Punctuated equilibrium in the energy regime complex

The concept of a regime complex has proved fruitful to a burgeoning literature in international relations, but it has also opened up new questions about how and why they develop over time. This article describes the history of the energy regime complex as it has changed over the past 40 years, and interprets this history in light of an interpretive framework of the sources of institutional change. One of its principal contributions is to highlight what Stephen Krasner referred to as a pattern of “punctuated equilibrium” reflecting both periods of stasis and periods of innovation, as opposed to a gradual process of change. We show that the timing of innovation depends on dissatisfaction and shocks and that the nature of innovation—that is, whether it is path-dependent or de novo—depends on interest homogeneity among major actors. This paper is the first to demonstrate the empirical applicability of the punctuated equilibrium concept to international regime complexes, and contributes to the eventual development of a dynamic theory of change in regime complexes.     

Domestic Violence and Social Support in a Clinical Sample of Deaf and Hard of Hearing Women

The present study examined domestic violence and perceived social support in a clinical sample of Deaf and Hard of Hearing women. Forty-six adult Deaf and Hard of Hearing females receiving outpatient mental health services completed a modified version of the Conflict Tactics Scale and the Interpersonal Support Evaluation List. Results showed that nearly three-quarters (71.7%) of the sample related experiencing psychologically abusive behaviors, and over one-half (56.5%) reported a history of physical violence from a partner. In addition, participants reported experiences of domestic abuse directly related to their deafness. Level of perceived social support did not differ for participants with a history of domestic violence victimization compared to those with no such history. Findings underscore the need for increased awareness of Deaf and Hard of Hearing women as a population at high risk, and warranting further investigative attention, with regard to domestic violence.     

Sleeping accidents in the elderly

Two cases of dangerous sleeping environments in the elderly are reported to demonstrate similarities and differences of these "sleeping accidents" to similar episodes that occur in infants and children. CASE REPORTS: An 87-year-old wheelchair-bound man with a history of dementia was found in his nursing home room hanging off the side of the bed from a vertical metal bar, and an 87-year-old woman with epilepsy, ischemic heart disease, and insulin-dependent diabetes mellitus was found in hospital wedged between an inflatable mattress and the bars of her bed. These cases demonstrate that, as in the very young, relatively poor coordination and strength in the elderly often with limited comprehension and ability to deal with dangerous environments may predispose to sleeping accidents. Significant underlying organic disease may, however, make determination of the precise lethal mechanisms difficult. Modification of beds should only be undertaken when safety issues have been carefully evaluated.     

Market introduction of innovative high risk medical devices: towards a recast of the directive concerning medical devices

The European Conformity (CE) marking grants early market introduction to innovative high risk medical devices based on safety and device performance only, without any requirement to demonstrate clinical efficacy or effectiveness. Hence healthcare providers, patients and payers are informed neither about the added clinical value compared to an existing medical device nor about the risks incurred by using such innovations. In addition there is a lack of coherence and uniformity of approach in the assessment of high risk medical devices. These gaps may put the health and safety of patients in danger. The European Commission, in concert with Competent Authorities, industry, Notified Bodies, and other stakeholders, is working on a "recast" of the directives regulating medical devices. This article identifies and discusses the critical points of the pre-market clinical evaluation of innovative high-risk medical devices in the European legal framework and compares it with the USA.     

The evaluation of climate policy: theory and emerging practice in Europe

Climate policy is a relatively young and dynamic area of public policy making. However, its development has attracted far more attention than the results it delivers in practice, which of course are the concern of policy evaluators. This article attempts to provide the first systematic cataloging of the emerging patterns of policy evaluation undertaken in different parts of the European Union. Theories of policy evaluation suggest that these evaluation practices should acknowledge the inherent complexity of climate policy making, be reflexive by questioning official policy goals, and be participatory. A meta-analysis of 259 climate policy evaluations suggests that current practice engages with some but not all of these issues. This article concludes by analyzing the implications of this finding for those in the academic and practitioner community who are keen to understand the extent to which climate policy evaluation is delivering on its promises.     

Potentially lethal complications of tracheostomy: autopsy considerations

Tracheostomy is widely used to facilitate respiration by protecting the airways. It may be performed to relieve upper airway obstruction from congenital stenoses or from acquired conditions such as foreign body impaction, swelling from neck trauma or anaphylaxis, benign or malignant tumors, and infection. Tracheostomy may also be performed in individuals with respiratory impairment who require suctioning for accumulated mucoid secretions and in those with obstructive sleep apnea. Review of autopsy files and the literature was undertaken to demonstrate the range of lethal circumstances that may involve tracheostomy. Unexpected death may result from incorrect positioning of an endotracheal tube with failure of oxygenation, tracheal perforation with pneumothorax, mucus plugging, accidental extubation, and hemorrhage from tracheovascular fistulas. Lethal tracheovascular fistulas usually involve the innominate artery and result from mural perforation by the tip of a tracheostomy tube, mural necrosis from a high-pressure cuff, prolonged intubation, radiotherapy, and low tracheal incisions. Increased movement of tubes in patients with impaired consciousness and excessive head movements may also increase the chances of hemorrhage, as may infiltrating tumors. Given the wide range of potential fatal mechanisms that may be found in such cases, careful autopsy evaluation and dissection will be required to demonstrate the exact nature and site of the lethal lesion in individuals who underwent tracheostomy and die unexpectedly.     

Urinary incontinence, hyperthermia, and sudden death

An 84-year-old woman is reported whose death was associated with strenuous exercise on an extremely hot day (maximum temperature=43.1 °C, 109.6 °F). At autopsy there was evidence of exposure to high environmental temperatures with early putrefactive changes and mummification. There was underlying cardiomegaly with mild pulmonary emphysema. No significant injuries were detected. Toxicology revealed therapeutic levels of oxybutynin prescribed for urinary stress incontinence. Death was considered to be heat related, exacerbated by oxybutynin therapy, exercise, and cardiomegaly. Given that it has been predicted that there may be an increase in the number of heatwaves and in their intensity and duration, it is possible that such cases may be encountered more often in future. The assessment of all deaths occurring during conditions of extreme heat will require consideration of postmortem toxicology, particularly if there are underlying conditions such as stress incontinence that may be associated with anticholinergic drug therapy.     

Pseudoxanthoma elasticum and sudden death

Pseudoxanthoma elasticum (PXE) is a generalized connective tissue disorder in which there is calcification of elastic fibers within arteries, eyes, and skin. Characteristic features include yellow-orange papular skin lesions, angioid streaks radiating out from the optic discs, and arterial calcification. The prevalence in the general population varies widely from 1/70,000 to 1/160,000. PXE has an autosomal recessive inheritance pattern and results from mutations in the ATP-binding cassette transporter C6 (ABCC6) that has been mapped to 16p13.1. Over 300 loss-of-function mutations have been identified. Individuals with PXE may come to forensic attention because of sudden death involving accelerated coronary atherosclerosis with acute myocardial ischemia, systemic hypertension, mitral valve prolapse, restrictive cardiomyopathy, gastrointestinal hemorrhage, and cerebral ischemia or hemorrhage. Because of the heritable nature of the disease, family counseling and screening are in order when previously unsuspected cases are encountered at autopsy.     

Lower extremity deep venous thrombosis with fatal pulmonary thromboembolism caused by benign pelvic space-occupying lesions--an overview

Venous stasis predisposes to thrombosis. One hundred and sixty cases of fatal pulmonary thromboembolism were reviewed to determine how many cases had deep venous thromboses associated with venous blood flow reduction caused by external pressure from benign pelvic masses. Three cases were identified, representing 2% of cases overall (3/160): a 44-year-old woman with a large uterine leiomyoma (1048 g); a 74-year-old man with prostatomegaly and bladder distension (containing 1 L of urine); and a 70-year-old man with prostatomegaly and bladder distension (containing 3 L of urine). Although a rare cause of fatal deep venous thrombosis and pulmonary thromboembolism, space-occupying pelvic lesions can lead to extrinsic pressure on adjacent veins reducing blood flow and causing stasis and thrombosis. Individuals with large pelvic masses may, therefore, be at increased risk of pulmonary thromboembolism from deep venous thrombosis, particularly in the presence of concurrent risk factors such as immobility, thrombophilias, malignancy, and significant cardiopulmonary disease.