Case Comment: Heller v. Uber Technologies Inc.

Canadian courts have accepted mandatory arbitration clauses as presumptively enforceable unless there is legislation that precludes their application. This position was confirmed by the Supreme Court in Seidel v. TEL US CommunicationsInc. In Heller v. Uber Technologies Inc., the Ontario Court of Appeal considered an arbitration clause in the context of legislation following the approach in Seidel, but the Court also undertook an unconscionability analysis. Reviewing a motion that was granted to stay a class action proceeding in favour of an arbitration clause, the Court unanimously held that the clause was invalid on two separate grounds. First, the arbitration clause amounted to an illegal contracting out ofthe Employment Standards Act. This is an application of the core principle from Seidel. Second, the Court held that the arbitration clause was unconscionable. This is a significant development because it is the first time a Canadian court has held an arbitration clause invalid on the basis of unconscionability

The Transformation of Asian Fathers: From Distant, Income Provider and Disciplinarian to Forgiven, Discipler & Benefactor

Asian fathers have a tough road to travel upon. The proper image of the father is one of the least successful cover-ups in today’s Asian church. On the surface, there is the attempt to portray him as being successful in his career, confident in his identity and respected as a spiritual leader in his home. Yet when his children are asked to discuss family relationships in the youth group, a different picture comes into focus. It is one of emptiness, distance and sometimes resentment. The typical stereotype of the stern father who shows more care for his personal success and reputation than for his children is all too common. Yet deep down, most fathers want their family relationships to be better, They simply do not know how to make the necessary adjustments. Asian churches may be aware of the issue, but have failed to respond with any effective and meaningful ministry. The shame factor, which dominates Asian culture, is a primary culprit in causing this malady. Men are fearful of openly discussing their personal struggles and failures because they do not want to be perceived as being incapable. Likewise, churches are reluctant to expose their weaknesses. Attempts to help men become better fathers have usually been addressed in the behavioral realm. But a deeper degree of transformation is needed that touches a father’s heart and soul. In this dissertation there is a call for Asian fathers to take a step upward and outward. Instead of being limited by the normal definition of being distant from his children and then being the family provider and disciplinarian, he is invited to receive forgiveness, and become a discipler and benefactor who leaves a spiritual inheritance. This will serve to put him into deeper relationships and allow him to make significant impact in his home. ix Section 1 will define the problem and reveal the broken relationships experienced in many Asian homes. Section 2 states alternative viewpoints and resulting solutions that have been proffered. Section 3 will demonstrate the power of forgiveness and the renewal that comes from a father becoming a discipler and pondering how to be a benefactor. Section 4 describes the artifact which is a collection of stories of Asian fathers as told by their young adult children. Section 5 is the book proposal. Section 6 is the postscript. The appendix contains the artifact which includes sample chapters from the book and an accompanying discipleship guide

Multimodal Evaluation Of Cerebrospinal Fluid (csf) Dynamics Following Extradural Decompression For Chiari I Malformation

Chiari I malformation is a hindbrain abnormality characterized by tonsillar herniation \u3e 5 mm below the level of the foramen magnum. Extradural decompression is a minimally invasive technique for treating Chiari I that involves a suboccipital craniectomy with removal of the outer dural layer. Other techniques the involve opening of the dura, arachnoid or even manipulation of the cerebellar tonsils have since been the mainstay of treatment, but are associated with a higher complication rate and longer hospital stays. While there is no agreement on which surgical method is optimal, mounting evidence demonstrates that extradural decompression effectively treats clinical symptoms with a minimal reoperation rate. Many of the symptoms associated with Chiari I are now understood to be related to obstructed cerebrospinal fluid (CSF) flow. Therefore, one goal of a successful decompression is improved CSF dynamics. Phase-contrast cine flow MRI provides insight into CSF dynamics before and after surgical decompression. This study describes a surgical series of 18 patients with Chiari I malformation undergoing extradural decompression, for which clinical improvement was correlated with radiologic changes. All 18 patients presented with symptomatic Chiari I malformation, confirmed on imaging to have tonsillar herniation \u3e 5 mm. Two patients had associated syringomyelia. All patients underwent suboccipital decompression and C1-laminectomy with dural splitting. Patients were categorized as having complete, partial, or no resolution of their symptoms. Posterior fossa area (PFA), cisterna magna area (CMA), and tonsillar herniation were assessed on T2-weighted magnetic resonance imaging (MRI). Improvement in CSF flow was evaluated with phase-contrast cine flow MRI. All patients received standard pre- and post-operative MRIs, 8 (44.4%) patients had pre- and post-operative phase-contrast cine, while the rest had only post-operative cine. Patients who had a complete resolution of their symptoms also had a greater relative increase in cisterna magna area compared with those with only partial improvement (p = 0.022). In addition, those with complete improvement had smaller pre-operative cisterna magna area compared with those who had either partial (0.020) or no (0.025) improvement. Ten (91%) of the 11 patients with improved flow also had improvement in their symptoms. There was one post-operative complication of dysphagia and dysphonia. None of the patients have required a second operation. Extradural decompression has the potential to be the first-line treatment for Chiari I malformation, but has since been lacking an objective measure by which to assess surgical success, as well as the need for reoperation. In our study, an increase in the CSF spaces and improved CSF dynamics and were associated with greater resolution of clinical symptoms. Including cine imaging as part of routine pre- and post-operative evaluation can help identify which patients are most likely to benefit from surgery, as well as determine a satisfactory decompression

Cost effectiveness analysis of cervical cancer screening in women until age 70

Background: 2017 US Preventive Services Task Force guidelines for screening cervical cancer and pre-malignant lesions advise that screenings cease for women over age 65, with qualifications. Recent literature has identified significant discrepancies in rates of cervical cancer in older women – if hysterectomies in this patient population is accounted for, cervical cancer incidence does not decline with age as previously established. This adjusted incidence of cervical cancer necessitates a re-examination of current practice.Methods: This study seeks to demonstrate the utility of extending the cervical cancer screening age recommendations to age 70. Cost effectiveness will be estimated, from a payer perspective, of extending screening to age 70 for the United States women’s population in those who have not undergone hysterectomy or otherwise been treated for past cervical cancer or premalignancy. A Markov model was constructed to project outcomes in a hypothetical cohort of 10 000 women aged 65 to 70, with a time horizon of lifetime. A Probability Sensitivity Analysis determined the robustness of the result, and the Incremental Cost-effectiveness Ratio (ICER) is charted.Results: The economic evaluation of screening compared to none in this population was determined to be cost effective, with an ICER demonstrating a cost benefit, and Quality Adjusted Life Year (QALY) benefit, to extended screening.Conclusions: The sensitivity analysis confirms the robustness of this result. Implementing extended screening guidelines could potentially be a significant gain for both patients and society

Astrocytic involvement in cortical inhibition and serotonin neuromodulation

A single astrocyte can ensheath more than 100,000 synapses within its domain. Thus, astrocytes are ideally positioned to integrate signals from a few synapses to have impact on all ensheathed synapses with high efficiency. As neuromodulators are released in a volume manner and are known to illicit astrocyte calcium responses, we hypothesized that astrocytes may be effector cells, extending neuromodulator action to every synapse. Using live mouse brain slices, extracellular recordings of evoked excitatory postsynaptic potentials (eEPSPs), and select pharmacology, we assessed the astrocytic involvement in paired-pulse suppression and serotonin-mediated shaping of a simple sensory cortical network containing both excitatory and inhibitory activity. Using a paired-pulse stimulus repeated every 20 seconds, we assessed the role of astrocytes in paired-pulse suppression by applying pharmacological agents in the bath perfusate to interfere with astrocyte function. We then applied them in the presence of the GABAA antagonist bicuculline to determine if effects were dependent on GABA. To assess the role of astrocytes in serotonin neuromodulation, serotonin was administered as a bolus to the bath perfusate upstream of the recording site to simulate transient effects on the network. Serotonin was applied both before and after bath application of pharmacological agents considered to affect astrocyte function or signaling mechanisms. In the absence of neuromodulators or pharmacological agents, the first cortical eEPSP is much larger in amplitude than the second due to the recruitment of longer-lasting inhibitory activity resulting from the first stimulus. Pharmacological disruption of 1) astrocytic mGluR5 receptors, 2) astrocyte metabolism, 3) gap junctions/hemichannels, or 4) purinergic receptors resulted in a significant loss of this evoked inhibition in field recordings, suggesting that astrocytes may play a role in tonic aspects of network inhibition. Furthermore, all significance was lost when performed in the presence of bicuculline, suggesting that astrocytic involvement in paired-pulse suppression is GABAA dependent. In addition to effects seen on tonic cortical inhibition, serotonin effects on frequency transmission in the cortical network are significantly altered following pharmacological astrocyte disruption. Lastly, serotonin-mediated frequency transmission could also be disrupted using P2 antagonists suggesting that ATP signaling (astrocyte currency) may be involved. These data highlight a potential role for astrocytes in cortical inhibitory activity seen in this sensory cortical network and that serotonin acts on astrocytes to partially exert its modulatory influence