Community Trial of a Faith-Based Lifestyle Intervention to Prevent Diabetes Among African-Americans.

About 75% of African-Americans (AAs) ages 20 or older are overweight and nearly 50% are obese, but community-based programs to reduce diabetes risk in AAs are rare. Our objective was to reduce weight and fasting plasma glucose (FPG) and increase physical activity (PA) from baseline to week-12 and to month-12 among overweight AA parishioners through a faith-based adaptation of the Diabetes Prevention Program called Fit Body and Soul (FBAS). We conducted a single-blinded, cluster randomized, community trial in 20 AA churches enrolling 604 AAs, aged 20-64 years with BMI ≥ 25 kg/m(2) and without diabetes. The church (and their parishioners) was randomized to FBAS or health education (HE). FBAS participants had a significant difference in adjusted weight loss compared with those in HE (2.62 vs. 0.50 kg, p = 0.001) at 12-weeks and (2.39 vs. -0.465 kg, p = 0.005) at 12-months and were more likely (13%) than HE participants (3%) to achieve a 7% weight loss (p < 0.001) at 12-weeks and a 7% weight loss (19 vs. 8%, p < 0.001) at 12-months. There were no significant differences in FPG and PA between arms. Of the 15.2% of participants with baseline pre-diabetes, those in FBAS had, however, a significant decline in FPG (10.93 mg/dl) at 12-weeks compared with the 4.22 mg/dl increase in HE (p = 0.017), and these differences became larger at 12-months (FBAS, 12.38 mg/dl decrease; HE, 4.44 mg/dl increase) (p = 0.021). Our faith-based adaptation of the DPP led to a significant reduction in weight overall and in FPG among pre-diabetes participants. CLINICALTRIALS. GOV IDENTIFIER: NCT01730196.

Design of a cluster-randomized controlled trial of a diabetes prevention program within African-American churches: The Fit Body and Soul study.

Evidence from varied community settings has shown that the Group Lifestyle Balance (GLB) Program and other adaptations of the Diabetes Prevention Program (DPP) intervention are effective in lowering diabetes risk. Most DPP data originated from studies of pre-diabetic whites, with only sparse evidence of the effect of DPP in African Americans (AAs) in community settings. This paper describes the design, methods, baseline characteristics and cost effective measures, of a single-blinded, cluster-randomized trial of a faith-based adaptation of the GLB program, Fit Body and Soul (FBAS). The major aims are to test efficacy and cost utility of FBAS in twenty AA churches. Randomization occurred at the church level and 604 AA overweight/obese (BMI≥25kg/m(2)) adults with fasting plasma glucose range from normal to pre-diabetic received either FBAS or a health-education comparison program. FBAS is a group-based, multi-level intervention delivered by trained church health advisors (health professionals from within the church), with the goal of ≥7% weight loss, achieved through increasing physical activity, healthy eating and behavior modification. The primary outcome is weight change at 12weeks post intervention. Secondary outcomes include hemoglobin A1C, fasting plasma glucose, waist circumference, blood pressure, physical activity level, quality of life measures, and cost-effectiveness. FBAS is the largest known cohort of AAs enrolled in a faith-based DPP translation. Reliance on health professionals from within the church for program implementation and the cost analysis are unique aspects of this trial. The design provides a model for faith-based DPPs and holds promise for program sustainability and widespread dissemination.

Leading causes of unintentional and intentional injury mortality: United States, 2000-2009.

OBJECTIVES: We have described national trends for the 5 leading external causes of injury mortality. METHODS: We used negative binomial regression and annual underlying cause-of-death data for US residents for 2000 through 2009. RESULTS: Mortality rates for unintentional poisoning, unintentional falls, and suicide increased by 128%, 71%, and 15%, respectively. The unintentional motor vehicle traffic crash mortality rate declined 25%. Suicide ranked first as a cause of injury mortality, followed by motor vehicle traffic crashes, poisoning, falls, and homicide. Females had a lower injury mortality rate than did males. The adjusted fall mortality rate displayed a positive age gradient. Blacks and Hispanics had lower adjusted motor vehicle traffic crash and suicide mortality rates and higher adjusted homicide rates than did Whites, and a lower unadjusted total injury mortality rate. CONCLUSIONS: Mortality rates for suicide, poisoning, and falls rose substantially over the past decade. Suicide has surpassed motor vehicle traffic crashes as the leading cause of injury mortality. Comprehensive traffic safety measures have successfully reduced the national motor vehicle traffic crash mortality rate. Similar efforts will be required to diminish the burden of other injury.

Evolution of the literature identifying physicians' roles in leadership, clinical development, and practice of the subspecialty of emergency medical services.

PURPOSE: The 2007 Institute of Medicine report entitled Emergency Medical Services at the Crossroads identified a need for the establishment of physician subspecialty certification in emergency medical services (EMS). The purpose of this study was to identify and explore the evolution of publications that define the role of the physician in EMS systems in the United States. METHODS: Three comprehensive searches were undertaken to identify articles that define the physician's role in the leadership, clinical development, and practice of EMS. Independent reviewers then evaluated these articles to further determine whether the articles identified the physician's role in EMS. Then, identified articles were classified by the type of publication in order to evaluate the transition from a non-peer reviewed to peer-reviewed literature base and an analysis was performed on the differences in the growth between these two groups. In addition, for the peer-reviewed articles, an analysis was performed to identify the proportion of articles that were quantitative versus qualitative in nature. RESULTS: The comprehensive review identified 1,504 articles. Ninety articles were excluded due to lack of relevance to the US. The remaining 1,414 articles were reviewed, and 194 papers that address the physician's role within EMS systems were identified; 72 additional articles were identified by hand search of references for a total of 266 articles. The percentage of peer-reviewed articles has increased steadily over the past three decades. In addition, the percentage of quantitative articles increased from the first decade to the second and third decades. CONCLUSIONS: This comprehensive review demonstrates that over the past 30 years an evidence base addressing the role of the physician in EMS has developed. This evidence base has steadily evolved to include a greater proportion of peer-reviewed, quantitative literature.

Rapid HIV testing in a southeastern emergency department serving a semiurban-semirural adolescent and adult population.

OBJECTIVE: We determine the feasibility and yield of universal opt-out HIV screening among adolescents and adults in a southeastern emergency department (ED) serving a semiurban-semirural population. METHODS: Individuals aged 13 to 64 years who visited the ED during specified hours received the OraQuick rapid HIV test (administered by trained counselors) if they did not opt out. Western blot was used to confirm reactive results. Patients were excluded if they had a history of HIV, had been tested within the past year, were physically or mentally incapacitated, did not understand their right to opt out, or did not speak English or Spanish. Basic demographic information was analyzed by using standard descriptive statistics. Measures of diagnostic test performance were calculated for all valid tests. RESULTS: From March 2008 through August 2009, 91% (n=8,493) of eligible patients accepted testing, and results were valid. Of 41 reactive results, 35 were confirmed HIV positive, 2 were indeterminate by Western blot, and 4 were false positive. Blacks accounted for the largest percentage (0.65%) of newly detected infections, and the percentage among black men (1%) was more than twice the percentage among black women (0.42%). Rapid-test specificity was estimated at 99.95% (95% confidence interval 99.88% to 99.98%). Nearly 75% of patients confirmed as HIV positive kept their first HIV clinic appointment. CONCLUSION: High rates of acceptance of testing in an ED and linkage to HIV care for adolescents and adults with newly detected infection can be achieved by using opt-out testing and trained HIV counselors.

Creating a nationally representative sample of patients from trauma centers.

BACKGROUND: The National Trauma Data Bank (NTDB) was developed as a convenience sample of registry data from contributing trauma centers (TCs), thus, inferences about trauma patients may not be valid at the national level. The NTDB National Sample was created to obtain nationally representative estimates of trauma patients treated in the US level I and II TCs. METHODS: Level I and II TCs in the Trauma Information Exchange Program were identified and a random stratified sample of 100 TCs was selected. The probability-proportional-to-size method was used to select TCs and sample weights were calculated. National Sample Program estimates from 2003 to 2006 were compared with raw NTDB data, and to a subset of TCs in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample, a population-based dataset drawn from community hospitals. RESULTS: Weighted estimates from the NTDB National Sample range from 484,000 (2004) to 608,000 (2006) trauma incidents. Crude NTDB data over-represented the proportion of younger patients (0 years-14 years) compared with the NTDB National Sample, which does not include children's hospitals. Few TCs in Trauma Information Exchange Program are included in Healthcare Cost and Utilization Project Nationwide Inpatient Sample, but estimates based on this subset indicate a higher percentage of older patients (age 65 year or older, 23.98% versus 17.85%), lower percentage male patients, and a lower percentage of motor vehicle accidents compared with NTDB National Sample. CONCLUSION: Although nationally representative data regarding trauma patients are available in other population-based samples, they do not represent TCs patients and lack the specificity of National Sample Program data, which contains detailed information on injury mechanisms, diagnoses, and hospital treatment.

Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage.

In the United States, injury is the leading cause of death for persons aged 1--44 years, and the approximately 800,000 emergency medical services (EMS) providers have a substantial impact on the care of injured persons and on public health. At an injury scene, EMS providers determine the severity of injury, initiate medical management, and identify the most appropriate facility to which to transport the patient through a process called "field triage." Although basic emergency services generally are consistent across hospital emergency departments (EDs), certain hospitals have additional expertise, resources, and equipment for treating severely injured patients. Such facilities, called "trauma centers," are classified from Level I (centers providing the highest level of trauma care) to Level IV (centers providing initial trauma care and transfer to a higher level of trauma care if necessary) depending on the scope of resources and services available. The risk for death of a severely injured person is 25% lower if the patient receives care at a Level I trauma center. However, not all patients require the services of a Level I trauma center; patients who are injured less severely might be served better by being transported to a closer ED capable of managing milder injuries. Transferring all injured patients to Level I trauma centers might overburden the centers, have a negative impact on patient outcomes, and decrease cost effectiveness. In 1986, the American College of Surgeons developed the Field Triage Decision Scheme (Decision Scheme), which serves as the basis for triage protocols for state and local EMS systems across the United States. The Decision Scheme is an algorithm that guides EMS providers through four decision steps (physiologic, anatomic, mechanism of injury, and special considerations) to determine the most appropriate destination facility within the local trauma care system. Since its initial publication in 1986, the Decision Scheme has been revised four times. In 2005, with support from the National Highway Traffic Safety Administration, CDC began facilitating revision of the Decision Scheme by hosting a series of meetings of the National Expert Panel on Field Triage, which includes injury-care providers, public health professionals, automotive industry representatives, and officials from federal agencies. The Panel reviewed relevant literature, presented its findings, and reached consensus on necessary revisions. The revised Decision Scheme was published in 2006. This report describes the process and rationale used by the Expert Panel to revise the Decision Scheme.

Acceptance of rapid HIV screening in a southeastern emergency department.

OBJECTIVES: The objective was to assess the acceptance of an emergency department (ED) human immunodeficiency virus (HIV) screening program based on the Centers for Disease Control and Prevention (CDC) recommendations for routine HIV screening in health care settings. METHODS: Rapid HIV screening was offered on an opt-out basis to patients aged 13 to 64 years presenting to the ED by trained HIV counselors. Patients were excluded if they had a history of HIV, were physically or mentally incapacitated, did not understand their right to opt-out, or did not speak English or Spanish. Statistical analyses, including logistic regression, were performed to assess the associations between the demographics of patients offered testing and their test acceptance or refusal. RESULTS: From March 2008 to January 2009, a total of 5,080 (91%) of the 5,585 patients offered the HIV test accepted, and 506 (9%) refused. White and married patients were less likely to accept testing than those who were African American and unmarried (p < 0.001). Adult patients were almost twice as likely to accept testing as pediatric patients (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.50 to 2.53). As age increased among pediatric patients, testing refusal decreased (OR = 0.71; 95% CI = 0.59 to 0.85), and as age increased among adult patients, testing refusal increased (OR = 1.17; 95% CI = 1.12 to 1.22). Two percent of persons accepting the test were considered high risk. Males were more likely to report high-risk behavior than females (OR = 1.83; 95% CI = 1.23 to 2.72). CONCLUSIONS: The opt-out approach results in high acceptance of routine HIV screening. Widespread adoption of the CDC's recommendations, although feasible, will require significant increases in resources.

A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness.

BACKGROUND: Various organizations and universities have developed competencies for health professionals and other emergency responders. Little effort has been devoted to the integration of these competencies across health specialties and professions. The American Medical Association Center for Public Health Preparedness and Disaster Response convened an expert working group (EWG) to review extant competencies and achieve consensus on an educational framework and competency set from which educators could devise learning objectives and curricula tailored to fit the needs of all health professionals in a disaster. METHODS: The EWG conducted a systematic review of peer-reviewed and non-peer reviewed published literature. In addition, after-action reports from Hurricane Katrina and relevant publications recommended by EWG members and other subject matter experts were reviewed for congruencies and gaps. Consensus was ensured through a 3-stage Delphi process. RESULTS: The EWG process developed a new educational framework for disaster medicine and public health preparedness based on consensus identification of 7 core learning domains, 19 core competencies, and 73 specific competencies targeted at 3 broad health personnel categories. CONCLUSIONS: The competencies can be applied to a wide range of health professionals who are expected to perform at different levels (informed worker/student, practitioner, leader) according to experience, professional role, level of education, or job function. Although these competencies strongly reflect lessons learned following the health system response to Hurricane Katrina, it must be understood that preparedness is a process, and that these competencies must be reviewed continually and refined over time.

Public health considerations in knowledge translation in the emergency department.

Effective preventive and screening interventions have not been widely adopted in emergency departments (EDs). Barriers to knowledge translation of these initiatives include lack of knowledge of current evidence, perceived lack of efficacy, and resource availability. To address this challenge, the Academic Emergency Medicine 2007 Consensus Conference, "Knowledge Translation in Emergency Medicine: Establishing a Research Agenda and Guide Map for Evidence Uptake," convened a public health focus group. The question this group addressed was "What are the unique contextual elements that need to be addressed to bring proven preventive and other public health initiatives into the ED setting?" Public health experts communicated via the Internet beforehand and at a breakout session during the conference to reach consensus on this topic, using published evidence and expert opinion. Recommendations include 1) to integrate proven public health interventions into the emergency medicine core curriculum, 2) to configure clinical information systems to facilitate public health interventions, and 3) to use ancillary ED personnel to enhance delivery of public health interventions and to obtain successful funding for these initiatives. Because additional research in this area is needed, a research agenda for this important topic was also developed. The ED provides medical care to a unique population, many with increased needs for preventive care. Because these individuals may have limited access to screening and preventive interventions, wider adoption of these initiatives may improve the health of this vulnerable population.

Blast-related injuries from terrorism: an international perspective.

Terrorism using conventional weapons and explosive devices is a likely scenario and occurs almost daily somewhere in the world. Caring for those injured from explosive devices is a major concern for acute injury care providers. Learning from nations that have experienced conventional weapon attacks on their civilian population is critical to improving preparedness worldwide. In September 2005, a multidisciplinary meeting of blast-related injury experts was convened including representatives from eight countries with experience responding to terrorist bombings (Australia, Colombia, Iraq, Israel, United Kingdom, Spain, Saudi Arabia, and Turkey). This article describes these experiences and provides a summary of common findings that can be used by others in preparing for and responding to civilian casualties resulting from the detonation of explosive devices.