A role in trauma care for advanced practice clinicians.

Advanced practice clinicians (APCs) are increasingly being utilized to care for patients on trauma services, but the quality of care provided by these alternate delivery models has been questioned. We hypothesized that APCs could safely administer trauma care that had traditionally been provided by surgical residents. Outcomes from an APC trauma-care delivery model were compared with those reported in the National Trauma Data Bank (NTDB). Parameters included in the comparison were mechanism of injury (MOI), length of hospital stay (LOS), injury severity score (ISS), and mortality. When MOI was used as the basis of comparison, the percentage of patients treated at the trauma center and the percentage of patients with information in the NTDB were similar. Despite having more seriously injured patients, the APC-staffed trauma center demonstrated a shorter LOS for all ISS categories; comparisons of patients with ISS >24 did not reach statistical significance. In addition, the APC-staffed trauma center had a statistically lower overall combined mortality rate when categorized by ISS. We conclude that an APC trauma-care delivery model provides outcomes at least as good as those reported by the NTDB.

How well do blood folate concentrations predict dietary folate intakes in a sample of Canadian lactating women exposed to high levels of folate? An observational study.

BACKGROUND: In 1998, mandatory folic acid fortification of white flour and select cereal grain products was implemented in Canada with the intention to increase dietary folate intakes of reproducing women. Folic acid fortification has produced a dramatic increase in blood folate concentrations among reproductive age women, and a reduction in neural tube defect (NTD)-affected pregnancies. In response to improved blood folate concentrations, many health care professionals are asking whether a folic acid supplement is necessary for NTD prevention among women with high blood folate values, and how reliably high RBC folate concentrations predict folate intakes shown in randomized controlled trials to be protective against NTDs. The objective of this study was to determine how predictive blood folate concentrations and folate intakes are of each other in a sample of well-educated lactating Canadian women exposed to high levels of synthetic folate. METHODS: The relationship between blood folate concentrations and dietary folate intakes, determined by weighed food records, were assessed in a sample of predominantly university-educated lactating women (32 +/- 4 yr) at 4-(n = 53) and 16-wk postpartum (n = 55). RESULTS: Median blood folate concentrations of all participants were well above plasma and RBC folate cut-off levels indicative of deficiency (6.7 and 317 nmol/L, respectively) and all, except for 2 subjects, were above the cut-off for NTD-risk reduction (>906 nmol/L). Only modest associations existed between total folate intakes and plasma (r = 0.46, P < 0.001) and RBC (r = 0.36, P < 0.01) folate concentrations at 16-wk postpartum. Plasma and RBC folate values at 16-wk postpartum correctly identified the quartile of folate intake of only 26 of 55 (47%) and 18 of 55 (33%) of subjects, respectively. The mean RBC folate concentration of women consuming 151-410 microg/d of synthetic folate (2nd quartile of intake) did not differ from that of women consuming >410 microg/d (3rd and 4th quartile). CONCLUSION: Folate intakes, estimated by food composition tables, and blood folate concentrations are not predictive of each other in Canadian lactating women exposed to high levels of folate. Synthetic intakes > 151-410 microg/d in these women produced little additional benefit in terms of maximizing RBC content. More studies are needed to examine the relationship between blood folate concentration and NTD risk. Until data from such studies are available, women planning a pregnancy should continue to consume a daily folic acid supplement of 400 microg.

[6S]-5-Methyltetrahydrofolate is at least as effective as folic acid in preventing a decline in blood folate concentrations during lactation.

BACKGROUND: Studies in nonpregnant, nonlactating women suggest that folate supplementation in the form of 5-methyltetrahydrofolate ([6S]-5-methylTHF) is at least as effective as folic acid in increasing blood folate indexes. No data, however, are available on the effect of supplemental [6S]-5-methylTHF on blood folate concentrations during lactation. OBJECTIVE: We assessed the relative effectiveness of [6S]-5-methylTHF, a placebo, and folic acid in maintaining blood folate indexes during lactation in a sample of healthy Canadian women consuming folic acid-fortified foods. DESIGN: This study was designed as a 16-wk, randomized, placebo-controlled intervention. Pregnant women (n = 72) advised to consume a folic acid-containing prenatal supplement (1000 microg/d) during pregnancy were enrolled at 36 wk gestation. After delivery, the women were randomly assigned to receive [6S]-5-methylTHF (416 microg/d, 906 nmol/d) or a placebo or were assigned to a folic acid (400 microg/d, 906 nmol/d) reference group. RESULTS: At 16 wk of lactation, the mean red blood cell (RBC) folate concentration in women in the [6S]-5-methylTHF group (2178; 95% CI: 1854, 2559 nmol/L) was greater than that in the folic acid (1967; 1628, 2377 nmol/L; P < 0.05) and placebo (1390; 1198, 1613 nmol/L; P < 0.002) groups after adjustment for baseline concentrations (36 wk gestation). The distribution of folate forms in RBCs did not differ significantly between the [6S]-5-methylTHF and placebo groups. However, the folic acid group had greater amounts of 5-formylTHF (P < 0.03). CONCLUSION: [6S]-5-MethylTHF appeared to be as effective as, and perhaps more effective than, folic acid in preserving RBC folate concentrations during lactation.

One-third of pregnant and lactating women may not be meeting their folate requirements from diet alone based on mandated levels of folic acid fortification.

Many women are advised to consume a folic acid-containing prenatal supplement for the duration of pregnancy and lactation. Whether this remains necessary after folic acid fortification of the food supply in North America has yet to be determined. Our objective was to assess the dietary folate intake of a sample of pregnant and lactating women at mandated and predicted folic acid-fortification levels and determine the prevalence of inadequate and excessive intakes. Weighed food records (for 3 d) were collected from predominantly university-educated women (32 +/- 4 y of age) at 36 wk of pregnancy (n = 61) and at 4 and 16 wk of lactation (n = 60). Dietary folate intakes during pregnancy and lactation, assuming fortification at mandated levels (140-150 micro g/100 g), were 562 +/- 106 and 498 +/- 99 micro g/d dietary folate equivalents (DFE), respectively. The prevalence of inadequacy for folate, or the proportion of individuals with usual folate intakes less than their nutrient requirement, was 36% for women during pregnancy (estimated average requirement of 520 micro g/d DFE), and 32% during lactation (estimated average requirement of 450 micro g/d DFE). Assuming fortification at twice the mandated level, mean dietary intakes during pregnancy and lactation were 786 +/- 132 and 716 +/- 150 micro g/d DFE, respectively, producing only a 3% prevalence of folate inadequacy. Grains contributed approximately 41% of total folate intake followed by fruits and vegetables (approximately 21%). To conclude, at mandated levels of fortification many pregnant and lactating women are unlikely to meet their folate requirements from dietary sources alone; however, the actual level of inadequacy cannot be determined until the level of folic acid in the food supply is known with greater precision.