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Clinical question
What is a better predictor of mortality: ambulatory or office-based measurement of blood pressure?
Bottom line
This study supports the guidelines recommending that treatment decisions be based on ambulatory blood pressure (BP) measurements rather than in-office BP results. The difference between the 2 measurements in this cohort was 19/11 mm Hg, which is enough to change the decision to prescribe a medication at all, or to add a second or third medication. (LOE = 2b)
Banegas JR, Ruilope LM, de la Sierra A, et al. Relationship between clinic and ambulatory blood-pressure measurements and mortality. N Engl J Med 2018;378:1509-1520.
Study design: Cohort (prospective)
Funding source: Government
Setting: Population-based
How we measure things matters: For example, nonfasting lipid levels are a better predictor of mortality than fasting lipid levels. Recent guidelines for hypertension, including from the U.S. Preventive Services Task Force, have emphasized the need to confirm elevated BPs in most patients using some form of ambulatory BP monitoring. This study used data from a large Spanish hypertension registry to look at the association between clinic BPs, ambulatory blood BPs, and mortality. The registry includes adults with an indication for ambulatory BP monitoring, such as suspected white coat hypertension, borderline or labile hypertension, or hypertension refractory to treatment. The registry supplies data on clinic BPs, measured by automated devices after 5 minutes of seated rest, and 24-hour ambulatory BP measurements. These data were linked to national vital statistics databases to determine cardiovascular and all-cause mortality. The analysis was adjusted for comorbidities, age, sex, tobacco use, and body mass index. The mean age of patients was 58 years, 58% were male, and only 11% had a diagnosis of cardiovascular disease. During a median 4.7 year follow-up, there were a total of 3808 deaths including 1295 cardiovascular deaths. The mean ambulatory BP was 129/76, compared with 148/87 in the clinic. Recall, the clinic BPs were measured by an automated device after 5 minutes of rest, yet they were still far higher than the ambulatory measurements. In the fully adjusted model that adjusted for clinic BPs, the hazard ratio for all-cause mortality was 1.58 (95% CI 1.56 - 1.60) for the ambulatory systolic BP versus 1.02 (1.00 - 1.04) for the clinic systolic BP adjusted for ambulatory BP. A similar pattern was seen for diastolic BPs. The inflection point for an increase in both cardiovascular and all-cause mortality is at a systolic BP of 140 to 160. Mortality was not increased in patients with controlled hypertension, but was increased in those with both white-coat and masked (normal in clinic, abnormal at home) hypertension.
Mark H. Ebell, MD, MS
University of Georgia
Athens, GA
Clinical question
Is a single office blood pressure measurement reliable to assess hypertension?
Bottom line
Don't rely on a single blood pressure measurement. The first blood pressure reading taken during an office visit will be substantially different than subsequent readings in almost half of typical patients, and if relied upon will result in 1 in 8 patients being falsely labeled as hypertensive. (LOE = 1b)(www.essentialevidenceplus.com)
Burkhard T, Mayr M, Winterhalder C, Leonardi L, Eckstein J, Vischer AS. Reliability of single office blood pressure measurements. Heart 2018;104(14):1173-1179.
Study design: Cross-sectional
Funding source: Self-funded or unfunded
Setting: Outpatient (primary care)
The authors enrolled 1000 consecutive patients who presented for internal medicine, obstetric, or gynecologic care, though only 802 patients completed the study. Each patient, after 5 minutes of rest, had 4 consecutive blood pressure measurements, 2 minutes apart, by 1 of 13 trained physicians. The first systolic blood pressure was more than 10 mm Hg higher than the mean of subsequent measurements in 23.9% of patients; in total, 45.9% of patients had a systolic difference of more than 5 mm Hg. Similarly, diastolic blood pressures were more than 10 mm Hg different in 4.4% of patients; in total, 21.6% of patients had a difference of more than 5 mm Hg. More important, hypertension would have been diagnosed in error in 1 in 8 patients (12%) if only the first measurement had been obtained, and 2% of patients would have had their hypertension undiagnosed by the single measurement.
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Alex Shreiber, PharmD
Clinical question
In patients with high blood pressure, does a second reading show lower results?
Bottom line
If you're not rechecking high blood pressures, you should. In fact, set your electronic health record to remind you to do it. In this large study, when reminded, clinicians rechecked elevated blood pressures 83% of the time, finding a median drop in blood pressure of 8 mm Hg during the same visit. That drop is equivalent to a typical reduction in blood pressure with pharmacologic treatment over time, and resulted in one-third fewer patients being labeled with high blood pressure at that visit. (LOE = 2b)(www.essentialevidenceplus.com)
Einstadter D, Bolen SD, Misak JE, Bar-Shain DS, Cebul RD. Association of repeated measurements with blood pressure control in primary care. JAMA Intern Med 2018 doi:10.1001/jamainternmed.2018.0315. [Epub ahead of print]
This study was conducted in primary care offices of a large US health system. The electronic health record was set to remind clinicians to recheck the blood pressure of a patient when a value greater than 140/90 mm Hg was documented. The reminder worked: Clinicians rechecked high blood pressures 83% of the time. The authors then evaluated the effect of this simple intervention on 38,260 patients, average age 61 years, 39% of whom had a high initial reading. With repeated measurement, the median drop in blood pressure was 8 mm Hg (interquartile range 2 mm Hg - 17 mm Hg) and 36% of patients no longer had a blood pressure of 140/90 mm Hg or higher.
Clinical question
At what systolic blood pressure should we begin treatment for the most benefit?
Bottom line
Beginning antihypertensive treatment when the systolic blood pressure (SBP) is greater than 140 mm Hg delays death and prevents major cardiovascular events in some people without pre-existing heart disease; in patients with existing heart disease it prevents further events, but does not extend life. These results may appear to conflict with those from SPRINT trial, which found benefit with lowering SBP to below 120 mm Hg. However, the SPRINT investigators measured blood pressure using automated devices which give readings 10 mm Hg to 20 mm Hg lower than typical office measurements. So, the goal of less than 120 mm Hg in the SPRINT study is likely to be very similar to the goal of less than 140 mm Hg in this study. (LOE = 1a)(www.essentialevidenceplus.com)
Brunstrom M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels. A systematic review and meta-analysis. JAMA Intern Med 2018;178(1):28-36.
Study design: Meta-analysis (randomized controlled trials)
Funding source: Foundation
Setting: Various (meta-analysis)
The authors followed PRISMA guidelines to search 3 databases, including Cochrane CENTRAL, as well as reference lists of identified studies to identify all randomized trials with at least 1000 patient-years of follow-up that compared drug treatment with placebo or compared blood pressure targets against one another. Two researchers independently extracted the data and assessed the quality of the research (more than two-thirds of the studies had a low risk of bias). They identified 74 studies enrolling 306,273 patients (60.1% men, average age 63.6 years). In patients without pre-existing heart disease (ie, primary prevention), lowering SBP that was initially greater than 140 mm Hg decreased the risk of death (relative risk [RR] = .93, 95% CI -.88 to 1.0 if SBP > 160 mm Hg; RR = 0.87, .75 to 1.00 if SBP 140 - 159 mm Hg) and major cardiovascular events (RR = .78, .7 to .87 if > 160 mm Hg; RR = .88, .8 - .96 if 140 - 159 mm Hg). Treating SBP that was initially less than 140 mm Hg did not affect morbidity or mortality. In patients with previous coronary heart disease and a mean SBP of 138 mm Hg, treatment reduced the risk for further major cardiovascular events (RR = .9; .84 to .97), but did not extend life. There was a high degree of heterogeneity among these trial results, reducing our confidence in the results. There was some evidence of publication bias in studies that evaluated the effect on major cardiovascular events, meaning that studies failing to show a difference in outcomes were not published.
Clinical question
Is lower systolic blood pressure associated with better outcomes in elderly patients who take antihypertension medications?
Bottom line
In this small cohort study of patients older than 85 years, lower systolic blood pressure during treatment with antihypertensive medications is associated with higher death rates and greater cognitive decline. (LOE = 1b-)(www.essentialevidenceplus.com)
Streit S, Poortvliet RKE, Gussekloo J. Lower blood pressure during antihypertensive treatment is associated with higher all-cause mortality and accelerated cognitive decline in the oldest-old data from the Leiden 85-plus Study. Age Ageing 2018;47(4):545-550.
Are you tired of all the ping-ponging, guideline-based blood pressure targets? Unfortunately, this study won't improve your fatigue. These researchers assembled a cohort of 570 residents of Leiden in the Netherlands who turned 85 years of age between 1997 and 1999. They excluded people who died within 3 months of enrollment and those who had no blood pressure measurement at baseline. At baseline, and periodically over the course of 5 years of follow up, the researchers collected all kinds of information: sociodemographics, medical diagnoses, medications, mental status, grip strength (as a proxy for frailty), blood pressure, and so forth. They assessed the main outcome—death from any cause—by using municipal records. Slightly fewer than half of the residents (44%) took antihypertensive medications at baseline; these patients were more likely to have other cardiovascular disorders than those not taking antihypertensive medications (62% vs 36%). During the 5 years of follow-up, 263 (46%) participants died. For those taking antihypertensive medications, all-cause mortality was significantly higher with decreasing systolic blood pressure (hazard ratio 1.29 per 10 mmHg lower systolic blood pressure; 95% CI 1.15 - 1.46). For the residents who were not taking antihypertensive medications, there was no significant correlation between systolic blood pressure and all-cause mortality. Additionally, the patients taking antihypertensives had more rapid cognitive decline with lower systolic blood pressure. Although many explanations for the differences in treatment thresholds are given by the various guidelines, one is how we value clinical trial versus observational data: The guidelines that promulgate lower blood pressure targets are more likely to value observational data. The data from this study are subject to many of the biases inherent in cohort studies, but they should moderate the enthusiasm for lower blood pressure targets.
Henry C. Barry, MD, MS
Michigan State University
East Lansing, MI
POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).
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City of CoronaHome Menu
Corona Recognized as a 2019 Digital Cities Survey Winner
For Immediate Release
November 14, 2019
CORONA, CA– The Center for Digital Government (CDG) has announced the City of Corona as one of the winners for the 2019 Digital Cities Survey, a nationwide survey that recognizes cities using technology to tackle social challenges, enhance cybersecurity, and improve transparency.
Now in its 19th year, the annual survey focuses on the top ten characteristics of a digital city: open, citizen-centric, collaborative, secure, staffed/supported, connected, efficient, resilient, innovative, with use of best practices. The survey is open to all U.S. cities and honors cities in five population classifications: 500,000 or more, 250,000 to 499,999; 125,000 to 249,999; 75,000 to 124,999 and fewer than 75,000. The City of Corona was ranked 6th place in the 125,000 to 249,999 population classification.
"Congratulations to this year's Digital Cities winners, who are working to make their communities more secure, user-friendly, efficient and resilient," said Teri Takai, executive director for CDG. "Their efforts are making technology a driver of better, smarter, more responsive government."
"Corona has taken an innovative approach toward technology, community engagement, transparency, and collaboration," said Mayor Jason Scott. "We are honored to be recognized on a national level as a Digital Cities Survey Winner for the second consecutive year."
The top-10 ranked cities will be honored at an awards dinner during the National League of Cities' annual conference in San Antonio, Texas, on November 21. Read more about the winners here.
About the Center for Digital Government: The Center for Digital Government is a national research and advisory institute focused on information technology policies and best practices in state and local government. CDG is a division of e.Republic, the nation's only media and research company focused exclusively on state and local government and education.
About the City of Corona: Corona is located adjacent to Orange County, California, at the junction of the 91 and 15 freeways, with a population of more than 160,000 residents. For more information regarding the City of Corona, visit www.CoronaCA.gov.
Media Contact
Cindy Solis
Community Information Specialist II, City of Corona

subset: commoncrawl


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Heterotaxy Connection Any Way 5k
Wednesday, May 4, 2016
Preliminary results are in! We only had 5 people report their finish times as of today (May 16th). I am going to hold off on sending out awards until the end of the week, just in case y'all are forgetful, like me. If you would like to be included in the results and considered for a hand-painted race medal, email your name and race results to email@example.com.
In the same fashion that the bodies of those with Heterotaxy find their own unique way to function, we would like to invite you to find your own unique path to complete a 5K! Participation is simple.
1. Register ($25 per person, includes awareness t-shirt) using the link below. UPDATE: The race fee of $25 will expire after April 10th. On April 11th, the new race fee will be $30. Unfortunately, we cannot promise a shirt to anyone who registers between April 11th-May 4th. However, ALL proceeds will go directly to the Heterotaxy Connection.
T-SHIRT info: 100% Cotton shirts are available in sizes Adult Small-5XL and are specific to Heterotaxy Awareness (not specific to the race itself). Unfortunately, youth sizes are not available to race registrants. If you are interested in purchasing additional shirts, including youth and women's sizes, check out this link: T-shirt Sales Page
2. Decide when and where you are going to walk or run.
3. Go out and enjoy the fresh air and 5K knowing you are getting exercise and helping others at the same time. You can run or walk any time or day, as long as you finish by 11:59pm on May 4th, 2016.
4. Email your finish time to firstname.lastname@example.com no later than May 7th, 2016 to be included in the official results.
5. Check your mailbox for your Heterotaxy Awareness T-shirt and wear it as often as possible.
All proceeds from this event go directly to the Heterotaxy Connection, which helps to empower, educate and support those impacted by Heterotaxy Syndrome. For more information, go to: www.heterotaxyconnection.org
Check us out on Facebook: www.facebook.com/heterotaxyconnection


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Hi all
I'm 53 & mid November had a terrible pain in my eye followed by a severe headache. Since then everything has escalated due to my blood test results being abnormal - 3 days in hospital, steroids for a week together with antibiotics for a sinus infection, ct scan, MRI & then a temporal lobe biopsy last Tuesday. To say I'm a bit scared is an understatement! I've been looking at posts on here (very informative & reassuring) but the one thing that baffles me is a lot of people say if the biopsy is negative it doesn't mean you haven't got GCA & a negative response seems the most common, which worries me! Has anyone had a positive biopsy?
Mandrose (a very anxious possible GCA)


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I found this photo by accident, it was one that had I had taken in Ottawa some years ago outside Sugar Mountain which is a candy shop selling all your childhood favourite chocolate bars and more.
The photo is not perfect so written out in candy wrappers (the capitals) it says.
GOOD NEWS it's Father's Day!
You are a huge NERD but you are full of SMARTIES. Mum thinks you are a BIG HUNK and a SWEETIE. You are MOUNDS of fun and you are worth more than 100 GRAND and we love you NOW & LATER. Our POP ROCKS!
Happy Father's Day


text: Employees from the Red Cross will be coming in from 10:00am-4:00pm conducting a blood drive. You are able to sign up through a link sent via email or sign ups will be held in the Shults Center on multiple occasions. If you are unable to sign up ahead of time walk-ins are welcome.


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A one yard rushing touchdown the third
Greece can seal a play-off spot with victory at home to Gibraltar, while Bosnia and Herzegovina – who are two points behind – be hoping for a Greek slip-up as they face Estonia Keith Kinkaid Authentic Jersey at the same time.Scotland prepare for their 2018 UEFA Nations League campaign with friendlies against Costa Rica, Hungary, Peru and Mexico, the Scottish FA have announced.since 2011.Da'Rick set a state high school record for receiving yards as a senior, but decided to head for Tennessee instead of staying with the home-state Bulldogs.soccer fans and consumers: jersey-front sponsor Chevrolet, adidas, 20th Century http://www.devilshockeyshop.com/adidas-keith-kinkaid-jersey Fox, , EA Sports, , New Era, Tag Heuer, Columbia , Epson, Foods, Toshiba and Uber.9 as part of The 13th Annual Chicago Ducky Derby to benefit Special Olympics Illinois.
The only previous meeting between the two sides ended a shock 1 win for Costa Rica at the 1990 FIFA World Cup Italy.Visiting North America give the team the best possible preparation for the new , using top class training facilities and playing some great stadiums, Woodward, Manchester United's executive vice chairman, said a statement.Has the lower body power to stop backs' momentum when head-up and brings power into his stops when attacking ballcarriers space.Houston Rockets 3 PM ?
July 26 Barcelona FedEx Field, Washington, D.C.July 26 Barcelona FedEx Field, Washington, D.C.Portland Trail Blazers vs.NaVorro Bowman Bottom Line.ManU's tour includes matches that are part of the International Champions Cup .
July 20 Manchester City TBD ?Models his style of play after Islanders forward John Tavares.I am sure our fans relish away trips to Hungary, Peru and Mexico and be looking forward to a long-overdue rematch against Costa Rica.isn't doing much more http://www.officialfloridapanthers.com/Adidas-Jamie-McGinn-Jersey than stating the obvious, considering Tennessee Titans offensive coordinator Matt LaFleur has spent most of his career Jamie McGinn Jersey working under Kyle Shanahan.Keeps eye on receivers running behind him, can stay with them across the field.


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To find a branch near you, please enter your town or postcode:
The annual Heathfield Agricultural Show will take place on Saturday 23rd May between 8am – 5:15pm.
The Heathfield Agricultural Show is a proud showcase of the products and produce of our region.
Ernest Doe will be featuring a trade stand at the event. Here you will be able to buy a range of different agricultural and horticultural equipment.
The show will also have a farmers market, flower show and so much more.
You can find out more about the show and buy tickets here.


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Session 3. Security Risks of Architectures for Enabling Government Access to Plaintext
In the workshop's third session, participants drilled deeper into the technical options for creating exceptional access mechanisms, discussed how these options might impact cybersecurity, and explored the motivations of and constraints on the government, industry, and society more broadly.
The session began with a presentation by Matt Blaze, associate professor of computer and information science at the University of Pennsylvania. He explored the historical evolution of technological solutions for exceptional access and presented an overview of the challenges faced today. The presentation was followed by a wide-ranging discussion moderated by Fred Chang and Susan Landau.
Blaze began his presentation with a look at the history of cryptography and exceptional access, starting with wiretapping. Originally, wiretaps involved law enforcement getting access to the target's phone line and connecting a device capable of capturing the analog audio and telephone network signaling being sent over the line—a relatively straightforward proposition. Eventually, as telephone systems became digital, the Communications Assistance for Law Enforcement Act was enacted to ensure that carriers would provide law enforcement with the necessary interface to their networks as well.
Crypto War I
Blaze called the period from 1992 to 2000 "Crypto War I," the time during which consumers, the government, and the telecommunications industry grappled with dramatic shifts in the encryption landscape. Blaze pegs the start of this "war" to AT&T's 1992 release of the TSD-3600, a secure telephone for consumers akin to the secure phones that had previously been used only by the government. The TSD-3600s used a Diffie-Hellman key exchange to set up encryption keys and a 56-bit data encryption standard to encrypt the digitized audio.
Although the telephone was expensive and not widely sold, the U.S. government nonetheless feared that technology like the TSD-3600 would spell the end of wiretapping and requested that AT&T make changes to accommodate lawful wiretaps on individuals who might use the device. The solution proposed was the Clipper Chip, which was designed by the National Security Agency (NSA) to be a drop-in replacement for the TSD-3600's data encryption chip. Using an enhanced algorithm called SkipJack, the Clipper Chip provided 80 bits of security
as opposed to 56 bits. It also introduced key escrow, a feature that allowed the government to recover plaintext from a call if a TSD-3600 was used by a person who was the subject of an approved wiretap. AT&T incorporated the Clipper Chip into all TSD-3600 phones and even recalled already-sold TSD-3600 phones that lacked the chip, Blaze recounted.
The Clipper Chip was a controversial proposal and had technical problems, Blaze said. The first problem was that protocol failures in the chip's design made it easy to bypass the key escrow feature; Blaze discovered some of these failures himself while working for AT&T. Although bypassability was likely a fundamental problem with the design, the protocol failures found by Blaze were comparatively minor and could be patched. Ultimately, a series of larger problems led to the Clipper Chip's demise by the dawn of the 21st century. One key problem, in Blaze's view, was that the Clipper Chip turned an inherently inexpensive technology for software-implemented cryptography into a hardware-based model that was expensive and difficult to integrate into the system. The Clipper Chip was built on a particular structure for performing encryption and required specific, tamper-resistant hardware and a classified algorithm that could not be made public. In addition, said Blaze, it had a central key database, which, although split between two government agencies, ultimately "amplified the risks extraordinarily by basically creating an end-to-end encryption system that was not, in fact, end-to-end." This ultimately led to a system that was expensive, riskier, and easily bypassed.
By 2000, Blaze said, the country had come to the conclusion that the use of encryption was "really too important to slow down" by requiring a key escrow system for government access, and "unfettered cryptography" was allowed to blossom.
Blaze noted that an unfortunate side effect of the focus on the Clipper Chip and key escrow systems during the 1990s was that insufficient attention was paid to the security standards being built into the communications and information infrastructure then in use, which many view as not having been sufficiently robust to support the sensitive applications that depended on it, such as commerce, finance, and national security. "We are paying that price to this day," Blaze said.
Crypto War II and the Cybersecurity Crisis
Blaze then turned to the current period, which he described as a time of both "Crypto War II" and a "cybersecurity crisis." The first term stems from the renewed debate over encryption spurred by comments from law enforcement and national security officials about the challenges posed by ubiquitous encryption, exemplified by an October 16, 2014, statement from Federal Bureau of Investigation (FBI) director James Comey:
Unfortunately, the law hasn't kept pace with technology, and this disconnect has created a significant public safety problem. We call it "Going Dark," and what it means is this: Those charged with protecting our people aren't always able to access the evidence we need to prosecute crime and prevent terrorism even with lawful authority. We have the legal authority to intercept and access communications and information pursuant to court order, but we often lack the technological ability to do so.1
At the same time, a daily barrage of data breaches and other cybersecurity incidents is affecting our critical systems, said Blaze, offering as an example the enormous 2015 breach at the U.S. Office of Personnel Management. The United States depends on the same platforms produced for the broad consumer market—operating systems and smartphones, and the like—for its critical infrastructure, financial systems, economy, and national security, as it does for its personal or even frivolous activities. Blaze stated that the adversaries perpetrating these breaches are not only ordinary criminals but also nation-states, and that the problem of securing all of this critical infrastructure is getting steadily worse rather than better.
1 From remarks of FBI director James Comey at the Brookings Institution on October 16, 2014, "Going Dark: Are Technology, Privacy, and Public Safety on a Collision Course?," https://www.fbi.gov/news/speeches/going-dark-are-technology-privacy-and-public-safety-on-acollision-course.
Fundamentals of the Current Cybersecurity Landscape
Noting that the challenge of building reliable systems at scale has plagued computer science since the field's inception, Blaze said that, in general, we still "don't know how to fix this." However, he pointed to two approaches as providing partial solutions: reducing the number of components in a system and using cryptography. One tried- and-true approach, he said, is to make systems as small and simple as possible in order to reduce the footprint of the vulnerabilities. Despite the merits of this approach, it has not proven practical in a world in which the endless thirst for capabilities leads to systems that are ever larger and more complex. New features are added to systems too quickly to allow them to be properly understood and to be made more robust.
The second approach is cryptography. By encrypting the data used in large swaths of a system's components, we can reduce the "attack surface" and confine vulnerabilities to a smaller number of components. End-to-end encryption is considered the best practice in this area because it allows only the sender and receiver access to plaintext in the case of communication and allows only the person storing the data access in the case of data storage, thus reducing the opportunities for compromise to a bare minimum.
Looking forward, Blaze identified two crucial problems that need to be addressed and balanced. The first is that the U.S. computing infrastructure is in "terrible shape" and "getting worse," and that any actions taken should at a minimum do no harm. The second is that encryption and similar technologies are, may be, or will be making lawful access to communications more difficult. The challenge, he said, is to address both issues without worsening the first.
Exceptional Access: Considerations and Challenges
Blaze then turned to the concept of exceptional access, which he defined as a mechanism that provides access to plaintext that is not inherent to the requirements of the application itself. In his view, exceptional access, by nature, makes a system more complex and makes it impossible to provide end-to-end encryption because it essentially introduces an additional end point.
He pointed to two critical considerations relevant to the policy and technical feasibility of an exceptional access system. The first, "Can we trust the system if it works properly?" is a policy question. The second, "Can we trust the system to work properly?" is a technical question and is the focus of the current workshop.
Citing the report of which he is a coauthor, Keys Under Doormats: Mandating Insecurity by Requiring Government Access to All Data and Communications,2 Blaze articulated some of the ways exceptional access is at odds with the need to better protect infrastructure. He said exceptional access necessarily makes cryptography weaker, increases the difficulty of integrating cryptography securely into applications and systems, creates operational vulnerabilities, and, in many cases, can be easily bypassed. Blaze pointed out that encryption systems can fail even if there are no additional complications from exceptional access. The most common reasons for such failures, Blaze said, have to do with the deployment of an encryption tool for a specific application—it is likely, say, that the tool does not meet some security requirement in the application, owing to some usability issue, or there may be problems with the application itself or the platform on which it is running. Problems with the engineering of the encryption tool, including implementation of the encryption algorithms, are also fairly common, he said. Less common, although still possible, are failures in the encryption algorithms or protocols themselves.
Although the algorithms and protocols are perhaps the easiest aspect of creating an encryption system that works, there are still weaknesses. Despite a great deal of mathematical work in this field, there is still no general theory of cryptography, Blaze posited. He called this "one of the dirty secrets of cryptography." Furthermore, occasionally it turns out that the assumptions underlying algorithms aren't entirely correct, he said. Protocols also can turn out to have weaknesses. As an example, he pointed to the protocol failures in the Clipper Chip, an encryption system designed by perhaps the world's best cryptographers at the time.
The biggest challenges to implementing exceptional access, Blaze said, would likely be related to design and software engineering, which are complicated by access requirements. As a result, he surmised, a requirement for
2 H. Abelson R. Anderson, S.M. Bellovin, J. Benaloh, M. Blaze, W. Diffie, J. Gilmore, et al., 2015, Keys Under Doormats: Mandating Insecurity by Requiring Government Access to All Data and Communications, Technical Report MIT-CSAIL-TR-2015-026, Massachusetts Institute of Technology Computer Science and Artificial Intelligence Laboratory, July 6.
exceptional access may lead many vendors to reduce their focus on security or forego encryption altogether due to the increased difficulty and expense of building secure encryption systems that also allow for exceptional access. As a result, he said, there's a danger that "we won't see the deployment of encryption in places where we really, really need to have it used."
Exceptional access also raises several operational challenges. Whether keys are kept in a single centralized escrow system or in multiple systems, the result is collections of secrets "that have to be guarded essentially in perpetuity," Blaze noted. Moreover, the complexity of operational infrastructure needed to add exceptional access may well dwarf all the other operational requirements of the application. These collections of secrets would have enormous value for adversaries, creating high-value targets. Maintaining and securing such systems, he said, would be both extremely difficult and extremely expensive.
Allowing that exceptional access can be built into certain applications under certain circumstances at an acceptable cost (and indeed this has already been done in some cases), Blaze said that the risks of implementing exceptional access in a more generalized sense are enormous and the consequences going forward would be "unbounded and unpredictable." Moreover, Blaze observed, in the context of a fast-moving technology industry involving numerous smaller actors, it is likely exceedingly difficult to implement exceptional access generally, particularly in the nonenterprise context. And given an evolving cast of adversaries that increasingly includes nation-states seeking to do serious harm to the security and economy of the United States, any failures in this realm are likely to be both high impact and expensive.
Fred Chang and Susan Landau moderated a broader discussion of the technical options and security risks related to exceptional access to encrypted information and communications. The discussion is broken into two sections: The first focuses on context and major issues and the second on potential solutions. The order in which the contributions are presented here is not the order in which they were discussed at the workshop.
Part 1: Issues and Context
Security Trade-offs
Chang inquired as to whether, instead of pitting cybersecurity and exceptional access against each other as opposing choices, it would be reasonable to frame the issue as a series of engineering trade-offs. Blaze agreed with that conceptualization in principle but noted that as the technological landscape grows more complex and the stakes become higher, it becomes increasingly challenging to truly understand what is being traded or sacrificed. A related weakness, he added, is that we have poor metrics for evaluating the security of our systems.
Blaze described the difficulty of creating a secure exceptional-access system as "unprecedented." He noted that, although the problems are subtle and there is no specific proposed system on the table to evaluate, it is hard to quantify exactly what the risks are. At a fundamental level, such a system would likely require (1) a secret held somewhere, (2) a mechanism for communicating that secret, and (3) a mechanism for guarding that secret effectively in perpetuity. Compounding the complexity of these basic requirements is the fact that apps and software can be used anywhere—and by anyone—around the globe.
Noting improvements in cryptography and key management systems, Chang asked whether any recent technological breakthroughs might make exceptional access more feasible. Although he acknowledged incremental progress in cryptography and its algorithms, Blaze said that because the range of vulnerabilities, or "problem space," has also expanded, the ultimate result is a mixed bag in terms of how much progress has been made relative to the actual problems.
Daniel Kahn Gillmor spoke of the trade-off between the (perhaps limited) benefits of an exceptional access system to law enforcement and the increased vulnerability to which such a system would expose everyone. Although exceptional access might enhance law enforcement's ability to catch the "dumb criminals" (those without the resources or knowledge necessary to procure end-to-end encryption tools), he predicted that many others would rapidly adopt
a less vulnerable encryption system, even if it were not available by default. Later, Patrick Ball reiterated this point, suggesting that sophisticated users will be able to circumvent exceptional access through what would amount to a form of steganography, by hiding secure encryption inside a layer of encryption with exceptional access. Until the outer layer is decrypted, an adversary or government would not even know that the material inside had been encrypted. Such a scheme, Ball said, would not be difficult for savvy users to implement; as a result, the only targets whose communications can be made visible through exceptional access schemes are "dumb criminals" and law-abiding citizens.
Gillmor emphasized that the costs of deploying exceptional access are borne by everyone. Even worse, in his view, we would be stuck with any downsides for years to come. A weakness in security was exploited in an analogous deployment in the 1990s to comply with U.S. regulations on the export of cryptography technologies. We are still paying the cost, Gillmor said, "even though we decided years ago that that was not a good cost to pay," for the introduction of export-grade cipher suites used by the Transport Layer Security and Secure Sockets Layer family of protocols.
Blaze noted some additional trade-offs. If, for example, a system is built with a centralized repository that application developers would make use of, this concentrates one part of the risk in a "fairly well hardened environment," but at the same time creates a "big central fat target" that may or may not be adequately secured. If the central repository fails, it fails catastrophically. Given the complexity of the requirements associated with exceptional access, he said it is quite likely that engineers designing one aspect of a system to meet one requirement could create a structural weakness somewhere else, perhaps without knowing it. Blaze went on to caution that the right set of requirements needs to be considered: It may be easy to meet the requirement that keys can be recovered, but that does not ensure that only the right people are recovering keys.
Landau raised two other trade-offs. First, if a smartphone's data are more easily accessible, it undermines the ability of the phone to act as a secure authenticator. The fact that everyone carries their phone with them—and we all notice when it's gone—makes it especially useful, she said, and losing this capability would impose a cost. Second, since the mid-1990s, the U.S. Department of Defense (DOD) has been using more and more off-the-shelf, commercial equipment, in part because of the speed of innovation in Silicon Valley. As a result, she observed, it is important to remember that DOD has a strong interest not just in the ability to break into encrypted devices or communication streams, but also in the ability to keep them secure.
Kevin Bankston explored how exceptional access mechanisms could create vulnerabilities that might be exploited. Bud Tribble agreed that operationalizing exceptional access at scale would indeed raise the risk that adversaries could tap into the decryption capability, pointing to that concern as one of the reasons Apple decided to implement end-to-end encryption. A requirement to maintain an exceptional access mechanism, he said, would create a persistent target for an adversary to exploit, a fundamentally riskier situation than the current system in which Apple can catch and patch security vulnerabilities as they become known.
Another issue to consider is how exceptional access would play out internationally—say, if a foreign government wanted to tap into a communications stream encrypted in a way that enables FBI access to the plaintext. Ball said that based on his experience working with human rights groups at risk of government persecution, faced with such a request, he "would be delighted to say 'I don't have the keys.'"
Finally, in a broader sense, there are trade-offs involved in action versus inaction relating to the alternative outcomes that might occur under different circumstances. Butler Lampson suggested that, in the absence of a credible technical solution from the technology community, legislators might come up with their own solution. At several points throughout the workshop, other participants pondered what might be sacrificed if the quest for a "perfect" solution is allowed to block the pursuit of workable, albeit imperfect, solutions.
The Law Enforcement Context
Participants discussed key concerns and challenges facing law enforcement related to data encryption.
Noting that companies will generally produce data that they have access to in response to law enforcement legal demands, Richard Littlehale asked why some companies are considered to provide adequate security even if they retain the ability to access encrypted data, while others argue that a total lack of access by anyone but the individual user is the only way to ensure adequate security.
At several points, Littlehale suggested that law enforcement is not seeking a perfect system of total access, but is instead looking to improve the current situation, where the increasing ubiquity of encryption for devices and communications is rapidly constraining the types of evidence accessible to law enforcement. In response to the point that technologically sophisticated criminals will likely continue to find ways to protect their data from law enforcement, Littlehale urged attendees not to underestimate the amount of human misery caused by criminals who are either "dumb" or "smart but lazy."
Littlehale underscored the fact that these issues are currently affecting real cases. If it is determined that exceptional access is either not technically feasible or not a policy the country wishes to pursue, what then is law enforcement expected to do to fulfill its mission? Blaze built on this point, noting that law enforcement and the FBI need viable alternatives if exceptional access does not work out. He predicted that a "Plan B" would involve more investment in lawful hacking and other forensics capabilities. This idea is discussed in greater depth below (see the section "Part 2: Exploring Solutions").
Joseph Lorenzo Hall suggested it will be important to measure the needs of law enforcement. Such insights would give society a more rational way to understand what is lost if more security is pursued at the expense of catching fewer perpetrators, or if we sacrifice security to achieve law enforcement goals. Landau commented that participants in the annual Workshop on the Economics of Information Security are pursuing research in this vein, but that it is often difficult to obtain the data needed to truly answer the question.
Littlehale agreed that these impacts are difficult to quantify. Rarely can law enforcement point to encrypted data as an absolute or insurmountable block to an investigation, he said; the typical impacts are more nuanced: cases take longer to investigate, and victims endure extra suffering as a result or resources are pulled from other cases. On the flip side, he said, it is appropriate to recognize the value of feeling secure, the feeling that one's privacy is protected.
Littlehale noted also that certain types of evidence previously available to law enforcement in the analog world are no longer available in the digital world. For example, under a physical search warrant, a police officer might once have patted down a suspect and found an address book. Now, a suspect's address book is likely to be stored on a smartphone, and its content is more and more often encrypted. In essence, he said, this means law enforcement is being expected to execute its mission—which includes not only prosecuting the guilty but exonerating the innocent—with potentially less evidence.
Ball offered a counterargument: today's digital world offers a great deal more information to law enforcement than was previously available, through means such as location tracking, metadata, unencrypted e-mails, and plaintext calls made through traditional cellular networks. Although we may be "going dark" in some places, we are going "brilliantly bright" in others, he argued, suggesting that abandoning our devices altogether would take a lot more evidence out of the reach of law enforcement than using fully encrypted devices would.
Addressing in a broader sense the aims of law enforcement, Littlehale noted that concerns about the potential for someone to steal an escrow key or abuse exceptional access to the detriment of human rights are also concerns of the law enforcement community. Such actions, he noted, would be crimes, and thus law enforcement has an interest in preventing and prosecuting them.
The Industry Context
Participants considered the market environment that has driven certain decisions by industry players, as well as how companies might respond to an exceptional access requirement.
From a practical standpoint, Blaze suggested that imposing an exceptional access system that is too complex or difficult to implement might drive many companies (with the possible exception of Apple, he conceded) to simply abandon encryption. Such an outcome would result in much less security for everyone.
Tribble explained that Apple's approach to implementing encryption has been a response to two trends: (1) an increasing level of threat to its customers and (2) the fact that consumers are keeping an increasing amount of important information on their phones. Given these trends, Apple opted to pursue end-to-end encryption, an approach, Tribble noted, that the technical community over the past 50 years has determined to be the best practice.
Tribble went on to acknowledge that when Apple does not have the keys to unlock something law enforcement needs access to, that can lead to a legal order not being enforceable, which, he conceded, is not a good thing. However, in the same way that it is hard to measure precisely how this impacts the efforts of law enforcement, it is hard to quantify the risks and benefits to customers whose data are protected (or not) with end-to-end encryption.
Noting that Apple recently introduced a feature that allows people to download their medical record to their phones, Tribble emphasized that these trends—rising threats and an increased amount of sensitive information on phones—are going to steepen in the coming years. Echoing a sentiment expressed earlier in the workshop by Baker, Tribble said the solutions to these problems are not for one company or one government agency to decide, but for society as a whole.
The Internet of Things
Landau moved the conversation toward the Internet of Things (IoT) to explore how the proliferation of network-connected devices affects the encryption landscape or exceptional access options. Although the IoT may seem trivial—for example, it may be unlikely that a network-connected toaster would reveal vital information—she pointed to the U.S. intelligence community's 2016 worldwide threat assessment that suggested "future intelligence services might use the IoT for identification, surveillance, monitoring, location tracking, and targeting for recruitment, or to gain access to network or user credentials."3
Eric Rescorla and Hall began by clarifying that many such devices do not or cannot practically use encryption. Hall remarked that some IoT devices take 10 seconds or more to perform an encryption, and those that do likely use the same TLS protocol that is widely used for Internet communications today. However, there are efforts to come up with lightweight cryptographic capabilities for such devices, said Hall. Andrew Sherman noted that many IoT devices involve constant watching or listening in private environments, which, depending on your viewpoint, could represent a tremendous opportunity or a tremendous risk.
James Burrell pointed to two main areas of concern from the law enforcement perspective: cybersecurity and forensics. Because the IoT introduces new devices into networks, a cyberattacker has many new points to attack. The compromise of a network-connected coffeemaker, for example, might not be useful on its own, but could be very valuable for an adversary if it allows access to other pieces of the network, he said. Burrell said that in the context of forensics, law enforcement would generally gain the most from being able to access data or communications from IoT devices at the point of data aggregation, where all of these devices are transmitting data to a cloud service or to a local hub, because direct physical access would otherwise be required. Later, Landau and Brian LaMacchia noted that in the absence of practical homomorphic encryption, data at the point of aggregation would need to be available as plaintext.
Littlehale offered a slightly different take, suggesting that physical devices themselves can prove useful to law enforcement. For example, in a homicide investigation, data stored from a sensing device could be accessed to discern when a person was or was not present in the home at a particular time. This type of information, he said, is already being used by law enforcement, although current uses typically involve devices that have a memory but no network connection.
Rescorla observed that the other speakers seemed to be saying that government would not need exceptional access to communications among IoT devices, because it would be able to extract needed data from the aggregation points. Littlehale responded that in the current environment, such access is likely not necessary, but it is unclear what the future may hold.
From a technical perspective, LaMacchia noted that for some portion of these devices—particularly ones meant to be built into houses, such as light switches—a major concern is the limited capability for security updates. Many low-end devices, he said, are based on a "rip and replace" model for updating, requiring new hardware for updates and not just new software. As a result, such devices are unlikely to be using up-to-date security. The ultimate result of this, he suggested, is likely to be a solution in which the more vulnerable pieces of a network are
3 J.R. Clapper, "Worldwide Threat Assessment of the US Intelligence Community," Statement for the Record, Senate Select Committee on Intelligence, February 9, 2016, p. 1, http://www.intelligence.senate.gov/sites/default/files/wwt2016.pdf.
walled off with a series of internal firewalls so they do not compromise the more secure portions of the network. If exceptional access is something society decides it wants, LaMacchia said, it may not actually be possible to add that capability to devices that cannot be updated.
Building on this point, Donner pointed to modern cars as an example of a relatively mature instance of the IoT that has already revealed how weak security, mismanagement at the configuration level, and a lack of updatability can lead to significant problems. He suggested that the same essential problems are likely to happen "on a larger scale and on a faster time line" as the IoT expands. Stephen Checkoway of the University of Illinois, Chicago, noted that he was one of the people who had hacked into cars in 2010 to demonstrate some of these issues. He said that although the security story then was "kind of a disaster," things have improved somewhat, and manufacturers are developing the capability for over-the-air security updates.
Rescorla noted that because IoT devices often are actuators capable of causing things to happen in the physical world, it is especially important that any exceptional access mechanism not pose a threat to authentication and integrity. For instance, an attacker who gained write access to the control channel for such a device might be able to cause physical harm, such as a fire.
Prompted by a question from Chang about system-to-system traffic, Blaze noted that as the IoT expands, in general, these devices will reuse building blocks from other computing systems. Already, that has meant that entire operating systems once intended for a desktop computer are being incorporated into embedded devices, a trend Blaze expects to continue.
Noting that it is impossible to accurately predict how the IoT will evolve in the coming years, Blaze cautioned that the decisions made today about security infrastructure are going to have profound effects on the security of future platforms. Because decisions made now with respect to smartphones, for example, are likely to apply to a great diversity of IoT devices down the road, Blaze said that what we are doing today is immensely important.
Part 2: Exploring Solutions
Looking forward, participants brainstormed the types of requirements that might be considered when designing an exceptional access system. They also explored the feasibility and security implications of several specific technological and operational options.
Requirements for an Exceptional Access System
Several participants expressed frustration over a lack of clarity on what exactly an exceptional access system would need to do to meet the government's expressed needs. Chang challenged attendees to brainstorm a set of possible requirements.
Matt Green, assistant professor in the Department of Computer Science at Johns Hopkins University, proposed a key first set of questions around what form a mandate for access might take:
- Would the government mandate exceptional access or only encourage companies to adopt it?
- Would the government issue a high-level requirement and let companies figure out how to implement it, or would it identify a specific implementation for everyone to adopt?
Burrell suggested that, at the end of the day, law enforcement really wants access to plaintext, and he noted that the vast diversity of systems in use makes it difficult to specify exactly how this would be implemented.
A second key set of questions, Green said, relates to responsibility:
- Who is responsible when things go wrong?
- What happens when escrow keys are stolen or someone finds a vulnerability?
Picking up on this point later, Ball suggested that law enforcement would need to be held accountable for any failures that result from a key escrow system.
Turning to the more technical aspects of the question, Green suggested that abuse detection should be considered an important requirement. As Gillmor mentioned, it is valuable to be able to detect a breach and stop further damage, even if you can't always prevent the breach in the first place.
A related question is whether government actors would need only prospective capabilities—for example, the ability to decrypt future communications under a wiretap warrant—or also retrospective capabilities, such as the ability to retrieve past messages sent by a suspect in a terrorist attack. Green said it is unlikely that an exceptional access system would be able to both provide retrospective capabilities and detect abuse, although abuse detection may be possible in a system that only supports prospective decryption. To do so, one would have to have a design in which there is a master key that can be sent to a target's phone to cause all subsequent communications to be encrypted in a different way that would allow exceptional access.
To this point, Littlehale said retrospective exceptional access is not currently the highest priority for state and local law enforcement. Most companies have business reasons to access their own historical data and will respond to legal demands for whatever they possess. Although it might become a problem in the future if companies were to change their practices, he said it is not currently a major impediment. He emphasized that a much bigger problem is the devices and communication systems that are designed such that even the manufacturer cannot access their stored data or communication streams. Prompted by a follow-up question from Green, Littlehale later added that if the market were to move in a direction where cloud backups are also encrypted under user control, law enforcement would consider the ability to decrypt that information a far higher priority.
Picking up on this point later, Bankston suggested that approaches like that proposed in the Feinstein-Burr bill, which would require entities with the ability to encrypt to also retain the capability to decrypt, would essentially outlaw perfect forward secrecy, a technology coming into widespread use with which communications are encrypted with keys that are thrown away after use, so that if adversaries were to gain the keys for one TLS session, they would still lack the keys for other TLS sessions. Thus, if adversaries were able to gain access to a device, they would not be able to decrypt communications recorded in the past.
Burrell said that in his view, law enforcement wants both prospective and retrospective capabilities. In a communications system with perfect forward secrecy, one can still wait for the data in motion to become stored data when received, and access it then. Burrell also raised the point that timing is a consideration. On a mobile device, for example, how long are the data effectively stored, and how does that compare to how long the data are of value to law enforcement? Green replied that, ultimately, decisions about encryption and access must be made before the data are created. Under the assumption that anyone could become a suspect at some point in the future, if access to their data is desired, then that decision would have to be applied uniformly to everyone. This, in his view, would undoubtedly affect the security of the system.
Rescorla raised the question of whether it is a requirement that one must be able to detect when someone is not using escrowed encryption, arguing that determined adversaries—especially in the counterterrorism context—will use non-escrowed encryption and that it is not practical to detect when adversaries do so.
Littlehale noted that there may well be things law enforcement desires that are either not technically feasible or beyond what the public is comfortable entrusting to law enforcement. It may be that only incremental changes are possible. Given that law enforcement faces real barriers now and will likely face more of them in the future, he suggested that the most important thing is for these barriers to be understood and appreciated so that society can make its decisions in an informed way. Audience member Anand Gupta, from Harvard University and Palantir Technologies, suggested it would be useful, in the case of a large number of sometimes conflicting desires and requirements, to prioritize their relative importance.
Exploring a "k out of n" Solution
Lampson discussed his ideas for a system design that would allow exceptional access while providing reasonable security. He began by pointing out that although exceptional access necessarily makes a system less secure, it is quite possible that the reduction in security could be kept to a minimum such that the level of security could remain acceptable. He asserted that a k out of n model could provide such a solution. In this type of system, the encryption key is itself encrypted with a set of "sealing keys," for which a set of matched "unsealing keys" is
created and given to trusted escrow agents. The escrowed encryption keys are broken into a number of pieces, n, and a certain number of them, k, must be combined in order to unlock the encryption.
Lampson identified two key weaknesses in such a system: First, one must determine what the sealing keys are—a configuration problem—and second, one must trust the escrow agents, which requires that technical bugs be eliminated from the escrow agent computer systems and, ultimately, involves trusting the people and institutions that operate each escrow agent. While acknowledging that such a scheme undoubtedly could be compromised, Lampson argued that such risks pale in comparison to the overall context and scale of existing security problems. He said the main counterargument he can envision relates to the policy issues articulated by Ball—namely, that the gain from an exceptional access system would not be worth the associated risks. From a practical standpoint, he added that it seems indubitable that countries like China and Russia are going to mandate exceptional access, including for American-made products sold in those countries.
Green commented that it is unlikely that such a system could be properly verified. Although certain types of programs are now formally verified in a research setting, he said that software engineers who would actually be building such a system "just don't speak that language." As a result, he said, any system built would likely have the same kinds of vulnerabilities that have been seen before. And while Green believed that it might be possible to find some number, k, of trustworthy organizations to serve as escrow agents, somewhere down the line, the systems they use to hold the escrowed keys will almost certainly share some common software. It is those pieces of software that Green believes would be the point where breaches occur and compromise the system.
Reiterating a previous point, Blaze reminded attendees that any such key escrow scheme would have to be robust against an attack by a nation-state, which is a significant risk, particularly for "important users" such as components of the national infrastructure that are critical for the U.S. economy and national security. In addition, unlike a system designed to protect seldom-used information, such as nuclear launch codes, for example, the exceptional access systems for the purposes being envisioned would have to be used every time there is a wiretap approval—perhaps on the order of once per hour or once per 15 minutes—yet provide security that is robust enough to deflect an adversary that is perhaps as sophisticated as the NSA. Landau reported that the number of federal and state wiretaps issued in 2014 was reported by the U.S. courts to be 3,554.4
In this vein, Rescorla noted that in addition to accommodating frequent access, it might be necessary to allow a large number of jurisdictions to have independent access. Lampson and Landau suggested that the mechanics of the institutions responsible for running the escrow agencies would require careful consideration and that keys would not be handed out at the level of every police department.
Landau wondered whether it matters if the escrow system uses off-the-shelf or specially developed communication software. While acknowledging that both approaches have downsides, Lampson reiterated that the relative risk of this system compared to what we have now is still minor. The larger threat, he emphasized, would be use of flawed methods to configure the sealing keys, which could put the sealing keys in the hands of adversaries. Green concurred with this point, citing as an example a configuration problem that resulted in a significant security vulnerability in Juniper network devices. But although the configuration challenge is a significant one, he expressed his belief that it might be solved but was not confident of this.
Sherman weighed in to urge caution, citing as a fundamental risk the increased complexity that a k out of n approach adds to a system: "We were all brought up to think that complexity is the enemy of security," he said. Pointing to largely offline, paper-based identification number storage systems of certain financial institutions as an example of a design that is compromised only rarely, he noted that any system in which we must store both data and keys online is, by nature, going to be more vulnerable than a system for which this information is not accessible via the Internet. LaMacchia expanded on this point, noting that "what we know about security for high-value assets is: We want stuff offline." Indeed, he said, some of Microsoft's cryptographic assets that are protecting high-value items involve keys that have both online and offline aspects. However, given the operational requirements currently envisioned for an exceptional access system, he said that such a system would likely need to be online.
4 U.S. Courts, Wiretap Report 2014, last updated on December 31, 2014, http://www.uscourts.gov/statistics-reports/wiretap-report-2014.
Participants discussed how the k out of n approach might be tested experimentally and how its security risks could be better understood by examining existing systems that use a similar scheme. Lampson suggested one approach would be to develop the system and then offer a $5 million prize to anyone who can break it. Donner and Rescorla pointed to the signing of the Domain Name System's (DNS's) root server credentials as an example of a k out of n system. A key difference in the DNS case is that the keys are not stored in network-accessible systems, and the people holding portions of the key must gather physically. This approach is very expensive, making it impractical as a template for an exceptional access system that must be used frequently.
Rescorla described his main concerns about the k out of n scheme as relating to management of the system once it is built, although he also noted that the code itself would be difficult to write, and there would likely be many defects in implementation. "We are nowhere near having the ability to have a complete system which would have high confidence and security from the ground up," he said.
Gillmor pointed out that the use of k out of n schemes for signing authorities like the DNSSEC (Domain Name System Security Extensions) root zone signing keys, as distinct from decryption keys that would be necessary for an exceptional access mechanism, provides an opportunity for detecting a compromise, because the signatures must be distributed to an intended victim for theft of a signing key to be useful. The signing keys themselves can be kept secret, but victims who store or publish copies of the signatures that they receive could eventually be able to detect that the signing key was misused because they can see an artifact of its use. On the other hand, if an encryption key is compromised, it can be used in secret to decrypt captured ciphertext without raising any flags. Another important consideration, Gillmor added, is timing and maintainability. Many encryption systems protect data that need to be kept secret for an undetermined amount of time. For a k out of n system or any other system that provides an exceptional access mechanism to allow access to such information, it must be secure and function properly over the sensitive lifetime of the data encrypted using it. This is a significantly harder problem than seeking a short-term or revocable solution.
One final problem raised by LaMacchia is that securing any single environment is difficult, and in the k out of n scheme, one must secure n systems in parallel and maintain the security of all the other systems, even if one should fail. This increases the scale of the problem, and LaMacchia cautioned about underestimating the difficulties of physically securing that many components.
The Role of Hardware
Turning to other potential options, Littlehale questioned whether requiring physical access to the device in question would make a difference. Lampson suggested the security risks could be reduced by keeping the escrowed keys, sealed by the keys of the various escrow authorities, on the device rather than sending them to the authorities. Then an attacker would need both the device and the cooperation of k escrow authorities to release the escrowed key, rather than just the latter. In addition, this approach no longer depends on being able to reliably deliver the sealed key over the Internet.
Returning to this topic later, Bankston pointed out that while it may on the surface seem like requiring physical access to the device would help to contain security vulnerabilities, it is feasible in some countries for the government to seize a large number of phones, thus allowing those governments to steal encryption keys on a large scale. Lampson countered that a government like that of China would be more apt to mandate exceptional access than to gain access by physically seizing millions of phones. This sparked further debate concerning how a company like Apple might respond if mandated to provide exceptional access to the U.S. and/or the Chinese government. Bankston held that if the United States mandates such access, China will most certainly do so as well.
With regard to the need for law enforcement to access information on encrypted devices, Blaze said the question becomes whether the cost of creating the infrastructure necessary for access would exceed the cost of developing other methods law enforcement could use to gain access—for example, reverse-engineering the hardware. In this way, it becomes an economic question as well as a security question, and the economic component would be felt especially acutely by local law enforcement bodies.
The Feasibility of Segmenting by User
The discussion turned to the feasibility of segmenting exceptional access, but by user instead of by sector or technological layer, as had been discussed in Session 2.
Littlehale questioned whether every smartphone must be engineered to withstand an attack from a nation-state adversary. Several participants observed that the idea of creating "more secure" and "less secure" hardware or software is not generally a viewpoint supported by industry. LaMacchia responded that as a Microsoft cryptographer he works under an explicit directive to give the strongest protection to all users and assume a nation-state level threat for all products. Looking toward the long term, Microsoft implements this by adopting approaches like perfect forward secrecy. Rescorla concurred, characterizing the notion of providing good security for some users and bad security for others as "extremely unpleasant" from the perspective of a software or hardware manufacturer. If users have to go to extra effort to get strong security, the vast majority will not bother and will find themselves with weak protection.
LaMacchia added that it cannot be assumed that a device sold to an American user will only be operated in the United States. High-value targets, such as company CEOs and indeed anyone doing business internationally, may need strong encryption to defend against nation-state adversaries when traveling to other countries. Bankston later built on this point, noting that often the point of the attack is not to access an individual's information but to use the compromise of an individual's system as a platform from which to attack the valuable information of others. In that sense, he said, it is reasonable to think about hardening the entire "ecosystem" against adversaries such as China or Russia.
Bolstering the case that all users deserve strong encryption, Sherman pointed out that many strong cyber adversaries come not from the realm of nation-states but from technically sophisticated criminal networks seeking to steal people's money. The targets of such attacks are not limited to high-profile or necessarily high-value individuals or organizations.
Raising another potential downside of segmented encryption, Blaze noted that the current technology industry is built on the idea of general-purpose platforms that are controlled by easily loaded software. Somehow restricting this system by implementing architectures that would disallow user-supplied encryption could have serious economic ramifications. Tribble clarified this point by emphasizing that a motivated person could always find a way to load software implementing such encryption onto a device. In addition, he said it is likely unwise to try to segment exceptional access based on a distinction between hardware and software, particularly in the context of regulation, because the hardware-software boundary tends to shift over time.
The Government's Technical Resources: Lawful Hacking and Other Considerations
At several points throughout the workshop, participants considered what role the government's own technical expertise and resources should play in addressing the challenge of encryption—for example, through lawful hacking. They also considered how the technology industry and its security solutions bolster the security of the government itself as well as other ways to improve the government's access to information in the absence of an exceptional access mechanism.
Donner asked whether there are sufficient skills and technical resources in the law enforcement community to make use of this approach. Having the requisite skills in house can ensure that devices are handled correctly in circumstances such those that transpired in San Bernardino. Although such an approach will not always provide access to all the data from sophisticated criminals, it could give law enforcement more capabilities, at least against less sophisticated criminals.
Littlehale suggested that a regime based on massively up-staffed technical capabilities in the law enforcement and national security communities, even as industry continues to strengthen security, would create a situation where the United States is simultaneously devoting significant resources to improving security, on the one hand, and finding ways to compromise it, on the other. Moreover, if the government spends $5 million to find a vulnerability it can use, is it expected to then share it with the software creator so that it can be patched, only to require the government to spend another $5 million to find a vulnerability in the patch? Blaze responded that in some ways,
building up the government's hacking capabilities will be feasible and indeed necessary, but not universally. Given that adversaries will in any case seek to bypass exceptional access mechanisms, lawful hacking will inevitably be needed even if there is a mechanism for exceptional access. If exceptional access is not given, he said, it certainly would require much greater investment by law enforcement.
Burrell weighed in on this matter, noting that lawful hacking is extremely complex due to the "vast universe" of devices and systems law enforcement would need to develop the capability to hack, and owing to the fact that those devices and systems have increasingly short life spans. In addition, the costs would comprise not only the direct cost of the experts working on this issue, it would also comprise the opportunity costs of removing those experts from other jobs and pulling resources from other tasks. Given all of this and the fact that law enforcement would be expected to reveal the vulnerabilities uncovered in the course of investigations to support cybersecurity aims, Burrell concluded by saying, "I just don't even see how that's even a feasible option."
Tribble suggested that better communication channels between companies and law enforcement could reveal currently unexploited resources that law enforcement could tap into even in the absence of an exceptional access system. Landau offered an anecdote to illustrate this point: A law enforcement organization complained that iMessage metadata sought for an investigation could not be accessed through communications providers like Verizon or AT&T. Instead, such information is held by Apple, where law enforcement never expected it to be. Given how rapidly the technology evolves, Tribble acknowledged that it is hard for law enforcement to keep up with what is actually available, and doing so is not something that law enforcement can be expected to do on its own. Cooperation from industry is important to building government capacity in this area, he suggested.
With regard to how government might take better advantage of available information, Burrell noted that just because more data or metadata are available does not mean they are accessible or necessarily useful to law enforcement. Sometimes, for example, they may be available but cannot be processed in a way that meets legal requirements for privacy or transparency. Sometimes those holding the data do not have a full understanding of what they are holding, Burrell said, and metadata are not standardized, so law enforcement does not always have a good idea of what it will receive when it asks for metadata. Moreover, just having metadata does not necessarily mean one has actionable information; sometimes there is a great deal of noise to sort through to find the useful pieces. Another key issue is timeliness: Burrell noted that it will not be workable for the government to spend 6 months hacking into a system if the information is needed in a matter of hours.
Landau pointed to the USA Freedom Act (P.L. 114-23), which caused the NSA to shift from collecting metadata to requesting metadata from individual communications firms. Burrell replied that the FBI does not have the same ability as the NSA to manage big data because it does not have the same business need for that capability. As a result, the company that holds the data or processes the communication would need to engineer special tools to transfer data to the FBI in a way that satisfies the FBI's legal requirements. He agreed with Landau's suggestion that requiring companies holding data to be able to provide them to law enforcement in a timely fashion would be an improvement over the current situation.
Littlehale added that law enforcement must know where data exist in order to request the data. If officers cannot get into a device, it would be impossible for them to find out if there is perhaps an unencrypted app or communications channel from which they could request data from the service provider. If the police were to try to get around this by prospectively sending a legal request for information, for example, to Google, they would be accused of fishing, he said. Pressing on this point, Landau asked whether law enforcement might make a request under 18 U.S. Code § 2703 (required disclosure of customer communications or records) to find out which communications came from the device. Littlehale said there are some technical challenges with such a request, some of which might be addressed by IPv6. Although it is possible in some cases to attribute activity to a particular device, in others it is not.
A related challenge, Littlehale said, is that law enforcement does not always receive instant responses from service providers. One potential avenue to explore is whether it would be possible to speed up these responses through automation. Another option for law enforcement is to open better communication channels with service providers to help its investigators understand which categories of data are available that they might not otherwise know about.
Building a More Productive Conversation
Even in the absence of any actual exceptional access mandate or policy, Landau noted that the government's posture toward end-to-end encryption could be affecting the technological landscape and wondered if it would be possible to work toward a different "default." For example, it is possible that government advocacy for exceptional access actually pushes the market more in the direction of user-controlled encryption.
Donner pointed out that the underlying driver stems in part from the fact that the Internet is constructed out of private components and open protocols—infrastructure the government doesn't control—and as such, the government is limited in its ability to protect citizens from bad actors operating online. If the government cannot adequately protect the network, then consumers have no choice but to protect themselves, and that in turn drives the trend toward end-to-end encryption.
Building on this point, Sherman pointed to the disclosures made by Edward Snowden as instrumental in raising interest in user-controlled encryption. However, given that government is asking for what it perceives as necessary to do its job, it is difficult to come up with anything the government could do to help the situation. Perhaps, he suggested, what is most needed is a more open and honest discussion between the government and its citizens. Littlehale concurred, noting that it would be useful to establish a less adversarial way of communicating about the issues. He reiterated the concern that a crisis situation can lead to hastily drawn-up legislation that does not necessarily achieve any of the desired goals.


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Baby Rocker – an in Depth Anaylsis on What Works and What Doesn't
Moms are nothing isn't creative. In any event, the kid is going to have really cool last name. If you'd like children, elect for that which we call a young child contract rather than a marriage contract. Many parents believe walkers will help children learn how to walk. Though most parents want battery-operated bouncers, you should understand that should you are likely to use a bouncer extensively, you'll need to modify batteries quite frequently. In fact, parents attempting to fit into the conventional marriage mold too often leads to disharmony, which is toxic for children.
The mattress has four positions, for straightforward adjustment in accordance with your child's growth. This chair may give your baby plenty of great rewards and possibly even devices you can provide your beloved child. It isn't unusual for this sort of chair to get hours of wear, baby collision stains, sour odors, or another number of feasible stains. Swivel rocker chairs are available in various styles and designs. For instance an auto seat at Mothercere can vary from 64-299. This form of chair may be used in various ways, based on how it was designed. There are differing kinds of rocking chairs offered and sold within the sector, and it's required to consider what it is that you are searching for thus that what you get are likely to be what you desire.
The Rise of Baby Rocker
There are a number of unique sorts of seated bouncers. If you are deciding on a high-end bouncer with a lot of extra features then you may even hook your MP3 player so that you may play your favourite tunes. Whilst an exersaucer looks fine to entertain a youngster whilst cooking dinner or doing other brief chores, no youngster, especially a youngster with underlying special needs related to motor development (high or very low muscle tone) should use this bit of equipment for at least a quick time period daily. It's comparatively low-tech (zero electronics, zero sounds, and just one motion), but zero less useful if you need to place your baby down, and zero less impressive in its design.
You might be absolutely nervous by the idea of producing your approach. Another notion is to put in a range of mirrors to the walls. It is to get wall mountable storage boxes. When picking a caterer friend" it may even be a good idea to pick their brain first prior to constructing your plan an excessive amount.
There are lots of fashions out there within the sector and they're offered in the least value ranges possible. As stated previously, the style can go together with the present trends. Other than that, it goes along with the current trend. Clearly, you must think about the fashion of the bouncer too.
Selecting a high-priced model doesn't mean you get additional features. Furthermore, it is especially designed to give proper support of the human body. In this way, your family's and child's health aren't at any risk. As you probably already know this already, your child's health and well-being is vital and step one is by keeping your house's environment clean and sanitized.


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Expiry Date: 15 May 2021


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London Transport Museum - Kids go free
- Last few tickets
- Limited availability
- Available
More information about London Transport Museum - Kids go free tickets
Additional InformationInclusions:
- Entry to London Transport Museum galleries and temporary exhibitions
- Food and Drink
- Transportation
- Access to any London Transport Museum events or external sites
DescriptionLondon Transport Museum is situated in the heart of Covent Garden and filled with stunning exhibits; the Museum explores the powerful link between transport and the growth of modern London, culture and society since 1800. Historic vehicles, world-famous posters and the very best objects from the Museum's extraordinary collection are brought together to tell the story of London's development and the part transport played in defining the unique identity of the city.
- Entry to London Transport Museum during the date of use.
- A dramatic 'World Cities' walk.
- Exciting exhibitions in the Exterion Gallery.
- Even more for families. Children can play and learn in the all aboard galleries.
- Explore the history of public transport, marvelling at the world's first underground steam train.
- Upper Deck Café serving morning coffee, lunch and afternoon tea throughout the day.
- Monday to Sunday: 10:00am to 06:00pm (Last Entry 5:15pm)
- 24th, 25th and 26th December
London Transport Museum, Covent Garden Piazza, London WC2E 7BB
Nearest Train Station: Charing Cross
Nearest Underground: Covent Garden


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Christine Won, MD, MSc
Research & Publications
Patient Care
Dr. Won is the Director of the Women's Sleep Health program. She is a Board Certified sleep specialist who is also trained and certified in Pulmonary and Critical Care medicine. Her areas of clinical and research interests include complex sleep related breathing disorders, and sex-differences in sleep disordered breathing and hypersomnias.
Dr. Won is the Director of the Yale Sleep Laboratory. She is the Associate Program Director for the Pulmonary and Critical Care Fellowship program. She is Chair of the Sleep-disordered breathing section of the American Academy of Sleep Medicine, member of the national VA Sleep Network, and sits on the Board of Directors of the Connecticut Sleep Society. Dr. Won received her medical degree at Albert Einstein College of Medicine. She completed her Sleep, Pulmonary and Critical Care, and undergraduate training at Stanford University.
Education & Training
- MScStanford University, Epidemiology (2006)
- MDAlbert Einstein College of Medicine (2000)
- BAStanford University, Human Biology (1996)
- FellowStanford University Medical Center
- Chief FellowStanford University
- FellowStanford Medical Center
- ResidentBeth Israel Medical Center
- Board CertificationAB of Internal Medicine, Internal Medicine (2003, recertified: 2013)
- "Post-operative Central Sleep Apnea: To Treat or Not to Treat?"Orlando, United States 2019
- "Sleep and Diversity: Sleep Health in the Underserved Population and Minorities"New Orleans, United States 2019
- Central Sleep Apneas Syndromes", and "Sleep-related Hypoventilation SyndromesIndianapolis, United States 2019
- Sleep disordered breathing in pregnancy"San Antonio, United States 2019
- Sex Differences in Obstructive Sleep Apnea Phenotypes, the Multi-Ethnic Study of Atherosclerosis"Dallas, United States 2019
- Prevalence of REM related OSA in Women with mild or no OSA"San Antonio, United States 2019
- Assessing Communication Between Physicians and Patients with Excessive Daytime Sleepiness Associated with Treated Obstructive Sleep Apnea: Insights From an Ethnographic Study of In-Office Visits"Dallas, United States 2019
- :" "Sleep Breathing Disorders in Women"Seoul, South Korea 2018
- "Sleep disorders in the critically ill patient"Seoul, South Korea 2018
- "Management and Leadership in Sleep Medicine"Baltimore, United States 2018
- "Sleep and Testosterone"Toronto, Canada 2017
- "Sleep and Hormones"Boston, United States 2017
- Managing Sleep and Circadian Disruption and Improving Cancer Outcomes"Los Angeles, United States 2016
- "Management of Sleep Disordered Breathing in Chronic Respiratory Failure"Montreal, Canada 2015
- "Management of Sleep Disordered Breathing in Neuromuscular Disease"Seattle, United States 2015
- "Medical Emergencies in the Sleep Lab"Seoul, South Korea 2015
- "Comorbid Sleep Disordered Breathing and PTSD"Seoul, South Korea 2015
- Impact of Sleep Disordered Breathing and Driving"New York, United States 2015
- "Obesity-Hypoventilation: An Emerging Outpatient and Inpatient Epidemic"Palo Alto, United States 2015
- "Sleep Breathing Disorders in Women"Cleveland, United States 2015
- Fatigue Management: from Circadian Disorders to Sleep Disordered Breathing"San Diego, United States 2014
- Optimizing treatment for SDB"New York, United States 2014
- "Obstructive sleep apnea and PTSD: What is the Link?"New York, United States 2014
- The Determining Risk of Vascular Events by Apnea Monitoring (DREAM) Study: Design, Rationale and Methods"Minneapolis, United States 2014
- The Determining Risk of Vascular Events by Apnea Monitoring (DREAM) Study: Design, Rationale and Methods"Minneapolis, United States 2014
- "Obstructive Lung Disease: To Lump or Split"Chicago, United States 2013
- Changing Landscape of Care for Sleep Disordered Breathing"Baltimore, United States 2013
- Female gender predicts longer time to diagnosis of narcolepsySan Francisco, United States 2012
- "Sleep disordered breathing infers greater risk for pulmonary hypertension in interstitial lung disease"San Francisco, United States 2012
- Sleep Disturbances in PTSD"Minneapolis, United States 2011
- "Obstructive Sleep Apnea and Pulmonary Hypertension"Oakland, United States 2010
- State of the Art Advances in Sleep Medicine"San Francisco, United States 2009
- "Obstructive Sleep Apnea and Pulmonary Hypertension"San Francisco, United States 2009
- Multimodality Cardiovascular Imaging Detects Improvement Of Subclinical Microvascular Dysfunction With Continuous Positive Airway Pressure Therapy In Obstructive Sleep Apnea Patients: A Prospective, Randomized, Double-blinded Study"New Orleans, United States 2008
- Severity of Sleep Apnea is an Independent Predictor of Mortality in Patients with Ischemic Heart Disease"New Orleans, United States 2008
- Duration of Hypoxia During Sleep is Associated with Increased Pulmonary Artery Systolic Pressure and Mortality"Chicago, United States 2008
- "Epidemiologic Bangkok (Thailand) study: Gender Differences in Sleep Disordered Breathing"Baltimore, United States 2008
- Epidemiology of Sleep Disordered Breathing in Bangkok, Thailand"Minneapolis, United States 2008
- Women and Sleep Disordered Breathing"Minneapolis, United States 2007
- Gender and Ethnicity Do Not Predict Effective Continuous Positive Airway Pressure in Severe Obstructive Sleep ApneaMinneapolis, United States 2007
- Effect of Continuous Positive Airway Pressure on Pulmonary Artery Hypertension"San Francisco, United States 2007
- Gender Differences in Sleep Disturbance Patterns and Sleep Architecture in Obstructive Sleep Apnea"San Francisco, United States 2007
- "Do Gender Differences Exist in Pre-pubertal and Adolescent Children with Obstructive Sleep Apnea?Minneapolis, United States 2007
- The Effect of Flexible Bronchoscopy on End-Expiratory Lung Volumes in Intubated Patients on Mechanical Ventilation"Orlando, United States 2003
- Sleep Medications and the FDA Labeling Rule"Los Angeles, United States 0001
Professional Service
|Society of Anesthesia and Sleep Medicine
|Board of Directors
|2019 - 2020
|O Magazine: How to Sleep Like a Baby at Any Age
|Featured Expert and Consultant
|The Curbsiders
|Sleep at Chest
|North Haven Medical Center Operations Committee, Yale-New Haven Hospital, Yale University
|Committee Member
|2019 - Present
|Society of Anesthesia and Sleep Medicine, Orlando, FL
|program committee chair
|2019 - Present
|Yale Sleep Symposium: Sleep and the Heart, New Haven, CT
|2019 - Present
|American College of Chest Physicians
|Sleep Network Steering Committee
|2018 - 2020
|Society of Anesthesia and Sleep Medicine
|SASM meeting 2019
|2018 - 2019
|Society of Anesthesia and Sleep Medicine
|Chair of Program Committee
|2018 - 2019
|Casebook on Complicated Sleep Breathing Disorders, Springer Publishing
|SLEEP national meeting, TRENDS course, Baltimore, MD
|ATS thematic poster facilitator, San Diego, CA
|Sleep and Respiratory Biology Network
|O Magazine: Sleep and Sex Hormones
|Featured Expert and Consultant
|Society of Anesthesia and Sleep Medicine
|Board of Directors
|2017 - 2019
|American Thoracic Society
|Program Committee
|2017 - 2018
|ATS international meeting, Washington, D.C., Sleep and Respiratory Biology Network
|Committee Member
|Yale Sleep Symposium: Sleep in the Acute Setting, New Haven, CT
|Course Syllabus Designer and Speaker
|SLEEP national meeting, Boston MA, Invited Lecture Series
|Year in Review
|SLEEP national meeting, Boston MA, Sleep Medicine Year in Review
|Editorial Board, Sleep Science and Medicine
|2016 - 2019
|Society of Anesthesia and Sleep Medicine
|Sleep Medicine Clinical Practice Committee
|2016 - 2019
|American Academy of Sleep Medicine
|APSS Program Committee
|2016 - 2019
|American Academy of Sleep Medicine
|Nominating Committee
|2016 - 2018
|World Association of Sleep Medicine
|Nominating Committee
|2016 - 2017
|CHEST national meeting, American College of Chest Physicians, Sleep Disordered Breathing research presentation
|SDB Research presentation
|Scientific American: The Hidden Risks of Poor Sleep in Women
|Featured Expert and Consultant
|Program Committee
|2015 - 2019
|WASM international meeting, Symposium: Sleep Disturbances in PTSD/TBI
|, SLEEP national meeting, Clinical Workshop: Management of Sleep Disordered Breathing in Neuromuscular Disease
|Inaugural Yale Sleep Symposium, New Haven, CT
|CHEST Physicians: Prevalence of sleep apnea in women: It matters how you slice and dice it
|Featured Expert and Consultant
|Section Editor, Sleep and Other Medical Disorders. Principles and Practices of Sleep Medicine, 6th edition, eds. M. Kryger, T. Roth, W. Dement. Elsevier, Philadelphia, PA
|2014 - 2019
|National Sleep Foundation
|Scientific Advisory Council Subcommittee: Sleep Disordered Breathing
|2014 - 2019
|Editorial Board, Journal of Sleep Medicine and Disorders
|2014 - 2016
|CHEST Physicians: An implantable tongue stimulator for select patients who can't tolerate PAP
|Featured Expert and Consultant
|NY Times: For Sleep Apnea Patients, a Possible Alternative to Masks
|Featured Expert and Consultant
|Conference Committee, Section of PCCSM, Yale University
|Committee Member
|2014 - Present
|VA National Sleep Network
|Steering Committee
|2013 - 2019
|VA Sleep Network
|Committee Member
|2013 - 2019
|American College of Chest Physicians
|Women's Health Network Steering Committee
|2013 - 2017
|Editorial Board, JSM Clinical Case Reports
|2013 - 2016
|American Academy of Sleep Medicine
|Sleep Disordered Breathing Section Committee
|2013 - 2015
|American Academy of Sleep Medicine
|Membership Selections Committee
|2013 - 2014
|CHEST national meeting, American College of Chest Physicians, Sleep Disordered Breathing research presentation
|Wall Street Journal: A Test for Sleep Apnea From Your Own Bedroom
|Featured Expert and Consultant
|Clinical Competency Committee, Section of PCCSM, Yale University
|Committee Member
|2013 - Present
|Internal Medicine Traditional Residency Intern Selection Committee, Yale University
|Committee Member
|2012 - 2013
|Yale University
|Research Advisory Committee
|2011 - 2014
|American Academy of Sleep Medicine
|PAP Adherence Education Task Force
|2011 - 2012
|World Association of Sleep Medicine
|Publication Committee
|2011 - 2012
|Pulmonary and Critical Care Fellowship Curriculum Committee, Yale University
|Committee Member
|SLEEP national meeting, Clinical Workshop: PTSD and Sleep
|American Academy of Sleep Medicine
|Education Committee
|2010 - 2013
|Connecticut Sleep Society
|Board of Directors
|2010 - 2013
|Connecticut Sleep Society
|Legislative Committee
|2010 - 2013
|Seattle Times: Down economy may be causing more to stay up nights
|Featured Expert and Consultant
|Columbia Tribune: Don't count sheep - get help
|Featured Expert and Consultant
|CBS5 News: Why do we count sheep to help us sleep?
|Featured Expert and Consultant
|Ad Hoc Reviewer for Journal of Clinical Sleep Medicine, Sleep Medicine, Chest, Journal of Cardiac Failure, Journal of Nursing & Care, European Journal of Neurology, Respirology
|2006 - 2019
Departments & Organizations
- Adult Sleep Medicine Program
- Internal Medicine
- Office of Cooperative Research
- Pulmonary, Critical Care & Sleep Medicine
- Yale Medicine
- Yale University
- Yale Women's Sleep Health Program (WSHP)