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Dr. Austin: Welcome to an MUSC Health Podcast. I'm Dr. Linda Austin, and I'm interviewing Dr. Megan Baker, who is a surgical oncologist with a specialty in surgery for breast cancer. She is Medical Director of the Breast Program here at Hollings Cancer Center at the Medical University of South Carolina. Dr. Baker, I know we're doing some very, very exciting work here in the area of surgery for breast cancer, and you have patients coming from all over the United States because of the very special services and approach that you offer. What is unique about the work you're doing in this area?
Dr. Baker: In general, breast cancer surgical treatment typically revolves around the choice between breast conservation therapy, , plus radiation therapy, which is removal of the entire breast. And traditionally, mastectomy's been done by removing the breast tissue, the breast mound itself, including the nipple and the complex of the breast, and that includes the colored area of the nipple. More recently, we've been doing quite a bit of nipple sparing mastectomy technique, one in which that whole nipple complex is preserved, and in about sixty to seventy percent of patients this also preserves the sensation of the nipple. This technique isn't appropriate for every patient, but for many this is certainly a very viable, aesthetically and functionally preferred option. This is paired at the same time with immediate breast reconstruction, and this can be paired with various types of reconstruction. It can range anywhere from implant reconstruction to more complex autograft meaning using your own tissue to remake your breast
Dr. Austin: So Dr. Baker, let's walk through that process then that you just outlined. A woman, let's say a woman here in South Carolina, or a woman in Idaho or wherever goes and gets her mammogram, she gets a call that there is something suspicious. And a biopsy is done, let's imagine, and in fact the diagnosis that there is carcinoma is made, what is the next step?
Dr. Baker: Well, the next step really revolves around education, and it's very important for patients to realize that they have options. And so the education comes not just from talking to physicians and nurses, but also doing some research on their own. As breast cancer treatment has gotten more progressive and more advanced, the choices have become far more in number. And the choices, although attractive, are often very confusing. And so it's very tempting, given the anxiety that comes with a breast cancer diagnosis, to rush to a surgical decision, or rush to a treatment plan, and I really encourage patients to make a thoughtful decision. And that thoughtful decision will require doing some research on their own, speaking to at least one physician, ideally getting a second opinion when possible, and seeing what the options are. Again, from the surgical perspective those options may be breast conservation, or maybe some form of mastectomy and not one mastectomy fits every woman anymore. So even within the realm of removing the breast there are even more options that are there. But what's very important, and something that you mentioned shouldn't be taken for granted, is getting that diagnosis first before you go to the operating room. The days of going to the operating room to get a diagnosis just because are long gone. And that's important because it really affords a woman an opportunity to know what the diagnosis is so they can consider their options, whereas if you're going to the operating room because you have a lump and you're not sure what it is, it will change what you do in the operating room, and it may burn a bridge and not allow you to do something later. So when technically possible and physically possible, having a minimally evasive biopsy first typically either done by either a surgeon or a radiologist is really a standard of care that we encourage. \par Dr. Austin: That's really helpful to know, and that really is a change from the old days when women would go to the operating room not knowing if they would wake up with a breast or not
Dr. Baker: Exactly. A woman should go to the operating room and wake up knowing exactly what the plan is from the very beginning. I encourage patients that what happens in the operating room should be boring, and there shouldn't be any surprises, because they should come out getting exactly what they planned for. And so that's where the planning really takes so much time for breast cancer. And when I say time and thoughtfulness to it, I don't mean to suggest weeks to months, but even just taking several days to a week or two to sort out what plan is best for you can really ensure a higher quality of care as well as a higher level of confidence in that care. And I'm a very firm believer that if a patient gets the very best of care but doesn't feel confident in the plan, then it really adversely effects their recovery. So it's not enough to have the right treatment, you have to believe that it's the right treatment, and that's where preparation ahead of time is really essential.
Dr. Austin: We had been talking about the nipple sparing procedure that you do. Who is a good candidate for that procedure, and who is not a good candidate for it
Dr. Baker: We typically will recommend nipple or areola sparing mastectomy for women who are considering prophylactic or preventative mastectomy. So women that are considered in that group are women who have been diagnosed with inherited breast cancer gene syndromes something called BRCA one or two. And we know from research those women are at extremely high risk for breast cancer, so much so it justifies removing the breast before they get cancer. Similarly though, there are actually women who have cancer, would like to reduce the risk of having a local recurrence as aggressively as they could, and would be a candidate for this. If their lesion or their tumor is located directly behind the nipple or is involving the nipple, then that certainly would be a contraindication, a reason not to consider this therapy. If they had a specific type of breast cancer ductal carcinoma in situ, which has a proclivity for traveling along the ducts which finish their tracts at the nipple itself, then doing this procedure certainly wouldn't always be appropriate. So nipple or areola sparing mastectomy is a wonderful option but only for a selected group of patients. And so that's where having a lot of preoperative information, particularly an MRI of the breast can be very helpful
Dr. Austin: You mentioned also that oftentimes in that first operation you often do the reconstruction of the breast after mastectomy, is that correct?
Dr. Baker: Mmhhmm.
Dr. Austin: Can you explain the procedure that you use there?
Dr. Baker. Sure. Some women who undergo mastectomy are candidates, meaning that it's safe to undergo immediate reconstruction. So they go to sleep with a breast, and wake up with a newly reconstructed breast. And that's certainly appealing for many reasons, the least of which is the psychological impact of going to sleep and waking up still with a breast. Having that sense of that physical and aesthetic symmetry can never be underestimated. When you're reconstructing the breast at the same time there are several options, the most simple of which would be an implant, the most complex of which would be using your own fatty tissue from other parts of your body, and bringing it up and sewing it into place using microsurgical technique to remake the breast. We're replacing fatty tissue with other fatty tissue, whether it comes from the tummy tuck area, or from someone's bottom. And this is very technically challenging surgery, that I'm very proud of our plastic surgery team that they do quite a bit of it, and the results are very impressive. It's certainly attractive for many young women who are physically active and are young, because this type of reconstruction doesn't take any muscle, and if you're not taking muscle from your six pack area, your rectus, or you're not taking muscle from your back, your latissimus, you don't have the resulting muscle weakness or potential hernia that's there. So you're replacing like with like, not at the expense of any functional unit of your body.
Dr. Austin: So just to clarify that a little bit, are you saying then that another approach that is done by other surgeons or at other centers might be to take muscle
Dr. Baker: Sure, and we will do that too. It's commonly called a tranflap, that comes from the rectus muscle, the six pack muscle of someone's abdomen, or the latissimus flap, coming from the back area just behind the arm. And for some women that's the best option for reconstruction, and our team offers that as well. But for other women that muscle weakness that results is very meaningful, and can make them uncomfortable or make them at risk for problems down the line. So one of those bits of research that I encourage women to do if they're thinking about reconstruction at any time, whether it be immediate or ten years after their mastectomy, that they really research the surgeon that they're going to see, make sure that what they're being offered isn't limited by that surgeon's repertoire but is only limited by what they're body will allow them to do. And not every surgeon can do every technique, and that's fine, but it's important that if they're interested in something that they know what their options are.
Dr. Austin: So who is the ideal candidate for the reconstruction using fat versus the ideal candidate for reconstruction for the muscle flap reconstruction
Dr. Baker: Sure. It's almost easier to talk about who's not the ideal candidate. Really nowadays, women who are getting the muscle reconstruction are women who are too thin, or who have too many other procedures on their abdomen to take that fatty tissue. So women who don't have that fatty tissue but still want to use their own body's tissue will use muscle, borrow muscle from an area to make a new breast mound, rather than using fatty tissue to do that. If a woman has enough ample fat to remake the breast, than it's preferable to just use that fat to remake the breast because they don't have the weakness.\par \par \par Dr. Austin: Plus they have a slimmer waistline then, don't they
Dr. Baker: That's the silver lining to each woman's difficult time through cancer. If they can get a tummy tuck or a lift on their backside that's certainly a major plus.
Dr. Austin: How about saline implants, are those also used, or are they used in addition to the muscle flap
Dr. Baker: Very rarely are they used in combination. For some women that may be an augmentation to their breast, meaning enlarging it to a size larger than what the muscle volume will allow them. You might do a combination of implant and muscle flap. More commonly, women who choose implants are choosing implants are choosing it because it's a less involved operation. And so the recovery is more straightforward, the recovery's not as difficult, and the time in the recovery room is significantly less. We use both saline as well as silicone implants, although historically that's been very controversial. However, we always reassure patients with the best research available, and to date there's been no high quality research that's demonstrated a problem with silicone based implants. Depending on what size a woman is trying to reconstruct their breast and what the rest of their body habit is, there are better choices, silicone versus saline for each woman, and that's where having a careful conversation with the plastic surgeon is very important.
Dr. Austin: What percentage of the time is that first procedure sufficient versus how often you have to go in and do an additional plastic surgery surgical procedure to really get the effect that you want.
Dr. Baker: Well for women who are undergoing reconstruction, it's rarely a one time procedure. In fact it's often multiple steps, the latter steps of them being much less involved, typically an out patient procedure. So for example if a woman had a mastectomy and had an immediate reconstruction with an implant, they normally go back one other day as an out patient, meaning in and out of the hospital the same day. If they're having a more involved surgery using flap, meaning their own tissue, whether it be muscle based or fatty tissue based, they're typically going to come back three months later to have things revised, what's called a stage two, and they may come back even a third time for a revision or a reconstruction of the nipple complex itself with a tattooing to remake the color of the areola and the nipple. So those procedures can sometimes even be done in the office, so they're much more straightforward, much more simple than the initial procedure. But it does require some fine tuning.
Dr. Austin: Does the initial procedure then usually require staying at the hospital overnight
Dr. Baker: Absolutely. So a mastectomy in general whether you're having reconstruction or not, typically requires one to two nights in the hospital. If you're having implants to reconstruct that breast at the same time, your stay in the hospital is about the same, it doesn't change. If you're reconstructing the breast with muscle or fatty tissue it typically adds two to three additional days, so you're in the hospital for a total of four to five days
Dr. Austin: Because you also have the wound site where the tissue's been harvested, is that right?
Dr. Baker: Exactly. So the recovery's a little more complicated.
Dr. Austin: What is the range of time that the initial procedures take?
Dr. Baker: In the operating room
Dr. Austin: In the operating room, mmhhmm
Dr. Baker: Sure. A mastectomy in general, of course it varies somewhat, but in general a mastectomy in general takes an hour and a half to two hours, if you're just doing that one side. And, if you're going to reconstruct that breast, probably another hour added onto that, reconstructing with an implant. If you're going to reconstruct with a flap, it can add on anywhere from four to eight hours. So it can be a whole day in the operating room, particularly if you're doing both breasts at the same time. So you can see why some patients who don't want a long time under anesthetic would certainly be guided more intuitively towards implant reconstruction because the operative time is shorter, the recovery is shorter. Whereas other women who are willing to undergo a longer operation and a slightly more difficult recovery to gain the aesthetic and functional benefits of an autologous using your own tissue will gravitate towards that direction in spite of the longer operative times.
Dr. Austin: Are you implying that the autologous reconstruction tissue might look a little bit better than the implant, or be softer to the touch than the saline implant
Dr. Baker: I think certainly long-term the aesthetic results certainly are better. In the immediate, you know, first year or two, they certainly are comparable to the visual inspection. Certainly as natural as implants can feel, fatty tissue feels more natural than an implant would. The biggest difference that we really see over time is that an autologous, using your muscle or fatty tissue reconstruction is going to age with you appropriately. So it's very normal for women as we get older for our breasts to fall closer to our waists. And it's something we aren't always happy about, but certainly we don't want an age inappropriate look to our breasts either. And so the autologous reconstruction are certainly more age appropriate over time, and you'll see those kind of gravitational changes, whereas with implants you often don't. And I have many patients who in ten years have to get them revised to kind of shift them appropriately so they look more appropriate to their age.
Dr. Austin: And so that each side, right side matches left side
Dr. Baker: Exactly. Symmetry is really one of the most important things. Many women think of breast reconstruction as an issue of size, where in reality it's an issue of symmetry. And so there's never a more unhappy patient than one who is asymmetrical when it comes to the reconstruction. If you're symmetrical in the way things look, left being equal to right, most women are exceptionally happy. \par \par \par \par Dr. Austin: But that's a challenge, because it's not just getting it right in the beginning, but having it stay right over time
Dr. Baker: Exactly.
Dr. Austin: So that's a real challenge
Dr. Baker: Absolutely.
Dr. Austin: Dr. Baker, thanks so much for talking with us today.
Dr. Baker: You're very welcome.
Dr. Austin: If you have any questions about the services or programs offered at the Medical University of South Carolina, or if you'd like to schedule an appointment with one of our physicians, please call MUSC Health Connection at 1(843)792-1414. That's 1(843)792-1414.


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Gillard to demand deeper integration with Asia
PUBLISHED: 24 Oct 2012 00:04:27 | UPDATED: 24 Oct 2012 06:41:08PUBLISHED: 24 Oct 2012 PRINT EDITION: 24 Oct 2012Craig Emerson wants Chinese investment in the north. Photo: Alex Ellinghausen
Greg Earl Asia-Pacific editor
The government's much-delayed policy on the Asian Century, to be released on Sunday, will set benchmarks for integration with Asia over the next two decades.
The white paper is not expected to involve additional spending as the government struggles to return the budget to surplus.
It will instead focus on long-term strategy that can be taken up by future governments and filter down to lower levels of administration.
It will anoint China, India, Indonesia, Japan and South Korea as the regional countries of key importance to Australia's long-term economic and security future, but also refer to the US in this context.
The core theme in the paper will be that to prosper in the Asian Century, Australia needs to go beyond depending on good relationships with executive governments in the region to lower-level engagement in education, the workplace and people-to-people connections.
It will argue Australia must be more receptive to foreign investment from the savings-rich region, will need to shift towards services exports after the mining boom and accept the growth in out-sourcing of Australian jobs in return for new income streams from sources such as Asian tourism.
The government will reject the need for significant new industrial relations changes to remain competitive in Asia but will nevertheless place more responsibility on businesses to develop a workforce which is more Asia literate in on-the-ground experience and languages.
But the paper will also acknowledge that Australian governments are not prepared for the challenges of integrating with the region and will need to improve their Asia literacy to cope with new flows of capital and people from the region.
Prime Minister Julia Gillard will release the report at the Lowy Institute for International Policy on Sunday, later than it was first promised in the middle of the year, but still only 13 months after it was announced last year as Ms Gillard started to build a foreign policy dimension to her prime ministership.
The paper started as a wide-ranging and independent public consultation process led by former Treasury secretary Ken Henry, but was then taken over by the Office of National Assessments and has since been massaged by a cabinet team to become a forward-looking agenda for the next election.
National consensus needed
While lack of significant new spending in areas including education and concessions to foster a financial services hub will disappoint many lobbyists, other participants in the white paper consultation say it is more important to get some degree of national consensus on a pathway ahead.
The idea of an Asian Century first emerged within the federal government in Treasury analysis of the changing global economic outlook. The white paper has been driven by the Treasury idea that Australia needs to embark on a new round of structural adjustment to reap the benefits of being close to the fast-growing Asian economies.
Trade Minister Craig Emerson, an architect of the paper, is pushing Chinese investment in northern agriculture as an example of this.
But the public consultation has raised the relative importance of educational and cultural links in long-term engagement alongside the trade and investment opportunities.
Long-term allies valued as much as tigers
While the consultation team was encouraged to leave security issues to the forthcoming defence white paper, the final document is expected to reflect the value of long-term regional allies such as Japan alongside the economic opportunities in newly emerging countries such as China.
Speaking in India last week, Ms Gillard said: "The Asian Century is the setting for the great national opportunities and challenges each of us faces.
"Global economic and strategic weight is shifting eastwards towards our region, driven by the rapid modernisation of Asian nations, by economic dynamism and by population growth.
"Asia is becoming the world's largest consumer market. For Australia, we are in the right part of the world at the right time."
But speaking at the recent launch of an Asialink report on an Asia-ready workforce, Dr Henry said Australia had gone backwards in its readiness to compete in the Asian Century and now needed a shared vision on how to recover.
"It [the shared vision] is going to be tested over the next few months, I think. Let's see if we have it."
The Australian Financial Review

subset: commoncrawl


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Very Good Recipes of No Bake from Make lemonade and more!
There is one No Bake recipe on the blog Make lemonade and more!. (238 on all the blogs)
Click on the title of a recipe or the photo of a dish to read the full recipe on its author's blog.
Chocolate Peanut Butter No Bake Cookies
By Make lemonade and more!
03/05/12 04:32
Okay... does anyone else always HAVE to make cookies or something on Sunday afternoon?? Today was no exception... and all of a sudden this afternoon, I was craving good old no-bake cookies. I have not been able to find my mom's recipe anywhere for a long...
Add to my recipe book


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Daeron patted Sven's shoulder and murmured, "That's why we stay." Looking to the flock, he thumbed towards them, motioning to the fellow shepherd to help, hopefully. Stitch was perked up now that the activity began, looking about with curiosity. Wary, the near-mute began signalling to the flock to begin a slow meander towards the western field, as if to simply rotate their grazing, while he
kept an eye out towards the western side of the land. If they were getting surrounded, things would be far worse.
Perception: Dice Roll: 1d20+3 d20 Results: 17 (Total = 20) |


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A number of things can happen this 4th of July weekend. What will you be doing?
Watching fireworks?
...A number of things can happen this 4th of July weekend. What will you be doing?
Watching fireworks?
...Today, New Jersey Attorney General Paula Dow is joining The Foundation for Advancing Alcohol Responsibility's Ron Engle and others to kick off a summer's worth of programs to fight underag
...Girl Talk: Choices and Consequences of Underage Drinking is making an appearance to
...One local program we're very proud to support is SoberRide.
...Originally published in The Globe and Mail
Summer is a funny time for teenagers. It's so different from the school year, when everything is scheduled and accounted for, filled with what needs to be done. But summer is this big chunk of time that can be like a block of unformed clay. It sits there and you can make of it what you want. Or you can let it just sit there.
"Yeah, that's my vote. Let me just have it sit there. The perfect summer. Nothing."
Parents may not have quite the same perspective. "That's exactly what I worry about. I don't want him to just waste a summer. The summer is an opportunity for him to make something out of it, to have some kind of valuable experience. Not spend two months as a vegetable. And then any opportunity is gone." So what is best for a teen to do with the summer? There are a number of rather different possibilities. Kids with an eye on university and career have the constant pressure of building their résumé, which, with each new entry, increases their chances of having a better future. Everything counts. No time can be wasted. No unspoken periods that were not somehow creatively utilized. Tutoring underprivileged school children. Taking a course in Western philosophy as it pertains to a more globalized world. Volunteering in a wildlife study that tracks the moose population during the summer months.


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Tag: mark kidwell
Showing results 1-11 of 11
Kidwell, Zornow Declare an Undead Uprising in "'68: Rules of War"
The zombies aren't the only things to be afraid in "'68: Rule of War," a new four issue series from Mark Kidwell, Jeff Zornow and Jay Fotos
PRESS RELEASE: "'68: Hallowed Ground" Print on Sale in Memory of Josh Medors
Kidwell Faces "Hardship," Drafts "Jungle Jim" for "'68"
Writer Mark Kidwell broadens his Vietnam-era zombie epic "'68" with a pair of new one-shots, "Hardship" and "Jungle Jim," coming out through Image Comics.
PRESS RELEASE: '68 #1 Marches Back to Press
Courtesy of Image Comics, CBR presents a first-look preview of "'68" #1 by Nat Jones, Mark Kidwell, and Jay Fotos, which sees a horde of zombies change the course of the Vietnam war.
EXTENDED PREVIEWS: "Hack/Slash," "Tyrannosaurus Rex"
Image Comics has provided CBR with extended looks at Tim Seeley's "Hack/Slash" #1 and "Tyrannosaurus Rex" by Mark Kidwell, Jay Fotos and Jeff Zornow, both on sale February 9.
PRESS RELEASE: Man Meets Dinosaur in "Tyrannosaurus Rex" from Image
"'68" Is The Year Of The Zombie
CBR spoke with creators Mark Kidwell, Nat Jones and Jay Fotos to discuss their 1960s era zombie miniseries about the Vietnam War, the infected flower power back home and the devastation across rest of the globe.
PRESS RELEASE: Welcome to 1968... and the End of the World!
Mark Kidwell Returns to Frank Frazetta's "Dark Kingdom"
Writer Mark Kidwell and artist Tim Vigil return to Frazetta Comics in October with "Dark Kingdom" #2. CBR News spoke with Kidwell to learn more about the Red Reaver's upcoming battle against the Death Dealer.
Kidwell & Cboins Talk "Frank Frazetta's Freedom"
"Frank Frazetta's Dark Kingdom" writer Mark Kidwell and newcomer illustrator John Cboins talk about their March-shipping one-shot, "Frank Frazetta's Freedom," the first western from the best-selling Frazetta line.
Archives: All | Comic Books | TV/Film | Video Games | Web Comics


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The only year I refused to go to my neighbor's Easter party was the year she dropped dead during the party.
tags: guilt death neighbor brain aneurysm [add]
2010-01-14 11:09:25 / Rating: 475.5 /
This is a single story of a single sentence. If you want more, visit the archives.


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Contact Us
Mailing Address:
SIUE Office of Human Resources
Campus Box 1040
Edwardsville, IL 62026-1040
Phone: (618) 650-2190
Fax: (618) 650-2696
Office Location:
Rendleman, Room 3210
Hours: M - F, 8 am - 4:30 pm
Faculty Position FY14-18
September 9, 2013
Position Title
Assistant Professor of English: Applied Linguistics, with secondary specialization in Second Language Acquisition
Hiring Unit
English Language and Literature
Job Description
The Department of English invites applications for a tenure-track position in applied linguistics, with secondary specialization in second language acquisition. Will teach courses in the MA TESL program, in undergraduate and graduate linguistics, in composition (ESL and regular), and some general education courses. Academic year: 3/3 load.
Qualifications Required
Ph.D. in Linguistics, Applied Linguistics, or related field required. If Ph.D. is not completed by the beginning of the contract period, appointment will be at rank of Instructor until all degree requirements are fulfilled. Desirable: record of ESL and TESL experience abroad.
Terms of Appointment
Tenure-track contract for academic year beginning August 16, 2014.
Source of Funds
Commensurate with experience and credentials. Excellent benefits package included.
Application Deadline
Completed applications postmarked by November 8, 2013 will have priority. Interviews at LSA in January. Position open until filled.
Application Process
Send cover letter, vita, unofficial transcript, statement of teaching philosophy, and three letters of recommendation to:
Linguistics Search Committee
Department of English
Box 1431G
Southern Illinois University Edwardsville
Edwardsville, IL 62026-1431
Candidates who advance to the second round will be asked to submit a writing sample and statement of research philosophy. Electronic applications will not be accepted for this position.
SIUE is a state university - benefits under state sponsored plans may not be available to holders of F1 or J1 visas.
Applicants will be subject to a background check prior to an offer of employment. Southern Illinois University Edwardsville is an equal opportunity employer and will not discriminate against any person on the basis of race, national origin, religion, disability, age, marital status, sex, sexual orientation or veteran's status in violation of Title VII.
The SIUE Annual Security and Fire Safety Report is available online at http://www.siue.edu/securityreport. The report contains campus safety and security information, crime statistics, fire safety policies, and fire statistics for the previous three calendar years. This report is published in compliance with Federal law, titled the "Jeanne Clery Disclosure of Campus Security Policy and Campus Crime Statistics Act" and the Higher Education Opportunity Act also known as the "Campus Fire Safety Right to Know." For those without computer access, a paper copy of the report may be obtained, with a 24-hour notice, from the Office of the Vice Chancellor for Administration, Rendleman Hall, Room 2228, 618-650-2536.
Central to SIUE's exceptional and comprehensive education, the College of Arts and Sciences has 19 departments and 85 areas of study. More than 300 full-time faculty and/or instructors deliver instruction to more than 8,000 undergraduate and graduate students.
Faculty help students explore diverse ideas and experiences, while learning to think and live as fulfilled, productive members of the global community. Study abroad, service-learning, internships, and other experiential learning opportunities better prepare SIUE students not only to succeed in our region's workplaces, but also to become valuable leaders who make important contributions to our communities.
Learn more at siue.edu/artsandsciences.


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2011 Equity Market Commentary
CIO, Equities
The year 2011 was marked by significant volatility in equity markets. Equity markets generally climbed in the first quarter of 2011 despite the continued sovereign debt crisis in Europe, political turmoil in North Africa and the Middle East, and the tragedy in Japan. An impressive corporate earnings season in the U.S. got the second quarter off to a strong start as well, but equity markets retreated in May and June over concerns about global economic growth prospects related to potential contagion resulting from the sovereign debt crisis in Europe, the end of the QE2 program, and political ambiguity surrounding the raising of the U.S. debt ceiling that resulted in a downgrade of U.S. government debt. The third quarter marked the worst performance by stocks since the 2008 financial crisis as the broad-based selloff in global equity markets erased gains from the first half of the year. However, a strong rebound in the fourth quarter left the Standard and Poor's (S&P) 500 and Russell 1000 Indices up 2.11% and 1.50% for the year, respectively.
Small-capitalization stocks did not fare as well, with the Russell 2000 Index ending the year down 4.18%. International markets, weighed down by the European sovereign debt crisis and the economic slowdown in China, fared even worse, with the MSCI EAFE and MSCI Emerging Markets Indices declining 11.73% and 18.17% in 2011, respectively. The growth investment style outperformed the value style for the year, with the Russell 1000 Growth Index up 2.64% while the Russell 1000 Value Index returned 0.39%.
While 2011 began with Energy and Industrials as the top-performing sectors, the short- term investor enthusiasm about the Energy sector was momentum driven, and we saw investor rotation into the traditionally more defensive sectors as the year progressed. For the year, the top-performing sectors within the Russell 1000 Index were Utilities, Consumer Staples, and Health Care, returning 19.08%, 14.06%, and 11.44%, respectively. Financials was by far the worst-performing sector for the year, down 14.82%. Materials and Industrials also lagged, returning -9.06% and -1.52% for the calendar year, respectively.
Sovereign Debt Crisis in Europe Weighs on Equity Markets Throughout the Year
Concerns about global economic growth prospects related to contagion in Europe caused by the sovereign debt crisis in that region impacted market sentiment throughout the year. Investors increasingly worried about the potential collapse of the eurozone and its likely disastrous consequences for the global financial system. The region's economic picture, including macroeconomic and fundamental earnings data, was looking increasingly grim towards the end of the year with peripheral economies firmly in a recessionary spiral and the entire union likely in a recession as retail purchasing managers index (PMI) and consumer spending data showed significant declines despite slower inflation.
Investors remained unconvinced that the eurozone's problems could be solved through the policy measures presented through most of the year and bond markets translated the sovereign risk crisis into soaring yields on the sovereign debt of Portugal, Spain, Greece, Italy, and France. Yields on French government debt reached 200 basis points above German bunds at one point. With Italian sovereign debt yields blowing through the 7% stress level and reaching 7.5% in November before pulling back, it was quite apparent that if credible European Union (EU) policy solutions to the crisis were not forthcoming, markets were going to force a solution by making borrowing extremely expensive for countries with poor balance sheets, a lack of fiscal discipline, and bleak economic prospects, thereby facilitating political change. This dynamic precipitated the progress toward new, technocratic governments in both Greece and Italy. While a welcome development, a more credible, structural integration in the eurozone on both an economic and a political level will be necessary for the monetary union to stay intact. Unfortunately, this outcome seemed more and more remote as the year progressed, and markets reacted accordingly, with U.S. Treasuries continuing to benefit from the turmoil in Europe.
After some political maneuvering, the parliaments of the EU countries voted to approve the July 21 EU Debt Summit decision to expand the size of the European Financial Stability Fund's (EFSF) lending capacity to €440 billion euros, which, at the time, allowed Greece to receive its much-needed next tranche of bailout funds. However, the plan to leverage the EFSF continued to hit obstacles during the year while the European Central Bank (ECB) and Germany remained reluctant to commit to an expanded role for the ECB in capping sovereign debt yields with bond purchases. German Chancellor Angela Merkel instead continued to push for closer economic ties among eurozone countries. The eurozone's move toward increased fiscal integration and fiscal austerity measures will likely create a fiscal drag on the region's economy and hurt the EU economy in the near term, although resulting structural changes should be positive in the long run. Tighter fiscal integration, if achieved, will help open the door for more active involvement by the ECB, which should be extremely helpful for market sentiment. ECB President Mario Draghi, who replaced France's Jean-Claude Trichet, cut interest rates by 25 basis points in November and by 25 basis points again in December to 100 basis points, supporting this view.
European bank stocks continued to be among those most adversely impacted by the eurozone debt crisis as the STOXX 600 Europe Banks Index approached the lows of the 2008 financial crisis. In addition to longer-term funding stress, the falloff in investment in European banks by U.S. money-market funds was a short-term stressor. Further consolidation in the European banking sector is likely to follow and, in the longer run, banks may shift to less risky strategies and assets, which will likely reduce returns and hurt their long-term profitability. This trend is also likely to apply to U.S. and other globally exposed banks.
The ECB lending program initiated towards the end of the year seemed to be successful and was received positively by investors. The ECB provided 489 billion euros in cheap three-year loans to European banks and lenders in the first tranche of "Longer Term Refinancing Operations (LTRO)," with additional funds available at the end of February. However, the belief that banks would use the cheap financing to purchase sovereign bonds, thereby pushing sovereign yields down, did not seem to play out in the fourth quarter.
At the time of writing this commentary, LTRO seems to be having a modest impact on sovereign yields to start 2012. In addition, the Standard & Poor's rating agency downgraded the sovereign debt of France from AAA to AA+ with a negative outlook, a development long anticipated by the markets. As expected, the downgrade of France's AAA rating led to a downgrade of the EFSF to AA+ as well.
Global Inflation Slows Toward End of the Year
In 2011, inflation became more of a focus for investors worldwide as food and energy prices increased globally in the first half of the year, causing concerns about global economic growth, especially in emerging economies. Crude oil hit 20-month highs during the first quarter in response to geopolitical instability in the oil-producing countries of the Middle East and North Africa. Another element impacting prices was extreme weather conditions around the world, from extreme heat in Russia to floods in Australia to severe snowstorms in Europe and North America over the past year.
However, the slow pace of global economic growth had a dampening effect on global inflation, allowing for global easing of monetary policies by central banks in the fourth quarter which, in turn, should help stimulate economic growth. Decreasing commodity prices are a positive for global economic growth in the near term, although the secular upward trend in commodity prices may persist in the long term, with emerging-market economies most severely affected since they rely more on commodity inputs for their fast economic growth.
China, which had been fighting inflation with a series of measures during the first half of the year, unexpectedly cut reserve rates for its banks on the heels of lower inflation numbers and lower-than-expected PMI data in the fourth quarter, which suggests the possibility of a hard landing for the Chinese economy. The move demonstrated China's shift to monetary easing in the face of a slowing economy and lower-than-expected inflation. A less orderly downturn in China's economic growth will likely spell trouble for global economic growth. This, combined with the potential risk of a significant negative event in Europe, could serve as a further shock to investor confidence sometime in 2012.
In the United States, core inflation remained stable and low, allowing the Fed to maintain its stimulative policy of a near-0% interest rate. Inflation expectations in the United States remain low for the time being and the consensus seems to indicate that, based on the current employment picture, wage inflation is not yet a concern, which means that the accommodating interest-rate policy could remain in place for some time.
S&P Downgrade of U.S. Debt
After months of partisan gridlock in Washington, U.S. political leaders finally reached an agreement and enacted legislation to raise the debt ceiling on August 2. Under the agreement, a special committee of lawmakers was tasked with finding another $1.5 trillion in reductions. The congressional "super committee" (the Joint Select Committee on Deficit Reduction) was not able to come up with a sufficient agreement on a package of spending cuts and tax increases by its November deadline. Although a backup package of spending cuts was to be automatically triggered if the committee failed to find at least $1.2 trillion in savings, it remains to be seen whether the previously agreed-to automatic spending cuts will be triggered and what effect the failure of the super committee to deliver solutions to the U.S. fiscal and debt problems might have on the U.S. government debt credit rating.
Despite the last-minute agreement, S&P followed through on its threat to cut the credit rating of U.S. government debt in light of the political indecision in Washington surrounding a concrete and credible plan for deficit reduction. As we expected, the S&P downgrade of U.S. government debt from AAA to AA+ on August 5 presented an additional blow to investor confidence and contributed to a global equity market selloff. It added to market volatility and further depressed investor sentiment while pushing U.S. Treasury yields down as risk aversion in the markets increased. Investors also increased purchases of safer assets like gold and silver, with the price of silver setting several new 30-year highs during the year.
However, even before the downgrade, investors were increasingly concerned about problems with European sovereign debt and about a significant slowdown in U.S. economic growth or, more ominously, a double-dip recession in the United States. We believe that these were significant underlying causes of the equity market volatility during the third quarter.
U.S. Housing Market Bottoming Out
The U.S. housing market, an important piece of the puzzle in U.S. economic recovery, is likely to continue its bottoming-out process into 2012 with prices continuing to firm up and likely to improve in some regions, starting a long-term upward trend, which means housing would no longer continue to be a drag on the economy. Housing affordability in the United States is at an all-time high which, combined with a pick-up in rents, should help provide support for housing pricing. The 30-year fixed mortgage rate dipped below 4% in October for the first time ever, indicating that the Federal Reserve's (Fed) "operation twist," designed to push longer-term Treasury yields down, is having that effect. However, while the refinance share of mortgage activity reached a 2011 high in the fourth quarter, financing for new borrowers is still hard to come by as banks' lending standards remain high.
High foreclosed home inventories continued to dampen improvements in the housing market. Though foreclosure activity declined 34% in 2011 compared to 2010, much of the drop was attributed to delayed filings caused by documentation and legal issues and is expected to pick back up in 2012. An estimated total of over four million homes have been repossessed by banks in the past five years. RealtyTrac, the online marketer of foreclosed properties, expects the number of home repossessions to increase around 25% in 2012 from the more than 800,000 properties seized during 2011.
Financial Sector Regulation
The Financial sector continued to be held under the regulatory microscope throughout 2011. As part of the Dodd-Frank financial services reform, the U.S. Securities and Exchange Commission (SEC) recommended that a uniform fiduciary standard be applied to brokers who provide personalized investment advice in the same way that it applies to registered investment advisers. At the time of writing this commentary, the SEC has delayed implementation of the new fiduciary standard in order to conduct a more detailed cost-benefit analysis of its impact. If passed, this regulation could significantly impact the retail investment industry's product offering and business model, with potentially negative implications for profitability.
Banks remained saddled with a variety of other issues as well, not the least of which was being ordered by regulators to pay back homeowners for losses on their foreclosed homes due to unsatisfactory loan documentation. Slow loan growth, balance sheets in need of restructuring to meet higher capital requirements, and long-term impairments and costs due to regulatory scrutiny and litigation added to the malaise. Additionally during the year, the Fed announced its intent to adopt the bank capital plans laid out in Basel III, an international regulatory framework for banks, which includes conducting annual stress tests.
Strong Corporate Earnings
In general, U.S. companies showed strength throughout the year, beating analysts' estimates on earnings, and in many cases exceeding revenue forecasts as well. Nearly three-quarters of companies in the S&P 500 Index beat consensus earnings estimates for each of the first three quarters in 2011.
Cash-rich U.S. companies continued to look for sources of growth in 2011 and used their impressive cash reserves for mergers and acquisitions. Express Scripts agreed to buy Medco Health for $29.1 billion during the year, which was a significant premium over Medco Health's stock market value prior to the acquisition announcement. Merger and acquisition activity continued with the announcement of one of the largest ever acquisitions in the energy industry, as Kinder Morgan offered to buy El Paso Corp. for $21.1 billion, a 37% premium. The acquisition would create the largest natural-gas pipeline operator in the United States. Additionally, Duke Energy agreed to buy Progress Energy for $13.7 billion. The combined company would become the largest U.S. electric utility. Also, Microsoft acquired Skype for $8.5 billion.
Continued Slow, Gradual Growth for the U.S. Economy
Despite the many risk pockets in the global market environment, the U.S. economy continued to proceed on the path of gradual recovery, driven primarily by continued health in earnings reports and macroeconomic data. Bank lending began improving while a weak U.S. dollar supported strong exports. The manufacturing-led recovery in the United States was complemented by improvements in consumer spending as the year progressed. The increased spending, however, seemed to be coming at the expense of a lower savings rate, with the U.S. savings rate at its lowest level in nearly four years. The combination of healthy manufacturing and consumer sectors of the economy will be the key to a self-sustained, robust economic recovery and continued earnings growth for U.S. companies.
Improvements in the household employment and temporary employment numbers were another welcome positive sign. The seasonally adjusted unemployment rate fell from 9.4% at the start of the year to 8.5% in December 2011 (and to 8.3% in January 2012), though some of the decline was due to a drop in the labor force participation rate. Unemployment claims in the United States were also slowing. The initial jobless claims four-week moving average was down to 375,000 at the end of the year—the lowest level since June 2008. We believe that these marginal improvements in the employment picture helped drive improvement in consumer confidence.
The health of U.S. consumer balance sheets also continued to improve, with consumer debt as a percentage of income declining, indicating that the consumer is deleveraging successfully. The quality of the U.S. government balance sheet, on the other hand, continued to deteriorate, with the U.S. budget deficit for the fiscal year ending September 30 reported at $1.3 trillion, the second-highest deficit level on record. Moreover, the U.S. policy stalemate in Washington continued to be frustrating and disappointing for both the country's citizens and market participants. U.S. policymakers need to resolve their differences in favor of the country's needs and address the U.S. debt issue head-on as soon as possible. At the end of December, Republicans finally agreed to a payroll tax break extension, albeit for two months instead of an entire year.
We believe that the market impact of a recession in Europe can be offset by economic expansion in the United States and emerging markets. We remain constructive on the U.S. economy and equity market going forward, especially given the strength of corporate earnings in the United States and the attractive valuation multiples of U.S. equities.
U.S. bank lending is improving. However, big bank risks in Europe that can impact systematically important U.S. institutions could upset that trend. A sustained recovery in U.S. financial stocks will continue to depend on orderly resolution of the European sovereign debt crisis. In 2012, significant portfolio underweights in the Financials sector, while beneficial over the past several quarters, will likely separate the "haves" from the "have nots" in investment manager alpha land.
In Europe, proposed policy measures are dealing primarily with the symptoms of the crisis. However, the underlying economic weakness of the peripheral eurozone countries and now probably of the core eurozone economies should continue for some time, which will likely worsen the symptoms policymakers are trying to address, i.e. sovereign debt issues. Additionally, Italy is so large and so indebted that it is too big to bail out, especially given the continued lack of agreement on the specifics of EFSF enhancements. Defaults and union exits by some EU peripheral economies such as Greece are no longer out of the question and are being openly debated. French sovereign spreads are spiking up, making the downgrade of French and possibly German debt ever more likely. This uncertainty is likely to keep European market volatility elevated with continued spillover into U.S. markets.
We believe that some of the stronger-than-expected economic data in the United States is a bounce-back from the shocks to the system that occurred earlier in 2011 with the supply chain disruptions caused by the environmental disasters in Japan (Japan's real GDP bounced back 6% in the third quarter) and with the political brinksmanship in Washington causing the downgrade of U.S. government debt.
As the U.S. economic recovery continues to gain momentum, smaller-cap names are likely to outperform large caps, while high-dividend stocks—the long-term darlings of investors—may lose momentum.
Similarly, the subsequent supply chain disruption caused by floods in Thailand may mean somewhat slower growth earlier in 2012 but is likely to have a positive multiplier effect later on as activity is restored and pent-up demand met. Overall, the debt crisis and recession (exacerbated by the fiscal drag from austerity measures) in Europe as well as inaction in Washington are likely to continue to have a dampening effect on U.S. growth in the medium term.
The downside risks for 2012 are some of the same issues we discussed over the past several months—European recession and a potential hard landing in China. Fiscal drag globally and in the United States will likely be a negative for global economic growth. Easing moves in several countries, especially within emerging markets, should provide some support for global economic growth. The U.S. economy, while not immune to the eurozone's recession, seems to be gathering positive, self-sustained momentum. We expect these trends to continue well into 2012 with the United States likely outperforming other developed economies.
This commentary represents the opinions of the author as of 2/16/12 and may change based on market and other conditions. These opinions are not intended to forecast future events, guarantee future results, or serve as investment advice. The statistics have been obtained from sources believed to be reliable, but the accuracy and completeness of this information cannot be guaranteed. Neither Calvert Investment Management, Inc. nor its information providers are responsible for any damages or losses arising from any use of this information.
Accounts managed by Calvert Investment Management, Inc. may or may not invest in, and Calvert is not recommending any action on, any companies listed.


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iPhone - iPod
This page contains What's My IQ? Hints for iPhone - iPod called "IQ Answer Level 6" and has been posted or updated on Aug 30, 2012 by vincenth. Let us know what you think of this Hint by thumbs voting.
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From Clinical Update, Summer 2003
by Thomas A. Nakagawa, MD, FAAPDepartment of Anesthesiology and PediatricsAbstract: Shaken baby syndrome is a serious form of child maltreatment that often goes unrecognized because of the diverse presentation of symptoms. Life-threatening complications such as respiratory embarrassment and/or cardiopulmonary arrest in a previously healthy infant with no explanation for the severity of symptoms is a common presenting scenario. The injuries sustained are the result of violent acceleration/deceleration forces as the head is whiplashed back and forth during violent shaking resulting in cerebral edema, subarachnoid and/or subdural hemorrhage, and retinal hemorrhages. Permanent neurologic injury or death can occur from this form of child abuse.
Eighty percent of deaths related to head trauma in infants and children less than 2 years of age occur because of non-accidental trauma (1), and homicide continues to be a leading cause of death in children under 1 year of age. Injuries sustained from violent shaking will result in the hospitalization of an estimated 1,500 infants annually, and many of these victims of shaken baby syndrome will have permanent neurologic injury. One-third or more of these infants will die from injuries sustained from violent shaking.
Shaken baby syndrome is a serious form of child maltreatment with recorded injuries related to violent shaking dating back at least 50 years. (2,3) It often involves children less than 2 years of age, although it may be seen in older children. Peak incidence occurs between 6 weeks to 4 months of age and males tend to be affected slightly more than females. The actual incidence of shaken baby syndrome is unknown since many cases go undiagnosed. In fact, a recent article by Jenny and colleagues reported that 31.2% of confirmed abusive head trauma cases were missed on initial presentation, and many infants sustained additional injury because of the delay in diagnosing abusive head trauma. (4) Therefore, the clinician must have a high index of suspicion that abuse may have occurred or the diagnosis of abusive head trauma may never be diagnosed. Bruising in any child who is non-ambulatory should raise suspicion of abusive trauma and be investigated.
The infant is at greater risk to sustain injury from violent shaking for several anatomic reasons. The head of the infant is the largest part of the body. The weak neck muscles allow the head to move in linear and rotational or angular directions if left unsupported. Additionally, the brain has a higher water content because of lack of mylenation and the larger subarachnoid space allows for more movement of the infant brain inside the skull. (5)
Injuries sustained from shaking are the result of violent forces. The American Academy of Pediatrics states, "The act of shaking leading to Shaken Baby Syndrome is so violent that individuals observing it would recognize it as dangerous and likely to kill the child." (6) Playful bouncing of an infant cannot generate enough force to create the injuries seen from violent shaking. Falls from beds, sofas and changing tables are commonly reported; however, studies show that falls from < 10 feet do not result in significant injury. (7) Additionally, vaccinations and seizures do not cause the constellation of symptoms seen with violent shaking. (6) Repetition of the shake injury is common, and although it may only last a few seconds, tremendous forces are generated and substantial intracranial injury can occur during this violent act. Although some medical professionals believe that impact injury must occur to produce the traumatic brain injury seen with violent shaking, the AAP states that violent shaking with or without impact identifies child abuse. (8) Lastly, the perpetrator is always larger than the victim.(6)
The common scenario is a crying infant with a frustrated caretaker who picks the infant up and violently shakes the child in an effort to stop the baby from crying. (6) The infant is grabbed by the shoulders or under the armpits and shaken violently. This violent shaking causes the infant's head to move back and forth rapidly, creating linear and rotational acceleration and deceleration forces. Linear forces result in retinal injury causing a hemorrhagic retinopathy. Additionally, compression of the chest may impede venous drainage from the head and neck region elevating intraretinal pressure contributing to retinal hemorrhages. (9) Rotational acceleration forces also occur and result in subarachnoid and subdural hemorrhages as the bridging veins are torn. Shearing of axons can result with longer shaking episodes resulting in diffuse axonal injury. The perpetrator may actually throw the infant back into the crib or bed causing further injury to the brain due to sudden deceleration forces. Impact of the head against a stationary surface can result in cerebral contusion or skull fractures and increases the magnitude of force generated from shaking. (10) During this violent act, the infant may actually cry more because of painful injury or lapse immediately into unconsciousness. Following this event the infant may be put to bed in hopes that recovery may occur, only to be found at a later time cyanotic, dyspneic, apneic, or in full cardiopulmonary arrest. The delay in treatment results in irreversible damage to the brain because of hypoxic and ischemic injury that is the major contributor to the poor neurologic outcome of many of these infants.
Injuries from shaking are due to tremendous forces. The forces involved with violent shaking have been estimated to be greater than 9 gravitational forces (G forces). This force is magnified if the head suddenly decelerates against a stationary object with G forces estimated to be 50 times greater. (10) The clinical presentation of infants who have been shaken can range from subtle findings including irritability, vomiting and poor feeding. In severe or lethal cases, infants may present with seizures, respiratory distress, cardiovascular collapse, coma and manifestations of cerebral edema with intracranial hypertension including vital sign changes and respiratory depression. The clinical symptoms correlate with the severity of the traumatic brain injury that occurs when the infant is violently shaken. Many times there is no history or sign of external trauma to explain why a child's condition rapidly deteriorated resulting in a critically ill state. When serious head injury is unexplained, the chances of inflicted injury are high and must be investigated. There is no evidence to support the claim that a child who has been severely shaken will be fine for hours then suddenly develop progressively worsening cerebral edema and deteriorating mental status. (11) When traumatic brain injury occurs, the infant will show signs of central nervous system insult almost immediately.
Clinical Findings
The findings of retinal hemorrhages, subarachnoid or subdural bleeding, and cerebral edema are characteristic of shaken baby syndrome. Each one of these findings alone or in combination helps the clinician diagnose shaken baby syndrome. Imaging studies of the head may show subarachnoid, subdural bleeding, cerebral edema, or older injury such as subdural effusions. Unilateral or bilateral retinal hemorrhages will be found in 75-90% of infants who are shaken. The hemorrhages tend to involve multiple layers of the retina and are the result of linear forces and/or chest compression resulting in venous stasis that disrupts the integrity of the retinal vessels causing hemorrhage. (5,12) Evaluation by a pediatric ophthalmologist and neurologist should be obtained to further document injuries to the infant.
The child should also be evaluated for other injuries such as skeletal trauma and chest and abdominal injury. A full skeletal survey should be performed looking for skeletal trauma. Rib fractures, although not present in all cases, can occur as the infant is grabbed and shaken by the perpetrator. Forces from the hands and fingers are applied to the chest, resulting in posterior and lateral rib fractures which are diagnostic of child abuse.
Many critically ill infants may have received CPR during their resuscitation. Although CPR can rarely cause retinal hemorrhages and rib fractures, the retinal hemorrhages seen with shaken baby syndrome are clearly different from those associated with CPR (13), and posterior rib fractures are not produced by closed chest compressions. Furthermore, rib fractures in any child suggest strong evidence of abuse until proven otherwise. Anemia may be present because of intracranial bleeding, and fresh blood in the cerebral spinal fluid may be noted if a lumbar puncture is performed. A coagulopathy may be present that results from the traumatic brain injury as tissue thromboplastin is released. (14) This coagulopathy will typically correct if there is no underlying bleeding disorder.
The poor outcome associated with shaken baby syndrome is the result of hypoxic ischemic injury that occurs secondary to cerebral edema and intracranial hemorrhaging. The delay in immediate treatment following the injury further compromises the infant's chance for a meaningful neurologic recovery. Mortality rates range from 15-38%. (6) Many infants who survive will be left neurologically impaired and will suffer from cortical blindness, seizures, hydrocephalus, learning disabilities, or be institutionalized in a persistent vegetative state. (2)
Child abuse has no socioeconomic boundaries, and there is no specific profile of perpetrators who shake infants and children. However, studies indicate that male caretakers, especially males in their early 20s who are left with the infant for short periods of time, are at greater risk to abuse infants. (15,16) Additionally, a high incidence of abuse exists in military families. (17)
Investigation of Events
Investigation of these cases can be emotionally challenging. A high index of suspicion for an unexplained injury should prompt a thorough investigation for non-accidental trauma, and the history needs to be consistent with the injuries. It is the medical professional's responsibility to report suspected child abuse. The case must be identified as suspicious and not the family. The health care team must be sensitive to the needs of the parents and remember our job is to treat the child and the family, not to determine who injured the child. Management includes the involvement of social services, law enforcement agencies and child protective services. Documentation of injuries and discussions with parents or guardians are essential.
Sadly, this preventable medical condition that plagues our society continues to exist. An estimated one-third of the American public still does not know that it is dangerous to shake a baby and that permanent neurological injury or death can occur after only 1-2 seconds of violent shaking. (18) Only through education of anyone who cares for infants and children can we hope to decrease the risk of injury from violent shaking. We must teach parents and caretakers to never, ever shake a baby. Caregivers need to understand that crying is a normal response for infants and when the caregiver becomes frustrated because of crying, the safest place for the infant is in the crib. Today's children are tomorrow's future. We must love them, protect them, and never, ever shake them.
Brenner Children's Hospital is western North Carolina's premier comprehensive pediatric service.
Disclaimer: The information on this website is for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, evaluation or care from your physician or other qualified health care provider.


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Tahitian paradise lost following Billabong wipeout
PUBLISHED: 13 Dec 2013 04:20:11 | UPDATED: 13 Dec 2013 09:51:45PUBLISHED: 13 Dec 2013 PRINT EDITION: 13 Dec 2013Billabong Pro Teahupo'o is one of global professional surfing's most eagerly awaited competitions and features surf stars such as Kelly Slater, above. Photo: Tim McKenna
Nick Carroll
Papa Parker guards the gate at the End Of The Road, Teahupo'o, Tahiti. Well, perhaps "guards" is too extreme a term. Papa sits at the gate, opening and closing it for anyone who has to travel by four-wheel-drive vehicle, sans bridge, to the other side of the Teahupo'o river and the growing collection of holiday houses that sits facing the lagoon and its famous surf spot. In his 60s, Papa is brown, bald and nuggety, with a huge grin. Rarely does he bother with a shirt. He will often grab passing friends by the shoulders and plant a big kiss on the top of their heads, bellowing their names with great good cheer. But he's slowly driving the Billabong surf contest event crew crazy. "Caps!" explains one crew member, sotto voce, so Papa can't hear. "Every time we come through the gate, he wants another cap. He'll look in the back seat just in case you're holding out on him. Last time we came through he got five caps – one from each of the guys in the car. And he still wants more."
The Billabong Pro Teahupo'o is one of global professional surfing's most eagerly awaited competitions. It stars the pro elite, the likes of Kelly Slater, Joel Parkinson and Mick Fanning, and occurs each August, in the middle of the Association of Surfing Professionals (ASP) World Tour year, when the world title race is settling into its rhythm and the top surfers are looking to break free of the pack. Overshadowing that in most surfers' minds is the wave itself, a raw, powerful coral reef break that sometimes verges on unrideable and has been known to take lives.
But beyond that lies a fascinating relationship between a big Western action-sports retailer and a tiny village on the edge of nowhere. On the one hand, millions of marketing dollars; on the other, that beautiful and terrifying wave. "They've done all right out of this," says event promoter Chris O'Callaghan, waving his hand across the incredible view from the lagoon judging tower. But which "they" does he mean?
Billabong's better days
The relationship goes back to 2001, when Billabong took over the franchise of the ASP's Tahiti event. Back then, the company was the Australian Securities Exchange's hot new arrival, its unrivalled core surf cred turned magically into millions for founders Gordon and Rena Merchant and many of their long-serving employees, along with various institutional investors, brokers and new chief executive Matthew Perrin. "Only a surfer knows the feeling", ran the company's flawlessly exclusive mantra; dry surf industry wits replaced "surfer" with "shareholder".
Teahupo'o, by contrast, was still basically a farming and fishing village, with a population of about 800 people that hadn't fluctuated for decades. The fishing families lived in shacks and rendered Besser-block houses along the lagoon front, and ran boats more than they drove cars. The road from Papeete literally stops at the river, which is why the first travelling surfers named it End Of The Road, and some of the older residents hadn't left the area for years. Former event coordinator Robert "Bushy" Mitchell recalls one 83-year-old saying he'd been out of town to Papeete only three times in his life. "Why do I need to?" he told Mitchell. "I have everything I need right here."
When the AFR Magazine returned in August during this year's event, things didn't seem much changed – other than the kids running around with Papa's expropriated Billabong caps on their heads. Walk the 1.5 kilometres down from the town's one shop to the End Of The Road and you'll still pass the same fishermen's shacks, the half-repaired outriggers, the dogs dozing by the roadside, the chickens too blasé to dash for cover. Teahupo'oians bicycle past barely quicker than walking pace, smiling easily and waving as they go, murmuring "ia orana!" or "Ça va?". Around here, nobody's in a hurry.
It's a bizarre contrast – the slow pace of life on land, compared with the fear and intensity of a good day's surfing on the deadly reef wave 400 metres offshore. The spot veers between a picture-postcard, blue-water break to a terrifying hole in the ocean. Surfing Teahupo'o at full throttle, when all the water drains off the reef and forms itself into a slab of Pacific four times your height and six times as thick, provides a startlingly clear insight into why surfers often seem so inarticulate. Until Billabong came to town, most towns-people had no idea of their greatest mar-keting asset. Other than a few local kids who'd surfed the place in the mid-1980s, they'd cruised past it in their sleek mahi-mahi hunting boats without a care. Teahupo'o hadn't sold much more than fish, and the taro, guavas and other crops that Papa Parker's family grew on farmland across the river and hauled up to the Saturday markets in Papeete.
Small-town politics
To action-sports marketers, the wave is a rare commodity, a truly awesome surf spot without a history. That's why Billabong has spent between $2 million and $5 million a year for the past 12 years securing ownership of the franchise and nurturing the goodwill of Teahupo'o farmers and fishermen.
According to a complex formula developed by Mitchell and O'Callaghan, anywhere from $200,000 to $300,000 flows directly each year into the pockets of local landowners, for event accommodation and compensation of various kinds. More goes to fishermen for boat hire, to surfers for water safety and lifeguard duties, to surfing clubs, to doctors on the contest medical team, and to the Tahitian branch of the Heart Foundation for assistance with youth health issues. Along the way the pair had to become adroit handlers of small-town politics. "You found yourself being a juggler," says O'Callaghan, who's been involved since the beginning. "You had to be across everything, know who was being paid what." Says Mitchell, who left the event in 2009: "You knew you were being rorted, but nine times out of 10, you went with it, because you knew that's how it worked."
It's a lot of board shorts sales to a lot of kids in wealthy Western nations and you can see where the money's gone. In between the locals on bikes, there are quite a few fishermen with rather expensive looking four-wheel-drive trucks cruising around. Real estate values are on the rise; middle-class Papeete residents have taken to buying blocks of land across the river not far from the taro farms and building holiday houses, hoping to be subsidised by pro surfer and staff rental during the contest. "There were three houses up there when the contest started," O'Callaghan tells me, pointing back from the lagoon tower to the land immediately facing the surf, where 14 or more roofs can be seen amid the palm trees. "Now look."
For local kids, an official event T-shirt or cap has become de rigueur. The big, comparatively rich entity is for them a source of excitement, glamour, even identity. "Everybody wants to be part of it," says Lewis Parker, one of Papa's nephews. It might resemble a classic South Pacific cargo cult but the Teahupo'oians are more subtle and graceful than that. Lewis Parker lives on a beautifully kept piece of land across the river, on which he's built several small cabins to help accommodate surfers and journalists (including this reporter) during the contest. His cousins recently put up a series of three bungalows nearby, managing the build in four months flat to get it done in time for the 2013 Billabong Pro. "I think maybe this was a record building time for Tahiti," says Parker.
"We wanted it to be nice for the contest crew," he adds. "We love having our friends come back each year." His charm and infectious good nature are so strong it takes an effort to recall that along with being a visitor's friend, he's on the payroll. That's how it is in South Pacific paradises.
Brand Teahupo'o
Over the years, Billabong's millions, along with all Papa's caps, have succeeded in branding Teahupo'o. The spot gave Billabong's superstar Hawaiian surfer, the late Andy Irons, a natural stage from which he launched the first of his three world titles. The company perfected the remote location webcast in lieu of live TV, and flew in its top retail accounts and sales force to mingle with surf stars each year and gape at the wave when it awoke. Pop star and Billabong ambassador Donavon Frankenreiter gave a concert on nearby Moorea. As a result, studies of the event show that the surf market connection between company name and location is a lot stronger than at most world tour events. But it's hard to know to what effect, especially since Billabong's financial wipeout.
Perrin's embarrassing departure a year after the float briefly dented Billabong's investment image, but he was soon replaced by a new chief, Derek O'Neill, the energetic Australian head of Billabong Europe. O'Neill and his management team prospered during seemingly unstoppable years of growth. They bought large houses in the designer beach enclave of Casuarina just south of Billabong's Gold Coast headquarters and made large plans.
Yet the company's undoing proved to be a badly timed investment in global retail real estate. Billabong bought up hundreds of surf retailers worldwide, planning to control every aspect of its product from factory to purchase, and racked up hundreds of millions of dollars in debt just as online retail took off and sales slowed in the wake of the global financial crisis. O'Neill paid the price with his job last year, along with numerous others; in a further irony, most of his team have sold out of Casuarina at con-siderable loss and moved on.
The company's core surf cred, inextricably linked to the brand of Billabong, its pride and joy in the pre-sharemarket days, and the whole point of the Teahupo'o relationship, is now officially worthless – written down to the tune of more than $500 million in its most recent quarterly statement. Its share price, once veering toward $20, is sitting around 38¢, and not moving. Its fortunes are in the hands of US private equity funds Centerbridge and Oaktree, who have extended the company a lifeline on its debt.
The next wave
There weren't any rock concerts or executive get-togethers this year. The event, run by O'Callaghan and his codirector Luke Egan, was stripped to a minimum and noticeably quieter than previous years. Billabong's glory days are long since past. It all makes a wipeout over the Teahupo'o reef look almost tame by comparison. At least the wipeout's over quicker.
Changes to the ASP's structure mean that next year, Billabong will devolve to naming-rights partner, saving about $2 million a year in running costs, but almost certainly altering the company's unique relationship with the town. Meanwhile, beneath its wonderfully sleepy facade, Teahupo'o is thriving. Resident numbers have increased to 1200. A big Carrefour supermarché recently opened in the nearby town centre of Taravao. There's now a footbridge across the river, though a car bridge is still a no-go; it's still the End Of The Road.
At the same time, it is interesting to note what hasn't happened. More than $150 million is spent by surf tourists worldwide each year. But while Tahitian tourism generally is coming out of an epic slump – a decline from 160,000 visitors in 2006 to 70,000 in 2009 – almost outdoing Billabong's, Teahupo'o has been remarkably passive in courting the surf travel dollar. No backpacker hostels, night spots or surf camps have sprung up in the contest's wake, unlike at almost every other globally renowned surf zone. It seems the townsfolk are happy to take the money, but just as happy to spend the rest of the year fishing.
Lewis Parker is not a fan of this approach. He feels the town should be on the case – finding ways to further leverage its major asset. The Parkers have already built a restaurant opposite the river mouth, and he plans to run for mayor next year on a tourist-friendly ticket. "We should have boats for hire, so people can go out and see the wave. Nice small pensions where they can stay." He draws the line at a vehicle bridge over the river, however. Is he concerned that Billabong's changed fortunes might mean an end to the annual cargo cult? "No," he says. "Someone else will come. Nike, maybe?"
AFR Magazine
Read more
Companies | Billabong |
People | Andy Irons, Derek O'Neill, Kelly Slater, Joel Parkinson, Mick Fanning, Gordon Merchant |
Topics | Consumer Goods & Services |


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((I'm serious. Every time there's something going on in this thread, "Tempest" goes and godmodes guards/soldiers to death. It's getting tiring. )) Poppy chuckles momentarily. "Whomper might be what I use for smithing, but a chainmail is hard to create with it even for me. It is often simpler, if possible, to melt the metal into it's molten state and pour it into a proper mold. Or, if nothing else is available, use a smaller hammer." She leads the way to the smithy, stopping in front of it and looking at the building silently for a moment before sighing and stepping inside. The forge room is quite a mess and all the surfaces are filled with coal dust. A blacksmith's "office" at it's finest. "Well, here we are."
( :/ ) Shyvana looked around, mildly curious. She had never really visited a blacksmith's forge. Her dragon half quite liked the darkness, heat, and ash, though her civilized half, not so much. "I see you cooked recently." Shyvana joked.
"Yes.... cooked. When I visit here, I often check old commissions my father had to see if there's anything I could finish." Poppy walks over to the forge, taking a box of matches from a table and lighting the forge. She watches at the flames silently for a long moment before turning around and walking towards a door on the side of the room. "I'll just go and change into a more fireproof outfit. I'll be back momentarily."
"Yes, a fireproof outfit." Shyvana said coyly. "It's too bad you're not a half dragon, like me."
"Hah... I wonder how that would even work with yordles." Poppy walks through the door and over to the living quarters of the building. She heads to her old room and looks around momentarily, moving quickly to her old cupboard. She opens it and takes up a blacksmith's outfit, seeming in good shape but covered in coal dust. She changes out her armor and the broken chainmail and puts on the fireproof outfit. She then walks back to the forge and looks at the forge, not properly heated up yet. "The forge will require some more time before it is heated enough for proper work. Now... let's see." Poppy starts walking around the forge room, searching for either a mold for the chainmail links or a small hammer to use. She knew Whomper would be too... unwieldy for something so miniscule.
"...you look quite thinner." Shyvana commented, watching Poppy. "And..." She walked over to Poppy, and lightly blew upon her outfit, sending a cloud of dust into the air. "...you might want to wash this thing once in a while."
((Okay...using my immortal powers of dungeon mastering again...no one immediately kills the guards. At least there has to be some struggle to them. :P))


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02 November 2012
What did the Victorians eat for Christmas dinner? Why do we decorate trees at Christmas? Who was the 'Lord of Misrule'? If you fancy partying medieval-style or joining Queen Victoria for a royal celebration, take a look at our tips for a truly historic Christmas.
Christmas decorations light up the house at Osborne
A traditional 'kissing bough' which was popular before the Victorian age
Find out more about Medieval celebrations at Belsay Hall in Northumberland on 8 December, and shop for treasures in Medieval surroundings at Lincoln Medieval Bishop's Palace from 6-9 December.
Christmas treats are prepared at Audley End
Find out more about Victorian Christmas celebrations at Audley End
Experience a true Victorian Christmas at Audley End in Essex on 24 & 25 November and 1 & 2 December. You can also find out how Queen Victoria would have celebrated Christmas on a festive tour at Osborne on the Isle of Wight throughout November and December. Belsay Hall in Northumberland and Apsley House in London will also be alive with Victorian festivities on 24 & 25 November and 8 & 9 December.
Some of the content included in this article originates from 'Eat, Drink and Be Merry', an entertaining and interesting book looking at Christmas traditions past. This is available in our Online Shop.
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Enter a world of Christmas past this festive season, from carol singing to meeting Father Christmas.
Make the past your present with a gift of membership, which offers free entry to hundreds of historic sites for a whole year.
Victorian Christmas Wreath
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Elizabethan Leach
Plum Cake (1897)
Mincemeat (1855)
Rabbit Soup (1880s)
Pigeon Pie with feet (abt.1865)
Gingerbread Cake (1880s)
Plum Pudding (1901)
Elizabethan Gingerbread
Medieval Hot Wine
Victorian Ginger Beer
Queen Victoria's Christmas Day Menus


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The City of Chicago's forfeiture processes violate due process. The rules are arcane, obscure, and hard to find, and people who actually try to follow them are essentially thwarted by the CPD's rules and failure to tell people how to do anything. Also, the City sends forfeiture notices to the residences of people in jail, and refuses to check the jail records to see if any of the notices returned involved people in jail. Gates v. City of Chicago, 2010 U.S. App. LEXIS 19940 (7th Cir. September 27, 2010)
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Learn More about Dr. Boyce Watkins
Under his leadership and influence, people have challenged corporations, government officials, and academic institutions on matters regarding discrimination and injustice.
He's the founder of the Your Black World Network, a digital media platform comprised of several different websites covering issues that are relevant to the African-American community. He grew the platform from a no-name network to a global medium that shapes conversations throughout the world about Black America.
Dr. Watkins' commentary has been featured on every major network (e.g. CNN, MSNBC, Huffington Post, etc.) and has sparked national campaigns that have changed many lives.
He's intelligent, intriguing, and courageous.


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The adorable retro remix Pix'n Love Rush has just been updated with Cursed mode, a run 'n jump variation on the game previously exclusive to the iPad version. This style of gameplay is much better suited for the smaller iOS devices, so it's a welcome addition. For more information on this new mode, check out our review of Pix'n Love Rush DX for iPad.
Also worth noting is that two new modes are slated as coming "soon" and "(not so) soon". We don't know anything else about these now, but we'll let you know as soon as we do.
We still randomly pick up Pix'n Love Rush from time to time. It's a great game, and we're happy to see the developers giving this little gem the continued support it deserves.
One of our favorite retro-style games, Pix'n Love Rush, just received a brand new gameplay mode. It's called Rainbow Rush, and while it's not as deep as the original modes, it's still fun.
Playing off the concept of changing the backgrounds as you advance, Rainbow Rush is all about getting a high score. The level scrolls by quickly, and you have to tap to jump up a level to avoid roadblocks, reappearing at the bottom once you jump up from the top.
The twist is that if you hit the rainbow power-ups, the backgrounds will change colors. It's visually appealing, but not quite as striking as the gaming-themed backgrounds in the original Classic Rush mode. Pix'n Love Rush is a great game, and even if Rainbow Rush isn't our favorite mode, we're not going to gripe about added value for your buck.
Love. It's in the title, and it's also certainly what we felt after stepping away from Pix'n Love Rush. This is one of the most original casual games we've played in a very long time.
Pix'n Love Rush has you frantically running through levels randomly picked from a pool of 125. Each sports its own unique flair, stemming from concepts such as falling down, jumping upward, or simple horizontal platforming. Regardless of the level type, the goal is to collect coins, avoid minus boxes, and shoot bats overhead with pellets while avoiding hitting the angels.
When you first open up Pix'n Love Rush, you only have a five minute mode available. Here you try to survive for five minutes without dying too many times. Once you pass this test, infinity mode opens up. This is a survival mode where you can go for a high score and then post it onto the OpenFeint leaderboards, and this is also where most of the replay value lies.
Monster vs. Mushroom Kingdom.
As you rack up combos by avoiding baddies, the graphical theme and music changes. These transitions add an extra layer of personality that take the game from being a blast to masterfully conducted mayhem. You'll always be eager to see the next theme, and left on the edge of your seat trying your hardest not to slip up.
The downside to Pix'n Love Rush's pre-made levels is that once you master each one, the level becomes easy. With 125, though, don't expect this to become a problem too quickly.
On top of all this, the game has stellar controls. We never felt cheated when we died, because we could control the little monster very well. With an excellent level of responsiveness, you'll be able to maneuver onto tiny platforms with precision.
For $0.99, what are you waiting for? This is a game you really must experience to truly 'get'. There just isn't much not to like about this modern, retro-styled gem.