Enhanced recovery after surgery

The Enhanced Recovery After Surgery model of perioperative care targets the obstacles to recovery following major abdominal surgery: pain, gastrointestinal dysfunction and immobility. This model of care combines elements that have individually been shown to attenuate the surgical stress response, reduce postoperative analgesia requirement or maintain perioperative nutrition. Through combining these elements it has been possible to improve early postoperative function and reduce the requirement for hospital stay with an unaltered or even reduced complication rate.Within the available ERAS studies subjective postoperative outcomes are employed and it is difficult to assess the true contribution of many of the individual protocol elements to postoperative recovery. The reduction in length of stay, in itself, may represent more efficient use of inpatient care rather than an improved rate of functional recovery. Further refinement and validation of the ERAS model will be achieved by establishing randomised controlled trials that test its feasibility and effectiveness within other surgical specialties, establish objective, reproducible outcome measures and examine the specific contribution of individual protocol elements within the ERAS protocol. It is expected that further improvement in postoperative recovery may specifically rely on reducing gut dysfunction in the early postoperative period. The establishment of randomised controlled trials and objective endpoints will facilitate testing individual element that target gastrointestinal recoveryThis thesis demonstrates that the application of an ERAS model of care to hepatic surgery is feasible and results in a reduction in postoperative stay similar to that seen in colorectal surgery. This suggests that the ERAS programme of care may be extrapolated to other surgical specialties. The present thesis also demonstrates that activity meters and stable isotope gastric empting breath tests can be employed in the early postoperative period to provide objective measures of postoperative recovery. Most significantly this thesis demonstrates through a randomised controlled trial that within an ERAS protocol early routine administration of laxatives can improve postoperative rate of gastrointestinal recovery following hepatic resection

Home Equity Lending in Texas: Are Loan Origination Fees Interest?

The constitutional amendment did not define what constituted a fee for purposes of a home equity loan, and this ambiguity has created much concern among lenders. This Comment argues that a loan origination fee charged by a lender in a home equity transaction should be considered interest and not a fee for purposes of the three percent fee limitation. Part II of this Comment will discuss homestead protection in Texas and the 1997 constitutional amendment authorizing home equity lending. Specifically, Part II will discuss the three percent fee limitation, the forfeiture and cure provisions contained in the constitutional amendment, and the problems inherent in interpreting what constitutes a fee for purposes of the cap on fees. Part III will discuss the potential charges to a borrower in a hypothetical home equity transaction by defining and describing the varying lender and non-lender charges. Part IV will discuss how interest and fees have historically been defined under Texas law. Part V will discuss whether the legislature intended a different definition of interest and fees for purposes of the three percent cap on fees. Part V will also examine the language of the pertinent section of the constitutional amendment, applying the rules of statutory construction in Texas, and will discuss how Texas regulatory agencies interpret the amendment. Part VI will discuss four recent judicial interpretations of the constitutional amendment relative to the classification of points and/or origination fees in Texas home equity transactions. Part VI will also discuss a recent decision by the Texas Supreme Court interpreting the cure provision contained in the constitutional amendment and its application to a violation of section 50(a)(6)(E). In addition, Part VI will provide a summary of recent home equity cases. Part VII will discuss the relevant policy considerations in classifying interest and fees for purposes of home equity lending in Texas and lender options for dealing with the problem created by the uncertainty of whether a loan origination fee constitutes interest or a fee. Part VII will also discuss the 2003 amendment to the Texas Constitution on home equity lending, to the extent that the amendment addresses the problem of interpretation and the process by which a lender or note holder may cure a violation of the home equity law. Finally, Part VIII will summarize why loan origination fees should be considered interest and not fees for purposes of home equity lending in Texas

Owners, traders and providers of capital: the multiple faces of institutional investors

We draw on a series of in-depth interviews with senior fund managers and senior company executives to explore how different and often-contradictory conceptualizations of institutional investors, their role in the corporate governance process, and their interactions with corporate management, are reflected in the attitudes and perceptions of the actors concerned. We find that while conceptualizations in terms of agency and ownership dominate both academic and popular discourses, the actors conceptualize institutional investors more as financial traders and, from the management perspective, politically powerful resource providers.corporate governance, institutional investors, power, resource dependence,shareholder value.

The corporate-fund manager interface: objectives, information and valuation

Fund managers are the primary investment decision-makers in the stock market, and corporate executives are their primary sources of information. Meetings between the two are therefore central to stock market investment decisions but are surprisingly under-researched. There is little in the academic literature concerning their aims, content and outcomes. We report findings from interview research conducted with chief financial officers (CFOs) and investor relations managers from FTSE 100 companies and with chief investment officers (CIOs) and fund managers (FMs) from large institutional investors. Of particular interest we note that FMs place great reliance on discounted cash flow valuation models (despite informational asymmetry in favour of CFOs). This leads the former to seek to control encounters with the latter and to place great store on the clarity and consistency of corporate messages, ultimately relying on them for purposes other than estimating fundamental value. We consider some of the consequences of this usage.valuation, institutional shareholders, investor relations

Phylogenetic divergence between the obligate luminous symbionts of flashlight fishes demonstrates specificity of bacteria to host genera

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107544/1/emi412135.pd

Family physicians’ continuing professional development activities: current practices and potential for new options

Background: As part of needs assessment processes, our Faculty of Medicine (FOM) continuing professional development office investigated the differences between physicians who do and those who do not frequently participate in planned group learning to gain insight into their interest in new forms of continuing professional development (CPD).Method: We sent a 19 item questionnaire to 485 randomly selected physicians of the 1050 family physicians in Eastern Ontario. The questionnaire examined present participation and satisfaction with CPD activities and perceptions regarding the potential impact of those; and appetite for new opportunities to meet their learning needs.Results: Of the 151 (31%) physicians responding, 61% reported attending at least one FOM group learning program in the past 18 months (attenders) and 39% had not (non-attenders). Non-attenders indicated less satisfaction (p = 0.04) with present opportunities and requested development in newer approaches such as support for self-learning, on-line opportunities, and simulation.Conclusions: Although there are high levels of satisfaction with the present CPD system that predominantly offers large group learning options, a substantial number of physicians expressed interest in accessing new options such as personal study and on-line resources

Genome Evolution in the Obligate but Environmentally Active Luminous Symbionts of Flashlight Fish

The luminous bacterial symbionts of anomalopid flashlight fish are thought to be obligately dependent on their hosts for growth and share several aspects of genome evolution with unrelated obligate symbionts, including genome reduction. However, in contrast to most obligate bacteria, anomalopid symbionts have an active environmental phase that may be important for symbiont transmission. Here we investigated patterns of evolution between anomalopid symbionts compared with patterns in free-living relatives and unrelated obligate symbionts to determine if trends common to obligate symbionts are also found in anomalopid symbionts. Two symbionts, ?Candidatus Photodesmus katoptron? and ?Candidatus Photodesmus blepharus,? have genomes that are highly similar in gene content and order, suggesting genome stasis similar to ancient obligate symbionts present in insect lineages. This genome stasis exists in spite of the symbiont?s inferred ability to recombine, which is frequently lacking in obligate symbionts with stable genomes. Additionally, we used genome comparisons and tests of selection to infer which genes may be particularly important for the symbiont?s ecology compared with relatives. In keeping with obligate dependence, substitution patterns suggest that most symbiont genes are experiencing relaxed purifying selection compared with relatives. However, genes involved in motility and carbon storage, which are likely to be used outside the host, appear to be under increased purifying selection. Two chemoreceptor chemotaxis genes are retained by both species and show high conservation with amino acid sensing genes, suggesting that the bacteria may actively seek out hosts using chemotaxis toward amino acids, which the symbionts are not able to synthesize