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Parenteral nutrition refers to nutritional support provided by an intravenous route. Access may be a peripheral vein or central vein. Peripheral venous access is usually used for short term support and limits the volume of fluids and nutrients that can be delivered. Whenever possible, enteral nutrition is preferred in order to provide nutrients to the gut and maintain the intestinal barrier.Indications for Parenteral NutritionParenteral nutrition is used in cases of gut failure or severe gastrointestinal disease. Catheter-related sepsis is a significant risk in immunocompromised patients. In HIV/AIDS, TPN will induce weight gain, the composition of which depends on the underlying etiology of the malnutrition. Septic patients tend to gain primarily fat whereas those with malabsorption or inadequate dietary intake gain more body cell mass. It is possible that this modality may not be widely available throughout the Region. However, it is an option that should be pursued when necessary.Components of Parenteral NutritionThe solution for parenteral nutrition consists of nutrients in their simple form,namely dextrose, amino acids, lipids and micronutrients. Dextrose is the monosaccharide that provides the major source of non-protein energy. Each gram of dextrose in parenteral solution provides 3. 4 kilocalories or 14. 2 kilojoules. Carbohydrate should be provided in adequate amounts to spare protein, but not in excess as this may cause hyperglycemia, fatty liver or other complications. The recommended rate of dextrose infusion should not exceed 4 to 5 mg/kg/minute. Amino acids provide protein to maintain nitrogen balance and prevent degradation of somatic proteins. Protein requirements are calculated based on clinical condition and goals of treatment. Amino acid solutions provide 4 kilocalories per gram or 18. 1 kilojoules per gram. Parenteral lipid emulsions provide a concentrated source of energy and essential fatty acids. They may be used in conjunction with carbohydrate and amino acid solutions or alone for caloric enhancement. The energy content of lipid emulsions depends on the formulation. ten percent yields 1. 1 kilocalorie per mL; 20% yields 2. 0 kilocalories per mL; 30% yields 3. 0 kilocalories per mL. There is some evidence that parenteral lipids may have a negative effect on immunity. In patients with HIV infection lipids should not exceed 30% of total energy intake or 1 g/kg/day. Hyperlipidemia may also develop if lipids are not cleared. Thus serum lipids should be monitored at baseline and regular intervals thereafter. Micronutrients and electrolytes are provided as standardized components of parenteral solutions. These may be modified according to the needs of the patient.Anabolic TherapyNutrition support will usually result in weight gain, but for some PLWHA, classified as non-responders, there is evidence of an anabolic block, whereby the regained weight is composed of a disproportionately high amount of body fat with limited accretion of lean tissue. This phenomenon can be identified with body composition analysis. Thus,although re-feeding is always necessary, it is not always sufficient for some individuals. In cases where lean tissue gains are insufficient, an anabolic agent may be required such as testosterone replacement. Other anabolic therapies that have shown favorable results include Oxandrin, Decadurabolan, and Recombinant Growth Hormone.Palliative CareWhen AIDS patients become terminally ill and medical care becomes mainly palliative,not curative, the nutrition care plan should reflect the overall goals of care. Nutritional therapy is directed to alleviating symptoms and providing comfort. Nutrition support should be considered to improve quality of life if the patient, caregivers and medical team agree to this intervention.Common Dietary ProblemsDuring the course of treatment and care, many dietary problems can arise. Strategies to help alleviate common problems are addressed inPregnancy, Lactation and HIVPregnancy, lactation, and HIV disease engender physiologic stress, with increased nutritional needs for energy, protein and micronutrients. It is well recognized that the nutritional health of a pregnant woman influences pregnancy outcome. Nutritionalstatus has even greater implications for the HIV-infected woman who is at higher risk of premature delivery and having a low birth weight infant.Low birth weight infants have an increased incidence of infant mortality as well as medical and developmental complications. Other risk factors, such as pregnancy during adolescence, substance use, opportunistic infection, low pre-pregnancy weight and inadequate gestational weight gain impose further risks of a poor pregnancy outcome. Moreover, vitamin A deficiency has been associated with poor pregnancy outcome and increased risk of perinatal HIV transmission. Pregnant HIV-positive women should be referred early in pregnancy to a dietitian or other suitable health care professional for counselling to optimize nutritional status and improve pregnancy outcome. It is essential to assess complementary therapy use, as mega-doses of vitamins and some herbal preparations are contraindicated in pregnancy.Weight Gain in PregnancyRecommended weight gain based on pre-pregnancy weight:Underweight (BMI 25):Nutritional Requirements12. 5-18. 0 kg11. 5-16. 0 kg7. 0-11. 5 kgAccording to the Recommended Dietary Allowances for use in the Caribbean, the following requirements for pregnancy/lactation are in addition to the requirements for HIV+ women:4? Additional 285 kilocalories per day to support fetal growth and developmentAdditional 6 grams protein per dayPrenatal multivitamin-mineral daily (to include at least 0. 4 mg folic acid)Other micronutrient supplements as needed (e. g. iron, calcium)Lactation: additional 500 kcal per day and 11 grams of protein Vitamin A:Maternal vitamin A deficiency is associated with increased risk of vertical HIV transmission to the infant. However, there is little evidence that vitamin A supplementation of the pregnant woman reduces the risk of HIV infection to the infant. Moreover, high doses of vitamin A can be teratogenic. Should supplementation be necessary, the following WHO guidelines can be used.Iron deficiency anemia is highly prevalent in pregnant women throughout the world. Anemia is associated with increased risk of maternal and fetal morbidity and mortality, as well as intrauterine growth failure. Iron status should be assessed and deficiency should be treated. WHO recommend that women receive 60 mg iron during 6 months of pregnancy and 120 mg per day to treat severe anaemia.Folate deficiency:Folate deficiency causes megaloblastic anemia and is associated with risk of neural tube defects in the infant (e. g. spina bifida). WHO recommends 0. 4 mg folate supplement daily.

Summary
SPDN is not the largest or oldest way to short the S&P 500, but it’s a solid choice.
This ETF uses a variety of financial instruments to target a return opposite that of the S&P 500 Index.
SPDN’s 0.49% Expense Ratio is nearly half that of the larger, longer-tenured -1x Inverse S&P 500 ETF.
Details aside, the potential continuation of the equity bear market makes single-inverse ETFs an investment segment investor should be familiar with.
We rate SPDN a Strong Buy because we believe the risks of a continued bear market greatly outweigh the possibility of a quick return to a bull market.
Put a gear stick into R position, (Reverse).
Birdlkportfolio

By Rob Isbitts

Summary
The S&P 500 is in a bear market, and we don’t see a quick-fix. Many investors assume the only way to navigate a potentially long-term bear market is to hide in cash, day-trade or “just hang in there” while the bear takes their retirement nest egg.

The Direxion Daily S&P 500® Bear 1X ETF (NYSEARCA:SPDN) is one of a class of single-inverse ETFs that allow investors to profit from down moves in the stock market.

SPDN is an unleveraged, liquid, low-cost way to either try to hedge an equity portfolio, profit from a decline in the S&P 500, or both. We rate it a Strong Buy, given our concern about the intermediate-term outlook for the global equity market.

Strategy
SPDN keeps it simple. If the S&P 500 goes up by X%, it should go down by X%. The opposite is also expected.

Proprietary ETF Grades
Offense/Defense: Defense

Segment: Inverse Equity

Sub-Segment: Inverse S&P 500

Correlation (vs. S&P 500): Very High (inverse)

Expected Volatility (vs. S&P 500): Similar (but opposite)

Holding Analysis
SPDN does not rely on shorting individual stocks in the S&P 500. Instead, the managers typically use a combination of futures, swaps and other derivative instruments to create a portfolio that consistently aims to deliver the opposite of what the S&P 500 does.

Strengths
SPDN is a fairly “no-frills” way to do what many investors probably wished they could do during the first 9 months of 2022 and in past bear markets: find something that goes up when the “market” goes down. After all, bonds are not the answer they used to be, commodities like gold have, shall we say, lost their luster. And moving to cash creates the issue of making two correct timing decisions, when to get in and when to get out. SPDN and its single-inverse ETF brethren offer a liquid tool to use in a variety of ways, depending on what a particular investor wants to achieve.

Weaknesses
The weakness of any inverse ETF is that it does the opposite of what the market does, when the market goes up. So, even in bear markets when the broader market trend is down, sharp bear market rallies (or any rallies for that matter) in the S&P 500 will cause SPDN to drop as much as the market goes up.

Opportunities
While inverse ETFs have a reputation in some circles as nothing more than day-trading vehicles, our own experience with them is, pardon the pun, exactly the opposite! We encourage investors to try to better-understand single inverse ETFs like SPDN. While traders tend to gravitate to leveraged inverse ETFs (which actually are day-trading tools), we believe that in an extended bear market, SPDN and its ilk could be a game-saver for many portfolios.

Threats
SPDN and most other single inverse ETFs are vulnerable to a sustained rise in the price of the index it aims to deliver the inverse of. But that threat of loss in a rising market means that when an investor considers SPDN, they should also have a game plan for how and when they will deploy this unique portfolio weapon.

Proprietary Technical Ratings
Short-Term Rating (next 3 months): Strong Buy

Long-Term Rating (next 12 months): Buy

Conclusions
ETF Quality Opinion
SPDN does what it aims to do, and has done so for over 6 years now. For a while, it was largely-ignored, given the existence of a similar ETF that has been around much longer. But the more tenured SPDN has become, the more attractive it looks as an alternative.

ETF Investment Opinion

SPDN is rated Strong Buy because the S&P 500 continues to look as vulnerable to further decline. And, while the market bottomed in mid-June, rallied, then waffled since that time, our proprietary macro market indicators all point to much greater risk of a major decline from this level than a fast return to bull market glory. Thus, SPDN is at best a way to exploit and attack the bear, and at worst a hedge on an otherwise equity-laden portfolio.

There are several potential financing options available to cash-strapped businesses that need a healthy dose of working capital. A bank loan or line of credit is often the first option that owners think of – and for businesses that qualify, this may be the best option.

In today’s uncertain business, economic and regulatory environment, qualifying for a bank loan can be difficult – especially for start-up companies and those that have experienced any type of financial difficulty. Sometimes, owners of businesses that don’t qualify for a bank loan decide that seeking venture capital or bringing on equity investors are other viable options.

But are they really? While there are some potential benefits to bringing venture capital and so-called “angel” investors into your business, there are drawbacks as well. Unfortunately, owners sometimes don’t think about these drawbacks until the ink has dried on a contract with a venture capitalist or angel investor – and it’s too late to back out of the deal.

Different Types of Financing

One problem with bringing in equity investors to help provide a working capital boost is that working capital and equity are really two different types of financing.

Working capital – or the money that is used to pay business expenses incurred during the time lag until cash from sales (or accounts receivable) is collected – is short-term in nature, so it should be financed via a short-term financing tool. Equity, however, should generally be used to finance rapid growth, business expansion, acquisitions or the purchase of long-term assets, which are defined as assets that are repaid over more than one 12-month business cycle.

But the biggest drawback to bringing equity investors into your business is a potential loss of control. When you sell equity (or shares) in your business to venture capitalists or angels, you are giving up a percentage of ownership in your business, and you may be doing so at an inopportune time. With this dilution of ownership most often comes a loss of control over some or all of the most important business decisions that must be made.

Sometimes, owners are enticed to sell equity by the fact that there is little (if any) out-of-pocket expense. Unlike debt financing, you don’t usually pay interest with equity financing. The equity investor gains its return via the ownership stake gained in your business. But the long-term “cost” of selling equity is always much higher than the short-term cost of debt, in terms of both actual cash cost as well as soft costs like the loss of control and stewardship of your company and the potential future value of the ownership shares that are sold.

Alternative Financing Solutions

But what if your business needs working capital and you don’t qualify for a bank loan or line of credit? Alternative financing solutions are often appropriate for injecting working capital into businesses in this situation. Three of the most common types of alternative financing used by such businesses are:

1. Full-Service Factoring – Businesses sell outstanding accounts receivable on an ongoing basis to a commercial finance (or factoring) company at a discount. The factoring company then manages the receivable until it is paid. Factoring is a well-established and accepted method of temporary alternative finance that is especially well-suited for rapidly growing companies and those with customer concentrations.

2. Accounts Receivable (A/R) Financing – A/R financing is an ideal solution for companies that are not yet bankable but have a stable financial condition and a more diverse customer base. Here, the business provides details on all accounts receivable and pledges those assets as collateral. The proceeds of those receivables are sent to a lockbox while the finance company calculates a borrowing base to determine the amount the company can borrow. When the borrower needs money, it makes an advance request and the finance company advances money using a percentage of the accounts receivable.

3. Asset-Based Lending (ABL) – This is a credit facility secured by all of a company’s assets, which may include A/R, equipment and inventory. Unlike with factoring, the business continues to manage and collect its own receivables and submits collateral reports on an ongoing basis to the finance company, which will review and periodically audit the reports.

In addition to providing working capital and enabling owners to maintain business control, alternative financing may provide other benefits as well:

It’s easy to determine the exact cost of financing and obtain an increase.
Professional collateral management can be included depending on the facility type and the lender.
Real-time, online interactive reporting is often available.
It may provide the business with access to more capital.
It’s flexible – financing ebbs and flows with the business’ needs.
It’s important to note that there are some circumstances in which equity is a viable and attractive financing solution. This is especially true in cases of business expansion and acquisition and new product launches – these are capital needs that are not generally well suited to debt financing. However, equity is not usually the appropriate financing solution to solve a working capital problem or help plug a cash-flow gap.

A Precious Commodity

Remember that business equity is a precious commodity that should only be considered under the right circumstances and at the right time. When equity financing is sought, ideally this should be done at a time when the company has good growth prospects and a significant cash need for this growth. Ideally, majority ownership (and thus, absolute control) should remain with the company founder(s).

Alternative financing solutions like factoring, A/R financing and ABL can provide the working capital boost many cash-strapped businesses that don’t qualify for bank financing need – without diluting ownership and possibly giving up business control at an inopportune time for the owner. If and when these companies become bankable later, it’s often an easy transition to a traditional bank line of credit. Your banker may be able to refer you to a commercial finance company that can offer the right type of alternative financing solution for your particular situation.

Taking the time to understand all the different financing options available to your business, and the pros and cons of each, is the best way to make sure you choose the best option for your business. The use of alternative financing can help your company grow without diluting your ownership. After all, it’s your business – shouldn’t you keep as much of it as possible?