text:
The Endurolytes Rationale
By William Misner Ph.D.
Why should the body be exposed to a minimal repletion electrolyte dose during extreme losses? Hypothetically electrolyte absorption should occur under the body's radar, without triggering a cascade of hormonal signals alter excretion rate by the kidneys. This hypothetically supports for taking the low sodium model as opposed to a higher sodium electrolyte. It needs to be emphasized that substrate repletion is never completed during high metabolic aerobic expense above sedentary state. Glycogen/glucose, electrolytes, fluids, and numerous other substrates are lost faster than they can be replaced during exercise. Waste matter and free radicals accumulate at 12-20 times that rate which is normally restored during sedentary inactivity. To suggest that a substrate must be replaced at or near the rate it is lost, is to suggest that 1-liter water, 2000 milligrams sodium, and 700 calories per hour must be consumed. We have observed that athletes who consume only 50% of this amount are more likely to have problems than those who consume 1/4 of the lost metabolites during ultra endurance exercise. This material may be shared in its entirety. This is a complex issue, since individual variations are difficult to explain without full understanding of how the individual response is effecting excretion versus re-absorption of sodium, fluids, and other substances. Reinking and Bennett have composed a texts to explain some of the complexities, though keep in mind neither suggests that one dose-size fits all.
There is a point in time at which the body cannot replace losses from exogenous sources. Overdose of a single electrolyte at its repletion rate may lead to other imbalances triggering other systemic reactions that may lead to further problems that may inhibit performance. This suggests adding small dose electrolyte dose before detectable overdose triggers hormone-activated mechanisms further impeding natural outcome and performance progress. Aldosterone levels control the rate of sodium recirculated in the human body.
ALDOSTERONE (Plasma) Males: 6-22 ng/dl is normal. Females: 4-31 ng/dl is normal. Pregnant females: 18 - 100 ng/dl is normal. Aldosterone is synthesized in the adrenal cortex. It stimulates the kidney tubule cells to increase their REABSORPTION OF SODIUM BACK INTO THE BLOOD. NORMAL SERUM OR PLASMA LEVELS OF ALDOSTERONE ARE DEPENDENT ON THE SODIUM INTAKE AND WHETHER THE PATIENT IS UPRIGHT OR SUPINE. High sodium intake will tend to suppress serum aldosterone, whereas low sodium intake will elevate serum aldosterone. The reference intervals for serum (plasma) aldosterone are based on normal sodium intake.
High Aldosterone levels occur in response to stress, renal dysfunction, adrenal cortical overactivity, pregnancy.
NORMAL ALDOSTERONE SERUM:
[A] Upright: 4.0-31.0 ng/dL
[B] Supine: <1.6-16.0 ng/dL
NORMAL ALDOSTERONE URINE:
NORMAL DIET: 6-25 µg/24 hrs
LOW SODIUM DIET: 17-44 µg/24 hrs
HIGH SODIUM DIET: 0-6 µg/24 hrs
NORMAL URINE VALUES OF ALDOSTERONE ARE DEPENDENT ON SODIUM INTAKE
Normal sodium intake: 100-200 mEq
Low sodium intake: < 25 mEq
High sodium intake: > 200 mEq
ELECTROLYTE REPLACEMENT: AN OVERVIEW
The thirst mechanism in animals is a complex interaction of control centers in the brain and hypothalamus; though the details of that mechanism go well beyond the scope of this note, it is important to know that the thirst mechanism is linked to water loss. When total body fluid volume decreases by 0.5-1.0%, the thirst mechanism asserts itself. Approximately 55% of water intake is derived directly from fluids, 35% from food, and 10% from water produced as a byproduct of metabolism. Kidneys excrete approximately 1 to 2 liters of urine per day. Approximately 900 milliliters (ml) of this amount is obligatory water excretion that gets rid of solutes and is constant from day to day. The remainder is excreted according to the fluctuating needs of the body and the changing renal tubular reabsorption rate. The process by which the body loses water through the skin is called insensible water loss. Approximately 350 ml of water is excreted by diffusion through the skin, while another 100 ml is lost through normal perspiration. Heavy perspiration in response to heat evaporative cooling need may cause a greater loss. Water loss through respiration is about 350 ml per day, varying with climate. About 150 to 200 ml is lost through feces. There are three main types of solutes: electrolytes, plasma proteins, and small organic compounds. Electrolytes are chemical elements such as acid, alkali, or salt dissociated into ions. SODIUM COMPRISES ABOUT 45% OF THE TOTAL ELECTROLYTE CONCENTRATION. The SODIUM CATION in extracellular fluids [ECF] is the primary osmotic force in maintaining maintains the necessary water volume for cells. Chloride, the main anion in ECF, provides balance to the SODIUM CATION. The intracellular fluids [ICF] contains POTASSIUM & PHOSPHATE. The concentration of electrolytes in a solution is based on the number of particles in solution. This concentration is measured in milliequivalents (mEq). On a broader, less localized level, the kidney is primarily responsible for maintaining water and electrolyte balance in the body. The kidney is alternately triggered to action by the hormones vasopressin and aldosterone.
VASOPRESSIN, also called antidiuretic hormone (ADH), is secreted by the pituitary gland and stimulates the reabsorption of water. ADH secretion can be stimulated by a loss of body water, whether it is an actual loss or the result of a shift of water from plasma to interstitial ECF spaces as occurs in congestive heart failure. ALDOSTERONE, secreted by the adrenal gland, acts PRIMARILY TO CONSERVE SODIUM, but in doing so has the affect of controlling water loss. The mechanism of action of aldosterone is referred to as the renin-angiotensin-aldosterone mechanism. Renin is an enzyme secreted by the renal cortex into the blood under the circumstances of decreased sodium intake, sodium loss, or decreased fluid volume. Renin interacts with a serum globulin from the liver to form angiotensin I and angiotensin II in the blood. Angiotensin II increases the force of the heart beat, constricts arterioles, and diminishes renal blood flow. This triggers the release of aldosterone. ALDOSTERONE CAUSES THE KIDNEYS TO RETAIN AND REABSORB SODIUM. This action, in turn, conserves water and results in loss of potassium.
HORMONE-ACTIVATED KIDNEY RESPONSE [1]
The kidneys are essential adjuncts to the cardiovascular system. These organs control erythrocyte production, direct the release of vasoactive hormones and regulate both the blood composition and volume. The concepts of renal function will be reviewed in this chapter in order to serve as a basis for better understanding of the Regulation of Arterial Blood Pressure. Perhaps the best way to appreciate the role of the kidneys is to consider their blood supply. THE KIDNEYS ARE PLACED IN A STRATEGIC POSITION IN THE CIRCULATION AND, AT REST, RECEIVE 20-25% OF THE CARDIAC OUTPUT. This is a huge amount of blood for a pair of organs that represent only about 1% of the body mass. It is important to consider that fluid processing, by the kidney, alters blood volume and an altered blood volume, in turn, alters cardiac filling. Combined, both human kidneys have about two million nephrons. There are two basic parts to the nephron, a glomerulus and a renal tubule. The glomerulus, a knot of capillaries, receives blood from the afferent arteriole. Blood leaves the glomerulus via the efferent arteriole, which then forms vessels that cover the renal tubule. The renal tubule is comprised of Bowman's capsule, the proximal convoluted tubule, the loop of Henle and the distal convoluted tubule. Many nephrons feed into a collecting duct and, ultimately, many collecting ducts flow into the ureter.
RENAL PROCESSES
FILTRATION - As blood flows through the glomerulus, fluid is filtered into Bowman's capsule. As we saw in the microcirulation lab, a number of osmotic and hydraulic forces influence this fluid movement. In humans, the GLOMERULAR FILTRATION RATE IS ABOUT 125 ML FLUID/MIN. This process is rather indiscriminate since everything except for the cells and large protein molecules filter from the glomerulus into Bowman's capsule. In other words, many valuable components such as water, ions, amino acids, vitamins and glucose are lost from the blood during filtration. If all of the glomerular filtrate resulted in urine, an individual would excrete (and replace) 180 liters per day. OBVIOUSLY, FURTHER PROCESSING STEPS MUST RECOVER MOST OF THIS FILTRATE.
REABSORPTION
The proximal convoluted tubule is lined with cells that actively transports solutes from the lumen of the tubule back into the blood (remember that the tubule is cover with peritubular capillaries). This process is specifically referred to as tubular reabsorption. Water movement is linked to this active transport of solutes and results in reabsorption of most of the filtered water. Additional reabsorption of solutes also can occur in other portions of the renal tubule. Sodium is mostly reabsorped in the proximal tubule but a small portion is reabsorped in the loop of henle and in the distal tubule. The reabsorption of sodium in the distal tubule is significant because it is under the control of the adrenal hormone, ALDOSTERONE.
As the forming urine passes through the renal tubule, some solutes are moved, via active transport, from the blood to the lumen of the tubule. This process is called tubular secretion. In particular, substance such as creatinine, urea, organic acids and potassium are secreted. Potassium secretion in the distal convoluted tubule is of particular interest because it is linked to sodium reabsorption and, thus, is also under the control of ALDOSTERONE.
As the forming urine reaches the end of the distal tubule, the osmotic concentration is about the same as that of the blood (˜300 mOsm/liter). If urine were excreted at this concentration, a person consuming a normal amount of fluid would become dehydrated due to a large water loss. In cases of normal hydration, urine must be concentrated before it leaves the kidney. They key to urine concentration is a solute gradient that is established in the tissues of the renal medulla. If we were to measure osmotic concentrations of tissue in the kidneys, we would find that the osmotic concentration in the cortex is about 300 mOsm/liter and progressively increases until it reaches 1,200 mOsm/liter in the innermost zone of the medulla. Passing through the medullary solute gradient are the loops of Henle, the vasa recta and the collecting ducts.
A NUMBER OF FACTORS CONTRIBUTE TO THE FORMATION OF THE MEDULLARY SOLUTE GRADIENT AND INCLUDE:
1) Sodium and chloride transport in the upper, thick portion of the loop of henle.
2) A countercurrent multiplier in the loop of henle.
3) Water impermeability of the distal tubule.
4) Urea moving from the collecting duct.
5) The unique, hair-pin shape of the vasa recta.
[The exact mechanism involved in forming this gradient is beyond the scope of this text.]
As fluid moves down the collecting duct, it encounters an increasingly greater osmotic gradient in the surrounding medullary tissue. Water, in response to the concentration gradient, tends to diffuse out of the collecting ducts into the surrounding tissue. As a result of this water extraction the urine in concentrated. Water, entering the medullary tissue, is then picked up by the vasa recta and returned to the circulation
VASOPRESSIN (ANTIDIURETIC HORMONE, ADH) CONTROLS WATER/FLUID LEVELS
ADH REGULATES WATER EXTRACTION FROM THE COLLECTING DUCT. WHEN INCREASED BLOOD OSMOTIC CONCENTRATION is sensed in the osmotic center of the brain, ADH is released by the posterior pituitary (neurohypophysis). This hormone travels through the blood, binds to receptors on the collecting ducts and CAUSES INCREASED WATER PERMEABILITY. As a result, more water is extracted and the urine becomes more concentrated. IN CASES OF OVER-HYDRATION, ADH is no longer released, the collecting duct becomes less permeable to water and more water is lost to the urine. ADH is also called VASOPRESSIN because this molecule promotes increased blood pressure via vasoconstriction (i.e., a VASOPRESSOR ACTION).
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM (RAAS)
This regulatory system, based in the kidneys, plays a key role in REGULATING BLOOD SODIUM CONCENTRATION, BLOOD POTASSIUM CONCENTRATION, BLOOD VOLUME AND BLOOD PRESSURE. The juxtaglomerular apparatus involves a portion of the distal tubule that has folded back toward the glomerulus (called the macula densa) plus a section of cells lining the afferent arteriole (the juxtaglomerular cells). The juxtaglomerular apparatus is able detect changes in sodium levels and renal blood pressure and flow. If sodium levels drop or if pressure or flow in the afferent arteriole drops, RENIN, a molecule stored in the juxtaglomerular cells in a precursor form, is released into the circulation. In the blood, RENIN converts circulating angiotensinogen into a decapeptide, angiotensin I. As ANGIOTENSIN I passes through the lungs it is converted into ANGIOTENSIN II (an octapeptide) by angiotensin converting enzyme (ACE) contained within the endothelial cells of the pulmonary vessels (minor conversion also occurs in other organs). Angiotensin II is a powerful vasoconstrictor and will cause an increase in blood pressure. Note that this action counters the original stimulus of decreased renal blood pressure. Angiotensin II also stimulates thirst via the central nervous system and stimulates ADH RELEASE. THESE ACTIONS WILL EVENTUALLY INCREASE BLOOD VOLUME. ADH CAUSES VASOCONSTRICTION. A final action of angiotensin II is to stimulate ALDOSTERONE production and release from the adrenal cortex. ALDOSTERONE IS A STEROID HORMONE THAT PROMOTES SODIUM REABSORPTION IN THE DISTAL TUBULE. INCREASED SODIUM REABSORPTION COUNTERS THE OTHER STIMULUS THAT TRIGGERS RENIN RELEASE. INCREASED SODIUM REABSORPTION WILL BE ACCOMPANIED WATER RETENTION AND INCREASED BLOOD VOLUME. [Angiotensin II formation: a decrease in serum sodium (or increase in serum potassium) triggers a chain of events that ultimately results in the secretion (and possible synthesis) of aldosterone by the adrenal cortex culminating in an action of this mineralocorticoid on the renal tubules to increase sodium reabsorption.]
CONTROL OF SERUM POTASSIUM
The renin-angiotensin-aldosterone system also plays a crucial role in regulating plasma potassium levels. Hyperkalemia, increased serum potassium, causes cardiac paralysis. INCREASE IN SERUM POTASSIUM DIRECTLY STIMULATES THE ADRENAL CORTEX TO PRODUCE AND RELEASE ALDOSTERONE. The increased sodium reabsorption in the distal tubule, caused by ALDOSTERONE, is linked to potassium secretion; the end result will be a reduced serum potassium concentration.
RELATION OF THE RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM (RAAS) TO OTHER VASOACTIVE SUBSTANCES
The renin-angiotensin-aldosterone system is closely linked to a clotting factor, plasmin and the kallikrein-kinin system. Kinins are vasodilators that are formed from tissue substrates called kininogens. This conversion is promoted by the action of KALLIKREINS, a class of proteolytic enzymes.
DIURETIC THERAPY is commonly used to treat cardiovascular disorders such as congestive heart failure. The actions of some types of diuretics are listed below. Water, alcohol, caffeine and acidifying salts are typically not used in clinical situations. Keep in mind that when a solute is excreted water will follow.
The following table summarizes the actions of common diuretics:
DIURETIC AGENT >>> MECHANISM OF ACTION
Water >>> Inhibits ADH release
Ethanol >>> Inhibits ADH release
Caffeine >>> Constricts efferent arteriole, glomer-filtration
(CaCl2, NH4 Carbonic anhydrase inhibitors >>> H+ buffered, Na+ excreted with excess anions
Carbonic anhydrase inhibitors Decrease H+ excretion, results in increased Na+ and K+ excretion
Loop diuretics such as furosemide (Lasix) and ethacrynic acid (Edecrin) >>> Inhibit Na+/Cl- reabsorption in loop of Henle
Potassium sparing, sodium diuretics >>> Decreases Na+/K+ exchange pump in distal tubule by inhibiting aldosterone
NORMAL PHYSIOLOGY
L-Arginine VASOPRESSIN (AVP, ADH), a nonapeptide, is synthesized in the bodies of magnocellular neurons in the paired supraoptic nuclei and paraventricular (lateral to the 3rd ventricle) nuclei and transported down axons which form the pituitary stalk in granules bound to neurophysin & glycoprotein to be stored in the posterior pituitary axon terminals. STORES ARE SUFFICIENT FOR 5-10 DAYS OF MAXIMUM ANTIDIURESIS OR ONE MONTH OF NORMAL ANTIDIURESIS. AVP is released in free form (does not bind to neurophysin at blood pH), and is degraded in the brain, liver, and kidney. AVP IS ALSO TRANSPORTED DIRECTLY TO THE ANTERIOR PITUITARY, WHERE IS STIMULATES ACTH SECRETION. AVP has antidiuretic activity by binding V2 receptors in kidney, stimulating cAMP production by adenyl cyclase, which leads to synthesis & insertion of aquaporin-2 water channels in cells of the collecting tubules, allowing water reabsorption in the hypertonic medulla. Water exits basolaterally via constitutively expressed aquaporins 3 and 4. ABSENCE OF AVP LEADS TO EXCRETION OF LARGE VOLUMES OF DILUTE URINE. Other effects of AVP: acts at a pressor agent at supraphysiologic levels (as in severe hypovolemia) by binding V1a receptors on blood vessels, which increase intracellular calcium and cause smooth muscle contraction. V1a receptors are found on vascular smooth muscle, liver, brain, renal medulla, testes, and platelets. AVP stimulates hepatic glycogenolysis via the V1a receptor. A new V3 (V1b) receptor has been cloned; like the V1a receptor, it acts via phospholipase C. It is found in the anterior pituitary, kidney, and in corticotropic pituitary tumors.
REGULATION OF AVP RELEASE: Integration of AVP secretion and thirst maintains plasma osmolality tightly at 280-290 mOsm/kg. PLASMA OSMOLALITY [Posm]: Anterior hypothalamic osmoreceptors (anterior to the 3rd ventricle) are very sensitive to changes in Posm (respond to change as low as 1%), and suppress AVP release when Posm < 280 mOsm/kg. Posm values less than those necessary to turn off AVP will not result in any increase in water excretion (18-20 L/d maximum), unless intake is extreme. As Posm increases, there is a linear increase in [AVP]. WHEN POSM EXCEEDS 292-5 mOsm/kg, plasma AVP reaches levels (~ 6 pg/mL) sufficient for maximum antidiuresis (Uosm > 800 mOsm/kg, Uvol < 2 L/d), with no further decrease in urine volume with higher Posm. THIRST IS STIMULATED AT----->290 mOsm/kg.
PLASMA VOLUME: Baroreceptors (stimulated by hypervolemia, inhibited by hypovolemia) inhibit AVP release via cranial nerves IX, X. The atrial cardiopulmonary low-pressure baroreceptors are less sensitive than osmoreceptors, requiring a 5-10% decrease in blood volume before AVP is released. Severe hypovolemia, however, triggers the sino-aortic high-pressure baroreceptors to cause exponential increases in AVP, which may be high enough to exert a pressor effect. Interaction of osmo- and baroreceptors: A decrease in left atrial pressure (as in hypovolemia, hypotension) leads to a reduction of the osmotic threshold and increases the sensitivity for osmotic AVP release. Volume expansion dampens the sensitivity for osmotic AVP release. Nausea is a very potent and rapid stimulus for AVP release, even up to 100-1000 times basal level. May be responsible for increases in AVP seen with chemotherapy, DKA, vasovagal reactions, motion sickness, and hypoxia. Pain and emotional stress may also stimulate AVP release, as can IV metoclopramide. Hypoglycemia may also stimulate AVP release, which then stimulates glycogenolysis.
THIRST REGULATION: osmoreceptors located nearby (not the same) initiate thirst at a higher Posm than the threshold for AVP release. Hypovolemia also triggers thirst even if Posm is normal [2].
ELECTROLYTE BALANCE
SODIUM<< >>POTASSIUM<< >>MAGNESIUM<< >>CALCIUM [3]
I. SODIUM NA+ ELECTROLYTE WATER BALANCE AND NEUROMUSCULAR MEMBRANE EXCITABILITY
-Major Cation in the extracellular fluids [ECF]- Water balance and neuromuscular membrane excitability
-Most Sodium is in the extracellular fluids [ECF], while intracellular levels of Sodium are relatively low.
-Sodium regulation at the cellular level is controlled by the Sodium-Potassium pump
-Body levels of Sodium (Sodium retention/excretion) are controlled by aldosterone.
-Aldosterone is controlled by the renin-angiotension system
HYPONATREMIA- LOW SODIUM - CAUSES OF ALTERATIONS IN SODIUM LEVELS
-Loss of Sodium from fluid loss
-Diuretics-Vomiting, Sweating, Bleeding, SIADH, Renal Failure -(inability to concentrate and save sodium)
-Movement of Sodium out of the ECF
-Failure of the Sodium Potassium Pump, Diabetic Ketoacidosis, Hypoxia, Liver Failure (Third Spacing)
-Dilution of Sodium from fluid overload
-Fresh water Drowning
-Over administration of Hypotonic Fluids
HYPONATREMIA - LOW SODIUM SIGNS AND SYMPTOMS OF ALTERATIONS IN SODIUM:
-Confusion
-Nausea and Vomiting
-Generalized Muscle Weakness progressing to coma -Late
TREATMENT OF LOW SODIUM LEVELS
Monitor I&O, Wt, V/S, LOC, Serum Sodium and Serum Osmolarity -expect H/A
Restrict hypotonic fluids as ordered
Encourage foods or fluids high in Sodium
Careful use of Hypertonic IV fluids
CAUSES OF ALTERATIONS IN SODIUM LEVELS: HYPERNATREMIA - HIGH SODIUM
-Renal Failure (inability to excrete Sodium)
-Hypertonic IV fluids and/or tube feedings
-Excessive Salt Ingestion
-Decreased Fluid Intake
-Diabetes Insipidus (Not Enough ADH)
-Aldosteronism - leads to Sodium and Water Retention
HYPERNATREMIA- HIGH SODIUM SIGNS AND SYMPTOMS
-Hyper Reflexes
-Hypertension
-Seizures
TREATMENT OF HIGH SODIUM LEVELS
Monitor I&O, Wt, V/S, LOC, Serum Sodium and Serum Osmolarity -expect muscle twitching
Careful use of hypotonic or isotonic IV Fluids
Restrict Food, Fluids and Meds high in Sodium.
Seizure Precautions
II. POTASSIUM (K+) 3.5-5.5 mEq/L
-Critical for electrical conduction of nerve impulses-particularly cardiac electrical conduction
-Potassium is the major cation in the ICF
-Potassium balance at the cellular level is maintained by the sodium-potassium pump.
-Body Potassium levels are maintained by the kidneys ability to retain extra Potassium if needed.
-Kidneys can excrete Potassium and in exchange for Sodium - controlled by aldosterone.
-The body is much more sensitive to small changes in Serum Potassium levels than to small changes in other Serum Electrolytes
HYPOKALEMIA, LOW POTASSIUM LEVELS CAUSES OF ALTERATIONS IN POTASSIUM LEVELS -
-Loss of K+ - excessive vomiting, suctioning, diarrhea
-Medications - Diuretics, Laxatives and Insulin
-Alkalosis
-Hemodilution from Over hydration, Renal tubular acidosis, Hepatic disease, hyperaldosteronism, Cushing's Syndrome or tumors of the adrenal cortex
-Acute Alcoholism
HYPOKALEMIA SIGNS- LOW POTASSIUM
-Weakness, N/V, Constipation, and Motility-ileus
-Hypotension and elevated pulse due to decreased cardiac output
-Signs of Hyperkalemia - High Potassium
-Diarrhea
-LOC Changes -Apathy and Confusion
-Numbness in hands and feet
-Acidosis
-Bradycardia and Cardiac Arrhythmias leading to Cardiac Arrest
HYPOKALEMIA TREATMENT- LOW POTASSIUM
-Place patient on a cardiac monitor
-Prevent injury from decreased B/P and muscle weakness
-Watch for digitalis toxicity (in persons on digitalis).
-Be sure patient has urine output of at least 30 cc/hour before giving any K+ supplement
-Give oral K+ supplements with food.
***NEVER GIVE POTASSIUM IV PUSH -It must be diluted and given as a drip. Watch for signs of infiltration, K+ can cause necrosis of tissues.
-Teach client to increase K+ in diet to prevent recurrence
HYPERKALEMIA - HIGH POTASSIUM LEVELS CAUSES OF ALTERATIONS IN POTASSIUM LEVELS -
-Use of Salt substitutes or K+ supplements
-Receiving old or improperly administered blood
-Movement of K+ out of cells due to decreased functioning of Sodium Potassium Pump related to hypoxia and/or acidosis
-Cell destruction - crushing injuries, burns and hemolysis
-Inadequate Potassium Excretion - from decreased aldosterone related to Adrenalectomy or -Addison's disease
TREATMENT OF ALTERATIONS IN POTASSIUM LEVELS
-Treatment of Hyperkalemia - High Potassium
-False high serum potassium levels can result from improper blood drawing techniques
-Prevent injury from bradycardia and diarrhea
METHODS TO LOWER SERUM POTASSIUM:
-Kayexalate exchange resin - most effective as a retention enema but can be given orally.
-Calcium gluconate -slow IV drip
-Concentrated glucose and insulin mixture IV (helps move K+ into cells)
-Sodium Bicarb for acidosis
-Teach client to avoid foods high in K+, such as cantaloupe, bananas, apricots, broccoli, and salt substitutes
III. CALCIUM (Ca++) 4.0-5.5 mEq/L or 8.5-10.5 mg/dl
-Required for normal skeletal muscle, smooth muscle, and cardiac muscle contraction. Also needed for blood clotting.
-Calcium is taken in through the diet, but Vitamin D must be present for it to be absorbed
REGULATION OF CALCIUM
-Varying rates of GI absorption - by Parathyroid control of Vitamin D absorption
-Parathyroid hormone - triggers calcium release from the bone and/or inhibits renal excretion of calcium
-Calcitonin - from the thyroid gland- causes ECF levels of calcium to decrease by inhibition of bone resorption (release) of calcium, inhibits Vitamin D absorption, and increases renal excretion of calcium
HYPOCALCEMIA - SERUM CALCIUM BELOW 4.5 mEq/L
-Usually due to a failure of normal regulatory mechanisms, such as acute or chronic renal failure
-Can also occur with: Malabsorption syndromes, Acute pancreatitis, and Alkalosis
HYPOCALCEMIA - PATHOPHYSIOLOGY
Calcium functions as a membrane stabilizer, so low levels increase excitability of nerves and muscles (especially GI). Although calcium is needed for blood clotting, prolonged deficiency or very low levels are needed before clotting mechanisms are altered Bones store calcium. If serum levels are low, bones release calcium and become osteoporotic Early ambulation and weight-bearing exercise can help prevent hypocalcemia.
HYPOCALCEMIA SIGNS AND SYMPTOMS
-Muscle spasms, cramps, and tremors
-Hyperactive reflexes
-Tingling of the fingers, toes, lips and face
-TETANY
-Positive Trousseau's sign - Carpopedal Spasm (hand spasm when B/P cuff inflated 3-4 minutes).
-Positive Chvostek's sign (tap facial nerve)
-Arrhythmia
-EKG Changes
TREATMENT OF HYPOCALCEMIA
-Monitor lab for other disturbances such as hypokalemia, hyperphospatemia, hypomagnesemia, and alkalosis
-Cardiac Monitor
-Seizure precautions
-Private room to decrease external stimuli
-Administer Oral calcium supplements and/or Vitamin D for mild to moderate hypocalcemia.
-Give oral calcium between meals to increase intestinal absorption.
-Administer IV Calcium for severe hypocalcemia via slow IV bolus followed by slow IV drip
-Watch for infiltration, calcium can cause necrosis and tissue sloughing.
-NEVER GIVE CALCIUM IM. Check Chvosteck's sign every hour when giving IV calcium.
-Teach Patient about foods and fluids high in Calcium
HYPERCALCEMIA - SERUM CALCIUM ABOVE 5.5 MEQ/L ETIOLOGY
-Disturbances in regulatory functioning which can cause hypercalcemia
-Decreased renal excretion
-Diuretic use that enhance calcium reabsorption
-Too much parathyroid hormone
-Hyperthyroidism
-Abnormal parathyroid hormone production
-Excessive Intake of Calcium
HYPERCALCEMIA SIGNS
-Related to decreased excitability of nerves and muscles and increased blood clotting.
-Muscle weakness
-Nausea, vomiting, constipation
-Check for hypoactive bowel sounds
-Extreme Thirst
-Polyuria (if normal kidney function)
-Kidney Stones
-Blood clots
-Check for Homan's Sign
-Arrhythmias
TREATMENT OF HYPERCALCEMIA [Dialysis may be used in severe cases ]
-Monitor High Risk Patients: those on long term bed rest, with cancer, with hyperparathyroidism
-Increase fluid intake to 3-4 liters daily
-If low serum Phosphorus, administer phosphorus orally, rectally, or IV
-Corticosteroids can decrease GI absorption of Calcium
-Moderate to Severe Hypercalcemia, give IV N/S at 200 ml/hr to flush Calcium from system
-Administer loop diuretics to prevent volume overload with N/S
-IV calcitonin will temporarily lower serum Ca levels
V. MAGNESIUM (MG ++) 1.5-2.5 MEQ/L
-Needed to prevent overexcitability of muscles
-Mg has a sedative effect on the neuromuscular junction, inhibits acetylcholine release, and diminishes muscle cell excitability
-Acts as a co- factor in enzyme reactions
MG IS NEEDED for Muscle contraction, Nerve conduction, Blood clotting, Carbohydrate metabolism, ATP activation, B vitamin activation, DNA, and Protein synthesis.
HYPOMAGNESEMIA - SERUM LEVELS BELOW 1.5 MEQ/L
-Decreased GI absorption of Magnesium
-Malnutrition, TPN without Magnesium, prolonged N/G suctioning, vomiting, prolonged laxative abuse, diarrhea, destruction of the intestinal villi, alcoholism, cancer chemotherapy, excessive intake of Calcium or Vitamin D, High dose steroids
-Increased excretion of magnesium
diuretics, hypoparathyroidism, hypoaldosteronism, Pregnancy induced hypertension
-Movement of Mg from the ECF to the ICF
-Burns and debridement therapy, diabetic ketoacidosis, hypercalcemia
SIGNS AND SYMPTOMS OF HYPOMAGNESEMIA
-Tachycardia, cardiac arrhythmias and hypotension
-Painful paresthesia and muscle spasms
-Tetany, Hyperactive Reflexes
-Positive Chvostek's and Trousseau's
-LOC changes - confusion, agitation
HYPOMAGNESEMIA TREATMENT
-Monitor those on digitalis for toxicity (low Mg enhances digitalis actions)
-Cardiac Monitor and Seizure Precautions
-Treat low Mg with oral, IM or IV Mg Salts
--GIVE SLOWLY - IV Mg Acts immediately, can cause cardiac and/or respiratory arrest. For Seizures, give IV 10% MgCl no faster than 1.5 ml/min
-Watch Serum Calcium while giving Mg IV, as it will cause serum calcium levels to fall, be prepared to give calcium gluconate if needed.
-Urine output must be at least 30cc/hr for adequate Mg elimination
-Assess deep tendon reflexes during Mg treatment and hold Mg treatment if reflexes are absent
-Teach patient to increase foods high in Mg - Green Vegetables.
HYPERMAGNESEMIA - SERUM LEVELS ABOVE 2.5 MEQ/L
-Relatively Rare
-Usually caused by a combination of increased intake and decreased renal function
-Increased Intake antacids & laxatives
-IV administration of Mg
-Decreased Excretion
-renal insufficiency
-Addison's disease
-Adrenalectomy
Hypermagnesemia Signs and Symptoms: [related to Mg sedative effect on the neuromuscular junction] is lethargy and drowsiness, Depressed respirations, Low B/P, Bradycardia progressing to cardiac arrest, Hypoactive reflexes, and Coma.
TREATMENT OF HYPERMAGNESEMIA
-Monitor those at risk
-On Mg supplements
-Renal failure
-Monitor V/S frequently, can decrease rapidly.
-Beware of Mg medications in persons with renal problems
-Be prepared to give calcium gluconate IV to temporarily relieve symptoms in an emergency.
-Teach the patient to avoid foods and medications high in Mg
WHAT IS THE ROLE OF ELECTROLYTES-FLUID-FUELS BALANCE IN HYPERTHERMIC [HOT] EVENTS?
For each kilogram of body mass a litre of fluid is lost. An athlete may account for the mass of fluid consumed during exercise versus total sweat rate, against their success in replacing fluid during the session. As muscle glycogen stores are rapidly metabolized nearly 2 full liters of water are released as byproducts of prolonged exercise. While it may be lost at nearly 34 fluid ounces per hour it can be replaced at only 16-24 fluid ounces per hour. Fluids lost in sweat may only be completely replaced during a time-aided reduced-rate-of-sweating recovery period. Cool drinks (ideally at 45-60 degrees F) are most rapidly absorbed in large volumes.
A CARBOHYDRATE-ENHANCED FLUID DRINK MIX improves performance during moderate-high intensity exercise of longer than 90 minutes. A carbohydrate intake of 60-70 grams or 240-280 calories per hour will provide additional fuel when muscle carbohydrate stores become depleted postponing fatigue. This goal may be achieved by ingesting 600-720 mL/hr of drinks containing 12-15% (g/100mL) carbohydrate in long-chain malto-dextrins. Drinks within this range of concentration can deliver fluid and carbohydrate at a rate that will benefit performance.
SODIUM 0.3-0.6 g/l or 12-24 mmol/L or 3-6 ENDUROLYTES per 24-34 fluid ounces consumed each hour during exercise. Sodium promotes retention of the fluid consumed and prevents hyponatremia [diluted low serum sodium] in susceptible individuals. Carbohydrate-electrolyte drinks address the goals of post-exercise rehydration and recovery by promoting fluid intake, providing a source of carbohydrate for glycogen storage, and promoting fluid retention. The replacement of electrolyte losses, particularly sodium, plays an important role in maximizing post-exercise fluid retention. Although sodium replacement will occur in the diet over time, immediate replacement is important when the athlete needs to rehydrate quickly from a significant fluid deficit greater than -2% of fluid body mass loss.
POST EXERCISE DEHYDRATION
ORAL REHYDRATION solutions used in the clinical treatment of dehydration contain a higher concentration of sodium 50-90 mmol/L. Athletes may replace salt losses using a combination of sodium-containing drinks and the sodium found in post-exercise recovery meals and snacks, either as a component of the food or added to the meal [4, 5].
RESEARCH REVIEW OF ELECTROLYTE DEPLETION
Not a lot has changed except to note the human body adapts quite variably to demand and expenditure within time if it is stressed and replenished periodically. Each of us needs to duplicate racing in the conditions in our chosen events at least 6 weeks prior to the event up to 60% of the distance or up to 24 hours duration for a multi-day. As you will note below, the differences you may effect in your performance is dramatic from an electrolyte and muscle glycogen metabolic storage point of view. I have taken the liberty to post some of the research below, should you want to know these details from observed research on ultrarunners and triathletes. Research has shown that potentially fatal hyponatremia or dehydration may develop during prolonged extreme exercise in ultramarathon running or triathlons attempted in hot and/or humid weather conditions.
HYPONATREMIA [Low Sodium or water intoxication]
To determine the incidence of hyponatremia in athletes competing in ultradistance events, Noakes [6] "Measured serum sodium levels in 315 of 626 (50%) runners who were treated for collapse after two 90 km ultramarathon footraces (total starters 20,335; total finishers 18,031) and in 101 of 147 (69%) finishers in a 186 km ultratriathlon. In both races the athletes drank fluids with low sodium chloride content (less than 6.8 mmol.l-1). Hyponatremia (serum sodium level less than 130 mmol.l-1) was identified in 27 of 315 (9%) collapsed runners in the 90 km races and in none of the triathletes. In response to diuretic therapy, the runner with the most severe hyponatremia (serum sodium level = 112 mmol.l-1) excreted in excess of 7.5 l dilute urine during the first 17 h of hospitalization. These data suggest that, although symptomatic hyponatremia occurs in less than 0.3% of competitors during prolonged exercise even when they ingest little sodium chloride, it is found in a significant proportion (9%) of collapsed runners. A regulated contraction of the extracellular fluid volume would explain why the majority of athletes maintain normal serum sodium levels even though they develop a significant sodium chloride deficit during prolonged exercise. Alternatively, sodium chloride losses during prolonged exercise may be substantially less than are currently believed. Physicians treating collapsed ultradistance athletes need to be aware that as many as 10% or more of such patients may be hyponatremic." Noakes [7] suggests water intoxication of hypotonic fluids [low electrolyte content] of 1000 ml./hour is likely to result in dilutional hyponatremia. He implied that athletes might do better on 500 ml/hour fluid intake as a correction device for ultra events performed in hyperthermic conditions. [500 ml='s 16 ounces]
Review of the depleted differences between sodium [NA], chloride [CL], potassium [K] and Magnesium [MG] losses were measured* in the sweat of fit-acclimatized and unfit-unacclimatized athletes.
ELECTROLYTE* FIT & ACCLIMATIZED [grams/hour] UNFIT & UNACCLIMATIZED[grams/hour]
SODIUM [NA] 1.8 g 3.5 g
CHLORIDE [CL] 0.9 g 1.4 g
POTASSIUM [K] 0.2 g 0.1 g
MAGNESIUM [MG] 0.1 g 0.1 g
From: Verde, T, Shephard, RJ, Corey P, Moore R., Sweat Composition in Exercise and Heat, Journal of applied Physiology, 1982;53;6:1541-1543. This is overwhelming evidence in favor of fitness and acclimatization protocols progressively pursued during preparatory training.
Speedy [9] described weight changes and the incidence of hyponatremia during an ultradistance triathlon in the athletes who attend medical care after the race. They researched the 1996 New Zealand Ironman Triathlon in which each athlete swam 3.8 km, cycled 180 km, and ran 42 km. Ninety-five athletes were seen for medical care after the race. One hundred sixty-nine athletes who did not attend for medical care were also weighed before and after the race. "Weights were measured at race registration and on finishing the race. Whole-blood sodium concentration was measured in those athletes with clinical evidence of fluid or electrolyte disturbances. Weights were significantly decreased at the end of the race in the athletes seeking medical care (n = 48, mean % delta wt = -2.5%, p < 0.001) and also in the athletes who did not seek medical care (n = 169, mean % delta wt = -2.9%, p < 0.001). Seventeen percent [17%] of race starters sought medical attention. Dehydration accounted for 26% of primary diagnoses and hyponatremia for 9%. One athlete with hyponatremia (Na 130 mEq/L) is described who drank 16 L over the course of the race, with a weight gain of 2.5 kg. [5.5 lbs.] This is consistent with the hypothesis of fluid overload as the cause of his hyponatremia. Hyponatremia accounted for four of five admissions to the hospital after the race. An inverse relationship between postrace sodium concentrations and percentage change in body weight was observed (r = -0.63)." Hyponatremia is an important risk to the health of athletes competing in an ultradistance triathlon, with fluid overload the likely cause. Other causes have been discussed for heat stress-induced performance retro-gradation by Toole [10]: "Thirty competitors in the Hawaii Ironman Triathlon were prospectively studied to determine whether fluid and electrolyte disturbances were causes for seeking race-day medical care. Athlete weights were significantly (p < 0.0001) decreased during the race, but decreases were not different in treated (n = 11; % delta wt -2.3 +/- 2.9) versus not treated (n = 19; % delta wt - 2.0 +/- 1.9) athletes. Hyponatremia occurred in nine athletes (30%), and hypomagnesemia in six (20%), but only half of athletes were either electrolyte imbalance sought care. Although athletes receiving medical care may have fluid and electrolyte problems, these abnormalities may also occur in healthy athletes."
MEDICAL CORRECTION DISCUSSION
Cluitmans and Meinders [11] present concerns with a medical correction protocol: "Case reports and the literature on the treatment of severe hyponatremia were reviewed. It appeared that the conflicting opinions with respect to the rate of correction of severe hyponatremia could be reduced to not differentiating between acute and chronic hyponatremia, to using different criteria for this distinction, and to differences in treatment strategy. After reviewing the available data in the literature, it is suggested that hyponatremia should be classified as acute whenever the rate of decrease of serum sodium exceeds 0.5 mmol/L/hour. If it is unknown at which rate the hyponatremia has developed, it can be assumed to be acute if within a short period of time (two to three days), large quantities of fluid are ingested orally or administered parenterally, especially hypotonic fluids in the presence of impaired water excretion. In other cases, chronic hyponatremia is probable. It is concluded that acute hyponatremia should be treated without delay and rapidly at a rate of at least 1 mmol/L/hour, to prevent severe neurologic damage or death. With respect to chronic hyponatremia, it appeared that severe neurologic complications almost exclusively occurred in patients who were treated with hypertonic or isotonic saline without the addition of furosemide or an osmotic diuretic agent, resulting in a (rapid) correction rate of 0.5 mmol/L/hour or more. In contrast, patients with severe chronic hyponatremia treated with furosemide and isotonic or hypertonic saline almost uniformly did well after rapid correction. Uneventful recovery is also the rule when severe chronic hyponatremia is corrected slowly, at a rate less than 0.5 mmol/L/hour. On pathophysiologic grounds, and bearing in mind that slow correction was used in the majority of reported patients in the literature with severe chronic hyponatremia who recovered without neurologic complications, this treatment modality is preferable. Whenever the available data do not permit a differentiation between acute or chronic hyponatremia, rapid correction has to be pursued by means of administration of hypertonic or isotonic saline together with furosemide [Lasix, a diuretic]."
When the humidity and heat exceed 60 percent and 60 degrees, athletes are advised to maintain fluid intake between 16-24 ounces per hour [16 for smaller athletes, 24 ounces for larger athletes]. Electrolyte intake with low sodium ENDUROLYTES are accommodated by a rate of 3-6 Endurolytes taken each hour or 1 Endurolyte for each 8 ounces fluid ingested in most subjects in most events, though there are exceptions. Each athlete prone to heat stress should spend time in training for not only fitness but also for physical acclimatization to the conditions forecast on race day. The more fit and the more acclimatized athletes prepare themselves for hyperthermic conditions, the more likely they are to realize intended goal finish times. The average size endurance athlete progresses well on the electrolyte ingredients formulated in Endurolytes taking between 3-6 capsules each hour during aerobic exercise. There are exceptions to this dose rule; a few perform well on only one Endurolyte per hour, while even fewer require more than 6 each hour. One point to emphasize is that as each reference author implies, overdose and underdose repletion rate is not as desirable as adequate repletion in time and dose fashion. It is our contention that low dose repletion rate generates electrolyte balance [homeostasis] without interfering with the electrolyte levels delicately monitored by natural endogenous processes. Taking too much sodium may resolve sodium deficiency temporarily but potentially risks inducing increased distal extremity fluid storage and elevated blood pressure. In addition, taking excessive sodium tends to increase the rate of sodium excretion and in prolonged events may inhibit performance. Taking above 600 mg sodium per hour may be justified in large, overweight, unfit subjects who otherwise deplete sodium stores at a too rapid rate. Excessive water weight gain, increased blood pressure is shown to accompany excess sodium salts dose. The endurance athlete should set out to determine not how to replace all of the sodium lost at once, but how to replace the minimum amount which for most athletes is between 300-600 milligrams per hour. The adjunct to electrolyte balance needs be considered beyond sodium, since other electrolytes contribute to serum minerals and pH balance. The ENDUROLYTE is the model formula suggested for serum mineral and pH balance during prolonged endurance exercise.
[1] FROM: CARDIOPULMONARY PHYSIOLOGY, Chapter 7 - Renal Considerations,
by Dr. Larry Reinking, Millersville University.
[2] UCLA Endocrinology by Dr. Mark Goodarzi, M.D., SYNDROME OF INAPPROPRIATE ADH
NORMAL PHYSIOLOGY Section @: http://www.endocrinology.med.ucla.edu/siadh.htm
[3] Electrolytes Course Online - N205; Indiana State University, School of Nursing
Mary Bennett, Assistant Professor of Nursing @:
http://www.indstate.edu/nurs/mary/lytenote.htm
[4] American College of Sports Medicine. Position stand on exercise and fluid replacement. Medicine and Science in Sports and Exercise, 28: i-vii, 1996.
[5] Hargreaves M (ed). Fluid and energy replacement for physical activity. Australian Journal of Nutrition and Dietetics. 53 (4:suppl): S2-S48, 1996.
[6] Noakes TD, Norman RJ, Buck RH, Godlonton J, Stevenson K, Pittaway D; The incidence of hyponatremia during prolonged ultraendurance exercise, Med Sci Sports Exerc 1990 Apr 22:2 165-70.
[7] Noakes TD, THE LORE OF RUNNING, Leisure Press, Champaign, Ill., 1991:115-119.
[8] Verde, T, Shephard, RJ, Corey P, Moore R., Sweat Composition in Exercise and Heat, Journal of applied Physiology, 1982;53;6:1541-1543.
[9] Speedy DB, Faris JG, Hamlin M, Gallagher PG, Campbell RG Hyponatremia and weight changes in an ultradistance triathlon. Clin J Sport Med 1997 Jul 7:3 180-4.
[10] Toole ML, Douglas PS, Laird RH, Hiller DB, Fluid and electrolyte status in athletes receiving medical care at an ultradistance triathlon, Clin J Sport Med 1995 5:2 116-22.
[11] Cluitmans FH, Meinders AE; Management of severe hyponatremia: rapid or slow correction? Am J Med 1990 Feb 88:2 161-6.
DISCLOSURE: Bill Misner Ph.D. is the Director of Research & Product Development for HAMMER NUTRITION LTD. Misner has competed in several 50-mile and 24-hour ultramarathon events and is a past multiple National Masters Champion. He was the first 10,000 mile and 20,000 kilometer finisher in the Internet "Million Mile Ultra." This statement declares competing interests for the low sodium electrolyte formula, "Endurolytes," marketed by HAMMER NUTRITION LTD.


text:
What is the legal basis for making patient records available?
The processing of personal data for the provision of direct care is supported under the Regulations in Article 6 (1)(e) 'necessary for the performance of a task carried out in the public interest and in the exercise of official authority' and Article 9(2)(h) 'necessary for the purposes of preventative or occupational medicine for the assessment of working capacity of the employee, medical diagnosis, the provision of health or social care or treatment or management of health or social care systems.'
Do staff have to ask permission to access my record?
Legally no, your patient record can be viewed and shared without your permission. The legal basis is outlined above. When the Great North Care Record was introduced, we had a 'permission to view' policy. That meant that every time an A&E doctor or mental health practitioner accessed your GP record, they had to ask permission. As the region has moved on and adopted the sharing of medical information – we have moved away from this model. This model becomes increasingly difficult to sustain as we extend record sharing to more services. We have talked about why we changed our policy in this blog.
What is your privacy notice?
Each organisation who accesses and makes data available on the Great North Care Record has its own privacy/fair processing notice which covers how data is shared and reflects their use of the Great North Care Record.
The Great North Care Record itself does not hold, host or share any data. However, working with information governance experts from around the region – we have produced a template statement about how data processing is facilitated by the Great North Care Record.
Can I access my joined-up care records?
If you want to find out what information a care organisation has about you, you can contact that organisation directly and request this from them. This is known as a Subject Access Request.
To do this, go to the website of the organisation in question (your hospital, GP, care organisation etc) and look for 'access to my record'. Information on each individual organisation's process will be published on the site.
Remember – joined up care records are health and care information from other organisations, displayed in one place, so that each organisation can work together to care for patients.
For more information about making a Subject Access Request visit the Information Commissioner's Office website.
I am a parent/guardian or have power of attorney for someone and I don't want their records to be made available. What do I need to do?
You can request that someone you are responsible for is opted out. This request is considered by your GP, who will make the final decision. While your GP will respect your views and may wish to discuss them with you, they could decide that it is right that details are shared. This is usually based on patient safety and providing the most appropriate care.
What about people who do not have the mental capacity to understand the Great North Care Record or the opt-out process?
If you are a guardian, carer or have power of attorney, you will have two choices:
Request that they be opted out of the Great North Care Record – contact our helpline on 0344 811 9587, email us, or visit our opt out page
Allow them to be automatically opted in – if you are happy with this, you will not have to do anything further
As health professionals, we believe that better sharing of information will mean safer care, so we hope that most people will remain opted in.
If a guardian, carer or person with power of attorney requests to have someone opted out of record sharing, their request is considered by the patient's GP. The GP would make the final decision in the patient's best interests.
Note on Lasting Power of Attorney
There are two types of Lasting Power of Attorney (LPA) 1.) property and affairs (including financial matters) and 2.) health and care (including healthcare and consent to medical treatment). An LPA must be registered with the Office of the Public Guardian (OPG) before it can be used.
Attorneys must meet the requirements set out in the Mental Capacity Act. The Code of Practice states that, most importantly, they must follow the statutory principles (http://www.legislation.gov.uk/ukpga/2005/9/section/1). They must make decisions in the best interests of the person who lacks capacity to make that specific decision.
Sometimes it may be necessary to make an application to the Court of Protection for more difficult decisions. This could be where disagreements can't be resolved, or where ongoing decisions need to be made.
The Court of Protection is the specialist Court which was established under the Mental Capacity Act 2005. It deals with issues relating to people who lack capacity to make specific decisions for them. The Court can make decisions on whether people have capacity in relation to particular decisions and make decisions on their behalf. It can also appoint or remove people who make decisions on people's behalf, and make decisions relating to Lasting Powers of Attorney or Enduring Powers of Attorney. See https://www.citizensadvice.org.uk/family/looking-after-people/managing-affairs-for-someone-else/#h-lasting-power-of-attorney for more information.

redpajama_set_name: RedPajamaCommonCrawl


Description: The CD4021BC is an 8-stage parallel input/serial output shift register. A parallel/serial control input enables individual JAM inputs to each of 8 stages. Q outputs are available from the sixth, seventh, and eighth stages. All outputs have equal source and sink current capabilities and conform to standard "B" series output drive.
When the parallel/serial control input is in the logical "0" state, data is serially shifted into the register synchronously with the positive transition of the clock. When the parallel/serial control is in the logical "1" state, data is jammed into each stage of the register asynchronously with the clock.
All inputs are protected against static discharge with diodes to VDD and VSS.


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What Is So Foreign About Foreign Influence Operations?
Hedvig Ördén, James Pamment
Source: Getty
Summary: When combating influence operations, focusing on discouraging misleading digital market techniques is a more versatile, effective strategy than focusing on whether foreign or domestic actors are involved.
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The Lines in the Sand paper series, produced by Carnegie's Partnership on Countering Influence Operations, uses multiple perspectives to analyze difficult policy questions and key challenges related to combating influence operations. The series seeks to draw lines in the sand to help industry leaders and government policymakers at the forefront of these efforts to develop effective countervailing policies.
Influence operations are increasingly seen as a threat to democratic societies because they can corrupt the integrity of political deliberation. As individuals engage in debate on social media, political deliberation becomes vulnerable to potentially destructive forms of interference. Many debates on what to do about influence operations emphasize that these operations constitute what is deemed to be a foreign threat. But does the notion of foreignness, viewed in isolation, constitute a helpful lens for distinguishing between legitimate and illegitimate influence operations?
Ultimately, the lens of foreignness is only helpful when applied to a narrow set of cases. One sensible way of reviewing when the concept of foreignness can be useful in distinguishing between legitimate and illegitimate influence operations is to consider three separate conceptions of how to determine what counts as foreign: foreign states, foreign citizens, and foreign interests. In the first case, influence operations are seen as threatening acts directed at a targeted state by foreign states, using behaviors seen as analogous to acts of war. In the second instance, influence operations are considered threatening acts conducted by foreign citizens that undermine domestic democratic systems in a targeted state. In cases of the third sort, influence operations are viewed as acts aimed at advancing foreign interests through the illegitimate employment of soft power.
Hedvig Ördén
Hedvig Ördén is a senior lecturer in political science and intelligence analysis at Lund University. Her research focuses on online disinformation and the intersection between security studies and political theory.
Given these various models, the notion of foreignness constitutes a useful lens for discussions of influence operations in cases when there is overwhelming evidence of state-based, hybrid, and irregular warfare. An argument can also be made for employing the distinction in relation to the protection of democratic institutions, such as elections. However, when influence operations are regarded as a more generalized threat to political deliberation, foreignness is not a helpful category for determining the legitimacy or illegitimacy of such campaigns. In such cases, rather than focusing on the (domestic or foreign) identity of the malicious actors themselves, it is more fruitful to conceive of illegitimacy in terms of specific manipulative communication techniques. Suitable countermeasures could include, for instance, creating greater transparency surrounding, or even restricting, the use of artificial techniques to inflate the level of perceived engagement a piece of online content generates.
Political Legitimacy and the Concept of Foreignness
Questions of what is deemed foreign and what is not are traditionally related to the legal and territorial boundaries of states and the legal status of citizens. Furthermore, the distinction between foreign and domestic is intimately linked to people's understandings of illegitimate and legitimate power. In international law, this reality is reflected in the foundational principle of state sovereignty, which relates legitimate authority to a bounded territory and the population residing there. The idea of equating foreignness with the nondomestic nationalities of particular groups of individuals that are not from a particular country, furthermore, goes back to the classical tenet of international law on diplomatic protection, which obliges states to protect their citizens abroad. In democratic societies, citizenship is related to the idea of a distinct polity whose designated inhabitants enjoy certain rights and obligations that do not pertain to foreigners, the most common of these rights being the right to vote. A legitimate democratic government is, quite simply, a government elected by the people living within, or in some other way belonging to, a defined territory.
Similarly, citizenship laws today rest on different principles than before. Naturalized individuals can be granted citizenship on the basis of long-term residency or other significant attempts to acquire it, such as joining an army or even pledging allegiance to a state.1 When such allegiance is pledged, an individual's place of birth, or even place of residency, is superseded by his or her expressed loyalties. Such a dynamic renders foreignness a more fluid category than it used to be. Furthermore, these developments also compound the complexity of ascertaining notions of political illegitimacy and legitimacy as self-evidently connected with the traditional dichotomy of foreign and domestic categories.
Judging Foreignness in Terms of Foreign States
A common way of trying to distinguish between legitimate and illegitimate influence operations is to label those conducted by foreign countries as illegitimate.2 Relevant academic literature and policy proscriptions that embrace this definition tend to view influence operations as one component of a varied, wide-ranging set of strategies that states employ. Such literature and policy documents use language that reflects the alleged link to the foreign state in question and to tools of war—including common parlance like Russian information operations, Chinese influence operations, or information warfare. To conceptualize foreign influence operations as part of state-affiliated military operations reflects an established way of thinking about international relations in terms of conflictual relationships between sovereign nations locked in a state of anarchy. From this perspective, general tenets of international law can arguably be applied to the "physical, logical, and social layers of cyberspace," such as network infrastructure, protocols, and individuals engaged in cyber activities.3 Acceptance of the principle of sovereignty, a fundamental tenet of international law, as applied to cyberspace by scholars like Michael Schmitt may thus potentially allow for a set of commonly recognized rules and norms in international relations. (This use of the general term sovereignty differs from the term cyber sovereignty that authoritarian countries like China and Russia use to justify online censorship within their borders.) Not all aspects of state sovereignty, however, transfer equally well into the cyber environment. Problems with this definition of influence operations become evident if one asks what constitutes a violation of sovereignty, and, in particular, what legal principles should be used to draw a line between the foreign and domestic spheres.
James Pamment
James Pamment was a nonresident scholar in the Technology and International Affairs Program at the Carnegie Endowment for International Peace.
First, the principle of territorial integrity constitutes a gray zone of "normative uncertainty" in the context of influence operations.4 The physical destruction of domestic targets by foreign adversaries is more clearly an attack than the dissemination of harmful ideas, which is not usually considered a violation of sovereign territory.5 The projection of information (and perhaps money and soft power in all its forms) may be defined better as interference in another sovereign state's internal affairs. At the heart of this discussion is the key question of whether "respect for sovereignty" is a rule in international law "alongside the prohibition of intervention."6 States still have different views on this matter. France, for instance, assumes an inherent respect for sovereignty exists, an approach that allows factors like the "distorting of election processes" to be considered a violation of sovereignty.7 By contrast, the UK instead remains in favor of applying the principle of nonintervention, which would require the presence of clear elements of coercion.8 On the whole, this lack of shared norms on how to interpret the rules surrounding sovereignty in international law, when influence operations are concerned, is a problem that needs to be overcome.
Second, influence operations could be regarded as violations of the principle of nonintervention in the internal affairs of one sovereign state by another.9 For this principle to be relevant, however, interference must involve a clear element of coercion.10 Overall, international law does not provide any cutoff points for determining when election-related activities connected to foreign states, while potentially coercive, constitute interference.11 Furthermore, while foreign influence operations that distribute divisive or false content may certainly distort domestic public debate, experts currently disagree on whether these tactics are sufficiently manipulative to be considered coercive.12 Some argue that "the threshold of coercion is reached if an information operation is covert," while others claim that coercion necessarily implies a kind of "forcible conduct" not present in interference that revolves around distributing ideas.13 As for influence operations on social media, the covert nature of data collection used to microtarget individuals could arguably cross the line of coercive behavior without forcible conduct being used.
Third, any cyber attack comes with the problem of attribution.14 Even if officials can determine that a violation of state sovereignty has occurred, the identity of the attacker, as well as the relationship between the attacker and the targeted state, remains to be proven.15 To get around this challenge, many actors simply define influence operations instigated from a sovereign territory separate from the targeted state as "foreign" and condemn such operations by appealing to the principle of due diligence, the duty of a state "not to allow knowingly its territory to be used for acts contrary to the rights of other States."16 This principle, however, can only be applied if an act has "serious adverse consequences," which—in the case of influence operations working "at a cognitive level"—is a difficult determination to make.17
Finally, the use of proxies—domestic actors within the victimized country who work on behalf of a foreign state—poses a challenge when discussing influence operations. While it is possible to describe foreign actors operating on domestic soil as interfering on behalf of a foreign state, it is far more challenging to say the same of citizens who choose to deliberately or inadvertently spread ideas that happen to align with those spread by a foreign state–backed influence operation. Agreeing with or even admiring Russian President Vladimir Putin is not a crime, for instance. Such acts fall far short of espionage and are unlikely to involve coercion. Rather, influence operations often target wedge political issues that generate strong opinions—this logic results in harmful content being organically shared and integrated into a country's political discourse.18 Labeling citizens as proxies just because they happen to engage in these debates and express fringe perspectives—but without evidence of coordinated wrongdoing—is wholly unsatisfying. And in any case, their speech is likely to be protected by legal provisions on the freedom of expression. In this sense, the information warfare analogy does not extend to casting domestic citizens as foot soldiers, except in cases of genuinely coercive interference.
All in all, it is clear that defining influence operations as illegitimate simply because they are conducted by foreign states is insufficient. There is a clear need for developing a set of shared norms on the ways that influence operations can constitute a violation of sovereignty. Furthermore, legal experts still disagree on whether influence operations should be regarded as coercive and thus as violations of the principle of nonintervention. An interesting path forward is perhaps to regard covert methods as a qualifier for determining when foreign interference constitutes a violation of sovereignty.19 Foreign state interference with inherently governmental functions (for instance, domestic elections) by means of deceitful methods can thus be regarded as a violation of sovereignty, although such operations may not be coercive in the true sense of the term. With this qualifier, the labeling of such influence operations conducted by foreign states as illegitimate could hold some value. Such determinations involve weighing the combined factors of any deceitful techniques that are used as well as whether the instigators are domestic or foreign actors.
Judging Foreignness in Terms of Foreign Citizens
A second approach to defining foreign influence operations looks at whether content is being distributed by foreign citizens regardless of their physical location. This approach rests on a distinction between what is deemed foreign and what is deemed domestic in certain democratic frameworks where citizenship comes with a collection of rights that noncitizens—as foreigners—lack.20 Associating foreign influence operations with these noncitizens is in line with an understanding of interference as directly affecting domestic political discussions in what is deemed an illegitimate way. In other words, just as foreign citizens do not enjoy the right to vote in domestic elections if they are residing as foreigners in another country, so too should they be barred from interfering in that country's domestic political debate.21
Making such a determination between foreign and domestic citizens might seem clear cut at first glance, but a closer look at the relationship between citizenship and democratic rights shows that there are a wide range of possible interpretations of where to draw the line.
Citizenship, and the democratic rights it imbues an individual with, can vary greatly by country. And those rights do not always mean the same thing. Even the right to vote in general elections, commonly accepted worldwide as pertaining to citizens, varies greatly from country to country. At one end of the spectrum, certain states, such as Ireland, demand that even citizens must also be permanent residents to vote, while at the other end of the spectrum, a country like Sweden extends the right to vote (at least in local elections) to resident noncitizens.22 The process of naturalization in some countries makes it possible for individuals to become citizens on a number of grounds. Some of these grounds challenge traditional understandings of individual citizenship as something that reflects an intimate (or at least tangible) connection to a specific country.23 The country of Malta, for instance, offers what it calls "citizenship by investment," meaning any person with the financial means could become a Maltese (and an EU) citizen with the right to vote in general elections.24
The link between citizenship and foreign influence is even vaguer when the conversation moves to online discourse. Guaranteeing freedom of speech is key for democratic regimes as a general rule,25 and most democratic states make no distinction between citizens and noncitizens living in their territory when it comes to the right to express their opinions (although questions have been raised in relation to immigrants residing in a country illegally and other foreign nationals when it comes to electoral spending and political ads).26 In addition, freedom of opinion and expression as well as freedom of thought are central principles of international human rights law, and democratic countries that have ratified human rights treaties are thus obliged to extend these rights to noncitizens.27
While it is possible to characterize influence operations as directly undermining human rights principles through various forms of manipulative interference, such determinations must be made based on the nature of the communicative act rather than the citizenship of the perpetrator.28 Similarly, freedom of speech is often limited in different ways through, for instance, legislation on hate speech, but such considerations are directly related to the content of the message.
According to some legal experts, it is possible to regard interference by foreign citizens in domestic political debate as illegal based on the collective right of self-determination that states have based on international law.29 The freedom of speech of foreign nationals could then be justifiably curtailed—at least in the context of another state's democratic elections—with the purpose of ensuring that free speech is "the will of the people" (the citizens of the state holding the election) rather than that "of some other people" (noncitizens).30
However, this definition poses challenges. Critics argue that this legal concept only applies to claims to self-determination in situations when a group is "denied the right to govern itself."31 This makes the right of self-determination difficult to appeal to in cases when "the people" are "all citizens of a State."32 In addition, the idea of interpreting freedom of speech as a right that exclusively belongs to a country's citizens goes against contemporary legal practice in many democratic countries.
Seen through the lens of citizenship, the foreignness of influence operations would always be inherently connected to the identity of the individual, rather than the message disseminated. The legitimacy of an individual exercising such political freedoms could then be questioned if, for example, a given influence operation involved efforts to obscure the identity of the speaking individual (and hence also included covert dimensions).
Apart from giving rise to recurring problems of attribution—especially when domestic proxies are involved—linking freedom of speech to citizenship could potentially lead to counterintuitive conclusions if one accepts the premise that such a right should reflect an intimate connection to a specific country.33 What about a citizen of Malta, naturalized through the country's citizenship-by-investment scheme (but otherwise with very few connections to the country), who would be allowed to express opinions about EU politics, while noncitizens living in the country are denied this right? Furthermore, is it reasonable to argue (as some legal experts do) that a long-term resident who happens to be a noncitizen expressing a "pure opinion" should be regarded as just as detrimental to democracy as a noncitizen spreading disinformation?34
In sum, the notion that foreign citizens are interfering if they participate in the political life of another country seems unlikely to lead to a strong basis for labeling influence operations as foreign. Apart from the overwhelming practical difficulties connected with policing individual messages on the basis of citizenship, and the mélange of different citizenship laws in different countries, the right to freedom of speech for noncitizens currently accepted by most contemporary democracies makes it difficult to regard messages disseminated by foreign citizens as inherently illegitimate. For instance, Article 10 of the European Convention on Human Rights—which has been ratified by the forty-seven countries in the Council of Europe—states: "Everyone has the right to freedom of expression."35 The Human Rights Committee similarly, and quite explicitly, notes that noncitizens (or "aliens") "have the right to freedom of thought, conscience and religion, and the right to hold opinions and to express them."36 Given this, the right to partake in political discourse is difficult to equate with other citizenship rights.
Judging Foreignness in Terms of Foreign Interests
A third common way of conceptualizing foreign influence operations is to consider their links to "foreign interests."37 In many cases, this definition rejects the notion that influence operations are acts of warfare infringing on (territorial) state sovereignty. Instead, they are seen as projections of "soft power."38 The key element here is not necessarily the identity of the state or the individual disseminating the message, but whose interests the message serves. This approach appears to allow a way around the notorious problem of attribution and also accounts for proxies operating on domestic soil.
Nevertheless, there are challenges with this approach, the first of which is that not all influence operations serving foreign interests should be considered interference. The core problem with conceptualizing foreign influence operations in terms of foreign interests is that complex tensions arise between a focus on the content of the message, the perceived legitimacy of the communication techniques used, the ways in which the messages spread, and the identity and intention of the messenger.39
An obvious case of projecting foreign interests according to this understanding is public diplomacy. Public diplomacy is defined as the "various government-sponsored efforts aimed at communicating directly with foreign publics."40 These efforts commonly entail the dissemination of strategic narratives in support of a state's "national culture, political ideals and policy" in cyberspace.41 Public diplomacy is generally accepted as a legitimate means of exercising state diplomacy, in contrast to "illegitimate" forms of foreign influence.42 The line between the two is often drawn on the basis of truthfulness, authenticity, and intention. In other words, public diplomacy becomes illegitimate when it is in some way deceptive. It may be deemed deceptive if, for example, identities are deliberately obfuscated, or if the messages turn into disinformation—that is to say, "the deliberate dissemination of carefully constructed and false messages into the communication system of a target group in order to deceive decision-making elites or public opinion."43
Yet not all untruthful messages are spread with an intention to deceive—individuals might unwittingly spread misinformation that supports their own worldview. Furthermore, there is debate over whether messages concerning national culture or political ideals should be judged entirely on the basis of perceived truth or facts.44 Instead, the classification of the illegitimate spread of foreign interests as foreign influence operations largely hinges on whether there is an intention to deceive. Indeed, even the truth might skillfully be used to deceive—particularly in a context where a one-sided picture can be amplified at the cost of a nuanced political debate.45
Defining foreign influence operations as inherently linked to deceptive intentions gives rise to a number of problems. While obvious untruths can be called out quite easily, intentions are vague concepts that have been used in largely unsatisfactory ways in debates about propaganda.46 If a messenger's intention is determined on the basis of the message itself, the perceived foreign interest the message appears to serve is a subjective judgment. This potentially allows for an interpretation of all untruthful or inconvenient messages as serving the interests of enemy states. Yet foreign interests might coincide with those of domestic groups or individuals, thus blurring the crucial distinction between what is deemed foreign and domestic (a blurring that might itself be in the interest of an enemy state and a goal of a given influence operation).
To avoid this blurred distinction, a messenger's intention can be determined by instead considering the identity of the state or individual messenger and determining whether the aim in the operation is to change or reinforce "attitudes and behaviors in ways that align with the [influence operation's] authors' interests."47 In such cases, however, the conceptualization of foreign influence operations as foreign interests no longer differs from that of foreign states, and the discussion returns to the aforementioned problem of attribution.
Discerning deceptive intentions through the range of behaviors and techniques a messenger employs, rather than focusing on the content or the identity of the messenger, seems a promising avenue for future research.48 In this way, illegitimacy can be linked to the use of manipulative techniques used to spread an influence operation. In addition to moving away from a narrow discussion of deceptive intentions, this approach would potentially allow a range of communicative techniques to be considered questionable in terms of the degree to which they are protected by international human rights law on "freedom of thought" rather than simply "freedom of expression."49 Departing from the principle of freedom of thought would allow policymakers to approach the problem more broadly and, for instance, work with social media companies to restrict (or create more transparency surrounding) techniques that are "proven to have manipulative effects."50 In this way, the problem is not so much deceptive intentions, but the techniques used to amplify the messages.
While the focus on communication techniques provides an opening for further analysis, it is unclear whether it solves, or simply sidesteps, the problem of determining which influence operations should be considered foreign. Perhaps foreign interests are best regarded as a persistent worry that should be solved by focusing only on systematic efforts at manipulation rather than individual pieces of content. Such determinations can be approached through technical means in the web infrastructures of digital platforms. To cite one example, it could be helpful to introduce imprints on political ads stating who paid for them to bring online behavior in line with existing election law.51 Furthermore, this understanding of illegitimacy could perhaps be used to determine when foreign state interference actually constitutes a violation of sovereignty under international law, as suggested by Schmitt.52
A Way Forward?
Ultimately, the concept of foreignness has no single, universal definition that can be used in discussing influence operations. International law is unlikely to provide a way to regulate foreign influence operations, democratic theory offers limited normative support to the debate on foreign influence operations, and individual states have inconsistent ways of legally defining foreignness. What is foreign and what is domestic appears more like a spectrum or scale than a binary distinction. What does this mean for the study of influence operations?
On the basis of this discussion, two clear lines in the sand can be drawn. Put simply, first of all, it appears that the term foreign is most applicable when foreignness is a systematic, constituent part of a larger-scale influence operation. Second, the term foreign is more pertinent when dealing with patterns of inauthentic or fraudulent behavior together with other more severe and subversive activities. Yet these are but two aspects of certain kinds of influence operations.
In thinking through how to most effectively combat influence operations, then, a complementary set of at least three different approaches ought to be considered in various situations. The first is a democratic discourse approach, which argues that democracies should be resilient to foreign participation in political discourse. The second is an institutional democratic approach, which argues that certain public institutions should receive special protection from foreign actors. Third is a national security approach, which argues that broader foreign state behavior should determine whether foreignness is an issue. These approaches offer opportunities for tangible change in dealing with influence operations.
A Democratic Discourse Approach
In liberal democracies, all individuals can participate in political discussions, regardless of citizenship. In democratic debate, it is a distraction to focus solely on foreignness at the expense of a more thorough and multifaceted examination of what represents acceptable ways of exerting political influence in democratic societies.53 Democratic populations should be able to cope with challenging ideas, whether domestic or foreign in origin. In the sense of allaying threats to democracy, discussions of democratic integrity are therefore best served by focusing on bolstering institutional resilience and preparing suitable countermeasures, including by educating citizens to become more media literate.
Some of the techniques used in influence operations, however, challenge democratic rights, namely when they threaten freedom of thought, a freedom that states are obliged to protect.54 Working to restrict techniques that allow bad actors to amplify influence operations and manipulate individual users should thus be a priority. While this approach successfully reorients the discussion on the question of societal norms and resilience, it fails to distinguish between individuals expressing their personal opinions and influence operations designed to undermine domestic democratic institutions. Nor does the foreignness of an influence operation matter much to this approach.
An Institutional Democratic Approach
When influence operations are directed at distinct domestic institutions, such as democratic elections, the institutional democratic framework becomes relevant. An important distinction here is that labeling influence operations as foreign is meant to protect domestic institutions—not democratic discussion. While the right to vote belongs to a specific group of citizens (making foreignness a relevant concept), any effort to protect democratic institutions must still consider fundamental rights like the freedom of speech and the freedom of thought on an individual level.55
The focus should therefore not be on single pieces of content or individual actors of foreign origin. Instead, the main role of states when it comes to the activities of foreign actors in an electoral context is to consider legislative changes to address foreign interference through, for example, changes to legal provisions regarding electoral funding and online political advertising.56 Another important task is to work toward greater transparency on potential manipulative techniques on social media platforms, such as algorithms skewing electoral content like political coverage of pertinent campaign issues (whether foreign or domestic). Again, foreignness is not a central issue.
The institutional democratic approach necessitates that decisionmakers make difficult judgments about foreignness. Specifically, using this approach entails incorporating legislation and government policy mainly aimed at protecting the integrity of important democratic institutions (like elections, electoral funding, and related advertising); this approach is not intended to focus on countering large-scale interventions by malicious foreign actors in an online environment. When it comes to countering such foreign interventions, a third approach is required.
A National Security Approach
When there is overwhelming evidence of foreign state interests interfering with domestic interests, it makes sense to use a national security approach for labeling foreign influence operations. In such cases, influence operations should be framed as one component of a hostile state actor's strategy. Foreign state interests in situations involving state-based hybrid and irregular warfare—where questions of coercion, interference, and espionage are ongoing concerns—are best understood by focusing on patterns of coordinated behavior, rather than focusing on the acts of individuals.57 If the patterns reveal a focus on influencing or undermining critical infrastructure using influence operations in combination with other techniques, the situation can be considered a matter of national security.
In such cases, foreign state interests become relevant by way of a definition of foreignness, but only when there is clear evidence of coordination, intent, and scale. Influence operations would not be the sole determining factor in such instances. Bringing in a broader range of national security assessments would also support stronger attribution. Foreign influence operations, then, are a central problem that needs to be reflected in, for example, a country-specific strategy that involves deterrence measures.
In sum, it is difficult to contend that foreignness is a decisive, or even central, problem in information operations, except in cases where a foreign actor clearly intends to persistently seek to undermine a sovereign state using a range of methods. In some cases, this determination is relevant to the protection of democratic institutions, particularly in instances when foreign interference aimed at undermining elections must be countered. However, such acts are likely to be one part of a broader strategy. Outside of national security concerns, there is little legal or theoretical basis to question the legitimacy of communication techniques in influence operations on the basis of foreignness. In essence, illegitimate behaviors are the same problem whether domestic or foreign actors use them. Rather than focusing narrowly on the identity of malicious actors, policymakers should consider illegitimacy in influence operations in relation to specific manipulative communication techniques and how systematic the campaigns are in scale.
1 Egdūnas Račius, "Caliphate Citizens: Revisiting the Concept of 'Foreign Fighters,'" in Not Only Syria? The Phenomenon of Foreign Fighters in a Comparative Perspective, ed. Kacper Rekawek (Amsterdam: IO Press, 2017), 58.
2 Mark Carleton-Smith, "Chief of General Staff - Introductory Remarks 2019," Royal United Services Institute (RUSI) 2019 Annual Conference, June 4, 2019, https://rusi.org/annual-conference/rusi-land-warfare-conference/chief-general-staff-introductory-remarks-2019; and Keir Giles, "Handbook of Russian Information Warfare," NATO Defense College Research Division, 2016, http://www.ndc.nato.int/news/news.php?icode=995.
3 Michael Schmitt, Tallinn Manual 2.0 on the International Law Applicable to Cyber Operations (Cambridge: Cambridge University Press, 2017), 12, https://doi.org/10.1017/9781316822524.
4 Michael Schmitt, "Grey Zones in the International Law of Cyberspace," Yale Journal of International Law Online 1 (2017): 2, https://ssrn.com/abstract=3180687.
5 Barrie Sander, "Democracy Under The Influence: Paradigms of State Responsibility for Cyber Influence Operations on Elections," Chinese Journal of International Law 18, no. 1 (2019): 19.
6 Henning Lahmann, "Information Operations and the Question of Illegitimate Interference Under International Law," Israel Law Review 53, no. 2 (2020): 202.
7 Ibid, 203.
8 Ibid, 202–203.
9 Nicholas Tsagourias, "Electoral Cyber Interference, Self-Determination and the Principle of Non-Intervention in Cyberspace," in Governing Cyberspace: Behavior, Power and Diplomacy, ed. Dennis Broeders and Bibi van den Berg (New York: Rowman & Littlefield, 2019), 45–65.
10 Lahmann, "Information Operations and the Question of Illegitimate Interference Under International Law," 200.
11 Michael Schmitt, "'Virtual' Disenfranchisement: Cyber Election Meddling in the Grey Zones of International Law Zones of International Law," Chicago Journal of International Law 19, no.1 (2018): 46.
12 Steven J. Barela, "Cross-Border Cyber Ops to Erode Legitimacy: An Act of Coercion," Just Security, January 12, 2017, https://www.justsecurity.org/36212/cross-border-cyber-ops-erode-legitimacy-act-coercion; Tsagourias, "Electoral Cyber Interference, Self-Determination and the Principle of Non-Intervention in Cyberspace"; Björnstjern Baade, "Fake News and International Law," European Journal of International Law 29, no. 4 (2018): 1357–1376; and Lahmann, "Information Operations and the Question of Illegitimate Interference Under International Law."
13 Lahmann, 202.
14 Nicholas Tsagourias, "Cyber Attacks, Self-Defence and the Problem of Attribution," Journal of Conflict and Security Law 17, no. 2 (2012): 229–244; Thomas Rid and Ben Buchanan, "Attributing Cyber Attacks," Journal of Strategic Studies 38, nos. 1–2 (2014): 4–37; and Kubo Mačák, "Decoding Article 8 of the International Law Commission's Articles on State Responsibility: Attribution of Cyber Operations by Non-State Actors," Journal of Conflict and Security Law 21, no. 3 (2016): 405–428.
15 Michael Schmitt and Liis Vihul, "Proxy Wars in Cyberspace: The Evolving International Law of Attribution," Fletcher Security Review 1 (2014): 53–72.
16 "The Corfu Channel Case," International Court of Justice, 1949, 22, https://www.icj-cij.org/files/case-related/1/001-19491215-JUD-01-00-EN.pdf.
17 Sander, "Democracy Under The Influence," 26.
18 Ben Nimmo, Camille Francois, C. Shawn Eib, Lea Ronzaud, Rodrigo Ferreira, Chris Hernon, and Tim Kostelancik, "Secondary Infektion," Graphika, 2020, https://secondaryinfektion.org/downloads/secondary-infektion-report.pdf; Mikeal Wigell, "Hybrid Interference as a Wedge Strategy: a Theory of External Interference in Liberal Democracy," International Affairs 95, no. 2 (2019): 255–275, https://doi.org/10.1093/ia/iiz018; and James Pamment, Howard Nothhaft, Henrik Agardh-Twetman, and Alicia Fjällhed, Countering Information Influence Activities: The State of the Art, (Stockholm: Swedish Civil Contingencies Agency [MSB], 2018), https://www.msb.se/RibData/Filer/pdf/28697.pdf.
19 Schmitt, "'Virtual' Disenfranchisement," 46.
20 Ugur Altundal and Richard Valelly, "Democratic Citizenship," Oxford Bibliographies: Political Science, 2020, https://www.oxfordbibliographies.com/view/document/obo-9780199756223/obo-9780199756223-0013.xml.
21 Tsagourias, "Electoral Cyber Interference, Self-Determination and the Principle of Non-Intervention in Cyberspace"; and Jens Ohlin, Election Interference: International Law and the Future of Democracy (Cambridge: Cambridge University Press, 2020), 98.
22 Jean-Thomas Arrighi, Rainer Bauböck, Derek Hutcheson, Alina Ostling, and Lorenzo Piccoli, Conditions for Electoral Rights 2019 (San Domenico di Fiesole: European University Institute, 2019).
23 Ayelet Shachar, "Citizenship for Sale?" in The Oxford Handbook of Citizenship (Oxford: Oxford University Press, 2017), 792.
24 "Citizenship by Investment Malta," Golden Visas, 2020, https://www.goldenvisas.com/malta.
25 Dieter Grimm, "Freedom of Speech in a Globalized World," in Extreme Speech and Democracy (Oxford: Oxford University Press, 2009), 11.
26 Michael Kagan, "When Immigrants Speak: The Precarious Status of Non-Citizen Speech Under the First Amendment," Boston College Law Review 57, no. 4 (2016): 1237–1286; Nicholas G. Karambelas, "A Foreign Concept: Examining the Law That Prohibits Foreign Nationals From Participating in U.S. Elections," Washington Lawyer, February 2010, https://www.dcbar.org/bar-resources/publications/washington-lawyer/articles/february-2010-foreign-concept.cfm; and Toni M. Massaro, "Foreign Nationals, Electoral Spending, and the First Amendment," Harvard Journal of Law and Public Policy 34 (2011): 663–703.
27 UN General Assembly, "Universal Declaration of Human Rights," 1948, https://www.refworld.org/docid/3ae6b3712c.html.
29 Ohlin, Election Interference: International Law and the Future of Democracy, 98.
32 Ibid, 56.
34 Ohlin, Election Interference: International Law and the Future of Democracy, 153.
35 Council of Europe, "European Convention for the Protection of Human Rights and Fundamental Freedoms," as amended by Protocols Nos. 11 and 14, November 4, 1950, 11.
36 UN Human Rights Committee, "CCPR General Comment No. 15: The Position of Aliens Under the Covenant," April 11, 1986, 2.
37 Eric V. Larson, Richard E. Darilek, Daniel Gibran, Brian Nichiporuk, Amy Richardson, Lowell H. Schwartz, and Cathryn Thurston, "Foundations of Effective Influence Operations: A Framework for Enhancing Army Capabilities," RAND Corporation, 2009, https://apps.dtic.mil/sti/pdfs/ADA503375.pdf; and Duncan Hollis, "The Influence of War: The War for Influence," Temple International and Comparative Law Journal 32, no. 1 (2018): 31–46.
38 Joseph S. Nye, "Public Diplomacy and Soft Power," The ANNALS of the American Academy of Political and Social Science 616, no. 1 (March 2008): 94–109.
39 Alicia Wanless and James Pamment, "How Do You Define a Problem Like Influence?" Journal of Information Warfare 18, no. 3 (2019); and Kristine Berzina and Etienne Soula "Conceptualizing Foreign Interference in Europe," German Marshal Fund Alliance for Securing Democracy, 2020, https://securingdemocracy.gmfus.org/wp-content/uploads/2020/03/Conceptualizing-Foreign-Interference-in-Europe.pdf.
40 "Public Diplomacy," Encyclopædia Britannica, 2017, https://www.britannica.com/topic/public-diplomacy.
41 Monroe E. Price, Free Expression, Globalism, and the New Strategic Communication (Cambridge: Cambridge University Press, 2014), 134.
42 Howard Nothhaft, James Pamment, Henrik Agadh-Twetman, and Alicia Fjällhed, "Information Influence in Western Democracies: A Model of Systemic Vulnerabilities" in Countering Online Propaganda and Extremism: The Dark Side of Public Diplomacy (New York: Routledge, 2018), 28–43.
43 Martin Kragh and Sebastian Åsberg, "Russia's Strategy for Influence Through Public Diplomacy and Active Measures: The Swedish Case," Journal of Strategic Studies 40, no. 6 (2017): 773–816.
44 Cristina Archetti, "The Unbearable Thinness of Strategic Communication," in Countering Online Propaganda and Extremism: The Dark Side of Public Diplomacy (New York, Routledge, 2018), 93; and Hedvig Ördén, "Instilling Judgement: Counter Narratives of Humour, Fact and Logic," Critical Studies on Security, 6, no. 1 (2019): 12.
45 Barela, "Cross-Border Cyber Ops to Erode Legitimacy."
46 Jens Ohlin, "Cyber Causation" in Cyber War: Law and Ethics for Virtual Conflicts (Oxford: Oxford University Press, 2015): 45; and Wanless and Pamment, "How Do You Define a Problem Like Influence?"
47 Duncan Hollis, "The Influence of War," 36.
48 Kate Jones, "Online Disinformation and Political Discourse: Applying a Human Rights Framework," Chatham House, 2019, 37, https://www.chathamhouse.org/sites/default/files/2019-11-05-Online-Disinformation-Human-Rights.pdf; and Pamment, Nothhaft, Agardh-Twetman, and Fjällhed, "Countering Information Influence Activities."
49 Jones, "Online Disinformation and Political Discourse," 53.
52 Schmitt, "'Virtual' Disenfranchisement."
53 Wanless and Pamment, "How Do You Define a Problem Like Influence?"; and Pamment, Nothhaft, Agardh-Twetman, and Fjällhed, "Countering Information Influence Activities."
54 Jones, "Online Disinformation and Political Discourse."
57 James Pamment, "The EU's Role in Fighting Disinformation: Taking Back the Initiative (Part 1)," Carnegie Endowment for International Peace, 2020, https://carnegieendowment.org/2020/07/15/eu-s-role-in-fighting-disinformation-taking-back-initiative-pub-82286; and James Pamment, "The EU's Role in Fighting Disinformation: Policy Interventions for the 2020s (Part 3)," Carnegie Endowment for International Peace, 2020, https://carnegieendowment.org/2020/09/30/eu-s-role-in-fight-against-disinformation-developing-policy-interventions-for-2020s-pub-82821
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During World War I, a battle line was drawn at the Western Front – stretching from Lorraine in the south to the English Channel in the north. Soldiers dug trenches and erected barbed wire to hold their positions. In places, the trenches were just yards apart and, as the soldiers realised that neither side was going to make any rapid victories or progress, the trenches became more fortified. The opposing forces now had time to regroup and strengthen their lines with more men. The proximity of the enemies also allowed men to shout out to their opponents or stick up signs on wooden boards. After a particularly heavy barrage of missiles or bullets, the soldiers might shout out "Missed" or "Left a bit".
For much of December it had been wet but on Christmas Eve the temperature dropped and a sharp frost enveloped the landscape. The shouting between troops turned into something more during Christmas Eve. Germans celebrate Christmas on December 24 more than they do on the day itself (in Britain and France, December 25 is the main day of celebration). So on the Western Front on Christmas Eve, German soldiers began to sing carols and place Christmas trees lit with lanterns above the trenches.
The enduring legacy of the informal 'Christmas truce' has been positive and it's looked upon today as a wonderful example of humanity during an dreadfully dark hour of man's history.