title: Cattle mutilation

text: Some ranchers have disputed the scientific "natural causes hypothesis" on the grounds that the mutilated animals often fall outside of the normal categories of natural deaths by predation or disease. One reason cited is that the animals were healthy and showed no sign of disease prior to death, and were large and strong enough not to be a likely target for a predator. In some cases, ranchers have reported that the mutilated cattle were among the healthiest and strongest animals in their herd.


title: Cattle mutilation

text: It is alternatively hypothesised that cattle mutilations are the result of two unrelated deviant phenomena. The bulk of mutilations are the result of predation and other natural processes, and those with anomalies that cannot be explained in this way are the work of humans who derive pleasure or sexual stimulation from mutilating animals.


title: Cattle mutilation

text: Human attacks against animals are a recognized phenomenon. There have been many recorded cases around the world, and many convictions. Typically the victims of such attacks are cats, dogs, and other family pets, and the actions of humans are usually limited to acts of cruelty such as striking, burning, or beating animals. However, attacks have also been recorded against larger animals, including sheep, cows, and horses.


title: Cattle mutilation

text: Humans, particularly those with sociopathic disorders, have been found to have mutilated animals in elaborate ways using knives or surgical instruments.


title: Cattle mutilation

text: On April 20, 1979, C Hibbs of the New Mexico State Veterinary diagnostics Laboratory spoke before a hearing chaired by Senator Harrison Schmitt. Hibbs testified that mutilation fell into three categories, one of which was animals mutilated by humans. FBI records did not record the percentage of mutilated animals that fell into this category.


title: Cattle mutilation

text: Closely related to the deviant hypothesis is the hypothesis that cattle mutilations are the result of cult activity. However, contrary to the deviancy hypothesis, which holds that cattle are mutilated at random by individual deviants, the cult hypothesis holds that cattle mutilations are coordinated acts of ritual sacrifice carried out by organized groups.


title: Cattle mutilation

text: The hypothesis that cults were responsible for cattle mutilation was developed in the U.S. during the 1970s and 1980s, a time of growing national concern over cults (such as the Peoples Temple and Jonestown) and ritual satanic abuse ("Satanic panic").


title: Cattle mutilation

text: In 1975, the US Treasury Department assigned Donald Flickinger to investigate the existence of connections between cults and the mutilation of cattle. The operation came under the jurisdiction of the Bureau of Alcohol, Tobacco and Firearms.


title: Cattle mutilation

text: Flickinger recorded a number of 'unusual' incidents and circumstantial evidence, but was unable to find sufficient evidence of cult involvement for the ATF to take further action. Media reports of the time reported his investigation was dropped when it was determined cattle deaths were not a prelude to a co-ordinated campaign against elected officials by cult members.


title: Cattle mutilation

text: However, there were various reports during the time of menacing groups prowling around mutilation sites. In September 1975, a forestry service employee in Blaine County, Idaho, reported seeing a group of people in black hooded robes. Several cattle were found mutilated in the area the following day. On October 9, 1975, a motorist on U.S Highway 95 in northern Idaho, in an area of frequent cattle mutilation, reported to police that some 15 masked individuals formed a roadblock with linked arms, forcing him to turn around.


title: Cattle mutilation

text: Since the beginning of the cult hypothesis, law enforcement agents in several states and provinces, including Alberta, Idaho, Montana, and Iowa have reported evidence implicating cults in several instances of cattle mutilations.


title: Cattle mutilation

text: During their investigations, the FBI and the ATF were unable to find appropriate evidence, including signs of consistency between mutilations, to substantiate that the animals had been the victims of any form of ritual sacrifice or organized mutilation effort. They were also unable to determine how or why a cult would perform procedures that would result in the anomalies reported in some necropsies, or to verify that the anomalies were 1) connected to the mutilations themselves 2) the result of human intervention.


title: Cattle mutilation

text: In most cases, mutilations were either ruled due to natural causes, or the cattle were too far decayed for any useful conclusions to be drawn. Some cases of cult hysteria were traced back to fabrication by individuals unrelated to the incident. In one case it was concluded that claims had been falsified by a convict seeking favorable terms on his sentence in exchange for information. In another case, claims were traced back to local high school students who had circulated rumors as a joke.


title: Cattle mutilation

text: In his 1997 article “Dead Cows I've Known”, cattle mutilation researcher Charles T. Oliphant speculates cattle mutilation to be the result of covert research into emerging cattle diseases, and the possibility they could be transmitted to humans.


title: Cattle mutilation

text: Additionally, a 2002 National Institute for Discovery Science report relates the eyewitness testimony of two Cache County, Utah, police officers. The area had seen many unusual cattle deaths, and ranchers had organized armed patrols to surveil the unmarked aircraft which they claimed were associated with the livestock deaths. The police witnesses claim to have encountered several men in an unmarked U.S. Army helicopter in 1976 at a small community airport in Cache County. The witnesses asserted that after this heated encounter, cattle mutilations in the region ceased for about five years.


title: Cattle mutilation

text: Biochemist Colm Kelleher, who has investigated several purported mutilations first-hand, argues that the mutilations are most likely a clandestine U.S. government effort to track the spread of Bovine spongiform encephalopathy ("mad cow disease") and related diseases, such as scrapie.


title: Cattle mutilation

text: A brief sampling of cases: On April 8, 1979, three police officers in Dulce, New Mexico, reported a mysterious aircraft which resembled a U.S. military helicopter hovering around a site following a wave of alleged mutilation which claimed 16 cows. On July 15, 1974, two unregistered helicopters, a white helicopter and a black twin-engine aircraft were reported to have opened fire on Robert Smith Jr. while he was driving his tractor on his farm in Honey Creek, Iowa. This attack followed a rash of alleged mutilations in the area and across the nearby border in Nebraska. The reports of "helicopter" involvement have been used to explain why some cattle appear to have been "dropped" from considerable heights.


title: Cattle mutilation

text: In 1974, a few months after the first spate of alleged mutilations in the US, multiple farmers in Nebraska claimed to witness UFOs on the nights their cattle were harmed. The sightings were hailed by UFO researchers as the first physical evidence of extraterrestrial life.


title: Cattle mutilation

text: At the same time that UFO reports were being filed with law enforcement, larger number of ranchers claimed to see black helicopters around their fields, coinciding with the cattle mutilations. Although some initially thought these were used by cattle rustlers, suspicion soon pointed toward a military operation running out of Fort Riley, Kansas.


title: Cattle mutilation

text: By 1975, the problem was so prevalent, that some ranchers formed armed vigilante groups to patrol their fields at night. Authorities ran ads in Colorado urging ranchers to not shoot at their survey helicopters.


title: Cattle mutilation

text: In July 1975, reporter Dane Edwards of the "Brush Banner" published a cattle mutilation story and began investigating a theory that a cult was responsible. When the origin of the cult theory was traced to a federal inmate and no cult members were ever identified, ranchers and law enforcement started looking for other explanations.


title: Cattle mutilation

text: Edwards reported his theory that the government was testing cattle parts to develop biological weapons to use in Vietnam, going so far as to write to Colorado Senator Floyd K. Haskell during Haskell's investigation to accuse agents of threatening him into silence.


title: Cattle mutilation

text: In October, Edwards gave an interview to the "Gazette" ("Colorado Springs Gazette Telegraph"), announcing a theory that a government project was behind the mutilations. He expressed frustration that the FBI would not get involved and said he would be writing a book explaining "how the project was conceived". Shortly after, he was fired by the "Gazette" and then disappeared. On December 5th 1975, Edwards' wife reported him as a missing person.


title: Cattle mutilation

text: Edwards reemerged in the 1990s. He had adopted a new name, Dr. David Ellsworth, and founded an English-language instruction program that was adopted by many federal universities in Mexico.


title: Binomial proportion confidence interval

text: In statistics, a binomial proportion confidence interval is a confidence interval for the probability of success calculated from the outcome of a series of success–failure experiments (Bernoulli trials). In other words, a binomial proportion confidence interval is an interval estimate of a success probability "p" when only the number of experiments "n" and the number of successes "n" are known.


title: Binomial proportion confidence interval

text: There are several formulas for a binomial confidence interval, but all of them rely on the assumption of a binomial distribution. In general, a binomial distribution applies when an experiment is repeated a fixed number of times, each trial of the experiment has two possible outcomes (success and failure), the probability of success is the same for each trial, and the trials are statistically independent. Because the binomial distribution is a discrete probability distribution (i.e., not continuous) and difficult to calculate for large numbers of trials, a variety of approximations are used to calculate this confidence interval, all with their own tradeoffs in accuracy and computational intensity.


title: Binomial proportion confidence interval

text: A simple example of a binomial distribution is the set of various possible outcomes, and their probabilities, for the number of heads observed when a coin is flipped ten times. The observed binomial proportion is the fraction of the flips that turn out to be heads. Given this observed proportion, the confidence interval for the true probability of the coin landing on heads is a range of possible proportions, which may or may not contain the true proportion. A 95% confidence interval for the proportion, for instance, will contain the true proportion 95% of the times that the procedure for constructing the confidence interval is employed.


title: Binomial proportion confidence interval

text: A commonly used formula for a binomial confidence interval relies on approximating the distribution of error about a binomially-distributed observation, formula_1, with a normal distribution. This approximation is based on the central limit theorem and is unreliable when the sample size is small or the success probability is close to 0 or 1.


title: Binomial proportion confidence interval

text: where formula_4 is the proportion of successes in a Bernoulli trial process, measured with formula_5 trials yielding formula_6 successes and formula_7 failures, and formula_8 is the formula_9 quantile of a standard normal distribution (i.e., the probit) corresponding to the target error rate formula_10. For a 95% confidence level, the error formula_11, so formula_12 and formula_13.


title: Binomial proportion confidence interval

text: An important theoretical derivation of this confidence interval involves the inversion of a hypothesis test. Under this formulation, the confidence interval represents those values of the population parameter that would have large "p"-values if they were tested as a hypothesized population proportion. The collection of values, formula_14, for which the normal approximation is valid can be represented as


title: Binomial proportion confidence interval

text: Since the test in the middle of the inequality is a Wald test, the normal approximation interval is sometimes called the Wald interval or Wald method, after Abraham Wald, but it was first described by Pierre-Simon Laplace in 1812.


title: Binomial proportion confidence interval

text: Extending the normal approximation and Wald-Laplace interval concepts, Michael Short has shown that inequalities on the approximation error between the binomial distribution and the normal distribution can be used to accurately bracket the estimate of the confidence interval around formula_1:


title: Binomial proportion confidence interval

text: where formula_1 is again the (unknown) proportion of successes in a Bernoulli trial process, measured with formula_5 trials yielding formula_22 successes, formula_8 is the formula_9 quantile of a standard normal distribution (i.e., the probit) corresponding to the target error rate formula_10, and the constants formula_26 and formula_27 are simple algebraic functions of formula_8. For a fixed formula_10 (and hence formula_8), the above inequalities give easily computed one- or two-sided intervals which bracket the exact binomial upper and lower confidence limits corresponding to the error rate formula_10.


title: Binomial proportion confidence interval

text: Let there be a simple random sample formula_32 where each formula_33 is i.i.d from a Bernoulli(p) distribution and weight formula_34 is the weight for each observation. Standardize the (positive) weights formula_34 so they sum to 1. The weighted sample proportion is: formula_36. Since the formula_33 are independent and each one has variance formula_38, the sampling variance of the proportion therefore is:


title: Binomial proportion confidence interval

text: The standard error of formula_1 is the square root of this quantity. Because we do not know formula_41, we have to estimate it. Although there are many possible estimators, a conventional one is to use formula_1, the sample mean, and plug this into the formula. That gives:


title: Binomial proportion confidence interval

text: For unweighted data, formula_44, giving formula_45. The SE becomes formula_46, leading to the familiar formulas, showing that the calculation for weighted data is a direct generalization of them.


title: Binomial proportion confidence interval

text: The Wilson score interval is an improvement over the normal approximation interval in multiple respects. It was developed by Edwin Bidwell Wilson (1927). Unlike the symmetric normal approximation interval (above), the Wilson score interval is asymmetric. It does not suffer from problems of "overshoot" and "zero-width intervals" that afflict the normal interval, and it may be safely employed with small samples and skewed observations. The observed coverage probability is consistently closer to the nominal value, formula_47.


title: Binomial proportion confidence interval

text: Transforming the relation into a standard-form quadratic equation for , treating formula_1 and as known values from the sample (see prior section), and using the value of that corresponds to the desired confidence for the estimate of gives this:


title: Binomial proportion confidence interval

text: The solution for estimates the upper and lower limits of the confidence interval for . Hence the probability of success is estimated by


title: Binomial proportion confidence interval

text: The practical observation from using this interval is that it has good properties even for a small number of trials and / or an extreme probability.


title: Binomial proportion confidence interval

text: Intuitively, the center value of this interval is the weighted average of formula_55 and formula_56, with formula_55 receiving greater weight as the sample size increases. Formally, the center value corresponds to using a pseudocount of , the number of standard deviations of the confidence interval: add this number to both the count of successes and of failures to yield the estimate of the ratio. For the common two standard deviations in each direction interval (approximately 95% coverage, which itself is approximately 1.96 standard deviations), this yields the estimate formula_58, which is known as the "plus four rule".


title: Binomial proportion confidence interval

text: Although the quadratic can be solved explicitly, in most cases Wilson's equations can also be solved numerically using the fixed-point iteration


title: Binomial proportion confidence interval

text: The Wilson interval can also be derived from the single sample z-test or Pearson's chi-squared test with two categories. The resulting interval,


title: Binomial proportion confidence interval

text: can then be solved for formula_14 to produce the Wilson score interval. The test in the middle of the inequality is a score test.


title: Binomial proportion confidence interval

text: Since the interval is derived by solving from the normal approximation to the binomial, the Wilson score interval formula_63 has the property of being guaranteed to obtain the same result as the equivalent z-test or chi-squared test.


title: Binomial proportion confidence interval

text: This property can be visualised by plotting the probability density function for the Wilson score interval (see Wallis 2021: 297-313) and then plotting a normal pdf at each bound. The tail areas of the resulting Wilson and normal distributions, representing the chance of a significant result in that direction, must be equal.


title: Binomial proportion confidence interval

text: The continuity-corrected Wilson score interval and the Clopper-Pearson interval are also compliant with this property. The practical import is that these intervals may be employed as significance tests, with identical results to the source test, and new tests may be derived by geometry.


title: Binomial proportion confidence interval

text: The Wilson interval may be modified by employing a continuity correction, in order to align the minimum coverage probability, rather than the average coverage probability, with the nominal value, formula_47.


title: Binomial proportion confidence interval

text: Just as the Wilson interval mirrors Pearson's chi-squared test, the Wilson interval with continuity correction mirrors the equivalent Yates' chi-squared test.


title: Binomial proportion confidence interval

text: The following formulae for the lower and upper bounds of the Wilson score interval with continuity correction formula_65 are derived from Newcombe (1998).


title: Binomial proportion confidence interval

text: Wallis (2021) identifies a simpler method for computing continuity-corrected Wilson intervals that employs functions. For the lower bound, let formula_69, where formula_10 is the selected error level for formula_8. Then


title: Binomial proportion confidence interval

text: The "Jeffreys interval" has a Bayesian derivation, but it has good frequentist properties. In particular, it has coverage properties that are similar to those of the Wilson interval, but it is one of the few intervals with the advantage of being "equal-tailed" (e.g., for a 95% confidence interval, the probabilities of the interval lying above or below the true value are both close to 2.5%). In contrast, the Wilson interval has a systematic bias such that it is centred too close to "p" = 0.5.


title: Binomial proportion confidence interval

text: The Jeffreys interval is the Bayesian credible interval obtained when using the non-informative Jeffreys prior for the binomial proportion . The Jeffreys prior for this problem is a Beta distribution with parameters , it is a conjugate prior. After observing successes in trials, the posterior distribution for is a Beta distribution with parameters .


title: Binomial proportion confidence interval

text: When and , the Jeffreys interval is taken to be the equal-tailed posterior probability interval, i.e., the and quantiles of a Beta distribution with parameters . These quantiles need to be computed numerically, although this is reasonably simple with modern statistical software.


title: Binomial proportion confidence interval

text: In order to avoid the coverage probability tending to zero when or , when the upper limit is calculated as before but the lower limit is set to 0, and when the lower limit is calculated as before but the upper limit is set to 1.


title: Binomial proportion confidence interval

text: The Clopper–Pearson interval is an early and very common method for calculating binomial confidence intervals. This is often called an 'exact' method, because it is based on the cumulative probabilities of the binomial distribution (i.e., exactly the correct distribution rather than an approximation). However, in cases where we know the population size, the intervals may not be the smallest possible. For instance, for a population of size 20 with true proportion of 50%, Clopper–Pearson gives [0.272, 0.728], which has width 0.456 (and where bounds are 0.0280 away from the "next achievable values" of 6/20 and 14/20); whereas Wilson's gives [0.299, 0.701], which has width 0.401 (and is 0.0007 away from the next achievable values).


title: Binomial proportion confidence interval

text: where 0 ≤ "x" ≤ "n" is the number of successes observed in the sample and Bin("n"; "θ") is a binomial random variable with "n" trials and probability of success "θ".


title: Binomial proportion confidence interval

text: Equivalently we can say that the Clopper–Pearson interval is formula_76 with confidence level formula_47 if formula_78 is the infimum of those such that the following tests of hypothesis succeed with significance formula_79:


title: Binomial proportion confidence interval

text: Because of a relationship between the binomial distribution and the beta distribution, the Clopper–Pearson interval is sometimes presented in an alternate format that uses quantiles from the beta distribution.


title: Binomial proportion confidence interval

text: where "x" is the number of successes, "n" is the number of trials, and "B"("p"; "v","w") is the "p"th quantile from a beta distribution with shape parameters "v" and "w".


title: Binomial proportion confidence interval

text: The binomial proportion confidence interval is then formula_88, as follows from the relation between the Binomial distribution cumulative distribution function and the regularized incomplete beta function.


title: Binomial proportion confidence interval

text: When formula_89 is either formula_90 or formula_5, closed-form expressions for the interval bounds are available: when formula_92 the interval is formula_93 and when formula_94 it is formula_95.


title: Binomial proportion confidence interval

text: The beta distribution is, in turn, related to the F-distribution so a third formulation of the Clopper–Pearson interval can be written using F quantiles:


title: Binomial proportion confidence interval

text: where "x" is the number of successes, "n" is the number of trials, and "F"("c"; "d", "d") is the "c" quantile from an F-distribution with "d" and "d" degrees of freedom.


title: Binomial proportion confidence interval

text: The Clopper–Pearson interval is an exact interval since it is based directly on the binomial distribution rather than any approximation to the binomial distribution. This interval never has less than the nominal coverage for any population proportion, but that means that it is usually conservative. For example, the true coverage rate of a 95% Clopper–Pearson interval may be well above 95%, depending on "n" and "θ". Thus the interval may be wider than it needs to be to achieve 95% confidence. In contrast, it is worth noting that other confidence bounds may be narrower than their nominal confidence width, i.e., the normal approximation (or "standard") interval, Wilson interval, Agresti–Coull interval, etc., with a nominal coverage of 95% may in fact cover less than 95%.


title: Binomial proportion confidence interval

text: The definition of the Clopper–Pearson interval can also be modified to obtain exact confidence intervals for different distributions. For instance, it can also be applied to the case where the samples are drawn without replacement from a population of a known size, instead of repeated draws of a binomial distribution. In this case, the underlying distribution would be the hypergeometric distribution.


title: Binomial proportion confidence interval

text: The interval boundaries are easily computed with numerical methods functions like qbeta in R and scipy.stats.beta.ppf in Python.


title: Binomial proportion confidence interval

text: where formula_103 is the quantile of a standard normal distribution, as before (for example, a 95% confidence interval requires formula_104, thereby producing formula_105). According to Brown, Cai, and DasGupta, taking formula_106 instead of 1.96 produces the "add 2 successes and 2 failures" interval previously described by Agresti and Coull.


title: Binomial proportion confidence interval

text: This interval can be summarised as employing the centre-point adjustment, formula_107, of the Wilson score interval, and then applying the Normal approximation to this point.


title: Binomial proportion confidence interval

text: The arcsine transformation has the effect of pulling out the ends of the distribution. While it can stabilize the variance (and thus confidence intervals) of proportion data, its use has been criticized in several contexts.


title: Binomial proportion confidence interval

text: This method may be used to estimate the variance of "p" but its use is problematic when "p" is close to 0 or 1.


title: Binomial proportion confidence interval

text: This family is a generalisation of the logit transform which is a special case with "a" = 1 and can be used to transform a proportional data distribution to an approximately normal distribution. The parameter "a" has to be estimated for the data set.


title: Binomial proportion confidence interval

text: The rule of three is used to provide a simple way of stating an approximate 95% confidence interval for "p", in the special case that no successes (formula_115) have been observed. The interval is .


title: Binomial proportion confidence interval

text: There are several research papers that compare these and other confidence intervals for the binomial proportion. Both Agresti and Coull (1998) and Ross (2003) point out that exact methods such as the Clopper–Pearson interval may not work as well as certain approximations. The Normal approximation interval and its presentation in textbooks has been heavily criticised, with many statisticians advocating that it be not used. The principal problems are "overshoot" (bounds exceed [0, 1]), "zero-width intervals" at formula_1 = 0 and 1 (falsely implying certainty), and overall inconsistency with significance testing.


title: Binomial proportion confidence interval

text: Of the approximations listed above, Wilson score interval methods (with or without continuity correction) have been shown to be the most accurate and the most robust, though some prefer the Agresti–Coull approach for larger sample sizes. Wilson and Clopper–Pearson methods obtain consistent results with source significance tests, and this property is decisive for many researchers.


title: Colonel general

text: Colonel general is a three- or four-star military rank used in some armies. It is particularly associated with Germany, where historically general officer ranks were one grade lower than in the Commonwealth and the United States, and was a rank above full , but below . The rank of colonel general also exists in the armed forces organized along the lines of the Soviet model, where it is comparable to that of a lieutenant general in many NATO armed forces (rank code OF-8). The rank of colonel general that exists within the Arab model () corresponds to a full general (NATO rank code OF-9).


title: Colonel general

text: () was the second-highest rank in the Austro-Hungarian Army, introduced following the German model in 1915. The rank was not used after World War I in the Austrian Army of the Republic.


title: Colonel general

text: The rank of colonel general () was created in the Czechoslovak army in 1950; it was dropped after the 1993 dissolution of the state.


title: Colonel general

text: The Egyptian Army uses a rank that translates as "colonel general". It is equal to the rank of 4-star or "full" general. Colonel general is, however, junior to the rank of field marshal and is an honorary distinction usually held only by defense ministers.


title: Colonel general

text: In the French Army, under the "Ancien régime", the officer in nominal command of all the regiments of a particular branch of service (i. e. infantry, cavalry, dragoons, Swiss troops, etc.) was known as the colonel general. This was not a rank, but an office of the Crown.


title: Colonel general

text: The Republic of Georgia adopted Soviet designations after its independence in 1991 so that the rank of colonel-general (, ) exists, yet it is only used as highest possible rank in the Patrol Police and Border Police of the Ministry of Internal Affairs. In the Defence Forces it is the highest possible rank for all general officers and the Chief of Defence Forces (who currently holds minimum rank of major general).


title: Colonel general

text: The rank of was introduced in the Prussian Army in 1854, originally as Colonel General with the rank of Field Marshal () as field marshal was a wartime promotion and excluded members of the royal family. It later was split into said two ranks and eventually was adopted by the other state forces of the German Empire.


title: Colonel general

text: It was also used in the "Reichswehr" of the Weimar Republic, and more prominently within the "Wehrmacht" and "Waffen-SS". The rank continued in the National People's Army of East Germany until German reunification in 1990. The "Bundeswehr", first in West Germany and since 1990 in unified Germany, does not use it and has "General" as highest rank.


title: Colonel general

text: In Hungary, the rank of colonel general ("vezérezredes") was introduced to the Imperial and Royal Army (the common ground force of the Dual Monarchy) in 1915. The rank replaced the ranks of "gyalogsági tábornok" (general of infantry), "lovassági tábornok" (general of cavalry), and "táborszernagy" (general of artillery) in the early 1940s.


title: Colonel general

text: The rank title "vezérezredes" is still in use for the highest ranking (four-star) general officers of the Hungarian Defence Forces () and foreign four-star general officers' rank titles are usually translated as "vezérezredes" in Hungarian, including Commonwealth air forces' Air Chief Marshals.


title: Colonel general

text: The equivalent rank for Colonel general in Iraq is called (), which is now considered the highest rank in the Iraqi Army.


title: Colonel general

text: In 1961, J.Lkhagvasuren was awarded the title of Colonel General of the People's Republic of Mongolia. There are 9 people in Mongolia who have been promoted to colonel general. Currently, one person is currently living. He is Sonomyn Luvsangombo. Since 2006, this rank has been removed from the ranks of the Mongolian Armed Forces.


title: Colonel general

text: The North Korean rank of "sangjang" translates as "colonel general". "Sangjang" is senior to that of "jungjang" (usually translated as "lieutenant general") and junior to that of "daejang" (usually translated as "general").


title: Colonel general

text: This rank is typically held by the commanding officer of units along the Korean DMZ and the North Korean security zone at Panmunjom. It is also the rank held by the KPA Pyongyang Defense Command's commanding general.


title: Colonel general

text: The rank of colonel general ( was first established in the Red Army on 7 May 1940, as a replacement for the previously existing (, "army commander of the second rank"). During World War II, about 199 officers were promoted to colonel general. Before 1943, Soviet colonel generals wore four stars on their collar patches (). Since 1943, they have worn three stars on their shoulder straps, so Charles Pettibone compares the rank to the US lieutenant general.


title: Colonel general

text: Unlike the German (which it most probably calqued), the Soviet and Russian colonel general rank is neither an exceptional nor a rare one, as it is a normal step in the "ladder" between a two-star lieutenant general and a four-star army general.


title: Colonel general

text: Other than that, the Soviet and Russian rank systems sometimes cause confusion in regard to equivalence of ranks, because the normal Western title for brigadier or brigadier general ceased to exist for the Russian Army in 1798. The Kombrig rank that corresponded to one-star general only existed in the Soviet Union during 1935–1940. Positions typically reserved for these ranks, such as brigade commanders, have always been occupied by colonels () or, very rarely, major generals (see History of Russian military ranks).


title: Colonel general

text: The rank has usually been given to district, front and army commanders, and also to deputy ministers of defense, deputy heads of the general staff and so on.


title: Colonel general

text: In some post-Soviet Commonwealth of Independent States armies (for example in Belarus), there are no generals of the army or marshals, and so colonel general is the highest rank, usually held by the minister of defense.


title: Colonel general

text: Colonel general ("generalöverste") has also been a senior military rank in Sweden, used principally before the 19th century.


title: Colonel general

text: The Syrian Arab Army uses the rank of colonel general ( ""Imad-awwal"عماد أول) only for the senior-most rank of the army beneath that of field marshal. Usually, only defence ministers have held this rank – only six officers have held this rank till now – Hafez al-Assad, Mustafa Tlass, Hikmat al-Shihabi, Ali Habib Mahmud, Dawoud Rajiha and Fahd Jassem al-Freij.


title: Colonel general

text: Colonel general () – obsolete military rank of general officers of the Ground Forces, Air Force, Navy (only Marine Corps, Naval Aviation and Shore Establishment). It was first introduced in 1920 as part of a rank system in Ukrainian People's Army replacing such terms as Sotnyk general and Bunchuk general.


title: Colonel general

text: From October 1, 2020, the rank of "Colonel General" in Ukraine was no longer assigned and the highest rank of "General" was introduced. Until 2020, it was a higher rank than a lieutenant general, but a lower rank than General of the Army of Ukraine.


title: Colonel general

text: Although the rank of colonel-general has not been awarded since 2020, it remains with its current bearers until they receive the military rank of general. Despite the fact that the military rank of colonel-general was withdrawn from circulation, after the next version of the order, the insignia of this rank were indicated. The colonel-general has shoulder straps with four four-rayed stars above the maces. To distinguish the holders of the rank of Colonel General from the holders of the newly introduced rank of General (have the same number of stars on the shoulder straps), it was decided to apply different schemes of star placement. The stars on the shoulder straps of the generals are located along the axis of the shoulder strap, and the stars of the colonel generals are arranged in a diamond.


title: Colonel general

text: Equivalent to the ranks of colonel-general and general in the navy is the rank of admiral. Until 2020, the ranks of Colonel General and Admiral were denoted by three stars. Since 2020, the ranks of General, Colonel General and Admiral have become four-star ranks (with existing Colonel Generals slotted below Generals of the Armed Forces).


title: Colonel general

text: The title of colonel general was used before and during the English Civil War in both Royalist and Parliamentarian armies. In these cases, it often appears to have meant a senior colonel as opposed to a senior general.


title: Colonel general

text: In Vietnam, the rank of colonel general is known as "Thượng Tướng" (literally "upper general"). It is a three-star rank (OF-9a) in the Ground Force and Air Force. "Thượng Tướng" is senior to "Trung Tướng" (usually translated as "lieutenant general") and junior to "Đại Tướng" (usually translated as "general"). It is used in the army and the air force. It is the equivalent to "Đô Đốc" (admiral) in the Navy.


title: Donkey Kong Country: Tropical Freeze

text: Donkey Kong Country: Tropical Freeze is a 2014 platform game developed by Retro Studios and published by Nintendo for the Wii U console. The fifth installment in the "Donkey Kong Country" series, "Tropical Freeze" is a direct sequel to the 2010 Wii game "Donkey Kong Country Returns" and was released in February 2014. An enhanced port for the Nintendo Switch was released in May 2018.


title: Donkey Kong Country: Tropical Freeze

text: Donkey Kong and his family must venture across five islands to save their home, Donkey Kong Island, after it is frozen over by the villainous Snowmads—a group of invaders from the northern seas. Like its predecessor, the game received mostly positive reviews. Praise was directed at the level design, gameplay, and soundtrack, although its high level of difficulty received more mixed opinions.


title: Donkey Kong Country: Tropical Freeze

text: The game continues on from the side-scrolling platform gameplay of the "Donkey Kong Country" series and sees Donkey Kong and his friends traveling through seven different islands in order to defeat the Snowmads. Controls are similar to the previous game, with the addition of being able to pluck items from the ground and pick up and throw stunned enemies, and various controllers can be used with customizable controls. Like the previous game, players primarily control Donkey Kong who is assisted by a companion, who either provide additional abilities to Donkey Kong, or can be controlled individually by a second player. Along with Diddy Kong, who returns with his barrel jet pack for crossing large gaps, two additional characters are added; Dixie Kong and Cranky Kong. Dixie has the ability to spin her ponytail into a propeller and slowly descend through the air, with an initial boost in height at the start, allowing her and Donkey Kong to fly up out-of-reach platforms or items. Cranky, in a similar mechanic to the "DuckTales" video game, can use his cane to bounce on dangerous surfaces such as spiky thorns and reach higher areas and defeat certain enemies the other Kongs cannot. Filling up a 'Kong-POW' meter allows Donkey Kong and his partner to perform a special move which defeats all on-screen enemies and converts them into items depending on the partner.


title: Donkey Kong Country: Tropical Freeze

text: The Super Guide from the previous game is absent and is replaced by an expanded shop, run by Funky Kong, offering various support items such as temporary invincibility. Like the previous game, each level contains various Kong letters and puzzle pieces, some of which require specific partners to reach, which unlock various bonuses and hidden levels. The Time Attack mode also returns, now featuring online leaderboards, allowing players to view video replays of the top ranked players.


title: Donkey Kong Country: Tropical Freeze

text: The Nintendo Switch version of the game features Funky Kong as a new playable character. In the optional easier NEW FUNKY MODE, Funky Kong is playable with no possible companions, along with an option to switch between him and Donkey Kong. Unlike Donkey Kong in the game's normal mode, Funky Kong comes with five hit points instead of two, while he is also able to double-jump, hover in mid-air, stand on spikes and breathe underwater for an unlimited time. When DK is played, he can gain a companion and each Kong has three hit points.


title: Donkey Kong Country: Tropical Freeze

text: As the Kongs celebrate Donkey Kong's birthday, their island is attacked by the Snowmads, arctic invaders. Their leader, Lord Fredrik, blows a horn that creates frozen winds and an ice dragon. The Kongs are blown away and the Snowmads seize the frozen Donkey Kong Island.


title: Donkey Kong Country: Tropical Freeze

text: The Kongs traverse a series of islands and make their way back to Donkey Kong Island. They make their way through the frozen fortress until they encounter the leader of the Snowmads, Lord Fredrik, who challenges them to a battle deep in the depths of the volcano. Donkey Kong delivers the final punch to Lord Fredrik, who crashes into the Snowmad ships, defeating the Snowmads. Donkey Kong blows into Fredrik's horn, producing a breeze that thaws Donkey Kong Island.


title: Donkey Kong Country: Tropical Freeze

text: The game's story focuses on the Snowmads, a group of Viking-themed arctic animals such as walruses, owls and penguins that invade Donkey Kong Island, forcing Donkey Kong to go against them with the help of his friends Diddy Kong, Dixie Kong, and Cranky Kong. This is Dixie Kong's third appearance in the main series and the first since "", released in 1996. This is also Cranky Kong's first appearance as a main playable character in the "Donkey Kong Country" series, although he was previously playable in minigames in the Game Boy Advance versions of "Donkey Kong Country 2" and "3" and 1984's "Donkey Kong Hockey" (when he went by the name of Donkey Kong).


title: Donkey Kong Country: Tropical Freeze

text: The game was first announced during Nintendo's E3 2013 Nintendo Direct presentation on June 11, and was produced by Kensuke Tanabe who, having previously worked on "Super Mario Bros. 2", has incorporated some elements from that game.


title: Donkey Kong Country: Tropical Freeze

text: Originally to be released on December 6, 2013, Nintendo pushed back the release date to February 21, 2014, citing the need for more time to optimize the game.


title: Donkey Kong Country: Tropical Freeze

text: The soundtrack was primarily composed by David Wise, who previously contributed music for the original SNES "Donkey Kong Country" games. Additional music was provided by Daisuke Matsuoka, Minako Hamano, Shinji Ushiroda, and Riyu Tamura under the supervision of Kenji Yamamoto.


title: Donkey Kong Country: Tropical Freeze

text: The development team designed the gameplay to be similar to that of previous series games, apart from a few new features. Retro Studios president Michael Kelbaugh told Nintendo of America president Reggie Fils-Aimé that production started on "Tropical Freeze" because the team "had a lot of gas left in the tank" after finishing "Returns", wanting to include underwater levels and 3D camera work, and to use the Wii U hardware to do "a lot of really new cool tricks". The addition of camera work was the team's biggest change. The dynamic camera swings from a side to a fully 3D view, bringing depth to obstacles in the characters' path. Additionally, "Tropical Freeze" adds Dixie Kong as a partner character, who has a mid-air hover ability that affects how players access platforms. The developers also added "plucking" objects out of the ground, similar to the game mechanic in "Super Mario Bros. 2", on which "Tropical Freeze" producer had also worked. Due to "Donkey Kong" series creator Shigeru Miyamoto being protective over the series, Retro Studios had to prove their ability to handle the license. Miyamoto influenced the game's "ground pound" design and gave other small tips, but was otherwise not involved in its development. Michael Kelbaugh of Retro Studios had worked on "Donkey Kong Country" series games in various capacities since the first release.


title: Donkey Kong Country: Tropical Freeze

text: An enhanced port for the Nintendo Switch was released on May 4, 2018. It was developed once again by Retro Studios and includes support for new control schemes and an easier difficulty option, "Funky Mode", which introduces Funky Kong as a playable character.


title: Donkey Kong Country: Tropical Freeze

text: Like its predecessor, "Donkey Kong Country: Tropical Freeze" received "generally favorable reviews" from critics.


title: Donkey Kong Country: Tropical Freeze

text: Destructoid gave the game a perfect 10 out of 10. GamesRadar gave the game 4 out of 5 stars, praising its presentation and challenge whilst criticising the co-operative multiplayer. Game Informer gave it a 9.25 out of 10 for the levels, gameplay and graphics, while also noting the game having a fewer levels than "Returns". GameTrailers gave the game a 9.1 out of 10, praising enhancements made to the gameplay, and the "stellar" soundtrack. IGN gave the game a 9 out of 10 for the game's challenge, level design, and boss battles. Gamnesia's Colin McIsaac chose "Tropical Freeze" as a Game of the Year, calling it "a masterpiece of mechanics and level design" and citing the level Grassland Groove as the best platforming level of the game.


title: Donkey Kong Country: Tropical Freeze

text: GameSpot, however, gave the game a 6 out of 10, saying that interesting boss battles and vehicle segments did not make up for "clunky, repetitive level design" and poor implementation of new mechanics. "GamesTM", who gave it a 7 out of 10, found the game to be as difficult as its predecessors, citing the enemy and obstacle placements, and the difficulty of boss battles.


title: Donkey Kong Country: Tropical Freeze

text: In their review of the Nintendo Switch version, GameSpot gave "Tropical Freeze" a more favorable assessment, awarding the game a 9 out of 10. IGN stood by their 9 out of 10 score, remarking that the addition of Funky Mode makes the game more accessible without reducing the formidable platforming difficulty.


title: Donkey Kong Country: Tropical Freeze

text: The game was nominated for Best Visual Design and Best Audio at the 2014 Golden Joystick Awards, as well as for Best Nintendo Game at the 2018 event.


title: Donkey Kong Country: Tropical Freeze

text: In Japan, the Wii U version of "Donkey Kong: Tropical Freeze" sold over 70,000 copies during its first month of release. During its first eight days of release in the United States, the game sold an estimated 130,000 units. This game, along with its predecessor, were added to the Nintendo Selects label on March 11, 2016, in North America. According to the 2021 CESA Games White Papers, it went on to sell 2.02 million units on the Wii U, as of December 2020.


title: Donkey Kong Country: Tropical Freeze

text: In addition to reviewing better, the Nintendo Switch version of "Tropical Freeze" had stronger sales. In Japan alone, the game sold roughly 88,421 units in the first five days of release, more than doubling its debut on Wii U. By December 2018, the game had sold 2.08million copies worldwide on the Switch, bringing total sales to over 4million units across both platforms. , the title has sold over 2.25 million units worldwide on the Switch, including 290,000 copies in Japan. The 2022 CESA Games White Papers revealed that the Nintendo Switch version had sold 4.12 million units, as of December 2021.


title: First United States Army

text: First Army is the oldest and longest-established field army of the United States Army. It served as a theater army, having seen service in both World War I and World War II, and supplied the US army with soldiers and equipment during the Korean War and the Vietnam war under some of the most famous and distinguished officers of the U.S. Army. It now serves as a mobilization, readiness and training command.


title: First United States Army

text: The First Army was established on 10 August 1918 as a field army when sufficient American military manpower had arrived on the Western Front during the final months of World War I. The large number of troops assigned to the American Expeditionary Forces (AEF) required the activation of subordinate commands. To fill this need, First Army was the first of three field armies established under the AEF. The first commander was General John J. Pershing, who also served as Commander-in-Chief (C-in-C) of the AEF. The headquarters planned and directed the first major American offensive, the St Mihiel Offensive (September 12 to 16, 1918). It later went on to fight in the largest and deadliest battle in the United States Army's history, the Meuse–Argonne offensive. Serving in its ranks throughout World War I were many figures who later played important roles in World War II. First Army, now under Lieutenant General Hunter Liggett, was inactivated on April 20th, 1919, five months after the Armistice with Germany which ended hostilities.


title: First United States Army

text: As part of an army reorganization and final realization of the 1920 amendment to the National Defense Act of 1916, Army Chief of Staff, General Douglas MacArthur directed the establishment of four field armies that each commanded three corps areas that were geographically located. The field armies were established to provide an organizational structure for large military organizations that might be mobilized in times of national need.


title: First United States Army

text: First Army was located in the northeast United States and was activated on 11 September 1933 at Fort Jay, Governors Island, New York. Initially activated as a paper army, it was commanded by General Dennis E. Nolan. Until 1942, First Army's commander was always the senior commander of one of its three corps areas. The First Corps Area was headquartered in Boston, Massachusetts, Second Corps Area was headquartered at Fort Jay, Governors Island, in New York, New York, and Third Corps Area was located at Fort Howard (Maryland) near Baltimore, Maryland. Since First Army was only a paper organization in its early days, its staff was the existing staff of the corps areas. The overall mission of the First Army was commanding and training the regular army, army reserve and national guard units in the three corps areas.


title: First United States Army

text: Nolan, the American Expeditionary Force's (AEF) chief of intelligence during World War I, commanded First Army from 1933 to 1936. He was followed by Major General Fox Conner, previously First Corps Area commander, who had been the AEF's Chief of Operations in World War I. In the years between the wars, Conner was a crucial mentor in the careers of Dwight Eisenhower and George C. Marshall. Passed over as a candidate for Army Chief of Staff for Douglas MacArthur in 1930, Conner was assigned to command the First Corps Area instead, later commanding First Army in 1936. Conner retired in 1938.


title: First United States Army

text: In 1938 First Army came under command of General Hugh A. Drum. Drum, who along with a buildup of the Army in 1939 and through the early 1940s, began to develop the First Army into a bona fide field army. It began to establish and develop its own staff and participated in the large-scale Army maneuvers in Louisiana and North Carolina between 1939 and 1941. As the United States entered World War II, Drum was assigned command of the newly established Eastern Defense Command, responsible for coastal and domestic defense, which relieved the First Army of this responsibility on 24 December 1942. Drum retired in 1943 when he reached mandatory retirement age. General George Grunert, commander of Second Service Command, assumed command of the First Army until Headquarters, First Army was activated in Bristol, England in January 1944 under command of General Omar Bradley.


title: First United States Army

text: First Army's entry into World War II began in October 1943 as Bradley returned to Washington, D.C. to receive his command and began to assemble a staff and headquarters to prepare for Operation Overlord, the codename assigned to the establishment of a large-scale lodgement on the European Continent following Operation Neptune, which was the invasion of Normandy. The headquarters were activated in January 1944 at Bristol, England.


title: First United States Army

text: Upon going ashore on 6 June 1944, D-Day, First Army came under General Bernard Montgomery's 21st Army Group (alongside the British Second Army) which commanded all American ground forces during the invasion. Three American divisions were landed by sea at the western end of the beaches, and two more were landed by air. On Utah Beach, the assault troops of VII Corps made good progress, but V Corps on Omaha Beach came nearest of all of the five landing areas to disaster. The two American airborne divisions that landed, the 82nd and 101st, were scattered all over the landscape, and caused considerable confusion among the German soldiers, as well as largely securing their objectives, albeit with units completely mixed up with each other. First Army captured much of the early gains of the Allied forces in Normandy. Once the beachheads were linked together, its troops struck west and isolated the Cotentin Peninsula, and then captured Cherbourg. When the American Mulberry harbour was wrecked by a storm, Cherbourg became even more vital.


title: First United States Army

text: After the capture of Cherbourg, First Army struck south. In Operation Cobra, its forces finally managed to break through the German lines. The newly established Third Army was then fed through the gap and raced across France.


title: First United States Army

text: With the arrival of more US troops in France, the Army then passed from the control of the 21st Army Group to the newly arrived 12th Army Group which commanded the First Army and the newly formed Third Army under Lieutenant General George S. Patton. General Bradley assumed command of the 12th Army Group and Lieutenant General Courtney Hodges was placed in command of the First Army. First Army followed Third Army, the American armies forming the southern part of the encirclement of Germans at the Falaise pocket.


title: First United States Army

text: After capturing Paris (the "Wehrmachtbefehlshaber von Groß-Paris", Dietrich von Choltitz, capitulated 25 August, ignoring Hitler's "Trümmerfeldbefehl"), During the Battle of the Mons Pocket VII Corps took approximately 25,000 prisoners. First Army headed towards the south of the Netherlands. First army liberated most of Luxembourg in three days from 9–12 September 1944.


title: First United States Army

text: When the Germans attacked during the Battle of the Bulge, First Army found itself on the north side of the salient, and thus isolated from 12th Army Group, its commanding authority. It was, therefore, temporarily transferred, along with Ninth Army, back to 21st Army Group under Montgomery on 20 December. The salient was reduced by early February 1945. Following the Battle of the Bulge, the Rhineland Campaign began, and First Army was transferred back to 12th Army Group. In Operation Lumberjack, First Army closed up to the lower Rhine by 5 March, and the higher parts of the river five days later.


title: First United States Army

text: On 7 March, in a stroke of luck, Company A, 27th Armored Infantry Battalion, part of Combat Command B, 9th Armored Division, found the Ludendorff Bridge across the Rhine at Remagen still standing. It quickly captured the bridge and established a secure bridgehead. in the next 15 days, over 25,000 troops and their equipment crossed the river. By 4 April, an enormous pocket had been created by First Army and Ninth Army, which contained the German Army Group B under Field Marshal Model, the last significant combat force in the northwest of Germany. While some elements of First Army concentrated on reducing the Ruhr pocket, others headed further east, creating another pocket containing the German Eleventh Army. First Army reached the Elbe by 18 April. There the advance halted, as that was the agreed demarcation zone between the American and Soviet forces. First Army and Soviet forces met on 25 April.


title: First United States Army

text: In May 1945, advance elements of First Army headquarters had returned to New York City and were preparing to redeploy to the Pacific theater of the war to prepare for Operation Coronet, the planned second phase of Operation Downfall the proposed invasion of Honshū, the main island of Japan in the spring of 1946, but the Japanese surrender in August 1945 thanks to the atomic bombings of Hiroshima and Nagasaki terminated that effort.


title: First United States Army

text: First Army returned to the United States in late 1945; first to Fort Jackson (South Carolina), then to Fort Bragg, North Carolina, returning to Fort Jay, Governors Island, New York, in the spring of 1946. Twenty years later, in 1966, First Army relocated to Fort Meade, Maryland, and took over the responsibilities of Second Army, which was inactivated. In 1973, First Army's mission changed from training and preparation of active units to Army Reserve units. In a 1993 reorganization, five divisions carried out that training and support mission:


title: First United States Army

text: In 1993, Headquarters First Army relocated to Fort Gillem, near Atlanta, Georgia, and became responsible for the training and mobilization of all Army Reserve and National Guard units in the United States and providing assistance to the civilian sector during national emergencies and natural disasters. In the latter role, First Army's contributions during the 2005 Hurricane Katrina disaster was a rare bright spot in leading federal relief efforts in the aftermath of the storm. Its commander, Russel L. Honoré, a Louisiana native, became a nationally recognized figure in his direct, no-nonsense approach to disaster relief which earned First Army a Joint Meritorious Unit Award.


title: First United States Army

text: In the 21st century, First Army was subjected to more changes as base closures and force structures were instituted to modernize, economize and change its mission. In 2005, a Base Realignment and Closure (BRAC) Commission decision called for the relocation of First Army headquarters to Rock Island Arsenal, Illinois, in 2011. Its former quarters at Fort Gillem was to transition to a single national location for the mobilization and demobilization of Army National Guard and Reserve units.


title: First United States Army

text: In a second change, as part of the 2006 reorganization of the United States Army program, First Army exchanged its civilian assistance mission for the training and support missions for military units in the western United States formerly held by US Fifth Army. Fifth Army then became U.S. Army, North with responsibilities for homeland defense and domestic emergency assistance.


title: First United States Army

text: First Army inactivated its training divisions and reactivated them as separate training brigades under two commands. First Army Division East, headquartered at Fort Knox, Kentucky (relocated from Fort Meade, Maryland in 2016), has responsibilities in all states east of the Mississippi River; and First Army Division West assuming Fifth Army's role and relocating from Fort Carson to its new headquarters at Fort Hood, Texas, oversees units in all states west of the Mississippi River.


title: First United States Army

text: On order, First Army expands to nine Mobilization force generation installations (MFGI) to mobilize the Reserve component of the US Army. The Army Reserve mobilizes Focused readiness units (FRU) to meet Operational plan (OPLAN) requirements of the combatant commander (CCDR).


title: Offutt Air Force Base

text: Offutt Air Force Base is a U.S. Air Force base south of Omaha, adjacent to Bellevue in Sarpy County, Nebraska. It is the headquarters of the U.S. Strategic Command (USSTRATCOM), the 557th Weather Wing, and the 55th Wing (55 WG) of the Air Combat Command (ACC), the latter serving as the host unit.


title: Offutt Air Force Base

text: Aviation use at Offutt began in September 1918 during World War I as an Army Air Service balloon field. Originally named Fort Crook, it was renamed in honor of World War I pilot and Omaha native 1st Lt. Jarvis Offutt in 1924.


title: Offutt Air Force Base

text: Offutt AFB's legacy includes the construction of the "Enola Gay" and "Bockscar", the planes that dropped Little Boy and Fat Man over Hiroshima and Nagasaki in World War II. Offutt served over 40 years as the headquarters for the former Strategic Air Command (SAC) and home for its associated ground and aerial command centers for the United States in the case of nuclear war during the Cold War. The population was 8,901 at the 2000 census.


title: Offutt Air Force Base

text: Offutt AFB is named in honor of First Lieutenant Jarvis Jennes Offutt (26 October 1894 – 13 August 1918). The first native of Omaha to become a casualty in World War I, Lieutenant Offutt died of injuries sustained when his SE-5 fighter crashed during a training flight near . The airfield portion of Fort Crook was designated Offutt Field on 10 May 1924.


title: Offutt Air Force Base

text: Offutt's history began with the commissioning by the War Department in 1890 of Fort Crook. Located some 10 miles south of Omaha and two miles west of the Missouri River, the fort was constructed between 1894 and 1896. The fort's namesake was Major General George Crook, a Civil War veteran and Indian fighter.


title: Offutt Air Force Base

text: It was first used as a dispatch point for Indian conflicts on the Great Plains. Troops from Fort Crook fought during the Spanish–American War when the 22nd Regiment under Charles A. Wikoff was dispatched to Cuba. The regiment suffered heavy casualties in the Battle of El Caney. Only 165 of the 513 regiment members survived with most succumbing to tropical diseases after the battle.


title: Offutt Air Force Base

text: The oldest surviving portion of Fort Crook is the parade grounds and surrounding red brick buildings that were constructed between 1894 and 1896. These structures are still in active use today as squadron headquarters, living quarters for high-ranking generals (Generals Row), and Nebraska's oldest operational jail.


title: Offutt Air Force Base

text: In 1918, the 61st Balloon Company of the Army Air Corps was assigned to Fort Crook at the close of World War I, which performed combat reconnaissance training. In the spring of 1921, the plowing, leveling, and seeding of 260 acres of land at Fort Crook created an airfield suitable for frequent takeoffs and landings and as a refueling stop for mail and transcontinental flights. The first permanent aircraft hangars were completed in 1921. Other known organizations assigned to the field were the 74th Balloon Company in November 1918; 60th Balloon Company in December 1918.


title: Offutt Air Force Base

text: On 6 May 1924, the airfield was officially named "Offutt Field". The field accommodated interim reserve flying training and regular Post Office Department airmail flights during the 1920s and 1930s; a small detachment of enlisted men (detached service) from Marshall Field and Fort Riley, Kansas, constituted the only military presence on the field between 1935 and 1940.


title: Offutt Air Force Base

text: In 1940 as American involvement in World War II loomed, the Army Air Corps chose Offutt Field as the site for a new bomber plant that was to be operated by the Glenn L. Martin Company. The plant's construction included a two-mile (3 km)-long concrete runway, six large hangars, and a aircraft-assembly building.


title: Offutt Air Force Base

text: Production switched to B-29 Superfortress very heavy bombers in 1944, and 531 Superfortresses were produced before the end of World War II. Among these were the "Enola Gay" and "Bockscar", the B-29's that dropped the first atomic weapons to be used in a military action (against the cities of Hiroshima and Nagasaki, Japan).


title: Offutt Air Force Base

text: Production ended on 18 September 1945, when the last B-29 rolled out of the assembly building. With the manufacturing plant's closure, custody of the airfield and ground facilities were assumed by the 4131st Army Air Force Base Unit, Air Materiel Command.


title: Offutt Air Force Base

text: In the initial months after the end of World War II, Offutt was used by the 2474th Separation Processing squadron to demobilize service members out of the armed forces after their return from overseas duty. In June 1946, the Army Air Force re-designated Fort Crook and the Martin-Nebraska facilities as Offutt Field. It became the headquarters for the Air Defense Command Second Air Force on 6 June. In 1947, the airfield opened for operational use, with the 381st Bombardment Group being assigned to the field with one squadron of B-29 Superfortresses, although the facility remained primarily a separation center.


title: Offutt Air Force Base

text: The newly established United States Air Force took control of the facility in September 1947, and on 13 January 1948, it was renamed Offutt Air Force Base. Later that same year, on 26 September, the 3902nd Air Base Group (later Wing) became the host unit at Offutt.


title: Offutt Air Force Base

text: On 9 November 1948, Offutt became the host base for Headquarters Strategic Air Command, which was moved from Andrews AFB, Maryland. Secretary of the Air Force Stuart Symington chose to locate the Air Force's long-range atomic strike force at Offutt primarily because the base was centrally located on the North American continent, placing it well beyond the existing range of long-range, nuclear-armed bombers to (then) stay safely out of range of hostile missiles or bomber aircraft.


title: Offutt Air Force Base

text: Offutt's population and facilities grew dramatically to keep pace with the increased operational demands during the Cold War. Several new dormitories and more than 2,000 family housing units – built in the late 1950s and 1960s under incremental Wherry and Capehart projects – quickly replaced the old quarters of Fort Crook. Headquarters SAC moved from the Martin-Nebraska complex to Building 500 in 1957, and new base facilities in the 1960s and 1970s included a hospital, main exchange, commissary, and library.


title: Offutt Air Force Base

text: During the late 1950s, Offutt housed a Royal Air Force facility for servicing Avro Vulcans, which visited the air base frequently while on exercise with SAC.


title: Offutt Air Force Base

text: Operational use of Offutt Air Force Base included the basing of alert tankers in the late 1950s and 1960s, support for intercontinental ballistic missile sites in Nebraska and Iowa in the 1960s, and worldwide reconnaissance from the mid-1960s to the present.


title: Offutt Air Force Base

text: To provide air defense of the base, the United States Army established the Offutt AFB Defense Area, and Nike-Hercules surface-to-air missile sites were constructed during 1959. Sites were located near Cedar Creek, Nebraska (OF-60) , and Council Bluffs, Iowa (OF-10) . They were operational between November 1960 and March 1966. The missiles were operated by the 6th Battalion, 43rd Artillery.


title: Offutt Air Force Base

text: During the Cold War, a general and various support personnel from the base were airborne 24 hours a day on an EC-135 from 3 February 1961 to 24 July 1990 in Operation Looking Glass, creating an airborne command post in case of war.


title: Offutt Air Force Base

text: The 3902d Air Base Wing was inactivated on 1 March 1986, and the 55th Strategic Reconnaissance Wing assumed host-unit responsibilities for Offutt. Increased defense spending during the 1980s brought additional operational improvements to Offutt, including the Bennie Davis Aircraft Maintenance Hangar, and a new command center for Headquarters SAC.


title: Offutt Air Force Base

text: Offutt again faced changes in 1992 when the easing of world tensions allowed the United States to reorganize the Air Force. The Strategic Air Command was inactivated on 1 June, succeeded by the U.S. Strategic Command (USSTRATCOM), a Unified Combatant Command of the Department of Defense. The 55th Strategic Wing then became the 55th Wing, under the newly created Air Combat Command.


title: Offutt Air Force Base

text: In 1998, the Strategic Air and Space Museum moved 30 miles (48 km) southwest to Ashland, just off Interstate 80, midway between Omaha and Lincoln.


title: Offutt Air Force Base

text: In 2005, Offutt began several major renovations. The on-base Wherry housing area was demolished for replacement with new housing. A new fire house, AAFES mini-mall, and U.S. Post Office were completed in 2006. Additionally, the Air Force Weather Agency broke ground on a new facility which was completed in 2008.


title: Offutt Air Force Base

text: The new headquarters for STRATCOM, the Command and Control Facility (C2F), is expected to be operational in September 2018.


title: Offutt Air Force Base

text: The base sustained significant damage in the spring of 2019 as a result of the Missouri River flooding; at one point, almost half of the base's runway was underwater. Flight operations and some support staff were temporarily relocated to nearby Lincoln Air National Guard Base while repairs (as well as some pre-planned construction projects) were undertaken.


title: Offutt Air Force Base

text: On 11 September 2001, President George W. Bush conducted one of the first major strategy sessions for the response to the September 11 attacks from a bunker at the base.


title: Offutt Air Force Base

text: Bush, who was in Florida at the Emma Booker Elementary School in Sarasota at the time of the attacks, first flew from Sarasota-Bradenton International Airport to Barksdale AFB in Louisiana and then to Offutt en route back to Washington, DC. Bush arrived at 2:50pm, conducted a video conference in an underground command bunker and left for Washington, DC at 4:30pm. Air Force One left Barksdale AFB for Offutt AFB around 1:30pm. The Air Force One entourage was pared down to a few essential staffers such as Ari Fleischer, Andrew Card, Karl Rove, Dan Bartlett, Brian Montgomery, and Gordon Johndroe, plus about five reporters. During the flight, Bush remained in "continuous contact" with both the White House Situation Room and Vice President Dick Cheney in the Presidential Emergency Operations Center.


title: Offutt Air Force Base

text: Air Force One landed at Offutt shortly before 3:00pm. At 3:06pm, Bush passed through security to the US Strategic Command Underground Command Center () and was taken into an underground bunker designed to withstand a nuclear blast. There, he held a teleconference call with Vice President Cheney, National Security Advisor Condoleezza Rice, Defense Secretary Donald Rumsfeld, Deputy Secretary of State Richard Armitage, CIA Director George Tenet, Transportation Secretary Norman Mineta, and others. The meeting lasted about an hour. Rice recalled that during the meeting, Tenet told Bush, "Sir, I believe it's al-Qaeda. We're doing the assessment but it looks like, it feels like, it smells like al-Qaeda." The White House staff was preparing for Bush to address the nation from the Offutt bunker, but Bush decided instead to return to Washington. Air Force One left Offutt around 4:30pm.


title: Offutt Air Force Base

text: In May 2011, base civilian employee George Sarris successfully settled with the government over claims that he was subjected to retaliation for talking to the media in 2008 about poor maintenance of RC-135 aircraft at the base. After Sarris' allegations appeared in the "Kansas City Star", base officials revoked his security clearance and reassigned him to menial duties. Later investigations by the government substantiated many of Sarris' claims. As part of the settlement, the USAF agreed to pay Sarris his full salary until he retired in 2014 and paid $21,000 of his attorney's fees. After retiring, Sarris published a book titled, "Cowardice in Leadership – A Lesson in Harassment, Intimidation, and Reprisals". Ten years after Sarris blew the whistle, the "Omaha World Herald" published a three-part series titled "In-flight emergency", which confirmed his earlier claims.


title: Offutt Air Force Base

text: The 549th Strategic Missile Squadron operated three SM-65D Atlas ICBM sites (1 October 1960 – 15 December 1964). Each site was composed of three missile silos (9 total).


title: Offutt Air Force Base

text: Beginning in 1958, the Army Corps of Engineers began planning for the sites, and construction began in 1959. The construction project was completed on 28 July 1960. In April and May 1961, the three complexes became the last Atlas D missiles to go on alert.


title: Offutt Air Force Base

text: The missiles were manned by the 549th Strategic Missile Squadron which was activated on 1 October 1960. The squadron began to phase down with the inactivation of the Atlas-D on 1 October 1964, and was inactivated 14 December 1964. Confusingly, the squadron was originally the 566th but on 1 July 1961 SAC swapped designators with the 549th at F.E. Warren AFB. The 549th SMS was under the 385th Strategic Aerospace Wing.


title: Offutt Air Force Base

text: Site "A" was abandoned for many years, until the late 1970s when the Nebraska National Guard took over ownership of the site to establish a training area called the Mead Training Site. The site is managed by the Camp Ashland Training Site Command. The training area has been used by the National Guard, United States Air Force, local law enforcement, and other entities as a training site for many years. 3/209th RTI out of Camp Ashland began using Mead Training Site in 2008 as the primary training facility for their 88M military occupational specialty reclassification school and continues to use the site year round. A MOUT site (Military Operations in Urban Terrain) was constructed at the site in 2009. Two Nebraska National Guard armories were built directly alongside the training area in 2012. Many other National Guard units use the site for drill weekends and annual trainings. Airmen out of Offutt Air Force Base practice Survival, Evasion, Resistance and Escape (SERE) Training at the site several weekends a year.


title: Offutt Air Force Base

text: Site "B" is in use for agricultural storage. Site "C" has been demolished, with only the access roads remaining.


title: Offutt Air Force Base

text: In September 2019, a shooting took place in Offutt's private housing community, killing Sgt. Zachary Firlik and his wife Kari Firlik. The case was identified as a murder-suicide; the shooter was an active off-duty airman, who afterwards killed himself.


title: Offutt Air Force Base

text: Offutt Air Force Base is the host station for the 55th Wing (55 WG), the largest wing of the United States Air Force's Air Combat Command. Additionally, the base is home to many significant associate units, including US Strategic Command Headquarters, the 557th Weather Wing, the Omaha operating location of the Defense Finance and Accounting Service, and many others.


title: Offutt Air Force Base

text: The mission of the 595th C2G is to consolidate the Air Force's portion of the nuclear triad, including Air Force nuclear command and control communications, under the auspices of Air Force Global Strike Command (AFGSC). Previously, portions of the Air Force's command and control of nuclear operations had been divided among AFGSC, Air Combat Command, and the Twentieth Air Force.


title: Offutt Air Force Base

text: The 557th Weather Wing, formerly the Air Force Weather Agency, is headquartered at Offutt AFB. It is the lead weather center of the United States Air Force.


title: Offutt Air Force Base

text: Offutt AFB is the headquarters of United States Strategic Command (USSTRATCOM) which is one of the ten Unified Combatant Commands of the United States Department of Defense (DoD). USSTRATCOM was established in 1992 as a successor to Strategic Air Command (SAC).


title: Offutt Air Force Base

text: It is charged with space operations (such as military satellites), information operations (such as information warfare), missile defense, global command and control, intelligence, surveillance, and reconnaissance (C4ISR), global strike and strategic deterrence (the United States nuclear arsenal), and combating weapons of mass destruction.


title: Offutt Air Force Base

text: Units marked GSU are Geographically Separate Units, which although based at Offutt, are subordinate to a parent unit based at another location.


title: Offutt Air Force Base

text: Most of the high-ranking officials at Offutt live on General's Row, a row of 4-story duplexes that was built in 1895.


title: Offutt Air Force Base

text: Because of its central position in the US, radio traffic to and from Offutt is often heard by shortwave listeners on 11175 kHz, USB.


title: Offutt Air Force Base

text: As of the census of 2000, there were 8,901 people, 2,304 households, and 2,255 families residing on the base. The population density was 2,113.1 people per square mile (816.3/km). There were 2,429 housing units at an average density of 576.6/sq mi (222.8/km). The racial makeup of the base was 78.0% White, 10.4% Black or African American, 0.7% Native American, 2.7% Asian, 0.3% Pacific Islander, 3.6% from other races, and 4.3% from two or more races. Hispanic or Latino of any race were 7.4% of the population.


title: Offutt Air Force Base

text: There were 2,304 households, out of which 79.1% had children under the age of 18 living with them, 90.5% were married couples living together, 5.3% had a female householder with no husband present, and 2.1% were non-families. 1.9% of all households were made up of individuals, and none had someone living alone who was 65 years of age or older. The average household size was 3.61 and the average family size was 3.64.


title: Offutt Air Force Base

text: On the base the population was spread out, with 41.9% under the age of 18, 16.8% from 18 to 24, 39.7% from 25 to 44, 1.4% from 45 to 64, and 0.1% who were 65 years of age or older. The median age was 22 years. For every 100 females, there were 105.4 males. For every 100 females age 18 and over, there were 109.7 males.


title: Offutt Air Force Base

text: The median income for a household on the base was $36,742, and the median income for a family was $36,619. Males had a median income of $25,391 versus $21,593 for females. The per capita income for the base was $11,580. About 4.4% of families and 5.6% of the population were below the poverty line, including 7.1% of those under age 18 and none of those age 65 or over.


title: Offutt Air Force Base

text: According to the United States Census Bureau, the base has a total area of 4.3 square miles (11.3 km), of which, 4.2 square miles (10.9 km) of it is land and 0.1 square miles (0.4 km) of it (3.22%) is water.


title: Offutt Air Force Base

text: Most of the base is in the Bellevue Public Schools school district. A portion is in the Papillion-La Vista School District.


title: Offutt Air Force Base

text: Offutt was brought to popular attention during its SAC period when the command was depicted in the 1955 film "Strategic Air Command" starring Jimmy Stewart, the 1963 film "A Gathering of Eagles" starring Rock Hudson, and 1964's "Fail-Safe" starring Henry Fonda (which not only claimed to show portions of the base but also a nearby Omaha neighborhood) and "" starring Peter Sellers (which depicts a nuclear first strike from a mad general at the fictional Burpelson Air Force Base).


title: Offutt Air Force Base

text: Offutt appeared in the "" episode "Tomorrow Is Yesterday" (identified as 'the Omaha installation'), when a fighter pilot stationed there detects the approaching USS "Enterprise" and is transported aboard.


title: Offutt Air Force Base

text: The Dale Brown novel "Plan of Attack" saw nuclear missiles launched by Russian bombers attacking multiple bomber bases all over the U.S, including Offutt, which is destroyed by four Kh-15 (AS-17 Kickback) missiles. Only one Boeing E-4 NEACP escapes in time, and the officials of the Eighth Air Force and STRATCOM are eliminated in the process. Pat Frank's iconic Cold War novel "Alas, Babylon" (1959) has Air Force Colonel Mark Bragg, the brother of the protagonist Randy Bragg, stationed at Offutt.


title: Offutt Air Force Base

text: In the 1983 post apocalyptic feature film for television, "The Day After", Offutt is represented as a SAC Aircraft departs the field as the cameras then change focus to the countryside as the credits roll.


title: Boeing C-97 Stratofreighter

text: The Boeing C-97 Stratofreighter was a long-range heavy military cargo aircraft developed from the B-29 and B-50 bombers. Design work began in 1942, the first of three prototype XC-97s flew on 9 November 1944 (none saw combat), and the first of six service-test YC-97s flew on 11 March 1947. All nine were based on the 24ST alloy structure and Wright R-3350 engines of the B-29, but with a larger-diameter fuselage upper lobe (making a figure of eight or "double-bubble" section) and they had the B-29 vertical tail with the gunner's position blanked off. The first of three heavily revised YC-97A incorporating the re-engineered wing (higher-strength 75ST alloy), taller vertical tail and larger Pratt and Whitney R-4360 engines of the B-50 bomber, flew on 28 January 1948 and was the basis of the subsequent sole YC-97B, all production C-97s, KC-97s and civilian Stratocruiser aircraft. Between 1944 and 1958, 888 C-97s in several versions were built, 811 being KC-97 tankers. C-97s served in the Berlin Airlift, the Korean War, and the Vietnam War. Some aircraft served as flying command posts for the Strategic Air Command, while others were modified for use in Aerospace Rescue and Recovery Squadrons (ARRS).


title: Boeing C-97 Stratofreighter

text: The C-97 Stratofreighter was developed towards the end of World War II by fitting a second lobe on top of the fuselage and wings of the B-29 Superfortress with the tail, wing, and engine layout being nearly identical.<ref name="Swanborough / Bowers 1989, p. 125">Swanborough and Bowers 1989, p. 125.</ref> The XC-97 and YC-97 can be distinguished from the Boeing 377 Stratocruiser and later C-97s by the shorter fin, and later ones by the flying boom and jet engines on the tanker models.


title: Boeing C-97 Stratofreighter

text: The prototype XC-97 was powered by the same Wright R-3350 engines as used in the B-29. The XC-97 took off for its first flight on November 9, 1944, just after the death of Boeing president Philip G. Johnson.


title: Boeing C-97 Stratofreighter

text: On 9 January 1945, the first prototype, piloted by Major Curtin L. Reinhardt, flew from Seattle to Washington, D.C. in 6 hours 4 minutes, an average speed of with of cargo. The tenth and all subsequent aircraft were fitted with the Pratt & Whitney Wasp Major engines and taller fin and rudder of the B-50 Superfortress.


title: Boeing C-97 Stratofreighter

text: The C-97 had clamshell doors under its tail, so that two retractable ramps could be used to drive in cargo but was not a combat transport able to deliver to primitive forward bases. The doors could not be opened in flight, but could be removed to carry out air drops. The C-97 had a useful payload of , which could include two 2½-ton trucks, towed artillery, or light tracked vehicles such as the M56 Scorpion. The C-97 featured cabin pressurization, which made long flights more comfortable.


title: Boeing C-97 Stratofreighter

text: The C-97 was developed into the civilian Boeing 377 Stratocruiser, a transoceanic airliner that could be fitted with sleeper cabins and featured a lower deck lounge. The first Stratocruiser flew on July 8, 1947. Only 56 were built.


title: Boeing C-97 Stratofreighter

text: The C-97 entered service in 1947, during a period of rapid development of heavy transport aircraft. Only 77 were built before the Douglas C-124 Globemaster II was delivered in 1950, with nearly twice the payload capacity of the C-97. The USAF Strategic Air Command operated C-97 Stratofreighters from 1949 to 1978. Early in its service life, it served as an airborne alternative SAC command post. While only 77 C-97 transports were built, 811 were built as KC-97 Stratofreighters for inflight refueling. The KC-97 began to be phased out with the introduction of the Boeing KC-135 Stratotanker in 1957. Many KC-97s were later refitted as C-97G transports and equipped several squadrons of the U.S. Air National Guard.


title: Boeing C-97 Stratofreighter

text: One YC-97A (45–59595) was used in the Berlin Airlift during April 1949, operating for the 1st Strategic Support Squadron. It suffered a landing gear accident at Gatow and by the time it was repaired, the Soviet Blockade was lifted.


title: Boeing C-97 Stratofreighter

text: C-97s evacuated casualties during the Korean War. C-97s also participated in the Biafran airlift, delivering relief materials to Uli airstrip in Biafra during the Nigerian Civil War. Flying under the cover of darkness and at treetop level to evade radar, at least two C-97s were lost.


title: Boeing C-97 Stratofreighter

text: Only one C-97 is still airworthy at the present day, (S/N 52-2718, named "Angel of Deliverance") operated by the Berlin Airlift Historical Foundation. It is painted as YC-97A 45–59595, the only C-97 to participate in the Berlin Airlift.


title: Boeing C-97 Stratofreighter

text: The Israelis turned to Stratocruisers and KC-97s when they could not buy the preferred C-130. They adapted Boeing 377 Stratocruiser airliners into transports, including many using C-97 tail sections including the loading ramps. Others were adapted with swiveling tails and refueling pods. One Israeli C-97 was downed by an Egyptian SA-2 Guideline missile on 17 September 1971, while flying as an electronic counter-measures platform some 12 miles from the Suez Canal.


title: Boeing C-97 Stratofreighter

text: The following Air Force wing organizations flew the various C-97 models at some time during their existence:


title: Parenteral nutrition

text: Parenteral nutrition (PN) is the feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion. The products are made by pharmaceutical compounding companies. The person receives a nutritional mix according to a formula including glucose, salts, amino acids, lipids and vitamins and dietary minerals. It is called total parenteral nutrition (TPN) or total nutrient admixture (TNA) when no significant nutrition is obtained by other routes, and partial parenteral nutrition (PPN) when nutrition is also partially enteric. It is called peripheral parenteral nutrition (PPN) when administered through vein access in a limb rather than through a central vein as central venous nutrition (CVN).


title: Parenteral nutrition

text: Total parenteral nutrition (TPN) is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity (it is blocked, or has a leak – a fistula) or because its absorptive capacity is impaired. It has been used for comatose patients, although enteral feeding is usually preferable, and less prone to complications. Parenteral nutrition is used to prevent malnutrition in patients who are unable to obtain adequate nutrients by oral or enteral routes. The Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition recommends waiting until the seventh day of hospital care.


title: Parenteral nutrition

text: TPN may be the only feasible option for providing nutrition to patients who do not have a functioning gastrointestinal tract or who have disorders requiring complete bowel rest, including bowel obstruction, short bowel syndrome, gastroschisis, prolonged diarrhea regardless of its cause, very severe Crohn's disease or ulcerative colitis, and certain pediatric GI disorders including congenital GI anomalies and necrotizing enterocolitis.


title: Parenteral nutrition

text: There are physical, physiological, or mental differences in the geriatric population that could potentially lead to poor nutrient intake that would require them to have nutrition therapy. Geriatric patients are more inclined to have delayed muscle restoration compared to the younger population. Additionally, older patients are observed to have greater cardiac and renal impairment, insulin resistance, and to have deficiencies in vitamins and crucial elements. Patients who require nutrition therapy but have contraindications for or cannot tolerate enteral nutrition are appropriate candidates for parenteral nutrition. In the geriatric population, it is indicated if oral or enteral nutrition is impossible for 3 days or when oral or enteral nutrition is likely insufficient for more than 7 to 10 days. While there are no complications of parenteral nutrition specific to the geriatric population, complications are more prevalent in this population due to increased comorbidities.


title: Parenteral nutrition

text: Patients who are diagnosed with cancer, whether as outpatient undergoing treatment or hospitalized, are at a greater risk of malnutrition and cachexia. Cancer-related malnutrition can be attributed to the decrease in food intake, increase in the need for energy, and the alteration of metabolism. Patients should be assessed early on in their cancer treatment for any nutritional risk, such as by taking routine weights and BMI. Parenteral nutrition is indicated in cancer patients when it is not possible to access the digestive tract or if the tract is ineffective. In advanced cancer patients, the use of PN should be discussed in context of the risks and benefits, such as if the approximate survival rate is longer than 3 months and if PN would be expected to greatly improve the patients' quality of life.


title: Parenteral nutrition

text: It is uncertain whether home parenteral nutrition improves survival or quality of life in people with malignant bowel obstruction.


title: Parenteral nutrition

text: Short-term PN may be used if a person's digestive system has shut down (for instance by peritonitis), and they are at a low enough weight to cause concerns about nutrition during an extended hospital stay. Long-term PN is occasionally used to treat people suffering the extended consequences of an accident, surgery, or digestive disorder. PN has extended the life of children born with nonexistent or severely deformed organs.


title: Parenteral nutrition

text: Approximately 40,000 people use TPN at home in the United States, and because TPN requires 10–16 hours to be administered, daily life can be affected. Although daily lifestyle can be changed, most patients agree that these changes are better than staying at the hospital. Many different types of pumps exist to limit the time the patient is "hooked up". Usually a backpack pump is used, allowing for mobility. The time required to be connected to the IV is dependent on the situation of each patient; some require once a day, or five days a week.


title: Parenteral nutrition

text: It is important for patients to avoid as much TPN-related change as possible in their lifestyles. This allows for the best possible mental health situation; constantly being held down can lead to resentment and depression. Physical activity is also highly encouraged, but patients must avoid contact sports (equipment damage) and swimming (infection). Many teens find it difficult to live with TPN due to issues regarding body image and not being able to participate in activities and events.


title: Parenteral nutrition

text: TPN fully bypasses the GI tract and normal methods of nutrient absorption. Possible complications, which may be significant, are listed below. Other than those listed below, common complications of TPN include hypophosphatemia, hypokalemia, hyperglycemia, hypercapnia, decreased copper and zinc levels, elevated prothrombin time (if associated with liver injury), hyperchloremic metabolic acidosis and decreased gastrointestinal motility.


title: Parenteral nutrition

text: TPN requires a chronic IV access for the solution to run through, and the most common complication is infection of this catheter. Infection is a common cause of death in these patients, with a mortality rate of approximately 15% per infection, and death usually results from septic shock. When using central venous access, the subclavian (or axillary) vein is preferred due to its ease of access and lowest infectious complications compared to the jugular and femoral vein insertions.


title: Parenteral nutrition

text: Catheter complications include pneumothorax, accidental arterial puncture, and catheter-related sepsis. The complication rate at the time of insertion should be less than 5%. Catheter-related infections may be minimised by appropriate choice of catheter and insertion technique.


title: Parenteral nutrition

text: Chronic IV access leaves a foreign body in the vascular system, and blood clots on this IV line are common. Death can result from pulmonary embolism wherein a clot that starts on the IV line breaks off and travels to the lungs, blocking blood flow.


title: Parenteral nutrition

text: Patients on TPN who have such clots occluding their catheter may receive a thrombolytic flush to dissolve the clots and prevent further complications.


title: Parenteral nutrition

text: Fatty liver is usually a more long-term complication of TPN, though over a long enough course it is fairly common. The pathogenesis is due to using linoleic acid (an omega-6 fatty acid component of soybean oil) as a major source of calories. TPN-associated liver disease strikes up to 50% of patients within 5–7 years, correlated with a mortality rate of 2–50%. Onset of this liver disease is the major complication that leads TPN patients to requiring an intestinal transplant.


title: Parenteral nutrition

text: Intralipid (Fresenius-Kabi), the US standard lipid emulsion for TPN nutrition, contains a 7:1 ratio of n-6/n-3 ratio of polyunsaturated fatty acids (PUFA). By contrast, Omegaven has a 1:8 ratio and showed promise in multiple clinical studies. Therefore n-3-rich fat may alter the course of parenteral nutrition associated liver disease (PNALD).


title: Parenteral nutrition

text: Because patients are being fed intravenously, the subject does not physically eat, resulting in intense hunger pangs (pains). The brain uses signals from the mouth (taste and smell), the stomach and gastrointestinal tract (fullness) and blood (nutrient levels) to determine conscious feelings of hunger. In cases of TPN, the taste, smell and physical fullness requirements are not met, and so the patient experiences hunger, although the body is being fully nourished.


title: Parenteral nutrition

text: Patients who eat food despite the inability can experience a wide range of complications, such as refeeding syndrome.


title: Parenteral nutrition

text: Total parenteral nutrition increases the risk of acute cholecystitis due to complete disuse of the gastrointestinal tract, which may result in bile stasis in the gallbladder. Other potential hepatobiliary dysfunctions include steatosis, steatohepatitis, cholestasis, and cholelithiasis. Six percent of patients on TPN longer than three weeks and 100% of patients on TPN longer than 13 weeks develop biliary sludge. The formation of sludge is the result of stasis due to lack of enteric stimulation and is not due to changes in bile composition. Gallbladder sludge disappears after four weeks of normal oral diet. Administration of exogenous cholecystokinin (CCK) or stimulation of endogenous CCK by periodic pulse of large amounts of amino acids has been shown to help prevent sludge formation. These therapies are not routinely recommended. Such complications are suggested to be the main reason for mortality in people requiring long-term total parenteral nutrition, such as in short bowel syndrome. In newborn infants with short bowel syndrome with less than 10% of expected intestinal length, thereby being dependent upon total parenteral nutrition, five-year survival is approximately 20%.


title: Parenteral nutrition

text: Infants who are sustained on TPN without food by mouth for prolonged periods are at risk for developing gut atrophy.


title: Parenteral nutrition

text: Hypersensitivity is a rarely described but significant complication of parenteral nutrition therapy. First reported in 1965, the incidence of these reactions is speculated to be around one in 1.5 million patients who are provided parenteral nutrition. There is a wide range in how and when these reactions manifest. Cutaneous manifestations are the most common presentation. Hypersensitivity is thought to occur to the individual components of TPN, with the intravenous lipid emulsion being the most frequently implicated component, followed by the multivitamin solution and the amino acid solution.


title: Parenteral nutrition

text: Patients who are receiving intravenous parenteral nutrition may also need to receive intravenous medications as well using the same Y-site. It is important to assess the compatibility of the medications with the nutrition components. Incompatibilities can be observed physically through discoloration, phase separation, or precipitation.


title: Parenteral nutrition

text: Metabolic complications include the refeeding syndrome characterised by hypokalemia, hypophosphatemia and hypomagnesemia. Hyperglycemia is common at the start of therapy, but can be treated with insulin added to the TPN solution. Hypoglycaemia is likely to occur with abrupt cessation of TPN. Liver dysfunction can be limited to a reversible cholestatic jaundice and to fatty infiltration (demonstrated by elevated transaminases). Severe hepatic dysfunction is a rare complication. Overall, patients receiving TPN have a higher rate of infectious complications. This can be related to hyperglycemia.


title: Parenteral nutrition

text: Pregnancy can cause major complications when trying to properly dose the nutrient mixture. Because all of the baby’s nourishment comes from the mother’s blood stream, the doctor must properly calculate the dosage of nutrients to meet both recipients’ needs and have them in usable forms. Incorrect dosage can lead to many adverse, hard-to-guess effects, such as death, and varying degrees of deformation or other developmental problems.


title: Parenteral nutrition

text: It is recommended that parenteral nutrition administration begin after a period of natural nutrition so doctors can properly calculate the nutritional needs of the fetus. Otherwise, it should only be administered by a team of highly skilled doctors who can accurately assess the fetus’ needs.