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A number of limitations of this analysis should be noted. Serum creatinine was measured 2 wk after randomization, which occurred on average 11 d after MI. The variation in time may have affected the results through either worsening or improvement of renal function. However, this variation in time not only underscores the prognostic value of WRF but also stresses the importance of repeating serum creatinine measurements from 1 to 3 wk after the acute event. The dosage of study medication (placebo or captopril) also was variable; although the study protocol did not specify that captopril should be stopped in the presence of WRF, titration regimens were left to the discretion of each patient’s physician.

Patients who tolerated the initial test dosage were included regardless of whether the study medication was not titrated fully to the target dosage of 25 mg three times daily by the end of 2 wk. The majority of patients were started at 12.5 mg and titrated upward, but there were patients who started at lower dosages or were down-titrated as a result of adverse drug reactions or cardiovascular events before 2 wk, which might have influenced the predictive value of increased creatinine. We would have expected to see an average decline in GFR for patients who started captopril but did not find this in SAVE. This finding most likely was due to variation in dose titration and patients’ not receiving the maximum therapeutic effect of captopril. The average change in GFR also may have been influenced by the 41 patients who dropped out of the trial as a result of adverse drug reactions from captopril. Our findings in the placebo group, however, would not have been influenced by dose titration. The results from this post hoc analysis were observed in post-MI patients with systolic dysfunction and cannot be extended to those with normal ventricular function. Finally, SAVE was conducted between 1988 and 1991. We cannot exclude the possibility that changes in the treatment of post-MI patients may have altered the current relation between WRF and cardiovascular risk. However, SAVE was conducted in a randomized, placebo-controlled setting and therefore allowed us to assess the true effect of ACE inhibition on cardiovascular outcomes in the setting of renal dysfunction using prospectively collected data.

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We have shown that in patients with acute MI and systolic dysfunction, WRF defined as an increase in creatinine of >0.3 mg/dl within the first 2 wk is not uncommon (12.0%) and when present is associated with a significant increase in risk for cardiovascular outcomes and mortality. In this population of patients with systolic dysfunction after MI, WRF was a more robust predictor of events and death than baseline serum creatinine. The risk that is associated with WRF was most prominent in patients who received placebo and seems to be attenuated in patients who receive captopril. These findings suggest that close monitoring of renal function during the first few weeks after acute MI may aid in long-term risk stratification for cardiovascular events and may argue against discontinuation of ACE inhibitor therapy after small, nonprogressive increases in creatinine.

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From the September 2013 Issue
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Executive Summary

Reprint: R1309G

Companies have long emphasized touchpoints—the many critical moments when customers interact with the organization on their way to purchase and after. But this focus can create a distorted picture, suggesting that customers are happier with the company than they actually are. And it distracts from the more important picture: the customer’s end-to-end experience.

In their research, the authors—partners at McKinsey—have found that organizations able to skillfully manage the entire customer journey reap enormous benefits: enhanced customer satisfaction, reduced churn, increased revenue, and greater employee satisfaction.

To realize these benefits, companies need to embed customer journeys into their operating models in four ways. They must identify key journeys, understand how they are performing in each, redesign and support those journeys, and change mind-sets to sustain the initiatives at scale.

Journey-based transformations may take years to perfect. But they create a culture that engages the organization across functions and from top to bottom. It’s a culture that’s hard to build otherwise, and a true competitive advantage goes to companies that get it right.

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The Problem

Many companies excel in individual interactions with customers, but they fail to pay adequate attention to the customer’s complete experience on the way to purchase and after.

The Argument

Companies that perfect customer journeys reap enormous rewards, including enhanced customer and employee satisfaction, reduced churn, increased revenues, lowered costs, and improved collaboration across the organization.

The Solution

Companies need to combine top-down, judgment-driven evaluations and bottom-up, data-driven analysis to identify key journeys, and then engage the entire organization in redesigning the customer experience. This requires shifting from siloed to cross-functional approaches and changing from a touchpoint to a journey orientation.

Companies have long emphasized touchpoints—the many critical moments when customers interact with the organization and its offerings on their way to purchase and after. But the narrow focus on maximizing satisfaction at those moments can create a distorted picture, suggesting that customers are happier with the company than they actually are. It also diverts attention from the bigger—and more important—picture: the customer’s end-to-end journey.

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» General English » Shakespeare
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What does show us about getting ahead? Shaheen Khan shares what she learned from playing Lady Macbeth and how performing in Asia helped her find comedy in Shakespeare's most famous tragedy.


The ambition of Lady Macbeth

Mmm, ambition. Don’t we all have it? I sort of wish I was a bit more like Lady Macbeth and the Macbeths actually. Well, the play is about ambition and about what happens when ambition goes, not too far, but sort of unchecked in yourself. We are all ambitious. We all want to get ahead. We all want that, you know, the crown, but we know that we’re not going to do certain things, you know? Because we feel we’re good people and you can’t do that, it’s wrong, whatever. But in this play they see an opportunity. And it’s interesting that actually Macbeth for me, at the beginning of the play, he’s a good guy to me. He’s like, ‘Yeah, I really want that but of course I’m not going to kill him to get it.’ And then his wife, she’s like, ‘He’s not going to do it, is he?’ And then what happens in the end? She realises, you know, ‘Naught’s had, all’s spent, where our desire is got without content.’ And you think, yes, you realise that now. It’s like all of us in a way. You know, when you absolutely really want that house and your stomach’s churning or whatever it is that you desire so badly, a car or any material thing. In the end you get it and then it loses its lustre.

A British Asian production of

So many Indian films and stories have taken their inspiration from Shakespeare that obviously they relate to it and it’s relevant for them. And so for us taking our Asian version of through Britain was quite extraordinary. The British Asian audience loved it as did a lot of white audiences actually. What a lot of white people really liked was that they saw a different take on a lot of the Shakespeares they had seen. I mean, for example, our witches were hijras. Now, hijras in India are actually transvestites, transgender. They’re actually seen as the third gender. For me that was very exciting using the hijras as the witches in . And the audience loved it. And it was interesting because there were people who said, you know, they’ve seen lots of s but they’ve never seen that kind of interpretation of the witches. And there was this lovely woman at one of the venues and she’d come with her children and she said, ‘It’s really interesting because this is their first . I’ve seen lots. And my first was typical witches with the pointy hats. And their version which they will take with them through their lifetime will be these, you know, half-men, half-women in these beautiful, colourful clothes.’ I think also we found quite a lot of comedy in the witches as well. Which I think is great because you don’t want the witches to just be these one-dimensional, you know, spooky kind of thing. You kind of want them to be a bit more. And what I loved about our was actually there was quite a lot of comedy for such a dark piece. Somehow the hijras managed to bring something special.

We use I wish and the past simple to express wishes about the present or future. For example, Shaheen says:

She uses the past simple ('was') but she's talking about the present.

Do you think it's true that we are all ambitious?

Can you identify with Lady Macbeth's ambition? To whatdegree?

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