SATURDAY, Aug. 6, 2022 (HealthDay News) -- Pickleball has become a wildly popular sport for older Americans, but seniors who enjoy playing it should know about potential injuries and how to avoid them.
Commercial real estate (CRE) is property used exclusively for business-related purposes or to provide a work space rather than a living space, which would instead constitute residential real estate. Most often, commercial real estate is leased to tenants to conduct income-generating activities. This broad category of real estate can include everything from a single storefront to a huge shopping center.
Commercial real estate comes in a variety of forms. It can be anything from an office building to a residential duplex, or even a restaurant or warehouse. Individuals, companies, and corporate interests can make money from commercial real estate by leasing it out, or holding it and reselling it.
Commercial real estate includes several categories, such as retailers of all kinds: office space, hotels and resorts, strip malls, restaurants, and healthcare facilities.
Commercial real estate and residential real estate comprise the two primary categories of real estate property. Residential properties include structures reserved for human habitation and not for commercial or industrial use. As its name implies, commercial real estate is used in commerce, and multiunit rental properties that serve as residences for tenants are classified as commercial activity for the landlord.
Commercial real estate is typically categorized into four classes, depending on function:
Individual categories may also be further classified. There are, for instance, a number of different types of retail real estate:
Similarly, office space has several subtypes. It is often characterized as class A, class B, or class C:
Note that some zoning and licensing authorities further break out industrial properties—sites used for the manufacture and production of goods, especially heavy goods—but most consider it a subset of commercial real estate.
Some businesses own the buildings that they occupy. However, the more typical case is that the commercial property is leased. Usually, an investor or a group of investors owns the building and collects rent from each business that operates there. Commercial lease rates—the price to occupy a space over a stated period—are customarily quoted in annual rental dollars per square foot. Conversely, residential real estate rates quote as an annual sum or a monthly rent.
Commercial leases will typically run from one year to 10 years or more, with office and retail space typically averaging five- to 10-year leases. This can be contrasted with more short-term yearly or month-to-month residential leases.
A study conducted by real estate market analyst firm CBRE Group found that the term—i.e., length—of a lease was proportional to the size of the space being leased. Further, the data showed that tenants would enter long leases to lock in prices in a rising market environment. But that is not their only driving factor. Some tenants with requirements for large spaces will enter long leases due to the limited availability of property that matches their needs.
There are four primary types of commercial property leases, each requiring different levels of responsibility from the landlord and the tenant.
Owning and maintaining leased commercial real estate requires full and ongoing management by the owner. Property owners may wish to employ a commercial real estate management firm to help them find, manage, and retain tenants, oversee leases and financing options, and coordinate property upkeep and marketability. The specialized knowledge of a commercial real estate management company is helpful, as the rules and regulations governing such property vary by state, county, municipality, industry, and size.
The landlord must often strike a balance between maximizing rents and minimizing vacancies and tenant turnover. Turnover can be costly for CRE owners because space must be adapted to meet the specific needs of different tenants—for example, if a restaurant is moving into a property once occupied by a yoga studio.
Investing in commercial real estate can be potentially lucrative and serve as a hedge against the volatility of the stock market. Investors can make money through property appreciation when they sell, but most returns come from tenant rents.
Investors can use direct investments where they become landlords through the ownership of the physical property. People best suited for direct investment in commercial real estate are those who either have a considerable amount of knowledge about the industry or can employ firms that do. Commercial properties are a high-risk, high-reward real estate investment. Such an investor is likely to be a high-net-worth individual since CRE investing requires a considerable amount of capital.
The ideal property is in an area with low CRE supply and high demand, which will provide favorable rental rates. The strength of the area’s local economy also affects the value of the CRE purchase.
Alternatively, investors may invest in the commercial market indirectly through either ownership of various market securities, such as real estate investment trusts (REITs) or exchange-traded funds (ETFs) that invest in commercial property-related stocks, or investment in companies that cater to the commercial real estate market, such as banks and Realtors.
One of the biggest advantages of commercial real estate is attractive leasing rates. In areas where the amount of new construction is limited by either land or law, commercial real estate can have impressive returns and considerable monthly cash flows. Industrial buildings generally rent at a lower rate, though they also have lower overhead costs compared with an office tower.
Commercial real estate also benefits from comparably longer lease contracts with tenants than residential real estate. This long lease length gives the commercial real estate holder a considerable amount of cash flow stability, as long as long-term tenants occupy the building.
In addition to offering a stable and rich source of income, commercial real estate offers the potential for capital appreciation, as long as the property is well-maintained and kept up to date. And, like all forms of real estate, it is a distinct asset class that can provide an effective diversification option to a balanced portfolio.
Rules and regulations are the primary deterrents for most people wanting to invest in commercial real estate directly. The taxes, mechanics of purchasing, and maintenance responsibilities for commercial properties are buried in layers of legalese. These requirements shift according to state, county, industry, size, zoning, and many other designations. Most investors in commercial real estate either have specialized knowledge or a payroll of people who do.
Another hurdle is the increased risk brought with tenant turnover, especially relevant in an economy where unexpected retail closures leave properties vacant with little advance notice.
With residences, the facilities requirements of one tenant usually mirror those of previous or future tenants. However, with a commercial property, each tenant may have very different needs that require costly refurbishing. The building owner then has to adapt the space to accommodate each tenant’s specialized trade. A commercial property with a low vacancy but high tenant turnover may still lose money due to the cost of renovations for incoming tenants.
For those looking to invest directly, buying a commercial property is a much more costly proposition than a residential property. Moreover, while real estate in general is among the more illiquid of asset classes, transactions for commercial buildings tend to move especially slowly.
Hedge against stock market
High-yielding source of income
Stable cash flows from long-term tenants
Capital appreciation potential
The U.S. commercial property market took a big hit during the 2008–2009 recession, but it has experienced consistent annual gains since 2010. These gains have helped recover the recession-era losses.
As reported by Forbes, the retail sector in particular has proved a pain point in the broader commercial property market, as widespread store closures intensified in 2017 and continued into 2018. For example, popular mall REIT Westfield Corp. saw its stock price shed about 30% from mid-2016 to late 2017 before reversing some losses through January 2018. Unibail-Rodamco SE acquired Westfield for $15.8 billion later in 2018, creating Unibail-Rodamco-Westfield (URW).
Most research maintains that the property market remains healthy overall. J.P. Morgan, in its 2019 Commercial Real Estate Outlook, largely echoed this view, commenting that 2019 was the 10th year of increases in commercial property rents and valuations.
Note that the global COVID-19 pandemic beginning in 2020 did not cause real estate values to drop substantially. Except for an initial drop at the beginning of the pandemic, property values have remained steady or even risen, much like the stock market, which recovered from its dramatic drop in the second quarter (Q2) of 2020 with an equally dramatic rally that ran through much of 2021. This is a key difference between the economic fallout occurring in 2020 and what happened a decade earlier. What is not known is if the required remote work environment that began in 2020 for most Americans will have any long-term impact on corporate office needs.
Residential real estate is used exclusively for private living quarters. Commercial real estate refers to any property used for business activities. Types of commercial real estate include hospitals, assembly plants, storage warehouses, shopping centers, office spaces, or any other location for a business enterprise.
It can be. Commercial real estate can have impressive returns and considerable monthly cash flows, and returns stood up well during the market shocks of the past decade. As with any investment, however, commercial real estate comes with risks.
Rules and regulations are the primary deterrents for most people wanting to invest in commercial real estate. The taxes, mechanics of purchasing, and maintenance responsibilities for commercial properties are buried in layers of legalese, and they can be difficult to understand without acquiring or hiring specialist knowledge.
Commercial real estate refers to real estate that is used specifically for business or income-generating purposes. It differs from residential real estate because it has the potential to provide rental income as well as capital appreciation for investors. The four main classes of commercial real estate are office space, industrial, multifamily rentals, and retail.
Investing in commercial real estate usually requires more sophistication and larger amounts of capital from investors than does residential real estate, but it can offer high returns. Publicly traded REITs are a feasible way for individuals to indirectly invest in commercial real estate without specialist knowledge of the sector.
By A.C. Thompson, Mosi Secret, Lowell Bergman and Sandra Bartlett
In detective novels and television crime dramas like CSI, the nation's morgues are staffed by highly trained medical professionals equipped with the most sophisticated tools of 21st-century science. Operating at the nexus of medicine and criminal justice, these death detectives thoroughly investigate each and every suspicious fatality.
The reality, though, is far different. In a joint reporting effort, ProPublica, PBS "FRONTLINE" and NPR spent a year looking at the nation's 2,300 coroner and medical examiner offices and found a deeply dysfunctional system that quite literally buries its mistakes.
Blunders by doctors in America's morgues have put innocent people in prison cells, allowed the guilty to go free, and left some cases so muddled that prosecutors could do nothing.
In Mississippi, a physician's errors in two autopsies helped convict a pair of innocent men, sending them to prison for more than a decade.
The Massachusetts medical examiner's office has cremated a corpse before police could determine if the person had been murdered; misplaced bones; and lost track of at least five bodies.
Late last year, a doctor in a suburb of Detroit autopsied the body of a bank executive pulled from a lake -- and managed to miss the bullet hole in his neck and the bullet lodged in his jaw.
"I thought it was a superficial autopsy," said Dr. David Balash, a forensic science consultant and former Michigan state trooper hired by the Macomb County Sheriff's Department to evaluate the case. "You see a lot of these kinds of things, unfortunately."
More than 1 in 5 physicians working in the country's busiest morgues -- including the chief medical examiner of Washington, D.C. -- are not board certified in forensic pathology, the branch of medicine focused on the mechanics of death, our investigation found. Experts say such certification ensures that doctors have at least a basic understanding of the science, and it should be required for practitioners employed by coroner and medical examiner offices.
Yet, because of an extreme shortage of forensic pathologists -- the country has fewer than half the certified it needs, a 2009 report by the National Academy of Sciences concluded -- even physicians who flunk their board exams find jobs in the field. Uncertified doctors who have failed the exam are employed by county offices in Florida, Michigan, Pennsylvania and California, officials in those states acknowledged. Two of the six doctors in Arkansas' state medical examiner's office have failed the test, according to the agency's top doctor.
In many places, the person tasked with making the official ruling on how people die isn't a doctor at all. In nearly 1,600 counties across the country, elected or appointed coroners who may have no qualifications beyond a high-school degree have the final say on whether fatalities are homicides, suicides, accidents or the result of natural or undetermined causes.
For 26 years, Tim Brown, a construction manager, has served as the coroner of rural Marlboro County in South Carolina, a $14,000-per-year part-time post. "It's been kind of on-the-job training, assisted by the sheriffs," he said.
Long before the current economic crisis began shrinking state and county government budgets, many coroner and medical examiner offices suffered from underfunding and neglect. Because of financial constraints, Massachusetts has slashed the number of autopsies it performs by almost one quarter since 2006. Oklahoma has gone further still, declining to autopsy apparent suicides and most people age 40 and over who die without an obvious cause.
Some death investigation units do a commendable job. While many coroners and medical examiners don't even have X-ray machines, New Mexico has a new facility equipped with a full-body CT scanner to help detect hidden injuries. Virginia has an efficient, thorough system, staffed by more than a dozen highly trained doctors. The autopsy suite in its Richmond headquarters is as sophisticated and sanitary as a top hospital.
Still, the National Academy of Sciences' study found far-reaching and acute problems. Across the country, the academy said, coroners and medical examiner offices are struggling with inadequate resources, poor scientific training and substandard facilities and technology.
Their limitations can have devastating consequences.
"You call a death an accident or miss a homicide altogether, a murderer goes free," said Dr. Marcella Fierro, Virginia's former chief medical examiner and one of the report's authors. "Lots of very bad things happen if death investigation isn't carried out competently."
After Cayne Miceli died in January 2009, her body was brought to the New Orleans morgue, a dingy, makeshift facility in a converted funeral home, for Dr. Paul McGarry to autopsy.
An autopsy, the dissection and evaluation of a corpse, generally begins with a physician scrutinizing the body, noting visible injuries. With a scalpel, a doctor then slices a long, Y-shaped incision in the torso and studies the innards, removing and weighing each organ, and using a small rotary saw to remove the top the skull. An autopsy can trace the path of a bullet through a body, or reveal microscopic damage to blood vessels in the brain, or identify a lethal clog in an artery.
By the time Miceli's body was laid on the stainless-steel examination table, McGarry had performed such work for three decades in Louisiana and Mississippi. In New Orleans, he was one of several forensic pathologists overseen by the parish coroner, Frank Minyard, a trumpet-playing local legend who has held his elected office for more than 35 years.
Miceli, 43, had died after being held in a cell in the parish jail, bound to a metal bed by five-point leather restraints. During the autopsy, McGarry observed "multiple fresh and accurate injection sites" on Miceli's forearms. He determined that drugs -- he didn't specify the variety -- had killed her, according to his report.
But doctors who had treated Miceli the day she died encouraged her father, Mike Miceli, to look more closely into his daughter's death. He had her body flown to Montgomery, Ala., for a second autopsy by Dr. James Lauridson, the retired chief medical examiner for the Alabama Department of Forensic Sciences.
Lauridson concluded that McGarry had misconstrued the needle marks on Miceli's arms. "In fact, all of the needle puncture marks were therapeutic -- drawing blood, IV's, that sort of thing," Lauridson said.
McGarry's finding also was contradicted by a central piece of evidence: a screen for drugs and alcohol didn't turn up either in Miceli's blood. McGarry had reached his conclusion days before he got the test results, records show.
Lauridson soon pinpointed the real reason for Miceli's demise. On the day of her death, Miceli had gone to the hospital to be treated for an asthma attack. She was arrested after an altercation with hospital staffers; Miceli thought they were trying to discharge her too soon, court records show. Peering at Miceli's lung tissue under a microscope, Lauridson was certain that severe asthma, combined with the way she was restrained at the jail, had caused her death.
"As I examined her lungs, it was very clear right away that her lungs and all of the airways were completely filled with mucous," he said. "To put an asthmatic flat and then tie them down during an acute asthma attack is nearly the same as giving them a death sentence."
McGarry had been wrong, and not for the first time. In fact, a review of medical records, court documents and legal transcripts shows McGarry has made errors and oversights in autopsy after autopsy.
In three instances since 2005, his findings in cases in which people died in the custody of police officers have been challenged by doctors brought in to perform second autopsies. In each case, McGarry's findings cleared officers of wrongdoing. The other certified concluded the deaths were homicides.
Contacted by phone, mail and in person, McGarry repeatedly declined to comment for this article or related radio and television stories.
Some in the field champion McGarry, praising his track record. "I have the utmost respect for Dr. McGarry and he taught me much when I was in a forensic fellowship program," said Dr. James Traylor in an e-mail. Traylor was trained by McGarry and worked alongside him in the New Orleans morgue. "I am unaware of any `mistakes' that he may have made."
Second autopsies are a rarity in most jurisdictions, but New Orleans civil rights attorney Mary Howell said she often taps forensic pathologists to perform follow-ups when she knows McGarry has handled a case. The degree to which their findings have differed from McGarry's is "shocking," Howell said. In some cases, they discovered, McGarry's work was so incomplete that bodies were "half-autopsied."
Gerald Arthur, a 45-year-old construction worker with a history of drug arrests, died after a struggle with police on a New Orleans street in 2006. Based on McGarry's findings, coroner Minyard ruled the death an accident, but a forensic pathologist with the Georgia Bureau of Investigation brought in by Arthur's family to perform a second autopsy found four broken ribs that McGarry had not noted. In his report, the GBI pathologist also stated that McGarry "failed to dissect" key neck muscles, causing him to miss hemorrhages that, in his view, suggested Arthur had been strangled.
In a deposition, McGarry disputed that assertion, saying he had dissected the neck muscles but had come to a different conclusion. "I don't have any evidence that this man had a death due to neck strangulation," he said.
No criminal charges have been brought in connection to Arthur's death. His family settled a lawsuit against the police department last year for $50,000.
Also in 2006, McGarry autopsied Lee Demond Smith, a 21-year-old man who died in jail in Gulfport, Miss. McGarry decided that Smith had been killed by a pulmonary embolism, a blood clot in the lungs, based on evidence of internal bleeding. Again, another specialist brought in to do a second autopsy found injuries that McGarry had not: abrasions on Smith's forehead and chest, as well as a half-dozen bruises on his legs and hands. The doctor concluded that Smith, like Arthur, had been strangled.
No criminal charges have been filed in Smith's death either.
Raymond Robair, a 48-year-old handyman who died shortly after an encounter with police, was autopsied by McGarry in 2005. Based on McGarry's examination, coroner Minyard declared Robair's death an accident.
But McGarry had not noted the wounds covering Robair's legs and arms. A second forensic pathologist hired by Robair's family documented 23 separate bruises, including a thigh contusion more than a foot long. The fatal injury was a severe laceration of Robair's spleen that caused extensive internal bleeding, according to the second autopsy, which was performed by another GBI doctor, Kris Sperry. Robair "was the victim of a beating," his autopsy report states.
Robair's sister, Pearl LeFlore, said her sibling's battered body was communicating a message: "This is what happened to me. … I died brutally. I was beaten." McGarry's autopsy was "a lie altogether," she said.
Based on McGarry's autopsy, records show, the district attorney's office decided not to prosecute any police officers in connection with Robair's death. "The officers were effectively exonerated by the initial autopsy performed by the Orleans Parish Coroner's Office," wrote an assistant district attorney in a 2008 letter sent to the police department.
Ultimately, in 2010, after conducting an extensive investigation, the U.S. Department of Justice indicted New Orleans Police officer Melvin Williams for allegedly beating Robair to death and charged another officer with allegedly helping to cover it up. The officers have pleaded not guilty.
Cayne Miceli's father is still seeking justice. Mike Miceli has sued McGarry in Orleans Parish court, saying his actions were "extreme and outrageous," and has filed a separate suit against the Orleans Parish Sheriff's Department for wrongful death. Both cases are pending.
"There's no reason for a family to have to go through this," Mike Miceli said. After the lawsuits were filed, Minyard amended the autopsy report, changing Miceli's cause of death from a drug overdose to asthma and labeling it a natural death.
Minyard declined to discuss the Miceli autopsy or other cases in which McGarry's findings have been challenged. He defended McGarry's work more generally. "I'm not aware of any impropriety," the coroner said. "I'm not aware of any mistakes."
Last year, McGarry stopped doing autopsies for Orleans Parish, but he is still working for three Mississippi counties. "He lives in Mississippi, and he's helping them over there," Minyard said. "The travel back and forth was too much."
Some experts see coroners like Minyard as throwbacks to an earlier, less scientific era.
The qualifications of those who oversee death investigations vary widely from state to state -- and, in some areas, from county to county. But the main divide is between medical examiner systems, run by doctors specially trained in forensic pathology, and coroner systems, run by elected or appointed officials who often do not have to be doctors.
While Minyard happens to be a physician -- he worked as an obstetrician-gynecologist before becoming coroner -- he isn't a forensic pathologist and never actually puts scalpel to flesh. In the end, though, it is Minyard who decides what words will be typed on the death certificate.
The 2009 report by the National Academy of Sciences, a comprehensive overview of defects in the nation's death investigation system authored by more than 50 luminaries in the field, recommended phasing out coroners and replacing them with medical examiners. (For a detailed, state-by-state breakdown, see our app.)
For Fierro, the Virginia forensic pathologist, the coroner-versus-medical-examiner debate is fundamentally about competence. In her view, only trained certified should oversee death investigations. "I'm not anti-coroner," said Fierro, one of the authors of the academy's report. "I'm pro-competency."
But another concern raised by the academy is that coroners often are closely aligned with law enforcement agencies. In 48 California counties, the local sheriff serves as coroner. In Nebraska, county prosecutors perform the coroner's duties. "Sensitive cases, such as police shootings and police encounter deaths … require an unbiased death investigation that is clearly independent of law enforcement," the NAS report stated.
Minyard's close ties to law enforcement have provoked controversy throughout his long career, and his decisions in certain cases, particularly that of Adolph Archie, illustrate just how much power a coroner can wield.
Archie died in 1990, soon after grabbing a revolver from a Superdome security guard and shooting a police officer to death.
When officers captured Archie, the chatter on the police radio turned sinister. "Somebody kill him," demanded one cop, according to a transcript of the radio traffic. "Hang the bitch by his balls," urged another.
By the time Archie reached Charity Hospital, he'd suffered a host of injuries, including broken facial bones and skull fractures, leading hospital staffers to conclude he had been kicked repeatedly, medical records show.
McGarry did the autopsy, noting many of Archie's injuries. Minyard initially told the media he was baffled and didn't know whether to rule the death a homicide. He speculated that Archie might have fallen backward and hit his head on the floor when he struggled with officers, or that officers might have struck him in self-defense.
Adolph Archie's autopsy report.
"When a perpetrator grabs a gun, a policeman has a right to defend himself," Minyard told the local newspaper.
Media reports later revealed that one of the officers who arrested Archie was a friend of Minyard's who rented an apartment from the coroner.
A second autopsy conducted by Sperry, the Georgia doctor, uncovered additional injuries overlooked by McGarry, including more skull fractures, -- crushing damage to Archie's larynx and bruising of his testicle. After public protests calling for the coroner's resignation, Minyard changed his determination, calling Archie's death a homicide.
Then he shifted his stance again, deciding that Archie had died of an allergic reaction to medication he received in the hospital. To this day, Minyard insists Archie wasn't killed by a police beating. "His trauma never caused his death," said the coroner, adding that "my position was that Adolph Archie died from an allergic reaction to iodine that he was given on the X-ray table."
Prosecutors never indicted anyone in connection with Archie's death.
"I don't think there's anybody in town who doesn't believe that he was beat to death by the police," said Mary Howell, the civil rights attorney who represented Archie's children in a wrongful-death suit. The city of New Orleans paid $330,000 to settle the case. From Howell's perspective, the Archie story -- and Minyard's role in it -- sent an "extremely damaging message."
"That was kind of a watershed incident in this city," she said.
Minyard believes criticism of coroners is "malarkey" -- in fact, he doesn't believe coroners even need a high-school diploma to do the job.
"Being a good coroner involves a lot more than finding out a cause of death," he said, adding that the key skills are the ability to speak to grieving families and to the media. "It has nothing to do with education. It has to do with you as an individual and the love that you have for your fellow man. And so that's why I say having a coroner who has no education sometimes is better than a medical examiner who has all of the education in the world."
Several of the country's most esteemed death-investigation units are overseen by coroners, including the coroner's office in Clark County, Nev., which was the model for the TV show CSI.
P. Michael Murphy, a former police chief, is the coroner there. He thinks the national academy report took an "off with their head" approach to his profession, even though coroners generally do "a really good job with what they have."
Murphy also made it clear that coroner systems come in many different forms, including those that insulate coroners from political pressure and the influence of law enforcement. In Clark County, for example, the coroner is appointed by the seven-member county commission, a process that mirrors the way many counties select their chief medical examiners.
In his view, laypeople are entirely capable of running a medical operation, noting that many hospitals are helmed by chief administrators who are more knowledgeable about finance than anatomy. "That model works well in hospitals all over the United States," he said.
Massachusetts became the first state to replace coroners with medical examiners back in 1877, but making that switch hasn't ensured that death investigations are carried out properly.
Hobbled by mismanagement and chronic underfunding, the state's Office of the Chief Medical Examiner has spent much of the last decade mired in disarray, its woes detailed in a succession of audits and reports.
At times, Massachusetts' forensic pathologists have toiled in disturbingly decrepit conditions. The National Association of Medical Examiners, a nonprofit body that inspects and accredits morgues, issued a blistering inspection report in 2000 identifying more than 50 significant problems at the agency's facilities. At one morgue, since shuttered, doctors were collecting blood, bile and other bodily fluids in 5-gallon buckets and pumping them back into corpses because a septic system had collapsed, making it impossible to wash the fluids down the drain.
"It was a terrible facility -- the worst I've ever seen," remembered the inspector, Dr. John E. Pless, an Indiana forensic pathologist, who said the practice posed "an obvious health risk."
Pless also concluded the office would need $10 million annually in additional funds to do its job properly.
The budget has nearly tripled in the past decade, but even today, it is $3 million below the threshold set by Pless 10 years ago. The agency has never regained its NAME accreditation.
The office has struggled with the most basic of tasks. In 2003, it mixed up the bodies of two women severely burned in a Gloucester house fire. The blaze killed Ann Goyette and injured her friend, Susan Anderson. But when Goyette's body was delivered to the morgue, a doctor mistakenly wrote the name Susan Anderson on the death certificate. In fact, Anderson, comatose, swathed in bandages and surrounded by an oxygen tent, was lying in a bed in Massachusetts General Hospital.
By the time the mistake was uncovered, the agency had cremated Goyette's body, further upsetting her already distraught family. "How could the ball be dropped so many times?" asked Goyette's brother, Scott Arnold, who unsuccessfully sued the state over the snafu.
A comparison of data from the nation's 17 statewide medical examiner systems shows that Massachusetts' autopsy rate has fluctuated wildly in accurate years. In 2004, it had the second-lowest autopsy rate among statewide systems, doing just three autopsies for every 100 deaths. Utah, the state with the highest rate, performed 15 autopsies for every 100 deaths that year.
By 2006, under the direction of an ambitious new chief, the medical examiner's office was taking on far more cases and had brought its autopsy rate up to the average level for statewide systems -- to about six per 100. But the agency didn't have the personnel or facilities to handle the increase. Unrefrigerated bodies began piling up in the hallways, and blunders mounted.
John Grossman, who oversees the medical examiner's operations as the state's Undersecretary for Forensic Science and Technology, said the agency has made improvements since then. It has hired new medical staffers and developed safeguards against errors.
"I know we've made great strides in the last three years, putting systems in place so that the office is not on the verge of collapse, creating a culture where the doctors feel supported," Grossman said.
But the state also has scaled back its operations since 2007, slashing the number of autopsies its physicians perform by almost 25 percent to about 2,700 per year.
"In a world of unlimited resources, we'd like to do more autopsies, but we don't live in a world of unlimited resources," Grossman said.
Despite the ubiquity of forensic pathologists in pop culture, the field has little appeal to most medical school graduates.
To become certified by the American Board of Pathology, doctors must receive an extra year of training in autopsies at a coroner's or medical examiner's office and pass a one-day exam. In addition, forensic pathologists are typically paid less than doctors in other specialties.
By most estimates the United States has only 400 to 500 full-time forensic pathologists. It's a tiny cadre of professionals for a country where roughly 2.5 million people die every year.
Partially because of the shortage of qualified practitioners, many of the nation's busiest coroner and medical examiner offices employ physicians who are not certified.
A survey of more than 60 of the nation's largest medical examiner and coroner offices by ProPublica, PBS "FRONTLINE" and NPR found 105 doctors who have not passed the exam -- or more than 1 in 5 doctors on their full-time and part-time staffs.
Some have recently completed their training and have not had a chance to take the test, which is offered once a year. Others are long-time practitioners who have no plans to become certified.
But in numerous cases, the doctors are not certified because they have failed their exams.
The Arkansas State Medical Examiner's Office employs two forensic pathologists who have flunked their exams multiple times, according to Chief Medical Examiner Dr. Charles Kokes. He described certification as a "personal goal" and said the doctors had no plans to take the test again.
In Kentucky, Chief Medical Examiner Dr. Tracey Corey acknowledged that the state employs a doctor who is not even eligible to take the forensic pathology test because she failed the anatomic pathology exam, which is a prerequisite. "I'm comfortable having her work because I know her competence," Corey said.
The sheriff-coroner in Orange County, Calif., contracts with Juguilon Medical Corporation to provide autopsies. One of the company's doctors has failed the certification exam at least five times, acknowledged Dr. Anthony Juguilon, the company's chief, in an e-mail.
Some experts put little weight on board certification, but many leaders in the field say it's a critical element -- that you can't raise the overall quality of death investigation unless the people who do autopsy work are subject to consistent professional standards.
"What does it mean? It means that they have not demonstrated they have minimum knowledge of the field," said Dr. Vincent Di Maio, the former chief medical examiner for Bexar County, Texas. "And these people get hired."
Lack of resources has forced Oklahoma to engage in a risky brand of triage.
The state's Office of the Chief Medical Examiner has been without its top doctor for nearly a year. Three of its nine slots for forensic pathologists are empty.
Its remaining six doctors handle overwhelming caseloads. Most did between 300 and 400 autopsies last year, said Timothy Dwyer, the state's chief investigator. One did more than 500 -- double the maximum number recommended by the National Association of Medical Examiners.
Because of the grueling pace, the state has had to impose limits on the types of cases it investigates: Oklahoma typically does not autopsy possible suicides or alleged murder-suicides. In most instances, it does not autopsy people age 40 or older who die of unexplained causes.
"If we did an autopsy on every suicide, it would be all consuming, as with drug overdoses," said Cherokee Ballard, the office's chief administrator. "With suicides, we don't autopsy most them because it's an obvious cause of death."
But experts called Oklahoma's practices alarming. A savvy criminal can make a murder look like a suicide, said Dr. Robert Bux, a forensic pathologist who serves as coroner for El Paso County, Colo.
"The only way you're going to be able to sort it out, from my standpoint, is to do a complete autopsy," Bux said.
"I've had a lot of suicide cases they didn't autopsy," added Kyle Eastridge, a former homicide detective with the Oklahoma City Police Department and the Oklahoma State Police. "I don't think that every suicide is a murder, but I think we miss murders."
In the absence of forensic findings, families sometimes are left to forage obsessively for clues about what became of their loved ones.
When a bullet shattered the face of 17-year-old Carissa Holliday and left her dead in a trailer outside of Tulsa, no doctor ever autopsied her body.
Instead, a forensic pathologist looked at her wound and filled vials with blood and fluid from her eyeballs, screening them for drugs and alcohol. Two days after her death, before the lab tests had even come back, the doctor ruled her death a suicide, records show.
Holliday's mother, Andrea, didn't believe the ruling -- Carissa left no suicide note, and the pathologist's report did not address potential clues such as whether there was gunshot residue on her hands.
"For a year and a half, I dug and investigated and got clues and witnesses to prove that she didn't kill herself," said Andrea Holliday, who wrote a self-published account of her daughter's final hours titled Never Forgotten.
The medical examiner has not reopened Carissa Holliday's case, and the official ruling on her death remains unchanged.
In 2009, NAME yanked Oklahoma's accreditation, in part because of its failure to autopsy suspected suicide and homicide cases.
Fierro, the Virginia forensic pathologist, called Oklahoma's decision not to look carefully into unexplained deaths of residents over 40 a mistake. Forensic pathologists have been critical in a range of investigations stretching beyond criminal justice, from identifying defective cribs to tracking the spread of infectious diseases. They play a crucial role in mapping public health trends, she said.
"If you want to Excellerate the quality of people's lives, then we need to know what it is that causes them to be ill, sick or injured so that they can prolong their life," Fierro said.
Even at some of the nation's more robust death investigation units, staffers worry that they do too few autopsies to fulfill their watchdog role.
The Los Angeles County Department of Coroner looks into a comparatively large portion of deaths, roughly one in three each year, said Craig Harvey, the chief death investigator. Yet he would like to do more.
"I would love to have the staff to respond to every nursing home death. They're fraught with potential misses," Harvey said. "But if anything was to go wrong in those facilities, unless somebody says something, there's a good chance the case will pass through the system without ever being seen by the coroner."
The National Academy of Sciences has mapped out a plan to Excellerate troubled coroner and medical examiner operations.
In its 2009 report, the academy called for the creation of uniform federal standards for death investigation and recommended making certification mandatory for doctors working in the field of forensic pathology.
So far, however, those suggestions have made little headway in Washington.
Sen. Patrick Leahy (D-Vt.) recently introduced legislation aimed at upgrading the quality of forensic evidence, but his bill would impose no new requirements on the doctors at the center of death investigations. Instead, it would establish a committee to examine how to ensure that qualified practitioners are doing autopsy work.
Many of the academy's proposals would take money -- money to educate doctors, to hire more of them and to construct up-to-date facilities.
It's not an overwhelming amount. DiMaio, the former Bexar County medical examiner, estimated that the price of a good medical examiner's office is about $2.50 per person per year, "which is probably less than what you pay for a Coca-Cola in a movie theater."
So far, however, even that is a price many communities have been unwilling to pay. Oklahoma, for example, spends about one-third less each year on its medical examiner than DiMaio's formula suggests it should.
Dr. Victor Weedn, the Maryland assistant medical examiner, said basic misunderstandings about the significance of death investigation have made it a hard sell.
"It's difficult for people to spend money on medical examiner systems," Weedn said. "They see it often as wasting money on the dead, without realizing that everything that is done in a medical examiner office, or a coroner office, is truly done for the living. We try to protect society. We look for deaths that are premature, or that should not have happened, so that we can go forth and correct those errors in society."
ProPublica Deputy Editor of News Applications Krista Kjellman-Schmidt and Director of Computer-Assisted Reporting Jennifer LaFleur and reporter Ryan Gabrielson of the Investigative Reporting Program at UC Berkeley contributed to this report.
Additional research was provided by Liz Day, Sydney Lupkin, Kitty Bennett, Sheelagh McNeill and Ryan Knutson of ProPublica, Jackie Bennion of PBS "FRONTLINE," and Barbara Van Woerkom of NPR.
SATURDAY, Aug. 6, 2022 (HealthDay News) -- Pickleball has become a wildly popular sport for older Americans, but seniors who enjoy playing it should know about potential injuries and how to avoid them.
The most common problem is with the rotator cuff tendon in the shoulder, which can cause pain. Issues can included tendonitis, bursitis and even a tear in the tendon. Bigger tears are harder to fix and can make your arm weak.
"The unfortunate reality of the rotator cuff is that everyday use can cause tearing and damage," said Dr. Bruce Moseley, a surgeon in the Joseph Barnhart Department of Orthopedic Surgery at Baylor College of Medicine in Houston.
"You don’t necessarily have to do anything wrong or abnormal to get a rotator cuff tear -- in many instances it just happens as a consequence of living," he said in a college news release.
For a lot of people, it’s not an accident or injury that causes rotator cuff damage, but use over time. Pickleball requires people to reach overhead while using a lot of force, which can risk damaging or tearing the rotator cuff.
Tears aren't always preventable, but stretching and light or moderate strength training may keep it healthier and more flexible.
"If you warm up and stretch before your activity and ice down afterwards, your shoulder will be better prepared for the activity and will recover quicker," Moseley said.
If you are experiencing shoulder pain, don't wait to see a doctor.
"The success rate of surgery to permanently fix the problem goes down as the size of the tear goes up, so if you're having lingering shoulder pain that isn't getting better over time and the pain is getting worse as the activity continues, I recommended seeing a specialist," Moseley said. “If we can get to the tear and fix it while it is small, the success rate is much higher.”
The only way to repair a torn rotator cuff is through surgery. Living with it can be painful and limit movement, and it would be difficult to remain active.
"Considering seeing a physician if you have pain that gets progressively worse in the shoulder or pain that persists for a long time after your activity. These may be warning signs of a torn rotator cuff tendon, so make sure to get it checked," Moseley said.
The U.S. National Library of Medicine has more on rotator cuff injuries.
SOURCE: Baylor College of Medicine, news release, Aug. 2, 2022
The “NCIS” and “NCIS: Hawai’i” teams are uniting for a crossover event as their respective season openers next month, CBS announced on Wednesday.
The episodes, which premiere Monday, Sept. 19, on CBS, will feature the D.C. team of “NCIS” traveling to Hawai’i in order to stop a dangerous suspect from fulfilling their next attack.
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In the Season 20 premiere of “NCIS,” the D.C. crew works with “NCIS Hawai’i’s” Special Agent Jane Tennant (Vanessa Lachey) and computer specialist Ernie Marlick (Jason Antoon) on tracking down their prime suspect, The Raven, in hopes of clearing Special Agent Alden Parker’s (Gary Cole) name. Meanwhile, Special Agent Parker and his ex-wife Vivian (Terri Polo) are still on the run.
Then, on “NCIS: Hawai’i,” Tennant’s team, along with NCIS agents Nick Torres (Wilmer Valderrama) and Jessica Knight (Katrina Law), discover that The Raven is located on the island of Oahu. There, he plans to attack the Rim of the Pacific Exercises (RIMPAC), the world’s largest international maritime warfare exercise. The “NCIS: Hawai’i” Season 2 premiere and final chapter of the crossover special is set to premiere at 10 p.m. ET. “NCIS” stars Gary Cole, Brian Dietzan and Diona Reasonover will guest star in the “NCIS: Hawai’i” episode.
“NCIS” and “NCIS: Hawai’i” first crossed over in March, when Tennant invited Torres to visit Hawai’i after learning that an old case they worked on together has a new lead.
The forthcoming crossover will start at 9 p.m. ET on Sept. 19 on CBS. The event will also be available to stream live and on demand on Paramount+.
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GREENWICH — XPO Logistics, one of the largest transporters of goods, will soon see the end of an era after announcing this week plans to change its chief executive officer for the first time in its 11-year history.
CEO and Chairman Brad Jacobs, who started Greenwich-based XPO in 2011, will step down as CEO following the spin-off of the Fortune 500 company’s truck-brokerage business. Mario Harik, XPO’s chief information officer since 2011 and acting president of its less-than-truckload trucking business, will succeed Jacobs.
21st Century paces of change in technology and rational behavior (not of emotional reactions) seriously disrupt the accepted productive investment strategy of the 20th century. Passive investing can't compete.
One required change is the shortening of forecast horizons. There must be a shift from the multi-year passive approach of buy and hold to the active strategy of specific price-change target achievement or time-limit actions, with reinvestment set to new nearer-term targets.
That change avoids the irretrievable loss of invested time spent destructively by failure to recognize shifting evolution, as in the cases of IBM, Kodak, GM, Xerox, GE, and many others.
It recognizes the progress in medical, communication, and information technologies and enjoys their operational benefits already present in extended lifetimes, trade-commission-free investments, and coming in transportation ownership and energy usage.
But it requires the ability to make valid direct comparisons of value between investment reward prospects and risk exposures in the uncertain future. Since uncertainty expands as the future dimension increases, shorter forecast horizons are a means of improving the reward-to-risk comparison.
That shortening is now best invoked at the investment entry point by using Market-Maker ("MM") expectations for coming prices. When reached, the expanded capital is then reintroduced at the exit/reinvestment point to new promising candidates, with their own specific near-term expectations for target prices.
The MM's constant presence, extensive global communications and human resources dedicated to monitoring industry-focused competitive evolution sharpen MM price expectations. But their job is to get buyers and sellers to agree on exchanging share ownership - without having to take on risk while doing it.
Others in the MM community provide protection for capital of the Transaction negotiators, which gets temporarily exposed to price-change risk. Derivative-securities deals to hedge undesired price changes are regularly created. The deals' prices and contracts provide a window of sorts to view MM price expectations, the best indication of likely near-term outlook.
This article focuses primarily on Radian Group Inc. (NYSE:RDN).
"Radian Group Inc., together with its subsidiaries, engages in the mortgage and real estate services business in the United States. Its Mortgage segment offers credit-related insurance coverage primarily through private mortgage insurance on residential first-lien mortgage loans, as well as other credit risk management, contract underwriting, and fulfillment solutions. This segment primarily serves mortgage originators, such as mortgage banks, commercial banks, savings institutions, credit unions, and community banks. The company's Homegenius segment offers title services. This segment serves consumers, mortgage lenders, mortgage and real estate investors, government-sponsored enterprises, and real estate brokers and agents. The company was founded in 1977 and is headquartered in Wayne, Pennsylvania."
Source: Yahoo Finance
The investment selections most frequently visited by users of Yahoo Finance were added to by principal holdings of stocks in the subject's exchange-traded fund ("ETF"), and as a market proxy, the SPDR S&P 500 ETF (SPY) in making up a comparison group against which to match RDN.
Following the same analysis as with RDN, historic sampling of today's Risk~Reward balances were taken for each of the alternative investments. They are mapped out in Figure 1.
(used with permission).
Expected rewards for these securities are the greatest gains from current closing market price seen worth protecting short positions. Their measure is on the horizontal green scale.
The risk dimension is of actual price drawdowns at their most extreme point while being held in previous pursuit of upside rewards similar to the ones currently being seen. They are measured on the red vertical scale.
Both scales are of percent change from zero to 25%. Any stock or ETF whose present risk exposure exceeds its reward prospect will be above the dotted diagonal line. Capital-gain attractive to-buy issues are in the directions down and to the right.
Our principal interest is in RDN at location , midway between locations [6 and 1]. A "market index" norm of reward~risk tradeoffs is offered by SPY at .
The Figure 1 map provides a good visual comparison of the two most important aspects of every equity investment in the short term. There are other aspects of comparison which this map sometimes does not communicate well, particularly when general market perspectives like those of SPY are involved. Where questions of "how likely" are present in other comparative tables, like Figure 2, may be useful.
Yellow highlighting of the table's cells emphasize factors important to securities valuations and the security RDN, most promising of near capital gain as ranked in column [R].
(used with permission)
Figure 2's purpose is to attempt universally comparable answers, stock by stock, of a) How big the prospective price gain payoff may be, b) how LIKELY the payoff will be a profitable experience, c) how soon it may happen, and d) what price drawdown risk may be encountered during its holding period.
Readers familiar with our analysis methods after quick examination of Figure 2 may wish to skip to the next section viewing Price range forecast trends for RDN.
Column headers for Figure 2 define investment-choice preference elements for each row stock whose symbol appears at the left in column [A]. The elements are derived or calculated separately for each stock, based on the specifics of its situation and current-day MM price-range forecasts. Data in red numerals are negative, usually undesirable to "long" holding positions. Table cells with yellow fills are of data for the stocks of principal interest and of all issues at the ranking column, [R].
The price-range forecast limits of columns [B] and [C] get defined by MM hedging actions to protect firm capital required to be put at risk of price changes from volume trade orders placed by big-$ "institutional" clients.
[E] measures potential upside risks for MM short positions created to fill such orders, and reward potentials for the buy-side positions so created. Prior forecasts like the present provide a history of relevant price draw-down risks for buyers. The most severe ones actually encountered are in [F], during holding periods in an effort to reach [E] gains. Those are where buyers are emotionally most likely to accept losses.
The Range Index [G] tells where today's price lies relative to the MM community's forecast of upper and lower limits of coming prices. Its numeric is the percentage proportion of the full low to high forecast seen below the current market price.
[H] tells what proportion of the [L] demo of prior like-balance forecasts have earned gains by either having price reach its [B] target or be above its [D] entry cost at the end of a 3-month max-patience holding period limit. [I] gives the net gains-losses of those [L] experiences.
What makes RDN most attractive in the group at this point in time is its basic strength in capturing much of the forecast upside [E] in realized payoffs of [I], shown in [N] as a credibility ratio. Only one of its competitors manages to realize profits of half of what has been implied as an upside price gain forecast target.
Further, Reward~Risk tradeoffs involve using the [H] odds for gains with the 100 - H loss odds as weights for N-conditioned [E] and for [F], for a combined-return score [Q]. The typical position holding period [J] on [Q] provides a figure of merit [fom] ranking measure [R] useful in portfolio position preferencing. Figure 2 is row-ranked on [R] among alternative candidate securities, with RDN in top rank.
Along with the candidate-specific stocks these selection considerations are provided for the averages of some 3000 stocks for which MM price-range forecasts are available today, and 20 of the best-ranked (by fom) of those forecasts, as well as the forecast for S&P 500 Index ETF (SPY) as an equity-market proxy.
Current-market index SPY is marginally competitive as an investment alternative. Its Range Index of 27 indicates 3/4ths of its forecast range is to the upside.
As shown in column [T] of figure 2, those levels vary significantly between stocks. What matters is the net gain between investment gains and losses actually achieved following the forecasts, shown in column [I]. The Win Odds of [H] tells what proportion of the demo RIs of each stock were profitable. Odds below 80% often have proven to lack reliability.
(used with permission)
No, this is not a "technical analysis chart" showing only historical data. It is a Behavioral Analysis picture of the Market-Making community's actions in hedging investments of the subject. Those actions define expected coming price change limits shown as vertical bars with a heavy dot at the closing price of the forecast's date.
It is an actual picture of the expected future, not a hope of the recurrence of the past.
The special value of such pictures is their ability to immediately communicate the balance of expectation attitudes between optimism and pessimism. We quantify that balance by calculating what proportion of the price-range uncertainty lies to the downside, between the current market price and the lower expected limit, labeled the Range Index [RI].
Here, the RI at zero indicates no further price decline is likely, but not guaranteed. The odds of 3 months passing without either reaching or exceeding the upper forecast limit or being at that time below the expected lower price (today's) are quite slight.
The probability function of price changes for RDN is pictured by the lower Figure 3 (thumbnail) frequency distribution of the past 5 years of RI values with the zero today indicated.
The multi-path valuations explored by the analysis covered in Figure 2 are rich testimony to the near-future value prospect advantage of a current investment in Radian Group Inc. over and above the other compared alternative investment candidates.
Homeownership is the best investment toward stable long-term wealth. However, purchasing a home can be a stressful and confusing process to navigate without expert help.
That’s why the Keri Shull Team, the top-selling real estate team in Virginia, is hosting a seminar to help home buyers understand today’s competitive DMV real estate market and better maximize their home search.
Angela Decint, ranked as a top realtor by the Washingtonian, and listing specialist Lane Brenner, will be leading this seminar for aspiring homebuyers at Keri Shull Team’s Rosslyn office. Bring us your burning real estate questions as you begin the search for your dream home!
Attendees will learn:
Are you ready to stop giving your hard-earned money to a landlord?
Join us on Wednesday, July 20, from 6 to 7 p.m. for this FREE in-person seminar! We validate parking for those commuting by car.