Reduction in massive postpartum haemorrhage and red blood cell transfusion during a national quality improvement project, Obstetric Bleeding Strategy for Wales, OBS Cymru: an observational study.

BACKGROUND: Postpartum haemorrhage (PPH) is a major cause of maternal morbidity and mortality and its incidence is increasing in many countries despite management guidelines. A national quality improvement programme called the Obstetric Bleeding Strategy for Wales (OBS Cymru) was introduced in all obstetric units in Wales. The aim was to reduce moderate PPH (1000 mL) progressing to massive PPH (> 2500 mL) and the need for red cell transfusion. METHODS: A PPH care bundle was introduced into all 12 obstetric units in Wales included all women giving birth in 2017 and 2018 (n = 61,094). The care bundle prompted: universal risk assessment, quantitative measurement of blood loss after all deliveries (as opposed to visual estimation), structured escalation to senior clinicians and point-of-care viscoelastometric-guided early fibrinogen replacement. Data were submitted by each obstetric unit to a national database. Outcome measures were incidence of massive PPH (> 2500 mL) and red cell transfusion. Analysis was performed using linear regression of the all Wales monthly data. RESULTS: Uptake of the intervention was good: quantitative blood loss measurement and risk assessment increased to 98.1 and 64.5% of all PPH > 1000 mL, whilst ROTEM use for PPH > 1500 mL increased to 68.2%. Massive PPH decreased by 1.10 (95% CI 0.28 to 1.92) per 1000 maternities per year (P = 0.011). Fewer women progressed from moderate to massive PPH in the last 6 months, 74/1490 (5.0%), than in the first 6 months, 97/1386 (7.0%), (P = 0.021). Units of red cells transfused decreased by 7.4 (95% CI 1.6 to 13.2) per 1000 maternities per year (P = 0.015). Red cells were transfused to 350/15204 (2.3%) and 268/15150 (1.8%) (P = 0.001) in the first and last 6 months, respectively. There was no increase in the number of women with lowest haemoglobin below 80 g/L during this time period. Infusions of fresh frozen plasma fell and there was no increase in the number of women with haemostatic impairment. CONCLUSIONS: The OBS Cymru care bundle was feasible to implement and associated with progressive, clinically significant improvements in outcomes for PPH across Wales. It is applicable across obstetric units of widely varying size, complexity and staff mixes.

Designing and implementing an all Wales postpartum haemorrhage quality improvement project: OBS Cymru (the Obstetric Bleeding Strategy for Wales).

BACKGROUND: Postpartum haemorrhage (PPH) contributes to substantial maternal morbidity. Research into PPH has led to improvements in care which have been incorporated into the Obstetric Bleeding Strategy for Wales. INTERVENTION: A national quality improvement team supported local teams in implementing multiple interventions including risk assessment, objective measurement of blood loss, multiprofessional assessment (at the bedside at 1000 mL blood loss) and point-of-care (POC) testing of coagulation to guide blood product resuscitation during PPH. The project was rolled out to all 12 obstetric units in 2017. The interventions were reinforced by an All Wales Guideline, PPH proforma and standardised training. A national database, biannual audits, and patient and staff surveys reported process and outcome measures. RESULTS: Process measures: during 2017, there was an increase in the percentage of maternities with documented risk assessment (0%-76%), objective measurement of blood loss (52%-88%) and POC testing for coagulation for PPH ≥1500 mL (38%-59%). Maternity staff survey indicated that 94% were aware of the project and 87% stated that it had changed their unit's management of PPH. Interim outcome measures: the incidence (95% CI) of PPH ≥2500 mL per 1000 maternities in 2017 was 6.03 (5.23-6.95). The annual number of women receiving any red blood cell transfusion, level 3 intensive care admission and hysterectomy for PPH was 19.7 (18.2 to 21.3), 0.702 (0.464 to 1.06) and 0.255 (0.129 to 0.504) per 1000 maternities, respectively. CONCLUSIONS: A high level of project awareness across Welsh maternity units has been achieved. Measurement of blood loss was reported to be the most important early change in practice, while PPH documentation and POC testing continue to be embedded. Combining qualitative and quantitative measures to inform implementation has improved project delivery and allowed teams to adapt to local contexts.

Effects of two dietary fibers as part of ready-to-eat cereal (RTEC) breakfasts on perceived appetite and gut hormones in overweight women.

The effects of an enzyme-hydrolyzed arabinoxylan from wheat (AXOS) versus an intact arabinoxylan from flax (FLAX) added to a ready-to-eat cereal (RTEC) on the postprandial appetitive, hormonal, and metabolic responses in overweight women (BMI 25.0-29.9 kg/m2) were evaluated. Subsequent meal energy intake was also assessed. Two randomized, double-blind, crossover design studies were completed. For trial 1, the participants consumed the following RTEC breakfast, matched for total weight and varied in energy content: low-fiber (LF, 4 g); high-fiber (HF, 15 g) as either AXOS or FLAX. For trial 2, the participants consumed LF, HF-AXOS, and HF-FLAX RTECs but also consumed another LF breakfast that was isocaloric (LF-iso) to that of the HF breakfasts. Perceived appetite and blood samples (trial 2 only) were assessed before and after breakfast. An ad libitum lunch was offered 4 h post-breakfast. No differences in postprandial appetite responses were observed among any breakfasts in either trial. The HF-AXOS and HF-FLAX led to increased postprandial GLP-1 and peptide YY (PYY) concentrations vs. LF-iso. No differences were observed in lunch meal energy intake among breakfast meals in either trial. Collectively, these data suggest that 15 g of low molecular weight fiber added to RTECs did not affect perceived appetite or subsequent energy intake despite differences in satiety hormone signaling in overweight females.

Fermentable fibers do not affect satiety or food intake by women who do not practice restrained eating.

BACKGROUND: Fiber is thought to enhance satiety, although not all fibers are equally effective. Colonic fermentation may influence satiety and food intake. OBJECTIVE: To test the satiating properties of four isolated fibers added to chocolate crisp bars. DESIGN: Within-subject preload design with repeated measures. Each participant completed five conditions, presented in random order. SUBJECTS: Participants were 22 adult women who do not practice restrained eating (body mass index 18 to 29). INTERVENTION: The experimental conditions were four fiber treatments: 10 g oligofructose, inulin, soluble corn fiber, or resistant wheat starch in chocolate crisp bars. A no-added-fiber bar was evaluated as the control. The night before each treatment, participants consumed a dinner bar containing 10 g of the same fiber given the next morning. MAIN OUTCOME MEASURES: Repeated ratings of feelings related to hunger and fullness at the lunch meal were the main measures. Secondary outcomes included breath hydrogen and methane, gastrointestinal symptoms, energy consumed at an ad libitum lunch, and energy from 24-hour dietary recall. STATISTICAL ANALYSES PERFORMED: Mixed-effect linear models with random intercept for participants to model within-subject correlation. RESULTS: All treatments were well tolerated. No differences were found in subjective satiety during the morning or food intake at lunch or over 24 hours. The oligofructose bar produced the greatest increase in breath hydrogen, and the most bloating and flatulence symptoms. CONCLUSIONS: Functional fibers incorporated into chocolate bars at high fiber doses produce greater gastrointestinal symptoms than control, but do not alter satiety, hunger, or food intake compared with control in the short term.

Effect of food form on postprandial plasma amino acid concentrations in older adults.

To assess the effect of food form (FF) on postprandial (PP) plasma amino acid (AA) concentrations, ten older adults (five men and five women, age 72 (sem 2) years, BMI 26.0 (sem 0.9) kg/m2) consumed, on separate days, energy and macronutrient-matched test meal replacement products (MRP) (approximately 25 % of the subject's daily energy need; approximately 54 % carbohydrate, 21 % protein, 25 % fat) in beverage and solid form. Blood samples were taken during fasting and throughout the 4 h PP period; plasma AA concentrations were assessed using HPLC. Consumption of each MRP led to an increase in total AA, branched-chain AA (BCAA), essential AA (EAA), non-essential AA (NEAA) and leucine concentrations (4 h area under the curve, AUC) (time effect; P < 0.05). The beverage MRP resulted in a greater initial (i.e. 30 min) and sustained (4 h AUC) increase in total AA, BCAA, EAA, NEAA and leucine concentrations compared with the solid MRP (each effect of FF; P < 0.05). Although there was no effect of FF on PP insulin response, glucose concentration was greater 1 and 2 h after the solid MRP was consumed (FF × time interaction; P < 0.05). For all PP time points combined, total AA concentration was positively associated with plasma insulin (r 0.25) and glucose (r 0.24) concentrations for the solid MRP but not for the beverage MRP. In conclusion, older adults can achieve higher plasma AA concentrations when a protein-containing MRP is ingested in beverage form. The implications of the higher AA availability on anabolic processes warrant investigation.

A comparison of the United Kingdom clinical aptitude test (UK-CAT) with a traditional admission selection process.

BACKGROUND: The United Kingdom Clinical Aptitude Test (UK-CAT) was introduced for the purpose of student selection by a consortium of 23 UK University Medical and Dental Schools, including the University of Aberdeen in 2006. AIM: To compare candidate performance on UK-CAT with local medical student selection outcome. METHOD: We compared the outcomes of all applicants to Medicine, University of Aberdeen (UoA), in 2006 who undertook the UK-CAT. The candidates were selected into one of five outcomes (academic reject, reject following assessment, reject following interview, reserve list or offer). The candidate performance in the UK-CAT was compared to candidate performance on the UoA selection. RESULTS: Data are reported on 1307 (85.0%) students who applied to UoA in 2006 and undertook the UK-CAT. Total UK-CAT scores were significantly correlated with local selection scores. However, of 314 students offered a place following the conventional selection process, only 101 were also in the highest scoring 318 on the UK-CAT. CONCLUSIONS: Results from this study indicate that UK-CAT scores show weak correlation with success in our medical admissions process. It appears therefore that the UK-CAT examines different traits compared to our selection process. Further work is required to establish which better predicts success as an undergraduate or as a doctor.

The effect of a plant-based low-carbohydrate ("Eco-Atkins") diet on body weight and blood lipid concentrations in hyperlipidemic subjects.

BACKGROUND: Low-carbohydrate, high-animal protein diets, which are advocated for weight loss, may not promote the desired reduction in low-density lipoprotein cholesterol (LDL-C) concentration. The effect of exchanging the animal proteins and fats for those of vegetable origin has not been tested. Our objective was to determine the effect on weight loss and LDL-C concentration of a low-carbohydrate diet high in vegetable proteins from gluten, soy, nuts, fruits, vegetables, cereals, and vegetable oils compared with a high-carbohydrate diet based on low-fat dairy and whole grain products. METHODS: A total of 47 overweight hyperlipidemic men and women consumed either (1) a low-carbohydrate (26% of total calories), high-vegetable protein (31% from gluten, soy, nuts, fruit, vegetables, and cereals), and vegetable oil (43%) plant-based diet or (2) a high-carbohydrate lacto-ovo vegetarian diet (58% carbohydrate, 16% protein, and 25% fat) for 4 weeks each in a parallel study design. The study food was provided at 60% of calorie requirements. RESULTS: Of the 47 subjects, 44 (94%) (test, n = 22 [92%]; control, n = 22 [96%]) completed the study. Weight loss was similar for both diets (approximately 4.0 kg). However, reductions in LDL-C concentration and total cholesterol-HDL-C and apolipoprotein B-apolipoprotein AI ratios were greater for the low-carbohydrate compared with the high-carbohydrate diet (-8.1% [P = .002], -8.7% [P = .004], and -9.6% [P = .001], respectively). Reductions in systolic and diastolic blood pressure were also seen (-1.9% [P = .052] and -2.4% [P = .02], respectively). CONCLUSION: A low-carbohydrate plant-based diet has lipid-lowering advantages over a high-carbohydrate, low-fat weight-loss diet in improving heart disease risk factors not seen with conventional low-fat diets with animal products.

Soy protein supplementation does not cause lymphocytopenia in postmenopausal women.

BACKGROUND: The health benefits of soy isoflavones have been widely investigated; however, there are some concerns as to whether soy isoflavones, similar to ipriflavone, a synthetic isoflavone, cause lymphocytopenia in postmenopausal women. Hence, the purpose of this study was to investigate the extent to which 12-month supplementation of 25 g soy protein containing 60 mg isoflavones alters lymphocyte counts or other hematological parameters in postmenopausal women who were not on hormone replacement therapy. METHODS: Eighty-seven postmenopausal women were randomly assigned to receive either soy protein or an equivalent amount of control protein devoid of isoflavones. Fasting venous blood was collected at baseline and at the end of twelve month study period for complete blood count analyses. RESULTS: Between the two treatment groups, the percent changes in hematological parameters, including lymphocytes, were not different. While women consuming the soy supplement had an increase in mean corpuscular hemoglobin concentration (MCHC) and red cell distribution width index (RDW; a marker of reticulocytes), women consuming the control diet had higher percentage of only MCHC. CONCLUSION: Overall, the results of the present study indicate that consumption of 25 g soy protein containing 60 mg isoflavones daily for one year does not cause lymphocytopenia.

Soy protein with isoflavones, but not an isoflavone-rich supplement, improves arterial low-density lipoprotein metabolism and atherogenesis.

OBJECTIVE: We sought to determine if arterial LDL metabolism contributes to the decreased atherosclerosis seen with soy and if isolated isoflavones would have similar effects. METHODS AND RESULTS: Ovariectomized monkeys were fed an atherogenic diet for 20 weeks with a protein source of (1) casein/lactalbumin (CAS, n=20), (2) soy protein isolate (SOY, n=20), or (3) casein/lactalbumin with isolated soy isoflavones (ISO, n=17). Plasma lipoprotein concentrations were improved with SOY but not ISO. Arterial LDL metabolism was characterized with one subset (n=12/group) injected with dual-labeled tyramine-cellobiose (TC)-LDL (125I-TC-131I-LDL) 24 hours before necropsy to determine LDL degradation and accumulation, while another subset (n=8/group) was injected with 125I-TC-LDL 1 hour before necropsy to determine LDL permeability and delivery. CONCLUSIONS: Coronary artery LDL degradation was reduced by 50% (P=0.02) with SOY but not with ISO compared with CAS. Neither treatment altered arterial permeability. Reduced LDL degradation with SOY was due to decreased arterial LDL delivery (P=0.02). Carotid artery cholesterol ester was also decreased with SOY, but not with ISO. Plasma isoprostanes or plasma markers of inflammation did not differ among treatment groups. Thus, the decreased arterial LDL delivery and subsequent LDL degradation may explain, in part, the atheroprotective effects of soy.

Cholesteryl ester transfer protein and lecithin:cholesterol acyltransferase activities in hispanic and anglo postmenopausal women: associations with total and regional body fat.

Reverse cholesterol transport is one process by which high-density lipoprotein (HDL) cholesterol has been hypothesized to play a role in reducing the risk of coronary heart disease. This study was designed to examine cholesteryl ester transfer protein (CETP) and lecithin:cholesterol acyltransferase (LCAT) activities, 2 modulators of reverse cholesterol transport, in Hispanic and Anglo postmenopausal women. The associations between plasma CETP and LCAT activities and body composition were also examined. Of the 199 subjects, 33% were of Hispanic origin and 47% were undergoing hormone replacement therapy (HRT). Body composition was measured by dual-energy x-ray absorptiometry (DXA) and anthropometry. Plasma CETP activity was higher in Hispanic compared to Anglo women, although the difference was eliminated when data were adjusted for abdominal fat. Hispanic women had lower plasma HDL cholesterol concentrations, higher total cholesterol:HDL cholesterol ratios and triglyceride concentrations, and greater susceptibility of low-density lipoprotein (LDL) particles to oxidation. Hispanic women also had a significantly greater relative deposition of body fat on the trunk and intra-abdominally than did Anglo women, even after adjusting for total body fat. There were no significant ethnic differences in LCAT activity. Plasma CETP and LCAT activities were negatively correlated with HDL cholesterol and positively correlated with total cholesterol, LDL cholesterol, and triglycerides, as well as total and regional body composition variables. In conclusion, results suggest a greater risk for coronary heart disease in Hispanic women compared to Anglo women.