Outcome in Children Admitted to the First PICU in Malawi.

OBJECTIVES: Dedicated PICUs are slowly starting to emerge in sub-Saharan Africa. Establishing these units can be challenging as there is little data from this region to inform which populations and approaches should be prioritized. This study describes the characteristics and outcome of patients admitted to the first PICU in Malawi, with the aim to identify factors associated with increased mortality. DESIGN: Review of a prospectively constructed PICU database. Univariate analysis was used to assess associations between demographic, clinical and laboratory factors, and mortality. Univariate associations ( p < 0.1) for mortality were entered in two multivariable models. SETTING: A recently opened PICU in a public tertiary government hospital in Blantyre, Malawi. PATIENTS: Children admitted to PICU between August 1, 2017, and July 31, 2019. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Of 531 included PICU admissions, 149 children died (28.1%). Mortality was higher in neonates (88/167; 52.7%) than older children (61/364; 16.8%; p ≤ 0.001). On univariate analysis, gastroschisis, trachea-esophageal fistula, and sepsis had higher PICU mortality, while Wilms tumor, other neoplasms, vocal cord papilloma, and foreign body aspiration had higher survival rates compared with other conditions. On multivariable analysis, neonatal age (adjusted odds ratio [AOR], 4.0; 95% CI, 2.0-8.3), decreased mental state (AOR, 5.8; 95 CI, 2.4-13.8), post-cardiac arrest (AOR, 2.0; 95% CI, 1.0-8.0), severe hypotension (AOR, 6.3; 95% CI, 2.0-19.1), lactate greater than 5 mmol/L (AOR, 4.2; 95% CI, 1.5-11.2), pH less than 7.2 (AOR, 3.1; 95% CI, 1.2-8.0), and platelets less than 150 × 10 9 /L (AOR, 2.4; 95% CI, 1.1-5.2) were associated with increased mortality. CONCLUSIONS: In the first PICU in Malawi, mortality was relatively high, especially in neonates. Surgical neonates and septic patients were identified as highly vulnerable, which stresses the importance of improvement of PICU care bundles for these groups. Several clinical and laboratory variables were associated with mortality in older children. In neonates, severe hypotension was the only clinical variable associated with increased mortality besides blood gas parameters. This stresses the importance of basic laboratory tests, especially in neonates. These data contribute to evidence-based approaches establishing and improving future PICUs in sub-Saharan Africa.

A diary study of Australian lawyers working with traumatic material.

Many lawyers experience regular exposure to traumatic material yet little is known about its effects. This study examines what traumatic material affects lawyers, how they respond in the moment and how they recover. The participants (n = 18 lawyers) completed a five-day diary study and a semi-structured interview regarding their experiences. The analysis identified clients' negative emotions and experiences, domestic violence and child abuse as most impactful. The participants reported experiencing sadness, anger, frustration, disgust and/or compassion; some reported not being overly distressed or not experiencing emotions. Most participants reported using social support and emotion-focused coping strategies, drawing on their identities as lawyers to suppress or conceal emotions. At the end of a working day many participants reported coping by working longer hours but also through physical activity and social interactions. We discuss the implications for lawyers' well-being and the role of organisations and education in managing the impacts of traumatic material.

Australian lawyers' experience of exposure to traumatic material: a qualitative study.

Lawyers experience significant levels of psychological distress. We argue that one reason, which has received insufficient attention from researchers, is their exposure to traumatic material. Our study examined the lived experience of lawyers who are exposed to traumatic material, including the role their organisation and profession play in shaping their experiences. Thirty-five lawyers or barristers, from both the public and the private sector, participated in in-depth interviews about how their exposure to traumatic material affected them, and how their organisation shaped their experiences. Our analysis identified six themes: when material becomes traumatic, fear of stigma, everyday recovery, boundaries through denial and distancing, using social support normatively and making meaning. Our findings identify that lawyers can experience strong emotional reactions to traumatic material, and their experience is influenced by the professional norms and training in law. Moreover, their organisation has an important role in either ameliorating or exacerbating their responses.

A qualitative description of successful aging through different decades of older adulthood.

OBJECTIVE: To qualitatively examine factors that contribute to successful aging during different decades of older adulthood. METHODS: Fundamental qualitative description was adopted as the methodological framework. Through purposeful sampling, 42 community dwelling older adults (mean age = 79.6 years, age range = 65-97 years; 19 males) were recruited. Focus groups (6) segmented by decade of life were conducted with participants 65-74 (n = 17) and 75-84 (n = 17) years of age. Semi-structured interviews (16) were conducted with four participants from each decade, as well as participants 85 years of age and older (n = 8). Data analyses were conducted independently for each decade of life and included inductive analysis of textual data through continuous comparisons of meaning units. RESULTS: Three primary themes related to successful aging were identified across all decades of older adulthood: (1) staying healthy (secondary themes: genetics and lifestyle choices), (2) maintaining an active engagement in life (secondary themes: social engagement and cognitive engagement), and (3) keeping a positive outlook on life. Participants in specific decades of older adulthood identified three additional secondary themes related to maintaining an active engagement in life: finances (65-74 and 85+ years), social support (75+ years), and successful marriage (75+ years). Similarly, only adults 65-84 years of age identified a secondary theme for keeping a positive outlook on life: acceptance and adaptation. CONCLUSION: Primary themes related to successful aging were agreed upon by participants in all decades of older adulthood, while age-based differences existed among secondary themes. Thus, what it means to age successfully may be age-dependent.

Relative Age and Positive Youth Development in Youth Sport: Do Developmental Assets Play a Role in Creating Advantage Reversals in Female Soccer?

Relative age effects (RAEs) are commonly associated with advantages for older athletes. However, a variety of benefits attributed to 'advantage reversals' have been observed among relatively younger professional athletes. Considering psychosocial development as a proposed mechanism, the purpose of this study was twofold: (1) To explore an association between developmental assets (i.e., facilitators of positive youth development [PYD]) and RAEs; (2) To assess whether overall developmental asset levels are protective against sport dropout. The Developmental Assets Profile© was distributed to members of a one-year cohort of post-adolescent, female soccer players from Ontario, Canada. The presence of differences between groups of relatively older (H1; n = 64) and younger (H2; n = 57) participants and developmental asset scales were assessed using discriminant analysis. A binary logistic regression was conducted to assess whether overall developmental asset levels are protective against sport dropout, with consideration of relevant factors. Findings suggest that relatively younger, female players score higher in two internal categories: commitment to learning and positive values. The overall developmental asset scores were not found to be protective against dropout. This study provides preliminary, albeit cautious, support that 'advantage reversals' may be in part associated with enhanced PYD resulting from developmental sport experiences.

The effect of posture category salience on decision times and errors when using observation-based posture assessment methods.

Observation-based posture assessment methods (e.g. RULA, 3DMatch) require classification of body postures into categories. This study investigated the effect of improving posture category salience (adding borders, shading and colour to the posture categories) on posture selection error rates and decision times of novice analysts. Ninety university students with normal or corrected normal visual acuity and who were not colourblind, were instructed to select posture categories as quickly and accurately as possible, in five salience conditions (Plain (no border, no shading, no colour); Grey Border; Red Border; Grey Shading (GS) and Red Shading (RS)) for images presented in randomised blocks (240 classifications made by each participant) on a computer interface. Participants responded quickest in the Border conditions, classifying postures about 5% faster than in the Plain condition. Coloured diagrams significantly reduced posture classification errors by approximately 1.5%. Overall, the best performance, based on both error rate and decision time combined, resulted from incorporating a Grey Border to the posture category diagrams; a simple enhancement that could be made to most current observation-based posture assessment tools. PRACTITIONER SUMMARY: The salience of posture diagrams used in observation-based posture assessment tools was evaluated with respect to analyst error rates and decision times. The best performance resulted from incorporating a grey border to the posture diagrams; a simple enhancement that can be made to most current observation-based posture assessment tools.

An Examination of Relative Age and Athlete Dropout in Female Developmental Soccer.

Sport dropout rates among children and youth are a concern for researchers and policy makers. The impact of relative age effects (RAEs) on dropout trends has not been adequately examined in female samples. The purpose of this study was to longitudinally examine dropout in a female soccer cohort in Ontario, Canada. Registration entries for a one-year cohort were examined across a seven-year period (n = 9908; age 10-16 years). A chi-square analysis established the presence of RAEs in the initial year of registration. Survival analyses assessed the impact of relative age, competition level, and community size on athlete dropout. A median survival rate of four years was observed for players born in the first quartile, while all remaining quartiles had a median survival of three years. Community size did not predict dropout in this analysis; however, competition level was a significant predictor, with competitive players being more likely to remain engaged vs. recreational players (55.9% vs. 20.7%). The observed trends are likely to have a significant impact from both a healthy development and systems perspective (e.g., economic/market loss). Intervention is needed to mitigate current dropout trends in female athletes. Practical applications are discussed.

Does Relative Age Influence Organized Sport and Unorganized Physical Activity Participation in a Cohort of Adolescents?

Despite their prevalence, the longitudinal impacts of relative age effects (RAEs) on sport and other forms of physical activity (PA) are understudied. This study examined longitudinal participation patterns in organized sport (team and individual), unorganized PA, and non-participation with respect to RAEs in a prospective cohort of adolescents. Data from the first 24 cycles of the MATCH study were used for analyses. Elementary students (n = 929) were recruited from 17 schools in Atlantic Canada. Respondents self-reported PA three times/year. Mixed multilevel logistic models compared the likelihood of participating in each context across birth quarter. Chronological age and gender were considered, along with the interaction between chronological and relative age. Individuals born in Quarter 1/Quarter 2 were more likely to report participation in organized team sport but not individual sports. Relatively older participants born in Quarter 2 were more likely to report participation in unorganized PA. Increasing chronological age was associated with decreased participation in organized sport (particularly team-based) and increased non-participation. Gender was not associated with organized sport participation, but girls were under-represented in unorganized PA and more likely to report non-participation. The interaction parameters suggested that RAEs were consistent throughout adolescence in each context. Longitudinal analyses suggest RAEs are context dependent.

The influence of training on decision times and errors associated with classifying trunk postures using video-based posture assessment methods.

The purpose of this study was to examine the influence of training on the decision times and errors associated with video-based trunk posture classifications. Altogether, 30 amateur and 30 knowledge-based participants completed a three-phase study (pre-training, training, post-training) that required them to classify static trunk postures in images on a computer screen into a posture category that represented the angle of the trunk depicted. Trunk postures were presented in both flexion/extension and lateral bend views and at several distances from the boundaries of the posture categories. Both decision time and errors decreased as distance from the boundaries increased. On average, amateur analysts experienced a larger decrease in decision time per posture classification than knowledge-based analysts (amateur: 0.79 s, knowledge-based: 0.60 s; p <0.05) suggesting that training can have beneficial effects on classification performance. The implications are that the analysis time associated with video-based posture assessment methods can be reduced with appropriate training, making this type of approach feasible for larger-scale field studies. Statement of Relevance:Understanding the role that training can play in reducing errors associated with the use of video-based posture assessment methods may result in more efficient use of these tools by ergonomic practitioners. Reducing decision time and misclassification errors will provide a more efficient, accurate and representative assessment of injury risk.

Female Youth Soccer Participation and Continued Engagement: Associations With Community Size, Community Density, and Relative Age.

Environmental context can impact youth engagement in sport and athlete development. Previous work has examined the population size of the birthplace of elite athletes; commonly known as the birthplace or community size effect. Community density has also been recognized as an important variable. Exact estimates for the ideal community characteristics and a thorough understanding of the underlying mechanisms has been somewhat elusive. Existing studies are cross-sectional in nature and there is evidence to suggest that significant variation exists within imposed categories. An athlete's birthdate position in a similar-age cohort can also impact development and has been associated with (dis)advantages resulting from subtle age differences (i.e., the relative age effect); it remains unknown if this variable is associated with population density. The objective of this study was to establish longitudinal participation trends among female youth soccer players in Ontario Canada, with consideration of community size, community density, and relative age. Within-category variation and associations between the variables were assessed. Registration entries at age 10 years (n = 9,826) and 16 years (n = 2,305) were isolated for analysis. Odds ratio analyses were conducted within each community size and density category for all 10 year old registrants; 95% confidence intervals were obtained. This procedure was repeated for all registrants at 16 years of age using the expected distribution at age 10 years to examine continued engagement. Findings suggest medium-sized communities (i.e., 10,000-249,999 inhabitants) provide the best odds of participation and continued engagement. Less densely populated communities (i.e., 50-<400 population/km2) appeared to be ideal for facilitating participation at age 10 years, but not for engagement at age 16 years. However, within-category variation was evident when each community was inspected individually. Consistent with previous attempts to find an association between community size and the relative age effect, there did not appear to be an association between community density and birth quartile distribution. Observations from this study show that community size and community density are truly unique and separate variables. Future studies should consider the underlying contributions to both low and high participation and continued engagement, while being mindful of within-category variation.

Gender, age, and sport differences in relative age effects among US Masters swimming and track and field athletes.

A relative age effect has been identified in Masters sports (Medic, Starkes, & Young, 2007). Since gender, age, and type of sport have been found to influence the relative age effect in youth sports (Musch & Grondin, 2001), we examined how these three variables influenced possible relative age effects among Masters swimmers and track and field athletes. Using archived data between 1996 and 2006, frequency of participation entries and record-setting performances at the US Masters championships were examined as a function of an individual's constituent year within any 5-year age category. Study 1 investigated the frequency of Master athletes who participated; Study 2 examined the frequency of performance records that were set across constituent years within an age category, while accounting for the distribution of participation frequencies. Results showed that a participation-related relative age effect in Masters sports is stronger for males, that it becomes progressively stronger with each successive decade of life, and that it does not differ across track and field and swimming. In addition, a performance-related relative age effect in Masters sport seems to be stronger for swimming than track and field, but it does not differ across gender and decades of life.

Does lifelong training temper age-related decline in sport performance? Interpreting differences between cross-sectional and longitudinal data.

In the face of remarkable aging trends in North American society, organized sport/physical activity is an important vehicle for promoting physical health, and a domain in which long-term participation might mitigate pessimistic trends for age decline. This investigation examined patterns of age-related decline in performance for 45 Masters runners who rigorously trained continuously for at least a decade. Longitudinal data for age and performance were collected for 200 m, 1500 m, and 10 km events retrospectively across participants' careers. Cross-sectional (CS) data representing normal patterns of aging were derived from online archives. Longitudinal data reflected within-participant training effects whereas CS data did not. Second-order regression analyses were performed separately for each data type and quadratic beta coefficients, indicative of accelerated age decline, were compared for CS and longitudinal samples on a within-event basis. Results showed evidence of accelerated decline with advancing age for both samples, although rates for longitudinal samples were moderated for the 200 m and 1500 m events. Findings for the long-distance event were anomalous. Results provide evidence for moderated age-decline in physical performance measures for individuals who sustain engagement in organized sport for lengthy periods. Discussion focuses on methodological considerations for advancing future research that contrasts CS and longitudinal samples, and the importance of encouraging sport involvement opportunities to aging individuals.

Relative Age Effects Across and Within Female Sport Contexts: A Systematic Review and Meta-Analysis.

BACKGROUND: Subtle differences in chronological age within sport (bi-) annual-age groupings can contribute to immediate participation and long-term attainment discrepancies; known as the relative age effect. Voluminous studies have examined relative age effects in male sport; however, their prevalence and context-specific magnitude in female sport remain undetermined. OBJECTIVE: The objective of this study was to determine the prevalence and magnitude of relative age effects in female sport via examination of published data spanning 1984-2016. METHODS: Registered with PROSPERO (No. 42016053497) and using Preferred Reporting Items for Systematic Reviews and Meta-analysis systematic search guidelines, 57 studies were identified, containing 308 independent samples across 25 sports. Distribution data were synthesised using odds ratio meta-analyses, applying an invariance random-effects model. Follow-up subgroup category analyses examined whether relative age effect magnitudes were moderated by age group, competition level, sport type, sport context and study quality. RESULTS: When comparing the relatively oldest (quartile 1) vs. youngest (quartile 4) individuals across all female sport contexts, the overall pooled estimate identified a significant but small relative age effect (odds ratio = 1.25; 95% confidence interval 1.21-1.30; p = 0.01; odds ratio adjusted = 1.21). Subgroup analyses revealed the relative age effect magnitude was higher in pre-adolescent (≤ 11 years) and adolescent (12-14 years) age groups and at higher competition levels. Relative age effect magnitudes were higher in team-based and individual sport contexts associated with high physiological demands. CONCLUSION: The findings highlight relative age effects are prevalent across the female sport contexts examined. Relative age effect magnitude is moderated by interactions between developmental stages, competition level and sport context demands. Modifications to sport policy, organisational and athlete development system structure, as well as practitioner intervention are recommended to prevent relative age effect-related participation and longer term attainment inequalities.

Correction to: Relative Age Effects Across and Within Female Sport Contexts: A Systematic Review and Meta-Analysis.

An Online First version of this article was made available at https://link.springer.com/article/10.1007/s40279-018-0890-8 on 13 March 2018. Some errors were subsequently identified by the authors, particularly in regard to Table 4. Although the details pertained to in the table were correct in the original manuscript, it appears that errors were introduced during production of the article. The published article has now been updated with a corrected version of Table 4. This corrected version of the table is also shown below.

Promoting care for acutely ill children-development and evaluation of a paediatric early warning tool.

The primary purpose of this paper was to develop and evaluate a physiologically based system for the identification of acutely ill children in hospital environments. The dependency of children in hospital is increasing and ensuring the appropriate and timely intervention by a team of health personnel experienced in the care of these children is paramount to ensure their optimal outcome. A paediatric early warning (PEW) tool was designed and demographic and physiological data collected on all children (n = 360) who triggered the tool over a 6-month period, between September 2003 and February 2004. Analysis of the data was undertaken on each criterion within the tool and by reviewing it against patient outcome, the decision for its retention or removal was made. The modified tool showed a 99% sensitivity and a 66% specificity. The resultant Paediatric Early Warning Tool has been validated for use in a tertiary children's hospital in the United Kingdom (UK). The use of such a tool by all staff caring for acutely ill children in hospital environments can help to ensure their early recognition and timely treatment. The tool together with an action plan must, however, be appropriate for use in individual ward or hospital areas.

Relative Age Effects in Women's Rugby Union From Developmental Leagues to World Cup Tournaments.

UNLABELLED: Annual age cohort groupings promote relative age effects (RAEs), which often, inadvertently, create participation and attainment biases between relatively older and younger players within the same age cohort. In a globally evolving sport, women's rugby team selection practices may potentially bypass qualified players as a result of maturational differences. PURPOSE: Our study examined the prevalence of RAEs in women's rugby union. METHOD: Player data (age range = 4-21+ years) were gathered from the 2006 and 2010 Rugby World Cups (n = 498) and from Canadian (n = 1,497) and New Zealand (NZ; n = 13,899) developmental rugby leagues. RESULTS: Although no evidence of an RAE was found in the World Cup samples, chi-square analyses identified some typical and atypical patterns of RAEs at the developmental levels (w ≥ .3). Younger developmental groups displayed a typical RAE patterning with a greater representation of older players (Canadian 13-year-olds, w = .58; NZ 4-year-olds, w = .35), whereas older developmental groups displayed an atypical RAE patterning with a greater representation of younger players (Canadian 19-year-olds, w = .58; NZ 17-year-olds, w = .32). Further, a traditional RAE emerged in the Canadian 11- to 15-year-old age group, χ2(3) = 10.92, p < .05, w = .30. CONCLUSION: The lack of homogeneity of traditional RAEs across the sample questions the existence of a single, clear RAE in women's rugby. Some evidence of participation inequalities at the developmental levels suggests that further RAE research in more varied sociocultural contexts may be necessary.

Factors Influencing Sedentary Behaviour in Older Adults: An Ecological Approach.

Sedentary behaviour is negatively associated with several health outcomes and is particularly problematic among older adults. Knowledge translation tools and public health promotion strategies are needed; however, little evidence is available to inform framing of such tools or development of intervention programs. The aim of the present study was to use data on the perceptions of sedentary time and the programs or supports older adults identify as important for reducing their sedentary time, to inform knowledge translation strategies targeting this population. Focus groups were conducted with four groups of older adults (n = 26) at local seniors' centres (Ontario, Canada). Participants were 74 ± 8.5 years old and were engaging in both sedentary and physical activities in a social environment. Using the Ecological Model for sedentary time in adults, we categorized data into leisure time, household, transport and occupation domains. Intrinsic and extrinsic factors that worked to either discourage or promote sedentary behaviour were identified. Drawing on both groupings of data, results were synthesized to inform public health strategies on appropriate messaging and better uptake of programming and guidelines. For example, successful programs developed on the topic will need to include a social component and a mentally stimulating component, as these were identified as critical for enjoyment and motivation. It was clear from this analysis that sedentary time reduction strategies will need to consider the different domains in which older adults accumulate sedentary time.

Manual patient transfers used most often by student and staff nurses are consistent with their perceptions of transfer training, and performance confidence.

BACKGROUND: A disconnect in manual patient transfer (MPT) training practices for nurses, between what is taught and used in academic and clinical settings, could have implications for injury. OBJECTIVE: This study aimed to determine: 1. what MPTs student and staff nurses use in clinical settings, and 2. if the MPTs used most often were also the ones they perceived that they received training for and had the most confidence performing. METHODS: Survey responses from student nurses (n=163) (mid-sized university) and staff nurses (n=33) (local hospital) regarding 19 MPTs were analyzed to determine which transfers were perceived to be used most often, and which ones they had received training for and had the greatest confidence performing. RESULTS: The MPTs nurses perceived using most often were the same transfers they had the greatest confidence performing and for which they perceived receiving training. However, these MPTs were not taught at the university at the time of this investigation. CONCLUSION: Reducing the disconnect between manual patient transfer training obtained in the academic and clinical environments will hopefully reduce the risk of injury for nurses and improve the quality of care for patients.

The use of online control: a developmental perspective.

To date very little research has addressed the abilities of young participants to respond to a change in visual information provided during movement execution. This study attempted to determine the ability of 45 participants (5, 7, 9 years) to respond to a change in visual information during a discrete rapid aiming movement. A perturbation paradigm where the target size changed after movement onset was used. In the control context, movements were made to each target size (small, medium, large) with no perturbation. In contrast, during the experimental context the target always began as a medium target. Upon movement initiation, the target size could remain constant or might unexpectedly become larger or smaller. Temporal, kinematic, and correction data were collected to determine the control process underlying the aiming movement. No interaction was found between age and condition for movement time (MT), and results indicated that all ages scaled movement time to final target size. The accuracy data revealed the 9-year-old participants were more accurate than the 5- and 7-year-old participants. To determine where the changes in duration were made, the time to and after peak velocity (TTPV, TAPV), and peak velocity values (PV) were examined. The PV values indicated that, during the control context, the participants scaled their movement to the target size. However, during the experimental condition generally no significant differences were found in either measure, suggesting a programmed response based on the original target size. This was supported by the correction data collected prior to peak velocity, lending further support to a programmed response. Following peak velocity, it was found that differences in MT were as a result of time spent in deceleration. This increased TAPV, and increased number of corrections observed, suggest that all participants were using on-line control following peak velocity in response to the change in visual information. The data collected supports a model of control that incorporates both open-loop control during the initial impulse phase, and closed-loop control during the current control phase for participants as young as 5 years.

Outcome of critically ill children before and after the establishment of a pediatric retrieval service as a component of a national strategy for pediatric intensive care.

OBJECTIVE: To compare outcomes of critically ill children transferred for intensive care by specialist and nonspecialist retrieval before and after the establishment of a dedicated pediatric intensive care transfer service. DESIGN: Prospective, observational study. SETTING: All hospitals that admitted children in a defined geographic region of the United Kingdom. PATIENTS: There were a total of 284 critically ill children (<16 yrs old) transferred from a district general hospital to a tertiary pediatric intensive care unit. MEASUREMENTS AND MAIN RESULTS: Age, diagnosis, Pediatric Risk of Mortality score, Therapeutic Intervention Scoring System, details of interhospital transfer, and survival to hospital discharge were analyzed for two periods, before and after the establishment of a regional transfer service. Patients were categorized as low or high risk (predicted mortality, 15%, respectively). Standardized mortality was calculated as the ratio of observed to predicted deaths in each category. After the transfer service was established, a significantly higher proportion of high-risk children were transferred by a specialist team, and there was a decreased standardized mortality rate of transferred patients (1.09 to 0.74). The greatest decrease in standardized mortality rate occurred in low-risk children transferred by nonspecialist teams (2.27 to 0.52). During the equivalent period in the same geographic region, standardized mortality rate of nontransferred children also fell in pediatric intensive care (1.59 to 0.60) and general intensive care units (1.11 to 0.81). CONCLUSIONS: We conclude that the establishment of a regional transfer service coincided with a fall in standardized mortality that reflected more general changes in intensive care performance rather than a specific benefit of a specialist transfer team.