Management of Childhood Psoriasis with Acitretin

Management of Childhood Psoriasis with Acitretin Abstract: Psoriasis is a chronic inflammatory disease of the skin which can occur at any age-group. Psoriasis in childhood is not uncommon and has genetic susceptibility but usually an environmental trigger such as infection is thought to initiate the disease process. Childhood psoriasis has profound effects on both physical and psychosocial health of the patient. Treatment of mild psoriasis can be done with topical therapies but those which do not respond to topical therapies can be treated with phototherapy and systemic therapies. The use of systemic therapies in childhood is mainly based on the published data, case series, expert opinion and the experience as there is lack of controlled trials in the age group. Based on the experience retinoid are probably the second line drugs for the treatment of childhood psoriasis which do not respond to topical therapies and phototherapy. Using acitretin in a low dose and with proper physical examinations and laboratory investigations will reduce the h azard of potential serious adverse events. This article gives the review of use of acitretin in the childhood psoriasis. INTRODUCTION: Psoriasis is the chronic inflammatory disease of the skin having the world wide prevalence of 1-3% and is clinically characterized by erythematous papules and plaques covered with silvery scales(1, 2). Psoriasis can occur at any age. Psoriasis in pediatric population is not uncommon and exerts a major impact on physical and psycho-social health of a child. In about one-third of the psoriatic population, the onset of disease is seen during the pediatric age(3). In a study of 419 patients from Northern India, the age of onset of psoriasis ranged from 4 days to 14 years(4). The presence of positive family history was found to be 23% and 34.3% in two different studies(5, 6). Pediatric psoriasis has the genetic susceptibility but the environmental factors often trigger the initiation of the disease process. The most common triggering factors include respiratory infection, sore throat, stress and trauma. There are different variants of psoriasis in children like plaque, guttate, napkin, er ythrodermic, pustular and nail psoriasis(2). Plaque psoriasis is the most common subtype and the pustular psoriasis is the least common subtype(7). Psoriasis in childhood and adolescence require proper management. Both the patient and the parents must be given the knowledge about the disease and its nature. Psoriasis in childhood affects the health-related quality of life. It is found that, the risk of mental illness like depression and anxiety is increased in children with psoriasis than those without psoriasis(8). Due to the presence of visible skin lesions the children with psoriasis suffer from the low self-esteem(9). Fortunately, childhood psoriasis is usually mild and can be treated with topical therapies. Systemic treatment is required only if the disease do-not respond to topical therapies, phototherapy and if the disease is significantly impairing the psychosocial aspect of the child health. Systemic therapies for psoriasis in children are not approved by FDA. Due to the lack of controlled trials use of systemic therapies are based on case reports, published data and expert opinion. On the basis of published data and experience retinoids appear to be the second-line drug of choice for children(10). ACITRETIN: Retinoids encompasses all the compounds either natural or synthetic, which possess the biological activity like vitamin A(11). Synthetic Retinoids are classified into three generations. Acitretin and etretinate are the second generation synthetic retinoids and are also known as aromatic retinoids(12, 13). Acitretin is the free and active metabolite of etretinate. Etretinate is strongly lipophilic and tends to accumulate more in the adipose tissue and thus has a longer elimination half-life, in contrast acitretin is less lipophilic and thus clears rapidly from the body and has the shorter elimination half-life(14).Intake with food increases the absorption of acitretin so, the bioavailability of acitretin is more when taken with food than on the empty stomach(15). Due to the longer elimination half-life of etretinate it has been largely replaced by acitretin. However, it is found that re-esterification of acitretin to etretinate can take place with the concomitant intake of alcohol. So , the female patient especially of childbearing age should be strictly instructed to not take alcohol during the period of treatment with and 2 months after the completion of treatment (16). USE IN PEDIATRIC PSORIASIS: Pediatric psoriasis is usually mild and topical therapies are the first choice of treatment. Systemic therapy is not the first choice in childhood psoriasis. It is used in the treatment of recalcitrant psoriasis which do not respond to topical therapy, phototherapy and if it is significantly impairing the psychosocial aspects of the child health. Due to the lack of controlled trials, the use of acitretin is based on the published data, case reports and the expert opinion. However, the significant risk benefit of the treatment should always be weighed with the risk of disease without treatment. Long term use of acitretin in children with inherited disorder of keratinization supports the safety of acitretin in children, but the monitoring is always required(17). Acitretin is used effectively in the treatment of generalized pustular psoriasis, erythrodermic psoriasis, palmoplantar psoriasis and severe recalcitrant plaque psoriasis but acitretin is not effective in psoriatic arthropathy( 12, 18). Acitretin is used as either monotherapy or in combination with topical agents and narrowband ultraviolet phototherapy. In a multicenter cohort study by Ergun et al. 61 patients among 289 patients were treated with acitretin at a dose of 0.3-0.5 mg/kg/day with the mean duration of treatment being 9.16+-9.06 months. 47.5% of the patient achieved at least PASI- 75 response. 70.7% of the patient well tolerated the treatment with no side effects. 25.9% experienced the mucocutaneous side-effects, 1.7% had hyperlipidemia and 1.7% had nausea(19). In a multicenter retrospective analysis by Lernia et al. including 18 children with plaque psoriasis ,8(44.4%) patient achieved a PASI-response 75 at 16 weeks. The starting dose of acitretin was 0.2-0.5mg/kg/day but the dose was increased to 0.6mg/kg/day in two patients after 8 weeks. Three out of eight patients achieving PASI-75 response stopped therapy for the interval of 2-6 months but had to restart the treatment after relapse and the treatment was effective even after re-introduction. 9 patient discontinued treatment due to lack of efficacy and 1 patient discontinued treatment due to arthralgia. All patients had the mucocutaneous side-effects like chelitis, dry lips, dry mouth and pruritus. The laboratory values of the patients were within the baseline during the treatment(20). Ergin et al. reported a case of infantile pustular psoriasis treated with acitretin with the initial dose of 0.5mg/kg/day which was later increased to 0.7mg/kg/day. The skin lesion was cleared in the end of 4 months and then the acitretin was tapered to 0.3mg/kg/day for three months and then discontinued. Oral prednisolone was used initially then it was tapered and discontinued. Slight increase in serum triglyceride was observed but it returned to normal after the dose was tapered. No other adverse events were observed(21). Salleras et al. reported a case of 4-year-old girl with congenital erythrodermic psoriasis treated with acitretin at a dose of 0.5mg/kg/day and the complete remission achieved in three months. The discontinuation of the drug led to relapse so the patient was maintained in 0.5-0.75mg/kg/day of acitretin during the aggravation of the disease. The patient was followed till 7 years of age and no other secondary effects were observed(22). A case of annular pustular psoriasis in a 14-month old girl reported by Haug et al. was treated with acitretin in the dose of 0.9mg/kg/day and the patient achieved complete remission after 4 months. The dose of acitretin was reduced and tapered at 0.1mg/kg/day and discontinued after 10 months with no relapse in the following three years. The patient experienced mild side effects like chelitis, reversible hypercholesterinemia and elevation of alkaline phosphatase(23). Acitretin is aa excellent option in a child with palmo-plantar psoriasis. A 14-year-old boy with palmo-plantar psoriasis treated with acitretin at a dose of 10mg/day had a good response with improvement within 6 weeks. At 3-month follow-up the patient had almost lesion free. The patient had experienced adverse events like mild chelitis and xerosis but the laboratory values remain unchanged. Later the patient was maintained on acitretin 10mg every other day together with the topical combination of 15% liquor carbonis detergens compounded in triamcinolone 0.1% ointment applied every night(24). Combination with other therapies: Acitretin has been used in combination with NB-UVB phototherapy, methotrexate and cyclosporine A(24, 25). The effect of acitretin together with NB-UVB is found to be synergistic. A case of 3.5-year-old boy with severe pustular psoriasis (von Zumbusch type) reported by kopp et al. was started on acitretin 1mg/kg/day with the short-term use of systemic methylprednisolone for controlling the acute stage. However, any attempt to reduce or discontinue the steroid led to exacerbation of the disease. Then the patient was given NB-UVB phototherapy three times per week. Later, after five exposures the corticosteroid was tapered and discontinued. The patient was then maintained on NB-UVB phototherapy two times weekly together with acitretin 0.3mg/kg/day. Disease was well controlled with this combination regimen. The laboratory values remained unchanged during the acitretin treatment(26). A 9-year-old boy with generalized pustular psoriasis was treated with acitretin 10mg/day and was maintained at 10mg three times week for a year. Later he developed skin pain and localized area of pustules which led to increase in the dose of acitretin 20mg/day during the flare but later tapered to 10mg/day for the next year. But the patient eventually required the addition of NB-UVB phototherapy to maintain the remission. The patient is well maintained by this combination(24). Adverse events of acitretin: Acitretin in known to exert a number of adverse events. Most of the adverse events are dose dependent and reverse back to normal after decreasing the dose or after discontinuation of therapy. However, it is usual to have the minor side-effects on the long term treatment with acitretin. The most common adverse events of acitretin is the muco-cutaneous adverse events. Dry lips being the most common one and be treated with the use of emollients. Others include dry dry mouth, cheilitis, stomatitis and gingivitis and taste disturbances. Acitretin causes dryness with inflammation of mucous membrane and transitional epithelia which occasionally leads to epistaxis, rhinitis, photophobia, conjunctivitis and xeropthalmia. Alopecia, nail-fragility and paronychia have also been observed(27). Rarely patients may have the photosensitivity reactions. Retinoid dermatitis which resembles unstable psoriasis can develop 25% of the patients receiving high dose of acitretin therapy(28). Muco cutaneous side effects can be treated symptomatically, and if severe effects occur the dose reduction can be tried before the discontinuation of the drug. Acitretin causes transient elevation of liver enzymes. The elevation is dose dependent and usually reverse back to normal after reducing the dose or after discontinuation of the therapy. Severe hepatotoxic reactions resulting from retinoids are rare. In a data of 1877 patients receiving oral acitretin only 0.26% of the patients showed overt chemical hepatitis(29). However, the hepato-toxic reactions in children are rare because the cofactors like diabetes, alcoholism, and obesity are less likely in children(12). Acitretin also exerts the effects on lipid profile which is reverse back to normal within 8 weeks after the discontinuation of the drug(30). Retinoids are seen to cause the elevation of triglyceride and cholesterol and decrease in the high density lipoprotein. In a study it is seen that 35% of the patients had the elevation in serum triglyceride above 300mg/dl and about 15% of the patients had the elevation of cholesterol level(31). The decrease in the high density lipoprotein is also observed(29). Retinoids have been known to cause the skeletal abnormalities especially in children. The long term treatment with etretinate is also associated with the extraspinal tendon and the calcification of ligament. However, the study including 19 children and young adults, treated with etretinate for continuous 5 years do not show any skeletal abnormality(32). No cases of diffuse idiopathic skeletal hyperostosis was seen in a retrospective study on long term use of acitretin in a low dose(33). No significant radiologic abnormalities associated with retinoids was detected in a patient of severe pustular psoriasis treated with low dose of acitretin for 9 years(34). It is usually not recommended to use oral retinoids for the treatment of psoriasis in children due to the report of occasional bone changes like premature epiphyseal closure, skeletal hyperostosis and extra-osseous calcification observed in the children on the long term treatment with etretinate(35, 36). If acitretin is to be used in a child, the child should be observed carefully for any abnormalities of growth and bone development. Routine radiography is not recommended because of the radiation hazards, but the atypical musculoskeletal pain must be investigated with x-rays. Growth chart of the child on acitretin should be maintained (27). Arthralgia, arthritis, myalgia may also occur during the treatment with acitretin. A few case of vasculitis, Wegener granulomatosis and erythema nodosum are also observed. Retinoids are teratogenic drugs. The defect due to retinoids is termed as retinoic acid embryopathy. The malformations seen in the fetus include microtia/anotia, micrognathia, cleft-palate, conotruncal heart disease and aortic arch abnormalities, thymic defects, retinal or optic nerve abnormalities and central nervous system malformations(37). Even though only one report of human teratogenicity due to acitretin has been published(27), acitretin should be cautiously used as acitretin is converted to etretinate which has a longer elimination half-life. The female patient of child-bearing should strictly be instructed for the use of two effective contraceptive method stating 1-month prior of treatment, during the period of treatment and 3 years after the discontinuation of treatment(38). However, the risk of teratogenicity by use of acitretin in children is less because of the least chance of a child to get pregnant. The concomitant use of retinoid with tetracycline and minocycline has led to pseudo-tumour cerebri(29). Pseudo-tumor cerebri was reported in a case of 14-year-old boy treated with isotretinoin and tetracycline(39). Retinoids also causes blurring of vision, headache and reduced night vision. Patient with severe headache, vomiting and visual disturbances should stop acitretin immediately and consult the doctor(27). The concomitant use of vitamin A with acitretin must be restricted. MONITORING GUDELINES: Before starting the treatment with acitretin, proper history taking and careful physical examination should be performed. Laboratory investigations including complete blood count, lipid profile, liver enzymes and blood sugar in diabetics should be done. Monitoring of the liver enzymes and fasting serum cholesterol and triglyceride must be done every 2-4 weeks of therapy for the first two months and then every three months(27). Children on acitretin therapy must have their growth charted. Female of child bearing age and their parents should be counselled about the teratogenic effect of the drug and use of contraception during and after the treatment. The pregnancy should be ruled out before the initiation of acitretin therapy with two negative pregnancy tests. CONCLUSION: Acitretin is a non-immunosuppressive drug that can be effective in the treatment of childhood psoriasis. It is seen that acitretin is more effective in pustular and erythrodermic psoriasis and moderately effective in the plaque type psoriasis in children. Acitretin is used both as monotherapy and as combination therapy. As the use of acitretin in children lack sufficient data and evidence, its use in children should always be weighed with risk benefit of treatment and risk if the disease is left untreated. The side effects are mostly dose dependent so it can be minimized by using the lowest possible dose. The dose of 0.5-1mg/kg/day was seen to be effective. It should be used cautiously in the female patient. Long term treatment with acitretin require proper clinical and laboratory evaluation. REFERENCES 1.Griffiths CE, Barker JN. Pathogenesis and clinical features of psoriasis. Lancet (London, England). 2007;370(9583):263-71. 2.Al-Mutairi N. Childhood Psoriasis: Springer International Publishing; 2016. 3.Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatric Dermatology. 2000;17(3):174. 4.Kumar B, Jain R, Sandhu K, Kaur I, Handa S. Epidemiology of childhood psoriasis: a study of 419 patients from northern India. Digest of the World Core Medical Journals. 2004;43(9):654-8. 5.Seyhan M, CoÃ…Å ¸kun BK, SaÄÅ ¸lam H, Ozcan H, KarincaoÄÅ ¸lu Y. Psoriasis in childhood and adolescence: evaluation of demographic and clinical features. Pediatrics International Official Journal of the Japan Pediatric Society. 2006;48(6):525-30. 6.Fan X, Xiao FL, Yang S, Liu JB, Yan KL, Liang YH, et al. Childhood psoriasis: a study of 277 patients from China. Journal of the European Academy of Dermatology Venereology. 2007;21(6):762. 7.de Moll EH, Chang MW, Strober B. Psoriasis in adults and children: Kids are not just little people. Clinics in Dermatology. 2016;34(6):717. 8.Kimball AB, Wu EQ, Guerin A, Yu AP, Tsaneva M, Gupta SR, et al. Risks of developing psychiatric disorders in pediatric patients with psoriasis. Journal of the American Academy of Dermatology. 2012;67(4):651-7.e1-2. 9.Fox FE, Rumsey N, Morris M. Ur skin is the thing that everyone sees and you cant change it!: exploring the appearance-related concerns of young people with psoriasis. Developmental neurorehabilitation. 2007;10(2):133-41. 10.Burden AD. Management of psoriasis in childhood. Clinical and experimental dermatology. 1999;24(5):341-5. 11.Orfanos CE, Stadler R, Gollnick H, Tsambaos D. Current developments of oral retinoid therapy with three generations of drugs. Non-aromatic, monoaromatic and polyaromatic retinoids (arotinoids). Current problems in dermatology. 1985;13:33-49. 12.Gautam M, Tahiliani H, Nadkarni N, Patil S, Godse K. Acitretin in pediatric dermatoses. 2016;17(2):87. 13.Brecher AR, Orlow SJ. Oral retinoid therapy for dermatologic conditions in children and adolescents Journal of the American Academy of Dermatology. Journal of the American Academy of Dermatology. 2003;49(2):171-82. 14.Wiegand UW, Chou RC. Pharmacokinetics of acitretin and etretinate. Journal of the American Academy of Dermatology. 1998;39(2 Pt 3):S25-33. 15.McNamara PJ, Jewell RC, Jensen BK, Brindley CJ. Food increases the bioavailability of acitretin. Journal of clinical pharmacology. 1988;28(11):1051-5. 16.Grà ¸nhà ¸j Larsen F, Steinkjer B, Jakobsen P, Hjorter A, Brockhoff PB, Nielsenà ¢Ã¢â€š ¬Ã‚ Kudsk F. Acitretin is converted to etretinate only during concomitant alcohol intake. British Journal of Dermatology. 2000;143(6):1164-9. 17.Lacour M, Mehta-Nikhar B, Atherton DJ, Harper JI. An appraisal of acitretin therapy in children with inherited disorders of keratinization. The British journal of dermatology. 1996;134(6):1023-9. 18.Cordoro KM. Systemic and light therapies for the management of childhood psoriasis: part II. Skin Therapy Letter. 2008;13(4):1-3. 19.Ergun T, Seckin Gencosmanoglu D, Alpsoy E, Bulbul-Baskan E, Saricam MH, Salman A, et al. Efficacy, safety and drug survival of conventional agents in pediatric psoriasis: A multicenter, cohort study. J Dermatol. 2016. 20.Di LV, Bonamonte D, Lasagni C, Belloni FA, Cambiaghi S, Corazza M, et al. Effectiveness and Safety of Acitretin in Children with Plaque Psoriasis: A Multicenter Retrospective Analysis. Pediatric Dermatology. 2016;33(5):530-5. 21.Ergin S, Ersoy-Evans S, Sahin S, Ozkaya O. Acitretin is a safe treatment option for infantile pustular psoriasis. Journal of Dermatological Treatment. 2009;19(6):341-3. 22.Salleras M, Sanchez-Regaà ±a M, Umbert P. Congenital Erythrodermic Psoriasis: Case Report and Literature Review. Pediatric Dermatology. 1995;12(3):231-4. 23.Haug V, Benoit S, Wohlleben M, Hamm H. Annular pustular psoriasis in a 14-month-old girl: a therapeutic challenge. The Journal of dermatological treatment. 2017:1-6. 24.Marqueling AL, Cordoro KM. Systemic treatments for severe pediatric psoriasis: a practical approach. Dermatologic clinics. 2013;31(2):267-88. 25.de Oliveira ST, Maragno L, Arnone M, Fonseca Takahashi MD, Romiti R. Generalized pustular psoriasis in childhood. Pediatr Dermatol. 2010;27(4):349-54. 26.Kopp T, Karlhofer F, Szà ©pfalusi Z, Schneeberger A, Stingl G, Tanew A. Successful use of acitretin in conjunction with narrowband ultraviolet B phototherapy in a child with severe pustular psoriasis, von Zumbusch type. Digest of the World Core Medical Journals. 2005;151(4):912-6. 27.Ormerod AD, Campalani E, Goodfield MJ. British Association of Dermatologists guidelines on the efficacy and use of acitretin in dermatology. British Journal of Dermatology. 2010;162(5):952-63. 28.Kragballe K, Jansen CT, Geiger JM, Bjerke JR, Falk ES, Gip L, et al. A double-blind comparison of acitretin and etretinate in the treatment of severe psoriasis. Results of a Nordic multicentre study. Acta dermato-venereologica. 1989;69(1):35-40. 29.Katz HI, Waalen J, Leach EE. Acitretin in psoriasis: an overview of adverse effects. Journal of the American Academy of Dermatology. 1999;41(3 Pt 2):S7-s12. 30.Vahlquist C, Selinus I, Vessby B. Serum lipid changes during acitretin (etretin) treatment of psoriasis and palmo-plantar pustulosis. Acta dermato-venereologica. 1988;68(4):300-5. 31.Gupta AK, Goldfarb MT, Ellis CN, Voorhees JJ. Side-effect profile of acitretin therapy in psoriasis. Journal of the American Academy of Dermatology. 1989;20(6):1088-93. 32.Glover MT, Peters AM, Atherton DJ. Surveillance for skeletal toxicity of children treated with etretinate. The British journal of dermatology. 1987;116(5):609-14. 33.Lee E, Koo J. Single-center retrospective study of long-term use of low-dose acitretin (Soriatane) for psoriasis. The Journal of dermatological treatment. 2004;15(1):8-13. 34.Halverstam CP, Zeichner J, Lebwohl M. Lack of significant skeletal changes after long-term, low-dose retinoid therapy: case report and review of the literature. Journal of cutaneous medicine and surgery. 2006;10(6):291-9. 35.Prendiville J, Bingham EA, Burrows D. Premature epiphyseal closurea complication of etretinate therapy in children. Journal of the American Academy of Dermatology. 1986;15(6):1259-62. 36.Halkier-Sorensen L, Laurberg G, Andresen J. Bone changes in children on long-term treatment with etretinate. Journal of the American Academy of Dermatology. 1987;16(5 Pt 1):999-1006. 37.Lammer EJ, Chen DT, Hoar RM, Agnish ND, Benke PJ, Braun JT, et al. Retinoic acid embryopathy. The New England journal of medicine. 1985;313(14):837-41. 38.Sarkar R, Chugh S, Garg VK. Acitretin in dermatology. Indian journal of dermatology, venereology and leprology. 2013;79(6):759-71. 39.Lee AG. Pseudotumor cerebri after treatment with tetracycline and isotretinoin for acne. Cutis. 1995;55(3):165-8.

Determination of Factors Contributing to Success Essay

These factors will be uncovered by nalyzing the internal and external factors influencing strategic alliances and the phases through which these alliances evolve. In order to provide this research study with a practical element two case studies within the airline industry have been incorporated, namely the Swissair Qualiflyer Alliance and Star Alliance. These case studies represent a successful and an unsuccessful alliance, which are analyzed on a basis of the provided literature study, in this case the phases through which these evaluation of the case studies numerous supportive results were identified, ontributing toward establishing determinant factors, which emphasize the importance of a successful implementation of the different phases, however limitations affect the reliability of this study, due to the lack of evidence found in various different phases. Keywords: strategic alliances, internal and external factors, strategic alliance phases Introduction In past years a visible increase in the amount of strategic alliances, concerning firms with varying economic objectives, was observed (Das, Teng 2000). Strategic alliances are the â€Å"relatively enduring inter-firm cooperative arrangements, involving flows and inkages that utilize resources and/or governance structures from autonomous organizations, for the Joint accomplishment of individual goals linked to the corporate mission of each sponsoring firm† (Parkhe 1991, p. ). The amount of strategic alliances has recently doubled, predicting additional raise in the future (Booz, Allen, Hamilton 1997). Especially alliances in the form of non-equity based, which are defined as two or more firms developing a contractual-relationship in order to establish competitive advantage by combining resources and capabilities (Globerman 007), have increased in importance which is visible in non equity alliances accounting for 80 per cent (Hagedoorn 1996). Strategic alliances provide firms with the opportunity to recognize synergies through combining operations, such as in research and development, manufacturing etc (Aaker 1995; Addler 1966). The growth of strategic alliances is related to growing competition and globalization (Das, Teng 2000). This is in alignment with Doz and Hamels (1998) view which states that globalization as well as changes in economic activities is a consequence for the growth in strategic alliances, which is visible in various different industries Hagedoorn 1993). The primary reasons for the growth of the number of alliances is 1) the ability of cost savings in executing operations 2) the ability to access particular markets 3) the reducing of financial and political risk in addition to cheapest labor and production costs (Wheelen, Hungar 2000). A strategic alliance by definition is a hybrid organizational form which Jensen and Meckling (1991) refer to as a network organization. Harbison and Pekar (1998) highlight numerous common characteristics visible within strategic alliances, namely a required commitment of at least ten years, he connection of the partners is based on equity or on shared capabilities, a complementary relationship based on a shared strategy, increasing companies’ value in the market place, the pressuring of competitors and the willingness of sharing and leveraging core capabilities. Nevertheless, strategic alliances have noticeable high instability rates (Das, Teng 2000); furthermore, according to Kalmbach and Roussel (1999) the failure rates are approximately as high as 70 per cent. Studies conducted by Das and Teng (2000) reportedly state that encountered problems are witnessed in he first two years of two thirds of all alliances. This study is going to provide a more in-depth analysis on the factors that are necessary for determining success in all strategic alliances. Starting with an analysis of strategic alliances based on the as to which extent these factors play a crucial role in the determination of success rate of strategic alliances. In order to incorporate a practical view on the strategic alliances, this study will additionally implement two case studies to the analysis. Conceptual Model [pic] This conceptual model starts the literature study on strategic alliances as a central concept. From this central concept, emphasis is drawn on internal and external factors influencing strategic alliances, as well as on the different phases through which alliance evolve. Additionally, strategic alliances lead to either successful or unsuccessful alliances. Based on the research from Bronder and Pritzl (1992), Hoffmann and Schlosser (2001), Waddock (1989) and Wolhstetter, Smith and Malloy (2005), a framework of seven phases is established. Within these seven phases the most important activities and processes are analyzed, including reasoning behind strategic alliances, potential intensions for forming strategic alliances, partner election, external factors influencing the design of the strategic alliance, negotiation methods, followed by the structuring of the alliance. Furthermore, implementation and management of the strategic alliance is examined. Finally, the last two phases concerning the evaluation of the formation of strategic alliances and the termination of the partnership are discussed. Resulting from this literature study are two outcomes, namely a successful implementation of the phases and an unsuccessful implementation. In order to apply a practical element to this thesis, two case studies ill be analyzed, those of Qualiflyer, which turned out to be an unsuccessful alliance and Star Alliance, which was able to incorporate a success strategic alliance in the airline industry. After analyzing the cases the findings compared to the literature analysis, will hopefully correlate to each other and the determinants that influence more success in alliances can be established. Problem Statement Based on past literature research studys the outcomes of implementing strategic alliances as a change strategy in organizations is unfavorable, especially when looking at the failure rates. Nevertheless, the adoption of strategic alliances is a customary implemented firm strategy (Gulati 1998), as a means of securing their competitive position. Much research is conducted in order to provide more guidance in determining factors that achieve sustainable strategic alliances, therefore in this thesis the main research question is; What factors determine the success of strategic alliances? This research question will be addressed by the help of analyzing and answering these various sub-questions; Why do firms choose strategic alliances as a change process? What are the potential ntentions of a strategic alliance? activities and processes occur in which phase? Preview of the organization of the thesis This report begins by indicating the problem that strategic alliances are a favorable organizational change strategy in the business world today, however the failure rate is extremely high. Secondly, by applying literature analysis the main determinants influencing more success in strategic alliances will be uncovered, which will be coupled to the case study part of the thesis where the determinants will be compared to the specific cases. Finally, the thesis will conclude on the part if the eterminants uncovered in the literature study correlate to the findings in the case study. Methodology and Research Design In this thesis the methodology contained two specific approaches, including a literature study as well as evaluating two case studies. Firstly, the literature analysis was conducted; with as primary focus an in-depth analysis of academic articles. The findings of the literature study are compared to two case studies, those of the Qualiflyer alliance and Star Alliance. These two cases were chosen because they represent the different outcomes an alliance can hold, namely the successful mplementation the alliance strategy at Star Alliance and the unsuccessful outcome of an alliance strategy of the Qualiflyer alliance. In addition, even though these two examples vary substantially in size, which provides difficulty when comparing the two alliances, they both started off at reasonably the same size; therefore this thesis incorporated these two examples anyway. This evaluation will be conducted by means of desk research, exploring the different implementations of this strategy. The time frame of the case studies is from the first phase up until the last phase, through hich they evolved, in order to identify dependent unsuccessful and successful aspects. The significance of implementing case studies in this thesis is relating the findings from the literature analysis to real life cases of both a successful alliances as well as a non-successful alliance. Furthermore, comparing if the determinants of success found in the literature analysis correlate with the factors observed in the cases. Internal versus External factors Influencing Strategic Alliances Our internal tensions perspective framework (Figure 2, Appendices) of strategic alliances comprises three airs of competing forces-namely, cooperation versus competition, rigidity versus flexibility, and short-term versus long-term orientations (Das, Teng 2000). Competition is defined as pursuing one’s own interest at the expense of others, while cooperation is the pursuit of mutual interests and common benefits in alliances. This tension of cooperation versus competition is most salient in selecting alliance partners, the first of three major stages in the alliance making process, along with structuring and managing an alliance (Das, Teng 1997). In conclusion, the stability and success of trategic alliances will be inversely related to the difference between the cooperation level and the competition level. Rigidity refers to the characteristics of mutual to adapt, unencumbered by rigid arrangements. The dominance of either flexibility or rigidity may change the status quo and trigger the evolution of a new structure, which leads to unsuccessful alliances. Therefore, the stability of strategic alliances will be inversely related to the difference between the rigidity level and the flexibility level. Short-term orientation views strategic alliances as transitional in nature, with a emand for quick and tangible results, whereas long-term orientation regards alliances as at least semi permanent entities, so that more patience and commitment are exercised. A strategy that reflects only one temporal orientation is not compatible with the foundation for a sustainable strategic alliance, in other words the stability of strategic alliances will be inversely related to the difference between the short-term orientation and the long-term orientation. Furthermore, the three internal pairs of contradictory forces are interrelated within an evolving system, resulting in the ollowing propositions, namely that the levels of rigidity and cooperation will be positively related when the partners have a short-term orientation in strategic alliances. However, a negative relatedness at a high level of rigidity, cooperation and rigidity (Das, Teng 2000). will be negatively related when the partners have a long- term orientation in strategic alliances (Das, Teng 2000). According to Das and Teng (2000) the contradictions and tensions in these force-pairs may lead to an overthrow of the status quo namely, the strategic alliance. Strategic alliances can nevertheless e sustained and successful if a careful balance between these competing forces can be maintained. According to Todeva and Knoke (2005) external factors influence alliance formation, due to differing economic condition and organizational frameworks in partnering countries; these can include legal requirements, price controls, distribution channels and contract enforcement. Furthermore, these regulative state activities comprehend the freedom when firms are forming alliances. Moreover, the formation of an alliance necessitates the authorization of national governments. Additionally, of influence to the formation of alliances is the omplicated collection of relations visible with firms, such as business associations, local governments and elite universities. On an industrial note alliances are influenced on an interflrm basis by direct impacts, where the decision on which activities to internalize is based on severity of competition within the industry and the organization of ad hoc product markets, in the challenge for increased market share, the cooperation for specific advantages and the process of internationalization (Todeva, Knoke 2005) . The partner under consideration for the formation of an alliance is in a certain sense an external factor. Firms are susceptible in the case of partnering with a dominant firm (Pennings 1994), due to technical and economic rationales. Thus, technology is a specific part of the process to establishing organizational boundaries as well as intrinsic structures. Of importance to alliances is obtaining research and development advantages, which to certain extent differs across industries on terms of expenses and the sources provided by the government (Todeva, Knoke 2005). Every alliance design commences with negotiations, thereafter the phase of structuring the alliance in which various aspects are aligned, such as he objectives of both parties, organizational structures, functional operations and cultures (Ring, van de Ven 1994). The distinguishing of phases through which strategic alliances evolve plays an essential role in the development toward successful alliances, which according to Bronder and Pritzl (1992) evolves through the three stages, which are categorized as strategic decision, confguration of strategic alliance and partner selection. Where Bronder and Pritzl terminate their research on the establishment of phases other researchers continue in identifying essential phases, for the reason that partner election as final phase represents an incomplete evolution of strategic alliances. With regard to the research conducted by Hoffmann and Schlosser (2001), the identification of strategic alliance phases resulted in a five phase path through which strategic alliances evolve, namely strategic analysis and decision to cooperate, search for a partner, designing the partnership, implementation and management of the partnership and finally termination. When comparing both Bronder and Pritzls (1992) and Hoffman and Schlossers (2001) phases, a comparison is visible in the primary hases of strategic alliances, namely the strategic analysis and decision to cooperate (Hoffmann, Schlosser 2001) which corresponds with the strategic decision phase from Bronder and Pritzl (1992). Furthermore, the partner selection phase is visible in both frameworks on strategic alliance phase. The main difference between the two studies is the more detailed approach from Hoffmann and Schlosser (2001) also distinguishing phases after the partner selection process. Finally, a study building on Waddocks (1989) work, which suggests that strategic alliances progress through hree phases, which are identified as initiation, establishment and maturity, Wohlstetter, Smith and Malloy (2005) consistently debated that the strategic alliances process is organized into three similar phases namely initiation, operations and evaluation. When comparing these views with the earlier stated reasoning on strategic alliance phases merely a fguration is enabled as to which phases from Bronder and Pritzl (1992) and Hoffmann and Schlosser (2001) are in comparison with Wohlstetters et al (2005) view and could be placed within their views, for example the artner selection phase distinguished the above stated views is probably placed within the initiation phase identified by Wohlstetter et al. (2005). In order to provide this thesis with an in-depth view on the phases through which strategic alliances evolve a combination of the three above stated views is implemented. Phase 1: Strategic Decision According to Bronder and Pritzl (1992) a clarification of the firms’ position is to be analyzed, refer ably because this is identified as the first direction toward alliance formation. Pumpin (1987), states that the evaluation of the actual situation of the firm s identified by exploring its mission, possible values and core competencies. Additionally, the firm identifies the reasoning behind incorporating an alliance strategy. According to Eisenhardt and Schoonhoven (1996), Harrigan (1985), Link and Bauer (1989), Pisano (1991) and Teece (1992) technological change faced by firms is related to the favorability toward flexible organizational forms like alliances. Additionally, Ciborra (1991) and Oster (1992) state that high-tech industries, in which learning and flexibility are key characteristics, will preferably choose alliances, lexibility, firms favorably adopt a merger and acquisition strategy. The flexibility of strategic alliances is suitable as organizational structure due to the fast expiring of new knowledge and the lengthy learning time from partners (Eisenhardt, Schoonhoven, 1996; Hagedoorn 1993). Furthermore, these flexible organizational structures appear more effectively in uncertain environmental situations when adjusting to changes (Lawrence, Lorsch 1967; Pffeffer, Salancik 1978). In continuation of Powells (1996) view, Hagedoorn and Duysters (2002) predict that strategic alliance xperience positively contribute to choosing alliances as instrument for obtaining external innovative capabilities. This view is aligned with that of Kogut et al. (1992) and Gulati (1993) who accentuate the relationship between actual alliance formation and past alliances, however emphasize on a more social basis. Therefore, the formation of strategic alliances is dependent on both strategic as well as social factors. According to Eisenhardt and Schoonhoven (1996), an extension of the resource-based view provides a basis for examining the relationship through which alliances form by means of strategic and social resources. This research study contributed numerous outcomes on strategic alliances to existing literature, namely that increasingly challenging market conditions and Jeopardous organizational strategies result into an increase of alliance formations as an organizational change process. Additionally, of importance to the rate of formation of alliances are managerial characteristics, visible when large, experienced teams were implemented through previous employers, the rates of alliances increased (Eisenhardt, Schoonhoven 1996). In conclusion of their research Eisenhardt and Schoonhoven 1996) state that in cases of either a vulnerable strategic situations or a strong social situation the likelihood of the formation of strategic alliances increase. Phase 2: Initiation Phase The initiation phase is characterized by informal structures and communication channels as the critical issue is the development and understanding of the purpose for strategic alliances (Waddock 1989). According to Hitt et al. 1997), the potential intentions to be realized behind entering into strategic alliances are categorized into three market types 1) namely markets characterized by slow cycle, which adopt trategic alliances for original intentions such as the gaining of access to restricted markets, establishing franchises in a new market and maintaining market stability 2) in markets characterized by a standard cycle amongst the intentions able to be achieved are the gaining of market power and access to complementary resources, over coming trade barriers, gaining knowledge and learning about new business techniques 3) in the final market, the fast cycle, the achievable goals are the speeding up of the entry of new products and services in addition to new markets, maintaining he market leadership position, sharing the risky Research and Development expenses and overcoming uncertainty. Furthermore, several internal conditions drive the initiation phase including, a champion taking responsibility, complementary needs and assets, compatible goals and trust. According to Waddock (1989), the main responsibility of the champion is the guidance of the organization through the initiation phase, especially visible in the process of partner selection. Stated in the initiation phase is essential for identifying needs in addition to the process of partner selection. Complementary needs and assets appear in various different forms, however is one of the main reasons for partnering (Oliver 1990; Robertson 1998). Additionally, the main goal of partnering is achieving compatible goals among the partners, which might not have been achieved otherwise (Austin 2000; Das, Teng 1998; Kanter 1994; Oliver 1990; Robertson 1998; Spillett 1999). Finally, the initiation phase stands no chance without trust, which is mainly established through existing networks (Austin, 2000; Waddock 1989; Waide 1999), within these networks similar interests are the main characteristic. Phase 3: Partner Selection The purpose behind strategic alliance partnering is to initiate and prolong a long- term partnership, which enables more effective competition with others firms which are positioned outside the partnership Carillo 1988; Walker, Poppo 1991). The crucial decision toward the correct partner selection is the primary focus after pursuing this alliance strategy (Hitt, Tyler, Hardee, Park 1995). According to Koot (1988) the selecting of a partner is a complex process however crucial to the success of an alliance. In the partner selection process perspectives of both resource-based and organizational earning provide an explanation as to why certain partners are selected (Barkema, Bell, Pennings 1996). In explanation, firms own certain resource endowments (Barney 1991) however, in order to obtain a competitive position in a specific market supplementary resources are necessary (Hitt, Nixon, Clifford, Coyne 1999), which is the main objective for engaging in strategic alliances. Hitt et al. (2000) argues that of importance to the partner selection process is the firms’ embeddedness in both emerging markets and developed markets. Furthermore, the access to necessary esources for leveraging as well as the obtaining of capabilities for learning are primary reasons for the selection of partners. Table 1 in the Appendices, state the concluding outcomes on the selection of partners by Hitt et al. (2000), which explains the fundamental elements of the process toward partner selection. Eisenhardt and Schoonhoven (1996) and Dacin and Olivers’ (1997) view state that legitimacy enhancements are an additional intention for establishing alliances, therefore the partner selection process is focused on those providing strong intangible assets, for example strong reputations. According to Bronder and Pritzl (1992) critical to the partner selection process is the establishment of fundamental, strategic and cultural fit. This fundamental fit is achieved if a win-win situation for both parties is established and potential value is increased. The strategic fit is realized when the alliance involves partners with harmony of the business plans. Finally, the cultural fit is an essential success factor for partner selection, which is accomplished after acceptance of cultural differences among the partners. Phase 4: Designing the Partnership Niederkofler (1991) argues that the negotiation process must essentially interpret learly understandable resources and interests of the partners involved, in order for the creation of strategic and organizational fit to be achieved, which will direct the accomplished through open and detailed communication, circumventing hidden agendas of any sort. The consequence of this open communication translates into a coherent attitude of sincerity toward the different partners, which demands trust. In addition to strategic fit, the negotiation process also initiates a solid basis for the enforcement of an operational fit within the partnership, which can be viewed in Figure 1 of the Appendices. An important aspect of the negotiation process is the creation of flexibility, which is increased through contract provisions in addition to developing and prolonging of trust. The process of conquering complexity in operations embarks with the communication of the discovered complexity, followed by a tracking and solving of this difficulty, which results in the avoidance of any operational unalignments. The flexibility within the partnering arrangement, in addition to trust, permits renegotiation processes within the partnership; however a coherent basis must be accomplished (Niederkofler 1991). The success of alliances is highly dependent on a competent and effective alignment, therefore of importance is the designing of the partnership, thus the structure implemented. This structure is in need of a fine constructed collection of strategy, procedures and management views, which can be viewed as the internal alignment (Miles, Snow 1994). In the process of obtaining internal alignment interests as well as environmental aspects must be balanced between the partners, enabling a profitable situation (Douma, Bilderbeek, Idenburg, Looise 2000). Additionally, their framework, Figure 3, Appendices, stress the act that the five features must sufficiently be aligned to prevent failure. One of the features, namely strategic fit, is established when expected advantages and possible risks are weighed against that of the individual interests in the alliance. Various driver of strategic fit can be identified, starting with a shared vision. Further conditions necessary for strategic fit are compatibility of strategies (Brouthers, Brouthers, Wilkinson 1993), strategic importance (Doz 1988), acceptance into the market and mutual dependency. In addition to strategic fit, organizational fit is a ecessity, however due to the differences in many aspects, such as market position, organizational structure and views, management style, this is a complex task. By clarifying these differences an understanding between partners is achieved. Numerous drivers toward organizational fit are identified, namely as stated above the addressing of organizational differences (Doz 1988) furthermore, essential drivers are facilitating strategic and organizational flexibility, minimal complexity to enhance manageability (Killing 1988), efficient management control, enhancing long-term tability by investigating possible strategic conflicts and finally, the achievement of the strategic objective. Of influence, however to lesser extent are the three remaining features in the framework, which are human, operational and cultural fit. Human fit is particularly of importance in alliances processes (Boersma 1999) and according to Lewis (1990) the cultural fit is specifically an issue among employers and employees, which translates to their functioning in for example boardrooms. Finally, operational fit, also relates to the functioning of the alliance and is often susceptible to various ontingencies, therefore must be aligned. Research and Development activities have gradually evolved since the 1980s (Peterson, 1991). Creamer (1976) and Pearce (1989) identified three primary types of Research and Development activities, namely basic purpose is an understanding of the inherent and fundamental scientific development, however disregarding commercial applications. Furthermore, applied research employs knowledge conceived from the basic research to certain dimensions such as technical problems or related commercial technology aspects. In conclusion, basic research generates new facts and theories which are thereafter roven through applied research. These proven facts are generated into products and processes in the development stadium. The intention of development activities is the configuration of applied research contributions into commercially feasible products, processes and technologies Oansen 1995; Jones, Davis 2000). Phase 5: Implementation and Management of the Partnership The role of the management of strategic alliances is valuable for the progression of the alliance toward a successful outcome, however it is complex to manage (Koza, Lewin 2000). An important aspect in serving this complexity is the acquiring of nowledge from past engaging in alliances, which provides meaningful know-how to be leveraged (Kale, Dyer, Singh 2001). The framework of the four C’s of learning and leveraging alliance know how provides a tool for obtaining valuable knowledge. The four components in the framework are, capture, codify, communicate and create, and coach (Kale, Dyer, Singh 2001), also visible in Figure 4, Appendices. Capture refers to managements’ role of accessing and obtaining of valuable alliance insights and past experiences. To codify past experiences and practices contributes to the accomplishing of alliance specific needs. In order to have a common thread through the organization on these past knowledge practices, communication is essential in sharing experiences. Additionally, the creation of networks within the alliance facilitates the distribution of these valuable experiences and knowledge. Intrinsically executed coaching and education programs increase the ability to obtain alliance skills. An additional benefit from coaching is the establishment of informal social networks, which provides assistance in key situations. Furthermore, networks are critical to the development of opportunities, the assessing of concepts and obtaining esources in order to construct the new partnership (Aldrich, Zimmer 1986). The incorporation of social networks within a firm improves communication between partners, which in turn results in improved decision making processes (Gulati 1993). Various intentions for the implementation of networks can be identified, one specific is the preserving of advantages (Lorenzoni, Baden- Fuller 1995). According to Madhaven, Koka and Prescott (1998) the initiation of inter-organizational networks is created by exogenous factors, which could include competition background and specific industrial activities. Building on this theory, Gulati et al. (1997) argues that the initiation of these inter-organizational networks is dependent on two aspects, namely exogenous resource dependencies, which achieve motivation of the cooperation and an â€Å"endogenous embeddedness† dynamic, which in turn familiarizes toward partner selection. According to Stinchcombe (1990), in flows of network information meaningful views are discovered,

A Pair of Tickets: Personal Response Essay

â€Å" A Pair of Tickets† is about a women named June May who is traveling through her native country of China. I really enjoyed this story because I could relate to it in my own life experiences. After June May’s mom passes away she starts thinking about all the questions she wishes she had asked her about her life. Just like when any family members of mine passes away, I always think back and think about what type of questions could I have asked him or her before they passed away. June May was raised in San Francisco (which had many Chinese people at this time). She had a father and a mother who raised her in San Francisco. When June May’s mother passes away she soon find out that she has a twin sister in China that she never knew about. Her twin sister had written her mother a letter that they received a couple of months after her mother had passed away. So June May and her father decided that they were going to travel to China and see if they could find her twin sister, in addition to looking for her they were also going to visit family they hadn’t seen in years. When they arrived in to China June May is constantly comparing things she sees to what America is like. Her mother brought her up by telling her that all Chinese people have no choice but to act Chinese; it’s in their blood. June May at first thinks she’s nuts and doesn’t believe her. But after she passes away she soon realizes her mother was right and starts seeing a lot of comparison of how her mother acted and how she acted. When she arrives in China she really starts to feel Chinese. She didn’t wear makeup; she even starts introducing herself by her Chinese name Jing-Mei to her family members. This kind of reminds me of the time when I was in high school playing on sport teams. During high school friends and/or people in school would call me Nelson (since it’s my last name). I also would just tell people to call me Nelson since I have a twin brother because that way if they couldn’t tell my brother and I apart they could just call me Nelson and it would be right every single time. Once I got to college, I had to tell people to start calling me Elliott instead of Nelson because in college, it’s like a new beginning; and in a new beginning to something you want people to know you by your first name before people know your last name. Overall, June May’s introducing of her actual Chinese name marked the beginning of her acceptance of being true to her Chinese inheritance. While in her hotel June May finally realizes why her mother had left her twin sister behind. She wants to do everything she can now to find her twin sister and grow her Chinese heritage like her mother would of wanted her to do. Even myself can relate to why a mother could leave someone because this happened to me. I am adopted; which is kind of similar to what happened to June May because it’s still basically a Mom or Dad leaving their son/daughter. Finally, June May has accomplished the meaning of her mother’s name, Suyuan which means,† Long Cherished Wish. † Suyuan wish was for June May to grow into her Chinese heritage. I think the story was telling us that we will never know who we are until we know what our past and heritage is really about. I’ll be honest, when I was 16 years old marked the first time I asked my parents I live with now about my actual Mom and Dad. Overall, what I learned from hearing about my own past was that I am way better off now in the family I am in now. But I still see my actual birth mom every year once or twice and she still loves me. She had to let Aron and I get adopted because of money purposes; basically means that she wanted what was best for Aron and I.

Fossil Fuels And Renewable Energy Essay - 1121 Words

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