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Transfer judicial services from central courts and judges to municipal courts and clerks antibiotic effects buy amoxil in india, establishment of new courts infection control policy cheap 650 mg amoxil overnight delivery, automation of judicial procedures virus worksheet order 500mg amoxil otc, and capacity building and training for lawyers antibiotic for sinus infection order amoxil 650 mg with mastercard, judges do antibiotics help for sinus infection order amoxil amex, and clerks are activities that help to improve enforcement mechanisms for businesses infection vaginal discharge buy cheap amoxil 250mg line. Doing this intervention aims to prepare subnational and national indicators related to Business nine of the Doing Business areas. This includes training with local partners on the Indicators Doing Business methodology, report preparation and disseminaition, and technical assistance to implement reform proposals and recommendations. Investment Under this intervention, laws and strategies to promote increased investment, both Policy and from foreign and domestic investors, and in key sectors and locations, are adopted. Promotion Investment promotion trainings and workshops are conducted, investor aftercare programs developed and implemented, and investment oversight committees and agencies formed. This is done through new or amended labor laws, addressing wage-setting mechanisms and hiring quotas, and revising residency permits for foreign skilled workers. Property this intervention addresses access to land, registering property, and protecting Rights intellectual property rights. Review of legislation, digitization of property records and development of cadaster systems, and one-stop shops for property registration are among the activities used to promote property rights. Cadastres or surveys, together with land registries, are tools used around the world to map, prove, and secure property and use rights. PublicPublic-Private Dialogue interventions support programs that improve the quality Private and sustainability of policy reforms by providing fexible and robust mechanisms Dialogue that address shortfalls in representation, communication, and coordination between relevant stakeholders. This is done through market demand analysis and feasibility studies, best practices frameworks, and identifcation of land, investors, and developers for the zone. Business this intervention aims at streamlining burdensome tax payment and administration Taxation procedures for businesses by implementing small business tax regimes, electronic fling, and taxpayer education and services. Other activities and tax laws work to harmonize the tax system and reduce certain taxes, while at the same time eliminating exemptions. Trade Trade logistics comprises three core areas of reforms: (a) simplifying and harmonizing Logistics trade procedures and documentation, integrating risk management systems into border inspections and clearance, and implementing electronic processing, automation, and single window systems; (b) industry-specifc reforms focus on agribusiness supply chains and on improving national logistics and distribution services; (c) regional integration reforms seek to improve trade logistics systems and services and border clearance at the regional level and foster mutual recognition of international standards, accreditation, and certifcation. Bankruptcy these interventions aim at identifying weaknesses in existing bankruptcy law and the main procedural and administrative bottlenecks in the bankruptcy process in order to implement good practices to improve both the effciency and the outcome of insolvency proceedings. Activities include improvements in existing regulations on company reorganization, through amendments to national bankruptcy acts and laws. Debt this intervention aims to improve insolvency laws, based on global best practices, Resolution/ with regard to provisions relating to assets of the debtor, avoidance of transactions Insolvency proceedings, reorganization, creditor rights, and secured lending. It improves institutional capacity for speedy resolution of disputes and technical assistance to improve court capacity. It is important to note, however, that although both institutions operate in the same space, the scope of their investment climate interventions is generally different, with some overlap. The Bank focuses more on higher-level reforms, such as revising and harmonizing laws and codes, reforming institutions, developing strategies, and coordinating government agencies and ministries. Excluding sector reforms, which account for some 20 percent of all interventions, both institutions focus the great majority of interventions (80 percent) on frm operation, with 15 percent on entry and the remaining 5 percent on exit. Across interventions, regulations, trade, and investment promotion account for almost half of all interventions. The World Bank conducts almost exclusively (over 80 percent of all) interventions in trade and property rights, as well as the majority of interventions on investment promotion. The distribution of interventions over time shows a remarkably similar trend for the two institutions. In terms of value, however, the two institutions provide a signifcantly different amount of support. The Middle East and north Africa and South Asia Regions have the fewest interventions (4 percent Figure 1. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 27 Figure 1. Similarly, both institutions 28 Investment Climate Reforms pay particular attention to lowerand lower-middle-income countries, where 8 of 10 interventions are implemented. All interventions have active projects, with regulation, investment policy, trade, and tax being 25 the most common and competition and labor the least. However, when in the World Bank these are part of lending operations, the average length is substantially higher. World Bank development policy operations with investment climate components are completed on average in less than two years; projects that include mostly investment climate components are implemented on average over six years. In terms of income the distribution of interventions shows that almost half of interventions are in low-income countries, whereas entry and exit almost equally distributed between the three income groups. In a few countries, for example, Cambodia, interventions focus on specifc areas such as trade promotion. In Vietnam, the World Bank supported investment climate reform through fve Poverty Reduction Support Credits. These projects supported trade and economic integration, tax regulations, land regulations, and labor skills. The program supported drafting and approval of an economic zoned act and assisted the Bangladesh Export Processing Zones Authority in developing an An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 29 Table 1. NotE: Regional projects are excluded because they mostly include knowledge management activities, data collection, and analytical products. The investment climate reform program was designed as a programmatic series of Advisory Services operations. Projects were coded based on whether they included an explicit targeting criterion for the benefciaries of the intervention and whether they reported results for the specifc group that was targeted. Only 8 percent of all projects specifcally aimed to target women, and a similar percentage targeted frms based on their industry and formality status. Targeting based on age, geographical area, or export status is even rarer (Table 1. Moreover, only a minority of projects with a specifc target actually report on results for the An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 31 Table 1. As for gender, fewer than 4 of 10 closed projects that had a gender target report any gender-disaggregated result or gender-relevant results. The increase in gender targeting in the last two fscal years likely refects the renewed focus on gender mainstreaming by the World Bank Group. According to the gender fag, 66 percent of World Bank investment climate operations are gender informed; based on the targeting criteria, however, only 23 percent are. The prevalence of specifc targeting in project design also varies by networks and regions. A close analysis of projects targeting gender reveals that many are small in size and mostly focused on capacity-building activities or on flling an information gap relative to genderbased barriers in the business enabling environment. Most of those projects target women as participants of training or consultative working groups rather than as entrepreneurs (or potential entrepreneurs) who may directly beneft from investment climate reforms. The gender dimension was also more easily found in activities aimed to produce diagnostic and baseline assessments. Whether investment climate interventions should explicitly target specifc subgroups of the population rather than promoting reforms aimed at improving the general business environment of a country is a question without a straightforward answer. On the one hand, by their very nature reforms are supposed to be general, and any specifc provision could be perceived as An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 33 Table 1. On the other hand, normally the playing feld is not leveled for everybody, and certain entrepreneurs or frms, current or potential, experience obstacles that are specifc to their group and, if not addressed, not only raise issues of fairness and equity, but can also hinder the growth potential of the whole economy. Gender-specifc obstacles make it harder for women than for men to start and grow enterprises. Fewer women than men own and manage businesses worldwide (Kelley and others 2012). Also, in all regions of the world, including in developed economies, female-owned enterprises are substantially and signifcantly smaller (Bardasi, Sabarwal, and Terrell 2011; Minniti 2010), partly because women are more likely to operate in industries where frms are smaller and less effcient, but also because women face disproportionate obstacles in obtaining licenses and permits (because of limited mobility, time constraints, and sometimes discrimination and higher exposure to bribes and sexual harassment) and in accessing a number of things: fnance, markets, courts and dispute resolution systems, networks, and assets and property. In addition to de facto constraints such as those highlighted above, in some countries women also suffer legal discrimination, as has been documented in the World Bank Group report Women, Business, and the Law. In several countries women have lower legal status and fewer property rights than men; they may be subject to travel restrictions; or they may be forbidden from pursuing certain trades or professions in the same way as men (World Bank 2014). Investment climate reforms may be designed with knowledge of legal or de facto constraints and explicitly aim to address those constraints to ensure inclusion. Alternatively, investment climate reforms may claim to be gender neutral, although they might be implemented in environments where specifc gender constraints exist. More specifcally, in 81 percent of interventions, investment climate reforms do not include gender targeting when there are no gender-specifc legal constraints (although other relevant constraints may exist), and in 8 percent of interventions investment climate reforms target businesswomen because of other nonlegal constraints. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 35 Table 1. NotE: the percentage in each cell refers to investment climate interventions (in client countries included in the database) for each case. The legal constraints considered four types of restrictions, based on the Women, Business, and the Law database: unequal ownership rights to property; inability to sign a contract in the same way as a man; inability to register a business in the same way as a man; and inability of opening a Bank account in the same way as a man. That is, investment climate reforms do not target women when there are legal constraints that would make such reforms not gender neutral. Moreover, several of these countries implement interventions that tend to be woman friendly, even if there is no explicit gender targeting. These are examples where targeting may not have been correctly done, as obstacles for businesswomen were not in the regulatory environment for businesses but in the discriminatory legal framework. The intervention (ongoing) aims to give married women the same economic An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Chapter 1 37 opportunities that men have (activities include support for legal reforms, communication along the reform process, and development of evaluation tool for measuring their effective impacts). According to the Project Appraisal Document, this will result in an improvement of the economic situation of women, measured by the increase in the number of individual enterprises owned by women. Investment ClImAte PortfolIo: fCs overall, 15 percent of investment climate projects are implemented in fCs countries. IfC shows a slightly higher share of investment climate projects in fCs countries than the World Bank. However, in absolute terms, both institutions have approximately the same number of investment climate projects. In terms of interventions, the most common interventions in fCs countries (accounting for over 50 percent of all) are regulation, investment promotion, trade, and public-private dialogue. Moreover, most of the population in developing countries lives in rural areas and depends on agriculture for its livelihood. Ineffcient market for inputs, overregulation, and costly trade logistics in turn make domestic products uncompetitive. It is second to agriculture in terms of employment generation per unit of investment and is a valuable source of foreign exchange. However, a range of impediments continues to inhibit investment, including complicated and nontransparent approval processes for tourism licenses; ineffective institutional structures of public or private sector agencies responsible for tourism development; weak institutional capacity to develop appropriate policy, plans, and processes for tourism investments; accessibility; complex land issues/limited availability of land for tourism development; ineffective aviation policies; and lack of access to fnance. The relevant portfolio includes both projects mapped under the Investment Climate for Industry practice and those not mapped to it but that cover sector-specifc sector reforms in agriculture and industry, including regulatory reforms. First, as part of the broad review of all investment climate projects, the portfolio analysis identifed projects within the investment climate portfolio that (i) promoted sector-specifc reforms in agribusiness or tourism; (ii) identifed agribusiness or tourism as industries of interest; and (iii) had components and/or project development objectives that mentioned developing the agribusiness and tourism sectors. Second, the team reviewed evidence from 19 completed case studies to consider if country strategy identifed these sectors as development priorities and if specifc interventions promoted Investment Climate for Industry in these two sectors. Thirteen percent of its investment climate industry advisory projects are not in any one region, but are global in focus. Many of the activities supported under investment climate for industry do not ft strictly within the confnes of the legal and regulatory focus of the investment climate portfolio. Instead, sectoral studies often identify a much broader variety of constraints, opportunities, and challenges and often map out relevant value chains or supply chains. In fact, both the investment climate for industry and the competitive industries practices often employ value chain approaches to promote sectoral development and increased sectoral competitiveness. When it comes to agricultural trade, specifc interventions are aimed at reducing compliance, transport, and transaction costs for agribusiness products and related inputs that can result in a more effcient and competitive trade and transport environment. The 2011 Philippines Agribusiness Trade Competitiveness and the Honduras Agribusiness Trade Logistics Projects are examples of this. When a project is aimed at improving the agricultural industry per se, reforms address the main regulatory and policy constraints hindering priority commodities (national produces) that aim to improve input market and storage capacity and modernize food safety, roads, and agricultural infrastructures (such as irrigation) and product certifcation system to facilitate investments in the sector. Another approach is to simplify procedures related to agriwaste processing and production of renewable energy, as in the Ukraine Investment Climate: Agribusiness and Cleaner Production Project. The interventions also support individual producers, community groups, and agricultural processors; they help test and develop technology appropriate to identifed market opportunities and facilitate access for individual small and medium-size farmers to fnance for small capital improvements and working capital through existing eligible microcredit organizations. An example of this is the Small-Scale Commercial Agriculture Development Project in Bosnia and Herzegovina. In tourism, interventions are typically less specifc and coincide with the creation of a diagnostic tool such as a database, interpretation and presentation of fndings and scores on the preparedness for sustainable development of the tourism sector, or benchmarking of destinations. This is the case of the Tourism Investment and Development Advisory Services Global Project. Sometimes, the interventions become more explicit and entail assisting the government in structuring hotel deals, attracting foreign investors, and updating the land legislation.

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The most recent agriculture strategy envisages the expansion of its role in regulatory reforms antibiotic resistance executive order buy amoxil 1000 mg free shipping. In parallel to corporate and sector strategies infection resistant to antibiotics buy generic amoxil canada, regional strategies identify improving the regulatory environment as an area to support antibiotics for diphtheroids uti order amoxil 250mg otc. In sum bacteria reproduce asexually buy 250mg amoxil with visa, improving and supporting investment climate reforms is viewed as a priority in Bank Group strategies at various levels antimicrobial 2008 buy amoxil 650 mg on-line. Virtually all regulatory areas for a business-friendly regulatory environment are covered by Bank Group interventions antibiotic otic drops cheap amoxil generic. A comparison between the severity of what frms see as obstacles and the intensity of Bank Group interventions shows a high and signifcant correlation, suggesting that priorities perceived by enterprise managers are broadly in line with interventions by the Bank Group. The results indicate that the Bank Group targets the right countries (those with worse initial conditions) in its support of regulatory reforms. In India, in fact, notwithstanding the multiplicity and geographical distribution of the stakeholders, the consultation process included client surveys, online consultations, workshops, and targeted meetings. This mapping showed that the use of diagnostic tools was more common in World Bank projects (68 percent). In sum, the World Bank Group has supported a comprehensive menu of investment climate reforms. For the interventions xx Investment Climate Reforms with available data, reforms were generally supported in the right countries and generally addressed the right areas of the regulatory environment. Finally, the Bank Group relies on a variety of investment climate diagnostic tools, but the coverage of these tools is incomplete. Effectiveness of World Bank Group Support to Investment Climate Reforms Have regulatory reforms supported by the World Bank Group improved the regulatory environment in which businesses operatefi There is a signifcant degree of variability in the success rate of different interventions. While with before and after almost 80 percent of the impact indicators refected signifcant and positive changes, this share drops to 30 percent and 60 percent with propensity score and difference in difference methods, respectively. Simplistic methods such as before and after show a much wider impact than more sophisticated approaches. This conclusion, nevertheless, is qualifed by at least four important considerations. First, the great majority of indicators used in the analysis are from Doing Business and present methodological problems that might compromise their reliability. Second, the literature on the impact of regulatory reforms on growth, investment, entry, and jobs is extensive but presents mixed and qualifed results. An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Overview xxi And fourth, a proper assessment of the impact of investment climate interventions must take into account that regulatory reforms should improve outcomes for society as a whole, not only for businesses. Overall evidence indicates that many regulatory reforms succeeded in simplifying procedures and reducing time and cost; however, the overall impact of these solutions on investments, jobs, and entry at the country level is not straightforward, as the case of Rwanda suggests. Explicit targeting is limited in the portfolio, but even projects targeting specifc groups do not necessarily report results for the group that was targeted. Only 11 of 19 closed projects targeting gender in their design report results by gender. This will allow a comparison of gender results achieved by interventions with explicit gender targeting (and genderrelevant actions) and those obtained by gender-neutral interventions, but with the potential to disproportionately beneft women. Evidence from country cases shows mixed results and indicates the importance of political feasibility, institutional capacity building, and implementation assistance as determinants of performance. For example, the difference in the design and implementation strategy between Sudan and South Sudan led to vastly different results. By contrast, World Bank investment climate investment projects in agribusiness and tourism on average are less successful than the general investment climate portfolio (71 percent versus 82 percent). Assessing the Social Impacts of Regulatory Reforms Governments typically implement regulatory reform to correct perceived market failures and improve market effciency. The twin goals of poverty elimination and shared prosperity guiding the new World Bank Strategy demand that regulatory reform be understood in the context of broader social values. In practice, though, diagnostics, reform design, and implementation tend to focus primarily on business costs. This is principally because assessments of regulatory reform focus on the real or perceived impact on businesses rather than on the full range of stakeholders whom regulation affects. It performs a necessary function in enabling markets to function and in protecting public health and safety. However, although regulatory reform often generates public goods, not all members of a population are guaranteed to beneft equally, and some may lose out. How societies defne social value is likely to be infuenced by a wide range of factors, including national policies, the level and distribution of wealth, availability of infrastructure, the role of civil society organizations, and demographic factors. Consequently, the appropriate analytical framework to measure this value comprises a theory of change connecting regulatory reform, the actions of businesses, and the wide variety of stakeholders with whom they interact (consumers, suppliers, employees, investors, and others), and a wide range of social value effects. Measuring the An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Overview xxiii benefts and costs of regulatory reform is a diffcult task. Various methodologies are available to measure social value, such as the social return on investment, the standard cost model, and regulatory impact assessment. Procedural indicators such as compliance cost savings do not tell us very much about social benefts. Business stakeholders are treated as paramount; nonbusiness stakeholders are barely visible. Moreover, compliance cost savings data are presented as though they are necessarily benefts for all businesses, yet such benefts are likely to be distributed unevenly, because some are better able to exploit regulatory change than others, and this might even generate adverse impacts for some businesses. Implementation delays and the onset of a crisis are the most commonly encountered implementation problems in Bank Group investment climate projects. This is in part because political stability plays such an important part in the success of investment climate projects. Because most investment climate work relies on the enactment of laws, regulations, and coordination among different ministries and agencies, a committed and strong government is key to success. In Rwanda a high level of commitment enabled it to become one of the top reformers in regulations captured by the Doing Business indicators. In addition, Bangladesh shows the importance of both political stability and commitment to sustain the reform process. The results show that frst, there are aspects under the control of the World Bank Group that can reduce or eliminate the negative effect of external factors. More specifcally, inadequate borrower performance can be alleviated by having a simpler project design, whereas a crisis can be dealt with better if the project does not have a complex design, there is good supervision, and there is a good risk assessment. Finally, there is one factor for which no aspect of implementation can compensate: inadequate technical design. Institutional capacity building and implementation assistance have been instrumental in determining the success of interventions. And the fragile political economy has, more than elsewhere, a fundamental bearing on the success of investment climate interventions. For the World Bank, projects are more likely to have too many components and are less likely to suffer from implementation delays. Beginning in July 2014, all investment climate units will operate under the Trade and Competitiveness Global Practice. This global practice will be the most integrated practice in the new World Bank Group structure. Evidence indicates that the higher the degree of collaboration, the higher the probability of achieving the development objectives is. It must be recognized, however, that these fndings rely on a small number of observations. Overall, half the time collaboration occurs, it refers to simple activities such as information sharing and peer reviewing. Only one-third of the collaboration is deep and involves design and implementation of projects. The factors that play a role in fostering collaboration can be grouped in three categories: the role of the unit and its strategy; systems or formal organization; and informal organization. In contrast, systems and formal organization are seen as mostly discouraging collaboration, although they present a signifcant opportunity for changing this perception. The interviews indicate the concern that the merger cannot be a simple juxtaposition of current systems and programs under one roof. From an operational perspective, many staff hope that serious attempts xxvi Investment Climate Reforms will be made to remove impediments to collaboration found in the formal organization, for example, governance and accountability systems, funding, pricing, human resources policies, and operational systems. Reforms can have broader social and distributional impacts that go beyond the economic and beyond the effects on business. These effects need to be taken into account in the design and implementation of regulatory reforms. The approach should be employed both ex ante (during the design of the project) as well as ex post (to assess the achieved impact of the reform). Such an approach should help better estimate the political economy risk associated with the reform, to identify potential groups that would sustain or oppose reforms and the extent of such support or opposition. The World Bank Group may also consider developing client capacity to conduct social value assessment in order to enable sustainability of investment climate reforms. The World Bank business model is implemented through lending and budget support and to a lesser extent through technical assistance. Yet there was a common sense that the World Bank is slow to respond and to implement projects. Interviews with World Bank Group management and staff surveys indicated that there is collaboration among the institutions, to varying degrees. Different systems and organizational structure are perceived as the main bottlenecks to collaboration. Management recognizes the complexity of this task, given the institutional set-up, with multiple units involved in the World Bank Group work program on investment climate topics, the comprehensiveness of the issues, and the technical sophistication of different reform areas. Management would like to underscore the timeliness of the report, given the important organizational changes taking place in the world Bank Group. The report provides relevant analysis and observations on past investment climate work that can inform the operations of the Trade and Competitiveness Global Practice. Management agrees with the report that World Bank Group interventions generally support reforms most needed by client countries and support regulatory interventions in those countries that need them most. The assessment demonstrates that the activities analyzed are relevant in a strategic and An Independent Evaluation of World Bank Group Support to Reforms of Business Regulations | Management Response xxxi client-oriented context and shows evidence of positive results and the overall effectiveness of investment climate activities across the World Bank Group. Management appreciates the useful set of lessons and agrees with the recommendations, which it looks forward to implementing. As mentioned in the report, these innovations relate to (i) defnition and scope of investment climate; (ii) strategies; (iii) monitoring and evaluation (M&E) frameworks (from output to outcomes/impact); (iv) institutional set-up/delivery models; and (v) consideration of political economy and reform sustainability. This shows major shifts in the strategy, focus areas, and approaches underlying investment climate work at least in the Investment Climate Department and Finance and Private Sector Development space, toward a stronger focus on results and impacts. It also shows shift toward more industry-specifc investment climate reform activities, and importance of cross-cutting topics such as competition, transparency, inclusion, and green growth/climate change. The investment climate work will continue to evolve in the light of experience on the ground and in response to internal developments, such as the new Global Practice agendas. The Bank Group has a comparative advantage in offering advice and in aiding reforms and needs to consider carefully which types of reforms matter more for the desired outcomes. In many cases, the World Bank Group may be far more relevant by being able to effectively help countries enact reforms in a very narrow subset of areas than attempting to be comprehensive and ending up working on several areas in which it does not have specialized expertise or where there is little likelihood of reforms occurring. However, practical experience across many areas shows that while regulatory reforms are indeed critical, they are not suffcient.

An estimated 20% of adults over 40 years of age and 30% of 3 those over age 70 have biliary calculi bacteria and viruses worksheets cheap amoxil 500 mg otc. Other risk factors include bacteria lab report generic amoxil 1000mg free shipping, but are not limited to antibiotic 5898 cheap 1000 mg amoxil with visa, terminal ileal disease bacteria staphylococcus aureus buy 250 mg amoxil with visa, diabetes mellitus bacteria 1 in urine buy amoxil 1000 mg mastercard, long-term parenteral nutrition antimicrobial towels martha stewart purchase discount amoxil line, haemolytic anaemia, liver cirrhosis, cystic fibrosis, and recurrent use of very low fat diets. Biliary colic describes the symptom complex arising from sudden and complete obstruction of the cystic duct or the 11 common bile duct by a stone. The Rome Group for the Epidemiology and Prevention of Cholelithiasis defines symptomatic gallstone disease as pain in the 12 epigastrium and/or hypochondrium lasting more than one half hour. A variety of other gastrointestinal complaints have been associated with uncomplicated gallstone disease, such as bloating, belching, nausea, and fatty food intolerance, but these other factors do not consistently discriminate between gallstone disease and other 4 causes. The clinical picture can depend on their location in the hepatobiliary tract (Table 1. This procedure can be performed by a key hole operation (laparoscopic cholecystectomy), by a small-incision cholecystectomy (incision less than [<] 8cm in length), or by 15 traditional open operation (incision >8cm in length). Laparoscopic cholecystectomy is associated with less pain, shorter hospital stay, faster return to activities of daily living and less abdominal scarring than open surgery, and it is therefore the treatment of choice in symptomatic gallstone disease. In addition, the laparoscopic approach is amenable to use in the day case setting with appropriate patient selection, improved operative techniques and 16 postoperative control of pain, nausea and vomiting. The mortality rate for a low risk patient undergoing laparoscopic cholecystectomy is <1%; operative risks usually arise from comorbid disease. Other complications of cholecystectomy include bile leak treated conservatively (0. Studies have reported that biliary colic remained in only 8% to 9% of patients, in contrast to non-colicky pain in 18% to 32%. It has been suggested that persistent functional gastrointestinal disorder (characterised by abnormal motility, sensation and perception of gut processes) causes post-cholecystectomy symptoms, especially in 20 those who are operated on for atypical symptoms. Between 10% and 18% of patients undergoing surgery for symptomatic gallstones 21 will also have stones in their common bile duct (choledocholithiasis). However, it is unclear if such thresholds are being used, or how consistently they are being applied. This procedure may be coded as the principal procedure or as a secondary procedure. Any variation in practice may be explained by differing catchment sizes or the availability of a particular surgical service, hospital size or specialisation. The number of elective cholecystectomies undertaken in the publicly-funded healthcare system increased by 19. The length of time a patient must wait to be reviewed varies according to the referral pathway and the individual hospital and consultant to which a patient is referred. Of note, delays in access to routine radiological services from primary care have also been noted. Where access is available, public patients were noted to have an average waiting period of 27 14 weeks (range one day to 42 weeks, depending on geographical location). The protocol specifies that patients should be treated based on clinical urgency, with urgent referrals seen and treated first. This had randomised just 75 patients, and the review authors regarded it as being at high risk of bias. In this instance, seven trials met the inclusion criteria, with data from six included for meta-analysis (244 patients in each group). No significant differences were seen in relation to primary outcomes: 39 mortality, bile duct injury, other serious adverse events, and quality of life. Although much of this guidance lay outside the scope of this present work, a number of relevant points were made regarding patients who present with right upper quadrant pain. Most patients who are medically fit will be offered an elective laparoscopic cholecystectomy (within six weeks ideally) after one severe attack of biliary colic as the likelihood of symptomatic recurrence is high. It went on to suggest that the presence of gallstones without abdominal symptoms is not an indication for cholecystectomy unless the patient is immunosuppressed or there is a predisposition for malignancy (for example, the gallbladder wall is calcified or there is a family history of gallbladder cancer). The guideline noted that once a patient with gallstones becomes symptomatic, elective cholecystectomy is indicated. It did note that although there is no single accepted scoring system to predict the presence of stones in the common bile duct (choledocholithiasis), by using factors such as age, liver test results, and ultrasound findings, patients can generally be categorised into low (<10%), intermediate (10%-50%), and high (>50%) probability of having stones in the common bile duct (Appendix 1. In addition, these patients are at risk of serious complications including pancreatitis, cholecystitis and biliary obstruction; over a 10-year period such complications can be expected to occur in 2%-3% of patients with initially silent gallbladder stones and hence cholecystectomy should be offered to all patients with symptomatic gallstones, with the exception of those in whom surgical risk is considered prohibitive. Similarly, in relation to patients with symptomatic common bile duct stones, the consequences are often serious and can include pain, partial or complete biliary obstruction, cholangitis, hepatic abscesses or pancreatitis. Based on these risks, the guideline recommends that wherever patients have symptoms, and investigation suggests ductal stones, extraction should be performed if possible. This report concluded that secondary prevention in the form of prophylactic cholecystectomy for people with asymptomatic gallstones could not be recommended. The guideline did outline a number of exceptions to this rule, however, and these are included in Appendix 1. Similarly, a review by Duncan and Riall, published in 2012, highlighted a number of instances in which those with asymptomatic gallstones should be 40 considered for cholecystectomy (Appendix 1. However, the thresholds that were previously developed by these trusts are likely to represent ongoing practice at a local level while new commissioning guides are being established. For illustrative purposes, the findings of a number of related studies are outlined below. Over this time, 114 patients were admitted for the treatment of confirmed gallstone-related diseases; only 40 patients (35. Delay in referral of symptomatic patients had substantial cost implications; more than half of the patients (11/21 [52. A total of 156 patients underwent cholecystectomy, after a mean duration of 12 months on the waiting list. Reasons for emergency admission included pancreatitis (one), cholangitis (three), choledocholithiasis (seven), cholecystitis (seven), and exacerbation of symptoms (10). The median waiting time for cholecystectomy was 130 days (1 to 1,481 days) (mean 188 days). In other words laparoscopic cholecystectomy within three days of index admission dominates (is less costly and as, or more efficacious) than the alternatives of delayed surgery during the same or a future admission. After three days, surgery during the same admission 47 conferred little advantage over elective admission at a later date. Note the remaining diagnosis-related groups accounted for five or fewer of the procedures each. This patient pathway should be managed by the secondary care team (including gastroenterology, general surgery and interventional radiology services, as appropriate). Where symptoms are suggestive of gallstone disease, all patients should have timely access to necessary radiological investigations via primary care services. Where surgery is indicated, it should be made available at a time when the patient is most likely to derive maximum potential benefit, with due consideration given to their associated risk factors and risk of disease progression. In this case, this pertains to the majority of patients with asymptomatic gallstones. Therefore, the thresholds developed here aim to provide primary care practitioners, surgeons and other clinicians involved in the care of these patients with a template upon which decision making can be standardised. As noted in section 1, obesity has been identified as a key risk factor for the development of gallstone disease. While the evidence regarding resource utilisation and post-operative outcomes may be equivocal at present, the likely continued increased demand within the obese population places an onus on the healthcare system to develop thresholds that will aid in defining which patients are suitable candidates for surgery. The reasons for the regional and local variation are currently unclear and therefore an analysis of the underlying causative factors would be useful in identifying how existing resources might be better utilised. While efficiencies have also been achieved in terms of length of stay and the total number of procedures undertaken, it is likely that waiting lists for surgical intervention will remain substantial. It is thus suggested that one mechanism through which this referral threshold might be implemented would be through its integration in the form of a standardised referral form into this project. As with all thresholds, it is imperative that there are opportunities for appeal mechanisms to ensure good governance. The correlation between ultrasonography and histology in the search for gallstones. Gall stones and mortality: a study of all gall stone related deaths in a single health district. Oral contraceptives, pregnancy, and endogenous oestrogen in gall stone disease-a case-control study. Contemporary outcomes of ambulatory laparoscopic cholecystectomy in a major teaching hospital. Early versus delayed laparoscopic cholecystectomy for people with acute cholecystitis. Referral pathways of patients with gallstones: a potential source of financial waste in the U. Elective laparoscopic cholecystectomy: implications of prolonged waiting times for surgery. Cost-effectiveness of early laparoscopic cholecystectomy for mild acute gallstone pancreatitis. Fat in the stomach releases cholecystokinin, which precipitates gallbladder contraction and might result in biliary pain. High suspicion of gallstones being present in the common bile duct in addition to the gallbladder. Surgical threshold for elective cholecystectomy: fi Symptomatic gallstones fi Gall bladder polyps larger than 8mm or growing rapidly fi Common bile duct stones. Documentation that the threshold criteria are fulfilled is mandatory and the referral letter or form should, as a minimum, contain: fi a clear indication of the grounds for referral against the threshold criteria; fi any relevant medical history and current medication; fi any known factors affecting the patients fitness for day surgery; fi a recent ultrasound report conducted within 2 months at the point of referral; fi a recent liver function test report conducted within 1 month at point of referral. Further guidance: Cholecystectomy should be performed laparoscopically in patients with an uncomplicated abdomen and in the absence of contra-indications. Among its other benefts, research studies have found that yoga increases strength, fexibility, and balance; helps people to maintain a healthy body weight; improves psychological well-being; lowers blood sugar and cholesterol levels; improves sleep; reduces stress; enhances the immune system; lessens fatigue and infammation; and improves quality of life. This white paper (1) provides a summary of research on the benefts of yoga for cancer patients and survivors, (2) highlights the most benefcial components of yoga for cancer survivors, (3) identifes barriers and solutions to the creation of accessible, evidence-based yoga programming, and (4) offers guidelines for developing yoga programs that best meet the unique needs of cancer patients and survivors. Health care providers seeking evidence-informed, cost-effective modalities to manage the shortand long-term effects of cancer and its treatment should consider the benefts of cancer-specifc yoga interventions. Despite advancements in treatment, cancer patients and survivors continue to face unique challenges to their physical and mental health, some of which persist for decades after initial treatment. Cancer survivors are more likely than those without a cancer history to experience poor health and disabilities. Survivors, defned as are more susceptible to other illness, report increased anxiety, and experience disruptions in daily functioning and family life. In 2014, cancer patients paid nearly $4 billion out of pocket for cancer treatments. For 27% of cancer survivors, fnancial hardships include reduced disposable income, increased debt, and/or bankruptcy. Cost-effective and impactful interventions are essential to help individuals manage the devastating impacts of cancer. Yoga is an effective, low-cost cancer management tool that has been shown to improve mortality rates, support individual health and well-being, and reduce health care costs and lost productivity due to cancer. Yoga programs for cancer patients and survivors must be accessible, professionally-led, and supported by oncology team members as well as institutions and health benefts systems. This white paper aims to: Highlight recent research on the therapeutic benefts of yoga interventions for cancer patients and survivors Demonstrate that yoga interventions are an effective and safe complementary modality that can improve health outcomes for cancer survivors Establish guidelines to help healthcare professionals develop safe, effective yoga programs for cancer patients and survivors Like acupuncture, massage therapy, chiropractic care, and other complementary and alternative modalities, yoga interventions can help to ameliorate the immediate and long-term effects of cancer and its treatment and should become a regular part of the continuum of care for cancer patients and survivors. A standard yoga class may include asana (poses), pranayama (breathing techniques), meditation, and relaxation practices to support physical, emotional, and mental health. Because of the varied techniques embedded in the yoga tradition, experimental research on its therapeutic benefts presents a unique set of challenges and considerations. Standardized yoga interventions often vary widely in length and content, making comparison between studies diffcult. Moreover, many yoga studies suffer from design and methodological faws and small sample sizes. Despite these limitations, the body of evidence on therapeutic effects of yoga interventions for cancer patients and survivors is robust and growing. National Library of Medicine (PubMed) yielded 435 results including observational studies, systematic reviews, and clinical trials. Although a full literature review is beyond the scope of this paper, the studies summarized here suggest yoga can not only help adult cancer patients and survivors manage symptoms and side effects, but also help them lead longer, healthier lives. While studies on yoga for cancer populations vary in their methods and sample sizes, this overview of medical research incorporates systematic reviews and randomized controlled trials whenever possible. The studies summarized herein provide substantial evidence on the benefts of cancer-specifc yoga interventions at clinically meaningful endpoints. The research includes a variety of cancers and stages (although breast cancer has been the most studied) and observes patients before, during, and after treatment. While yoga is no cure-all, there is strong evidence that well-crafted interventions have measurable positive effects on health and healing. Ample research suggests yoga interventions increase strength and fexibility; improve balance and mobility; lower blood sugar and cholesterol levels; support healthy body weight; improve psychological well-being; lessen fatigue; improve sleep; reduce anxiety and stress; improve quality of life; and enhance the immune system.

Teaching students self-regulation can reduce anxiety and increase academic performance (Ader & Erktin antibiotic resistance symptoms purchase amoxil 650mg fast delivery, 2010) antibiotics sinus infection pink eye order amoxil amex. Statement of the Problem Many students suffer from anxiety when facing difficult academic tasks virus vaccine buy 500mg amoxil visa. Students with learning disabilities often face more anxiety than general education students (Nelson & Harwood antibiotics overview purchase 250 mg amoxil overnight delivery, 2011) antibiotic prophylaxis purchase amoxil without prescription. People with anxiety have difficulty storing and retrieving information (Nelson & Harwood virus yontooc generic 500 mg amoxil with mastercard, 2011). Some students are very difficult to formally or informally assess because of anxiety. Not all teachers understand the signs of anxiety and the effects on their students. If teachers can recognize the signs, they can help the students cope with academic anxiety. Because all students are different, understanding multiple methods for coping with anxiety can be beneficial for more students. Theoretical Framework or Model According to the Attribution theory, students need to feel in control over the outcome of an academic task. Students who feel more in control over the outcome will have more motivation to successfully complete that task (Lim, 2007). For example, a student who never studies for a spelling test and fails each week might not understand the reason for the poor performance. If the student understands that studying is important for on the spelling tests, the student will be more motivated to study and do well on the test. Causes of success or failure can be external or internal, stable or unstable, and controllable or uncontrollable. Controllable causes are something a student can change, but uncontrollable causes are believed to be unchangeable (Vockell, n. Males tend to focus more on ability and other internal factors while females tend to focus on effort and external factors (McClure, Meyer, Garisch, Fischer, Weir, & Walkey, 2011). Students who have learning goals are students who want to learn more and work hard to succeed. Students who self-handicap are convinced that success will not happen and will not do anything to try for success. The theory and the relationship with motivation and anxiety propose the following research questions. Definition of Terms the following terms are found throughout the literature review. Some of the terms were not defined in the journal articles so the definitions are from the dictionary. Coping, mindfulness, and self-regulation are important to define because each is a strategy use to deal with academic anxiety. Helping students understand learning by using metacognition is an important part of teaching students to control their learning. Students using mindfulness are more likely to understand when they are experiencing anxiety. Stress is how a person mentally and physically reacts to circumstances that are considered difficult or challenging (Beckner, 2004). If teachers and parents help students learn to control anxiety early on, more serious academic problems related to anxiety can be avoided. Contemporary research is supportive of the negative effects of anxiety and stress on academic performance in students of all ages. Low self-concept and lack of motivation have been linked to higher levels of anxiety. Metacognition may help students learn to cope with anxiety and use self-regulation of emotions to combat academic anxiety. Anxiety and Student Performance Student anxiety has long been a topic of discussion amongst researchers. Some research from the 1950s indicates a negative correlation between anxiety and academic performance and other research that did not support that correlation. The researcher worked with students at Brigham Young University to test the hypothesis that honors students with high academic ability have less anxiety than honors students with lower academic ability (Robinson, 1966). After reviewing some of the data, the groups were divided again based on gender because of a significant difference between anxiety levels of male and female students. The results were not necessarily conclusive when comparing honors students to the general population. The article is very informative and lists characteristics, causes, and types of anxiety. Characteristics of anxiety can affect students behaviorally, cognitively, and physiologically. Teachers and parents can work together to help students learn to cope with anxiety. Swan and Howell (1996) conducted a study to determine how test anxiety affects students with learning disabilities and behavior disorders. In this study, researchers worked with 82 students in eighth through twelfth grade. All students in the study had learning disabilities; 61 also had behavior disorders, and 39 also had attention deficit disorder. Students who thought about unrelated subjects during a test had higher levels of anxiety. Teachers read the questions to measure test anxiety, self-concept, internal dialogue, and study habits so all students with low reading levels were not at a disadvantage. Researchers found that test anxiety is a significant problem for students with learning disabilities. Grills-Taquechel, Fletcher, Vaughn, & Stuebing (2012) conducted a quantitative, nonexperimental study to determine the relationship between reading difficulties and anxiety in students. The researchers analyzed the anxiety levels and achievement test scores of 153 average or at-risk general education first grade students. Because the scale is normally used for children who are at least eight years old, the questions were read to the students. At the beginning and at the end of the study, the oral reading fluency levels of the students were monitored using the Continuous Monitoring of Early Reading Skills program. Students who had lower reading scores at the beginning of the study tended to decrease their harm avoidance tendencies at the end of the study. Those same students tended to increase their separation anxiety tendencies at the end of the study. The students did not necessarily worry about their reading skills, but they were more likely to avoid going to school. When using anxiety at the beginning of the study as a predictor of fluency at the end of the study, researchers found that students with higher levels of harm avoidance at the beginning of the study showed increases in reading skills at the end of the study. Nelson and Harwood (2010) performed a study comparing research on learning disabilities and anxiety to determine the connection between the two. The results of the effect size computations were used to determine whether or not students with learning disabilities experienced higher levels of anxiety than students without learning disabilities. The higher the effect size, the stronger the relationship between learning disabilities and anxiety. Negative effect sizes means that a relationship was not found between learning disabilities and anxiety levels. Researchers found a positive effect size value for 95% of the studies with an average of 0. Researchers determined that students with learning disabilities are significantly more likely to suffer from academic anxiety. High levels of academic anxiety can negatively affect working memory (Owens, Stevenson, Hadwin, & Norgate, 2012). Anxiety is also associated with high levels of worry that can affect academic performance. Two groups of 12-13year old students completed self-report questionnaires about anxiety. Parents and students each had to sign consent forms for the students to participate in the studies. Results of the self-report questionnaires indicated a negative correlation between anxiety, depression, and worry, and academic performance with r = 0. High levels of anxiety and depression also contributed to higher levels of worry in students. There was a negative correlation between anxiety, depression, and worry, and working memory. Higher levels of anxiety, depression, and worry can lead to lower academic performance and poorer working memory function. School tasks that involve more working memory are greatly affected by anxiety and depression (Owens et al. Students benefit from lowering the levels of anxiety in school to support healthy working memory. Lower self-efficacy of students can lead to higher levels of anxiety (Ahmed, Minnaert, Kuyper, & van der Werf, 2011). In this quantitative, non-experimental study, researchers had 495 seventh grade students complete questionnaires about math self-concept and math anxiety. The results indicated that higher self-concept correlated with lower levels of anxiety. Researchers were unable to determine whether lower self-concept leads to higher levels of anxiety or if higher levels of anxiety lead to lower levels of self-concept. However, when comparing the data using a chi-square difference test, data suggest that low self-concept is a strong cause of anxiety more than anxiety is a cause of low self-concept. Average students and students with learning disabilities are not alone in suffering from academic anxiety. Fletcher and Speirs (2012) conducted research on how perfectionism and achievement motivation can affect gifted students. Perfectionist students can suffer from academic anxiety because of unrealistic expectations set by themselves or others. There is some disagreement in research as to whether perfectionism is harmful or helpful because not all students react to pressure in the same ways, and research generally focuses on either the good or bad results of perfectionism. Self-prescribed perfectionism is when students have high expectations for themselves. Socially-prescribed perfectionism is when others imposed their high expectations on students. Students may develop anxiety problems because they are very worried about fulfilling others expectations. Researchers did not fully explore the connection between perfectionism and anxiety. McClue, Meyer, Garisch, Fischer, Weir, and Walkey (2011) conducted a study about the relationship between success attributions and motivation in students. Ability-based and effort-based are two types of attributions that researchers related to anxiety levels in students. For this study, researchers used a stratified national sample of 5333 students representing the demographics of public schools in New Zealand. The students were 14 and 15 year olds from 19 public schools throughout the country. Students rated the influence of different reasons for their good and bad performances on tests. The survey used a scale of 1 to 4 with 1 meaning no influence and 4 meaning big influence. Do they go above and beyond what is needed to pass, or do they just do the minimumfi Female students were more likely than males to believe their good grades were because of effort, but poorer grades were because of ability. Students attribute their academic performance to ability tend to have higher levels of anxiety. Students who attribute their academic performance to the effort they put forth tend to have higher levels of anxiety.

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