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Heart Disease Death Not as Pervasive as ReportedByChris Kaiser, Cardiology Editor, MedPage TodayPublished: May 21, 2013ReviewedbyZalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN,dr dre headphones, RN, Nurse PlannerAction PointsHeart disease deaths are over-reported in the U.S.A hospital-level intervention to reduce heart disease over-reporting led to substantial changes in other leading causes of death, changing the leading cause of premature death.
Hospitals in the U.S. tend to over-report death from heart disease,monster headphones, researchers found, but a simple intervention can improve the quality of cause-of-death reporting.
Hospitals involved in the intervention reduced their reports of heart disease as the leading underlying cause of death from 69% before the intervention to 32% afterwards -- a relative decline of 54%, according to Teeb Al-Samarrai, MD, of the Santa Clara County Department of Public Health in San Jose,beats headphones,dr dre headphones Kim Kardashian's baby shower, cr, Calif.,cheap beats by dre, and colleagues.
As reports of heart disease deaths declined, there were increases in four other conditions as leading underlying causes of death, the most dramatic being a 252% relative increase for reported deaths from chronic lower respiratory disease , they reported in the latest issue of the CDC's Preventing Chronic Disease.
The other three causes of death that spiked after the intervention were: Influenza and pneumonia -- 193% relative increase, going from 4% to 11% Cerebrovascular disease -- 115% relative increase, going from 2% to 4% Malignant neoplasms -- 48% relative increase, going from 11% to 16%
However, the hospitals not involved in the intervention saw minimal relative changes in leading causes of death -- all 6% or less.
The investigators also determined that the postintervention changes were not an effect of a trend that might have begun before the intervention. A secondary analysis revealed that between 2000 and 2009 , deaths from heart disease at the hospitals that subsequently were involved in the intervention remained steady -- around 60% to 71%.
Al-Samarrai, who was formerly with the CDC, and colleagues noted that they took on this study because the quality of the information on death certificates "affects the usefulness of vital statistics for public health action."
Lack of physician training serves as the greatest contributor of poor quality of mortality data, they wrote, adding that "Cause-of-death assignment practices also appear to vary by region."
One group for which determining the cause of death is particularly difficult is patients of advanced ages, the researchers noted. "This suggests that inaccurate reporting of cause of death for patients aged 85 or older reflects not only lack of training but also the complexity and challenge of identifying a single underlying condition or clear sequence of events leading to death. Death certificates force physicians to simplify what might be a complex medical situation."
"As the population lives longer and multiple chronic medical conditions become more common, documenting which disease is the underlying cause of death will become more challenging," they continued. "Therefore, using the current 1-cause-to-1-death model for cause-of-death coding might not be appropriate when describing mortality among persons ages 85 or older."
To assess whether the situation could be improved, the investigators performed an intervention consisting of training and communication with staff at eight hospitals in New York City. The pre-intervention period was from July though December 2009. Postintervention spanned January to June 2010.
The total number of deaths at the intervention hospitals was similar in the pre- and postintervention periods .
In the pre-intervention period, the total number of deaths attributed to heart disease in the intervention hospitals ranged from 58% to 80%. This dropped in the postintervention period by 28 to 53 percentage points -- to a range of 26% to 44%, researchers noted.
In a subgroup analyses, researchers found that sex and race/ethnicity had no impact on the ranking of leading cause of death.
When researchers restricted for cause of premature death , however, malignant neoplasm took the lead over heart disease . No such change was seen in the nonintervention hospitals.
After the intervention, influenza and pneumonia as a leading cause of death moved from third to second; no change occurred in the nonintervention hospitals. Importantly,converse all star shoes Hicks homers again as Twin, the largest increase in influenza and pneumonia deaths occurred among those 85 years or older.
When Al-Samarrai and colleagues controlled for age, heart disease as the leading cause of death declined in the intervention group from 36% to 17%. In the nonintervention hospitals, however, this number increased from 16% to 18%.
"To our knowledge, this is the first study to investigate the impact of reducing heart disease over-reporting on other leading causes of death," Al-Samarrai and colleagues wrote. No prior study had demonstrated a reduction in heart disease death concomitant with an increase in other leading causes of death, they added.
The intervention in this study has been expanded to more New York City hospitals, "with preliminarily positive results."
The limitations of the study include the fact that death certificates were not validated, individual physician understanding of death certificates was not evaluated, standardizing for race/ethnicity could have hidden reporting differences, and results may not apply to other settings.
Preventing Chronic Disease is a publication of the CDC.
The authors had no financial or conflicts of interest to disclose.
From the American Heart Association:
Heart Disease and Stroke 2013 Statistical Update

Primary source: Preventing Chronic Disease Source reference: Al-Samarrai T, et al "Impact of a hospital-level intervention to reduce heart disease overreporting on leading causes of death" Prev Chronic Dis 2013; 10: 120210.

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Chris Kaiser
Cardiology Editor
Chris has written and edited for medical publications for more than 15 years. As the news editor for a United Business Media journal, he was awarded Best News Section. He has a B.A. from La Salle University and an M.A. from Villanova University. Chris is based outside of Philadelphia and is also involved with the theater as a writer, director, and occasional actor.
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发表于 2013-6-4 12:27:25 | 只看该作者

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Frank Giustra has a new travelling companion.
It’s not his pal, Bill Clinton. It’s not a dark-haired Italian movie-star. It’s not even a book.
Believe it or not, it’s olive oil.
“I won’t go anywhere without my olive oil,” the Lionsgate Entertainment founder, mining financier and philanthropist says. “I always travel with several bottles in my luggage everywhere I go, because you never know when it comes into conversation. So you whip out a bottle of oil and you serve it. And people dip their bread in it. ... I’m really proud of the stuff.”
Giustra has not simply rediscovered his tastebuds, he has also recently won an award for producing the best organic, medium-blend olive oil in the world.
It has been three years since Giustra bought his first olive tree in Umbria, Italy. At the time, he knew nothing about olive oil and was buying it at Safeway like everyone else.
But Domenica Fiore Olio Reserva, named after his mother, has received the highest score of more than 700 entries from 22 countries at the inaugural New York International Olive Oil Competition, and Giustra can’t stop talking about it. He had been prepared to wait 10 or 20 years for his reward.
Giustra has always loved food, but now he is obsessed.
To see a photo gallery of Giustra's new obsession, click here
A chance vacation encounter with a small Umbrian olive grower three years ago sent the jet-setting mining financier off on a “slow food” journey.  Within a few months, he owned 1,800 olive trees and his first parcel of mineral-rich Umbrian land. He has bought more parcels since, and now owns 9,000 trees.
Organic,dr dre headphones Did You Know That Both Houses in, natural, sustainable and heritage food not only dominates his kitchen, it is now in his investment portfolio. His new stable of agri-business investments range from a Vancouver Island sablefish hatchery to a Saskatchewan grain farm; a Chilliwack organic farm that raises heritage pigs and poultry; Sole Food, a company that turns vacant urban land into street farms; and Alter Eco,beats headphones, a San Francisco specialty food company that produces organic chocolate, among other items, sourced from small-scale farmers in 11 countries.
“The olive oil started everything,” Giustra said. “I’m not thinking about a food empire. I’m thinking about learning and seeing where the opportunities are.”
He has invested mostly in small,dr dre headphones, “slow food” operations, but also owns some industrial farmland in the Prairies.
The farmland part of the equation is a straightforward, unemotional investment.
“If you believe in hard money philosophy, which is to say that government continues to print enormous amounts of money ... we’re heading into an environment where you’d better own hard assets as opposed to paper assets,” he said. “Farmland, in times of hyperinflation,beats by dre, is one of the best assets to own.”
At the same time, he is among those who have noted the growing North American and European food movement in which consumers care where their food comes from. So he has “dabbled a bit” in related businesses, but “I haven’t done anything on a grand scale yet.”
He has even launched a 138-page quarterly magazine while everyone else is bailing from print. Modern Farmer, the brain child of Monocle magazine founding editor Ann Marie Gardner, is aimed at both the new food-conscious consumer and the farmer.
In the process, the mining and movie mogul is learning what farmers have known for centuries: Mother Nature does not really care about business plans or cash flow. Last year,cheap beats by dre, rain right through June messed up his planting season. And this past year’s scorching Italian summer reduced his olive oil production by half, to just 5,monster headphones,000 litres.
Giustra is also learning,dr dre headphones New drug approved for Type 2 diabetes  588, for the first time, about retail, wholesale, packing, advertising and branding. Domenica Fiore Olio Reserva extra virgin olive oil  is encased in stainless steel bottles, and vacuum sealed with nitrogen to preserve antioxidants and polyphenols. Each bottle is labelled with a hand-written lot number.
Giustra’s is so enthusiastic about the new product that he has been approached to host his own cooking show.
But, being Frank Giustra, play is never just play.
“This is a very particular business,” he said. “Most of all, I’m having fun with it. But it’s always a business.”
To date, Domenica Fiore oil has been available only in Vancouver. But Giustra is looking to sell elsewhere in North America, Japan and parts of Europe.
Kim Galavan, a former Giustra executive assistant from his early career at Yorkton Securities, has returned to the fold as COO of Fiore Fine Foods. She is responsible for packaging, marketing and selling the new product. Meanwhile, farmer Cesare Bianchini is looking after Giustra’s 9,000 olive trees in Italy.
“He creates it. She sells it. I taste it,” Giustra said.
jennylee@vancouversun.com
Blog: vancouversun.com/smallbusiness
?
Frank Giustra’s Domenica Fiore Filet Tenderloin:
Take a beef tenderloin and massage it with Domenica Fiore olive oil. Massage with generous amounts of rock salt and black pepper.
Sear all sides in a hot skillet. Put tenderloin in the oven at high heat  for 10 minutes. Cut into steak size pieces.
Grill three minutes on each side on the barbecue. Cut steaks into thin slices and arrange on a platter. Dress with fresh arugula and drizzle generously with Domenica Fiore olive oil.</p
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2012 has shown that the landscape for currency investment vehicles has considerably changed. While growth in the previous years was largely driven by currency ETFs and ETNs, the market proved to be challenging for these vehicles. Assets in currency ETFs and ETNs have decreased by almost 40% in 2012, yet actively managed mutual funds experienced a growth of more than 14%. Increased Focus on Currency Asset Class Low correlations to traditional asset classes, inherent market inefficiencies and potential profit opportunities, relatively low volatility and high levels of liquidity may explain the increase in investor demand for currency exposure.1 Global currency market turnover has risen substantially, from $3.3 trillion in average daily turnover in April 2007 to $4.0 trillion in 2010. This increase has been largely driven by increased trading activity in a category of investors including hedge funds, pension funds, mutual funds and insurance companies, where turnover rose by 42% during this same time period.The absolute number of listed currency investment vehicles available, along with the total size of assets managed,beats headphones, has grown significantly over recent years. This has occurred amid a global financial crisis and subsequent crash in the value of many financial assets. The financial crisis which began in 2008 may have acted as a catalyst in increasing demand for currency exposure: many investors came to the harsh realization that their portfolios were not adequately diversified to protect against downside risks. Indeed, finding uncorrelated asset classes has proven increasingly difficult: most asset classes moved up in tandem approaching the credit crisis; most asset classes moved down together as the credit crisis took hold; and most asset classes continue to move in lock-step today. In an environment with increased correlations across many asset classes, portfolio diversification is of the utmost importance. The currency asset class may help meet this objective. There are three types of listed currency investment vehicles commonly available to investors: currency mutual funds, currency exchange traded funds (ETFs) and currency exchange traded notes (ETNs).As a result of the increased investment demand, many new currency mutual funds, currency ETFs and currency ETNs have been launched over the past few years. Investors now have greater options available for currency investing, a trend that is likely to continue as the currency asset class becomes an evermore-established component of investors portfolios. Currency mutual funds, ETFs and ETNs all share similarities, and each vehicle also displays unique characteristics and distinct risk and return profiles. Investors should be cognizant of these differences when considering a currency investment. Growth of Listed Currency Investment VehiclesAggregate assets under management for listed currency investment vehicles grew at an annualized pace exceeding 62% between December 2004 and December 20123 . As of December 31, 2004,beats headphones Boy Wins National Spelling Bee Wi, total assets managed in listed currency investment vehicles totaled $311 million; in contrast, aggregate assets managed as of December 31, 2012 stood at $15.0 billion.As of December 31, 2004, only two currency mutual funds were available for investment. The first currency ETF was launched in 2005 and the first ETN was launched in 2007. Until the end of the year 2011, the number of currency investment vehicles expanded rapidly but experienced overall negative growth for the first time in 2012. A total of four ETFs and one mutual fund were delisted in 2012, with an additional mutual fund liquidation in the first quarter of 2013. Assets under management in ETFs and ETNs decreased by $3.1 billion in 2012, while mutual funds assets continued to grow by $1.3 billion last year. As of December 31, 2012, there were a combined total of 59 listed currency investment vehicles (21 currency mutual funds; 25 currency ETFs; 13 currency ETNs).Currency Mutual Funds
Mutual funds are open-end funds, regulated primarily under the Investment Company Act of 1940.1 The specific objectives of any currency mutual fund will differ from one fund to another, and will be outlined in its prospectus. However, its investment approach can generally be classified as one of two types: directional or non-directional. Directional approaches generally take a specified position in a managed basket of currencies relative to one currency, typically either long or short vs. the U.S. dollar. In contrast, a non-directional strategy has no pre-determined view on any one currency; non-directional strategies may take long or short positions in a variety of currencies.
Currency mutual funds typically invest in wide baskets of currencies and typically do not track a predefined index. Therefore the portfolio rebalancing and management of currency exposures tends to be driven by the portfolio manager of the mutual fund, who invests according to the investment objectives outlined in the prospectus. Specific holdings are required to be reported semi-annually, though many report more frequently. Investors typically
do not purchase mutual fund shares in the secondary market. Rather, shares are purchased from the fund itself or via a broker. The price investors pay for a share is the NAV per share plus any commissions if applicable. The NAV for a mutual fund is typically calculated at the close of the trading day, therefore the price an investor pays for a share will be determined at the close of the trading day in which the investor places their order. As such, a mutual fund generally does not trade at a premium or discount to its NAV, nor does it typically trade continuously throughout the trading day. Currency ETFs and ETNsThe objective of most ETFs or ETNs, currency or not, is to reliably track an underlying index, less any expense ratio. This is not the case for actively managed ETFs; as of December 31, 2012, there were no actively managed currency ETFs.2 Generally speaking, a currency ETF or ETN will have a defined index before it is launched. This index, its structure and rebalancing, if any, will be outlined in the prospectus. An ETF is an open-ended investment company or unit investment trust that is registered under the Investment Company Act of 1940. An ETF allows investors to buy and sell shares that represent a fractional ownership of a portfolio of securities. This portfolio of securities typically tracks, as closely as possible, an underlying index, such that the investment return produced reflects, as closely as possible, the investment return that would be produced by investing directly in the underlying index.As opposed to an ETF, an ETN is not a fund, nor registered under the Investment Company Act of 1940. Rather, an ETN is a debt instrument. This is an often overlooked,dr dre headphones, yet critical aspect of an ETN. Notably, there is counterparty risk with ETNs; investors should understand that while the objective of an ETN is to provide returns that track some definable benchmark or index,cheap beats by dre, ultimately the financial health of the issuer may have a marked effect on whether coupons, or even the principle of an ETN, will actually be paid. Essentially, an ETN is another way that a financial organization can access debt financing. For these organizations, an ETN is treated the same way as any other issued debt instrument: it is a liability for the issuer. From an investor’s standpoint, buying an ETN is essentially the same as purchasing a bond of that financial organization; an ETN could be considered a special case floating rate note, with the coupons, if any, and principal typically linked to an underlying index or benchmark, less any fees. As such, investors may want to consider assessing the financial health of any ETN issuer before investing. A key similarity between currency ETFs and ETNs is that both are typically designed to track a defined index or benchmark. Generally speaking, the simpler the index, the easier it is for any ETF or ETN manager to track it. In this respect, many currency ETFs and ETNs tend to take a simple directional approach to currency investing. A simpler index also makes it easier to communicate to investors the objective of the investment vehicle, and may give investors a greater level of clarity surrounding what they should expect in terms of a risk-return profile. For currencies, the simplest index is often to track the value of one currency, as measured in U.S. dollars. As such, many single currency ETFs and ETNs have been launched in recent years – from the Australian dollar to the euro to the Japanese yen. As of December 31, 2012, 30 of the 38 listed currency ETFs and ETNs were aimed at tracking a single currency.3 In addition, leveraged currency ETFs and ETNs have also been launched. The aim of a leveraged ETF or ETN is to replicate some multiple of the underlying index, such as 200% (2x). As of December 31, 2012 there were six leveraged ETFs and four leveraged ETNs.
Both ETFs and ETNs are listed on an exchange and can be bought and sold throughout the trading day. This allows investors to take advantage of very short movements in price; indeed, some investors may trade an ETF or ETN multiple times a day. There may, at times, be a mismatch between supply and demand for the securities, which may cause the price of each vehicle to deviate from the net asset value (NAV) of the underlying portfolio of securities (in the case of an ETF) or the asset value underlying the debt obligation (in the case of an ETN). In fact, some investors trade on this unique attribute alone; devising trading rules based upon whether an ETF or ETN is trading at a premium or discount.
Which Investment Vehicle?
There are numerous factors that may ultimately impact a currency investment decision. Investors may want to consider the following issues when assessing the various listed currency investment vehicles.
Investment Comparison
Generally speaking, currency investment vehicles can be classified as either static baskets or managed baskets, and directional or non-directional in investment approach. Static baskets refer to set positions in a defined basket of currencies, or a basket which is predetermined by some set formula (in many cases the basket is a single currency), whereas a managed basket vehicle refers to an actively managed basket of currencies, oftentimes having no predetermined allocation. Typically, currency ETFs and ETNs tend to be static baskets,monster headphones, with many vehicles following a directional investment approach. On the other hand, mutual funds tend to follow a managed basket investment approach, and may be both directional and non-directional. These dynamics are visually depicted in the chart below:
Investment StyleIn many ways, the decision of whether to invest in a currency ETF or ETN, or a currency mutual fund, parallels the decision of whether to invest in an individual equity or an equity mutual fund. In general, when investing in an ETF or ETN,beats headphones Utah Jazz assistant Sidney Lowe t,beats by dre, one must first understand the underlying index, and then formulate an opinion on that index. In many instances the underlying index is a single currency, so investors must ask themselves whether or not they believe that particular currency will appreciate or depreciate, and over what timeframe. This is similar to how an investor might assess the future price direction of an individual stock. It logically follows that many currency ETFs and ETNs are better suited for short-term, tactical investors who have strong convictions on one currency or another, or a small basket of currencies, over a specified time frame. Oftentimes the holding period may be quite small, sometimes intra-day, so the ability to trade ETFs and ETNs multiple times a day may be advantageous for such investors. Unlike currency mutual funds, ETFs and ETNs specifically aim to track a particular currency ora basket of currencies intra-day with a minimum tracking error, whereas mutual funds typically have investment objectives that seek longer-term exposure of currency risk through active management.
On the other hand, because mutual funds typically invest in an actively managed basket of currencies, often take
long and short positions, and do not typically track a pre-determined index, mutual funds may not lend themselves as well to short-term, high-turnover investors. Rather, the mutual fund’s portfolio managers typically rebalance and update portfolio allocations based on specialized investment processes and perceived implications of market dynamics. Moreover, because currency mutual funds are generally priced only once per day, they do not lend themselves to very short term trading strategies (day trading currency mutual funds, for example, is not possible). As such, mutual funds may be more suited to an investor who is seeking the diversification aspects of the currency asset class over the medium to long-term, and who personally does not wish to speculate on the short-term price movements of specific currencies.
Another consideration is the flexibility the different vehicles have with respect to trading currencies. Currencies can be traded 24 hours every business day, yet ETFs and ETNs typically rebalance during U.S. trading hours. Currency mutual funds are often able to trade while the U.S. markets are closed. This can be beneficial should significant news flow occur overnight, and with regards to some of the less liquid currencies available, which may exhibit higher levels of liquidity at times when the U.S. markets are closed (for example, select Asian currencies are often more liquid during Asian trading hours).
Volatility
Because the value of currency ETFs and ETNs are typically tied to a one-way directional view on one currency, or a small basket of currencies, whereas mutual funds typically invest in a larger basket of currencies, the return series generated by ETFs and ETNs have historically often been more volatile than those exhibited by currency mutual funds. Importantly, currency mutual funds have the ability to adjust currency allocations in such a way that minimizes expected volatility of returns. In fact, many currency mutual funds specifically employ such a strategy in the overall allocation process. The following chart depicts annualized volatility of returns for unleveraged currency mutual funds and ETFs/ETNs for calendar years 2010, 2011 and 2012. For comparison purposes, we have also included the annualized volatility exhibited by the S P 500 index. Note that leveraged vehicles have been excluded from the below comparison.
It is also possible that a currency ETF does not track its underlying index, commonly referred to as “tracking error”. This can be caused when the manager is unable to invest in securities such that the NAV of the fund does not reliably track the underlying index. Currency mutual funds, because they generally do not track a pre-defined index, are not subject to “tracking error” in this respect.
Expenses As outlined above, currency ETFs and ETNs tend to follow simpler, more easily communicated investment approaches relative to mutual funds. As such, currency ETFs and ETNs tend to have lower fee structures. As of December 31, 2012 many currency ETF and ETN expense ratios were approximately 0.6%, whereas the average fee charged by currency mutual funds was approximately 1.3%. Some currency mutual funds have front-end and/or back-end sales loads in addition to a management fee, although no-load funds are also available. These additional fees and higher expense ratios are generally representative of the active management approach employed by many mutual funds, which often requires a higher level of process specialization and resources. Leveraged funds tend to have higher expense ratios, as the use of leverage typically generates interest expenses, which tends to be reflected in the overall expense ratio. Investors should be cognizant of the fee structure charged by any currency investment vehicle before investing. The below chart outlines the average and range of expense ratios for the various listed currency investment vehicles:
Summary
In conclusion, when considering a listed currency investment, investors may want to first consider the type of investment style they wish to pursue. An investor’s style has a large bearing on which type of listed currency vehicle they may ultimately choose, given the attributes unique to each vehicle outlined above. Generally speaking, when an investor takes a more tactical, short-term approach to investing, with a higher level of turnover and short expected holding period, and is willing to accept a higher level of volatility, they may wish to consider ETFs or ETNs. On the other hand, investors seeking the portfolio diversification benefits of the currency asset class over the medium and long-term, with a longer anticipated holding period may wish to consider currency mutual funds.
If investors have the time and expertise to pick specific currencies, currency ETFs or ETNs may be the better option; if investors wish to access the benefits of the currency asset class, but do not have the time to pick specific currencies, then currency mutual funds may be more feasible.
Investors should however not ignore the current market dynamics when evaluating this generalized decision rule for their investment choice. ETFs and ETNs, although generally demonstrating lower expense ratios in comparison with mutual funds, have historically exhibited higher volatility. Since the focus of mutual funds is not merely intra-day tracking but an active management of currency exposure, mutual funds have higher fees but in turn produce returns with lower volatility when compared to ETFs and ETNs. The potentially added value of this active management approach of mutual funds, which besides long-term strategic components is often designed to also react to medium or short term market developments, should therefore be critically evaluated by the investor when making his or her investment decision. Market data suggests that investors are increasingly willing to pay to pay a premium for active currency management, as assets in currency mutual funds continue to grow throughout 2012.

Merk Hard Currency Fund
website


Axel Merk is the Founder and President of Merk Investments. Merk is an expert on macro trends, hard money, international investing and on building sustainable wealth. An authority on currencies, he is a pioneer in the use of strategic currency investing to seek diversification.
More articles by this author
Legal disclaimer and risk disclosure
The Merk Hard Currency Fund is a no-load mutual fund that invests in a basket of hard currencies from countries with strong monetary policies assembled to protect against the depreciation of the U.S. dollar relative to other currencies. The Fund may serve as a valuable diversification component as it seeks to protect against a decline in the dollar while potentially mitigating stock market, credit and interest riskswith the ease of investing in a mutual fund.
The Fund may be appropriate for you if you are pursuing a long-term goal with a hard currency component to your portfolio; are willing to tolerate the risks associated with investments in foreign currencies; or are looking for a way to potentially mitigate downside risk in or profit from a secular bear market.
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