Successful Liberation Research Articles

Management of Autism in the Adult Intensive Care Unit

Autism comprises a growing segment of the population and can be a management challenge in the intensive care unit (ICU). We present the case of a 22-year-old male with severe autism and intellectual disorder who developed respiratory failure and required a prolonged ICU course. This patient exhibited severe distress, aggression, and self-injurious behavior. Management challenges included sedation, weaning from sedation, and liberation from mechanical ventilation. Success was achieved with a multispecialty team and by tailoring the environment and interactions to the patient's known preferences. The use of dexmedetomidine to wean high-dose benzodiazepines and opiates also permitted successful liberation from mechanical ventilation.

Hezbollah’s War of Position: The Arab–Islamic Revolutionary Praxis

The May 2000 victory of Hezbollah over Israel, and the liberation of southern Lebanon, proposed and advanced a new and hitherto successful grand Arab liberation strategy. Inspired by this victory, ...

Capital Folws, capital account liberalisation and the southern Mediterranean countries

This paper examines questions related to possible capital account liberalisation in the Mediterranean countries. First, we provide an overview of the extent to which these countries have capital controls along with their exchange rate regimes and some basic macroeconomic aggregates. Second, we examine the case for capital account liberalisation, along with the prerequisites for successful liberalisation. Here we consider issues such as sequencing and possible benefits of synchronisation. Finally, we examine the experience with capital flows – both FDI and other capital flows. We explain these flows and use the past experience of these countries to draw some conclusions for the successful opening up of the capital account. JEL Codes: F21, F32, O19, O24

The association between body mass index, processes of care, and outcomes from mechanical ventilation

To determine the association between excess weight and processes of care and outcomes for critically ill adults. Prospective cohort study. Three medical intensive care units at two hospitals. Five hundred eighty mechanically ventilated adult patients admitted between February 1, 2006 and January 31, 2008. None. After adjusting weight based on the recorded fluid balance before enrollment, 21.9% of subjects were categorized into different body mass index categories than without this adjustment. We used a competing risk analysis with events of interest considered death during hospitalization and successful liberation from mechanical ventilation. We found no statistically significant difference between body mass index categories (<25 kg/m² vs. 25 to <30 kg/m² vs. ≥30 kg/m²) in the competing risks analyses when the results were unadjusted or adjusted for severity of illness and comorbidities. When the analyses were adjusted for the use of continuous infusions of opioids and/or sedatives and ventilator parameters (tidal volume per ideal body weight, positive end-expiratory pressure, and airway pressure), subjects with an overweight fluid-balance-adjusted body mass index had significantly lower hazard ratios for dying while hospitalized (adjusted hazard ratio 0.68 [95% confidence interval 0.47-0.99], p=.044), and those with an obese fluid-adjusted body mass index had significantly higher hazard ratios for successful extubation (adjusted hazard ratio 1.53 [95% confidence interval 1.14-2.06], p=.005). An analysis of longer-term mortality found lower adjusted hazard ratios for subjects with overweight (adjusted hazard ratio 0.74 [95% confidence interval 0.56-0.96]) and obese (adjusted hazard ratio 0.74 [95% confidence interval 0.59-0.94]) fluid-balance-adjusted body mass indices. Processes of provided care may affect the observed association between excess weight and outcomes for critically ill adults and should be considered when making inferences about observed results. It is unknown if disparities in processes of care are due to clinically justified reasons for variation, bias against heavier patients, or other reasons.

Emergency Bedside Extracorporeal Membrane Oxygenation for Rescue of Acute Tracheal Obstruction

A 39-year-old man experienced total obstruction of a distal tracheal plastic stent by a tumor mass, preventing effective ventilation and resulting in cardiac arrest. Resuscitation by emergency bedside venoarterial extracorporeal membrane oxygenation (ECMO) permitted time to physically remove the obstructing tumor and reestablish successful ventilation and liberation from ventilatory support. We review several other reported cases of emergency ECMO to resuscitate patients with acute airway obstruction.

Dialyse sans héparine : dialysat au citrate et AN69ST hépariné

To examine the association between continuous renal replacement therapy (CRRT) liberation and clinical outcomes among patients with acute kidney injury (AKI) requiring CRRT.This single-center, retrospective cohort study included adult patients admitted to intensive care units with AKI and treated with CRRT from January 1, 2007, to May 4, 2018. Based on the survival and renal replacement therapy (RRT) status at 72 hours after the first CRRT liberation, we classified patients into liberated, reinstituted, and those who died. We observed patients for 90 days after CRRT initiation to compare the major adverse kidney events (MAKE90).Of 1135 patients with AKI, 228 (20%), 437 (39%), and 470 (41%) were assigned to liberated, reinstituted, and nonsurvival groups, respectively. The MAKE90, mortality, and RRT independence rates of the cohort were 62% (707 cases), 59% (674 cases), and 40% (453 cases), respectively. Compared with reinstituted patients, the liberated group had a lower MAKE90 (29% vs 39%; P=.009) and higher RRT independence rate (73% vs 65%; P=.04) on day 90, but without significant difference in 90-day mortality (26% vs 33%; P=.05). After adjustments for confounders, successful CRRT liberation was not associated with lower MAKE90 (odds ratio, 0.71; 95% CI, 0.48 to 1.04; P=.08) but was independently associated with improved kidney recovery at 90-day follow-up (hazard ratio, 1.81; 95% CI, 1.41 to 2.32; P<.001).Our study demonstrated a high occurrence of CRRT liberation failure and poor 90-day outcomes in a cohort of AKI patients treated with CRRT.

Trade Liberalization Sequence for Sustained Economic Growth

This paper delivers a simple model to generalize the successful trade liberalization experiences in East Asian countries as a strategy for attaining inclusive and sustained economic growth. The sequential approach, based on preserving existing production units while liberalizing export-oriented sectors, can be understood as a way to promote international interactions and learning by practice, to extend the limit of market and to introduce market incentive and pressure on all related agents for attaining dynamic efficiency. It provides a regular liberalization sequence to ignite and sustain economic growth for most lagged economies.

Los nudos de la desunión: conflictos y divergencias en la dirigencia del ejército realista durante la emancipación del Perú, 1810-1824

This article uses unpublished letters sent by Gererals La Serna, Canterac, Ramirez, and Ricafort to Intendant Juan Bautista de Lavalle in Arequipa to examine the conflicts that arose within the royal army during the Peruvian War of Independence. It argues that the royal army was seriously undermined by such internal conflicts, which lay at the heart of the disunity which in turn contributed to the successful liberation of the colonies.

Prediction of extubation outcome: a randomised, controlled trial with automatic tube compensation vs. pressure support ventilation

IntroductionTolerance of a spontaneous breathing trial is an evidence-based strategy to predict successful weaning from mechanical ventilation. Some patients may not tolerate the trial because of the respiratory load imposed by the endotracheal tube, so varying levels of respiratory support are widely used during the trial. Automatic tube compensation (ATC), specifically developed to overcome the imposed work of breathing because of artificial airways, appears ideally suited for the weaning process. We further evaluated the use of ATC in this setting.MethodsIn a prospective study, patients who had received mechanical ventilation for more than 24 hours and met defined criteria for a weaning trial, underwent a one-hour spontaneous breathing trial with either ATC (n = 87) or pressure support ventilation (PSV; n = 93). Those tolerating the trial were immediately extubated. The primary outcome measure was the ability to maintain spontaneous, unassisted breathing for more than 48 hours after extubation. In addition, we measured the frequency/tidal volume ratio (f/VT) both with (ATC-assisted) and without ATC (unassisted-f/VT) at the start of the breathing trial as a pretrial predictor of extubation outcome.ResultsThere were no significant differences in any of the baseline characteristics between the two groups apart from a significantly higher Acute Physiology and Chronic Health Evaluation (APACHE) II score in the ATC group (p = 0.009). In the PSV group, 13 of 93 (14%) patients failed the breathing trial compared with only 6 of 87 (6%) in the ATC group; this observed 8% difference, however, did not reach statistical significance (p = 0.12). The rate of reintubation was not different between the groups (total group = 17.3%; ATC = 18.4% vs. PSV = 12.9%, p = 0.43). The percentage of patients who remained extubated for more than 48 hours was similar in both groups (ATC = 74.7% vs. PSV = 73.1%; p = 0.81). This represented a positive predictive value for PSV of 0.85 and ATC of 0.80 (p = 0.87). Finally, the ATC-assisted f/VT was found to have a significant contribution in predicting successful liberation and extubation compared with the non-significant contribution of the unassisted f/VT (unassisted f/VT, p = 0.19; ATC-assisted f/VT, p = 0.005).ConclusionsThis study confirms the usefulness of ATC during the weaning process, being at least as effective as PSV in predicting successful extubation outcome and significantly improving the predictive value of the f/VT.Trial registrationCurrent Controlled Trials ISRCTN16080446

Acute respiratory failure due to refeeding syndrome and hypophosphatemia induced by hypocaloric enteral nutrition

We report a case of acute respiratory failure due to refeeding syndrome caused by hypocaloric enteral tube feeds. A 60-y-old obese man, with a diagnosis of esophageal carcinoma with local metastases, underwent feeding jejunostomy tube insertion. Enteral tube feeding was initiated at small volumes providing 4.4 kcal · kg −1 · d −1 and gradually increased over 48 h to 29 kcal · kg −1 · d −1 (based on adjusted body weight). The patient then developed acute respiratory distress requiring intubation and ventilatory support. Serum phosphorus (P) level was extremely low at <0.7 mg/dL. Serum potassium (K) and magnesium (Mg) levels were also low. It took >4 d to adequately correct the electrolyte derangements. Successful liberation from mechanical ventilation was then possible. In chronically malnourished patients undergoing nutritional support, even hypocaloric feeding should be considered a risk factor for developing refeeding syndrome leading to severe and acute electrolyte fluid-balance and metabolic abnormalities.

Early intravenous unfractionated heparin and mortality in septic shock*

Sepsis and septic shock represent a systemic inflammatory state with substantial pro-coagulant elements. Unfractionated heparin is a known anticoagulant, which also possesses anti-inflammatory properties. Unfractionated heparin has been shown to increase survival in experimental models of septic shock. To evaluate the impact of intravenous therapeutic dose unfractionated heparin in a cohort of patients diagnosed with septic shock. Retrospective, propensity matched, multicenter, cohort study. Regional intensive care units in Winnipeg, Canada between 1989 and 2005. Two thousand three hundred fifty-six patients diagnosed with septic shock, of which 722 received intravenous therapeutic dose heparin. The primary outcome of study was 28-day mortality, and mortality stratified by severity of illness (Acute Physiologic and Chronic Health Evaluation II quartile). Safety was assessed by comparing rates of gastrointestinal hemorrhage, intracranial hemorrhage, and the need for transfusion. By using a Cox proportional hazards model, systemic heparin therapy was associated with decreased 28-day mortality (307 of 695 [44.2%] vs. 279 of 695 [40.1%]; hazard ratio 0.85 [confidence interval (CI) 95% 0.73-1.00]; p = 0.05). In the highest quartile of severity of illness (Acute Physiologic and Chronic Health Evaluation II score 29-53), heparin administration was associated with a clinically and statistically significant reduction in 28-day mortality [127 of 184 (69.0%) vs. 94 of 168 (56.0%); hazard ratio 0.70 (CI 95% 0.54-0.92); p = 0.01]. The use of intravenous unfractionated heparin was associated with successful liberation from mechanical ventilation [odds ratio of 1.42 (CI 95% 1.13-1.80); p = 0.003], and successful discontinuation of vasopressor/inotropic support [odds ratio of 1.34 (CI 95% 1.06-1.71); p = 0.01]. No significant differences in the rates of major hemorrhage or need for transfusion were identified. Early administration of intravenous therapeutic dose unfractionated heparin may be associated with decreased mortality when administered to patients diagnosed with septic shock, especially in patients with higher severity of illness. Prospective randomized trials are needed to further define the role of this agent in sepsis and septic shock.

Chromium(III)-isocinchomeronato and quinolinato complexes: kinetic studies in NaOH solutions and effect on 3T3 fibroblast proliferation

The aquation of chromium(III)-isocinchomeronato and quinolinato complexes, mer-[Cr(icaH)3]0 and mer-[Cr(quinH)3]0 (where icaH− and quinH− are N,O-bonded isocinchomeronic and quinolinic acid anion, respectively) was studied in NaOH solutions. The process leads to successive ligand liberation in the fully deprotonated species. The kinetics of the first ligand liberation were studied spectrophotometrically in the visible region. A mechanism is proposed in which the rate of the chelate-ring opening at the Cr–N bond is much faster than the rate of the Cr–O bond breaking. The rate-determining step is described by the rate law: kobs1 = kOH(1) + kOQ2 [OH−], where kOH(1) and kO are rate constants of the first ligand liberation from the hydroxo- and oxo-forms of the intermediate, respectively, and Q2 is an equilibrium constant between these two protolytic forms. The first pseudo-first-order rate constants (kobs1) were calculated using SPECFIT software for an A → B → C reaction pattern. The results are compared with those determined in acidic medium. Kinetics of the second and third ligand liberation were also studied and values of successive pseudo-first-order rate constants (kobs2, kobs3) are [OH−] independent. Effect of chromium(III)-quinolinato and isocinchomeronato complexes on 3T3 fibroblast proliferation was evaluated. Cytotoxicity of these complexes is low, suggesting they may be promising candidates as novel dietary supplements.

The Institutional Challenge of the ACP/EU Economic Partnership Agreements

The Economic Partnership Agreements between the African, Caribbean and Pacific countries and the European Union should serve as an opportunity to accelerate ACP global and regional trade integration and as an important tool for development and the eradication of poverty. There are, however, a number of preconditions. This article argues that institutional quality plays a key role in successful trade liberalisation. In fact, only countries with high‐quality institutions, partly in the form of good government regulation, are likely to benefit from trade. Unfortunately, the vast majority of African countries have excessive regulation that hinders them from taking advantage of trade. The necessary reforms to resolve this problem pose significant challenges, implying major risks for these countries in the EPA process.

The telecommunications regulatory regimes in Hong Kong and Singapore: when direct state intervention meets indirect policy instruments

Successful economic liberalization somewhat paradoxically requires high levels of state capacity, while ‘deregulated’ markets deploy new regulatory mechanisms that, rather than diminishing state power, reconfigure it. A comparative case study into the recent liberalization reforms of the telecommunications sectors of Hong Kong and Singapore is presented here in order to throw light on these developments. The end result of the reform processes in each jurisdiction is quite similar – globally open, competitive and highly efficient telecommunications markets in which major global companies are leading players. However, the routes by which this end result was achieved tell different stories about the manner in which governments balance domestic interests in the process of liberalization. They build on local institutional strengths and deploy instruments appropriate to their own bureaucratic and political contexts. Correspondingly, in constructing the ‘new regulatory state’, they produce subtle variations on the pro-competitive model of regulation. However, detailed analysis of the two reformed telecommunications regimes shows that underlying these differences is the prominence of a common set of instruments that make less use of highly intrusive, direct forms of state power but greater use of more indirect forms that thrive ‘in the shadow’ of state authority, a phenomenon that is at the heart of theorizing about the new regulatory state. These instruments enhance rather than diminish state capacity where they are deployed strategically by governments.

Computable General Equilibrium Micro-Simulation Analysis of the Impact of Trade Policies on Poverty in Zimbabwe

Abstract There is an ongoing debate on the role of trade policies in alleviating poverty. Winters et al (2002), Reimer (2002) and Rajan and Bird (2002) among others give a comprehensive literature review of the evidence on the impact of trade liberalization and poverty. Reimer (2002 summarizes the main links between trade and poverty coming from the Winters (2000) paper and concludes that there is no simple generalization about the relationship between trade liberalization and poverty and that it is difficult in one study to take into account all these linkages. It does seem though that there is no strong evidence that trade liberalization will increase poverty or vulnerability but no guarantees either that the poor will always benefit. These conclusions seem to suggest that such evidence from a particular country must be obtained empirically. An important question is therefore, to what extent is the poverty in Africa attributable to trade liberalisation? Using the example of Zimbabwe, this paper explores how successful trade liberalisation has been in alleviating poverty and improving income distribution. Like many other countries, Zimbabwe implemented trade liberalization in 1991, which reversed a long tradition of dirigisme. The import control, industrial licensing and fixed exchange rate associated with the colonial period were dismantled. Despite the serious drought in 1991-92, liberalisation policy was not reversed. The aggregate response of trade to the opening up was quite dramatic. Total trade rose from 45 percent of GDP in 1988, to more than 100 percent ten years later. Despite compelling evidence of its many benefits, trade liberalisation still remains an unfinished business in Zimbabwe. While it is generally agreed that the programme significantly altered the contours of the Zimbabwean economy, it is also clear the programme could have sharpened inequality and increased poverty. Poverty has been on the increase in Zimbabwe, particularly since the implementation of the structural adjustment program in 1991 leading people to blame the reforms for increased poverty. For the reader who is more interested in trade policy effects than Zimbabwe, the question is whether Zimbabwe’s experience is an inevitable consequence of trade liberalization or whether it is simply a result of ‘local’ mismanagement. This paper will attempt to show that, while the last of these reasons is important, there are lessons to be drawn by a wider audience. This paper aims to establish the longer-term impact of trade liberalisation on incomes, poverty and inequality in Zimbabwe. In thinking about these lessons, it is useful to realize that the majority of computable general equilibrium (CGE) models used in poverty and inequality analysis are aggregated CGEs with representative households to infer changes on income distribution due to trade liberalisation. In such models, not much can be done in terms of poverty analysis since, by its nature, the study of poverty relies on micro data. To overcome this limitation we replace the assumption of a representative household by incorporating all the households from a nationally representative survey. In this way, we endogenize intra- group variations. To our knowledge there is no work yet that looks at poverty and trade at the household level in a CGE model in Zimbabwe. Preliminary results show that the complete removal of tariffs favours export-oriented sectors and all imports increase. Poverty falls in the economy while inequality hardly changes. The results differ between rural and urban areas.

Kinetic and Structural Analysis of Enzyme Sliding on a Substrate: Multiple Attack in β-Amylase

Beta-amylase (EC 3.2.1.2) is starch-hydrolyzing exo-type enzyme that can catalyze the successive liberation of beta-maltose from the nonreducing ends of alpha-1,4-linked glucopyranosyl polymers. There is a well-known phenomenon called multiple or repetitive attack where the enzyme releases several maltose molecules in a single enzyme-substrate complex. In order to understand it further, we examined the beta-amylase-catalyzed reaction using maltooligosaccharides. The Monte Carlo method was applied for simulation of the beta-amylase-catalyzed reaction including the multiple attack mechanism. Through site-directed mutagenesis, we have successfully prepared a mutant enzyme which may be simulated as a multiple attack action reduced one with retaining significant hydrolytic activity. From the results of X-ray structure analysis of the mutant enzyme, it was clarified that one carboxyl residue plays a very important role in the multiple attack. The multiple attack action needs the force of enzyme sliding on the substrate. In addition, it is important for the multiple attack that the enzyme and substrate have the characteristics of a stable productive substrate-enzyme complex through a hydrogen bond between the nonreducing end of the substrate and the carboxyl residue of the enzyme.

Services in a Development Round: Three Goals and Three Proposals

The benefits of services trade reform are huge but services negotiations in the World Trade Organization (WTO) are making little progress. A proximate cause is the current negotiating process, based on an inertial request-and-offer approach rather than a set of goals that would give direction and momentum to the negotiations. The paper suggests that WTO members should consider: (1) locking in the current openness of cross-border trade for a wide range of services; (2) eliminating barriers to foreign investment either immediately or in a phased manner where regulatory inadequacies need to be remedied; and (3) allowing greater freedom of international movement at least for intra-corporate transferees and for service providers to fulfill specific services contracts. A deeper problem is that WTO members have sought to negotiate market access in services without adequately addressing concerns that the General Agreement on Trade in Services (GATS) commitments limit regulatory freedom unduly and unpredictably, that regulatory institutions in many countries are too weak to cope with liberalized markets, and that there is no provision for the regulatory cooperation that is necessary for successful liberalization, particularly of temporary labor mobility. Three types of actions are needed: (1) at the current stage of its development, the GATS must focus primarily on disciplines for measures that discriminate against foreign services and providers, rather than on politically sensitive and legally complex rules for nondiscriminatory measures; (2) a credible assistance mechanism must be established to help developing countries make the regulatory improvements needed for successful liberalization; and (3) where necessary, WTO members should make access commitments on labor mobility conditional on the fulfillment of specific conditions by source countries-to screen services providers, accept and facilitate their return, and combat illegal migration.

Independent regulatory authorities in European electricity markets

Liberalisation of the electricity market has taken place in most European countries within the last decade. It is considered a precondition of successful liberalisation to establish so-called independent regulatory authorities. In this article, we compare the status and practice of them in 16 European countries, and discuss the relationship between the organisation of the regulation and the market outcome.

Policy networks and market opening: Telecommunications liberalization in Spain

Abstract. For a broad range of policy sectors, liberalization was the predominant goal during the 1990s, and the policy change involved gave rise to a wide range of academic debates. In this article we analyze the consequences of these far‐reaching policies for the policy process itself. We ask whether the policy changes significantly altered the characteristics of policy processes by considering the timing and extent of the changes in policy networks during those years. More concretely, we discuss the extent to which policy networks changed as a result of market opening, considering the case of the telecommunications policy network in Spain. Using data from two successive surveys, we compare the network structure before and after market opening. Our findings show that only slight changes occurred during this period, making the network denser but not more open. Thus, we suggest that a more successful liberalization probably would have required a network that was more open to new entrants and in which power was less centralized and so able to guarantee a competitive environment.

Capital Flows, Capital Account Liberalisation and the Mediterranean Countries

This paper examines questions related to possible capital account liberalisation in the Mediterranean countries. First, we provide an overview of the extent to which these countries have capital controls along with their exchange rate regimes and some basic macroeconomic aggregates. Second, we examine the case for capital account liberalisation, along with the prerequisites for successful liberalisation. Here we consider issues such as sequencing and possible benefits of synchronisation. Finally, we examine the experience with capital flows – both FDI and other capital flows. We explain these flows and use the past experience of these countries to draw some conclusions for the successful opening up of the capital account.