Where do you go when your periods go?: A case-study examining secondary amenorrhea in a professional internationally-capped female soccer player through the lens of the sport nutritionist.

This case study follows a professional internationally capped female soccer player's two-year journey from eumenorrhea, through injury, to amenorrhea, and the challenges faced by the player and nutritionist. The two years are split into three sections: (Areta et al. 2013) longitudinal profiling of the player, (Baker et al. 2020) nutrition to support her return from injury, and (Beato et al. 2018) investigation into the observed secondary amenorrhea. The cause of amenorrhea was investigated through the assessment of energy availability via doubly labelled water, remote food photography, blood biomarkers and resting metabolic rate. Despite having secondary amenorrhea and anovulatory cycles, the player did not have low energy availability. This study shows the importance for practitioner's, particularly nutritionists, to not assume that all menstrual irregularities are caused by low energy availability and could be caused by a combination of factors (e.g., clinical, physiological, and psychological), which requires a multi-disciplinary investigation and intervention team. This study also showed that education needs to be provided about menstrual health to elite female soccer players as the player (i) believed that not having a period was beneficial for performance and unsure of possible health implications; (ii) was convinced that a one-day bleed indicated a regular menstrual cycle; and (iii) was reluctant to waste the practitioners time discussing menstrual issues and was nervous of finding out if she had an actual health issue. It is therefore crucial that players feel comfortable in discussing their menstrual status with practitioners to support their performance and long-term health.

Dietary supplements for consideration in elite female footballers.

The physical demands of professional female football have intensified in recent years. Supplements are only advised in addition to a healthy, balanced diet, but may warrant a greater prevalence in the professional game to support well-being, recovery and performance. Supplements used by players should be safe, legal and scientifically proven to be effective. An individual approach should be taken to using supplements dependant on the needs and goals of the player. Female players should aim to improve the frequency of protein intake throughout the day, whilst tailoring doses to individual body mass. Vitamin D supplementation is vital throughout the winter months in countries with limited sun exposure, however doses should be administered based on individual blood test results. Iron is likely to be important to the well-being of female athletes throughout the season, in particular during the menses. Omega-3 and collagen may be of greater benefit to female than male athletes during recovery from soft tissue injury, whilst probiotics and creatine are beneficial throughout the season for reducing risk of illness and optimising recovery, respectively. Ergogenic supplements for football include beta-alanine, nitrate and caffeine. Caution should be taken with caffeine use due to the varying tolerance of difference athletes and sleep impairments that can follow.

Seasonal training and match load and micro-cycle periodization in male Premier League academy soccer players.

We quantified on pitch external loading of English Premier League (EPL) academy soccer players (n=76; U12-U18 age groups) over an entire competitive season. Mean accumulative weekly duration and total distance, respectively, was similar in the U12 (329±29 min; 19.9±2.2 km), U13 (323±29 min; 20.0±2.0 km) and U14 (339±25 min; 21.7±2.0 km; P>0.05 for all comparisons) age-groups, though all teams were less than U15 (421±15 min; 26.2±2.1 km), U16 (427±20 min; 25.9±2.5 km) and U18 (398±30 min; 26.1±2.6 km) players (P<0.05 for all comparisons). Mean weekly high-speed running and sprint distance was not different between U12 (220±95 m and 6±9 m respectively), U13 (331±212 m and 6±27 m) and U14 (448±193 m and 21±29 m) age-groups (P>0.05 for all pairwise comparisons) though all squads were less than U15 (657±242 m and 49±98 m), U16 (749±152 m and 95±55 m) and U18 (979±254 m and 123±56 m) age-groups (P<0.05 for all pairwise comparisons). Data demonstrate that absolute weekly training volume in EPL academy soccer players increases throughout the academy pathway. Furthermore, although U16-U18 players are capable of achieving similar training and match volumes as previously reported in adult EPL players, they do not yet achieve the absolute intensities of adult EPL players.

Energy Requirements of Male Academy Soccer Players from the English Premier League.

PURPOSE: This study aimed to inform the energy requirements of highly trained adolescent soccer players. Total energy expenditure (TEE) was quantified in academy soccer players from the English Premier League (EPL). METHODS: Twenty-four male adolescent soccer players from an EPL academy (under (U) 12/13 (U12/13), n = 8; U15, n = 8; U18, n = 8) were assessed for baseline maturity (maturity offset), body composition (dual-energy x-ray absorptiometry), and resting metabolic rate (indirect calorimetry). Subsequently, TEE, energy intake (EI) and physical loading patterns were assessed over a 14-d in-season period using doubly labeled water, the remote food photographic method, and global positioning system technology, respectively. RESULTS: U18 players presented with greater resting metabolic rate (2236 ± 93 kcal·d) and TEE (3586 ± 487 kcal·d; range, 2542-5172 kcal·d) than did both U15 (2023 ± 162 and 3029 ± 262 kcal·d, respectively; TEE range, 2738-3726 kcal·d) and U12/13 players (1892 ± 211 and 2859 ± 265 kcal·d, respectively; TEE range, 2275-3903 kcal·d; all, P < 0.01), although no difference in TEE was apparent between the U12/13 and U15 age groups. Fat-free mass was significantly different between all comparisons in a hierarchal manner (U18: 57.2 ± 6.1 kg > U15: 42.9 ± 5.8 kg > U12/13: 31.1 ± 3.5 kg; all, P < 0.01). Within age groups, no differences were apparent between EI and TEE (U12/13: -29 ± 277 kcal·d, P = 0.78; U15: -134 ± 327 kcal·d, P = 0.28; U18: -243 ± 724 kcal·d, P = 0.37), whereas U18 players (3180 ± 279 kcal·d) reported higher EI than did both U15 (2821 ± 338 kcal·d; P = 0.05) and U12/13 players (2659 ± 187 kcal·d; P < 0.01). CONCLUSIONS: The TEE of male academy soccer players progressively increase as players progress through the academy age groups. In some individuals (evident in all age groups), TEE was greater than that previously observed in adult EPL soccer players.

Cross-sectional comparison of body composition and resting metabolic rate in Premier League academy soccer players: Implications for growth and maturation.

For the first time we aimed to: (1) assess fat-free mass (FFM) and RMR in youth soccer players, (2) compare measured RMR to estimated RMR using previously published prediction equations, and (3) develop a novel population-specific prediction equation. In a cross-sectional design, 99 males from a Premier League academy underwent assessments of body composition (DXA) and RMR (indirect-calorimetry). Measured RMR was compared to estimated values from five prediction equations. A novel RMR prediction equation was developed using stepwise multiple regression. FFM increased (P<0.05) between U12 (31.6±4.2 kg) and U16 (56.3±5.3 kg) after which no further increases occurred (P>0.05). RMR in the U12s (1655±195 kcal.day-1), U13s (1720±205 kcal.day-1) and U14s (1846±218kcal.day-1) was significantly lower than the U15s (1957±128 kcal.day-1), U16s (2042±155 kcal.day-1), U18s (1875±180 kcal.day-1) and U23s (1941±197 kcal.day-1) squads (P>0.05). FFM was the single best predictor of RMR (r2=0.43; P<0.01) and was subsequently included in the novel prediction equation: RMR (kcal.day-1) = 1315 + (11.1 x FFM in kg). Both FFM and RMR increase from 12-16 years old, thus highlighting the requirement to adjust daily energy intake to support growth and maturation. The novel prediction RMR equation developed may help to inform daily energy requirements.

Use of computer decision support in an antimicrobial stewardship program (ASP).

OBJECTIVE: Document information needs, gaps within the current electronic applications and reports, and workflow interruptions requiring manual information searches that decreased the ability of our antimicrobial stewardship program (ASP) at Intermountain Healthcare (IH) to prospectively audit and provide feedback to clinicians to improve antimicrobial use. METHODS: A framework was used to provide access to patient information contained in the electronic medical record, the enterprise-wide data warehouse, the data-driven alert file and the enterprise-wide encounter file to generate alerts and reports via pagers, emails and through the Centers for Diseases and Control's National Healthcare Surveillance Network. RESULTS: Four new applications were developed and used by ASPs at Intermountain Medical Center (IMC) and Primary Children's Hospital (PCH) based on the design and input from the pharmacists and infectious diseases physicians and the new Center for Diseases Control and Prevention/National Healthcare Safety Network (NHSN) antibiotic utilization specifications. Data from IMC and PCH now show a general decrease in the use of drugs initially targeted by the ASP at both facilities. CONCLUSIONS: To be effective, ASPs need an enormous amount of "timely" information. Members of the ASP at IH report these new applications help them improve antibiotic use by allowing efficient, timely review and effective prioritization of patients receiving antimicrobials in order to optimize patient care.

The epidemiology of nephrotoxicity associated with conventional amphotericin B therapy.

PURPOSE: We sought to quantify the incidence of, define risk factors for, and examine the relation between renal functional impairment and treatment with conventional amphotericin B. SUBJECTS AND METHODS: We performed a 9-year retrospective analysis of amphotericin B-associated nephrotoxicity in 494 adult inpatients who received > or = 2 doses of amphotericin B. Nephrotoxicity was classified according to two nonmutually exclusive severity categories (50% increase or doubling in the baseline creatinine level). RESULTS: The median cumulative dosage of amphotericin B was 240 mg (interquartile range, 113 to 500 mg), with the majority of patients (n = 361) receiving it for empiric treatment. Overall, 139 (28%) patients experienced renal toxicity, including 58 (12%) with moderate-to-severe nephrotoxicity. The rate of nephrotoxicity was relatively constant during amphotericin B treatment. For each 10-mg increase in the mean daily amphotericin B dose, the adjusted rate of renal toxicity increased by a factor of 1.13 (95% confidence interval: 1.02 to 1.25). We defined 5 categorical risk factors: mean daily amphotericin B dose > or = 35 mg, male sex, weight > or = 90 kg, chronic renal disease, and use of amikacin or cyclosporine. The incidence of moderate-to-severe nephrotoxicity was 4% (6 of 137) in patients with none of these risk factors, 8% (14 of 181) in those with 1 risk factor, 18% (21 of 117) in those with 2 risk factors, and 29% (17 of 59) in patients with > or = 3 risk factors. Nephrotoxicity rarely led to hemodialysis (n = 3); however, at the time of discharge or death, 70% of patients with moderate-to-severe nephrotoxicity had a serum creatinine level that was > or = 0.5 mg/dL above baseline. CONCLUSION: Amphotericin B-related nephrotoxicity is an important dose-dependent and duration-dependent toxicity that is accentuated by certain nephrotoxic drugs and patient characteristics. Patients with more than two risk factors for nephrotoxicity are potential candidates for alternative antifungal therapy.

Clinical and financial impact of intravenous erythromycin therapy in hospitalized patients.

OBJECTIVE: To determine the economic consequences of intravenous erythromycin use in hospital patients in a variety of clinical circumstances. DESIGN: Retrospective cohort study of patients with specified primary diagnosis-related group discharge diagnoses treated from January 1, 1990, to December 31, 1994, who received erythromycin, and a matched cohort group from the same period who did not receive erythromycin. SETTING: LDS Hospital, Salt Lake City, UT, a 520-bed teaching hospital. PATIENTS: A long-term archive of clinical and financial data from a computerized hospital information system was searched for patients meeting a strict case definition. This archive contained information on erythromycin exposure as well as concurrent drug therapy and adverse drug events that had been prospectively evaluated during hospitalization throughout the study and cohort periods. Detailed costs were available for each patient. MAIN OUTCOME MEASURE: Attributable differences in lengths of stay and total costs determined using linear regression modeling. RESULTS: For 797 erythromycin patients and 2771 cohort patients, we found an attributable increased length of stay of 2.14 days and an increased cost of hospitalization of $6061 for erythromycin case patients. Case patients also had a significantly increased risk of adverse drug events. Linear regression modeling showed that erythromycin use was significantly related to increased length of stay and cost of hospitalization. CONCLUSIONS: Intravenous erythromycin use has been associated with significant increases in hospital length of stay and total hospital cost.

A computer-assisted management program for antibiotics and other antiinfective agents.

BACKGROUND AND METHODS: Optimal decisions about the use of antibiotics and other antiinfective agents in critically ill patients require access to a large amount of complex information. We have developed a computerized decision-support program linked to computer-based patient records that can assist physicians in the use of antiinfective agents and improve the quality of care. This program presents epidemiologic information, along with detailed recommendations and warnings. The program recommends antiinfective regimens and courses of therapy for particular patients and provides immediate feedback. We prospectively studied the use of the computerized antiinfectives-management program for one year in a 12-bed intensive care unit. RESULTS: During the intervention period, all 545 patients admitted were cared for with the aid of the antiinfectives-management program. Measures of processes and outcomes were compared with those for the 1136 patients admitted to the same unit during the two years before the intervention period. The use of the program led to significant reductions in orders for drugs to which the patients had reported allergies (35, vs. 146 during the preintervention period; P<0.01), excess drug dosages (87 vs. 405, P<0.01), and antibiotic-susceptibility mismatches (12 vs. 206, P<0.01). There were also marked reductions in the mean number of days of excessive drug dosage (2.7 vs. 5.9, P<0.002) and in adverse events caused by antiinfective agents (4 vs. 28, P<0.02). In analyses of patients who received antiinfective agents, those treated during the intervention period who always received the regimens recommended by the computer program (n=203) had significant reductions, as compared with those who did not always receive the recommended regimens (n= 195) and those in the preintervention cohort (n = 766), in the cost of antiinfective agents (adjusted mean, $102 vs. $427 and $340, respectively; P<0.001), in total hospital costs (adjusted mean, $26,315 vs. $44,865 and $35,283; P<0.001), and in the length of the hospital stay days (adjusted mean, 10.0 vs. 16.7 and 12.9; P<0.001). CONCLUSIONS; A computerized antiinfectives-management program can improve the quality of patient care and reduce costs.

Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality.

OBJECTIVE: To determine the excess length of stay, extra costs, and mortality attributable to adverse drug events (ADEs) in hospitalized patients. DESIGN: Matched case-control study. SETTING: The LDS Hospital, a tertiary care health care institution. PATIENTS: All patients admitted to LDS Hospital from January 1, 1990, to December 31, 1993, were eligible. Cases were defined as patients with ADEs that occurred during hospitalization; controls were selected according to matching variables in a stepwise fashion. METHODS: Controls were matched to cases on primary discharge diagnosis related group (DRG), age, sex, acuity, and year of admission; varying numbers of controls were matched to each case. Matching was successful for 71% of the cases, leading to 1580 cases and 20,197 controls. MAIN OUTCOME MEASURES: Crude and attributable mortality, crude and attributable length of stay, and cost of hospitalization. RESULTS: ADEs complicated 2.43 per 100 admissions to the LDS Hospital during the study period. The crude mortality rates for the cases and matched controls were 3.5% and 1.05%, respectively (P<.001). The mean length of hospital stay significantly differed between the cases and matched controls (7.69 vs 4.46 days; P<.001) as did the mean cost of hospitalization ($10,010 vs $5355; P<.001). The extra length of hospital stay attributable to an ADE was 1.74 days (P<.001). The excess cost of hospitalization attributable to an ADE was $2013 (P<.001). A linear regression analysis for length of stay and cost controlling for all matching variables revealed that the occurrence of an ADE was associated with increased length of stay of 1.91 days and an increased cost of $2262 (P<.001). In a similar logistic regression analysis for mortality, the increased risk of death among patients experiencing an ADE was 1.88 (95% confidence interval, 1.54-2.22; P<.001). CONCLUSION: The attributable lengths of stay and costs of hospitalization for ADEs are substantial. An ADE is associated with a significantly prolonged length of stay, increased economic burden, and an almost 2-fold increased risk of death.

Evaluation of the financial impact of ketorolac tromethamine therapy in hospitalized patients.

This retrospective cohort study aimed to determine the resource utilization and cost consequences of ketorolac tromethamine in postoperative pain management in a variety of clinical circumstances. All patients were treated at LDS Hospital, Salt Lake City, Utah, a 520-bed teaching hospital. A long-term archive of clinical and financial data from a computerized hospital information system was searched for patients with specified primary International Classification of Diseases, 9th Revision, Clinical Modification discharge diagnoses treated from June 1, 1990, to July 1, 1992, who received ketorolac (n = 229). These patients were matched with cohort patients (n = 821) treated from July 1, 1989, to May 31, 1990, who did not receive ketorolac. The archive contained information on ketorolac exposure as well as concurrent drug therapy and adverse drug events that had been prospectively evaluated during hospitalization throughout the study and cohort periods. Detailed costs were available for each patient. The study examined attributable differences in lengths of stay and total costs using linear regression modeling. We found a statistically significant attributable decreased length of stay for ketorolac patients of 1.15 days. Case patients also had reduced usage of narcotic drugs (4.39 fewer doses than cohorts and 15.6 hours shorter duration of narcotics than cohorts), reduced use of antiemetic and antipruritic medications, and reduced numbers of adverse events. Linear regression modeling showed that ketorolac use was significantly related to reduced cost using inflation-adjusted dollars. We believe that ketorolac has significant cost advantages over opiate analgesics because of its narcotic-sparing effects. Advantages of ketorolac use include reduced rates of adverse drug events, reduced lengths of stay, especially for orthopedic surgery, and reduced overall hospital costs for diagnosis-related groups associated with cholecystectomy.

A retrospective analysis of twice-daily cefotaxime compared to conventional therapy for the treatment of infections in a USA hospital.

A retrospective, matched cohort study was performed to determine the cost outcomes among 495 hospitalized patients who received twice-daily dosing of cefotaxime and 3949 matched cohorts who received other antibiotics. By an attribution model, twice-daily use was associated with shorter mean lengths of stay (-0.498 day, P < .7) and lower mean total costs of hospitalization (-$623, P < .8). Twice-daily dosing of cefotaxime is commonly employed for the treatment of a variety of serious infections, and appears to be cost effective.

Using a hospital information system to assess the effects of adverse drug events.

The most common adverse events experienced by hospitalized patients are drug related. While numerous studies have described the incidence and types of adverse drug events (ADEs), the actual effect of these events on patient outcomes have only been estimated. The studies that have described the effects of ADEs on patient outcomes have not stratified patients by severity of illness and hospital costs were estimated based on a percent of hospital charges. We designed a study to utilize the resources of our hospital information system to assess the attributable effects of ADEs on hospital length of stay and cost of hospitalization. This approach emphasized the difference between study patients and their matched control patients rather than overall differences between patients with and without ADEs. In addition, we used nursing acuity data to help adjust severity of illness within DRG groups and actual hospital costs were used instead of estimated costs. This study found that while the average length of stay for patients with ADEs was 8.19 days compared to 4.36 days for matched control patients, the attributable difference due to the ADEs was 1.94 days. Similar methods found that patients with ADEs had an average cost of hospitalization of $10,584 compared to $5,350 for those without and the attributable difference due to ADEs was $1,939. This indicates that the 569 ADEs at our hospital during 1992 resulted in an additional 1,104 extra patient days at a cost of $1,103,291.