Using stochastic simulation modelling to study occupancy levels of decentralised admission avoidance units in Norway.

Identifying alternatives to acute hospital admission is a priority for many countries. Over 200 decentralised municipal acute units (MAUs) were established in Norway to divert low-acuity patients away from hospitals. MAUs have faced criticism for low mean occupancy and not relieving pressures on hospitals. We developed a discrete time simulation model of admissions and discharges to MAUs to test scenarios for increasing absolute mean occupancy. We also used the model to estimate the number of patients turned away as historical data was unavailable. Our experiments suggest that mergers alone are unlikely to substantially increase MAU absolute mean occupancy as unmet demand is generally low. However, merging MAUs offers scope for up to 20% reduction in bed capacity, without affecting service provision. Our work has relevance for other admissions avoidance units and provides a method for estimating unconstrained demand for beds in the absence of historical data.

Prediction of occult atrial fibrillation in patients after cryptogenic stroke and transient ischaemic attack: PROACTIA.

AIMS: Studies with implantable cardiac monitors (ICMs) show that one-third of patients with cryptogenic stroke/transient ischaemic attack (TIA) have episodes of subclinical atrial fibrillation (SCAF) and benefit switching from antiplatelet- to anticoagulant therapy. However, ICMs are costly and resource demanding. We aimed to build a score based on participant's baseline characteristics that could assess individual risk of SCAF. METHODS AND RESULTS: In a prospective study, 236 eligible patients with a final diagnosis of cryptogenic stroke/TIA had an ICM implantated during the index hospitalization. Pre-specified evaluated variables were: CHA2DS2-VASc, P-wave duration, P-wave morphology, premature atrial beats (PAC)/24 h, supraventricular tachycardia/24 h, left atrial end-systolic volume index (LAVI), Troponin-T, NT-proBNP, and D-dimer. SCAF was detected in 84 patients (36%). All pre-specified variables were significantly associated with SCAF detection in univariate analysis. P-wave duration, followed by PAC/24 h, NT-proBNP, and LAVI, had the largest ratio of SCAF prevalence between its upper and lower quartiles (3.3, vs. 3.2, vs. 3.1 vs. 2.8, respectively). However, in a multivariate analysis, only PAC/24t, P-wave duration, P-wave morphology, and LAVIs remained significant predictors and were included in the PROACTIA score. Subclinical atrial fibrillation prevalence was 75% in the highest vs. 10% in the lowest quartile of the PROACTIA score with a 10-fold higher number of patients with an atrial fibrillation burden >6 h in the highest vs. the lowest quartile. CONCLUSION: The PROACTIA score can identify patients with cryptogenic stroke/TIA at risk of subsequent SCAF detection. The large difference in SCAF prevalence between groups may provide a basis for future tailored therapy. CLINICAL TRIAL REGISTRATION: Clinical Trial Registration: ClinicalTrials.gov; NCT02725944.

Stroke unit demand in Norway - present and future estimates.

BACKGROUND: All stroke patients should receive timely admission to a stroke unit (SU). Consequently, most patients with suspected strokes - including stroke mimics (SM) are admitted. The aim of this study was to estimate the current total demand for SU bed capacity today and give estimates for future (2020-2040) demand. METHODS: Time trend estimates for stroke incidence and time constant estimates for length of stay (LOS) were estimated from the Norwegian Patient Registry (2010-2015). Incidence and LOS models for SMs were based on data from Haukeland University Hospital (2008-2017) and Akershus University Hospital (2020), respectively. The incidence and LOS models were combined with scenarios from Statistic Norway's population predictions to estimate SU demands for each health region. A telephone survey collected data on the number of currently available SU beds. RESULTS: In 2020, 361 SU beds are available, while demand was estimated to 302. The models predict a reduction in stroke incidence, which offsets projected demographic shifts. Still, the estimated demand for 2040 rose to 316, due to an increase in SMs. A variation of this reference scenario, where stroke incidence was frozen at the 2020-level, gave a 2040-demand of 480 beds. CONCLUSIONS: While the stroke incidence is likely to continue to fall, this appears to be balanced by an increase in SMs. An important uncertainty is how long the trend of decreasing stroke incidence can be expected to continue. Since the most important uncertainty factors point toward a potential increase, which may be as large as 50%, we would recommend that the health authorities plan for a potential increase in the demand for SU bed capacity.

Stroke Mimics on the Stroke Unit - Temporal trends 2008-2017 at a large Norwegian university hospital.

OBJECTIVES: The objective was to quantify temporal trends in stroke mimics (SM) admissions relative to cerebrovascular accidents (CVA), incidence of hospitalized SMs and characterize the SM case-mix at a general hospital's stroke unit (SU). MATERIALS & METHODS: All SU admissions (n = 11240) of patients aged 15 or older to Haukeland University Hospital between 2008-2017 were prospectively included and categorized as CVA or SM. Logistic regression was used to estimate time trends in the proportion of SMs among the admissions. Poisson regression was used to estimate time trends in age- and sex-dependent SM incidence. RESULTS: SMs were on average younger thaan CVA patients (68.3 vs. 71.4 years) and had a higher proportion of females (53.6% vs. 44.5%). The total proportion of SM admissions was 51.0%. There was an increasing time trend in the proportion of SM admissions, odds ratio 1.150 per year (p < 0.001), but this trend appears flattening, represented by a significant quadratic time-term, odds ratio 1.009 (p < 0.001). A higher SM proportion was also associated with the time period of a Mass Media Intervention (FAST campaign) in 2014. There was also an increasing trend in SM incidence, that remains after adjusting for age, sex, and population; also, for incidence the trend appears to be flattening. CONCLUSIONS: SMs account for approximately half of the SU admissions, and the proportion has been increasing. A FAST campaign appears to have temporarily increased the SM proportion. The age- and sex-dependent incidence of SM has been increasing but appears to flatten out.

Long-term prognosis for patients admitted to a medical intermediate care unit. / Langtidsprognose for pasienter innlagt i en medisinsk overvåkningsavdeling.

BACKGROUND: The intermediate care unit at Akershus University Hospital treats patients with incipient or manifest organ failure. Selecting patients who might benefit from treatment in an intermediate care unit is challenging. Few data are available on long-term survival of patients treated in medical intermediate care units and on how assumed favourable and unfavourable prognostic factors predict long-term survival in this population. MATERIAL AND METHOD: Comorbidity, reason for admission and whether an infection was a direct or contributory reason for the admission were prospectively registered for patients in the unit in 2014 and 2016. We registered mortality up to six years after the admission and conducted a logistic regression analysis with three-year survival as the outcome variable. RESULTS: Of the 2 170 included patients, 153 (7 %) died in the intermediate care unit. Of the 2 017 patients who were discharged alive from the intermediate care unit, 55 % were still alive three years later, including 28 % of older patients aged over 80 years and 23 % of patients with cancer. Age, malignancy, other comorbidity and infection were predictors of mortality. INTERPRETATION: Many patient groups in an intermediate care unit have a poor long-term prognosis. However, people older than 80 years, cancer patients or patients with another serious comorbidity may live long after their stay in an intermediate care unit, and the fact of belonging to these groups should not be an independent reason for withholding treatment.

Neural classification of Norwegian radiology reports: using NLP to detect findings in CT-scans of children.

BACKGROUND: With a motivation of quality assurance, machine learning techniques were trained to classify Norwegian radiology reports of paediatric CT examinations according to their description of abnormal findings. METHODS: 13.506 reports from CT-scans of children, 1000 reports from CT scan of adults and 1000 reports from X-ray examination of adults were classified as positive or negative by a radiologist, according to the presence of abnormal findings. Inter-rater reliability was evaluated by comparison with a clinician's classifications of 500 reports. Test-retest reliability of the radiologist was performed on the same 500 reports. A convolutional neural network model (CNN), a bidirectional recurrent neural network model (bi-LSTM) and a support vector machine model (SVM) were trained on a random selection of the children's data set. Models were evaluated on the remaining CT-children reports and the adult data sets. RESULTS: Test-retest reliability: Cohen's Kappa = 0.86 and F1 = 0.919. Inter-rater reliability: Kappa = 0.80 and F1 = 0.885. Model performances on the Children-CT data were as follows. CNN: (AUC = 0.981, F1 = 0.930), bi-LSTM: (AUC = 0.978, F1 = 0.927), SVM: (AUC = 0.975, F1 = 0.912). On the adult data sets, the models had AUC around 0.95 and F1 around 0.91. CONCLUSIONS: The models performed close to perfectly on its defined domain, and also performed convincingly on reports pertaining to a different patient group and a different modality. The models were deemed suitable for classifying radiology reports for future quality assurance purposes, where the fraction of the examinations with abnormal findings for different sub-groups of patients is a parameter of interest.

No Correlation Between Ethical Judgment in Trolley Dilemmas and Vaccine Scenarios for Nurse Specialist Students.

We tested whether responses to trolley problems by nurse specialist students correlated with their responses to hypothetical vaccine problems, as a follow-up to a similar study on ethics committees. No statistically significant correlation was found between the trolley and vaccination scores. These results confirmed and strengthened the finding of a very weak correlation (possibly zero), and the point estimate was even lower than for the ethics committees. Hence, the nurse specialists' responses to the trolley problems cannot be used to indicate any direction for their responses to the vaccine problems, although there is a common core issue of sacrificing some for many. The respondents reported a relatively high willingness to push one man in front of a trolley to save five. They also reported a high willingness to act in trolley dilemmas compared with vaccination dilemmas, although the dimensions of risk-reward ratios and consent heavily favored the latter.

A Markov chain method for counting and modelling migraine attacks.

To ensure reproducibility in research quantifying episodic migraine attacks, and identifying attack onset, a sound theoretical model of a migraine attack, paired with a uniform standard for counting them, is necessary. Many studies report on migraine frequencies-e.g. the fraction of migraine-days of the observed days-without paying attention to the number of discrete attacks. Furthermore, patients' diaries frequently contain single, migraine-free days between migraine-days, and we argue here that such 'migraine-locked days' should routinely be interpreted as part of a single attack. We tested a simple Markov model of migraine attacks on headache diary data and estimated transition probabilities by mapping each day of each diary to a unique Markov state. We explored the validity of imputing migraine days on migraine-locked entries, and estimated the effect of imputation on observed migraine frequencies. Diaries from our patients demonstrated significant clustering of migraine days. The proposed Markov chain model was shown to approximate the progression of observed migraine attacks satisfactorily, and imputing on migraine-locked days was consistent with the conceptual model for the progression of migraine attacks. Hence, we provide an easy method for quantifying the number and duration of migraine attacks, enabling researchers to procure data of high inter-study validity.

Capacity and patient flow planning in post-term pregnancy outpatient clinics: a computer simulation modelling study.

BACKGROUND: The demand for a large Norwegian hospital's post-term pregnancy outpatient clinic has increased substantially over the last 10 years due to changes in the hospital's catchment area and to clinical guidelines. Planning the clinic is further complicated due to the high did not attend rates as a result of women giving birth. The aim of this study is to determine the maximum number of women specified clinic configurations, combination of specified clinic resources, can feasibly serve within clinic opening times. METHODS: A hybrid agent based discrete event simulation model of the clinic was used to evaluate alternative configurations to gain insight into clinic planning and to support decision making. Clinic configurations consisted of six factors: X0: Arrivals. X1: Arrival pattern. X2: Order of midwife and doctor consultations. X3: Number of midwives. X4: Number of doctors. X5: Number of cardiotocography (CTGs) machines. A full factorial experimental design of the six factors generated 608 configurations. RESULTS: Each configuration was evaluated using the following measures: Y1: Arrivals. Y2: Time last woman checks out. Y3: Women's length of stay (LoS). Y4: Clinic overrun time. Y5: Midwife waiting time (WT). Y6: Doctor WT. Y7: CTG connection WT. Optimisation was used to maximise X0 with respect to the 32 combinations of X1-X5. Configuration 0a, the base case Y1 = 7 women and Y3 = 102.97 [0.21] mins. Changing the arrival pattern (X1) and the order of the midwife and doctor consultations (X2) configuration 0d, where X3, X4, X5 = 0a, Y1 = 8 woman and Y3 86.06 [0.10] mins. CONCLUSIONS: The simulation model identified the availability of CTG machines as a bottleneck in the clinic, indicated by the WT for CTG connection effect on LoS. One additional CTG machine improved clinic performance to the same degree as an extra midwife and an extra doctor. The simulation model demonstrated significant reductions to LoS can be achieved without additional resources, by changing the clinic pathway and scheduling of appointments. A more general finding is that a simulation model can be used to identify bottlenecks, and efficient ways of restructuring an outpatient clinic.

Surgical site infection after hip fracture - mortality and risk factors: an observational cohort study of 1,709 patients.

Background and purpose - Surgical site infection (SSI) is a devastating complication of hip fracture surgery. We studied the contribution of early deep SSI to mortality after hip fracture surgery and the risk factors for deep SSI with emphasis on the duration of surgery.Patients and methods - 1,709 patients (884 hemi-arthroplasties, 825 sliding hip screws), operated from 2012 to 2015 at a single center were included. Data were obtained from the Norwegian Hip Fracture Register, the electronic hospital records, the Norwegian Surveillance System for Antibiotic Use and Hospital-Acquired Infections, and the Central Population Register.Results - The rate of early (≤ 30 days) deep SSI was 2.2% (38/1,709). Additionally, for hemiarthroplasties 7 delayed (> 30 days, ≤ 1 year) deep SSIs were reported. In patients with early deep SSI 90-day mortality tripled (42% vs. 14%, p < 0.001) and 1-year mortality doubled (55% vs. 24%, p < 0.001). In multivariable analysis, early deep SSI was an independent risk factor for mortality (RR 2.4 for 90-day mortality, 1.8 for 1-year mortality, p < 0.001). In univariable analysis, significant risk factors for early and delayed deep SSI were cognitive impairment, an intraoperative complication, and increasing duration of surgery. However, in the multivariable analysis, duration of surgery was no longer a significant risk factor.Interpretation - Early deep SSI is an independent risk factor for 90-day and 1-year mortality after hip fracture surgery. After controlling for observed confounding, the association between duration of surgery and early and delayed deep SSI was not statistically significant.

Erlang could have told you so-A case study of health policy without maths.

Little consideration is given to the operational reality of implementing national policy at local scale. Using a case study from Norway, we examine how simple mathematical models may offer powerful insights to policy makers when planning policies. Our case study refers to a national initiative requiring Norwegian municipalities to establish acute community beds (municipal acute units or MAUs) to avoid hospital admissions. We use Erlang loss queueing models to estimate the total number of MAU beds required nationally to achieve the original policy aim. We demonstrate the effect of unit size and patient demand on anticipated utilisation. The results of our model imply that both the average demand for beds and the current number of MAU beds would have to be increased by 34% to achieve the original policy goal of transferring 240 000 patient days to MAUs. Increasing average demand or bed capacity alone would be insufficient to reach the policy goal. Day-to-day variation and uncertainty in the numbers of patients arriving or leaving the system can profoundly affect health service delivery at the local level. Health policy makers need to account for these effects when estimating capacity implications of policy. We demonstrate how a simple, easily reproducible, mathematical model could assist policy makers in understanding the impact of national policy implemented at the local level.

Fewer ischemic strokes, despite an ageing population: stroke models from observed incidence in Norway 2010-2015.

BACKGROUND: Stroke incidence rates have fallen in high-income countries over the last several decades, but findings regarding the trend over recent years have been mixed. The aim of the study was to describe and model temporal trends in incidence of stroke by age and sex between 2010 and 2015 in Norway, and to generate incidence projections towards year 2040. METHODS: All recorded strokes in Norway between 2010 and 2015 were extracted from the National Patient Registry and the National Cause of Death Registry. We report incidence by age, sex, and year; in raw numbers, per 100,000 person-years, by WHO and European standard populations; and generated statistical models by stroke type, age, sex, and year; and projected stroke incidence toward year 2040. RESULTS: The data covered 30.1 million person-years at risk, 53431 unique individuals hospitalized with a primary stroke diagnosis, and 6315 additional individuals registered as dead due to stroke. From 2010 to 2015, individuals suffering stroke per 100,000 person-years dropped from 239 to 195 (208 to 177 excluding immediate deaths). The decline was driven by ischemic strokes, with a statistically non-significant time trend for hemorrhagic stroke. CONCLUSIONS: The age-dependent incidence of ischemic strokes in Norway is declining rapidly, and more than compensates for the growth and ageing of the population. Comparisons with historic incidence statistics show that the reduction in incidence rates has accelerated over the last two decades.

Identifying menstrual migraine- improving the diagnostic criteria using a statistical method.

OBJECTIVE: To develop a robust statistical tool for the diagnosis of menstrually related migraine. BACKGROUND: The International Classification of Headache Disorders (ICHD) has diagnostic criteria for menstrual migraine within the appendix. These include the requirement for menstrual attacks to occur within a 5-day window in at least [Formula: see text] menstrual cycles ([Formula: see text]-criterion). While this criterion has been shown to be sensitive, it is not specific. Yet in some circumstances, for example to establish the underlying pathophysiology of menstrual attacks, specificity is also important, to ensure that only women in whom the relationship between migraine and menstruation is more than a chance occurrence are recruited. METHODS: Using a simple mathematical model, a Markov chain, to model migraine attacks we developed a statistical criterion to diagnose menstrual migraine (sMM). We then analysed a data set of migraine diaries using both the [Formula: see text]-criterion and the sMM. RESULTS: sMM was superior to the [Formula: see text]-criterion for varying numbers of menstrual cycles and increased in accuracy with more cycle data. In contrast, the [Formula: see text]-criterion showed maximum sensitivity only for three cycles, although specificity increased with more cycle data. CONCLUSIONS: While the ICHD [Formula: see text]-criterion is a simple screening tool for menstrual migraine, the sMM provides a more specific diagnosis and can be applied irrespective of the number of menstrual cycles recorded. It is particularly useful for clinical trials of menstrual migraine where a chance association between migraine and menstruation must be excluded.

Clinical validation of a novel automated cell-free DNA screening assay for trisomies 21, 13, and 18 in maternal plasma.

OBJECTIVE: To evaluate clinical performance of a new automated cell-free (cf)DNA assay in maternal plasma screening for trisomies 21, 18, and 13, and to determine fetal sex. METHOD: Maternal plasma samples from 1200 singleton pregnancies were analyzed with a new non-sequencing cfDNA method, which is based on imaging and counting specific chromosome targets. Reference outcomes were determined by either cytogenetic testing, of amniotic fluid or chorionic villi, or clinical examination of neonates. RESULTS: The samples examined included 158 fetal aneuploidies. Sensitivity was 100% (112/112) for trisomy 21, 89% (32/36) for trisomy 18, and 100% (10/10) for trisomy 13. The respective specificities were 100%, 99.5%, and 99.9%. There were five first pass failures (0.4%), all in unaffected pregnancies. Sex classification was performed on 979 of the samples and 99.6% (975/979) provided a concordant result. CONCLUSION: The new automated cfDNA assay has high sensitivity and specificity for trisomies 21, 18, and 13 and accurate classification of fetal sex, while maintaining a low failure rate. The study demonstrated that cfDNA testing can be simplified and automated to reduce cost and thereby enabling wider population-based screening.

Fast track hip fracture care and mortality - an observational study of 2230 patients.

BACKGROUND: Hip fracture patients are frail and have a high mortality. We investigated whether the introduction of fast track care reduced the 30-day mortality after hip fractures. METHODS: Fast track hip fracture care was established at our institution in October 2013. Data from the Norwegian Hip Fracture Register and electronic hospital records were merged for 2230 hip fracture patients operated in our department from January 2012 through December 2015. 1090 of these patients were operated before (conventional treatment group) and 1140 patients were operated after the introduction of fast track care (fast track group). Data were analysed by univariate analysis and binary logistic regression. RESULTS: Mortality did not differ significantly between the conventional treatment group and the fast track group at 30 days (7.9% vs. 6.5%), 90 days (13.5% vs. 12.5%) and one year (22.8% vs. 22.8%). Median admission time and time to surgery were significantly shorter in the fast track group than in the conventional treatment group (1.1 h vs. 3.9 h and 23.6 h vs. 25.7 h, both p <  0.0001). The 30-day reoperation rate was significantly lower in the fast track group compared to the conventional treatment group (odds ratio = 0.35 (95% CI: 0.15-0.84), p = 0.019). A composite 30-day outcome (reoperation, surgical site infection and/or death) was significantly less frequent in the fast track group (8.1%) than in the conventional treatment group (10.7%) in unadjusted analysis (p = 0.006), but not after adjusting for age, gender, cognitive impairment and ASA score (odds ratio = 0.85 (95% CI: 0.63-1.16), p = 0.31, 8.0% missing). Reoperations within 1 year, surgical site infections, 30-day readmissions and length of hospital stay did not differ significantly between the conventional treatment group and the fast track group. CONCLUSIONS: Fast track hip fracture care is safe. However, we observed no statistically significant change in 30-day, 90-day or 1-year mortality after the introduction of fast track hip fracture care. TRIAL REGISTRATION: The study was registered retrospectively at ClinicalTrials.gov (Protocol Record 284907 ) 6 December 2016.

Trolley Dilemmas Fail to Predict Ethical Judgment in a Hypothetical Vaccination Context.

We investigated whether the responses of 68 ethics committee members and staff to trolley dilemmas could predict their responses to research ethics problems concerning vaccine trials. Trolley dilemmas deal with the issue of sacrificing some for the benefit of many, which is also a core issue in the vaccination trial dilemmas. The subjects' responses to trolley dilemmas showed no statistically significant correlation with their responses to our vaccination trial dilemmas. We concluded that, if there is a component of transferable intuition between the contexts, it must be small and dominated by other factors. Furthermore, the willingness to sacrifice some for many was larger in the trolley context, despite a more favorable risk/reward ratio and the voluntary participation of the subjects at risk in the vaccination situations. We conclude that one's general willingness to trade lives in the trolley context may be an artifact that is due to its unrealistic setting.

Stroke incidence in the young: evidence from a Norwegian register study.

INTRODUCTION: While there is a general agreement that stroke incidence among the elderly is declining in the developed world, there is a concern that it may be increasing among the young. The present study investigates this issue for the Norwegian population for the years 2010-2015. Cerebrovascular accidents (CVAs) for patients younger than 55 years were identified through the Norwegian Patient Registry and the Norwegian Cause-of-death Registry. METHODS: Negative binomial regression modelling was used to estimate temporal trends in the CVA incidence rates for the young, aged 15-54, with 10-year sub-intervals, and for children below the age of 18. The main outcomes were CVA incidence per 100,000 person-years at risk (PY), 30-day stroke mortality per 100,000 PY, and 30-day case-fatality rates. RESULTS: The analysis showed a negative and non-significant temporal trend in the CVA incidence ([Formula: see text]) as well as for 30-day mortality ([Formula: see text]) for the age group 15-54. Overall, the inclusion of an interaction for age in the bracket 45-54 suggested that any temporal decline is restricted to this age bracket. The analyses of the 10-year age brackets 15-24, 25-34, and 34-45, provided evidence neither for an increase, nor for a decrease, in incidence. Among the children, the estimated temporal coefficients were positive, but non-significant, consistent with a stationary trend. CONCLUSION: Weak statistical evidence was found for a decline in CVA incidence and for overall stroke 30-day case fatality for 15-54 year olds, but the decline was significant only for the 45-54 age band. All results considered, the study suggests a stationary or decreasing temporal trend in CVA incidence and stroke fatality for children (0-18) and young (15-54) in Norway. Even larger data sets are needed to estimate these temporal trends accurately.

Epidemiology and prognoses in a medical intermediate care unit. / Epidemiologi og prognoser i en medisinsk overvåkningsavdeling.

BACKGROUND: The purpose of medical intermediate care units is the observation and treatment of patients with incipient or manifest organ failure. We wished to obtain data on which conditions result in admission to these units and the prognosis for these patients. MATERIAL AND METHOD: All patients admitted to the medical intermediate care unit at Akershus University Hospital in 2014 were registered prospectively with reason for admission, period of hospitalisation, degree of severity, comorbidity, last place of hospitalisation prior to medical intermediate care and treatment limitations (do-not-resuscitate order and/or do-not-intubate order). Mortality in the hospital and one year after hospitalisation were registered retrospectively. Multiple regression analysis was performed with hospital mortality as the outcome variable. RESULTS: Altogether 1369 patient hospitalisations for 1118 unique patients were included. The most frequent reasons for admission were pneumonia, chronic obstructive pulmonary disease, sepsis, poisonings and hyponatraemia. The degree of severity of the condition for which patients were admitted corresponded to that reported by intensive care departments in Norwegian local hospitals. A total of 13 % died during their stay in hospital and a further 14 % in the course of one year. The highest mortality was for patients with severe infection, cardiac failure and restrictive/neuromuscular respiratory disorder. The degree of severity, age, infection, comorbidity and ward as admitting unit were predictors of mortality during the hospitalisation period. Risk-adjusted mortality ratio of 0.64 satisfied the quality objective for intensive care departments (<0.7). A total of 5.6 % of hospitalisations in the medical intermediate care unit entailed transfer to the intensive care ward. INTERPRETATION: The degree of severity of the condition for which patients were admitted was high, and the treatment outcomes judged upon expected mortality were good. Medical intermediate care units can relieve pressure on wards with seriously ill patients without taking up intensive care beds.

Imaging single DNA molecules for high precision NIPT.

Cell-free DNA analysis is becoming adopted for first line aneuploidy screening, however for most healthcare programs, cost and workflow complexity is limiting adoption of the test. We report a novel cost effective method, the Vanadis NIPT assay, designed for high precision digitally-enabled measurement of chromosomal aneuploidies in maternal plasma. Reducing NIPT assay complexity is achieved by using novel molecular probe technology that specifically label target chromosomes combined with a new readout format using a nanofilter to enrich single molecules for imaging and counting without DNA amplification, microarrays or sequencing. The primary objective of this study was to assess the Vanadis NIPT assay with respect to analytical precision and clinical feasibility. Analysis of reference DNA samples indicate that samples which are challenging to analyze with low fetal-fraction can be readily detected with a limit of detection determined at <2% fetal-fraction. In total of 286 clinical samples were analysed and 30 out of 30 pregnancies affected by trisomy 21 were classified correctly. This method has the potential to make cost effective NIPT more widely available with more women benefiting from superior detection and false positive rates.