Movement demands and match performance in professional Australian football.

This study examined the relationship between coaches' perception of match performance and movement demands in Australian Football. Movement demands were collected from 21 professional players over 12 matches during one Australian Football League season, with 69 player files collected. Additionally, match events relative to playing time and distance covered, along with player physical characteristics were collected. Based on coaches subjective rating of match performance (out of 20), relatively high calibre (HC) players (≥ 15/20) were compared with relatively low calibre (LC) players (≤ 9/20) for all variables. The HC players were older (+17%, p=0.011), spent a greater percentage of time performing low-speed running (+2%, p=0.039), had more kicks (38%, p=0.001) and disposals (35%, p=0.001) per min and covered less distance per kick (- 50%, p=0.001) and disposal (- 44%, p=0.001) than the LC group, with the effect sizes also supporting this trend. Further, HC players covered less distance (- 14%, p=0.037), spent less percentage of time (- 17%, p=0.037) and performed fewer (- 9%, p=0.026) efforts per min high-speed running than LC players, which was further confirmed by the effect sizes. Movement demands and match events are related to coaches' perception of match performance in professional Australian Football. Further, high levels of involvement with the football appeared to be more important to performance than high exercise speed.

Cost-effectiveness Analysis of the Dental RECUR Pragmatic Randomized Controlled Trial: Evaluating a Goal-oriented Talking Intervention to Prevent Reoccurrence of Dental Caries in Children.

BACKGROUND: The formation of dental caries is the most common chronic disease in children, and is preventable. The oral health-related quality of life has an immense impact on an individual's daily functioning, well-being or overall quality of life. OBJECTIVES: This study aims to investigate the cost effectiveness of the Dental RECUR Brief Negotiated Interview for Oral Health (DR-BNI). This 30-minute therapeutic "talk" by a dental nurse with a parent/guardian was compared with a placebo-controlled intervention in preventing reoccurrence of dental caries in children who have had a primary tooth extracted. METHODS: An economic model was developed to simulate the clinical progression of dental caries among children who have previously had a primary tooth extracted. The analysis was conducted using the UK NHS perspective. The main outcome was the incremental cost-effectiveness ratio (ICER) based on the quality-adjusted life years (QALYs). Estimates of costs and probabilities were obtained from the DR-BNI multicentre randomised controlled trial (RCT), while QALY values were obtained from published literature. Univariate and probabilistic sensitivity analyses were conducted to assess the uncertainty of the result and robustness of the model. Affordability and risk-aversion of the intervention were investigated to help decision makers make the best possible choices. RESULTS: With an intervention cost of £6.47, the results from the RCT showed the healthcare cost for the DR-BNI intervention was £115.90 per child while the control had a healthcare cost of £119.46 per child. The QALYs gained for the prevention of reoccurrence of dental caries was higher in the DR-BNI intervention arm by 0.023 QALYs; thus, the DR-BNI was the dominant intervention. At willingness to pay threshold of £3500/QALY gained, a maximum probability of being cost effectiveness is achieved at 86%. The secondary analysis showed a cost-savings of £20.94 per participant for the prevention of at least one filling or extraction. Affordability results showed that the DR-BNI programme is affordable to the UK health system at a moderately low budget. CONCLUSIONS: This study shows the proactive talking intervention to have a very moderate cost and to be effective in providing better health related quality-of-life gains. The intervention is cost savings with a dominant ICER even with a 200% increase in the cost of intervention. The NHS will be providing better oral health for children at a better net monetary benefit-to-risk ratio by adopting the DR-BNI intervention in preventing the reoccurrence of dental fillings and extractions for each participant. TRIAL REGISTRATION: This trial was registered prospectively on 27th September 2013 with the trial registration number ISRCTN 24958829.

The relationship between right duct lymph flow and extravascular lung water in dogs given alpha-naphthylthiourea.

The relationship between right duct lymph flow and extravascular lung water was studied in 3 normal dogs and 15 dogs with pulmonary edema induced by alpha-naphthylthiourea (ANTU). Right duct lymph was collected in a pouch created by ligating jugular, subclavian, and brachiocephalic veins. Extravascular lung water was measured in vivo by double indicator dilution and post-mortem by weighting lungs before and after drying. Cardiac output, pulmonary artery and pulmonary artery wedge pressures, and the concentration of protein and electrolytes in plasma and right duct lymph were determined. Eight lungs were examined by light and electron microscopy. There was a direct relationship between right duct lymph flow (RDLF in milliters per hour per gram dry lung) and extravascular lung water (Qwl in milliliters per gram dry lung) which was best described by the equation RDLF=0.75-0.26 Qwl+0.03 (Qwl).2 Dogs with severe ANTU-induced edema had extensive lung capillary endothelial destruction but only mild interstitial swelling and no visible damage to type I alveolar epithelial cells. Cardiac output, pulmonary artery and wedge pressures, and protein and electrolyte concentrations did not correlate with either extravascular water or right duct flow. Thus, in ANTU-induced pulmonary edema right duct lymph flow was directly related to extravascular lung water with the highest flows occurring with severe edema. The absence of a rapid increase in lymph flow with small increases in extravascular water may be due to early sequestration of fluid in the alveolar space. Hemodynamic changes did not account for changes in lung water or lymph flow. The pulmonary interstitial factors relating increased extravascular water to lymph drainage remain to be determined.

Free amino acid pools of rodent mammary tumors.

Intracellular pools of free amino acids were compared individually in mammary tumors of Wistar Furth and Sprague-Dawley rats and C3H and DBA/2 mice. Of 11 transplantable and 7,12-dimethylbenz[a]anthracene-induced adenocarcinomas of the rat, all nonmetastasizing tumors could be distinguished from metastasizing tumors by the accumulation of high glutamine pools and significant-to-high cystathionine pools. In primary mammary tumors of C3H mice and transplanted mammary tumors of DBA/2 mice, intracellular free arginine was frequently below that of the circulating plasma level and approached that in the arginine-destroying organ, the liver. Arginine pool depletion was also noted in normal mammary tissue, particularly in the actively lactating mouse. Individual rat or mouse mammary tumors also contained high levels of taurine, beta-alanine, and gamma-aminobutyric acid, which, like cystathionine, are distinctive for or are enriched in neural tissue. None of these pool enrichments were characteristic of normal rat or mouse mammary tissue. Free hydroxyproline was low in primary induced rat mammary tumors and higher in transplanted mammary tumors and in normal lactating mammary glands, particularly in the mouse. In contrast, the hydroxyproline residues of collagen, taken as an index of mesenchymal cell contribution, were very low in all tumors.

Excess mortality and morbidity associated with right bundle branch and left anterior fascicular block.

Excess mortality and morbidity associated with right bundle branch and left anterior fascicular block were evaluated in 108 patients with block (age 74 +/- 10 years, 69% male) and 108 age- and sex-matched control patients with normal conduction. Clinical characteristics were similar initially except for more congestive heart failure in patients with block. Life table analysis revealed a higher 12 year mortality with block, even after omitting patients with moderate or severe congestive heart failure (risk ratio 1.47, p less than 0.05). Compared with control subjects, the group of patients with block had more sudden death and deaths of unknown cause, but a similar number of noncardiac and diagnosed cardiac deaths. More patients with block developed new second and third degree atrioventricular block or new overt coronary artery disease, but this finding did not support prophylactic pacing in asymptomatic patients. The importance of internal controls in assessing the natural history of clinical and electrocardiographic abnormalities is emphasized.

Development of an in vitro model of excess intracellular reactive oxygen species.

These investigations characterize an in vitro model for generating excess intracellular reactive oxygen species (ROS). This novel model may be useful in the identification and delineation of cellular mechanisms associated with aging due to the link between age and excess oxidative events. The human cell line, MCF7, was stably transfected using the pSV3.neo plasmid housing a gene encoding the Aequorea victoria green fluorescent protein (GFP). Transfected cells were analyzed for maintenance of GFP over time, showing stability of the GFP gene. These studies demonstrate that the presence of fluorescing GFP significantly increases intracellular ROS, creating oxidative stress in these cells. Antioxidant supplementation was evaluated to determine the effectiveness of intracellular H2O2 reduction. The results demonstrate that supplementation with a potent antioxidant, such as reduced glutathione, protects cells from oxidative damage by decreasing intracellular concentrations of H2O2. This model for intracellular generation of excess ROS establishes a clear method by which the utility of antioxidant supplementation to protect against intracellularly generated reactive oxygen species may be evaluated.

Resistance of contracting myocardium to swelling with hypoxia and glycolytic blockade.

The interrelationship of myocardial metabolism, performance and tissue hydration was examined in isolated contracting rat, guinea pig and dog myocardium. Myocardial metabolism was altered by blocking aerobic, and both aerobic and anaerobic metabolism. Myocardial water content and distribution were measured in rat myocardium using 3H-inulin and 51Cr-EDTA as extracellular markers. Myocardial hydration was also evaluated by light and electron microscopy. The relative susceptibility of non-contracting slices of rat and guinea pig myocardium and kidney to swelling secondary to these interventions was also explored. Hypoxia resulted in a partially reversible reduction in mechanical function; hypoxia plus glycolytic blockade led to irreversible severe contracture and total loss of tension development. Neither hypoxia nor hypoxia plus glycolytic blockade resulted in increased total tissue or extracellular water in previously contracting preparations or in non-contracting slices of myocardium. On the other hand, there were significant increases in cellular water in similarly treated kidney slices after each intervention. Thus, despite severe, irreversible derangements of mechanical function, myocardium did not swell under conditions which produced swelling in renal cortex.

Player acceleration and deceleration profiles in professional Australian football.

This study aimed to determine the validity and reliability of global positioning system (GPS) units for measuring a standardized set of acceleration and deceleration zones and whether these standardized zones were capable of identifying differences between playing positions in professional Australian football. Eight well trained male participants were recruited to wear two 5 Hz or 10 Hz GPS units whilst completing a team sport simulation circuit to measure acceleration and deceleration movements. For the second part of this article 30 professional players were monitored between 1-29 times using 5 Hz and 10 Hz GPS units for the collection of acceleration and deceleration movements during the 2011 and 2012 Australian Football League seasons. Players were separated into four distinct positional groups - nomadic players, fixed defenders, fixed forwards and ruckman. The GPS units analysed had good to poor levels of error for measuring the distance covered (<19.7%), time spent (<17.2%) and number of efforts performed (<48.0%) at low, moderate and high acceleration and deceleration zones. The results demonstrated that nomadic players and fixed defenders perform more acceleration and deceleration efforts during a match than fixed forwards and ruckman. These studies established that these GPS units can be used for analysing the distance covered and time spent at the acceleration and deceleration zones used. Further, these standardized zones were proven to be capable of distinguishing between player positions, with nomadic players and fixed defenders required to complete more high acceleration and deceleration efforts during a match.

Clinical relevance of verapamil plasma levels in stable angina pectoris.

Plasma levels of verapamil and norverapamil were evaluated in 77 patients who received oral verapamiL for treatment of angina pectoris. There was a sixfold interpatient variation in verapamil plasma concentrations, but plasma concentrations were linearly related to doses of the drug (240 to 480 mg/day) in the same patient (r = 0.81). Plasma concentrations of norverapamil, the major active metabolite of verapamil, were similar to those of verapamil. Although verapamil produced a significant improvement in exercise tolerance in most patients, the increase in exercise time was not related to plasma levels of the drug; however, most patients with improvement had plasma levels exceeding 100 ng/ml. An increase in the dose of verapamil from 320 to 480 mg daily produced a substantial (71%) increase in plasma levels of the drug but no significant increase in exercise tolerance (4%). The average increase in the P-R interval with 480 mg of verapamil in these 77 patients was small (8%) (161 +/- 18 to 174 +/- 22 ms); on.y six patients had first-degree heart block. These minor effects on atrioventricular conduction were noted despite plasma verapamil concentrations in 76 patients that exceeded 100 ng/ml, a level that successfully converts supraventricular tachycardias after intravenous drug administration. We differences between the effects of oral and intravenous verapamil on atrioventricular conduction may be the result of stereoselective hepatic inactivation of verapamil's I-isomer. Determination of plasma levels of verapamil is of limited value in the management of patients with angina pectoris, but may be useful in the identification of nonresponders with plasma levels less than 100 ng/ml who may benefit from a further increment in drug dose.

Aortic valve replacement with the De Bakey valve.

De Bakey prostheses were inserted in 29 patients with aortic valve disease between October, 1970, and May, 1972. Ten patients have died, but all but one of the remaining 19 have beel followed for a minimum of 19 months. Evaluation of the results in these subjects indicates that the function of the De Bakey valve compares favorably with that of other aortic valve prostheses.

Mechanical circulatory support in postoperative cardiogenic shock.

A 38-year-old white woman had cardiogenic shock after elective mitral valve replacement and was unresponsive to pressor drugs and intra-aortic balloon counterpulsation. A left ventricular assist device (left ventricle to ascending aorta) was implanted 16 hours after the initial operation and provided circulatory support for 8 days. Improvement in the patient's own cardiac performance was documented, and there were no complications attributable to the assist device. However, intercurrent medical problems resulted in clinical deterioration on the fifth day after operation, and the patient died 8 days after operation. The findings in this patient suggest a potential role for this left ventricular assist device in future cases of acute, intractable, but potentially reversible myocardial failure.

Detection of bacteraemia in critically ill patients using 16S rDNA polymerase chain reaction and DNA sequencing.

OBJECTIVE: To confirm the sensitivity of the polymerase chain reaction (PCR) technique (versus blood cultures) and to gain a better understanding of the incidence of true- and false-positive results when using this technique. DESIGN: Observational study. SETTING: Fourteen-bed, level 3 intensive care unit. PATIENTS: Hundred twenty-six critically ill adult patients. Hundred ninety-seven blood culture and PCR samples taken as clinically indicated for suspected sepsis, according to routine ICU protocol. MEASUREMENTS AND RESULTS: The PCR product (16SrDNA: 341F-1195R) was sequenced and compared with a database of known species (Genebank) to identify the bacterial nucleic acid. The PCR or blood culture result was classified as a true-positive if there was other microbiological or clinical supporting evidence.

Cerebrospinal fluid ions in metabolic acidosis in dogs: effects of acetazolamide.

We hypothesized that, during isosmotic isonatremic HCl acidosis with maintained isocapnia in cisternal cerebrospinal fluid (CSF), acetazolamide, by inhibiting carbonic anhydrase (CA) in the central nervous system (CNS), should produce an isonatric hyperchloric metabolic acidosis in CSF. Blood and CSF ions and acid-base variables were measured in two groups of anesthetized and paralyzed dogs with bilateral ligation of renal pedicles during 5 h of HCl acidosis (plasma [HCO3-] = 11 meq/l). Mechanical ventilation was regulated such that arterial PCO2 dropped and CSF Pco2 remained relatively constant. In group I (control group, n = 6), CSF [Na+] remained unchanged, [HCO3-] and strong ions difference (SID) fell, respectively, 6.1 and 5 meq/l, and [Cl-] rose 3.5 meq/l after 5 h of acidosis. In acetazolamide-treated animals, (group II, n = 7), CSF [Na+] remained unchanged, [HCO3-], and SID fell 11 and 7.1 meq/l, respectively, and [Cl-] rose 7.1 meq/l. We conclude that during HCl acidosis inhibition of CNS CA by acetazolamide induces an isonatric hyperchloric metabolic acidosis in CSF, which is more severe than that observed in controls.

Referral selection bias in the Medicare hospital mortality prediction model: are centers of referral for Medicare beneficiaries necessarily centers of excellence?

OBJECTIVE: Although the Health Care Financing Administration (HCFA) uses Medicare hospital mortality data as a measure of hospital quality of care, concerns have been raised regarding the validity of this concept. A problem that has not been fully evaluated in these data is the potential confounding effect of illness severity factors associated with referral selection and hospital mortality on comparisons of risk-adjusted hospital mortality. We address this issue. DATA SOURCES AND STUDY SETTING: We analyzed the 1988 Medicare hospitalization data file (MEDPAR). We selected data on patients treated at the two Mayo Clinic-associated hospitals in Rochester, Minnesota, and a group of seven other hospitals that treat many patients from large geographic areas. These hospitals have had observed mortality rates substantially lower than those predicted by the HCFA model for the period 1987-1990. STUDY DESIGN: Using the multiple logistic regression model applied by HCFA to the 1988 data, we evaluated the relationship between distance from patient residence to the admitting hospital and risk-adjusted hospital mortality. PRINCIPAL FINDINGS: Among patients admitted to Mayo Rochester-affiliated hospitals, residence outside Olmsted County, Minnesota was independently associated with a 33 percent lower 30-day mortality rate (p < .001) than that associated with residence in Olmsted County. When patients at Mayo hospitals were stratified by residence (Olmsted County versus non-Olmsted County), the observed mortality was similar to that predicted for community patients (9.6 percent versus 10.2 percent, p = .26), whereas hospital mortality for referral patients was substantially lower than predicted (5.0 percent versus 7.5 percent, p = < .001). After incorporation of the HCFA risk adjustment methods, distance from patient residence to the hospitals was also independently associated with mortality among the Mayo Rochester-affiliated hospitals and seven other referral center hospitals. CONCLUSIONS: The HCFA Medicare hospital mortality model should be used with extreme caution to evaluate hospital quality of care for national referral centers because of residual confounding due to severity of illness factors associated with geographic referral that are inadequately captured in the extant prediction model.

Potential effectiveness of comparative casemix-corrected adverse outcome rates as quality monitors in a simulated hospital system.

To facilitate outcome-based medical quality assurance, a screening technique was developed which corrected facility-specific data for casemix using mean outcome rates from pooled data to establish norms for "uniform-risk groups" of patients. A stimulated health care system (108 facilities treating over 500,000 annually) was created to evaluate this technique's ability to distinguish between systems whose adverse outcomes were determined solely by casemix and random variations and those with true differences in quality of care. Specificity and sensitivity of quality of care decisions for individual facilities also were assessed. The screening technique achieved excellent differentiation between "homogeneous" systems and those with facility-specific variations in quality of care. No more than 3% of facilities without quality of care problems were ever inaccurately labeled, unless systematic or random errors in patient risk classification were introduced. Sensitivity in detecting substandard facilities was 35% when true deviation from standard was 2.5%, and rose to virtually 100% when deviation was 25% or greater. Thus, simulation can serve as an efficient method of testing the potential performance of casemix-corrected quality assurance screening under a wide variety of circumstances.

Potential effectiveness of quality assurance screening using large but imperfect databases.

To examine the effect of imprecise classification of patient risk (severity of illness) on an otherwise highly accurate quality assurance screening technique, data on clinical outcomes were generated for a simulated hospital system consisting of 108 facilities treating approximately 565,000 patients a year. In these simulations, marked differences in facility size, casemix distribution, and quality of care were combined with random variations in outcome. Pooled data for all 108 facilities were used to create algorithms that combined 468 discrete patient risk classifications into either ten or three groups with broad, overlapping ranges of patient-specific risks of unfavorable clinical results. When derived algorithms were applied to independently generated facility-specific data, the ability to identify hospital systems with and without quality of care problems was maintained with ten, but not with three, risk groups. However, even three moderately heterogeneous risk groups were sufficient to preserve a high degree of sensitivity and specificity in screening for potential quality of care problems within individual facilities. Thus, outcome-based quality assurance screening can be highly accurate in actual health care situations in which only imprecise estimations of patient-specific risk can be achieved.

Anthem Blue Cross and Blue Shield's coronary services network: a managed care organization's approach to improving the quality of cardiac care for its members.

OBJECTIVE: To describe a managed care organization's efforts to improve value for its members by forming a coronary services network (CSN). DESIGN: To identify high-quality facilities for its CSN, Anthem Blue Cross and Blue Shield reviewed claims data and clinical data from hospitals that met its general quality standards. An external firm measured and risk-adjusted applicant hospitals' mortality rates. Hospitals that demonstrated superior performance were eligible to join the CSN. In 1996, 2 years after the CSN was formed, clinical outcomes of participants and new applicants were analyzed again by the same external firm. PATIENTS AND METHODS: Data on more than 10,000 consecutive (all-payer) inpatients discharged after coronary bypass surgery in 1993 were collected from 16 applicant hospitals using a uniform format and data definitions. This analysis was expanded to 23 participating and applicant hospitals that discharged more than 13,000 patients who underwent either bypass surgery or coronary revascularization in 1995. We compared risk-adjusted routine length of stay (a measure of efficiency), mortality rates, and adverse outcome rates between CSN and non-CSN facilities. RESULTS: From 1993 to 1995, overall length of stay in the network decreased by 20%, from 12.3 to 9.8 days (P < or = 0.01) and severity-adjusted mortality rates decreased by 7.3%, from 2.9% to 2.7%. Initially, facilities outside the network had comparable efficiency but much higher mortality. However, they improved so much in both measures that their severity-adjusted mortality rate for bypass surgery in 1995 was no more than 10% higher than that of CSN hospitals. CONCLUSION: The creation of a statewide CSN that emphasized and improved the level of performance among providers ultimately benefited the carrier's managed care members. The desirability of participation was evidenced by an increase in the number of applicant hospitals over the 2 years. This may have stimulated quality improvement among competing providers in the region and among CSN facilities themselves.

Generation and partial characterization of a transformed cetacean cell line.

A primary epithelial cell line, DK1, established from renal tissue of a spontaneously aborted female Atlantic bottlenose dolphin was transfected with linearized pSV3.neo, an SV40 virus-derived plasmid encoding large tumor antigen (Tag). Transfected cells were grown in cetacean culture medium supplemented with 400 microg/ml geneticin (G418), and individual clones were selected using cloning rings. DKN1 was the first clone to be evaluated for future research use, and has been continuously cultured for 8 years. Intracellular cytokeratin and the expression of Tag were determined in DKN1, and cell growth was evaluated under different concentrations of l-glutamine, glutathione, and N-acetylcysteine. DKN1 cells did not require high levels of l-glutamine as previously reported for cetacean cells, and addition of antioxidants at the concentrations used in this study (2.0mM) decreased the rate of cell division. These data suggest strongly that these immortalized bottlenose dolphin epithelial cells have different levels of, and requirements for, glutathione than would be considered normal for terrestrial mammalian cells, do not require high levels of l-glutamine as previously suggested for dolphin cells, and exhibit decreased levels of cell growth and viability in high levels of the antioxidant GSH and its precursor, NAC.

State rate regulation and inpatient mortality rates.

Most research on hospital rate regulation has focused on costs, but concern about its consequences for quality of care, particularly mortality rates, has also been raised. In this study mortality rates and standardized mortality ratios (SMR) were computed to estimate any effect on quality, using data about Medicare beneficiaries hospitalized during 1986. Regulated states had lower SMRs for both patients and the general population than unregulated states and admitted significantly fewer patients. We found no basis for concluding that rate regulation is adversely related to patient mortality or population mortality, despite lower admission rates.

Forming a coronary services network on the basis of quality of care.

An Ohio insurance company's initiative to emphasize risk-adjusted clinical outcomes as criteria for selecting and reimbursing members of a network is stimulating a new emphasis on quality of care throughout the market area. Hospitals inside the network are cooperating to improve their collective results, while providers on the outside have launched major quality improvement programs in the effort to become measurably competitive with these centers of excellence. This case study in network selection demonstrates a new role for fiscal intermediaries in health care.