Optimization of OSEM parameters in myocardial perfusion imaging reconstruction as a function of body mass index: a clinical approach

AbstractObjective:The present study is aimed at contributing to identify the most appropriate OSEM parameters to generate myocardial perfusion imaging reconstructions with the best diagnostic quality, correlating them with patients' body mass index.Materials and Methods:The present study included 28 adult patients submitted to myocardial perfusion imaging in a public hospital. The OSEM method was utilized in the images reconstruction with six different combinations of iterations and subsets numbers. The images were analyzed by nuclear cardiology specialists taking their diagnostic value into consideration and indicating the most appropriate images in terms of diagnostic quality.Results:An overall scoring analysis demonstrated that the combination of four iterations and four subsets has generated the most appropriate images in terms of diagnostic quality for all the classes of body mass index; however, the role played by the combination of six iterations and four subsets is highlighted in relation to the higher body mass index classes.Conclusion:The use of optimized parameters seems to play a relevant role in the generation of images with better diagnostic quality, ensuring the diagnosis and consequential appropriate and effective treatment for the patient.

Color ad spectral image assessment using novel quality and fidelity techniques

The ongoing development of the digital media has brought a new set of challenges with it. As images containing more than three wavelength bands, often called spectral images, are becoming a more integral part of everyday life, problems in the quality of the RGB reproduction from the spectral images have turned into an important area of research. The notion of image quality is often thought to comprise two distinctive areas – image quality itself and image fidelity, both dealing with similar questions, image quality being the degree of excellence of the image, and image fidelity the measure of the match of the image under study to the original. In this thesis, both image fidelity and image quality are considered, with an emphasis on the influence of color and spectral image features on both. There are very few works dedicated to the quality and fidelity of spectral images. Several novel image fidelity measures were developed in this study, which include kernel similarity measures and 3D-SSIM (structural similarity index). The kernel measures incorporate the polynomial, Gaussian radial basis function (RBF) and sigmoid kernels. The 3D-SSIM is an extension of a traditional gray-scale SSIM measure developed to incorporate spectral data. The novel image quality model presented in this study is based on the assumption that the statistical parameters of the spectra of an image influence the overall appearance. The spectral image quality model comprises three parameters of quality: colorfulness, vividness and naturalness. The quality prediction is done by modeling the preference function expressed in JNDs (just noticeable difference). Both image fidelity measures and the image quality model have proven to be effective in the respective experiments.

Survival and Quality of Life among Patients with Severe Lower Extremity Peripheral Arterial Disease

Lower extremity peripheral arterial disease (PAD) is associated with decreased functional status, diminished quality of life (QoL), amputation, myocardial infarction, stroke, and death. Nevertheless, public awareness of PAD as a morbid and mortal disease is low. The aim of this study was to assess the incidence of major lower extremity amputation due to PAD, the extent of reamputations, and survival after major lower extremity amputation (LEA) in a population based PAD patient cohort. Furthermore, the aim was to assess the functional capacity in patients with LEA, and the QoL after lower extremity revascularization and major amputation. All 210 amputees due to PAD in 1998–2002 and all 519 revascularized patients in 1998–2003 were explored. 59 amputees alive in 2004 were interviewed using a structured questionnaire of QoL. Two of each amputee age-, gender- and domicile-matched controls filled in and returned postal self-administered QoL questionnaire as well as 231 revascularized PAD patients (the amount of these patients who engaged themselves to the study), and one control person for each patient completed postal self-administered QoL questionnaire. The incidence rate of major LEA was 24.1/100 000 person-years and it was considerably high during the years studied. The one-month mortality rate was 21%, 52% at one-year, and the overall mortality rate was 80%. When comparing the one-year mortality risk of amputees, LEAs were associated with a 7.4-fold annual mortality risk compared with the reference population in Turku. Twenty-two patients (10%) had ipsilateral transversions from BK to AK amputation. Fifty patients (24%) ended up with a contralateral major LEA within two to four amputation operations. Three bilateral amputations were performed at the first major LEA operation. Of the 51 survivors returning home after their first major LEA, 36 (71%) received a prosthesis; (16/36, 44%) and were able to walk both in- and outdoors. Of the 68 patients who were discharged to institutional care, three (4%) had a prosthesis one year after LEA. Both amputees and revascularized patients had poor physical functioning and significantly more depressive symptoms than their controls. Depressive symptoms were more common in the institutionalized amputees than the home-dwelling amputees. The surviving amputees and their controls had similar life satisfaction. The amputees felt themselves satisfied and contented, whether or not they lived in long-term care or at home. PAD patients who had undergone revascularizations had poorer QoL than their controls. The revascularized patients’ responses on their perceived physical functioning gave an impression that these patients are in a declining life cycle and that revascularizations, even when successful, may not be sufficient to improve the overall function. It is possible that addressing rehabilitation issues earlier in the care may produce a more positive functional outcome. Depressive symptoms should be recognized and thoroughly considered at the same time the patients are recovering from their revascularization operation. Also primary care should develop proper follow-up, and community organizations should have exercise groups for those who are able to return home, since they very often live alone. In rehabilitation programs we should consider not only physical disability assessment but also QoL.

Towards increased productivity and quality in software development using agile, lean and collaborative approaches

Dagens programvaruindustri står inför alltmer komplicerade utmaningar i en värld där programvara är nästan allstädes närvarande i våra dagliga liv. Konsumenten vill ha produkter som är pålitliga, innovativa och rika i funktionalitet, men samtidigt också förmånliga. Utmaningen för oss inom IT-industrin är att skapa mer komplexa, innovativa lösningar till en lägre kostnad. Detta är en av orsakerna till att processförbättring som forskningsområde inte har minskat i betydelse. IT-proffs ställer sig frågan: “Hur håller vi våra löften till våra kunder, samtidigt som vi minimerar vår risk och ökar vår kvalitet och produktivitet?” Inom processförbättringsområdet finns det olika tillvägagångssätt. Traditionella processförbättringsmetoder för programvara som CMMI och SPICE fokuserar på kvalitets- och riskaspekten hos förbättringsprocessen. Mer lättviktiga metoder som t.ex. lättrörliga metoder (agile methods) och Lean-metoder fokuserar på att hålla löften och förbättra produktiviteten genom att minimera slöseri inom utvecklingsprocessen. Forskningen som presenteras i denna avhandling utfördes med ett specifikt mål framför ögonen: att förbättra kostnadseffektiviteten i arbetsmetoderna utan att kompromissa med kvaliteten. Den utmaningen attackerades från tre olika vinklar. För det första förbättras arbetsmetoderna genom att man introducerar lättrörliga metoder. För det andra bibehålls kvaliteten genom att man använder mätmetoder på produktnivå. För det tredje förbättras kunskapsspridningen inom stora företag genom metoder som sätter samarbete i centrum. Rörelsen bakom lättrörliga arbetsmetoder växte fram under 90-talet som en reaktion på de orealistiska krav som den tidigare förhärskande vattenfallsmetoden ställde på IT-branschen. Programutveckling är en kreativ process och skiljer sig från annan industri i det att den största delen av det dagliga arbetet går ut på att skapa något nytt som inte har funnits tidigare. Varje programutvecklare måste vara expert på sitt område och använder en stor del av sin arbetsdag till att skapa lösningar på problem som hon aldrig tidigare har löst. Trots att detta har varit ett välkänt faktum redan i många decennier, styrs ändå många programvaruprojekt som om de vore produktionslinjer i fabriker. Ett av målen för rörelsen bakom lättrörliga metoder är att lyfta fram just denna diskrepans mellan programutvecklingens innersta natur och sättet på vilket programvaruprojekt styrs. Lättrörliga arbetsmetoder har visat sig fungera väl i de sammanhang de skapades för, dvs. små, samlokaliserade team som jobbar i nära samarbete med en engagerad kund. I andra sammanhang, och speciellt i stora, geografiskt utspridda företag, är det mera utmanande att införa lättrörliga metoder. Vi har nalkats utmaningen genom att införa lättrörliga metoder med hjälp av pilotprojekt. Detta har två klara fördelar. För det första kan man inkrementellt samla kunskap om metoderna och deras samverkan med sammanhanget i fråga. På så sätt kan man lättare utveckla och anpassa metoderna till de specifika krav som sammanhanget ställer. För det andra kan man lättare överbrygga motstånd mot förändring genom att introducera kulturella förändringar varsamt och genom att målgruppen får direkt förstahandskontakt med de nya metoderna. Relevanta mätmetoder för produkter kan hjälpa programvaruutvecklingsteam att förbättra sina arbetsmetoder. När det gäller team som jobbar med lättrörliga och Lean-metoder kan en bra uppsättning mätmetoder vara avgörande för beslutsfattandet när man prioriterar listan över uppgifter som ska göras. Vårt fokus har legat på att stöda lättrörliga och Lean-team med interna produktmätmetoder för beslutsstöd gällande så kallad omfaktorering, dvs. kontinuerlig kvalitetsförbättring av programmets kod och design. Det kan vara svårt att ta ett beslut att omfaktorera, speciellt för lättrörliga och Lean-team, eftersom de förväntas kunna rättfärdiga sina prioriteter i termer av affärsvärde. Vi föreslår ett sätt att mäta designkvaliteten hos system som har utvecklats med hjälp av det så kallade modelldrivna paradigmet. Vi konstruerar även ett sätt att integrera denna mätmetod i lättrörliga och Lean-arbetsmetoder. En viktig del av alla processförbättringsinitiativ är att sprida kunskap om den nya programvaruprocessen. Detta gäller oavsett hurdan process man försöker introducera – vare sig processen är plandriven eller lättrörlig. Vi föreslår att metoder som baserar sig på samarbete när processen skapas och vidareutvecklas är ett bra sätt att stöda kunskapsspridning på. Vi ger en översikt över författarverktyg för processer på marknaden med det förslaget i åtanke.

Comparison of two questionnaires which measure the health-related quality of life of idiopathic pulmonary fibrosis patients

The objective of the present study was to determine if there is a health-related quality of life (HRQL) instrument, generic or specific, that better represents functional capacity dysfunction in idiopathic pulmonary fibrosis (IPF) patients. HRQL was evaluated in 20 IPF patients using generic and specific questionnaires (Medical Outcomes Short Form 36 (SF-36) and Saint George's Respiratory Questionnaire (SGRQ), respectively). Functional status was evaluated by pulmonary function tests, 6-min walking distance test (6MWDT) and dyspnea indexes (baseline dyspnea index) at rest and after exercise (modified Borg scale). There was a restrictive pattern with impairment of diffusion capacity (total lung capacity, TLC = 71.5 ± 15.6%, forced vital capacity = 70.4 ± 19.4%, and carbon monoxide diffusing capacity = 41.5 ± 16.2% of predicted value), a reduction in exercise capacity (6MWDT = 435.6 ± 95.5 m) and an increase of perceived dyspnea score at rest and during exercise (6 ± 2.5 and 7.1 ± 1.3, respectively). Both questionnaires presented correlation with some functional parameters (TLC, forced expiratory volume in 1 s and carbon monoxide diffusing capacity) and the best correlation was with TLC. Almost all of the SGRQ domains presented a strong correlation with functional status, while in SF-36 only physical function and vitality presented a good correlation with functional status. Dyspnea index at rest and 6MWDT also presented a good correlation with HRQL. Our results suggest that a specific instead of a generic questionnaire is a more appropriate instrument for HRQL evaluation in IPF patients and that TLC is the functional parameter showing best correlation with HRQL.

Effect of melatonin administration on subjective sleep quality in chronic obstructive pulmonary disease

Disturbed sleep is common in chronic obstructive pulmonary disease (COPD). Conventional hypnotics worsen nocturnal hypoxemia and, in severe cases, can lead to respiratory failure. Exogenous melatonin has somnogenic properties in normal subjects and can improve sleep in several clinical conditions. This randomized, double-blind, placebo-controlled study was carried out to determine the effects of melatonin on sleep in COPD. Thirty consecutive patients with moderate to very severe COPD were initially recruited for the study. None of the participants had a history of disease exacerbation 4 weeks prior to the study, obstructive sleep apnea, mental disorders, current use of oral steroids, methylxanthines or hypnotic-sedative medication, nocturnal oxygen therapy, and shift work. Patients received 3 mg melatonin (N = 12) or placebo (N = 13), orally in a single dose, 1 h before bedtime for 21 consecutive days. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness was measured by the Epworth Sleepiness Scale. Pulmonary function and functional exercise level were assessed by spirometry and the 6-min walk test, respectively. Twenty-five patients completed the study protocol and were included in the final analysis. Melatonin treatment significantly improved global PSQI scores (P = 0.012), particularly sleep latency (P = 0.008) and sleep duration (P = 0.046). No differences in daytime sleepiness, lung function and functional exercise level were observed. We conclude that melatonin can improve sleep in COPD. Further long-term studies involving larger number of patients are needed before melatonin can be safely recommended for the management of sleep disturbances in these patients.

Monitoring renal function: measured and estimated glomerular filtration rates - a review

Chronic kidney disease (CKD) is a world-wide public health problem, with adverse outcomes of kidney failure, cardiovascular disease, and premature death. This finding has led to the hypothesis that earlier recognition of kidney disease and successful intervention may improve outcome. The National Kidney Foundation, through its Kidney Disease Outcomes Quality Initiative (K/DOQI), and other National institutions recommend glomerular filtration rate (GFR) for the definition, classification, screening, and monitoring of CKD. Blood creatinine clearance, the most widely used clinical marker of kidney function, is now recognized as an unreliable measure of GFR because serum creatinine is affected by age, weight, muscle mass, race, various medications, and extra-glomerular elimination. Cystatin C concentration is a new and promising marker for kidney dysfunction in both native and transplanted kidneys. Because of its low molecular weight, cystatin C is freely filtered at the glomerulus and is almost completely reabsorbed and catabolized, but not secreted, by tubular cells. Given these characteristics, cystatin C concentration may be superior to creatinine concentration in detecting chronic kidney disease. This review aims to evaluate from recent literature the clinical efficiency and relevance of these GFR markers in terms of screening CKD.

Psoriasis severity and hypothalamic-pituitary-adrenal axis function: results from the CALIPSO study

Psoriasis is a chronic inflammatory disease that significantly impacts life quality, being associated with stress and mental disorders. We investigated whether the activity of the hypothalamic-pituitary-adrenal (HPA) axis was associated with psoriasis severity, daily life stress and anxiety, and depressive symptoms. In this ancillary study, which was part of the CALIPSO (coronary artery calcium in psoriasis) study, saliva was collected from 102 patients with psoriasis immediately upon awakening, 30, and 60 min after awakening, at 2:00 pm and at bedtime (five time points) to determine salivary cortisol levels. We used Pearson's correlation coefficient to evaluate the association of clinical and psychopathological variables with HPA activity. We found a direct correlation between bedtime cortisol and psoriasis severity evaluated by the psoriasis area severity index (PASI; r=0.39, P<0.001). No correlations between other clinical and psychopathological variables or with other cortisol assessments were observed. The findings indicated that HPA dysfunction may be present in psoriasis, as bedtime cortisol was correlated with psoriasis severity. Our study is limited by the lack of a control group; therefore, we were not able to explore whether these cortisol values were different compared with a concurrent, healthy sample.

Negative emotions affect postoperative scores for evaluating functional knee recovery and quality of life after total knee replacement

This study aimed to determine whether psychological factors affect health-related quality of life (HRQL) and recovery of knee function in total knee replacement (TKR) patients. A total of 119 TKR patients (male: 38; female: 81) completed the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), State Trait Anxiety Inventory (STAI), Eysenck Personality Questionnaire-revised (EPQR-S), Knee Society Score (KSS), and HRQL (SF-36). At 1 and 6 months after surgery, anxiety, depression, and KSS scores in TKR patients were significantly better compared with those preoperatively (P<0.05). SF-36 scores at the sixth month after surgery were significantly improved compared with preoperative scores (P<0.001). Preoperative Physical Component Summary Scale (PCS) and Mental Component Summary Scale (MCS) scores were negatively associated with extraversion (E score) (B=-0.986 and -0.967, respectively, both P<0.05). Postoperative PCS and State Anxiety Inventory (SAI) scores were negatively associated with neuroticism (N score; B=-0.137 and -0.991, respectively, both P<0.05). Postoperative MCS, SAI, Trait Anxiety Inventory (TAI), and BAI scores were also negatively associated with the N score (B=-0.367, -0.107, -0.281, and -0.851, respectively, all P<0.05). The KSS function score at the sixth month after surgery was negatively associated with TAI and N scores (B=-0.315 and -0.532, respectively, both P<0.05), but positively associated with the E score (B=0.215, P<0.05). The postoperative KSS joint score was positively associated with postoperative PCS (B=0.356, P<0.05). In conclusion, for TKR patients, the scores used for evaluating recovery of knee function and HRQL after 6 months are inversely associated with the presence of negative emotions.

Asleep or not asleep? Evaluation of the Quality of Patients’ Sleep in Critical Care Nursing

Sleep is important for the recovery of a critically ill patient, as lack of sleep is known to influence negatively a person’s cardiovascular system, mood, orientation, and metabolic and immune function and thus, it may prolong patients’ intensive care unit (ICU) and hospital stay. Intubated and mechanically ventilated patients suffer from fragmented and light sleep. However, it is not known well how non-intubated patients sleep. The evaluation of the patients’ sleep may be compromised by their fatigue and still position with no indication if they are asleep or not. The purpose of this study was to evaluate ICU patients’ sleep evaluation methods, the quality of non-intubated patients’ sleep, and the sleep evaluations performed by ICU nurses. The aims were to develop recommendations of patients’ sleep evaluation for ICU nurses and to provide a description of the quality of non-intubated patients’ sleep. The literature review of ICU patients’ sleep evaluation methods was extended to the end of 2014. The evaluation of the quality of patients’ sleep was conducted with four data: A) the nurses’ narrative documentations of the quality of patients’ sleep (n=114), B) the nurses’ sleep evaluations (n=21) with a structured observation instrument C) the patients’ self-evaluations (n=114) with the Richards-Campbell Sleep Questionnaire, and D) polysomnographic evaluations of the quality of patients’ sleep (n=21). The correspondence of data A with data C (collected 4–8/2011), and data B with data D (collected 5–8/2009) were analysed. Content analysis was used for the nurses’ documentations and statistical analyses for all the other data. The quality of non-intubated patients’ sleep varied between individuals. In many patients, sleep was light, awakenings were frequent, and the amount of sleep was insufficient as compared to sleep in healthy people. However, some patients were able to sleep well. The patients evaluated the quality of their sleep on average neither high nor low. Sleep depth was evaluated to be the worst and the speed of falling asleep the best aspect of sleep, on a scale 0 (poor sleep) to 100 (good sleep). Nursing care was mostly performed while the patients were awake, and thus the disturbing effect was low. The instruments available for nurses to evaluate the quality of patients’ sleep were limited and measured mainly the quantity of sleep. Nurses’ structured observatory evaluations of the quality of patients’ sleep were correct for approximately two thirds of the cases, and only regarding total sleep time. Nurses’ narrative documentations of the patients’ sleep corresponded with patients’ self-evaluations in just over half of the cases. However, nurses documented several dimensions of sleep that are not included in the present sleep evaluation instruments. They could be classified according to the components of the nursing process: needs assessment, sleep assessment, intervention, and effect of intervention. Valid, more comprehensive sleep evaluation methods for nurses are needed to evaluate, document, improve and study patients’ quality of sleep.

Physiological quality of wheat seeds submitted to saline stress

The objective of this experiment was to determine the influence of different salt levels (zero, 15, 30, 45 and 60mM NaCl) on seed physiological quality of two wheat cultivars (BRS 177 and BRS 179). SUMMARIZE METHODOLOGY. The results allow the following conclusions: the physiological quality (germination and vigor) of wheat seeds, cultivars BRS 179 and BRS 177, decrease with the increase of the salinity. The wheat seeds cv. BRS 179 performs better than BRS 177, mainly in higher salt concentrations (³ 45mM of NaCl). The electric conductivity of wheat seeds increases in function of the increment of the saline concentrations.

Incidence of green soybean seeds as a function of environmental stresses during seed maturation

Hot and dry weather conditions during soybean [Glycine max (L.) Merrill] seed maturation can cause forced maturation of the seed, resulting in the production of high levels of green seed, which may be detrimental to seed germination. These stressful conditions were imposed on soybean plants during seed maturation to investigate the production of green seeds and seed quality. Plants of the CD 206 cultivar were grown in a greenhouse until the R5.5 growing stage and then transferred to phytotrons at R6 and R7.2 for stress induction. Plants were subjected to two temperature regimes, high (28ºC to 36ºC) and normal (19ºC to 26ºC), and four soil water availability conditions, control (adequate water supply), 30% gravimetric moisture (GM), 20% GM and no water supply. Seed were harvested at R9. Green seed percentages and 100-seed weights from the lower, middle and upper thirds of each plant were determined. Seed quality was assessed by germination, tetrazolium (viability and vigor) and electrical conductivity tests. Occurrence of green seed varied from 9% to 86%, depending on the severity of the stresses imposed. High temperature, coupled with no water supply at R6, resulted in a pronounced occurrence of green seeds. There was no difference in the percentage of green seeds among the plant segments. Seed quality was negatively affected by the incidence of green seeds. A procedure for screening soybean genotypes in a phytotron for their tolerance and/or susceptibility to the production of green seeds was developed.

I Believe in me, not OCB: Evaluation of Group Function-Based CBT as a Treatment for Obsessive Compulsive Behaviour in Four Children with HFA

Researchers have conceptualized repetitive behaviours in individuals with Autism Spectrum Disorder (ASD) on a continuum oflower-Ievel, motoric, repetitive behaviours and higher-order, repetitive behaviours that include symptoms ofOCD (Hollander, Wang, Braun, & Marsh, 2009). Although obsessional, ritualistic, and stereotyped behaviours are a core feature of ASD, individuals with ASD frequently experience obsessions and compulsions that meet DSM-IV-TR (American Psychiatric Association, 2000) criteria for Obsessive-Compulsive Disorder (OCD). Given the acknowledged difficulty in differentiating between OCD and Autism-related obsessive-compulsive phenomena, the present study uses the term Obsessive Compulsive Behaviour (OCB) to represent both phenomena. This study used a multiple baseline design across behaviours and ABC designs (Cooper, Heron, & Heward, 2007) to investigate if a 9-week Group Function-Based Cognitive Behavioural Therapy (CBT) decreased OCB in four children (ages 7 - 11 years) with High Functioning Autism (HFA). Key treatment components included traditional CBT components (awareness training, cognitive-behavioural skills training, exposure and response prevention) as well as function-based assessment and intervention. Time series data indicated significant decreases in OCBs. Standardized assessments showed decreases in symptom severity, and increases in quality of life for the participants and their families. Issues regarding symptom presentation, assessment, and treatment of a dually diagnosed child are discussed.

Conceptions of Quality and Approaches to Quality Assurance in Ontario’s Universities

Many international, political, and economic influences led to increased demands for development of new quality assurance systems for universities. Like many policies and processes that aim to assure quality, Ontario’s Quality Assurance Framework (QAF) did not define quality. This study sought to explore conceptions of quality and approaches to quality assurance used within Ontario’s universities. A document analysis of the QAF’s rationale and structure suggested that quality was conceived primarily as fitness for purpose, while suggested indicators represented an exceptional conception of quality. Ontario universities perpetuated such confusion by adopting the framework without customizing it to their institutional conceptions of quality. Drawing upon phenomenographic traditions, a qualitative investigation was conducted to better understand various conceptions of quality held by university administrators and to appreciate ways in which they implemented the QAF. Three main approaches to quality assurance were identified: (a) Defending Quality, characterized by conceptions of quality as exceptional, which focuses on administrative accountability and uses a hands-off strategy to defend traditional notions of quality inputs and resources; (b) Demonstrating Quality, characterized by conceptions of quality as fitness for purpose and value for money, which focuses on accountability to students and uses centralized engaged strategies to demonstrate how programs meet current priorities and intended outcomes; and (c) Enhancing Quality, characterized by conceptions of quality as transformation, which focuses on reflection and learning experience and uses engaged strategies to find new ways of improving learning and teaching. The development of a campus culture that values the institution’s function in student learning and quality teaching would benefit from Enhancing Quality approaches to quality assurance. This would require holistic consideration of the beliefs held by members of the institution, a clear articulation of the institution’s conceptions of quality, and a critical analysis of how these conceptions align with institutional practices and policies.

The FCLT with Dependent Errors: an Helicopter Tour of the Quality of the Approximation

This note investigates the adequacy of the finite-sample approximation provided by the Functional Central Limit Theorem (FCLT) when the errors are allowed to be dependent. We compare the distribution of the scaled partial sums of some data with the distribution of the Wiener process to which it converges. Our setup is purposely very simple in that it considers data generated from an ARMA(1,1) process. Yet, this is sufficient to bring out interesting conclusions about the particular elements which cause the approximations to be inadequate in even quite large sample sizes.