Effects of remifentanil on pharyngeal swallowing : A double blind randomized cross- over study in healthy volunteers

Copyright © European Society of Anaesthesiology. This author accepted manuscript is made available following 12 month embargo from date of publication (Sept 2016) in accordance with the publisher's copyright policy.BACKGROUND: Exposure to remifentanil increases the incidence of pulmonary aspiration in healthy volunteers. This effect may be explained by impairment of airway defence mechanisms and/or altered swallowing function. Pressure-flow analysis is a technique that allows objective assessment of swallowing based on pressure-impedance patterns recorded during bolus swallowing. OBJECTIVES: The aim of this study was to use pressure-flow analysis to quantify the effect of remifentanil on healthy pharyngeal swallowing and to compare these effects with morphine. DESIGN: A double-blind, randomised, cross-over study. SETTING: A tertiary care teaching hospital. VOLUNTEERS: Eleven young volunteers (mean age, 23 years) and seven older volunteers (mean age, 73 years). INTERVENTIONS: Volunteers were studied twice and received either a target-controlled remifentanil infusion (target concentrations: young, 3 ng ml-1; old, 2 ng ml-1) or a bolus injection of morphine (dose: young, 0.1 mg kg-1; old, 0.07 mg kg-1). Pharyngeal pressure and impedance were recorded with an indwelling catheter while swallowing 10 boluses of liquid during each measuring phase. Variables defining swallowing function were calculated and compared to determine drug effects. MAIN OUTCOME MEASURES: Pharyngeal pressure-flow variables following remifentanil exposure. RESULTS: Changes produced by remifentanil in the measured variables were consistent with greater dysfunction of swallowing. Both the strength of the pharyngeal contractions and pharyngeal bolus propulsion were reduced, whereas flow resistance was increased. The swallow risk index, a global index of swallowing dysfunction, increased overall. At the experimental doses tested, morphine produced similar, but less extensive effects on swallowing. CONCLUSION: Remifentanil induced dysfunction of the pharyngeal swallowing mechanism. This may contribute to an increased risk of aspiration

Co-creation as a Market Entry Strategy : Key areas to consider when entering a market by co-creating digital HR-tools

Due to digitalization, companies face a wide range of opportunities and challenges when it comes to attracting, recruiting and retaining talents. To meet these, companies need to present and achieve originality regarding values and corporate culture. One possible solution to this may be customized Human Resource tools.  Co-creation is an increasingly common product development strategy to create customized tools. It is based on collaboration and joint production of value between a supplier and customer. Cocreation may be a favorable strategy for early stage companies to gain customers and enter the market. While there are a variety of market entry strategies, this study is based on the insufficient attention among these to the customer as a possible collaborator when entering. This lack of attention is noteworthy since theory shows that the customer is gaining increased power over a supplier’s business decisions, largely due to digitalization.  There is a need to introduce a strategy that defines how companies co-create with their customers and regards them as an allied. This close relationship provides mutual benefits, sustainable relationships and networks. Consequently, this study aims to investigate if a co-creation strategy can be used to enter a market for an early stage company. The study is based on inductive reasoning and qualitative research methods. It uses semi- structured interviews, active participating observations and a literature study to collect primary and secondary data. The study proposes that co-creation is a new type of market entry strategy and suggests three key areas to consider for an early stage company when entering. These areas are: development approach, ownership and product protection, and expectation and communication.Digitalisering har skapat både möjligheter och utmaningar för företag när det gäller att locka, rekrytera och behålla talanger. För att möta dessa måste företag presentera och uppnå originalitet kring företagskultur och värderingar. En lösning till detta kan vara företagsanpassade Human Resource-verktyg. Co-creation är en allt vanligare produktutvecklingsstrategi för att skapa företagsanpassade lösningar. Det bygger på samarbete och gemensamt utvecklande av värde mellan leverantör och kund. Co-creation kan vara en gynnsam strategi för ett företag i tidigt stadie att bygga kundrelationer och komma in på marknaden. Baserat på den akademiska litteraturstudien identifierades bristfälligt fokus på kunden som en möjlig samarbetspartner vid marknadsinträde. Detta är anmärkningsvärt eftersom teorin visar att kunden har fått en ökad makt över leverantörens affärsbeslut, till stor del tack vare digitalisering.  Det finns ett behov av att införa en strategi som definierar hur företag samverkar med sina kunder och anser dem som allierade. Denna nära relation ger ömsesidiga fördelar, hållbara relationer och nätverk. Följaktligen syftar denna undersökning till att undersöka om en strategi baserad på co-creation kan användas för att komma in i en marknad för ett företag i tidigt stadie. Studien bygger på induktiva resonemang och kvalitativa forskningsmetoder. Den är baserad på semistrukturerade intervjuer, aktivt deltagande observationer samt en litteraturstudie för att samla primär- och sekundärdata. Studien föreslår att co-creation är en ny typ av marknadsinträdesstrategi och föreslår tre viktiga områden att överväga för ett företag i tidigt stadie. Dessa områden är: produktutvecklingsmetod, ägande och skydd av produkt samt förväntan och kommunikation

Guidelines to improve teamwork in software projects

In consulting firms one of the goals is to have the consultants on an assignment with an external client to bring in capital. In some consulting firms, when the consultants are not on an assignment with a client, they work on internal projects until a new assignment arrives. Since most of the team members do not work for more than a few days or weeks on the projects, it leads to a high team member turnover. In projects with such a turnover, problems such as hasty handovers, unclear roles and responsibilities and low-quality documentation may occur. The purpose of this thesis was to create guidelines to improve teamwork in teams with a high team member turnover. This thesis was based on a case study of a company specializing in information technology and management consulting. To begin to tackle this problem, a literature review was conducted and the data was collected by conducting interviews. The interviews were performed with team members that had been on a project for the longest and shortest period of time in order to identify problems from different perspectives. Based on the interviews and the literature study, guidelines were created to counteract the problems experienced in this type of volatile teams. The guidelines are categorized in four areas: processes, resources, people and long-term perspective. The areas cover the problems experienced and can be ultimately implemented in all teams with high team member turnover to improve teamwork in software projects.I konsultföretag är ett av målen att konsulterna ska vara på uppdrag hos en extern kund för att dra in pengar. I vissa konsultföretag, när konsulterna inte är hos en extern kund, arbetar de på interna projekt tills dess att ett nytt uppdrag kommer. Eftersom de flesta teammedlemmar inte jobbar i mer än några dagar på dessa interna projekt leder det till en hög omsättning av projektmedlemmar. I projekt med den typen av höga omsättning kan problem uppstå som förhastade överlämningar, otydliga roller och skyldigheter samt lågkvalitativ dokumentation. Målet med denna uppsats var att skapa riktlinjer för att förbättra lagarbete i teams med hög omsättning av projektmedlemmar. Denna uppsats var baserad på ett fallstudie på ett företag som är specialiserat på informationsteknik och management consulting. För att börja tackla detta problem utfördes en litteraturstudie och data samlades in genom intervjuer. Intervjuerna utfördes med de teammedlemmar som har deltagit i projektet längst respektive kortast tid, för att identifiera problemen utifrån olika perspektiv. Baserat på intervjuerna och litteraturstudien, skapades riktlinjer för att motverka dessa problem som uppstår i sådana typer av rörliga team. Riktlinjerna kan kategoriseras i fyra områden: processer, resurser, människor och långtids perspektiv. Dessa områden täcker de upplevda problemen och kan implementeras av teams som har hög omsättning av medlemmar för att förbättra arbetet inom teamet i mjukvaruprojekt

Survival after primary breast cancer surgery following propofol or sevoflurane general anesthesia—A retrospective, multicenter, database analysis of 6305 Swedish patients

Background: Retrospective studies indicate that the choice of anesthetic can affect long-term cancer survival. Propofol seems to have an advantage over sevoflurane. However, this is questioned for breast cancer. We gathered a large cohort of breast cancer surgery patients from seven Swedish hospitals and hypothesized that general anesthesia with propofol would be superior to sevoflurane anesthesia regarding long-term breast cancer survival. Methods: We identified all patients who were anaesthetized for breast cancer surgery between 2006 and 2012. The patients were matched to the Swedish Breast Cancer Quality Register, to retrieve tumor characteristics, prognostic factors, and adjuvant treatment as well as date of death. Overall survival between patients undergoing sevoflurane and propofol anesthesia was analyzed with different statistical approaches: (a) multiple Cox regression models adjusted for demographic, oncological, and multiple control variables, (b) propensity score matching on the same variables, but also including the participating centers as a cofactor in a separate analysis. Results: The database analysis identified 6305 patients. The 5-year survival rates were 91.0% and 81.8% for the propofol and sevoflurane group, respectively, in the final model (P =.126). Depending on the statistical adjustment method used, different results were obtained, from a non-significant to a "proposed" and even a "determined" difference in survival that favored propofol, with a maximum of 9.2 percentage points higher survival rate at 5 years (hazard ratio 1.46, 95% CI 1.10-1.95). Conclusions: It seems that propofol may have a survival advantage compared with sevoflurane among breast cancer patients, but the inherent weaknesses of retrospective analyses were made apparent

Survival after primary breast cancer surgery following propofol or sevoflurane general anesthesia—A retrospective, multicenter, database analysis of 6305 Swedish patients

Background: Retrospective studies indicate that the choice of anesthetic can affect long-term cancer survival. Propofol seems to have an advantage over sevoflurane. However, this is questioned for breast cancer. We gathered a large cohort of breast cancer surgery patients from seven Swedish hospitals and hypothesized that general anesthesia with propofol would be superior to sevoflurane anesthesia regarding long-term breast cancer survival. Methods: We identified all patients who were anaesthetized for breast cancer surgery between 2006 and 2012. The patients were matched to the Swedish Breast Cancer Quality Register, to retrieve tumor characteristics, prognostic factors, and adjuvant treatment as well as date of death. Overall survival between patients undergoing sevoflurane and propofol anesthesia was analyzed with different statistical approaches: (a) multiple Cox regression models adjusted for demographic, oncological, and multiple control variables, (b) propensity score matching on the same variables, but also including the participating centers as a cofactor in a separate analysis. Results: The database analysis identified 6305 patients. The 5-year survival rates were 91.0% and 81.8% for the propofol and sevoflurane group, respectively, in the final model (P =.126). Depending on the statistical adjustment method used, different results were obtained, from a non-significant to a "proposed" and even a "determined" difference in survival that favored propofol, with a maximum of 9.2 percentage points higher survival rate at 5 years (hazard ratio 1.46, 95% CI 1.10-1.95). Conclusions: It seems that propofol may have a survival advantage compared with sevoflurane among breast cancer patients, but the inherent weaknesses of retrospective analyses were made apparent

Impact of general anaesthesia on breast cancer survival : a 5-year follow up of a pragmatic, randomised, controlled trial, the CAN-study, comparing propofol and sevoflurane

Background: Anaesthesia may impact long-term cancer survival. In the Cancer and Anaesthesia study, we hypothesised that the hypnotic drug propofol will have an advantage of at least five percentage points in five-year survival over the inhalational anaesthetic sevoflurane for breast cancer surgery. Methods: From 2118 eligible breast cancer patients scheduled for primary curable, invasive breast cancer surgery, 1764 were recruited after ethical approval and individual informed consent to this open label, single-blind, randomised trial at four county- and three university hospitals in Sweden and one Chinese university hospital. Of surveyed patients, 354 were excluded, mainly due to refusal to participate. Patients were randomised by computer at the monitoring organisation to general anaesthesia maintenance with either intravenous propofol or inhaled sevoflurane in a 1:1 ratio in permuted blocks. Data related to anaesthesia, surgery, oncology, and demographics were registered. The primary endpoint was five-year overall survival. Data are presented as Kaplan-Meier survival curves and Hazard Ratios based on Cox univariable regression analyses by both intention-to-treat and perprotocol. EudraCT, 2013-002380-25 and ClinicalTrials.gov, NCT01975064. Findings: Of 1764 patients, included from December 3, 2013, to September 29, 2017, 1670 remained for analysis. The numbers who survived at least five years were 773/841 (91.9% (95% CI 90.1-93.8)) in the propofol group and 764/829 (92.2% (90.3-94.0)) in the sevoflurane group, (HR 1.03 (0.73-1.44); P = 0.875); the corresponding results in the per-protocol-analysis were: 733/798 (91.9% (90.0-93.8)) and 653/710 (92.0% (90.0-94.0)) (HR = 1.01 (0.71-1.44); P = 0.955). Survival after a median follow-up of 76.7 months did not indicate any difference between the groups (HR 0.97, 0.72-1.29; P = 0.829, log rank test). Interpretation: No difference in overall survival was found between general anaesthesia with propofol or sevoflurane for breast cancer surgery