Early practical experience and the social responsiveness of clinical education: Systematic review

Objectives To find how early experience in clinical and community settings (early experience) affects medical education, and identify strengths and limitations of the available evidence. Design A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001. Data sources Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration. Selection of studies All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication. Results Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries,junior students provided preventive health care directly to underserved populations. Conclusion Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.

Development of a quasi-chemical viscosity model for fully liquid slags in the Al2O3-CaO-'FeO'-MgO-SiO2 system. Part 2. A review of the experimental data and the model predictions for the Al2O3-CaO-MgO, CaO-MgO-SiO2 and Al2O3-MgO-SiO2 systems

A structurally-based quasi-chemical viscosity model has been developed for the Al2O3 CaO-'FeO'-MgO-SiO2 system. The model links the slag viscosity to the internal structure of melts through the concentrations of various anion/cation Si0.5O, Me2/nn+O and Me1/nn+Si0.25O viscous flow structural units. The concentrations of structural units are derived from the quasi-chemical thermodynamic model. The focus of the work described in the present paper is the analysis of experimental data and the viscosity models for fully liquid slags in the Al2O3-CaO-MgO, Al2O3 MgO-SiO2 and CaO-MgO-SiO2 systems.

Is pulse palpation helpful in detecting atrial fibrillation? A systematic review

Background Atrial fibrillation in the elderly is common and potentially life threatening. The classical sign of atrial fibrillation is an irregularly irregular pulse. Objective The objective of this research was to determine the accuracy of pulse palpation to detect atrial fibrillation. Methods We searched Medline, EMBASE, and the reference lists of review articles for studies that compared pulse palpation with the electrocardiogram (ECG) diagnosis of atrial fibrillation. Two reviewers independently assessed the search results to determine the eligibility of studies, extracted data, and assessed the quality of the studies. Results We identified 3 studies (2385 patients) that compared pulse palpation with ECG. The estimated sensitivity of pulse palpation ranged from 91% to 100%, while specificity ranged from 70% to 77%. Pooled sensitivity was 94% (95% confidence interval [CI], 84%-97%) and pooled specificity was 72% (95% CI 69%-75%). The pooled positive likelihood ratio was 3.39, while the pooled negative likelihood ratio was 0.10. Conclusions Pulse palpation has a high sensitivity but relatively low specificity for atrial fibrillation. It is therefore useful for ruling out atrial fibrillation. It may also be a useful screen to apply opportunistically for previously undetected atrial fibrillation. Assuming a prevalence of 3% for undetected atrial fibrillation in patients older than 65 years, and given the test's sensitivity and specificity, opportunistic pulse palpation in this age group would detect an irregular pulse in 30% of screened patients, requiring further testing with ECG. Among screened patients, 0.2% would have atrial fibrillation undetected with pulse palpation.

Risk of serious NSAID-related gastrointestinal events during long-term exposure: a systematic review

Objective: Exposure to non-steroidal anti-inflammatory drugs (NSAIDs) is associated wit increased risk of serious gastrointestinal (GI) events compared with non-exposure. We investigated whether that risk is sustained over time. Data sources: Cochrane Controlled Trials Register (to 2002); MEDLINE, EMBASE, Derwent Drug File and Current Contents (1999-2002); manual searching of reviews (1999-2002). Study selection: From 479 search results reviewed and 221 articles retrieved, seven studies of patients exposed to prescription non-selective NSAIDs for more than 6 months and reporting time-dependent serious GI event rates were selected for quantitative data synthesis. These were stratified into two groups by study design. Data extraction: Incidence of GI events and number of patients at specific time points were extracted. Data synthesis: Meta-regression analyses were performed. Change in risk was evaluated by testing whether the slope of the regression line declined over time. Four randomised controlled trials (RCTs) provided evaluable data from five NSAID arms (aspirin, naproxen, two ibuprofen arms, and diclofenac). When the RCT data were combined, a small significant decline in annualised risk was seen: -0.005% (95% Cl, -0.008% to -0.001%) per month. Sensitivity analyses were conducted because there was disparity within the RCT data. The pooled estimate from three cohort studies showed no significant decline in annualised risk over periods up to 2 years: -0.003% (95% Cl, -0.008% to 0.003%) per month. Conclusions: Small decreases in risk over time were observed; these were of negligible clinical importance. For patients who need long-term (> 6 months) treatment, precautionary measures should be considered to reduce the net probability of serious GI events over the anticipated treatment duration. The effect of intermittent versus regular daily therapy on long-term risk needs further investigation.

Vascular remodelling in the internal mammary artery graft and association with elevated endothelin-1 expression

Introduction: The vasoconstricting peptide Endothelin-1 (ET-1) has been associated with atherosclerotic cardiovascular disease, AAA, hypertension and hypercholesterolemia. It is known to stimulate quiescent vascular smooth muscle cells (VSMC) into the growth cycle and has been linked to intimal thickening following endothelial injury and is associated with vessel wall remodelling in salt-sensitive hypertension models. Enhanced ET-1 expression has been reported in the internal mammary artery (IMA) and was markedly higher in patients undergoing cardiac bypass surgery who were diabetic and /or hypercholesterolemic. Aims: To firstly review the histopathology of the IMA and secondly, determine the relationship between ET-1 expression in this vessel and mitogenic activity in the medial VSMC. Methods: Vessel tissue collected at the time of CABG surgery was formalin-fixed and paraffin-embedded for histological investigation. Cross sections of the left distal IMAwere stained with Alcian Blue/Verhoeff’s van Gieson to assess medial degeneration and identify the elastic lamellae and picrosirius red to determine the collagen content (specifically type I and type III). Immunohistochemistry staining was used to assess VSMC growth (PCNA label), tissue ET-1 expression, VSMC (SMCa-actin) area and macrophage/monocyte (anti-CD68) infiltration. Quantitative analysis was performed to measure the VSMC area in relation to ET-1 staining. Results: Fifty-five IMA specimens from the CABG patients (10F; 45M; mean age 65 years) were collected for this study. Fourteen donor IMAspecimens were used as controls (7F; 7M; mean age 45 years). Significant medial hypertrophy, VSMC disorganisation and elastic lamellae destruction was detected in the CABG IMA. The amount of Alcian blue staining in the CABG IMA was almost double that of the control (31.85+/14.52% Vs 17.10+/9.96%, P= .0006). Total collagen and type I collagen content was significantly increased compared with controls (65.8+/18.3% Vs 33.7 + / 13.7%, P= .07), (14.2 + /10.0% Vs 4.8 + /2.8%, P= .01), respectively. Tissue ET-1 and PCNA labelling were also significantly elevated the CABG IMA specimens relative to the controls (69.99 + /18.74%Vs 23.33 + /20.53%, P= .0001, and 37.29 + /12.88% Vs 11.06 + /8.18, P= .0001), respectively. There was mild presence of macrophages and monocytes in both CABG and control tissue. Conclusions: The IMA from CABG patients has elevated levels of type I collagen in the extracellular matrix indicative of fibrosis and was coupled with deleterious structural remodelling. Abnormally high levels of ET-1 were measured in the medial SMC layer and was associated with VSMC growth but not related to any chronic inflammatory response within the vessel wall.

Does internal marketing improve service quality in call centres?

Although internal marketing has been conceptually argued to improve service quality, empirical evidence in this respect has been limited. This research investigates the relationship between rewards, which are a key component of internal marketing paradigm, and service quality of frontline employees in banking call centres. In this context, the authors develop hypotheses with the help of literature review, and empirically examine the effects of various extrinsic and intrinsic rewards on service quality. The results indicate that intrinsic rewards have greater effect on service quality than extrinsic rewards, which offer managerial implications and directions for future research.

Professional Services in the EU Internal Market: Quality Regulation and Self-Regulation, by T. Heremans (Oxford: Oxford University Press, 2012, ISBN 9781849462402); xxii+366pp., £75.00 hb.

Book review

Myopic foveoschisis:a clinical review

To review the literature on epidemiology, clinical features, diagnostic imaging, natural history, management, therapeutic approaches, and prognosis of myopic foveoschisis. A systematic Pubmed search was conducted using search terms: myopia, myopic, staphyloma, foveoschisis, and myopic foveoschisis. The evidence base for each section was organised and reviewed. Where possible an authors' interpretation or conclusion is provided for each section. The term myopic foveoschisis was first coined in 1999. It is associated with posterior staphyloma in high myopia, and is often asymptomatic initially but progresses slowly, leading to loss of central vision from foveal detachment or macular hole formation. Optical coherence tomography is used to diagnose the splitting of the neural retina into a thicker inner layer and a thinner outer layer, but compound variants of the splits have been identified. Vitrectomy with an internal limiting membrane peel and gas tamponade is the preferred approach for eyes with vision decline. There has been a surge of new information on myopic foveoschisis. Advances in optical coherence tomography will continually improve our understanding of the pathogenesis of retinal splitting, and the mechanisms that lead to macular damage and visual loss. Currently, there is a good level of consensus that surgical intervention should be considered when there is progressive visual decline from myopic foveoschisis.

Emberi erőforrás menedzsment és gyakorlatai a lean termelésben – a tevékenységmenedzsment irodalmának tükrében = Human resource management and practices in lean manufacturing – review of Operations Management’s literature

A lean bevezetése nem korlátozódik a termelés újraértelmezésére, hanem jellemzően a vállalati belső működés (számvitel, emberi erőforrás, beszerzés) és külső kapcsolatok (beszállítók, ellátási lánc) újszervezését is megköveteli. Ezek a kapcsolódási pontok számos, tudományterületek határán fekvő kutatási irányt nyitnak meg. Ebben a tanulmányban a lean termelés és a belső működéshez sorolt emberi erőforrás menedzsment kapcsolatára fókuszálok. Célom, hogy a tevékenységmenedzsment vonatkozó irodalmának áttekintésével bemutassam a lean termelés logikájához illeszkedő emberi erőforrás menedzsmentet, annak jellemző gyakorlatait. = Lean goes beyond manufacturing, implementing its principles usually requires companies to reorganize their companywide internal operations (accounting, human resource, purchasing) and also external relations (supplier, supply chain). This linkages offer several multidisciplinary research directions, this study focuses on the relationship between human resource management and lean production. The main aim of this working paper is to review Operations Management’s literatures on this issue and present the human resource policy and its practices that fit and support lean production.

A versenyképesség és a társaságok belső ellenőrzése (Competitiveness and corporate internal audit)

A cikk a belső ellenőrzésnek a hatékony társaságirányításhoz való hozzájárulását és ennek a versenyképességre gyakorolt hatását vizsgálja. A belső ellenőrzés és a társaságirányítás kölcsönös összefüggésben áll egymással. Nemcsak a belső ellenőrzés hat a társaságirányításra, hanem a releváns társaságirányítási struktúrák, emberi kapcsolatok és magatartásformák jelentős hatást gyakorolnak a belső ellenőrzés színvonalára és hatékonyságára. A cikk ezért különös figyelmet szentel a belső ellenőröknek az igazgatósággal, az auditbizottsággal/felügyelőbizottsággal, a menedzsmenttel és a könyvvizsgálóval való kapcsolatainak vizsgálatára. Rávilágít a belső ellenőrzés legfőbb funkciójára, amely objektív bizonyosságot nyújt az igazgatóság és a felső vezetők számára a kockázatok azonosítására, kezelésére és elfogadható szintre történő csökkentésére szolgáló kontrollfolyamatok megfelelőségéről és hatékonyságáról. A bemutatott belső ellenőrzési modell azt a szemléletet közvetíti, hogy a belső ellenőrzés által nyújtott objektív bizonyosság megszerzése nemcsak a jogszabályoknak vagy az ajánlásoknak való megfelelés, hanem a társaságok versenyképessége szempontjából is kiemelkedő jelentőségű. _________ The purpose of this paper is to consider the contribution of internal audit to the sound corporate governance and the impact of that on the competitiveness of the companies. There is a mutual dependency between internal audit and corporate governance. Not only the internal audit has impact on the corporate governance but the relevant governance structures, relationships and behaviour influence the level and effectiveness of the internal audit. Therefore the present paper is highly concerned with the internal auditors` relationships with the board, audit committee/supervisory board, senior management and the external auditor. It highlights the internal audit function, that provides objective assurance to the board and senior management about the adequacy and effectiveness of the processes by which risks are identified, managed, controlled and mitigated to acceptable levels. The internal audit model demonstrated represents an approach, according to that getting objective assurance provided by internal audit is important not only to be in line with laws and recommendations but to facilitate the corporate competitiveness.

Resource-based view and dynamic capabilities - Achieving competitive advantage through internal resources and competences

Strategy has always been important for success. Whether strategy is applied for military purposes, in large firms, or even for personal objectives, there are certain key characteristics that every successful strategy carries on: clear, objective and simple goals; deep knowledge and understanding of the competitive environment; objective understanding and exploitation of resources; and an effective plan implementation. In this paper, the author’s attention will be focused on the role of internal resources, routines and processes as the bases of sustained competitive advantage (hereafter SCA) into what is now known as the resourcebased view of the firm (RBV) and Dynamic Capabilities (DC). First, the relevance of RBV and DC approaches and the main characteristics of those are briefly mentioned. Second, RBV and DC are examined as an important piece to achieve SCA. Later on, the author deepens into some examples and the manager’s importance when using these RBV and DC approaches. Then issues related with complexity and undefined concepts in RBV and DC are briefly mentioned. Finally, conclusions and personal comments are presented.