BetonmastHæhre Eiendoms focus on MOMD in the early stages : development of care homes through PPP

Denne oppgaven har til hensikt å kartlegge hvilke tiltak BetonmastHæhre Eiendom (BHE) har gjennomført for å få best mulig sammenheng mellom tidligfase og FDVU i to OPS-prosjekter. BHE har inngått OPS-avtaler med henholdsvis Nesodden og Lunner kommune om finansiering, planlegging, prosjektering, bygging og drifting av omsorgsboliger for en periode på 30 år, og har ingen erfaring med OPS-modellen fra tidligere. Oppgavens hovedproblemstilling er: Hvilke tiltak har BetonmastHæhre Eiendom gjennomført for å få best mulig sammenheng mellom tidligfase og FDVU i et OPS-prosjekt? Hovedproblemstillingen ble belyst gjennom følgende underproblemstillinger: ● Hvilke organisatoriske tiltak har BetonmastHæhre Eiendom gjennomført for å få best mulig sammenheng mellom tidligfase og FDVU? ● Hvilke kontraktsmessige tiltak har BetonmastHæhre Eiendom gjennomført for å få best mulig sammenheng mellom tidligfase og FDVU? ● Hvilke kalkulasjonsmessige tiltak har BetonmastHæhre Eiendom gjennomført for å få best mulig sammenheng mellom tidligfase og FDVU? ● I hvilken grad har de kalkulasjonsmessige tiltakene til BetonmastHæhre Eiendom vært tilstrekkelige? Oppgavens metode omfatter et casestudie av OPS-avtalene. Casestudiet og tilgangen fra BHE ga oss mulighet til å studere de aktuelle casene i detalj, der vi har gjennomført semistrukturerte intervjuer av sentrale personer, dokumentanalyser og egne kalkulatoriske beregninger. På bakgrunn av våre undersøkelser kan vi konkludere med at BHE har gjennomført tiltak for å skape en best mulig sammenheng mellom tidligfase og FDVU. Gjennom de samme undersøkelsene har vi også kommet frem til at noen av tiltakene ikke nødvendigvis skaper en best mulig sammenheng. BHE har organisert prosjektene sine i egne single purpose selskaper, som fungerer som egne rettssubjekter og eier av den respektive eiendommen. De har innhentet ekstern kompetanse på mva og skatt, og hatt egen advokat til å kvalitetssikre avtaleverket. Interne entreprenører er benyttet i begge prosjektene, og de har gjennom brukermedvirkning forsøkt å legge til rette for løsninger som støtter kjernevirksomheten i byggene. Brukermedvirkning viste seg å ikke fungere optimalt, grunnet problemer med å omsette erfaring, krav og behov til fysisk utforming. I avtaleverket med kommunene er det utarbeidet en tydelig ansvar- og kostnadsmatrise som tydeliggjør rammene i prosjektene. BHE har redusert sin risiko ved å ikke stille garantier utover vedlikeholdsfondet. Mot egen entreprenør har de brukt målsum som et styrende tiltak, og dette kan resultere i at entreprenør tenker mer på eget budsjett enn kvalitet og FDVU. For å oppnå kontroll på kalkulasjonen av fremtidige FDVU-kostnader, har BHE engasjert ekstern kompetanse. ISS har bistått med utarbeidelse av FDVU-budsjett og ga råd på materialvalg som påvirker kostnadene. Verken BHE eller ISS har utført LCC-beregninger på materialer eller andre løsninger. På den annen side har det vært interne vurderinger hos entreprenør og BHE på kvalitet og levetid på materialer. BHE driftsbudsjett er priset høyere enn egne beregninger vi har utført. Dette kan tyde på at BHE får et tilfredsstillende vederlag fra kommunen til å dekke utgifter til fremtidig FDVU.The purpose of this thesis is to map out which incentives BetonmastHæhre Eiendom (BHE) has implemented in order to achieve best possible correlation between early phase and MOMD in two specific OPS-projects. BHE has signed OPS-agreements with Nesodden and Lunner municipality including support concerning financial decisions, planning, engineering, contracting and the daily operation of care homes over a period of 30-years. BHE did not have any previous experience with the OPS model at this point. The main thesis statement of the following discussion is: Which measures has BetonmastHæhre Eiendom conducted in order to achieve the best possible correlation between early stages and MOMD in a specific OPS-project? In order to test and answer the main thesis statement we will use the application of the following four sub-questions: ● Which organization measures has BetonmastHæhre Eiendom implemented in order to gain the best possible correlation between early stages and MOMD? ● Which contractual measures has BetonmastHæhre Eiendom implemented in order to gain the best possible correlation between early stages and MOMD? ● Which analytical measures has BetonmastHæhre Eiendom implemented in order to gain the best possible correlation between early stages and MOMD? ● To what extent have the analytical measures taken been sufficient? The methodology used in this thesis is a case study of the OPS-agreements. The case study format, and the accessibility to the corporate operations given to us by BHE, gave us the opportunity to study the relevant cases meticulously and in depth by the means of semi-structured interviews of key people, document analysis and our own independent calculations. Based on our investigations we conclude that BHE has seen through a series of measures in order to create a best possible correlation between early phase and MOMD. Through the same set of investigations, we have also deduced that some of the measures taken not necessarily contributes to create the best possible correlation. BHE has organized its project in single purpose entities, which serves as independent legal entities and owners of the respective properties. Issues concerning VAT and taxation BHE have relied on external expertise and been worked out with a full-time legal advisor to ensure quality in the agreement documents. In-house contractions have been involved in both projects and have through user involvement aimed to facilitate the solutions in harmony with the core business of the buildings. User involvement did not give the expected results, mainly due to difficulty concerning capturing experience, demands and needs for physical design. In the general agreement in partnership with the municipalities a clear responsibility and cost matrix map out the framework of the projects. BHE has reduced its own risk by not offering warranty exceeding the restrictions from the maintenance fond. Target price has been governing towards in-house contractors, which may cause the contractions to focus more on budget and less on quality and MOMD. In order to achieve control regarding future calculations of MOMD, BHE has brought in external consultants. ISS has contributed in the development of MOMD budget and advised upon choice of material that will affect cost. BHE nor ISS has conducted LCC-calculations on materials or alternative solutions. On the other hand, there has been internal discussion concerning quality and life span of materials in both the Construction and Property departments. BHE’s budget of operations exceeds our own calculations, which may suggest that BHE is the recipient of a significant contribution from the municipality in order to cover expenses on future MOMD.submittedVersionM-EUT

Post procedure headache in patients treated for neurovascular arteriovenous malformations and aneurysms using endovascular therapy

BACKGROUND: Though endovascular therapy (EVT) is increasingly applied in the treatment of intracranial vascular lesions, little is known about the effect of EVT on post-procedure headache. We aimed to investigate the prevalence of headache in patients who have undergone EVT for cerebral arteriovenous malformations (AVMs) and aneurysms. METHODS: A total of 324 patients underwent EVT treatment for aneurysms and AVMs at the Danish National Hospital from January 2012 to December 2014. We applied strict exclusion criteria in order to minimize the effect of other factors on headache occurrence, e.g., craniotomy. Eligible subjects were phone-interviewed using a purpose-developed semi-structured questionnaire. Headaches were classified according to ICHD-III beta criteria. RESULTS: The 59 patients underwent treatment of aneurysms (n = 43), cranial dural fistulas (n = 11), and AVMs (n = 5). There was a significant increase in overall headache (p = 0.017) and tension-type headache (TTH) (p = 0.012) within the first 3 months after EVT compared to 1 month before EVT. However, at interview time (median 2.5 years post-EVT), the increase in overall headache, migraine, and tension-type headache was not statistically significant. A minority of patients experienced headaches for the first time within 3 months of their EVT (migraine 4, TTH 10). At interview time, 50 % of these new headaches still persisted. CONCLUSION: Our results suggest a temporary increase in headache in the first 3 months after EVT, which normalizes over time. Clinicians may use this knowledge to better inform their patients of functional outcomes after their EVT procedure

Aneurysmal and clinical characteristics as risk factors for intracerebral haematoma from aneurysmal rupture

Intracerebral haematoma (ICH) occurs in one-third of patients with aneurysmal subarachnoid haemorrhage (SAH) and is associated with poor prognosis. Identification of risk factors for ICH from aneurysmal rupture may help in balancing risks of treatment of unruptured aneurysms. We assessed potential clinical and aneurysmal risk factors for ICH from aneurysmal rupture. In all 310 SAH patients admitted to our service between 2005 and 2007, we compared clinical risk factors (gender, age, smoking, hypertension, history of SAH and family history) of patients with and without an ICH. From the latest admitted, 50 patients with and 50 without ICH, we compared the location, shape and direction of blood flow of the aneurysms on CT-angiography. Relative risks (RRs) of ICH were 1.2 (95% confidence interval, CI):0.7–1.8) for males, 1.0 (95%CI:0.7–1.4) for age ≥55 year, 1.0 (95%CI:0.6–1.6) for smoking, 0.9 (95%CI:0.5–1.5) for hypertension, 0.6 (95%CI:0.1–3.8) for history of SAH and 0.5 (95%CI:0.2–1.3) for family history of SAH. RRs of ICH were 1.8 (95%CI:1.2–2.5) for MCA aneurysms, 0.5 (95%CI:0.3–1.0) for ICA aneurysms, 0.4 (95%CI:0.1–1.3) for posterior circulation aneurysms, and 0.7 (95%CI:0.3–1.3) for multilobed aneurysms. The RRs of other aneurysmal characteristics varied between 0.9 and 1.2. Patients with MCA aneurysms are at a higher risk of developing ICH. The other aneurysmal or clinical factors have no or only minor influence on the risk of ICH after rupture and are, therefore, not helpful in deciding on treatment of unruptured aneurysms

Surgical Interventions for Cervical Radiculopathy without Myelopathy:A Systematic Review and Meta-Analysis

BACKGROUND: The effectiveness of surgical interventions for cervical degenerative disorders has been investigated in multiple systematic reviews. Differences in study population (e.g., patients with myelopathy and/or radiculopathy) were often neglected. Therefore, the objective of this study was to investigate the effectiveness of surgical interventions for patients with symptoms of cervical radiculopathy without myelopathy by conducting a systematic review and meta-analysis based on randomized controlled trials (RCTs). METHODS: A comprehensive systematic search was conducted in MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) to identify RCTs that investigated the effectiveness of surgical interventions using an anterior or posterior approach compared with other interventions for patients with pure cervical radiculopathy. Outcomes were success rates (Odom criteria, similar rating scales, or percentage of patients who improved), complication and reoperation rates, work status, disability (Neck Disability Index), and pain (arm and neck). The Cochrane risk-of-bias tool was used to assess the likelihood of the risk of bias. A random-effects model was used. Heterogeneity among study results (I ≥ 50% or p < 0.05) was explored by conducting subgroup analyses. Funnel plots were used to assess the likelihood of publication bias. RESULTS: A total of 21 RCTs were included, comprising 1,567 patients. For all outcomes, among all surgical techniques, only 1 pooled estimate showed a significant effect on success rate, which was in favor of anterior cervical discectomy with fusion compared with anterior cervical discectomy without an intervertebral spacer (p = 0.02; risk ratio [RR] = 0.87; 95% confidence interval [CI] = 0.77 to 0.98). Complication rates were higher when autologous bone graft from the iliac crest was used as an intervertebral spacer (p < 0.01; RR = 3.40; 95% CI = 1.56 to 7.43), related to donor-site morbidity. CONCLUSIONS: This meta-analysis demonstrated consistent results regarding clinical outcome for pure cervical radiculopathy among all studied interventions. Complication and reoperation rates were also similar, with the exception of higher complication rates in patients in whom autologous bone grafts were used. On the basis of clinical outcome and safety, there is no superior surgical intervention for pure cervical radiculopathy. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence

Consciousness in Neurocritical Care Cohort Study Using fMRI and EEG (CONNECT-ME): Protocol for a Longitudinal Prospective Study and a Tertiary Clinical Care Service

Aims and Objectives: To facilitate individualized assessment of unresponsive patients in the intensive care unit for signs of preserved consciousness after acute brain injury.Background: Physicians and neuroscientists are increasingly recognizing a disturbing dilemma: Brain-injured patients who appear entirely unresponsive at the bedside may show signs of covert consciousness when examined by functional MRI (fMRI) or electroencephalography (EEG). According to a recent meta-analysis, roughly 15% of behaviorally unresponsive brain-injured patients can participate in mental tasks by modifying their brain activity during EEG- or fMRI-based paradigms, suggesting that they are conscious and misdiagnosed. This has major ethical and practical implications, including prognosis, treatment, resource allocation, and end-of-life decisions. However, EEG- or fMRI-based paradigms have so far typically been tested in chronic brain injury. Hence, as a novel approach, CONNECT-ME will import the full range of consciousness paradigms into neurocritical care.Methods: We will assess intensive care patients with acute brain injury for preserved consciousness by serial and multimodal evaluation using active, passive and resting state fMRI and EEG paradigms, as well as state-of-the-art clinical techniques including pupillometry and sophisticated clinical rating scales such as the Coma Recovery Scale-Revised. In addition, we are establishing a biobank (blood, cerebrospinal fluid and brain tissue, where available) to facilitate future genomic and microbiomic research to search for signatures of consciousness recovery.Discussion: We anticipate that this multimodal approach will add vital clinical information, including detection of preserved consciousness in patients previously thought of as unconscious, and improved (i.e., personalized) prognostication of individual patients. Our aim is two-fold: We wish to establish a cutting-edge tertiary care clinical service for unresponsive patients in the intensive care unit and lay the foundation for a fruitful multidisciplinary research environment for the study of consciousness in acute brain injury. Of note, CONNECT-ME will not only enhance our understanding of consciousness disorders in acute brain injury but it will also raise awareness for these patients who, for obvious reasons, have lacked a voice so far.Trial registration: The study is registered with clinicaltrials.org (ClinicalTrials.gov Identifier: NCT02644265)