for such enlistment, appointment, or separation because it was prohibited by law, regulation, or order; and c. That the accused knew he was charged with knowledge of such facts at the time of the enlistment, appointment, or separation. A check of personnel records of every subject or logical suspect should be conducted and reported. The fact that a subject received pay and/or allowances should be established by documentary evidence at the finance office.
Initiative operations are reserved for significant problems depression or adhd cheap 15 mg abilify with visa, and the objective of these operations will be specific and realistically attainable depression mood swings purchase abilify 10mg free shipping. As such mood disorder with psychotic features code generic abilify 5mg amex, inquiries to determine the existence of a p problem will be completed p prior to consideration to conduct an p (b)(7)(E) operation depression numbness generic 10 mg abilify. A basic step in developing a criminal operation is the identification of suspected high crime or problem areas within a command depression lyrics buy abilify 20mg cheap, unit or area major depression definition psychology cheap abilify 10mg line. An operation will normally have more potential for success if specific problem areas rather than entire commands are targeted. Routine complaints from commands that a problem exists or is believed to exist, but specific criminal activity and suspects are unknown. Analysis of known or reported losses of property by a command to include volume of material surveyed as lost or misplaced during a given period. Reports of inspection or review, which indicates that security conditions within a command, provide an opportunity for criminal activity to flourish. Indications that deficiencies revealed during previous crime surveys, audits, Inspector General reports, etc. Unexplained frequent cash overages or shortages in units responsible for appropriated or non-appropriated funds. Frequent inventory shortages, which are treated routinely by command personnel as being "paperwork errors. Once the existence of criminal activity has been established and a specific target area has been defined, a tentative operational plan should be formulated to include operational objectives and a proposed method of approach to the problem. To prevent compromise and therefore necessitate the need to abort the operation, command personnel must exercise care to limit knowledge of operations. The productive phase of any criminal operation involves the initiation of criminal investigations to document evidence gleaned against suspects within the target area. A criminal operation may result in many criminal investigations of various categories before it is completed. Termination of an operation should occur only after evidence of criminal activity has abated and the operation has met its objectives. The documentation will set forth the operational direction in sufficient detail to allow for evaluation of the need to continue the operation and the likelihood of success in obtaining its objectives. Criminal Operation (Open) (b)(7)(E) Pages 194 through 196 redacted for the following reasons: -(b)(7)(E) (b)(7)(E) 9-4. An example would be when the operation is about to change from a covert phase to overt and press releases/conferences are planned. Keeping operational security in mind, the command will be kept apprised of the status of the overall operation. This information would include such things as administrative anomalies, security weaknesses and any other information, which should be brought to the attention of the command for possible corrections or improvements. Once the objectives of a particular operation have been accomplished or it is determined the original suspicions within the target area are unfounded or the operational scenario is not feasible, the operation will be terminated. Additionally, if the operation was non-productive, a summary statement should be made regarding the probable reason for its non-productivity. If oral/wire interception was authorized but not used, a statement as to the reason for not using the technique will be included. Forensic Document Evidence normally consists of a piece of paper bearing handwritten entries in ink or pencil, typewriting, or other machine-generated text. The term "document" may also be applied to any surface bearing writing, marks or symbols applied by varied media, such as spray-paint writing on a wall, scratched or carved letters on a door or plane canopy, etc. Each document tells a story, transmits a message, or in some manner depicts the thoughts or intention of the author. Most Department of Defense document investigations involve forged or altered medical prescriptions, anonymous letters, forged or worthless checks, and various types of military, government, and non-government forms. Forensic Document Examinations generally attempt to identify or eliminate suspect writers (or machines) as the source of questioned features on a document. Some questioned documents require that several types of Forensic Document Examinations be performed. In addition to the identification of handwriting, Forensic Document Examinations include typewriting, alterations, erasures, date determination, photocopy machines and copies, computer printers, fax machines, multi-function office machines, charred and watersoaked documents, indentations, inks, paper, rubber stamps, shredded-paper document reconstruction, and various others. Forensic Document Examinations seek to reveal the pertinent information present in each item of evidence. Whether the examination results in an elimination or identification of a writer or machine as the source of a questioned document, or provides other information concerning a document, depends upon the features observed in the evidence. Background information from an investigation does not influence the examination results. Handwriting is still prevalent in many business transactions and personal matters. Handwriting imparts the desired personal touch that individualizes documents and, in many cases, makes them legally acceptable. Most persons learn to write at a young age by repeating letter forms in a particular system. Writers deviate to varying degrees from the system used to teach them, with handwriting habits becoming relatively stabilized during the teenage years. The handwriting habits of adults tend to be as firmly fixed as any other personal habit. Though writers may share varying numbers of similarities in their handwriting features with other writers, no two writers have ever been found whose handwriting habits were indistinguishable. When provided with identifiable questioned writing and sufficient known writings for a comparison examination, a properly trained Forensic Document Examiner can accurately identify the writer of questioned writings, and conversely, eliminate those who did not make a questioned writing. Handwriting identification examinations generally involve the comparison of questioned and known writings to determine the author of the questioned writing. Examinations may also involve comparing questioned writings with other questioned writings to determine whether they were written by the same person. A forensic handwriting examination involves assessing the similarities and differences of the features among two or more sets of writings. Questioned Writings - these writings generally involve some doubt as to their authenticity. Standards refer to known writings executed outside the scope of (and normally prior to) an investigation. Standards are also called "Non-requested Writings", "Unsolicited Writings", "Course-of-Business Writings", or "Pre-existing Writings". Standard writings are those that are known to have been authored by an individual in the normal course of personal or business writings. Standards are usually written before an investigation, but when there is too great a time differential between the standards and questioned writing, the value of the standards may be reduced. For example, the writing of a young schoolboy may differ in many essentials from his mature writings made later in life. Exemplars refer to known writings made by a writer (suspect, victim or witness) at the request, and in the presence of, an investigator. Exemplars are also called "Collected Writings", "Solicited Writings", and "Prepared Writings". Exemplars repeating the questioned document entries are necessary to insure that sufficient known letterforms, letterform combinations, and other handwriting features are present to provide for a meaningful comparison between the questioned and known writings. Acquiring standard known writings first allows the investigator to use them as a point of comparison when Exemplars are being written later. To be of value for comparison, standard known writings should repeat as much of the questioned writings as possible: a. Standard writings should repeat the questioned handwritten (or cursive) and hand printed letter forms. Standard writings should repeat the questioned upper-case and lower-case letter forms. Standard writings should repeat the slow, neatly-written letterforms, or rapid and abbreviated letter forms, etc. The authenticity of standard known writings must be proven to the satisfaction of the court. Any document or writing attributed as a known writing by a specified person for a comparison examination, must be logically linked to the person who wrote them. By having an employee (often someone designated as the "record custodian") testify about the production, handling and maintenance of the known writing document(s) during the course of daily business. By the testimony of a family member, friend or other witness who is familiar with the writing of the person to whom the known writing is attributed. The best standards for comparison are those from the same general class as the questioned writing. For example, if the questioned signature is on a check, known writings of the suspect on other checks should be included when available. Good quality copies of these personal items may be submitted if it is not possible to submit the original documents. Suspect writers have often been involved as witnesses or suspects in unrelated matters wherein the military police have obtained handwritten statements. Education centers often have entries on file documents pertaining to service members. If the service member is participating in classes through the center, educators may have handwritten homework papers, essays or exams available. Unit personnel files may contain entries on forms, test papers bearing handwritten answers (sometimes in essay form), counseling statements, handwritten letters and notes from the service member to his/her chain of command concerning disciplinary actions, appeals to unfavorable efficiency reports, requests for off-post housing, explanations of bad debts and bounced checks, and a variety of other items. You may find draft letters and reports, calendar entries, appointment books, pocket notebooks, etc. A non-office worker may make entries in clothing records, on receipts for tools and equipment, equipment logbooks, maintenance records, etc. Friends and relatives of the service member may possess handwritten letters, notes, greeting cards, and other correspondence by the service member. No self-incrimination warnings are required when requesting exemplars from military or civilian subjects, victims and witnesses. Military members can be ordered to provide exemplars (see United States vs Airman Basic Timothy P. These missions allowed examiners to screen large quantities of questioned documents enabling them to extract representative samples that they judged to be most productive for future examination at the laboratory. Examiners also will screen large numbers of known writings by large suspect populations (cursory handwriting screenings of personnel forms have identified writers of hate letters, forged documents, suicide letters, etc. Policy considerations concerning the use of technical investigative aids often depend on whether the investigation is purely criminal in nature or involves intelligence aspects. Guidance issued separately should be reviewed prior to requesting or employing those aids for intelligence purposes. Based on the nature of the request, a secure means of communications may be required. The investigator should describe in detail the specific situation faced, and depending upon the situation encountered, may receive techniques or guidance. Making regular periodic downloads help prevent modern equipment from rapidly overwhelming and outstripping analytical capabilities. Enhancement is not a substitute for a quality recording and cannot replace what is not already there. Typical examples include theft of money or property from cash registers, lockers, security cages, and freight loading docks and cases of malicious destruction targeting specific objects or areas with the likelihood of being targeted again. Video surveillance is not useful in resolving cases in which the investigation has not progressed to the point of establishing a probable and a specific, definable location at which the crime is being perpetrated. Typical examples of no-hope video surveillances are those cases involving inventory losses at warehouses, commissaries, or exchanges where determination of an actual crime is uncertain. Some practical considerations to keep in mind when considering video surveillance: a. Illumination levels slightly below that of the average office normally are sufficient. Lower levels, however, may downgrade video quality to the point of being unusable. Inspect the target for possible camera concealment modalities, particularly taking note of false ceilings; they afford ready-made camera concealment and facilitate installation in a number of other ways as well. Utilize desks, cabinets, lockers, and other containers if securable and the risk of discovery can be sufficiently minimized. Installation and concealment of a video camera and transmission link may take as long as ten minutes or in excess of ten hours depending on the type of installation needed and conditions encountered. Undetected access to the target area by the installation team and the reasonable assurance of privacy during the installation process are absolutely essential. Another important consideration of video surveillance is to secure space in which to locate the video monitor and recorder at the receiving end of the video link. The fewer persons involved and the fewer intrusions into the area of concern, the more likely of successful technical support. Places such as offices, cashier booths, and strong-room doors pose no problem, but residences or rest rooms can be difficult. This includes the use of cameras, closed circuit television systems, binoculars, infrared viewers, and night vision devices. While many of the supporting technical entities will provide an initial or starter issue of consumables, the user is responsible for obtaining and maintaining adequate working materials. Non-traditional investigative techniques are unique or exceptional investigative methods employed during the course of an investigation or inquiry. These techniques are infrequently utilized and are not required during most investigations. Many of these techniques may require assets not normally possessed at the field office and may require substantial lead and preparation times. Video/documentation ruse technique is the use of videotape or other media and information.
The February 22 bombing of the al-Askari mosque led to an extraordinary spike in violence keynes depression definition buy 15 mg abilify with visa. By most accounts Iraq began to degenerate into open civil war mood disorders 11 year old buy abilify 10 mg lowest price, a conflict that the new Maliki government was unwilling or unable to control anxiety 60 mg cymbalta 90 mg prozac buy cheap abilify 5mg online. That summer anxiety vitamins buy abilify 20 mg on-line, officials with the National Security Council staff began to push for a "policy review depression test dsm iv abilify 15 mg visa. In early December great depression usa definition cheap abilify 20 mg otc, the bipartisan Iraq Study Group released its report, stating that "the situation in Iraq is grave and deteriorating. He was provided essentially with three options: to accelerate the withdrawal of American troops and the handover to Iraqi security forces, to pull back from the capital and allow the factions to fight it out, or to surge forces dramatically to regain the initiative and reestablish security. In the end, the President elected to surge five Army brigades to the capital and 4,000 Marines to Anbar Province in western Iraq, with a mandate to focus strongly on securing the population. In so doing, President Bush chose not to adopt the military advice provided by the formal chain of command, opting instead for the Surge option recommended by outside advisors. Moving swiftly, he replaced Secretary Rumsfeld with Robert Gates, installed General Petraeus as his new field commander, announced an increase in the size of the Army and Marine Corps, directed an associated "civilian surge," and expedited the deployment of the fresh troops. This achievement staved off defeat and a precipitous withdrawal, perhaps the best outcome available under the prevailing circumstances. Any scholar assessing this period must confront the fact that in this case, the President, as commander in chief, disregarded the best military advice proffered by the Joint Chiefs, combatant commander, and theater commander. It is also worth noting that by late 2006, the President had been engaged and focused on Iraq for at least 4 years and was by then experienced, highly knowledgeable, and possessed of his own firm views. For his part, President Bush was careful to solicit the views and inputs of his most senior military and civilian advisors and weighed them carefully. Yet he also went outside the circle of formal advisors to ensure that all points of view were brought forward. His ultimate decision was clear and unambiguous, and he generously supported the requests of his military commanders. Against strong opposition in Congress and much criticism in the media, he displayed a persistence and determination that proved most helpful to the theater commander and chief of mission charged with implementing his strategy. In his time in office, much went wrong in Iraq, and observers have found much to criticize. Three years later, President Barack Obama found himself in a similar quandary in Afghanistan. This prompted an increase in troop strength in 2008, bringing the full contingent of coalition forces to 68,000. McChrystal, who was thought to be a commander with greater skills in counterterrorism and counterinsurgency. At issue was the split between White House officials who opposed a large increase and military officials who supported it. A September 4, 2009, Washington Post article quoted General Petraeus as stating that success in Afghanistan was unlikely without many more troops. The Obama administration was new, with its national security team still shaking itself out. The President, Vice President, Chief of Staff, and Secretary of State had just come from Congress, where aggressive questioning in committee was the norm, a sharp contrast to the previous 8 years. As most new administrations are, the Obama team was keen to assert civilian control. Central Command commander had extensive experience, their views shaped by years of involvement in the Long War and particularly by the perceived success of the surge in Iraq. These and other factors contributed to quite different frames of reference and at times a clash of perspectives that proved difficult for all concerned. This gave General McChrystal much of what he had asked for, albeit with a limited timeline; the Surge troops would redeploy 411 Hooker and Collins in only 18 months. When a Rolling Stone article quoting McChrystal aides as critical and even contemptuous of White House officials was published 6 months later, McChrystal was relieved and retired, as McKiernan had been, barely a year into his tour. What seems clear, however, is that a perception formed in the minds of senior White House staff that the military had failed to bring forward realistic and feasible options, limiting serious consideration to only one, and that it had attempted to influence the outcome by trying the case in the media, circumventing the normal policy process. Where successful, as in the settling of the American West and in the Philippines, the methods used were often brutal and indiscriminate. More recently, in Vietnam, Iraq, and Afghanistan, our experiences have on the whole been difficult, costly, and indecisive. The ability of the enemy to fight from sanctuary, his unwillingness to present himself for destruction by our superior technology, the incapacity of host governments, and the loss of public support occasioned by protracted and indecisive combat all militated against clear-cut success. The historical record of large-scale, foreign expeditionary forces in counterinsurgencies is a poor one. More broadly, the normal military preference for overmatching force in armed conflict is often right, even as it commonly invokes opposition from 412 Reflections on Lessons Encountered civilian decisionmakers. Strong forces can smother friction, provide options, and avoid long, protracted conflicts that in the end may be far more expensive and casualty producing. Clear objectives accompanied by ample resources intelligently applied, with strong congressional and public support, typically evoke success. The authors in this volume have attempted an assessment of strategic decisionmaking in Iraq and Afghanistan, but it will be years before a full accounting is possible. Many key issues, such as the gradual evolution of command and control structures, use of Provincial Reconstruction Teams, challenge of coalition partner caveats, and many others, deserve a fuller and more comprehensive assessment. The foregoing discussion, supported by interviews with a number of prominent civilian leaders and four-star officers, nevertheless sheds light on U. Military involvement in national security decisionmaking at the best of times carries an element of tension inherent in civil-military relations. For example, strategy often founders on poorly defined or overly broad objectives that are not closely tied to available means, and here military leaders could and should play a key role. Vigorous debate and a clear presentation of military perspectives are essential for informed and successful strategy. Best military advice should be provided, nested within a larger appreciation of the strategic context and its political, economic, diplomatic, and informational dimensions. This conversation must be carried on 413 Hooker and Collins in confidence, respecting the prerogatives of civilian leaders with whom the ultimate decision rests. In most cases, civilian leaders look for a range of feasible options from the military, framed by clear cost and risk estimates, each of which could achieve the policy objective. In cases where the objective is unclear or unachievable, military leaders should press for clarity or state clearly that available resources could not support a successful outcome. Pressing for a commitment to success, defined as achieving sustainable political outcomes worthy of the sacrifices made, does not abrogate the civil-military compact. Rather, it reflects the gravity of any decision for war and the need for a determined commitment to prevail. In crafting policy and strategy, well-considered ideas matter and could often carry the day. Though time is scarce and resources precious, prior preparation and rehearsal are always good investments. Informed and articulate advocacy has a quality all its own, and skilled communicators with a convincing message are more likely to win acceptance. Policy and strategy take place in an operating universe that is highly sensitive to budget, election, and news cycles. Career military officers are not always attuned to these realities, whereas civilian policymakers are. Awareness and flexibility with respect to this reality improve the quality and utility of military advice. The art of generalship at the highest levels must also encompass an ability to understand and adapt to different Presidential and secretarial leadership styles and modes. Within a general interagency framework, each constructs decision settings composed of personalities and processes they find most helpful and congenial. These may, and often will, vary significantly from one administration to the next. At the four-star level, the ability to adapt to different civilian leadership styles is critical and may spell the difference between success and failure. These include interagency acumen, media savvy, a detailed understanding of congressional relations, a strong grasp of the defense planning, programming, and budgeting system, and skill in multinational environments. Normal career development patterns do not always provide opportunities to build these competencies. Sustained tenure in high-level command positions may also be a significant consideration. While the ultimate power of decision rests firmly in civilian hands, senior military officials have a duty to support effective and successful policy and strategy and to offer their best military advice and, if necessary, respectful dissent to help preclude strategic failure. As one senior four-star officer put it when interviewed for this study, "We have a sacred responsibility to provide best military advice. National security decisionmaking is a highly personal endeavor relying heavily on trust relationships. As much as possible, senior leaders will find it advantageous to maintain good working relationships with civilian partners, even-or perhaps especially-when they find themselves on opposite sides of the issue. If Afghanistan and Iraq are any guide, future wars will present national security decisionmakers with problems that will challenge their minds and souls. A lesson here for future senior officers is that there is no substitute for lifelong 415 Hooker and Collins learning. And while history does not repeat itself, there are age-old patterns that senior officers and politicians will always face. Sir Winston Churchill, writing in the years between the world wars, leaves us with this cautionary reminder: Let us learn our lessons. Never, never, never believe any war will be smooth and easy, or that anyone who embarks on the strange voyage can measure the tides and hurricanes he will encounter. The Statesman who yields to war fever must realize that once the signal is given, he is no longer the master of policy but the slave of unforeseeable and uncontrollable events. Antiquated War Offices, weak, incompetent or arrogant Commanders, untrustworthy allies, hostile neutrals, malignant Fortune, ugly surprises, awful miscalculations-all take their seats at the Council Board on the morrow of a declaration of war. Always remember, however sure you are that you can easily win, that there would not be a war if the other man did not think that he also had a chance. See "Costs of War," the Watson Institute for International Studies, Brown University, May 2014. A detailed accounting of the costs related to the campaigns in Iraq and Afghanistan is found in annex A of this book. Statistics provided from various sources including Central Intelligence Agency, the World Factbook, available at < Michael Howard and Peter Paret (Princeton: Princeton University Press, 1976 and 1984), book one, chapter one, 80. Feith, War and Decision: Inside the Pentagon at the Dawn of the War on Terrorism (New York: Harper, 2008), 371. Central Command, refers to the "Heroic Assumption"-the expectation that the liberation of Iraq would resemble the liberation of France in 1944. Kohn, "Out of Control: the Crisis in Civil Military Relations," the National Interest, no. Olin Institute for Strategic Studies, June 1997); and "The Erosion of Civilian Control of the Military in the United States Today," Naval War College Review 55 (Summer 2002). In the end, I only presented the President the course of action we selected-accelerated transition- and I believe that I should have offered him a wider range of options to meet his policy needs. In addition to weekly meetings of the National Security Council on Iraq, President George W. The President eventually ordered a troop surge of 30,000 as recommended by Secretary Gates, announcing his decision at West Point on December 1, 2009. General Petraeus also described in some detail the chain of events that led to these misunderstandings. Former Secretary of State and Chairman of the Joint Chiefs of Staff General Colin Powell might also be included. Government data and private studies that attempt to capture the direct costs of U. Many organizations, both public and private, have developed cost assessments for the wars. Some document the expense solely in terms of casualties and funds, while others attempt to include indirect costs such as environmental impact and macroeconomic costs. The Center for Strategic and International Studies and Center for Strategic and Budgetary Assessments have produced several studies that document the costs of the wars. Kennedy School of Government at Harvard University have published extensively on the financial legacy of Iraq and Afghanistan, specifically highlighting how wartime spending decisions will impact future national security budgets. For the most part this annex relies on numbers provided from official government sources. However, where gaps exist in official data, this annex relies on figures and conclusions reached by some of the academic studies listed herein. Finally, in reality, determining an accurate ultimate cost sheet for the wars is an impossible endeavor at this point as the war in Afghanistan is ongoing, while U. Undoubtedly, the reduction 422 the Human and Financial Costs of Operations in Afghanistan and Iraq in casualty numbers and high survival rates for seriously wounded troops can be attributed to the incredible advancements in the field of medicine, armored vehicles, body armor, and the asymmetric nature of the conflicts. According to the Veterans Health Administration, 1,158,359 veterans of Afghanistan and Iraq have been treated for a wide range of medical issues, the vast majority of them as outpatients. The most frequent diagnoses of veterans have been musculoskeletal ailments, mental disorders, and "Symptoms, Signs and Ill-defined Conditions. Between 2005 and 2012 (the peak of the war efforts in Iraq and Afghanistan), 423 Thannhauser and Luehrs Table 1. Defense Casualty Analysis System, "Principal Wars in Which the United States Participated-U. Operation Iraqi Freedom includes casualties that occurred between March 19, 2003, and August 31, 2010, in the Arabian Sea, Bahrain, Gulf of Aden, Gulf of Oman, Iraq, Kuwait, Oman, Persian Gulf, Qatar, Red Sea, Saudi Arabia, and the United Arab Emirates. Personnel injured in Iraqi Freedom who die after September 1, 2010, will be included in statistics from that operation.
Syndromes
PrognosisThe prognosis for lymphoplasmacytic enteritis is variable and depends on its severity and the preence of concurent disease depression buy abilify 20 mg with visa. As no accurate criteria exist for predicting response it is wise to give a guarded prognosis depression definition finance buy abilify 10mg otc. Alimentary lymphoma the changing and variable phenotype of feline alimentary lymphoma: Lymphomas represent up to ninety percent of hematopoietic tumors in the cat and are one of the most frequently diagnosed tumors of domestic cats depression psychology buy abilify 20 mg. Alimentary lymphoma is now the most common anatomic form and predominantly affects middle age to older cats anxiety natural supplements buy 5mg abilify overnight delivery, in contrast to mediastinal or multicentric lymphoma that typically affect younger cats definition of depression pdf abilify 10 mg low cost. This increase in alimentary lymphoma has also been accompanied by a change in immunophenotype zyprexa mood disorder 10 mg abilify fast delivery, from predominantly high grade B cell to predominantly low grade T cell. In a study of 41 cats with low-grade lymphocytic lymphoma evaluated at the Cornell University Hospital for Animals and South Carolina Veterinary Internal Medicine between 1995-2005, the median age at diagnosis was 13 years 148 (range, 6-17 years) and 40/41 were Domestic Shorthair (n = 33) or Domestic Longhair (n = 7). Lymphoma was confined to the gastrointestinal tract in 68% of cats and eighty-nine percent (32 of 36) of lymphomas were determined to be of T-cell origin by immunohistochemistry, while 8% (3 of 36) were of B-cell origin. This diversity in cell morphology and immunophenotype has potential implications for etiopathogenesis and treatment, and subsequent studies should be stratified on the basis of tumor immunophenotype and cell morphology. The response to therapy has also changed, with overall median survival time reaching 704 days in low-grade lymphoma versus weeks to months in high-grade large cell lymphoma. The factors responsible for the changes in prevalence, immunophenotype and biology of feline alimentary lymphoma are not known. Hepatosplenomegaly, renomegaly, generalized lymphadenopathy and abdominal mass may also be detected. Acute abdominal pain and shock may be present if intestinal perforation has occurred. Anemia which is either normocytic normochromic non-regenerative or microcytic and hypochromic, and neutrophilia may also be present. Ultrasound is useful for evaluating intestinal thickness / layering, presence or ansence of mucularis hypertrophy, and detecting mesenteric lymphadenopathy and abnormalities in liver/kidney/spleen and pancreas. Diagnosis can be made by demonstrating neoplastic lymphocytes in aspirates or biopsies from enlarged intestinal or peripheral lymph nodes, but is more often made by intestinal biopsy. However, endoscopy can also miss submucosal and serosal lesions or yield a diagnosis of "lymphoplasmacytic enteritis". Treatment and prognosis:In a recent study of 41 cats with low-grade lymphoma, lymphoma was confined to the gastrointestinal tract in 68% of cats, while 32% had other organ systems affected with or without gastrointestinal involvement. Eighty-nine percent (32 of 36) of lymphomas were determined to be of T-cell origin via immunohistochemistry, while 8% (3 of 36) were of B-cell origin. Fifty-five per cent of cats achieved a complete response to therapy and 37% achieved a partial response. Partial response to therapy was associated with shorter remission duration (P = 0. Interestingly, 78% of cats tested in this study had hypocobalaminemia, which was associated with short remission duration, but only in the univariable analysis. Lymphoblastic lymphoma, is much more aggressive than lymphocytic lymphoma, is generally treated with combination chemotherapy, and carries a poor prognosis. In the study of Fondacaro et al clinical signs, physical exam findings and endoscopic localization of disease overlapped in cats with lymphoblastic and lymphocytic lymphoma. Lethargy and the presence of an abdominal mass tended to be more frequent in cats with lymphoblastic lymphoma. However, endoscopy can miss submucosal and serosal lesions or yield a diagnosis of "lymphoplasmacytic enteritis". Concurrent renomegaly or splenomegaly should also prompt consideration of lymphoma and aspiration/biopsy. This can be relatively straightforward where biopsies are considered adequate in size and number, and unequivocal lymphoblastic cells or a monomorphic population of small lymphocytes are present. There is strong evidence in people that low grade mucosa associated lymphomas develop as a consequence of a genetic predisposition (typically chromosomal translocations that impact mucosal inflammation or apoptosis) and a chronic infections with bacteria and viruses are increasingly associated with lymphoma. We have established that cats with lymphoplasmacytic enteritis have shifts in mucosal Enterobacteriaceae, E. Recent studies have expanded our knowledge of the role that viruses may play in promoting chronic intestinal inflammation, which is a known risk factor for tumorigenesis. Mucosal inflammation depended on the presence of the intestinal microbiome and pro-inflammatory cytokines. Taken as a whole, the evidence to date supports the possibility that an underlying bacterial or viral infection could be involved in the etiopathogenesis of feline alimentary lymphoma References and further reading Baez, J. Signalment, history, and outcome of cats with gastrointestinal tract intussusception: 20 cases (1986-2000). Evaluation of high-throughput sequencing for identifying known and unknown viruses in biological samples. Ultrasonographic thickening of the muscularis propria in feline small intestinal small cell T-cell lymphoma and inflammatory bowel disease. Comparison of endoscopic and full-thickness biopsy specimens for diagnosis of inflammatory bowel disease and alimentary tract lymphoma in cats. Immunophenotypic and histological characterisation of 109 cases of feline lymphosarcoma. Feline idiopathic inflammatory bowel disease: what we know and what remains to be unraveled. Diagnostic algorithm to differentiate lymphoma from inflammation in feline small intestinal biopsy samples. Evaluation of two diets in the nutritional management of cats with naturally occurring chronic diarrhea. Low-grade alimentary lymphoma: clinicopathological findings and response to treatment in 17 cases. Response rates and survival times for cats with lymphoma treated with the University of Wisconsin-Madison chemotherapy protocol: 38 cases (1996-2003). The role of antigenic drive and tumor-infiltrating accessory cells in the pathogenesis of helicobacter-induced mucosa-associated lymphoid tissue lymphoma. Feline lymphoma (145 cases): proliferation indices, cluster of differentiation 3 immunoreactivity, and their association with prognosis in 90 cats. Journal of veterinary internal medicine / American College of Veterinary Internal Medicine 12:349-354. The histologic classification of 602 cases of feline lymphoproliferative disease using the National Cancer Institute working formulation. Characterization of feline immunoglobulin heavy chain variable region genes for the molecular diagnosis of B-cell neoplasia. The relationship of serum cobalamin to methylmalonic acid concentrations and clinical variables in cats. It can be further classified according to its effect on the patient as mild or severe, nonfatal or fatal, and also by the presence of sequela such as abscess formation. Histologically, acute pancreatitis is characterized by findings that range from pancreatic edema to necrosis, variable infiltrates of mononuclear and polymorphonuclear cells, and local changes such as peripancreatic fat necrosis and thrombosis. Acute pancreatitis may resolve or persist and can be complicated by secondary infection and pseudocyst or abscess formation. It is tempting to equate mild acute pancreatitis with pancreatic edema, and severe or fatal pancreatitis with pancreatic necrosis, but this relationship has not been critically examined in patients with naturally occurring pancreatitis. Etiology and Pathogenenesis the etiology and pathogenesis of spontaneous pancreatitis is poorly understood. In the normal pancreas safeguards are present to ensure that harmful pancreatic enzymes are not activated until they reach the intestinal lumen. Vacuole formation is thought to be a consequence of the uncoupling of exocytosis of zymogens and abnormal intracellular trafficking of digestive and lysosomal enzymes. These subcellular alterations are considered to precipitate the intracellular activation of digestive enzymes. Pancreatic hyperstimulation may be of direct relevance to naturally occurring pancreatitis in dogs. It is possible that high fat diets exert their effects via the excessive release of cholecystokinin and that hypercalcemia, organophosphates and high levels of circulating glucocorticoids also facilitate (potentially by changing pancreatic sensitivity to hyperstimulation), or cause pancreatic hyperstimulation; however, this is not proven. This concept of pancreatic down regulation is important when considering nutritional intervention in acute pancreatitis. Often pancreatic inflammation is a self-limiting process, but in some animals reduced pancreatic blood flow and leukocyte and platelet migration into the inflamed pancreas may cause progression to pancreatic necrosis. It is the development of multisystemic abnormalities that separates mild from severe, potentially fatal pancreatitis. Diagnosis There is currently no single specific test for pancreatitis in dogs and diagnosis is based on a combination of compatible clinical, clinicopathological and imaging findings. Surgical biopsy may be required to confirm a diagnosis, and to distinguish inflammation from neoplasia. Clinical findings Signalment and History Midlle aged to old dogs (>5yrs years old) who are overweight appear at higher risk. Miniature Schnauzers, Yorkshire and Silky Terriers, non-sporting breeds and perhaps miniature poodles may be at increased risk of developing pancreatitis. Endocrinopathies such as hypothyroidism, diabetes mellitus and hyperadrenocorticism may also be risk factors. Thirteen percent of 221 dogs with diabetes mellitus had histological evidence of acute pancreatitis. The history may reveal a recent episode of dietary indiscretion, toxin ingestion or drug administration. Polyuria and polydipsia may be present in dogs with diabetes mellitus and pancreatitis. Physical Examination Physical findings in dogs with acute pancreatitis are variable and range from depression, to mild dehydration with signs of abdominal pain, to acute abdominal crisis with shock (tachycardia, prolonged capillary refill time, tacky mucous membranes, hypothermia), petechiation, icterus and ascites. Diagnostic approach and differential diagnosis the differential diagnosis of acute pancreatitis in dogs is usually centered round the problems of vomiting and abdominal pain. In vomiting dogs the initial approach is to distinguish self-limiting from more severe causes of vomiting on the basis of physical findings and a minimum database. Packed cell volume, total protein, azostick, urinalysis, plasma concentrations of sodium and potassium). Where vomiting is associated with systemic signs of illness, or is persistent, the clinician has to differentiate metabolic, polysystemic infectious, toxic and neurologic causes from intra-abdominal causes. This is usually achieved on the basis of combined historical and clinical findings coupled with a minimum database and the evaluation of hematology and serum chemistry profile, urinalysis and abdominal radiography. Measurement of serum amylase or lipase is often reported on routine serum chemistry profile. Where abdominal pain is the major finding localizing abnormalities such as abdominal distension are rapidly pursued with radiography, ultrasonography and paracentesis while providing supportive treatment on the basis of physical findings and a minimum data base and awaiting the results of hematology, serum chemistry profile and urinalysis. Musculoskeletal disorders such as discospondylitis and prolapsed discs can be hard to distinguish from abdominal causes of pain. Diarrhea, which was bloody in some cases, is reported as a more frequent sign than vomiting in dogs with experimental acute pancreatitis. Acute pancreatitis and its complications (infection, pseudocyst or abscess formation) should also be considered in the differential diagnosis of icterus and pyrexia. Diagnosis in these animals requires a high index of suspicion and use of versatile diagnostic tests such as ultrasonography. Clinicopathological findings Hematology: Extremely variable, ranging from mild neutrophilia and slightly increased haematocrit, through marked leukocytosis with or without a left shift, to thrombocytopenia, anemia and neutropenia with a degenerative left shift. The presence of glucose or ketonuria should prompt consideration of diabetes mellitus. Pancreas specific markers: Classically, elevations in serum amylase and lipase activity have been used as indicators of pancreatic inflammation in dogs. However these enzymes can be increased in non-pancreatic disease, and dogs with confirmed pancreatitis may also have normal amylase and lipase activity. For example, in dogs with histologically confirmed pancreatitis, lipase is normal in 28 to 61% of dogs, and amylase is normal in 31 to 47% of dogs. This resulted in a specificity using the lower cutoff value of 95% (95% confidence interval 83. This was a lower sensitivity than for total lipase (54% and 71%, respectively) in the same cohort of dogs! Punctate calcification may occasionally be identified in dogs with long-standing pancreatitis; it indicates saponification of mesenteric fat around the pancreas. Thoracic radiographs may enable the detection of pleural fluid, edema or pneumonia which has been associated with pancreatitis in dogs and cats. One study of dogs with fatal acute pancreatitis indicated that ultrasound supported a diagnosis of pancreatitis in 23/34 dogs. Fine needle aspirates of cavitary lesions may be useful to distinguish abscess from pseudocyst. Abdominal paracentesis: Examination of peritoneal fluid may aid the detection of various causes of acute abdominal signs such as pancreatitis, gastrointestinal perforation or ruptured bile duct. Prognostic indicators Stratifying the severity of pancreatitis is useful when deciding how aggressive to be with medical and nutritional support, and in offering a prognosis. Severe pancreatitis requires aggressive support and carries a guarded prognosis, whereas mild pancreatitis often responds to short term symptomatic therapy and has agood prognosis. Clinical and clinicopathological criteria can be used to predict the severity of acute pancreatitis.
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