bluuebunny/crossref_metadata_2025 huggingface dataset:
Exploring the development of a protean career orientation: values and image violations
Authors: Sargent Leisa D. , Domberger Shelley R.
Published: October 2007

Purpose

The purpose of this study is to examine the development of a protean career orientation. In doing so, the paper also aims to assess how work experience, parents and peer networks co‐influence the development of a protean career orientation.

Design/methodology/approach

The paper uses semi‐structured interviews with young adults and explores their past, present and future work and career experiences. They were also asked them to explain what career success meant to them. Interview transcripts were reviewed and coded based on two main categories representing protean orientation: self‐directed career management and the expression of personal values as a mechanism for career decisions. The paper also process mapped how a protean career orientation developed in the interviewees. Those who reported a protean career orientation were interviewed two‐and‐a‐half years later so as to further explore their career experiences and the extent to which self‐directedness and value congruence influenced career decisions.

Findings

Results suggest that some reported a protean career orientation and of those that did they reported experiencing an image violation based on their personal values. Two types of personal values appeared important to the protean group, they were, making a contribution to society and maintaining work‐life balance. Those that were categorised as having a protean orientation also engaged in critical reassessment by interrogating the basis of their career values and strategies and this distinguished them from the rest of the interviewees who exhibited a more traditional career orientation. These findings are consistent with image theory's concept of a progress decision. This concept encapsulates the idea that individuals decide whether a career plan is moving them towards achievement of a career goal and if it is not, new or modified plans need to be taken up.

Research limitations/implications

The exploratory findings have important implications for understanding the career strategies of protean careerists. Specifically, they elucidate how violations of values, goals and plans lead to career reappraisals. This paper provides important insights into reframing career choice and change in terms of image violations.

Originality/value

The paper provides a process map of the mechanisms that contribute to the development of a protean career orientation. Specifically, it focuses on image violations that appear to distinguish protean careerists from the remainder of the interviewees. Thus, the paper links protean careers with image theory as a means of understanding the underlying processes involved in early career decision making.
What “career success” means to blue‐collar workers
Authors: Hennequin Emilie
Published: October 2007

Purpose

Career success such as it is classically modelled and measured is not necessarily representative of the perceptions of blue‐collar workers. Therefore, the goal of the present study is to understand what it means to succeed in blue‐collar occupations. A definition and a measure are useful starting points in explaining the individual's evaluation of success and in analysing the behaviour which results from it.

Design/methodology/approach

After a review of literature, in order to develop the theoretical framework for the research, 25 exploratory interviews were conducted with blue‐collar workers in order to obtain their criteria for career success. The results are reported, together with the methodological decisions and a proposed explanatory model.

Findings

Success is traditionally described as having an objective and a subjective part. In order to understand the perceptions of blue‐collar workers, it is necessary to recognise that their perceptions are influenced by material, psychological and social aspects.

Practical implications

The definitions developed in this paper could be used to develop employment programmes addressing the expectations of blue‐collar workers, and to attract new employees to this kind of occupation. More generally, with the flattening of organizations, it is necessary to re‐evaluate the concept of success for all workers, and to develop policies that are appropriate to changes in the labour market.

Originality/value

The majority of career studies focus on “white collar” workers. Traditional career theory has developed models which consider that all the employees are guided by the same systems of values (status, power, wages, etc.). Thus, this paper fulfils a need to develop an understanding of career success from the perspective of blue‐collar workers.
Collaborative benchmarking, transparency and performance
Authors: Braadbaart Okke
Published: October 2007

Purpose

The purpose of this paper is to investigate how benchmarking affects transparency and economic performance in the public sector.

Design/methodology/approach

The paper applies a quasi‐experimental method to 1989‐2000 time series data on benchmarking and non‐benchmarking water utilities in The Netherlands.

Findings

Benchmarking immediately enhanced transparency, but only affected utility economic performance after benchmarking information entered the public domain. This confirms that benchmarking enhances transparency and performance. The findings do not support the yardstick regulation hypothesis that utility managers will only tighten financial discipline when benchmarking is embedded in a regime of managed competition.

Research limitations/implications

The main limitation of this study is its single‐industry scope. Further testing of benchmarking effects in other public services is needed to validate its findings.

Originality/value

The paper presents evidence from the Dutch water supply industry focusing on transparency and performance in collaborative benchmarking.
Benchmarking firm performance
Authors: Dawkins Peter , Feeny Simon , Harris Mark N.
Published: October 2007

Purpose

The aim of the paper is to provide a framework for benchmarking firm performance (profitability) using panel data. Further, to illustrate how the estimation results can be used for simulation (what if?) exercises.

Design/methodology/approach

The authors apply the econometric techniques used in panel data to estimate profit functions, thereby enabling us to compute measures of firm efficiencies which can subsequently be used as benchmarking tools.

Findings

The results suggest that both large firms and those highly specialised, enjoy higher profit margins, whereas the more capital intensive a firm is, the lower is its profitability. As with previous studies there is strong evidence of the U‐shaped relationship between market share and profitability. The authors present an analysis of the distribution of firm efficiencies across industries as a whole, and by a number of industry groups.

Research limitations/implications

Only a limited sample (with regard to the time span) of Australian firms is used. A major assumption of the procedure is that firm efficiencies are constant over time. Given the short time period used in the empirical application, this does not appear to be unrealistic.

Practical implications

The paper provides firms with easy‐to‐use tools with which to benchmark their performance relative to other firms, conditional on their base characteristics.

Originality/value

This is the first time that this type of benchmarking exercise has been applied to firm profitability using relatively simple panel data techniques: it will be of use to market analysts, managers and shareholders alike.
Increasing the benefits of product‐level benchmarking for strategic eco‐efficient decision making
Authors: Wever Renee , Boks Casper , Marinelli Thomas , Stevels Ab
Published: October 2007

Purpose

Widely accepted classifications of benchmarking distinguish between different levels of benchmarking. Strategic‐level benchmarking is considered to be of a higher sophistication than product‐level benchmarking. Such strategic benchmarking would be based on process information instead of product information. The purpose of this paper is to research the possibility of obtaining strategic‐level information based on an extensive amount of product‐level benchmark data.

Design/methodology/approach

The data used in this paper originate from the environmental benchmarking program of Philips Consumer Electronics (CE). Philips CE has successfully implemented benchmarking as an environmental improvement strategy for its products. Product‐level competitive benchmarking is used to assess the environmental performance of a Philips' product compared to its main economic rivals. Since the start of environmental benchmarking a considerable pool of product‐level benchmark data has been generated. This paper reports on an extensive data analysis of product‐level benchmarking data concerning the packaging of these consumer electronics products.

Findings

It is shown how strategic‐level information is obtained from a data analysis of these separate benchmarking studies, resulting both in useful strategic‐level managerial information and practical design input. Finally, advantages of this approach as compared to classic strategic‐level benchmarking are identified.

Research limitations/implications

The study has yielded empirical data indicating a limitation in current benchmarking classification.

Originality/value

The paper offers insights into the benefits of product level benchmarking for strategic eco‐efficient decision making.
Using benchmarking to determine efficient usage of nodes in a cluster
Authors: Luecke Glenn R. , Li Ying , Cuma Martin
Published: October 2007

Purpose

The purpose of this paper is to evaluate how to use nodes in a cluster efficiently by studying the NAS Parallel Benchmarks (NASPB) on Intel Xeon and AMD Opteron dual CPU Linux clusters.

Design/methodology/approach

The performance results of the NASPB are presented both with one MPI process per node (1 ppn) and with two MPI processes per node (2 ppn). These benchmark results were analyzed by considering the impact of cache effects, code scalability, memory bandwidth within nodes, and the impact of MPI and the MPI communication network. Memory bandwidth was benchmarked using MPI versions of the Streams benchmarks. The impact of MPI and the MPI communication network are evaluated by benchmarking the performance of MPI sends and receives, MPI broadcast, and the MPI all‐to‐all routines.

Findings

The performance results from running the NASPB and from the memory bandwidth benchmarks show that better performance can sometimes be achieved using 1 ppn. Performance results show that the AMD Opteron/Myrinet cluster is able to achieve significantly better utilization of the second processor than the Intel Xeon/Myrinet cluster.

Practical implications

Most Linux clusters are purchased with two processors per node. One would like to run all applications on a cluster with two processors per node using 2 ppn instead of 1 ppn in order to utilize the second processor on each node. However, our results show that this is not always the best choice. Users should always assess their program performance with both 1 ppn and 2 ppn before running production calculations. This issue becomes even more important with the emergence of multi‐core processors.

Originality/value

To the authors' best knowledge, this is the only detailed comparison of AMD Opteron and Intel Xeon dual processor node parallel performance on large Myrinet clusters. The paper should be of value to everybody considering running on or purchasing AMD or Intel‐based Linux cluster.
Benchmarking in Maltese internal audit units
Authors: Balzan Lara , Baldacchino Peter J.
Published: October 2007

Purpose

The organisation‐wide drive towards total quality management (TQM) and the call for sound corporate governance require that Maltese internal audit (IA) units benchmark their operations as a first step towards the critical evaluation of their processes and the management of change. The purpose of this paper is to determine the awareness of this process in Maltese IA units, its perceived major benefits and limitations and also major barriers in its implementation.

Design/methodology/approach

The objective of this study is achieved through a series of semi‐structured interviews with 12 Maltese IA executives representing most Maltese IA units.

Findings

This study concludes that Maltese IA executives have a weak grasp of the benchmarking process and that, current IA evaluation techniques are mere rudimentary comparisons, essentially backward‐ and inward‐looking in nature. Maltese IA executives appreciate the benefits of benchmarking as an effective IA quality tool but are divided as to its limitations. In addition, there are organisational and cultural barriers preventing them from attaining its potential benefits.

Originality/value

In addition to the analysis of major obstacles to the implementation and development of this TQM tool in a European ministate, this study points to possible regulatory and organisational changes for future improvements.
Gender‐based income disparity among self‐employed professionals
Authors: Mueller Stephen L.
Published: October 2007

Purpose

The purpose of this study is to test two possible explanations for persistent income disparity between male and female self‐employed professionals. First, men are more likely than women to be motivated by the potential for high income to establish a professional practice. Second, men are more likely than women to adopt a thinking‐over‐feeling cognitive decision‐making style.

Design/methodology/approach

This study uses a gender role/career motivation model to develop a set of hypotheses that explain observed gender‐based income disparity among self‐employed professionals. Hypotheses were tested using multivariate regression analysis with data drawn from a large‐scale national survey of male and female veterinarians in private practice.

Findings

Male veterinarians showed less empathy toward their clients and were more likely to use a thinking‐over‐feeling decision‐making style than were female veterinarians. Also, practice income was greater for male veterinarians with high client empathy (CE) and feeling‐over‐thinking decision‐making style than for male veterinarians with low CE and thinking‐over‐feeling decision‐making style. However, there was no significant difference in practice income between female veterinarians with high CE and feeling‐over‐thinking decision‐making style and female veterinarians with low CE and thinking‐over‐feeling decision‐making style.

Research limitations/implications

While this study was limited to American veterinarians, future research on income disparity should be expanded to include other self‐employed professionals and/or other national settings.

Originality/value

This study contributes to research on gender‐based income disparity among self‐employed professionals by examining underlying factors that potentially contribute to these differences such as motives for establishing the practice and the practice owner's decision‐making style.
Taos Pueblo: an indigenous community holding on to Promethean values
Authors: Paul Dana Leo , Brent Anderson Robert
Published: October 2007

Purpose

This paper aims to give an account – using photographs as well as words – to describe a North American indigenous community that is retaining pre‐contact Promethean values.

Design/methodology/approach

The paper adopts as its approach ethnographic literature and field interviews coupled with extensive photography.

Findings

Entrepreneurship may be linked to Promethean values, a characteristic of Pueblo Indians who were imaginatively original, long before the arrival of Europeans. Since ancient times, the use of irrigation in agriculture allowed the Pueblo Indians to reside in permanent houses; these two features – sophisticated farming and settlements – resulted in these indigenous people being unlike their nomadic neighbours. Farming – as opposed to hunting – was the backbone of the Pueblo economies, and theocratic government developed to control land and water usage; complex religious ceremonies became prerequisites to harvests. Religion taught discipline, and religious values remain important. Discipline – significant in this community even today – may be the causal variable explaining Promethean over Dionysian values.

Research limitations/implications

Future research might examine further differences between indigenous groups.

Practical implications

Regardless of how religious a person is, values perpetuated by religion can transcend to a generation that practises them less than their elders. In the case of Taos Pueblo Indians, traditional Promethean values are being perpetuated, including a highly disciplined work ethic.

Originality/value

The paper suggests that entrepreneurship values may be linked to traditional religion and historic innovation.
Community economic development through partnerships
Authors: Mount Joan , Mulc Helen
Published: October 2007

Purpose

This paper seeks to present a partnering model pioneered in Sudbury, Canada, that combats fragmentation in the delivery of business support services. Partnerships form the backbone of a comprehensive business support centre. The Sudbury Regional Business Centre brings together banking, government, communications, education, legal, and accounting partners. These partners coordinate their efforts to provide services to area businesses, striving to improve the odds for a dynamic and resilient local economy. This model has been replicated and adapted by various communities across Ontario, Canada's most populous province.

Design/methodology/approach

The methodology consists of qualitative research by two participant‐observers.

Findings

If a solid business case can be made, banks and three levels of government can be persuaded to act in concert with other partners through a community business support centre; economic upheaval in the Sudbury area precipitated urgency and resolve; several postulates regarding key success factors were supported.

Research limitations/implications

The reporting is retrospective; the postulates are examined in a single context.

Practical implications

Disparate players can form a working partnership so that business support services from various quarters blend effectively, and are easily accessed to give clients the best help available.

Originality/value

This paper describes how a community forged partnerships designed to overcome fragmentation in the delivery of business support services. Comprehensive enterprise support offered by committed public and private sector partners can be channelled through a physically accessible centre. The factors which proved most critical to success are discussed.
Can lean save lives?
Authors: Fillingham David
Published: October 2007

Purpose

The purpose of this paper is to show how over the last 18 months Bolton Hospitals NHS Trust have been exploring whether or not lean methodologies, often known as the Toyota Production System, can indeed be applied to healthcare.

Design/methodology/approach

This paper is a viewpoint.

Findings

One's early experience is that lean really can save lives. The Toyota Production System is an amazingly successful way of manufacturing cars. It cannot be simply translated unthinkingly into a hospital but lessons can be learned from it and the method can be adapted and developed so that it becomes owned by healthcare staff and focused towards the goal of improved patient care.

Originality/value

Working in healthcare is a stressful and difficult thing. Everyone needs a touch of inspiration and encouragement. Applying lean to healthcare in Bolton seems to be achieving just that for those who work there.
Can Six Sigma be the “cure” for our “ailing” NHS?
Authors: Antony Jiju , Downey‐Ennis Kay , Antony Frenie , Seow Chris
Published: October 2007

Purpose

The purpose of this research is to analyse whether Six Sigma business strategy can be used to improve the financial and operational performance of the NHS. The paper will also look at some of the major challenges and barriers in the implementation of this powerful process improvement strategy within the healthcare sector.

Design/methodology/approach

This paper discusses whether Six Sigma DMAIC methodology can be a useful and disciplined approach to tackle process‐ and quality‐related problems in the NHS.

Findings

The paper presents some key findings from other researchers in the field, followed by some comments on whether Six Sigma is a useful approach to be considered by the NHS for cost reduction and defect reduction strategies.

Originality/value

The paper illustrates the point that Six Sigma is not confined just to manufacturing industry, rather it is equally applicable to service industry, especially the healthcare and financial sectors. The application of Six Sigma in the UK health sector is relatively new and the purpose of the paper is to increase the awareness of this powerful business strategy in healthcare discipline.
Should doctors stop taking the generic history?
Authors: Gudena R. , Khetan N. , Luwemba S. , Jenkinson L.R.
Published: October 2007

Purpose

The purpose of this paper is to show how the implementation of the European Working Time Directive in August 2004 has dramatically decreased junior doctors' working hours, as a consequence of which new ways of working will need to be found. Traditionally both doctors and nurses record the same generic history (past medical history, social and family history, drug history and allergies) in their own notes. This is unnecessary duplication and maybe only nursing staff should record this information. This study is undertaken to identify the differences between junior doctors' and nurses' clerking to assess whether they are comparable.

Design/methodology/approach

A prospective study of 100 case notes from elective and emergency admissions was undertaken. The completeness of various parts of the history and the recording of the vital signs were compared between nurses and house officers.

Findings

The Past Medical History was complete in only 30 per cent of the house officers' notes and 42 per cent of nursing records. The social history was complete in all the nursing records but only 35 per cent of the doctors' notes. Nurses recorded a complete personal history more than doctors (62 per cent v. 13 per cent respectively). The drug history was poorly recorded in house officers' notes, being complete in 22 per cent, whereas this was complete in 73 per cent of nursing records. The record of the history of allergies was poor in both groups at just over 10 per cent. Finally 87 per cent of nurses managed to record vital signs but these were missing from nearly half of the house officers' notes.

Originality/value

The study has shown that details of the generic medical history are recorded more completely by the nursing staff and only they should record this information. This will allow junior doctors more time to deal with the increased demands and reduced hours of work.
The effect of cannula material on the incidence of peripheral venous thrombophlebitis
Authors: Gupta A. , Mehta Y. , Juneja R. , Trehan N.
Published: October 2007

The incidence of thrombophlebitis following the use of two types of cannulae, a new generation polyurethane cannula Biovalve PUR and a polyurethane hybrid co‐polymer Vialon cannula, was compared in a randomised trial. Seventy patients scheduled for elective cardiac surgery were randomly assigned to have either a Biovalve cannula or a Vialon cannula inserted before induction of anaesthesia. Postoperatively, the cannulae were removed either as soon as signs of thrombophlebitis were observed or at the end of seven days, whichever was earlier. There was a significantly lower incidence of thrombophlebitis in the Biovalve PUR group (17%) compared to the Vialon group (60%) at the end of seven days (p < 0.001). None of the cannulae tip cultures resulted in the growth of micro‐organisms. There was also a lower incidence of the need for re‐siting with the Biovalve than with the Vialon cannulae.
Interpleural block – part 2
Authors: Dravid R. M. , Paul R. E.
Published: October 2007

Interpleural blockade is effective in treating unilateral surgical and non‐surgical pain from the chest and upper abdomen in both the acute and chronic settings. It has been shown to provide safe, high‐quality analgesia after cholecystectomy, thoracotomy, renal and breast surgery, and for certain invasive radiological procedures of the renal and hepatobiliary systems. It has also been used successfully in the treatment of pain from multiple rib fractures, herpes zoster, complex regional pain syndromes, thoracic and abdominal cancer, and pancreatitis. The technique is simple to learn and has both few contra‐indications and a low incidence of complications. In the second of two reviews, the authors cover the applications, complications, contra‐indications and areas for future research.
Identification of the correct lumbar level using passive intersegmental motion testing
Authors: Chakraverty R. C. , Pynsent P. B. , Westwood A. , Chakraverty J. K.
Published: October 2007

This study aimed to assess the accuracy and agreement between examiners when attempting to identify a single lumbar spinal level using passive intersegmental motion testing, a technique commonly used by physical therapists. Thirty‐five adults were examined independently by an experienced and a novice clinician. Each examiner was asked to identify and note the interspace between the fifth lumbar vertebra and the first sacral vertebra, and to mark it. The mark was invisible to the second clinician asked to identify the same lumbar interspace. The true level was then identified by fluoroscopic imaging and was correct in 54–57% of cases. Interobserver agreement was poor. A significant learning effect was found for the experienced examiner, with proportionately more correct levels identified during the second part of the study (79%) when compared to the first (31%). The results show that intersegmental motion testing is a relatively unreliable method of identifying the correct spinal level.
The pressure effects of facemasks during noninvasive ventilation: a volunteer study
Authors: Munckton K. , Ho K. M. , Dobb G. J. , Das‐Gupta M. , Webb S. A.
Published: October 2007

Noninvasive ventilation by facemask is commonly used for patients with respiratory failure. We evaluated the pressure exerted by two types of facemask on the faces of 12 healthy volunteers while they were being given different levels of continuous or bi‐level positive airway pressure ventilation. The mean (SD) pressure recorded on the bridge of the nose was much higher than that on the cheek (nose: 65.8 (21.2) vs cheek 15.4 (7.2) mmHg, p < 0.0001). Progressive tightening of the harness and increasing of the volume of air in the facemask cushions increased the pressure on the bridge of the nose, and the effect of these two factors was additive. Some commercially available facemasks can produce substantial pressure on the bridge of the nose and this explains why pressure complications on the bridge of the nose are common during noninvasive ventilation.
A comparison of the disposable vs the reusable laryngeal tube in paralysed adult patients
Authors: Amini A. , Zand F. , Sadeghi S. E.
Published: October 2007

A disposable laryngeal tube (LT‐D) with dimensions identical to, but physical properties different from (stiffer tube/thicker cuff), the reusable laryngeal tube (LT‐R) has recently become available. We performed a randomised, single blind trial among 100 anaesthetised and paralysed patients to compare these devices in terms of ease of insertion, airway sealing pressure, position assessed fibreoptically and postoperative throat complications. Anaesthesia was administered with midazolam, fentanyl, propofol, atracurium, oxygen and isoflurane. The LT‐D and LT‐R showed similar clinical performances, as shown by their insertion times (28.4 and 23.6 s, respectively). Successful insertion at the first attempt was achieved in 90% with LT‐D and 96% with LT‐R. There were no differences in airway sealing pressure, fibreoptic position or post operative sore throat and dysphagia. The intra cuff pressure remained stable for the LT‐R but decreased slightly for the LT‐D. In paralysed, anaesthetised patients, the single use and reusable laryngeal tubes are similar in clinical performance.
Drug selection errors in relation to medication labels: a simulation study
Authors: Garnerin P. , Perneger T. , Chopard P. , Arès M. , Baalbaki R. , Bonnabry P. , Clergue F.
Published: October 2007

The aim of this study was to assess the impact of differences in drug label information on injectable drug selection errors. Differences in the display of drug strength information were assessed in a randomised controlled trial involving ward nurses, intensive care nurses, nurse anaesthetists, ward physicians, and anaesthetists. A set of 24 on‐screen tasks were constructed. For each task, a label corresponding to an instruction consisting of two from three possible pieces of information (concentration, quantity, volume) had to be selected from a list of 10 items. The set was presented three times to participants using three different label formats. Format A provided two pieces of strength information different from those in the instruction. Format B and C provided all three pieces in a random and a fixed sequence, respectively. The frequency of errors was statistically higher with formats A and B than with format C, and greater in nurses than in anaesthetists. Regulatory bodies should therefore implement a standard requiring that the concentration (expressed in ‘mg.ml−1’), the amount and the volume of drug be displayed on medication labels in fixed locations.
A comparison of direct and indirect laryngoscopes and the ILMA in novice users: a manikin study
Authors: Maharaj C. H. , McDonnell J. G. , Harte B. H. , Laffey J. G.
Published: October 2007

Direct laryngoscopic tracheal intubation using the Macintosh laryngoscope is taught to many healthcare professionals as it is a potentially life‐saving procedure. However, it is a difficult skill to acquire and maintain. Several alternative intubation devices exist that may provide a better view of the glottis and require less skill to use. We conducted a prospective, randomised trial of four different laryngoscopes and the ILMA in 30 medical students who had no prior airway management experience. The devices were tested in both normal and cervical immobilisation laryngoscopy scenarios. Following brief didactic instruction, each participant took turns performing laryngoscopy and intubation using each device under direct supervision. Each student was allowed up to three intubation attempts with each device, in each scenario. The Airtraq, McCoy, and the ILMA each demonstrated advantages over the Macintosh laryngoscope. In both the easy and difficult airway scenarios, the Airtraq, McCoy, and the ILMA reduced the number of intubation attempts, and reduced the number of optimisation manoeuvres required. The Airtraq and ILMA reduced the severity of dental trauma in both scenarios. The performance of the other devices studied was more variable. Overall, participants found that only the Airtraq was less difficult to use and they were more confident using it compared to the Macinosh laryngoscope.
Use of thromboelastography to demonstrate persistent anticoagulation after stopping enoxaparin*
Authors: Simons R. , Mallett S. V.
Published: October 2007

Peri‐operative guidelines exist for neuraxial anaesthesia and anticoagulant therapy. We describe the use of thromboelastography to assess the coagulation status of a patient with moderate renal impairment who had been receiving enoxaparin and was being managed in accordance with current recommendations. This report demonstrates that current guidelines for discontinuing treatment with enoxaparin may not allow a sufficient safety margin in all patient groups and that thromboelastography is a useful tool in such situations.
Multiple system atrophy as a cause of upper airway obstruction
Authors: Lim Y. S. , Kennedy N. J.
Published: October 2007

A patient presented to the ear, nose and throat department with inspiratory stridor, dysphagia and a sore throat. Clinical and radiological examination was normal. During induction of anaesthesia for a planned microlaryngoscopy, the patient developed complete upper airway obstruction that was overcome by applying positive pressure via a facepiece until awake. He subsequently developed respiratory failure, requiring mechanical ventilatory support. An elective tracheostomy was inserted for his symptoms. Neurological opinion confirmed the diagnosis of multiple system atrophy with akinetic rigid syndrome. We review this obscure condition and how it may occasionally present to anaesthetists.
A comparison of dexmedetomidine and midazolam for sedation in third molar surgery*
Authors: Cheung C. W. , Ying C. L. A. , Chiu W. K. , Wong G. T. C. , Ng K. F. J. , Irwin M. G.
Published: October 2007

This randomised, double‐blind study compared dexmedetomidine and midazolam for intravenous sedation during third molar surgery under local anaesthesia. Sixty patients received either dexmedetomidine (up to 1 μg.kg−1) or midazolam (up to 5 mg), which was infused until the Ramsay Sedation Score was four or the maximum dose limit was reached. Intra‐operative vital signs, postoperative pain scores and analgesic consumption, amnesia, and satisfaction scores for patients and surgeons, were recorded. Sedation was achieved by median (IQR (range)) doses of 47 μg (39–52 (25–76)) or 0.88 μg.kg−1 (0.75–1.0 (0.6–1.0)) dexmedetomidine, and 3.6 mg (3.3–4.4 (1.9–5.0)) or 0.07 mg.kg−1 (0.055–0.085 (0.017–0.12)) midazolam. Heart rate and blood pressure during surgery were lower in dexmedetomidine group. There was no significant difference in satisfaction or pain scores. Midazolam was associated with greater amnesia. Dexmedetomidine produces comparable sedation to midazolam.
Combining multiple comorbidities with Acute Physiology Score to predict hospital mortality of critically ill patients: a linked data cohort study
Authors: Ho K. M. , Finn J. , Knuiman M. , Webb S. A. R.
Published: October 2007

We investigated whether replacing the Acute Physiology and Chronic Health Evaluation (APACHE) II weighted comorbidity score with other measures of prior comorbidity would improve the prediction of hospital mortality in critically ill patients. Clinical data of 24 303 critically ill patients were linked to the Western Australian hospital morbidity database to identify prior comorbidities. Minor comorbidities as described in the Charlson comorbidity index and Elixhauser comorbidities were prevalent in critically ill patients. Among 24 303 admissions, 3615 (14.9%), 10 223 (42.1%), and 11 597 (47.7%) patients had at least one comorbidity as defined in the APACHE II score, Charlson comorbidity index, and Elixhauser comorbidities, respectively. The ability of comorbidity alone to discriminate between hospital survivors and non‐survivors was poor. Replacing the APACHE II weighted comorbidity score with other more comprehensive measures of comorbidity did not significantly improve the discrimination of the APACHE II score.
Evaluation of medication reviews conducted by community pharmacists: a quantitative analysis of documented issues and recommendations
Authors: Krska J. , Avery A. J. ,   The Community Pharmacy Medicines Management Project Evaluation Team
Published: October 2007

What is already known about this subject?

• There is conflicting evidence concerning the potential benefits of pharmacist‐led medication review.

• Little work has been published on the completeness of medication reviews provided by community pharmacists.

What this study adds

• The 60 community pharmacists taking part in a large randomized controlled trial showed considerable variation in the completeness of the reviews they recorded for intervention patients.

• Overall, pharmacists recorded only a minority of the potential issues present in these patients.

• The frequency with which pharmacists recorded issues was not related to key characteristics or to the number of reviews completed.

Aims

To describe issues noted and recommendations made by community pharmacists during reviews of medicines and lifestyle relating to coronary heart disease (CHD), and to identify and quantify missed opportunities for making further recommendations and assess any relationships with demographic characteristics of the pharmacists providing the reviews.

Methods

All issues and recommendations noted by 60 community pharmacists during patient consultations were classified and quantified. Two independent reviewers studied a subsample of cases from every participating pharmacist and identified and classified potential issues from the available data. The findings of the pharmacists and the reviewers were compared. Relevant pharmacist characteristics were obtained from questionnaire data to determine relationships to the proportion of potential issues noted.

Results

A total of 2228 issues and 2337 recommendations were noted by the pharmacists in the 738 patients seen, a median of three per patient (interquartile range 2–4). The majority of the recommendations made (1719; 74%) related to CHD. In the subsample of 169 patients (23% of the total), the reviewers identified 1539 potential issues, of which pharmacists identified an average of 33.8% (95% confidence interval 30.1, 36.4). No relationship was found between the proportion of issues noted and potentially relevant factors such as pharmacists' characteristics and their experience of doing reviews.

Conclusions

The majority of issues and recommendations noted by pharmacists related to CHD, although pharmacists recorded only a minority of the issues identified by reviewers. Variation between pharmacists in the completeness of reviews was not explained by review or other relevant experience.
Identifying how age and gender influence prescription drug use in a primary health care environment in Catalonia, Spain
Authors: Fernández‐Liz Eladio , Modamio Pilar , Catalán Arantxa , Lastra Cecilia F. , Rodríguez Teresa , Mariño Eduardo L.
Published: October 2007

What is already known about this subject

• Knowledge of prescription patterns in primary health care is an important tool in rational drug therapy.

• Age and gender are the principal determining factors of cost variability between medical practices, due to drug prescriptions.

• Age and gender are the principal determining factors of cost variability in relation to the therapeutic group.

What this study adds

• This study provides specific information on the use of drugs in the primary health care environment of the Catalan Health System, and the differences observed are analyzed with respect to age and gender of the population receiving care.

• The study shows that there is a high prevalence of drugs in the under 5 year old age group, and also in persons over 54 years of age.

• The variability found in the cost per patient suggests that adjustment should be made for age in practitioners' prescription evaluation procedures in primary health care in Catalonia.

Aims

To determine the prevalence and usage patterns of prescription drugs according to patients' age and gender, and to identify their relative importance in the prescription costs, in primary health care within the Catalan Health Institute.

Methods

This was a cross‐sectional study using computerized pharmacy dispensing records for 5 474 274 members registered, during 2002. Twenty age‐gender categories were established. Use of a drug group was defined as filling at least one prescription. The variables studied were age, gender, number of prescriptions and net cost. The prevalence of use, the number of prescriptions and cost issued to each age category were reported.

Results

The overall prevalence of drug use was 74.53% (women 80.93%, men 67.84%). This was higher in the group of 0–4 year‐olds, and in the ≥ 55 year‐olds. Age (P < 0.001) produced a statistically more significant effect than gender (P < 0.05). The most used therapeutic groups were analgesics, nonsteroidal anti‐inflammatory drugs, antiulcer drugs, anxiolytics, expectorants and mucolytics. The number of prescriptions and costs per patient rose with age and showed great variation in the use of these groups for patients in different age groups. The risk of prescription in women was 23% higher than in men (RR 1.23, 95% CI 1.11, 1.37, P < 0.001).

Conclusions

The majority of subjects were exposed to one or more drugs. The variability in the number of prescriptions and in the prescribing cost per patient between the different age groups suggests that adjustments should be made for age in practitioners' prescription evaluation processes in primary health care in Catalonia.
Effect of CYP2C19 polymorphism on nelfinavir to M8 biotransformation in HIV patients
Authors: Hirt Déborah , Mentré France , Tran Agnès , Rey Elisabeth , Auleley Solange , Salmon Dominique , Duval Xavier , Tréluyer Jean‐Marc ,   The COPHAR2‐ ANRS Study Group
Published: October 2007

What is already known about this subject

• Nelfinavir is an HIV protease inhibitor, substrate of the transporter P‐glycoprotein and metabolized via CYP2C19, CYP3A4 and CYP3A5 enzymes.

• Pharmacokinetic studies have shown wide interindividual variability of nelfinavir concentrations, some of this variability perhaps caused by variant drug metabolism or transporter genes.

• For CYP3A4*1B and CYP3A5*3 polymorphism, results from three studies are in agreement, showing no difference in nelfinavir concentrations between patients with these different genotypes.

• However, for MDR1 and CYP2C19 polymorphism, there have been contradictory studies, showing either no impact on nelfinavir concentration or modified concentrations which could influence virological response.

What this study adds

• Patients with an *1/*2 or *2/*2 genotype for CYP2C19 had a nelfinavir to M8 biotransformation divided by 2 compared with *1/*1 patients.

• No evidence of any influence of MDR1 polymorphism on nelfinavir absorption could be detected.

Aims

To evaluate the effect of CYP2C19 polymorphism on nelfinavir and M8 pharmacokinetic variability in human immunodeficiency virus‐infected patients and to study the link between pharmacokinetic exposure and short‐term efficacy and toxicity.

Methods

Nelfinavir (n = 120) and M8 (n = 119) concentrations were measured in 34 protease inhibitor‐naïve patients. Two weeks after initiating the treatment, blood samples were taken before, 1, 3 and 6 h after drug administration. Genotyping for CYP3A4, 3A5, 2C19 and MDR1 was performed. A population pharmacokinetic model was developed to describe nelfinavir‐M8 concentration time‐courses and to estimate interpatient variability. The influence of individual characteristics and genotypes were tested using a likelihood ratio test. Estimated mean (Cmean), maximal (Cmax) and trough (Ctrough) nelfinavir and M8 concentrations were correlated to short‐term virological efficacy and tolerance using Spearman nonparametric correlation tests.

Results

A one‐compartment model with first‐order absorption, elimination and metabolism to M8 best described nelfinavir data. M8 was modelled by an additional compartment. Mean pharmacokinetic estimates and the corresponding intersubject variabilities were: absorption rate 0.17 h−1 (99%), absorption lag time 0.82 h, apparent nelfinavir total clearance 52 l h−1 (49%), apparent nelfinavir volume of distribution 191 l, M8 elimination rate constant 1.76 h−1 and nelfinavir to M8 0.39 h−1 (59%) in *1/*1 patients and 0.20 h−1 in *1/*2 or *2/*2 patients for CYP2C19*2. Nelfinavir Cmean was positively correlated to glycaemia and triglyceride increases (P = 0.02 and P = 0.04, respectively).

Conclusions

The rate of metabolism of nelfinavir to M8 was reduced by 50% in patients with *1/*2 or *2/*2 genotype for CYP2C19 compared with those with *1/*1 genotype.
Bioavailable testosterone is associated with a reduced risk of amnestic mild cognitive impairment in older men
Authors: Chu Leung‐Wing , Tam Sidney , Lee Peter W. H. , Wong Rachel L. C. , Yik Ping‐Yiu , Tsui Wilson , Song Youqiang , Cheung Bernard M. Y. , Morley John E. , Lam Karen S. L.
Published: October 2007

Objective  We investigated the risk of amnestic mild cognitive impairment (aMCI) in relation to serum bioavailable (BT) and total testosterone (TT) levels in older men.

Design, setting and subjects  A cross‐sectional study in an ambulatory setting, with older men aged 55–93 years with normal cognition, aMCI and Alzheimer's disease (AD).

Measurements  Morning serum BT and TT levels were determined. AD was diagnosed by the Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS‐ADRDA) criteria for probable AD and aMCI by the Petersen criteria.

Results  We recruited 203 Chinese older men (48 aMCI, 66 AD and 89 with normal cognition). Mean serum BT, but not TT, levels were significantly lower in the aMCI (mean BT ± SEM 1·06 ± 0·10 nmol/l) and AD (0·99 ± 0·08 nmol/l) groups than in the normal controls (1·82 ± 0·12 nmol/l) (P < 0·001, one‐way anova) with no significant difference between the aMCI and AD groups. After adjustment for education, age and apolipoprotein E (apoE) genotype, logistic regression analyses showed that the serum BT level [adjusted odds ratio (OR) = 0·52, 95% confidence interval (CI) 0·32–0·85] was an independent protective factor for aMCI. For the combined outcome of aMCI and AD, the serum BT level was an independent protective factor but age and apoE ɛ4 were independent risk factors. There was no interaction between BT and age.

Conclusions  In older men, serum BT, but not TT, levels were associated with a lower risk of aMCI and AD.
Leptin therapy for partial lipodystrophy linked to a PPAR‐γ mutation
Authors: Guettier Jean‐Marc , Park Jean Y. , Cochran Elaine K. , Poitou Christine , Basdevant Arnaud , Meier Muriel , Clément Karine , Magré Jocelyne , Gorden Phillip
Published: October 2007

Aims/hypothesis  Partial lipodystrophy (PL) is most commonly characterized by loss of subcutaneous fat in the extremities with preservation of truncal fat and is associated with insulin resistance, diabetes and hyperlipidaemia. Recombinant human leptin (r‐metHuLeptin) therapy has been shown to be effective in treating metabolic abnormalities associated with congenital or acquired generalized lipodystrophy and PL associated with lamin A/C (LMNA) gene mutations or highly active antiretroviral therapy (HAART). Our aim was to assess the effectiveness of leptin therapy in treating metabolic complications of PL associated with heterozygous peroxisome proliferator activated receptor gamma (PPARG) mutations. This is the first report to detail the clinical response of a patient with PL due to a PPARG mutation treated with r‐metHuLeptin.

Methods  A 36‐year‐old female with PL associated with a heterozygous PPARG mutation complicated by poorly controlled diabetes and severe, refractory hypertriglyceridaemia was enrolled in a National Institutes of Health (NIH) protocol to evaluate the role of r‐metHuLeptin in lipodystrophy. The patient received escalating doses of r‐metHuLeptin until a dose 0·12 mg/kg/day was reached. Metabolic parameters, including serum chemistries, fasting blood glucose, glycated haemoglobin (HbA1c), lipid profile, an oral glucose tolerance test (OGTT), an insulin tolerance test (ITT), liver volume, percentage body fat and energy expenditure were followed at regular time intervals over 18 months of therapy.

Results  Eighteen months of r‐MetHuLeptin therapy was associated with a marked improvement in glucose homeostasis as evidenced by normalization of the fasting blood glucose (baseline = 8·3 mmol/l; 18 months = 4·9 mmol/l), lowering of HbA1c (baseline = 9·9%; 18 months = 7·2%) and improved tolerance to an oral glucose load. In addition, a striking amelioration in the patient's refractory, severe hypertriglyceridaemia was observed (baseline = 21·15 mmol/l; 18 months = 5·96 mmol/l).

Conclusion  r‐MetHuLeptin is effective in treating metabolic complications associated with PL due to PPARG mutations. In the context of previously published work, our findings suggest that the response to r‐MetHuLeptin is independent of the aetiology in lipodystrophy.