Decisional responsibility for mechanical ventilation and weaning: an international survey

Introduction: Optimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement.

Methods: A multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making.

Results: Response rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0)). Country of ICU location influenced the profile of responsibility for all decisions. Automated weaning modes were used in 55% of ICUs.

Conclusions: Collaborative decision making for ventilation and weaning was employed in most ICUs in all countries although this was influenced by nurse-to-patient ratio, presence of a protocol, and varied across countries. Potential clinical implications of a lack of collaboration include delayed adaptation of ventilation to changing physiological parameters, and delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation.

A study of the 10% electric vehicles target of the single electricity market

In late 2008, the Government of the Republic of Ireland set a specific target that 10% of all vehicles in its transport fleet be powered by electricity by 2020 in order to meet European Union renewable energy targets and greenhouse gas emissions reduction targets. International there are similar targets. This is a considerable challenge as in 2009, transport accounted for 29% of non-emissions trading scheme greenhouse gas emissions, 32% of energy-related greenhouse gas emissions, 21% of total greenhouse gas emissions and approximately 50% of energy-related non-emission trading scheme greenhouse gas emissions. In this paper the impacts of 10% electric vehicle charging on the single wholesale electricity market for the Republic of Ireland and Northern Ireland is examined. The energy consumed and the total carbon dioxide emissions generated under different charging scenarios is quantified and the results of the charging scenarios are compared to identify the best implementation strategy.

Down with MNE-centric theories! Market entry and expansion as the bundling of MNE and local assets

Both Anderson and Gatignon and the Uppsala internationalization model see the initial mode of foreign market entry and subsequent modes of operation as unilaterally determined by multinational enterprises (MNEs) arbitraging control and risk and increasing their commitment as they gain experience in the target market. OLI and internalization models do recognize that foreign market entry requires the bundling of MNE and complementary local assets, which they call location or country-specific advantages, but implicitly assume that those assets are freely accessible to MNEs. In contrast to both of these MNE-centric views, I explicitly consider the transactional characteristics of complementary local assets and model foreign market entry as the optimal assignment of equity between their owners and MNEs. By looking at the relative efficiency of the different markets in which MNE and complementary local assets are traded, and at how these two categories of assets match, I am able to predict whether equity will be held by MNEs or by local firms, or shared between them, and whether MNEs will enter through greenfields, brownfields, or acquisitions. The bundling model I propose has interesting implications for the evolution of the MNE footprint in host countries, and for the reasons behind the emergence of Dragon MNEs.

International Projects and Cross-Cultural Adjustment of British Expatriates in Middle East: A Qualitative Investigation of Influencing Factors

Increased globalisation within the British AEC (Architectural, Engineering and Construction) sector has increased the need for companies to transfer staff to manage their overseas operations. To be able to perform abroad, expatriates must harmonise themselves to the conditions prevailing in the host country. These include getting accustomed to living, working and interacting with the host country nationals. The process is commonly referred to as 'cross-cultural adjustment'. Various factors influence the process of adjustment. In order to identify these issues, a qualitative study was undertaken, which mainly comprised of comprehensive literature review, individual interviews and focus group discussion with British expatriates working on international AEC assignments in Middle Eastern countries. Through interpretative approach, the current study aims to understand the concept of cross-cultural adjustment of British Expatriates based in Middle East and their influencing factors.

The findings suggest that success of expatriation does not entirely rest on an expatriate's ability but also on organisational support and assistance that expatriates receive prior to and during the assignment. Organisational factors such as selection mechanisms, job design, training, logistical and social support, mentoring, etc., influence various facets of expatriate adjustment. Striking cultural contrasts between British and Arab culture both in work and non work situations also dictate the level of support required by the expatriate, suggesting that relocation to less developed, remote or politically unstable regions, demands additional support and consideration by the parent company. This study is relevant to the AEC companies employing British expatriates, who need to be cognisant of the issues highlighted above to make rational and informed decisions when handling international assignments in the Middle East.

Late industrialization and the increased merit selection hypothesis - Ireland as a test case

The Irish case provides a particularly appropriate test of the increasing merit selection hypothesis deriving from the liberal theory of industrialization. This is so not only because the lateness and speed of economic change allows us to capture such change through a set of national surveys conducted in the past three decades, but also because such change was based on a sustained policy of increased openness to international competitive forces. The functional requirements of the economy and a rapid increase in the supply of those with higher educational qualifications provided an ideal context in which to observe the movement from ascription to achievement predicted by the liberal theory. However, while changes in the class structure and a rapid expansion of educational opportunity had significant consequences in terms of absolute mobility, there was no evidence of a significant shift towards meritocratic principles. At the same time as the service class increased their advantage over other classes in the pursuit of educational qualifications, the impact of educational qualifications on class destination diminished. Controlling for education, we find that the impact of class origin effects is substantial and shows little sign of diminishing over time. In our conclusion we discuss the implications of our findings in the context of the recent debate on meritocracy.

Avoidance Techniques: State Related Defences in International Antitrust Cases

Despite its economic significance, competition law still remains fragmented, lacking an international framework allowing for dispute settlement. This, together with the growing importance of non-free-market economies in world trade require us to re-consider and re-evaluate the possibilities of bringing an antitrust suit against a foreign state. If the level playing field on the global marketplace is to be achieved, the possibility of hiding behind the bulwark of state sovereignty should be minimised. States should not be free to act in an anti-competitive way, but at present the legal framework seems ill-equipped to handle such challenges.

This paper deals with the defences available in litigation concerning transnational anti-competitive agreements involving or implicating foreign states. Four important legal doctrines are analysed: non-justiciability (political question doctrine), state immunity, act of state doctrine and foreign state compulsion. The paper addresses also the general problem of applicability of competition laws to a foreign state as such. This is a tale about repetitive unsuccessful efforts to sue OPEC and recent attempts in the US to deal with export cartels of Chinese state-owned enterprises

Fraternities and Labor Market Outcomes

We model how student choices to rush a fraternity, and fraternity admission choices, interact with signals firms receive about student productivities to determine labor-market outcomes. The fraternity and students value wages and fraternity socializing values. We provide sufficient conditions under which, in equilibrium, most members have intermediate abilities: weak students apply, but are rejected unless they have high socializing values, while most able students do not apply to avoid taint from association with weaker members.

Generalized Selection Combining in Cognitive MIMO Relay Networks

We propose transmit antenna selection with receive generalized selection combining (TAS/GSC) in dual-hop cognitive decode-and-forward (DF) relay networks for reliability enhancement and interference relaxation. In this paradigm, a single antenna which maximizes the receive signal-to-noise ratio (SNR) is selected at the secondary transmitter and a subset of receive antennas with the highest SNRs are combined at the secondary receiver. To demonstrate the impact of multiple primary users on the cognitive relay network, we derive new closed-form expressions for the exact and asymptotic outage probability with TAS/GSC in the secondary network. Several important design insights are reached. We corroborate that the full diversity gain is achieved, which is entirely determined by the total number of antennas in the secondary network. The negative impact of the primary network on the secondary network is reflected in the SNR gain.