Specialist integrated haematological malignancy diagnostic services: an Activity Based Cost (ABC) analysis of a networked laboratory service model.

AIMS: Specialist Integrated Haematological Malignancy Diagnostic Services (SIHMDS) were introduced as a standard of care within the UK National Health Service to reduce diagnostic error and improve clinical outcomes. Two broad models of service delivery have become established: 'co-located' services operating from a single-site and 'networked' services, with geographically separated laboratories linked by common management and information systems. Detailed systematic cost analysis has never been published on any established SIHMDS model. METHODS: We used Activity Based Costing (ABC) to construct a cost model for our regional 'networked' SIHMDS covering a two-million population based on activity in 2011. RESULTS: Overall estimated annual running costs were £1 056 260 per annum (£733 400 excluding consultant costs), with individual running costs for diagnosis, staging, disease monitoring and end of treatment assessment components of £723 138, £55 302, £184 152 and £94 134 per annum, respectively. The cost distribution by department was 28.5% for haematology, 29.5% for histopathology and 42% for genetics laboratories. Costs of the diagnostic pathways varied considerably; pathways for myelodysplastic syndromes and lymphoma were the most expensive and the pathways for essential thrombocythaemia and polycythaemia vera being the least. CONCLUSIONS: ABC analysis enables estimation of running costs of a SIHMDS model comprised of 'networked' laboratories. Similar cost analyses for other SIHMDS models covering varying populations are warranted to optimise quality and cost-effectiveness in delivery of modern haemato-oncology diagnostic services in the UK as well as internationally.

Spatiotemporal independent component analysis of event-related fMRI data using skewed probability density functions.

We introduce two independent component analysis (ICA) methods, spatiotemporal ICA (stICA) and skew-ICA, and demonstrate the utility of these methods in analyzing synthetic and event-related fMRI data. First, stICA simultaneously maximizes statistical independence over both time and space. This contrasts with conventional ICA methods, which maximize independence either over time only or over space only; these methods often yield physically improbable solutions. Second, skew-ICA is based on the assumption that images have skewed probability density functions (pdfs), an assumption consistent with spatially localized regions of activity. In contrast, conventional ICA is based on the physiologically unrealistic assumption that images have symmetric pdfs. We combine stICA and skew-ICA, to form skew-stICA, and use it to analyze synthetic data and data from an event-related, left-right visual hemifield fMRI experiment. Results obtained with skew-stICA are superior to those of principal component analysis, spatial ICA (sICA), temporal ICA, stICA, and skew-sICA. We argue that skew-stICA works because it is based on physically realistic assumptions and that the potential of ICA can only be realized if such prior knowledge is incorporated into ICA methods.

When is now? Perception of simultaneity.

We address the following question: Is there a difference (D) between the amount of time for auditory and visual stimuli to be perceived? On each of 1000 trials, observers were presented with a light-sound pair, separated by a stimulus onset asynchrony (SOA) between -250 ms (sound first) and +250 ms. Observers indicated if the light-sound pair came on simultaneously by pressing one of two (yes or no) keys. The SOA most likely to yield affirmative responses was defined as the point of subjective simultaneity (PSS). PSS values were between -21 ms (i.e. sound 21 ms before light) and +150 ms. Evidence is presented that each PSS is observer specific. In a second experiment, each observer was tested using two observer-stimulus distances. The resultant PSS values are highly correlated (r = 0.954, p = 0.003), suggesting that each observer's PSS is stable. PSS values were significantly affected by observer-stimulus distance, suggesting that observers do not take account of changes in distance on the resultant difference in arrival times of light and sound. The difference RTd in simple reaction time to single visual and auditory stimuli was also estimated; no evidence that RTd is observer specific or stable was found. The implications of these findings for the perception of multisensory stimuli are discussed.

Bilirubin, ferritin, D-dimers and erythrophages in the cerebrospinal fluid of patients with suspected subarachnoid haemorrhage but negative computed tomography scans.

AIM: To assess the diagnostic value of cerebrospinal fluid (CSF) spectrophotometry, cytology, ferritin, and D-dimer measurements in the investigation of suspected subarachnoid haemorrhage in patients with negative or equivocal computed tomography (CT) scans. METHODS: CSF specimens submitted for assessment of xanthochromia were examined for erythrophages using a cytospin preparation stained with Wright's stain, for ferritin using the Ciba-Corning Magic IRMA assay, D-dimers using the Dimertest 2 latex agglutination slide test, and for bilirubin by scanning spectrophotometry. The patients were divided into three groups for data analysis and the results compared with the existing methods, CT, and angiogram results. Final diagnoses were reviewed by a consultant neurologist. RESULTS: Thirty six patients were recruited. In those patients with confirmed subarachnoid haemorrhage CSF cytology had a low sensitivity and there were false negative results with both the D-dimer and ferritin assays. Eleven patients with a negative or equivocal CT scan underwent angiography, but only one aneurysm and no arterio-venous malformations or bleeding points were identified. In the patient with the aneurysm there was no laboratory evidence of subarachnoid haemorrhage. Six patients had CSF abnormalities detected by the special tests only and in none of these cases was subarachnoid haemorrhage confirmed. All results were normal in four out of five cases of traumatic tap. CONCLUSIONS: This is a small study, but it shows that, depending on the timing of the lumbar puncture, false negative results can occur with both ferritin and D-dimer measurements. It suggests that neither of these tests adds significantly to the information provided by CT, visualisation of CSF, and spectrophotometry and confirms that, despite the use of spectrophotometry, D-dimer and ferritin assays in selecting patients for angiography, the proportion of patients with negative CT scans and colourless CSF with demonstrable vascular lesions remains low.

The effect of beta-adrenoceptor antagonists on the pharmacokinetics and pharmacodynamics of warfarin after a single dose.

The effects of three beta-adrenoceptor antagonists (propranolol, metoprolol and atenolol) on the serum kinetics and pharmacodynamics of warfarin given in a single oral dose (15 mg) were studied in six normal subjects. At the same degree of beta-adrenoceptor blockade, as assessed by the decrease of exercise tachycardia, propranolol increased the area under the serum warfarin concentration time curve (AUC) by 16.3 +/- 14.2 s.d.% (P less than 0.01) and the maximum serum warfarin concentration by 23.0 +/- 14.3 s.d.% (P less than 0.001). Atenolol increased the maximum serum warfarin concentration by 12.5 +/- 12.3% s.d. (P less than 0.05) but was without effect on warfarin AUC. Metoprolol had no effect on warfarin kinetics. The extent of changes in the prothrombin time and the plasma clotting Factor VII activity caused by warfarin were not altered by any of the beta-adrenoceptor antagonists.

Elevated beta-thromboglobulin levels and circulating platelet aggregates in diabetic microangiopathy.

beta-Thromboglobulin levels and platelet-aggregate ratios were determined in blood-samples from healthy control subjects and from diabetic patients with and without microangiopathic complications. Patients with diabetic microangiopathy had significantly elevated beta-thromboglobulin levels and also reversible platelet aggregates. In nine newly treated diabetics blood-glucose control was associated with a significant fall in plasma beta-thromboglobulin. Since beta-thromboglobulin is a platelet-specific protein the results indicate that diabetic microangiopathy is associated with evidence of platelet activation and that this may be influenced by the degree of biochemical control.

Platelet abnormalities in diabetic peripheral neuropathy.

Abnormal platelet function has been demonstrated in 20 patients with diabetic peripheral neuropathy. The results are compared to those obtained from 19 matched diabetic patients with no clinical evidence of complications and 20 matched normal control subjects. Platelets from patients with diabetic neuropathy showed an increased sensitivity to the aggregating agents adenosine diphosphate and adrenaline. Spontaneous platelet aggregation was demonstrated in both groups of diabetic patients.