IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. OBJECTIVE To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. INTERVENTIONS Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H 2 O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H 2 O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with SpO 2 Յ92% for >1 minute). RESULTS Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, −2.3% [95% CI, −5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, −8.6% [95% CI, −11.1% to 6.1%]; P < .001). CONCLUSIONS AND RELEVANCE Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications.

One of the main problems in evaluating financial performance arises in carrying out comparisons between municipalities, as no account is taken of the impact of certain factors of the social and economic environment on the indicators in question. In this study, the concept of financial condition is applied, revealing the influence of such factors, and a methodology is proposed to minimize their effects on the results of the evaluation. The results of applying these to a sample of municipalities in Spain reveal that the model is useful for reinforcing the value of benchmarking between municipalities with similar characteristics. Points for practitioners The use of indicators for evaluating financial performance has advanced considerably in recent years. However, many criticisms have been made by public sector managers concerning the application of such indicators. One of these is that, in many cases, the values measured by different authorities are not comparable, as the services they provide differ significantly. If local authorities were grouped according to the social and economic factors influencing their provision of public services, the evaluations made would be much more effective, facilitating decision-making by supervisory bodies and by municipal managers.

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The current economic crisis is increasingly affecting the public sector, requiring stricter control of deficits, and local administrations are not exempt from these requirements. Therefore, it is essential to consider management forms that may produce cost savings in the provision of public services. In this article we propose an evaluation of municipal waste collection and disposal services to determine whether single/joint or public/private municipal service provision, together with other factors including quality, political aspects, and the socio‐economic environment, most contribute to reducing costs. The results obtained for the period 2002–08 show that joint management (inter‐municipal cooperation) and public management (in relation to single and private management systems, respectively) have a greater effect on reducing the costs of this service. Thus, small and medium‐sized local authorities can identify formulas for reducing costs and thus be in a better position to overcome the economic crisis.

Corporate Social Responsibility (CSR) and its disclosure in the university environment is a topic of current relevance, as it makes the entities' commitments visible and provides indicators that enable them to improve the institution management and communication with stakeholders. The goal of this study is to determine to what extent the structure and mechanisms for governance and the demands of stakeholders influence policy for disclosing CSR information, both in general (more related to a strategic perspective) and specifically (more focused on specific social, environmental, economic, and educational issues). The results of our analysis of a sample of the top 200 universities in the Shanghai Ranking show no association of the profile and gender of the university's rector and frequency of board meetings with CSR disclosure policy, but leadership team, the size of governance board, committees in the governance board and stakeholder participation are factors determining disclosure of information on matters of CSR. The results show that proximity to the day-to-day, diversification of functions, and communication with interest groups are crucial to transparency and disclosure of CSR information.Given the growing concern for CSR, this situation requires in-depth study to enable fuller development in the university environment of a theoretical framework based fundamentally on stakeholder theory. We can understand the behaviors carried out by universities based on stakeholder theory. According to this theory, universities, as agents of society, seek to meet the demands and needs of stakeholders and acquire commitments on social and environmental issues. This theory can explain the disclosure of CSR information to fulfil the responsibility of being transparent and thus achieving the commitment of stakeholder [7]. Therefore, one essential point for effective development and integration of CSR policies and strategies in the culture of higher education institutions is identification of stakeholders' expectations and needs-that is, entering into dialogue with these actors [8,9] by establishing communication channels and improving transparency through disclosure of financial and non-financial information [10,11]. Such actions make universities accountable to society and improve the satisfaction of their different social interlocutors by showing understanding that satisfaction of these interlocutors revolves around demand for more information, a more transparent mode of functioning, and the possibility of participation [12]. We propose that this approach involves a top-down strategy in the organizational structure of the universities. This proposal requires the analysis of Corporate Governance (CG) mechanisms in managing the institution and how they find out and assumes the different interest groups-employees, investors, suppliers, customers, local communities, and society in general-that affect and are affected by its activities [13]. One of the contributions of this paper is to establish the relationship between the CG str...