Corticosteroid Use in Duchenne Muscular Dystrophy

 Patients with Duchenne muscular dystrophy (DMD) are prescribed corticosteroid anti-inflammatory drugs as standard of care, but long-term use comes with significant adverse effects.

For individuals with DMD, corticosteroids have been the only treatment shown to significantly impact physical function, observed Tina Duong, MPT, PhD, director of neuromuscular medicine clinical outcomes research at Stanford University in Palo Alto, California.

"Boys undergoing glucocorticoid treatment often experience improvements in their ability to run, walk, and perform daily activities," Duong told MedPage Today. "Over the long term, these patients also exhibit a slower disease progression compared with those not receiving glucocorticoids."

The side effects of glucocorticoids present significant challenges for families and caregivers, Duong pointed out.

"Weight gain, Cushingoid appearance, behavioral difficulties, and stunted growth are some of the potential adverse effects that require careful consideration," she noted. "This necessitates a close collaboration between families and their clinical teams to weigh the benefits of glucocorticoids against these possible side effects."

In addition to prednisone and prednisolone, both used off-label, two corticosteroid formulations have been approved for DMD in recent years: the glucocorticoid deflazacortopens in a new tab or window (Emflaza) in 2017, and the dissociative steroid vamoroloneopens in a new tab or window (Agamree) in 2023.

Deflazacort

Deflazacort is approved for patients ages 2 years and olderopens in a new tab or window; a generic versionopens in a new tab or window for patients ages 5 and older is now available.

In 2016, a phase III trialopens in a new tab or window of prednisone versus deflazacort showed that both agents improved muscle strength compared with placebo, but deflazacort was associated with less weight gain.

The deflazacort labelopens in a new tab or window carries warnings about endocrine, immunologic, cardiovascular, renal, gastrointestinal, behavioral, bone, eye, skin, and vaccination concerns. The most common adverse events with treatment are Cushingoid appearance, increased appetite, weight gain, upper respiratory infection, cough, pollakiuria, hirsutism, central obesity, and nasopharyngitis.

A prospective cohort studyopens in a new tab or window in The Lancet that evaluated the long-term effects of glucocorticoids in DMD, including deflazacort, found that treatment was associated with reduced risk in loss of mobility and upper limb function milestones. Subgroup analysis found deflazacort was associated with an increased median age at loss of three clinical milestones by 2.1 to 2.7 years compared with prednisone or prednisolone (P<0.012).

The study added "evidence of the long-term benefits of glucocorticoids and the effect on all causes of mortality -- a very important message because these are fairly cheap and easily accessible drugs -- for the benefit of all patients with Duchenne muscular dystrophy," noted pediatric neurologist Nathalie Goemans, MD, PhD, of University Hospitals Leuven in Belgium, in an editorialopens in a new tab or window accompanying the study.

A 2022 study in JAMAopens in a new tab or window compared three corticosteroid regimens in previously untreated boys with DMD. Daily prednisone and daily deflazacort led to significantly better outcomes compared with intermittent prednisone, with no significant difference between the two daily regimens.

Vamorolone

Last year, the FDA approved vamorolone for DMD patients ages 2 years or older.

"Vamorolone is a new dissociative steroid drug that aims to retain or improve the therapeutic benefit of traditional glucocorticoids while reducing severe adverse side effects associated with long-term administration," wrote Miranda Grounds, PhD, and Erin Lloyd, PhD, both of the University of Western Australia, in a commentary published in the Journal of Neuromuscular Diseasesopens in a new tab or window.

The synthetic agent was designed to dissociateopens in a new tab or window pro- and anti-inflammatory steroid functions. It reduced pro-inflammatory signaling in the nuclear factor kappa B (NF-κB) pathway in preclinical studies.

In 2022, a phase II trialopens in a new tab or window showed that, from baseline to week 24, time to stand from supine velocity was significantly greater in boys receiving vamorolone 6 mg/kg compared with placebo. The relative efficacy of prednisone and vamorolone 6 mg/kg was similar for motor outcomes. A trial update in 2024opens in a new tab or window showed the efficacy of vamorolone 6 mg/kg was maintained over 48 weeks.

Safety data in the phase II trial showed the height percentile declined with prednisone, but not vamorolone. Bone turnover markers also declined with prednisone, but not vamorolone.

The most common adverse events versus placebo were Cushingoid features, vomiting, and vitamin D deficiency. Warnings on the vamorolone labelopens in a new tab or window address endocrine, immunosuppression, ophthalmologic, and vaccine concerns as well as effects on cardiovascular, renal, gastrointestinal, and bone function.

A non-randomized open-label extension studyopens in a new tab or window found similar efficacy for vamorolone compared with traditional glucocorticoids in two historical control cohorts for up to 30 months, with a relatively beneficial adverse outcome profile for vamorolone.

How new drugs may change the role of steroids in DMD is unclear. DMD treatment now includes four exon-skipping drugs, the histone deacetylase inhibitor givinostatopens in a new tab or window (Duvyzat), and gene therapy with delandistrogene moxeparvovecopens in a new tab or window (Elevidys).

One possible change for the role of steroids was outlined in a review published in the Orphanet Journal of Rare Diseasesopens in a new tab or window.

"Although novel dissociative steroids may be a superior substitute to glucocorticoids, other potential therapeutics should be explored," wrote Emma Rybalka, PhD, of Victoria University in Australia, and co-authors.

Fumaric acid esters (FAEs), including dimethyl fumarate (Tecfidera) and diroximel fumarate (Vumerity) -- which are approved to treat multiple sclerosis -- have anti-inflammatory effects with demonstrated efficacy in diseases associated with inflammation and oxidative stress, Rybalka and colleagues observed.

Repurposing or developing new therapies like these that could address the downstream consequences of dystrophin deficiency may be a viable option to improve patient quality of life in DMD, they noted.

"Since they activate alternative receptors/signaling pathways to glucocorticoids, there is also scope for combined FAE and corticosteroid regimens that could synergistically amplify therapeutic potential," they suggested.

Disclosures

Duong reported being an advisory board member for Biogen, CureSMA, Novartis, Roche, and Scholar Rock, and a consultant for Astellas, Avidity, Biohaven, Dyne, Genentech, Novartis, Roche, and Sarepta Therapeutics.

https://www.medpagetoday.com/spotlight/dmd/111324

IBA gender tests on two boxers were flawed and illegitimate, says IOC

 The International Olympic Committee was warned in writing more than a year ago that Olympic women’s boxer Imane Khelif had the DNA of a “male”.

Mark Adams, spokesman for the IOC, confirmed the existence of the International Boxing Association (IBA) letter, leaked to the 3 Wire Sports website on Sunday.

Khelif and Lin Yu-ting have been at the centre of a storm, sweeping into their boxing semi-finals despite previous IBA disqualifications for gender eligibility.

However, it has now emerged that the IBA – which has been repeatedly criticised by the IOC – told the Olympics in June last year of its test results on Khelif.

One test in India last year and a prior test in Turkey in May 2022 “concluded the boxer’s DNA was that of a male consisting of XY chromosomes,” the IBA correspondence in June 2023 said.

‘Tests are not legitimate’

On Sunday, the IOC confirmed receiving a letter from the IBA last year, and did not dispute the contents of it during multiple questions at the daily press conference. However, the body insisted that the tests should be regarded as illegitimate as they were conducted on an ad-hoc basis in the middle of last year’s World Championship.

“First off, it won’t surprise you to know I’m going to repeat the line that those tests are not legitimate tests,” said Adams.

“So there was indeed a letter. I can confirm that. But the tests themselves, the process of the tests, the ad hoc nature of the tests are not legitimate. And you will also expect me to tell you that I’m not going to discuss the individual intimate details of athletes in public, which I think is pretty disgraceful for those who have leaked that material, frankly. To be put in that position must be awful. On top of all of the social media harassment that these athletes have had.”

Adams was speaking as Taiwan’s Lin faced protests from her opponent as she was guaranteed a medal at the Paris Olympics.

As Lin swept into her semi-final just as easily as Imane Khelif had done the night before, losing Bulgarian opponent Svetlana Staneva pulled off her gloves, pointed to herself and made a double tap X symbol with her fingers. The Bulgarian’s coach had also been holding a white piece of paper with the words “I only want to play with women I am XX” scrawled on it.

Fairness-for-sport campaigners have been outraged by fights in recent days, with both boxers easing past their opponents.

But IOC president Thomas Bach and his spokesman Adams have poured scorn on the IBA for allegedly fuelling the flames around the furore. The IOC and the IBA organisations have been at war since 2019, when the IBA was suspended as the body leading Olympic boxing.

On Saturday, the IBA announced it would award prize money to Angela Carini, whose fight against Khelif was ended in 46 seconds, “as if she were an Olympic champion”.

Adams said that the IBA, run by Moscow-born administrator Umar Kremlev, has “no credibility”. The IBA was stripped of its status as boxing’s world governing body last year. That decision came four months after the body disqualified Khelif and Lin from the 2023 World Championships. Kremlev last year described the IOC leadership as “prostitutes in sports who get involved in politics”.

https://www.yahoo.com/news/ioc-first-received-imane-khelif-140550195.html

Exchanged prisoner Yashin condemns his 'illegal expulsion' from Russia

 Ilya Yashin, a Russian opposition activist freed from jail in Thursday's prisoner swap, pledged to carry on his political fight against President Vladimir Putin from abroad, but expressed fury at having been deported against his will.

The prisoner swap, the largest since the Cold War, saw eight Russians, including a convicted murderer, exchanged for 16 prisoners in Russian and Belarusian jails, many of them dissidents. It was hailed as a win by Western leaders who feared for the dissidents' lives after the death in jail last year of politician Alexei Navalny.

But Yashin, imprisoned in 2022 for criticising Putin's full-scale invasion of Ukraine, said he had not given his consent to deportation and that others in more urgent need of medical care should have gone instead of him.

"From my first day behind bars I said I was not willing to be a part of any exchanges," he said in an emotional news conference in Bonn on Friday during which he occasionally removed his glasses to blink back tears.

He directed his ire not at the Western governments that had secured his release, who he said had faced a difficult moral dilemma, but at the Kremlin for expelling a political rival against his will.

"What happened on Aug. 1 I don't view as a prisoner swap ... but as my illegal expulsion from Russia against my will, and I say sincerely, more than anything I want now to go back home," he added.

He was speaking alongside activists Vladimir Kara-Murza and Andrei Pivovarov at the freed prisoners' first public appearance since arriving in Germany.

On their second day out of prison, where they had had limited contact with the outside world, Kara-Murza and Yashin especially seemed fired with resolve, and to have kept abreast of world events. All expressed scorn for the government of Putin whom Kara-Murza described as an illegitimate usurper.

Yashin pledged to continue his work "for Russia" from abroad. "Though I don't yet know how," he added.

Pivovarov agreed: "We will do everything to make our country free and democratic, and get all political prisoners released."

Former Russian president Dmitry Medvedev, commenting on the prisoner exchange on Thursday, said that what he called traitors to his country should rot and die in prison, but that it was more useful for Moscow to get its own people home.

'A USURPER AND A MURDERER'

Kara-Murza recounted that when he had been asked by prison officers to sign an appeal for clemency, he had taken the pen offered and written "that I consider him (Putin) not to be a legitimate president, to be a dictator, a usurper and a murderer."

Kara-Murza blamed Putin for the deaths of Navalny and Russian politician Boris Nemtsov, killed in Moscow in 2015, as well as thousands of Ukrainians, including children killed in the bombing of a Kyiv hospital last month.

Kara-Murza had been serving a 25-year sentence and said he had been certain he would never see his wife again and would die in a Russian jail.

While he said he was glad to be free, he also expressed reservations about the manner of his leaving, which he called an illegal expulsion under the letter of Russian laws. He also acknowledged the dilemma German Chancellor Olaf Scholz had faced in deciding whether to release convicted murderer Vadim Krasikov to secure their safety.

The operation was "about saving lives, not exchanging prisoners," he said. "Scholz is being criticised in some quarters for the difficult decision to release Putin's personal killer... But easy decisions come only in dictatorships."

Had things been easier, Navalny might not have died, he added.

"It's hard for me not to think that, maybe if these processes had somehow moved quicker ... if there had been less resistance that the Scholz government had to overcome in terms of freeing Krasikov, then maybe Alexei would have been here and free," he said.

He described an ordeal that had amounted to psychological torture. A prison doctor had told him he had just a year to a year-and-a-half of life remaining as a consequence of two poisonings he had suffered.

He was allowed to speak with his wife just once and his children twice in more than two years of imprisonment, he said, and spent 10 months in solitary confinement. A Christian, he was banned from attending church, he added.

https://uk.news.yahoo.com/released-prisoners-dont-confuse-russians-171535647.html

Two Russian ex-prisoners from East-West swap want to return home

 Two of the Russian dissidents who were freed from prison and arrived in Germany as part of last week's major East-West prisoner swap say they are already thinking about returning to Russia, but vow to continue political activism even from abroad.

The swap saw eight Russians, including a convicted murderer, returned home from Western countries in exchange for 16 prisoners freed from Russian and Belarusian jails, many of them Russian dissidents alongside Americans like Wall Street Journal reporter Evan Gershkovich.

“As people who were actually deported, who were kicked out of the country, we all have a great desire to return,” dissident Andrei Pivovarov told Reuters in an interview in Bonn on Saturday.

"I definitely want to be in Russia. I am a Russian politician and that is very important to me," Pivovarov said. "It is clear that they (the Russian authorities) will not allow us to return, although we want to."

Ilya Yashin, an opposition activist imprisoned in 2022 for criticising President Vladimir Putin's full-scale invasion of Ukraine, also expressed his desire to return home.

"I am truly pained by my expulsion from Russia, despite all the gratitude I feel towards those who wished me well and saved me," Yashin told Reuters. "But I sincerely say that my place is in Russia ... I have dedicated my life to my country."

Yashin said he was happy to see his family and friends for the first time in a long while. But on the other hand, he said it was "a hard pill to swallow".

"It’s very difficult for me emotionally because I understand that I was set free at the price of setting free an assassin, a person who actually committed a bloody crime," Yashin said.

This referred to Vadim Krasikov, a Russian convicted of the 2019 murder of a former Chechen militant in Berlin, who was among those freed.

"I said it a number of times that I did not want to be part of any exchange lists," Yashin said. "The Kremlin representatives gladly included my name because for them my exchange essentially means expulsion," he added.

He said he planned to continue with what he called the anti-war education of Russians, and helping Russian political prisoners.

Pivovarov also said he wanted to continue with his opposition activities from outside of Russia.

"Coordinating anything from inside is impossible," Pivovarov said. "I’m not planning to step aside," he added.

https://www.yahoo.com/news/two-russian-ex-prisoners-east-103547600.html

Ukraine finally deploying F-16 fighter jets, says Zelenskiy

 Ukraine’s newly arrived F-16 fighter jets were put on display Sunday by President Volodymyr Zelenskyy, who said the planes will boost the country’s war effort against Russia.

“These jets are in our sky and today you see them,” said Zelenskyy, standing in front of two of the fighter jets as two others flew overhead in close formation. “It’s good that they are here and that we can put them to use.”

Ukraine is also trying to get neighboring countries to help defend it against Russian missiles, Zelenskyy said.

“This decision is probably a difficult one for our partners, as they are always afraid of unnecessary escalation,” said Ukraine's president. “We will work on this ... I think we have a good option of a NATO-Ukraine council ... so that NATO countries could talk to Ukraine about the possibility of a small coalition of neighboring countries that would shoot down enemy missiles.”

Two F-16 jets, sporting Ukraine’s trident insignia on their tails and draped in camouflage netting, were a dramatic background for Zelenskyy’s address to Armed Forces Day, an event held under tight security at an undisclosed location to protect the fighter jets from Russian attacks.

“Since the beginning of this war, we have been talking with our partners about the need to protect our Ukrainian skies from Russian missiles and Russian aircraft,” Zelenskyy said. “Now we have a new reality in our skies. The F-16s are in Ukraine. We made it happen. I am proud of our guys who are mastering these aircraft and have already started using them for our country. ... Our combat aviation will bring us closer to victory.”

Ukraine may keep some of the F-16 fighter jets at foreign bases to protect them from Russian strikes, according to a senior Ukrainian military official. Russian President Vladimir Putin has warned that Moscow could consider launching strikes at facilities in NATO countries if they host the warplanes used in Ukraine.

The American-made F-16 is an iconic fighter jet that’s been the front-line combat plane of choice for the NATO alliance and numerous air forces around the world for 50 years.

Although new to Ukraine, the F-16s are actually older jets that have been donated by Western allies of Ukraine. Belgium, Denmark, the Netherlands and Norway have committed to providing Ukraine with more than 60 of them over coming months in what could be a slow trickle of deliveries. Zelenskyy did not say how many F-16s have arrived in Ukraine or which countries they came from.

United States President Joe Biden gave the go-ahead in August 2023 for used F-16s to be deployed to Ukraine, though the U.S. won’t be providing any of its own planes.

The F-16s will boost Ukraine’s military strength, especially by upgrading its air defenses. But analysts say they won’t turn the tide of the war on their own.

Russia is making small but steady battlefield gains in Ukraine’s eastern Donetsk region and its steady forward movement is adding up as Ukraine gradually yields ground.

https://ca.news.yahoo.com/ukraines-zelenskyy-displays-newly-arrived-142302079.html

Former Commerce secretary questions if Biden’s ‘well enough’ to remain president

 Former Commerce Secretary Wilbur Ross, who served under the Trump administration, raised concerns Sunday over President Biden’s ability to finish his term.

“If he’s not well enough to run, how can he be well enough to stay in there as president?” Ross said Sunday in an interview on “The Cats Roundtable” with host John Catsimatidis.

His question comes after Biden announced late last month that he would be stepping aside from the presidential race against former President Trump — and later endorsed Vice President Harris to run in his place. His decision came after weeks of pressure from fellow Democrats for him to drop out of the race following a rough debate performance that sparked worries over his age, mental fitness and ability to recapture the White House in the fall.

In the weeks since, Harris has garnered key endorsements, officially became the presumptive Democratic nominee for president and raked in large fundraising hauls.

Asked by Catsimatidis about who he believes is in control in the Oval Office if it isn’t Biden, Ross answered, “clearly it must be the staff people.”

“You saw and remember the press conferences,” he continued. “President Biden would occasionally say, ‘Oh, my staff won’t let me talk about that,’ ‘My staff doesn’t like me saying this or that.’”

“So, clearly, the staff has been uniquely in control of a lot of activities, even before he announced he was not going to run,” the former Trump official added.

The White House and Biden have pushed back on questions around his health. The administration released a letter last month from the president’s physician attempting to clarify why a neurologist with a specialty in Parkinson’s disease had gone to the White House multiple times.

“Seeing patients at the White House is something that Dr. [Kevin] Cannard has been doing for a dozen years,” Dr. Kevin O’Connor wrote in the letter, talking about the neurologist.

“Dr. Cannard was chosen for this responsibility not because he is a movement disorder specialist, but because he is a highly trained and highly regarded neurologist here at Walter Reed and across the Military Health System, with a very wide expertise which makes him flexible to see a variety of patients and problems,” he added.

https://thehill.com/homenews/campaign/4809575-wilbur-ross-commerce-joe-biden-kamala-harris-2024-election/

Israel has not escalated; it has merely retaliated

 The White House has strongly implied that Israeli retaliatory strikes on Iran and its proxies are escalating the conflict in the Middle East. But that’s not what they are — they are reactions to escalations.

In other words, the Biden-Harris Administration’s global escalation paralysis is being projected unfairly upon Israel’s offensive actions to defend themselves.

Israel is the victim, not the perpetrator. The invasion of Gaza was the result of the Oct. 7 Hamas terrorist attack on Israel. The airstrike on Iran was a response to the April 13 missile-drone attack on Israel. The airstrike on the port of Hodeidah, Yemen was in response to a Houthi drone strike in Tel Aviv on July 19.

None of these was escalatory. The Israeli actions were and are, militarily speaking, defensive in nature and execution. 

The Israeli airstrikes against Hamas, which eliminated Ismail Haniyeh and Mohammed Deif, and the strikes Hezbollah senior commanders Fuad Shukr and Ali Nazih Abed Ali, were responses to the missile attack that killed 12 Druze children on a soccer field in the Golan Heights. The same goes for Israeli strikes on Islamic Revolutionary Guard Corps (IRGC) leadership in Tehran, Gaza, Southern Lebanon, and Beirut — including Milad Bidi.

Israel has repeatedly demonstrated it has the intelligence and operational reach to hold Iran and its proxies accountable, despite ongoing reluctance in the Biden White House.

Despite Washington’s interference, Israeli Prime Minister Benjamin Netanyahu has vowed to keep fighting, saying Israel is “ready for any scenario” and has delivered “crushing blows” to its enemies throughout the Middle East.

Israel demonstrated its considerable operational reach on July 20, when F-15 and F-35 fighter jets struck multiple targets at the Red Sea port of Hodeidah, Yemen — over 1,000 miles away. The strikes came in response to a Houthi drone attack in Tel Aviv that struck a civilian apartment building near the U.S. Embassy branch office, killing one person and wounding eight others the day prior.

According to Israeli military spokesman Rear Adm. Daniel Hagari, the sites struck in Yemen were used for military purposes. The port is a major point of entry for Iranian weapons and ammunition for the Houthi rebels. 

In April, Israel penetrated Iranian air defenses to strike targets deep in Iran’s interior, near the cities of Tabriz and Isfahan, and the Natanz nuclear complex. In July, Israel was able to kill Ismail Haniyeh in Tehran. The precise means of delivery remains unknown. One theory is that the Mossad enlisted Iranian agents from the Ansar al-Mahdi security unit to plant explosives in the Tehran guesthouse where Haniyeh was staying.

Haniyeh’s demise was originally planned for May, when he attended Iranian President Ebrahim Raisi’s funeral. But the bombing was called off due to the large number of people in the building at the time and a seemingly high possibility of failure; however, the agents allegedly emplaced the explosives in the event that he or any other senior leader returned.

Regardless, Iran has an insider threat problem. Esmail Qaani, commander of the Quds Force, stated “The breach has humiliated everyone,” and has summoned people to be fired, arrested and likely executed.

By killing Haniyeh, Israel has exposed vulnerabilities in Iran’s defenses and demonstrated it can exploit them seemingly at will. To date, Jerusalem has been remarkably constrained, choosing to deliver messages of capability designed to deter further attacks instead of direct strikes that could risk sparking a wider regional conflict.

Tehran is vowing immediate revenge. Iranian Supreme Leader Ayatollah Ali Khamenei is threatening to strike Israel directly for a second time this year. He issued the order for Iran to hit Israel directly after an emergency meeting of Iran’s Supreme National Security Council Wednesday morning.

Once again, Washington is playing catch-up. Caught flat-footed after the return of the USS Eisenhower to its home port in Virginia, the Pentagon has had to scramble air and naval assets back into the region. 

While visiting the Philippines last week, U.S. Defense Secretary, Lloyd Austin told reporters, “If Israel is attacked, we certainly will help defend Israel.” The U.S. will not likely support any offensive actions, but it will have Israel’s back, should Iran retaliate with more missiles and drones. Netanyahu will take it. 

Meanwhile, Israel is continuing its top-down approach to neutralize Iranian proxies. The defeat of Hamas in Gaza remains its main effort, yet the larger Hezbollah threat looms in Lebanon to the north. So do the Houthi rebels in Yemen to the south. The connective tissue is Iran’s IRGC, which coordinates and supports these Iranian proxies. 

Systematically removing key leaders within the Iranian proxy hierarchy weakens command and control and adversely affects morale within the ranks. It may be easier to break it than to destroy it — and at a lesser cost in Israeli lives.

Without proxies to shield Tehran, Iran is vulnerable. Israel struck yet again in the West Bank on Saturday, killing Haitham Balidi, a Qassam Brigade commander. Eight other terrorists from several other terrorist groups were killed in the same series of strikes that occurred near Nablus and Tulkarem.

Time is not on Iran’s side. Israel is systematically deconstructing the IRGC’s leadership and soon will be turning its attention to Iran. These are dangerous times for an increasingly desperate Iran, frantically in pursuit of a nuclear weapon to ensure its survival. Israel will do what it takes to prevent that.

A massive retaliatory strike may very well be in the cards. But can Iran deliver a debilitating blow to Israel? We may be starting to get that answer. Late Saturday night, Hezbollah began launching upwards of 60 rockets into northern Israel. 

Again, the Biden-Harris Administration’s escalation paralysis is leading our nation’s enemies to escalate. We have witnessed Russia repeatedly do this in Ukraine — and now Iran and its proxies are doing so in the Middle East. 

There is no limit to Israel’s escalation paradigm. It is a simple matter of survival. They will keep climbing the escalation ladder with Iran, while the Biden-Harris Administration observes and, weighed down by November electoral considerations, objects.

Col. (Ret.) Jonathan Sweet served 30 years as a military intelligence officer and led the U.S. European Command Intelligence Engagement Division from 2012 to 2014. Mark Toth writes on national security and foreign policy. 

https://thehill.com/opinion/national-security/4809825-israel-strikes-iran-proxies/