Inotropes, Vasopressors and Vasodilators

Inotropes, Vasopressors and Vasodilators Suruchi Hasija, Jatin Narula ,Vandana Maravi. ADRENERGIC RECEPTORS AND SIGNALING PATHWAYS The main control over cardiac contractility is provided by the ÃŽ ²Ã¢â‚¬â€œadrenergic signaling pathways and that over the vascular tone by both ÃŽ ±- and ÃŽ ²Ã¢â‚¬â€œadrenergic pathways. The ÃŽ ± and ÃŽ ² receptors are stimulated by catecholamines circulating in the bloodstream and those released locally from the adrenergic nerve endings. The two main subtypes of ÃŽ ²Ã¢â‚¬â€œadrenergic receptors (ÃŽ ²Ã¢â‚¬â€œARs) in the cardiovascular system are the ÃŽ ²1 and ÃŽ ²2 subtypes. Myocardial ÃŽ ²1 and ÃŽ ²2-AR stimulation leads to increased contractility, whereas vascular ÃŽ ²2-AR stimulation induces vascular smooth muscle relaxation. Drug binding to myocardial ÃŽ ²Ã¢â‚¬â€œARs activates stimulatory G protein. This leads to activation of the enzyme adenylate cyclase that catalyzes the conversion of ATP to cAMP. A cascade of intracellular reactions finally leads to the physiological effect of increased myocardial contraction or vasodilation. The ÃŽ ±Ã¢â‚¬â€œadrenergic receptors (ÃŽ ±Ã¢â‚¬â€œARs) are further classified as ÃŽ ±1 and ÃŽ ±2 subtypes. ÃŽ ±1-AR on vascular smooth muscles are the main mediators of vasoconstriction. ÃŽ ±2-AR on the neurons function in a negative feedback loop to control ÃŽ ±-adrenergic vasoconstriction. Stimulation of ÃŽ ±1-AR coupled to G protein activates phospholipase C which in turn raises intracellular Ca+2. Stimulation of ÃŽ ±2-AR coupled to inhibitory G protein inhibits adenylate cyclase, thereby lowering intracellular Ca+2. INOTROPES Inotropy or contractility is the intrinsic property of the cardiac myofibril. It defines the amount of work that the heart can perform at a given load. Contractility is primarily determined by the availability of intracellular calcium. Depolarization of the cardiac myofibril leads to the entry of a small amount of Ca+2 into the cell which triggers the release of additional Ca+2 from intracellular storage sites (sarcoplasmic reticulum). The binding of Ca+2 to troponin, displacement of tropomyosin from the binding site on actin and formation of actin-myosin crossbridges eventually leads to contraction of the myofibril. All inotropic agents act by increasing intracellular calcium. Catecholamines, phosphodiesterase inhibitors and calcium sensitizers are the broad classes of available inotropic agents. Catecholamines Catecholamines comprise the major type of available inotropic agents. Their chemical structure includes a catechol ring, catechol hydroxyl groups and variable side chains. Endogenous(present naturally in the body) catecholamines include epinephrine, norepinephrine and dopamine, and synthetic catecholamines include isoprenaline, dobutamine, dopexamine and fenoldopam. Besides acting directly on adrenergic receptors, some catecholamines may act indirectly by releasing or inhibiting reuptake of norepinephrine at the nerve terminal or by metabolism to form norepinephrine. Table 1: Site and mechanism of action of sympathomimetics Table 2: Haemodynamic effects of catecholamines and phosphodiesterase inhibitors CO=cardiac output, dp/dt=force of myocardial contraction(change in pressure/time), HR=heart rate, SVR=systemic vascular resistance, PVR=pulmonary vascular resistance, PCWP=pulmonary capillary wedge pressure, MVO2=myocardial oxygen consumption Modified from Lehmann A, Boldt J: New pharmacologic approaches for the perioperative treatment of ischemic cardiogenic shock. J Cardiothorac Vasc Anesth 19:97-108, 2005. Epinephrine Epinephrine, a naturally occurring catecholamine, is secreted from the adrenal medulla. The effects on ÃŽ ²Ã¢â‚¬â€œARs predominate at lower doses and on ÃŽ ±Ã¢â‚¬â€œARs at higher doses (> 0.1  µg/kg/min). It increases heart rate (HR), stroke volume (SV) and coronary blood flow (CBF). The rise in blood pressure (BP) results from increase in HR and cardiac output (CO). Systemic vascular resistance (SVR) decreases at low doses (ÃŽ ²2-AR effect) but increases at high doses (ÃŽ ± effect). It is metabolized in the liver by the enzymes catechol-O-methyl transferase (COMT) and monoamine oxidase (MAO), and the metabolites are excreted in urine. It has arrhythmogenic potential. In cardiac surgical patients it is used as an infusion at 0.01-0.4  µg/kg/min to wean patients with poor ventricular function off cardiopulmonary bypass (CPB). (Tables 1 and 2) Norepinephrine Norepinephrine is the postganglionic neurotransmitter in the sympathetic nervous system. It acts on ÃŽ ±1–AR, ÃŽ ±2–AR and ÃŽ ²1–AR, and has negligible action on ÃŽ ²2–AR. The ÃŽ ²1-AR action predominates at lower doses, thereby increasing inotropy, SV and CBF. It increases BP and SVR; but decreases HR. The CO remains unchanged. It has arrhythmogenic potential. The clinical dose range is 0.01 to 0.1  µg/kg/min. Like epinephrine, it is easily oxidized. It is metabolized by COMT and MAO and taken up by the sympathetic neurons. It decreases renal, hepatic, mesenteric and splanchnic blood flow. Dopamine Dopamine is a neurotransmitter in the central and peripheral nervous system. It is the immediate metabolic precursor of norepinephrine and epinephrine. It acts on ÃŽ ±Ã¢â‚¬â€œARs, ÃŽ ²Ã¢â‚¬â€œARs and dopaminergic receptors (DA1-DA5). At 0.5-3  µg/kg/min it increases renal and mesenteric blood flow (dopaminergic effects), between 3-8  µg/kg/min it increases HR and contractility (ÃŽ ²-AR effects) and, above 8  µg/kg/min it causes vasoconstriction (ÃŽ ±-AR effects). Intravenous dopamine does not cross the blood brain barrier. It is metabolized in the liver by COMT and MAO. Isoprenaline Isoprenaline has pure ÃŽ ²Ã¢â‚¬â€œAR agonist activity. It causes an increase in HR and contractility (ÃŽ ²1-AR effect) and decreases SVR (ÃŽ ²2-AR effect). CO increases due to combined ÃŽ ²1 and ÃŽ ²2-AR effect. It dilates pulmonary, skeletal, renal and mesenteric vascular beds. It is indicated in the treatment of pulmonary hypertension, bradycardia (especially after orthotopic heart transplantation), heart block and conduction abnormalities. It is used in the dose 0.01 to 0.1  µg/kg/min. it is metabolized in the liver by COMT. It is arrhythmogenic. Dobutamine Dobutamine is primarily a ÃŽ ²1-AR agonist and has positive inotropic effects. It causes modest increase in HR (ÃŽ ²2-AR effect) and decrease in SVR (ÃŽ ²2-AR effect). The clinical dose range varies from 2-15  µg/kg/min. It is particularly indicated in patients with myocardial pump failure. Its chemical structure lacks the hydroxyl group of catecholamines. It is metabolized in the liver, although not by COMT and MAO. It increases SV, CO and CBF. The arrhythmogenic potential is less than other catecholamines. Dopexamine Dopexamine is a synthetic analog of dopamine. It has potent ÃŽ ²2-AR and dopamine agonist properties and little ÃŽ ²1-AR and ÃŽ ±-AR activity. It causes vasodilation, increase in HR and inotropy. CO and renal blood flow are increased. It is used in the dose 1-10  µg/kg/min. It undergoes methylation and sulfation in the liver and is taken up into the tissues via extraneuronal catecholamine uptake mechanisms. Unlike other catecholamines, it lacks arrhythmogenic potential. Fenoldopam Fenoldopam mesylate is a dopamine DA1 receptor agonist that causes systemic and renal arteriolar vasodilation. It increases renal blood flow at doses of 0.05-0.1  µg/kg/min and reduces BP at 0.1-0.3  µg/kg/min. Phosphodiesterase inhibitors Phosphodiesterase inhibitors act by preventing the breakdown of cAMP, thereby prolonging its physiological response. They do not act via ÃŽ ²-AR stimulation. Their addition to a catecholamine has a synergistic effect in increasing inotropy. They also produce vasodilation and are termed ‘inodilators’. They improve myocardial diastolic relaxation (positive lusitropic effect) and augment coronary perfusion. The clinically used phosphodiesterase inhibitors include amrinone, milrinone and enoximone. Amrinone Amrinone is a bipyridine derivative. It provides positive inotropy and decreases SVR. The decrease in SVR is apparent immediately after administration, whereas positive inotropy is appreciable after 10-15 minutes. They are particularly useful in heart failure by increasing forward flow. It is administered as a bolus loading dose (0.5-1.5 mg/kg) followed by infusion (5-20  µg/kg/min). The potential side effects are thrombocytopenia (2-3%), gastrointestinal upset, myalgia, fever, hepatic dysfunction, ventricular arrhythmias and allergy. Milrinone Milrinone is a derivative of amrinone and is 20 times more potent. It does not cause fever or thrombocytopenia. It is administered as a bolus loading dose (50  µg/kg over 10 minutes) followed by infusion (0.375-0.75  µg/kg/min). Enoximone Enoximone is an imidazole derivative that has more pronounced vasodilatory effect than inotropic effect. It is administered as a bolus loading dose (0.5-1 mg/kg) followed by infusion (5-10  µg/kg/min). Levosimendan Levosimendan is a new inotropic agent belonging to the class of calcium-sensitizing agents, i.e., it sensitizes the myocardium to the actions of calcium. It has vasodilating and anti-ischemic properties mediated by opening of K+-ATP channels. The haemodynamic effects include increase in SV and CO and reduction in filling pressures, mean arterial pressure (MAP), mean pulmonary artery pressure (MPAP) and SVR. It also promotes lusitropy. It is useful in patients with compromised left ventricular function, difficulty in weaning from CPB and right ventricular failure. It is used in a loading dose of 12  µg/kg over 10 minutes followed by an infusion of 0.1  µg/kg/min. Calcium chloride Calcium ions play an important role in excitation-contraction coupling in the cardiac myofibrils. It has positive inotropic effect that is effective after CPB and in the short-term treatment of myocardial pump failure. The rise in BP occurs secondary to increased inotropy and vasoconstriction. However, it can attenuate the ÃŽ ²-AR effects of epinephrine in the postoperative cardiac surgical patients. It is administered in the dose of 2-4 mg/kg every 10 minutes. Calcium Gluconate the clinically available compound of calcium ,contains less than half of ionized calcium and has to be metabolized in the liver before action. VASODILATORS Vasodilators cause relaxation of arterial smooth muscle thereby reducing SVR and MAP. In addition, they also have venodilating property. They aid discontinuation of CPB by decreasing preload, right and left ventricular afterload, improving lusitropy and CBF. They are useful in the perioperative treatment of systemic and pulmonary hypertension, myocardial ischemia and ventricular dysfunction complicated by excessive pressure or volume overload. Sodium nitroprusside Sodium nitroprusside (SNP) acts by acting as a substrate for the formation of nitric oxide (NO) in the vascular endothelium. Binding of NO to its receptor induces a conformational change in the enzyme guanylate cyclase and production of cGMP from GTP. cGMP is the second messenger that eventually leads to vascular smooth muscle relaxation via numerous intermediate steps. SNP predominantly causes arterial and arteriolar vasodilation, but at high doses venodilation also occurs. Reflex tachycardia is apparent with its administration. SV and CO are increased only if the preload is maintained with intravenous fluids. SNP has a potential to cause ‘coronary steal’ phenomenon in patients with coronary artery disease as the epicardial coronary arteries also dilate diverting blood away from the stenosed endocardial coronary arteries. It decreases pulmonary vascular resistance (PVR) and MPAP. It abolishes hypoxic pulmonary vasoconstriction and may contribute to hypoxia. The infusion rate is 0.5  µg/kg/min, and titrated to effect. It is reconstituted in a dextrose-containing solution. SNP is sensitive to light, therefore the infusion syringe and tubing are wrapped with opaque material to prevent light induced structural breakdown of the drug. Cyanide toxicity may occur with the use of SNP above 1.5 mg/kg acute dose or 8  µg/kg/min chronic infusion. SNP is used during hypothermic CPB to promote uniform cooling by preventing cold induced vasoconstriction, to reduce the perfusion pressure, to reduce afterload by decreasing SVR and to increase pulmonary blood flow by decreasing PVR. Nitroglycerin Nitroglycerin (NTG) acts by the same mechanism as other nitrates. NTG is primarily a venodilator and reduces ventricular preload and myocardial oxygen consumption. NTG is of particular importance in patients with congestive heart failure as it unloads the left ventricle. It has modest effects on SVR and BP. It reduces PVR. The starting dose of intravenous nitroglycerin is 0.5  µg/kg/min which may be titrated to effect. Attention must be paid to the fluid status as CO may drastically reduce. At higher doses systemic vascular dilation occurs. NTG is helpful in coronary artery disease because it causes epicardial coronary artery dilation. It is metabolized in the liver. Methemoglobinemia occurs at high infusion rates. Intravenous nitroglycerin has a half-life of 1-3 minutes. Tolerance develops when administered for more than 8 hours. Nitric oxide Nitric oxide (NO) is the endothelium derived relaxing factor. Its mechanism of action has been described above. It has a very short half-life of 5 seconds. Inhaled NO promotes pulmonary vascular dilation. It can be used upto 80 parts per million (ppm) in patients with severe right ventricular failure and pulmonary arterial hypertension. As inhaled NO is rapidly taken up by the heme group of guanylate cyclase, it only acts locally in the pulmonary vascular bed causing pulmonary vasodilation. It has no systemic effects. Phenoxybenzamine Phenoxybenzamine is a non-competitive ÃŽ ±1 and ÃŽ ±2-AR blocker. It decreases PVR and SVR, thereby increasing CO. It is used to promote vasodilation during deep hypothermic circulatory arrest for uniform cooling and for the treatment of pulmonary hypertension. Phenoxybenzamine is a very potent and long acting vasodilator. It was traditionally used for afterload reduction, pulmonary vasodilatation, and in adrenal tumors such as pheochromocytoma. Phentolamine, a shorter acting agent is now more commonly used. VASOPRESSORS Vasopressors act on arteries and arterioles to increase SVR (ÃŽ ±-AR effect). They have some ÃŽ ² –AR effect also. Catecholamines such as norepinephrine, and epinephrine and dopamine at high concentrations are potent vasoconstrictors. In addition, sympathomimetics such as phenylephrine, methoxamine, ephedrine, metaraminol and mephentermine are also vasoconstrictors. They are metabolized by COMT and MAO. Phenylephrine Phenylephrine is a pure ÃŽ ±1-AR agonist and its primary action is to increase SVR. Reflex bradycardia may be seen. Vasoconstriction of renal, splanchnic and other vascular beds occurs. Coronary perfusion pressure is increased due to increase in diastolic pressure. The intravenous bolus dose is 50-100  µg and infusion rate is 0.5-1.0  µg/kg/min. Its effect is apparent in 1 minute and lasts upto 20 minutes. It is commonly used to increase SVR and therefore the perfusion pressure on CPB. Mephentermine Mephentermine has direct action on ÃŽ ±-AR and ÃŽ ²-AR, and indirect action by releasing norepinephrine at the nerve terminal. It increases CO and SVR. Its acts immediately on intravenous injection and it’s action lasts 30 minutes. It is used in 15-45 mg bolus doses and as 0.1% infusion titrated to effect. Vasopressin Vasopressin,a hormone of the anterior pituitary is a potent vasoconstrictor. It mediates vasoconstriction by inhibiting K+ ATP channels on vascular smooth muscles and blunting the rise in cGMP (due to NO and ANP) and cAMP (due to ÃŽ ²2-AR stimulation). It is one of the modalities of treating vasodilatory shock after CPB. It is used in the infusion dose of 0.01-0.1 U/min for this purpose. At higher doses it has the potential to cause renal and splanchnic vasoconstriction. It is also administered as a bolus dose of 40 U i.v. during cardiopulmonary resuscitation. Suggested reading Hoffman TM. Newerinotropesin pediatric heart failure. J Cardiovasc Pharmacol. 2011 Aug;58(2):121-5 Rognoni A, Lupi A, Lazzero M, Bongo AS, Rognoni G. Levosimendan: from basic science to clinical trials. Recent Pat Cardiovasc Drug Discov. 2011 Jan;6(1):9-15. Tavares M, Rezlan E, Vostroknoutova I, Khouadja H, Mebazaa A. New pharmacologic therapies for acute heart failure. Crit Care Med. 2008 Jan;36(1 Suppl):S112-20. Petersen JW, Felker GM. Inotropesin the management of acute heart failure. Crit Care Med. 2008 Jan;36(1 Suppl):S106-11 Ward RM, Lugo RA Cardiovascular drugs for the newborn.Clin Perinatol. 2005 Dec;32(4):979-97 Hug CC Jr. Making a choice ofinotropesandvasodilatorsin clinical situations.J Card Surg. 1990 Sep;5(3 Suppl):272-7 Stanford GG. Use of inotropicagentsin critical illness. Surg Clin North Am. 1991 Aug; 71(4):683-98.

Role Off Company Secretary

A Company Secretary is a person at very high position in a private sector company or public sector organization, normally at a managerial position. In some countries in a public sector the company secretary is reoffered as Corporate Secretary or Secretary. There is a requirement to appoint company secretary. It is already understood that a company is the creation of law, having rights, duties and obligations just as that of human being. The so-called legal entity may therefore sue and be sued: Saloman’s case. But because of the abstract nature of a company as a ‘person’ it becomes necessary that directors be put in place to see to the effective running of the corporation. However, the directors are not required to be lawyers nor know anything about the company law. In the same regard, the prompters of the company need not be lawyers or know anything about company law. But a company being an artificial person, created by operation of law, must subsist as a person on law – it must continue to obey the provisions of the law since it derives its existence as a person from it. Therefore it becomes necessary that the company be run effectively in a manner that conforms to the statutes and other regulations and best practices hence the need for a Company Secretary. The position of a company secretary is created by the law creation of law in section 293 -298 of the Companies and Allied Matters, Act, 2004 which provides for the appointment and functions of the Company Secretary, with special reference to public companies . The Company Secretary is responsible for the efficient functioning and administration of a company, particularly with regard to ensuring compliance with statutory and regulatory requirements and for ensuring that decisions of the Board of Directors are implemented. [1] Even though the name suggests the job of a clerk or secretary it is nothing related to it. The company secretary ensures that an organization complies with relevant legislation and regulation, and keeps board members informed of their legal responsibilities. Company secretaries are the company’s named representative on legal documents, and it is their responsibility to ensure that the company and its directors operate within the law. It is also their responsibility to register and communicate with shareholders, to ensure that dividends are paid and to maintain company records, such as lists of directors and shareholders, and annual accounts. In many countries, private companies have traditionally been required by law to appoint one person as a ompany secretary, and this person will also usually be a senior board member. A company secretary is one of the senior board members according to the law in India. Most people forming a company undervalue the importance of a company secretary. The company secretary is the named representative on legal documents and it is their responsibility to advice the directors of their corporate compliance obligations. In moat established companies the company secretary serves as a focal point between the board of directors, senior management and the company’s shareholder. Since 6th April 2008 there is no longer a legal requirement to have a company secretary, although many limited companies appoint one to cover a range of jobs roles. A job of a company secretary is to organize and prepare agendas. A company secretary takes minutes at the board meeting and annual general meetings. Filing with the companies house, maintaining company records and statutory books are some of the important deals of company secretary. A company secretary deals with stock transfer and dividends he ensures the security of the company’s legal documents. He also ensures compliance with all the legal and the statutory requirements. He builds up a contact with external and regulatory bodies Roles and responsibilities The Company in all sectors have high level responsibilities including governance structures and mechanisms, corporate conduct within an organization’s regulatory environment, board, shareholder and trustee meetings, compliance with legal, regulatory and listing requirements, the training and induction of non-executives and trustees, contact with regulatory and external bodies, reports and circulars to shareholders/trustees, management of employee benefits such as pensions and employee share, insurance administration and organization, the negotiation of contracts, risk management, property administration and organization and the interpretation of financial accounts. Company secretaries are the primary source of advice on the conduct of business and this can span everything from legal advice on conflicts of interest, through accounting advice on financial reports, to the development of strategy and corporate planning. Among public companies in North America, providing advice on corporate governance issues is an increasingly important role for corporate secretaries. Many shareholders, particularly institutional investors, view sound corporate governance as essential to board and company performance. They are quite vocal in encouraging boards to perform frequent corporate governance reviews and to issue written statements of corporate governance principles. The corporate secretary is usually the executive to assist directors in these efforts, providing information on the practices of other companies, and helping the board to tailor corporate governance principles and practices to fit the board's needs and expectations of investors. In some companies, the role of the corporate secretary as corporate governance adviser has been formalized, with a title such as Chief Governance Officer added to their existing title. In view of the important roles the company secretary plays in business, PLC’s and large companies require the company secretary to be suitably trained, experienced and professionally qualified for these responsibilities. In the UK, the company secretary may be qualified by virtue of examination and membership of the institute of chartered company secretary and administration (ICSA), which is the main qualification specifically for company secretaries. ICSA is the body dedicated to the advancement and recognition of professional administration based on a combination of degree-level studies, carefully vetted experience and sponsorship by two people of professional status. Only a person thus qualified is entitled to be designated a ‘Chartered Secretary' or ‘Chartered Company Secretary'. The Faculty of Secretaries and Administrators founded in 1930 is the second body of corporate secretaries in the United Kingdom and now has a strong emphasis on equality work and governance and its members are designated ‘corporate secretaries' or ‘certified public secretaries'. It is expected that Company Secretaries of Publicly Quoted Companies will be professionally qualified through ICSA, one of the Chartered Professional Bodies in the Accountancy Profession or have appropriate training and experience through another body. In India, the Institute of Company Secretaries of India (ICSI) regulates the profession of Company secretaries. ICSI is a statutory professional body which has more than 29,010 associate members. Chartered secretaries are employed as chairs, chief executives and non-executive directors, as well as executives and company secretaries. Some chartered secretaries are also known in their own companies as corporate secretarial executives/managers or corporate secretarial directors. Chartered Secretaries are the sixth highest paid employees in the UK according to the Office for National Statistics Annual Survey of Hours and Earnings (March 2010). Many corporate secretaries of North American public companies are lawyers and some serve as their corporation's general counsel. While this can be helpful in the execution of their duties it can also create ambiguity as to what is legal advice, protected by privilege, and what is business advice. In India every company having a paid up share capital of Rs. 50 million (5 crores) or more is required to appoint a qualified person as Company Secretary. A company having not less than Rs. one million (10 lacs) paid up capital and not required to appoint a full-time company Secretary should file a compliance certificate signed by a practising Company Secretary with the Registrar of Companies. Section 383A of the Companies Act, 1956 provides for the mandatory appointment of a whole time secretary where the paid up capital of the Company exceeds Rs. 50 million (5 crores). If the capital is less than Rs. 50 million (5 crores), the company is required to obtain a secretarial compliance certificate and attach the same to the Directors' Report and file it with the Registrar of Companies. Statutory declarations of compliance under various other provisions of the Companies Act, 1956 are also to be certified by practicing company secretaries. Under the MCA 21 e filing regime several forms (including some, exclusively) are required to be pre-certified by practicing company secretaries. The MCA 21 regime has ushered in a dramatic change in the role and profile of the profession, particularly, the practicing side. The annual returns of companies listed on recognized stock exchanges are to be signed by a practising company secretary. Further, the Securities and Exchange Board of India (SEBI) also recognizes the Company Secretary as the Compliance Officer and the practicing company secretary to issue various certificates under its Regulations. Further, the practicing Company Secretaries are also authorized to certify compliance of conditions of corporate governance in case of listed companies. The Reserve Bank of India also authorizes company secretaries to issue various certificates. The Institute of Company Secretaries of India is the premier professional body to develop and regulate the profession of Company Secretaries in India. It was set up by an Act of Parliament in 1980. When the Companies Bill, 2011 will be passed by the parliament and becomes an Act, the National Company Law Tribunal (NCLT) will be given powers of a court and all matters relating to Company Law would be heard before it instead of High Court. A Company Secretary would be eligible to appear before NCLT. This will open more opportunities for a Company Secretary. What Does a Corporate Secretary Do? So just what does a Corporate Secretary* do, anyway? A good question, but difficult to answer! While the basic duties of the Corporate Secretary can be outlined easily, the position's overall responsibilities–and the fit of the role within senior management–vary and are more difficult to explain. A â€Å"Corporate Secretary† is required by state corporation laws for every corporation; he or she is, at the most basic level, the individual who keeps the official records and minutes of the corporation. Corporate by-laws set forth the powers and duties of the Corporate Secretary and other corporate officers. One may think that the Corporate Secretary is merely a combination of scrivener and custodian, but this is not the case in practice. The Corporate Secretary in today's world is a senior corporate officer with wide-ranging responsibilities, who serves as a focal point for communication with and between the board of directors, senior management and the company's shareholders, and who has a key role in the administration of the Board and critical corporate matters. The Corporate Secretary is often a confidante and counselor to the Chief Executive Officer, members of the Board, and other members of senior management, especially on corporate governance matters. A key responsibility for the Corporate Secretary is to ensure that Board members have the proper advice and resources for discharging their fiduciary duties to shareholders under state law. A Corporate Secretary also is responsible for ensuring that the records of the Board's actions reflect the proper exercise of those fiduciary duties. Some Corporate Secretaries who are lawyers handle this function themselves; others partner with the General Counsel and/or outside counsel. The function ranges from making sure new directors have training in the applicable state law duties and the business of the company, to ensuring that management follows the proper steps for major corporate actions such as share issuances, the declaration of dividends, and mergers, acquisitions, or dispositions of corporate assets. A Corporate Secretary also provides advice on corporate governance ssues, particularly related to the re-election of directors and other shareholder action taken at Annual Meetings. Many shareholders, particularly institutional investors, view sound corporate governance as essential to board and company performance. The Corporate Secretary is usually responsible for a comp any’s Corporate Governance Principles or Guidelines. In some companies, the role of the Secretary as corporate governance adviser has been formalized, with a title such as Chief Governance Officer or Corporate Governance Officer added to their existing title. Most Corporate Secretaries are responsible for the following : (More details are available by clicking on some of these topics. ) 1. Board and Committee Meetings

Force Feeding Anorexic Patients Is This Practice Doing...

Force Feeding Anorexic Patients: Is This Practice Doing More Harm Than Good? One of my high school best friends was diagnosed with anorexia my junior year of high school. Her condition was not severe, but still very serious because it led her to attempt to kill herself. After coming back to school from being in a mental health institution, she had gained weight from being forced to eat and was more than ever determined to lose the weight that she had gained. Clearly, being forced to eat made her condition worse. Patients with anorexia nervosa who are alarmingly thin, around 15% or so below their expected body weight, are sometimes force fed, more often than not through a tube inserted through their nose. This has raised many questions†¦show more content†¦Judges do realize what is at stake for these patients, but there are still varying opinions: some favor forced feeding because it keeps the patient alive while some are opposed to it because it takes away their dignity and right to refuse lifesaving medical treatment. Furthermore, there are different types of forced feedings. The most common type is the patient sits at a table and they must clean their plate before they are allowed to leave. Once they are done, there is a resting period wear patients are not left alone and cannot exercise. The other type is the type where the nutritious substance is sent through a feeding tube inserted through the nose to the stomach. I acquired my information from online peer reviewed journals like PubMed and articles from CNN and Huffington Post. The peer reviewed articles conducted experiments and observational studies to help further discuss whether or not this method was beneficial or harmful. The articles on websites like CNN and Huffington Post further analyze these studies but also bring up really good pros and cons and let you decide what stance you take. Despite having looked up some information about force feeding anorexic patients, there is still more info rmation that I need to know to effectively take a stance and back it up. Some of these questions that I need to research and learn more about include: Do ethical standards dictate what