46 MEASURING THE IMPACT OF COVID-19 RESTRICTIONS ON MOBILITY IN OLDER ADULTS WITH FRAGILITY FRACTURES USING THE NEW MOBILITY SCORE

Background

Methods

Results

Conclusion

References

47 DOSING OF DIRECT ORAL ANTICOAGULANTS IN OLDER ADULTS

Background

Direct oral anticoagulants (DOACs) are approved for a variety of uses including prevention of stroke in non-valvular atrial fibrillation and treatment and prevention of deep vein thrombosis and pulmonary embolism. Adjustment to DOAC dosing may be required for age, weight and renal impairment. Incorrect lower dosing puts patients at risk of thromboembolic events whereas inappropriate higher dosing increases the risk of bleeding. We compared current DOAC dosing for patients admitted to our hospital and compare this against HSE best practice to determine if patients were receiving the correct dose [1].

Methods

A prospective single-centre study. Patients admitted to our hospital following a fracture and reviewed by the Orthogeriatric team between August–October 2020 were eligible for inclusion. We recorded admission DOAC dose, age, weight and renal function. We also obtained data including sex and Clinical Frailty Scale (CFS).

Results

Thirty-one patients were included. Mean age was 86 years [range 66–99] and 21(68%) were female. Apixaban was the most commonly used DOAC; 25(81%). Stroke prevention in non-valvular atrial fibrillation was the most common DOAC indication; 29(93%). Twelve patients (39%) had an inappropriate DOAC dose prescribed. Eight patients (67%) had an inappropriately low dose and 4 patients (33%) had an inappropriately high dose. The mean CFS was 5 [Range 2–7] classifying our cohort as mildly frail.

Conclusion

Our study has shown that over one-third of our patients were on an inappropriate DOAC dose on admission with the majority (67%) due to under-dosing. Many factors may have influenced dosing choices by clinicians but our findings highlight the challenges in dosing, monitoring and the overall management of DOAC therapy in older people. Further studies and research are required to establish the most accurate and effective dosing strategies for DOACs in older adults.

Reference

1. Health Service Executive [Internet]. Ireland ‘Anticoagulation Prescribing Tips’ https://www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/noac-prescribing-tips-for-noacs.pdf.

Biomedical journals lack a consistent method to detect outcome reporting bias: a cross-sectional analysis

WHAT IS KNOWN AND OBJECTIVE

An increasing amount of recently published literature has implicated outcome reporting bias (ORB) as a major contributor to skewing data in both randomized controlled trials and systematic reviews; however, little is known about the current methods in place to detect ORB. This study aims to gain insight into the detection and management of ORB by biomedical journals.

METHODS

This was a cross-sectional analysis involving standardized questions via email or telephone with the top 30 biomedical journals (2012) ranked by impact factor. The Cochrane Database of Systematic Reviews was excluded leaving 29 journals in the sample.

RESULTS

Of 29 journals, 24 (83%) responded to our initial inquiry of which 14 (58%) answered our questions and 10 (42%) declined participation. Five (36%) of the responding journals indicated they had a specific method to detect ORB, whereas 9 (64%) did not have a specific method in place. The prevalence of ORB in the review process seemed to differ with 4 (29%) journals indicating ORB was found commonly, whereas 7 (50%) indicated ORB was uncommon or never detected by their journal previously. The majority (n = 10/14, 72%) of journals were unwilling to report or make discrepancies found in manuscripts available to the public. Although the minority, there were some journals (n = 4/14, 29%) which described thorough methods to detect ORB.

WHAT IS NEW AND CONCLUSION

Many journals seemed to lack a method with which to detect ORB and its estimated prevalence was much lower than that reported in literature suggesting inadequate detection. There exists a potential for overestimation of treatment effects of interventions and unclear risks. Fortunately, there are journals within this sample which appear to utilize comprehensive methods for detection of ORB, but overall, the data suggest improvements at the biomedical journal level for detecting and minimizing the effect of this bias are needed.

Experience with the European quality assurance guidelines for digital mammography systems in a national screening programme

The transition to a fully digital breast screening programme, utilising three different full-field digital mammography (FFDM) systems has presented many challenges to the implementation of the European guidelines for physico-technical quality assurance (QA) testing. An analysis of the QA results collected from the FFDM systems in the screening programme over a 2-y period indicates that the three different systems have similar QA performances. Generally, the same tests were failed by all systems and failure rates were low. The findings provide some assurance that the QA guidelines are being correctly implemented. They also suggest that there is more scope for the development of the relevance of the guidelines with respect to modern FFDM systems. This study has also shown that a summary review of the QA data can be achieved by simple organisation of the QA data storage and by automation of data query and retrieval using commonly available software.

Rural and urban distribution of trauma incidents in Scotland

Background

Trauma systems reduce mortality and improve functional outcomes from injury. Regional trauma networks have been established in several European regions to address longstanding deficiencies in trauma care. A perception of the geography and population distribution as challenging has delayed the introduction of a trauma system in Scotland. The characteristics of trauma incidents attended by the Scottish Ambulance Service were analysed, to gain a better understanding of the geospatial characteristics of trauma in Scotland.

Methods

Data on trauma incidents collected by the Scottish Ambulance Service between November 2008 and October 2010 were obtained. Incident location was analysed by health board region, rurality and social deprivation. The results are presented as number of patients, average annual incidence rates and relative risks.

Results

Of the 141 668 incidents identified, 72·1 per cent occurred in urban regions. The risk of being involved in an incident was similar across the most populous regions, and decreased slightly with increasing rurality. Social deprivation was associated with greater numbers and risk. A total of 53·1 per cent of patients were taken to a large general hospital, and 38·6 per cent to a teaching hospital; the distribution was similar for the subset of incidents involving patients with physiological derangements.

Conclusion

The majority of trauma incidents in Scotland occur in urban and deprived areas. A regionalized system of trauma care appears plausible, although the precise configuration of such a system requires further study.

Investigation of the effect of anode/filter materials on the dose and image quality of a digital mammography system based on an amorphous selenium flat panel detector

A comparison, in terms of image quality and glandular breast dose, was carried out between two similar digital mammography systems using amorphous selenium flat panel detectors. The two digital mammography systems currently available from Lorad-Hologic were compared. The original system utilises Mo/Mo and Mo/Rh as target/filter combinations, while the new system uses W/Rh and W/Ag. Images of multiple mammography phantoms with simulated compressed breast thicknesses of 4 cm, 5 cm and 6 cm and various glandular tissue equivalency were acquired under different spectral conditions. The contrast of five details, corresponding to five glandular compositions, was calculated and the ratio of the square of the contrast-to-noise ratio to the average glandular dose was used as a figure-of-merit (FOM) to compare results. For each phantom thickness and target/filter combination, there is an optimum voltage that maximises the FOM. Results show that the W/Rh combination is the best choice for all the detection tasks studied, but for thicknesses greater than 6 cm the W/Ag combination would probably be the best choice. In addition, the new system with W filter presents a better optimisation of the automatic exposure control in comparison with the original system with Mo filter.

Collaborative decision-making between paramedics and CCU nurses based on 12-lead ECG telemetry expedites the delivery of thrombolysis in ST elevation myocardial infarction

OBJECTIVES

To describe a prehospital thrombolysis (PHT) and expedited inhospital thrombolysis (IHT) programme in south-east Scotland using prehospital 12-lead ECG recordings transmitted by telemetry and autonomous paramedic-administered thrombolysis with decision support being provided by coronary care nurses.

DESIGN

Retrospective observational study.

SETTING

Three hospitals in south-east Scotland covering a population of 778,468 served by 54 ambulance vehicles.

PATIENTS

11,840 patients who telephoned the ambulance service with "chest pain" over 20 months, during which 812 patients were admitted with ST segment elevation myocardial infarction (STEMI).

MAIN OUTCOME MEASURES

All calls and cardiac/potential cardiac calls to the ambulance service, type/time of patient presentation, symptoms/call/door-to-thrombolysis times.

RESULTS

Of the 11,840 calls to the ambulance service for chest pain over 20 months of the initiative, 60% were cardiac/potentially cardiac-related by Scottish Ambulance Service triage. ST segment elevation was present in 8% of the 5150 12-lead ECGs transmitted by paramedics to the ECG receiving station in the CCU. Over the 20 months, 812 patients were admitted to the three hospitals with STEMI and 71% received thrombolysis. Median symptom-to-thrombolysis times were 91, 148 and 184 min, respectively, in the PHT, telemetry-facilitated IHT and self-presenting IHT groups. Median call-to-needle time for the PHT group was 40 min. In 2/146 cases the cardiologists judged that the patient should not have been administered PHT.

CONCLUSIONS

Based on prehospital 12-lead ECG telemetry, it is possible for paramedics and CCU nurses to conduct live reperfusion decision-making in patients with STEMI, with resultant benefits in symptoms-to-thrombolysis time.

Fronto-parietal activation in attention-deficit hyperactivity disorder, combined type: functional magnetic resonance imaging study

A functional magnetic resonance imaging mental rotation paradigm was used to investigate the patterns of activation of fronto-parietal brain areas in male adolescents with attention-deficit hyperactivity disorder, combined type (ADHD-CT) compared with age-, gender-, handedness- and performance IQ-matched healthy controls. The ADHD-CT group had (a) decreased activation of the 'action-attentional' system (including Brodmann's areas (BA) 46, 39, 40) and the superior parietal (BA 7) and middle frontal (BA10) areas and (b) increased activation of the posterior midline attentional system. These different neuroactivation patterns indicate widespread frontal, striatal and parietal dysfunction in adolescents with ADHD-CT.

Physiological and pathophysiological influences on thirst

Thirst motivates animals to seek fluid and drink it. It is regulated by the central nervous system and arises from neural and chemical signals from the periphery interacting in the brain to stimulate a drive to drink. Our research has focussed on the lamina terminalis and the manner in which osmotic and hormonal stimuli from the circulation are detected by neurons in this region and how that information is integrated with other neural signals to generate thirst. Our studies of osmoregulatory drinking in the sheep and rat have produced evidence that osmoreceptors for thirst exist in the dorsal cap of the organum vasculosum of the lamina terminalis (OVLT) and in the periphery of the subfornical organ, and possibly also in the median preoptic nucleus. In the rat, the hormones angiotensin II and relaxin act on neurons in the periphery of the subfornical organ to stimulate drinking. Studies of human thirst using functional magnetic resonance imaging (fMRI) techniques show that systemic hypertonicity activates the lamina terminalis and the anterior cingulate cortex, but the neural circuitry that connects sensors in the lamina terminalis to cortical regions subserving thirst remains to be determined. Regarding pathophysiological influences on thirst mechanisms, both excessive (polydipsia) and inadequate (hypodisia) water intake may have dire consequences. One of the most common primary polydipsias is that observed in some cases of schizophrenia. The neural mechanisms causing the excessive water intake in this disorder are unknown, so too are the factors that result in impaired thirst and inadequate fluid intake in some elderly humans.

Neuroimaging evidence implicating cerebellum in the experience of hypercapnia and hunger for air

Recent neuroimaging and neurological data implicate cerebellum in nonmotor sensory, cognitive, vegetative, and affective functions. The present study assessed cerebellar responses when the urge to breathe is stimulated by inhaled CO(2). Ventilation changes follow arterial blood partial pressure CO(2) changes sensed by the medullary ventral respiratory group (VRG) and hypothalamus, entraining changes in midbrain, pons, thalamus, limbic, paralimbic, and insular regions. Nearly all these areas are known to connect anatomically with the cerebellum. Using positron emission tomography, we measured regional brain blood flow during acute CO(2)-induced breathlessness in humans. Separable physiological and subjective effects (air hunger) were assessed by comparisons with various respiratory control conditions. The conjoint physiological effects of hypercapnia and the consequent air hunger produced strong bilateral, near-midline activations of the cerebellum in anterior quadrangular, central, and lingula lobules, and in many areas of posterior quadrangular, tonsil, biventer, declive, and inferior semilunar lobules. The primal emotion of air hunger, dissociated from hypercapnia, activated midline regions of the central lobule. The distributed activity across the cerebellum is similar to that for thirst, hunger, and their satiation. Four possible interpretations of cerebellar function(s) here are that: it subserves implicit intentions to access air; it provides predictive internal models about the consequences of CO(2) inhalation; it modulates emotional responses; and that while some cerebellar regions monitor sensory acquisition in the VRG (CO(2) concentration), others influence VRG to adjust respiratory rate to optimize partial pressure CO(2), and others still monitor and optimize the acquisition of other sensory data in service of air hunger aroused vigilance.

Neuroimaging of cerebral activations and deactivations associated with hypercapnia and hunger for air

There are defined medullary, mesencephalic, hypothalamic, and thalamic functions in regulation of respiration, but knowledge of cortical control and the elements subserving the consciousness of breathlessness and air hunger is limited. In nine young adults, air hunger was produced acutely by CO(2) inhalation. Comparisons were made with inhalation of a N(2)/O(2) gas mixture with the same apparatus, and also with paced breathing, and with eyes closed rest. A network of activations in pons, midbrain (mesencephalic tegmentum, parabrachial nucleus, and periaqueductal gray), hypothalamus, limbic and paralimbic areas (amygdala and periamygdalar region) cingulate, parahippocampal and fusiform gyrus, and anterior insula were seen along with caudate nuclei and pulvinar activations. Strong deactivations were seen in dorsal cingulate, posterior cingulate, and prefrontal cortex. The striking response of limbic and paralimbic regions points to these structures having a singular role in the affective sequelae entrained by disturbance of basic respiratory control whereby a process of which we are normally unaware becomes a salient element of consciousness. These activations and deactivations include phylogenetically ancient areas of allocortex and transitional cortex that together with the amygdalar/periamygdalar region may subserve functions of emotional representation and regulation of breathing.

Brain responses associated with consciousness of breathlessness (air hunger)

Little is known about the physiological mechanisms subserving the experience of air hunger and the affective control of breathing in humans. Acute hunger for air after inhalation of CO(2) was studied in nine healthy volunteers with positron emission tomography. Subjective breathlessness was manipulated while end-tidal CO(2-) was held constant. Subjects experienced a significantly greater sense of air hunger breathing through a face mask than through a mouthpiece. The statistical contrast between the two conditions delineated a distributed network of primarily limbic/paralimbic brain regions, including multiple foci in dorsal anterior and middle cingulate gyrus, insula/claustrum, amygdala/periamygdala, lingual and middle temporal gyrus, hypothalamus, pulvinar, and midbrain. This pattern of activations was confirmed by a correlational analysis with breathlessness ratings. The commonality of regions of mesencephalon, diencephalon and limbic/paralimbic areas involved in primal emotions engendered by the basic vegetative systems including hunger for air, thirst, hunger, pain, micturition, and sleep, is discussed with particular reference to the cingulate gyrus. A theory that the phylogenetic origin of consciousness came from primal emotions engendered by immediate threat to the existence of the organism is discussed along with an alternative hypothesis by Edelman that primary awareness emerged with processes of ongoing perceptual categorization giving rise to a scene [Edelman, G. M. (1992) Bright Air, Brilliant Fire (Penguin, London)].

Neuroimaging evidence implicating cerebellum in support of sensory/cognitive processes associated with thirst

Recent studies implicate the cerebellum, long considered strictly a motor control structure, in cognitive, sensory, and affective phenomenon. The cerebellum, a phylogenetically ancient structure, has reciprocal ancient connections to the hypothalamus, a structure important in vegetative functions. The present study investigated whether the cerebellum was involved in vegetative functions and the primal emotions engendered by them. Using positron emission tomography, we examined the effects on the cerebellum of the rise of plasma sodium concentration and the emergence of thirst in 10 healthy adults. The correlation of regional cerebral blood flow with subjects' ratings of thirst showed major activation in the vermal central lobule. During the development of thirst, the anterior and posterior quadrangular lobule, lingula, and the vermis were activated. At maximum thirst and then during irrigation of the mouth with water to alleviate dryness, the cerebellum was less activated. However, 3 min after drinking to satiation, the anterior quadrangular lobule and posterior cerebellum were highly activated. The increased cerebellar activity was not related to motor behavior as this did not occur. Instead, responses in ancient cerebellar regions (vermis, fastigal nucleus, archicerebellum) may be more directly related to vegetative and affective aspects of thirst experiences, whereas activity in neocerebellar (posterior) regions may be related to sensory and cognitive aspects. Moreover, the cerebellum is apparently not involved in the computation of thirst per se but rather is activated during changes in thirst/satiation state when the brain is "vigilant" and is monitoring its sensory systems. Some neocerebellar activity may also reflect an intentionality for gratification by drinking inherent in the consciousness of thirst.

Neuroimaging of genesis and satiation of thirst and an interoceptor-driven theory of origins of primary consciousness

There are defined hypothalamic functions in the genesis of thirst, but little is known of the cortical processes subserving consciousness of thirst notwithstanding the medical disorders that occur in psychiatric illness, addiction, and the attested decline of thirst with aging. In 10 adult males, positron emission tomography scans were made (i) during genesis of moderate thirst by infusion of i.v. hypertonic saline 0.51 M, (ii) after irrigation of the mouth with water to remove the sensation of dryness, and (iii) 3, 14, 45, and 60 minutes after drinking water to fully satiate thirst. The correlation of regional cerebral blood flow with thirst score showed the major activation to be in the posterior cingulate. Maximum thirst sensation evoked 13 highly significant activations and 9 deactivations in cingulate and parahippocampal gyri, insula, thalamus, amygdala, and mesencephalon. It is possible that cingulate sites (Brodmann's areas 32, 24, and 31) that persisted with wet mouth but disappeared immediately after drinking to satiation may have an important role in the consciousness of thirst. Consciousness of thirst, a primal vegetative emotion, and satiation of thirst appear to be subserved by phylogenetically ancient brain regions. This is salient to current discussion on evolutionary emergence of primary consciousness.

Correlation of regional cerebral blood flow and change of plasma sodium concentration during genesis and satiation of thirst

Positron emission tomography studies were conducted during genesis of moderate thirst by rapid i.v. infusion of hypertonic saline (0.51 M) and after satiation of thirst by drinking water. The correlation of regional cerebral blood flow with the change in the plasma Na concentration showed a significant group of cerebral activations in the anterior cingulate region and also a site in the middle temporal gyrus and in the periaqueductal gray. Strongest deactivations occurred in the parahippocampal and frontal gyri. The data are consistent with an important role of the anterior cingulate in the genesis of thirst.

Characterization of dynamic 3-D PET imaging for functional brain mapping

Methods for optimizing the acquisition, reconstruction and analysis of positron emission tomography (PET) images for functional brain mapping have been investigated. The scatter fraction and noise-equivalent count rate characteristics were measured for the ECAT 951/31R PET scanner operating in septa-extended two-dimensional (2-D) and septa-retracted three-dimensional (3-D) modes. The 3-D mode is shown to provide higher signal-to-noise images than the 2-D mode at specific activities less than 30 kBq/ml. To enable increased temporal resolution in dynamic 3-D PET activation studies, a parallel version of the 3-D reconstruction algorithm was developed. Implementation of the reprojection algorithm on an 88 processor 1860 supercomputer resulted in a more than tenfold increase in reconstruction speed compared to a single 1860 processor system. An investigation of the optimal duration for imaging brain activations was undertaken in 12 normal subjects using repeated H2(15)O slow infusions and a visually presented lexical decision task. The significance of change in regional cerebral blood flow (CBF) was determined using statistical parametric maps for images acquired during stimulation, immediately after stimulation, and commencing 1 min after cessation of the stimulus. Regions of CBF change were detected in all three images. Dynamic 3-D, or four-dimensional (4-D), PET activation scanning is shown to be practical and likely to further improve the sensitivity of PET for detection of subtle regional CBF changes in functional brain mapping research.

Dose distribution following selective internal radiation therapy

Selective Internal Radiation Therapy is the intrahepatic arterial injection of microspheres labelled with 90Y. The microspheres lodge in the precapillary circulation of tumor resulting in internal radiation therapy. The activity of the 90Y injected is managed by successive administrations of labelled microspheres and after each injection probing the liver with a calibrated beta probe to assess the dose to the superficial layers of normal tissue. Predicted doses of 75 Gy have been delivered without subsequent evidence of radiation damage to normal cells. This contrasts with the complications resulting from doses in excess of 30 Gy delivered from external beam radiotherapy. Detailed analysis of microsphere distribution in a cubic centimeter of normal liver and the calculation of dose to a 3-dimensional fine grid has shown that the radiation distribution created by the finite size and distribution of the microspheres results in an highly heterogeneous dose pattern. It has been shown that a third of normal liver will receive less than 33.7% of the dose predicted by assuming an homogeneous distribution of 90Y.

Increased H-2Dd expression following infection by a molecularly cloned ecotropic MuLV

The biological consequences of radiation leukemia virus (RadLV) infection include the stimulation of H-2Dd antigen expression in resistant mouse strains and thymoma induction in susceptible strains. In an effort to understand the genetic basis of these phenomena, the integrated ecotropic RadLV genome has been examined in a number of primary RadLV-induced tumors, as well as thymomas adapted to in vitro passage; considerable heterogeneity was observed. Examination of these polymorphic viral sequences should help define the viral gene(s) involved in the biological effects of RadLV infection; toward this end, integrated RadLV genomes were molecularly cloned and examined. The genomes and their flanking sequence were characterized by restriction enzyme analysis. Three unique viral genomes were obtained which represent four integration sites. The three RadLV genomes are shown to carry polymorphisms of the original tumor. Following DNA transfection, one of the three genomes replicated in and reinfected both mouse thymocytes and fibroblasts, but not mink fibroblasts in vitro. Virus encoded by the other two DNA genomes could not be recovered following transfection into any of the three cell types. One of these two apparently defective retroviruses encodes a truncated p15E molecule, while the other has elongated long terminal repeats (LTRs). The non-defective ecotropic isolate was collected from in vitro tissue culture supernatants, concentrated, and used to infect mice. Thymocytes of infected, resistant mice were shown to express elevated levels of H-2Dd antigen as early as 12 days post infection, a hallmark of RadLV infection.

Extension of the H-2 TLb molecular map. Isolation and characterization of T13, T14, and T15 from the C57BL/6 mouse

A region of the TLb locus encompassing T11 to T13 contains retroviral sequences TLev1 and TLev2. As part of a study to determine whether the retroviral elements are involved in the expression of TL genes, the genomic organization of this region was reexamined in greater detail. A result of these investigations is the extension of the H-2 TLb molecular map. Two additional TL genes have been isolated from C57BL/6 mice, T14 and T15. The genomic organization of T9 through T15 is presented. The nucleotide sequence has been determined for exons 4, 5, and 6 of T13. As a result of a C to T conversion, a termination codon is introduced into exon 4, indicating that T13 either encodes a secreted protein or is a pseudogene. T13 was found to be more homologous to the H-2 genes outside the TL region. T14 has been physically disrupted by the integration of TLev1, and the H-2 sequences appear to have diverged greatly. The relationship of the TL regions of the b and c haplotypes has been investigated using numerous low copy probes. The genome of BALB/c (TLc) is shown to lack a counterpart of the T13-T15b region. Homologous regions exist in the two haplotypes; yet considerable polymorphism is observed. TLb mice do not express TLa on the cell surface of normal thymocytes while TLc mice do; TLa expression is activated in many TLb leukemias. The diversity seen in the T13-T15 region may provide insights into the phenotypic expression or regulatory mechanisms of TL expression in these two haplotypes.

Covert cross reactants in a two-site immunoassay studied with monoclonal antibodies

A one-step two-site immunoradiometric assay for the measurement of free beta subunit of human chorionic gonadotrophin (beta-hCG) was developed using monoclonal antibodies. The immobilized antibody was specific for free beta subunit and the radiolabeled antibody recognized both intact human chorionic gonadotrophin (hCG) and free beta subunit. Although the level of hCG "cross-reaction" was low when studied using conventional techniques, the apparent beta-hCG content of samples was found to be inversely proportional to the hCG level. From both experimental evidence and computer simulation studies this was found to be due to the binding of hCG to the limited amount of 125I-labeled antibody present. The term covert cross reactants has been introduced to describe substances which bind to only one of the antibodies in a two-site immunoassay. When establishing such an assay the effect of covert cross reactants on the response of an analyte should be investigated.

The evaluation of imprecision in collaborative immunoassay quality-assessment programmes

The calculation of within-laboratory imprecision in quality-assessment (QA) programmes normally involves combining data from different analyte concentrations to calculate an average standard deviation (SD) or coefficient of variation. However, for immunoassay neither of these parameters is concentration independent. This paper describes a method of calculating within-laboratory imprecision in QA programmes by assuming a linear relationship between SD and analyte concentration. This method is used in programmes conducted by the Australian Joint Working Party for Quality Control in Immunoassay to calculate imprecision at the limits of the reference range. Results from these programmes show that this method better represents the differences in imprecision between analytes, methods and laboratories than the calculation of a single imprecision parameter. The method is trivial for a computer and its robustness has been validated by Monte Carlo simulation. It is suggested that major differences in laboratory performance between different QA programmes may be due to inappropriate calculation of single imprecision parameters.