Showing papers by "Lee A. Green published in 2009"

AAFP guideline for the detection and management of post-myocardial infarction depression

Abstract: EVIDENCE-BASED RECOMMENDATIONS The American Academy of Family Physicians (AAFP) Commission on Science convened a panel to review the evidence on the effect of depression on persons after myocardial infarction. The evidence report on this topic was published in May 2005 by the Agency for Healthcare Research and Quality (AHRQ) and is used as the basis for this review.1 The AAFP Post–Myocardial Infarction Depression Clinical Practice Guideline Panel (Post-MI Guideline Panel) was charged with examining the evidence and developing an evidence-based clinical practice guideline for the detection and management of persons with postmyocardial infarction (post-MI) depression. The following recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they refl ect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations.

ACC/AHA guideline update for the management of ST-segment elevation myocardial infarction.

Abstract: The American College of Cardiology and American Heart Association, in collaboration with the Canadian Cardiovascular Society, have issued an update of the 2004 guideline for the management of patients with ST-segment elevation myocardial infarction. The American Academy of Family Physicians endorses and accepts this guideline as its policy. Early recognition and prompt initiation of reperfusion therapy remains the cornerstone of management of ST-segment elevation myocardial infarction. Aspirin should be given to symptomatic patients. Beta blockers should be used cautiously in the acute setting because they may increase the risk of cardiogenic shock and death. The combination of clopidogrel and aspirin is indicated in patients who have had ST-segment elevation myocardial infarction. A stepped care approach to analgesia for musculoskeletal pain in patients with coronary heart disease is provided. Cyclooxygenase inhibitors and nonsteroidal anti-inflammatory drugs increase mortality risk and should be avoided. Primary prevention is important to reduce the burden of heart disease. Secondary prevention interventions are critically important to prevent recurrent events in patients who survive.

An update on family medicine participation in Clinical and Translational Science Awards (CTSAs).

Abstract: Family medicine researchers play leading roles in many of the 38 institutions that have received Clinical Translational Science Awards (CTSAs). We have described the purposes, successes, and strategies for engaging in institutional CTSA applications in past Annals columns in 2007 and 2008.1,2 We refer interested readers to those columns and the cited references for rich sources of background material. NIH plans to award 50 to 60 CTSAs and applications for the next round due in October 2009. Our purpose here is to provide an update on family medicine participation in CTSAs. We conducted a Web-based survey of the 145 Chairs of departments (which includes allopathic, osteopathic, and large regional medical center members of ADFM) in October 2008 and received responses from 69 departments (48%). Of these 69, 22 (32%) departments were in institutions that had been awarded a CTSA. The medical school in which the department was located was the lead institution in all but 1 case, in which the department was located in a collaborating institution. Of those who have not yet been awarded a CTSA, 44 (64%) had applied for a planning grant, and 17 received a planning grant. We conclude that a majority of the medical schools in this sample would like to obtain CTSA funding. Among our respondents, family medicine faculty have leadership positions in 12—about one-third—of all funded CTSAs. These roles include leading units devoted to engaging the community in research, leading the development and implementation of practice based research networks, and directing training units in clinical translational research. Family medicine faculty also have important roles in bioinformatics, clinical trials, epidemiology, biostatistics, and knowledge translation components. In each of these instances, family medicine faculty contributed directly to the success of their institution’s CTSA application. In several cases, participation by family medicine was instrumental in achieving funding on the first submission, and in several additional cases family medicine participation was instrumental in getting funded on a revised application. Despite these key roles, the majority of family medicine departments do not have substantive involvement in a CTSA. Either their medical school does not have a CTSA, or the department does not have faculty with the requisite experience to contribute meaningfully. In contrast to the first 2 rounds of CTSA applications, in which we learned of several departments with valuable research track records who, by their estimation, were not sufficiently included in their institutional CTSA proposal, none of the respondents to this survey indicated that they had not been appropriately engaged. Examination of the 38 funded CTSAs reveals that areas such as community engagement and practice based research, the primary components to which family medicine has made essential contributions, are important elements for successful funding in most, though not all, instances. Many respondents indicated that their institution, department, or both lacked the infrastructure to be competitive for these awards. The original budgets for the CTSA were reduced, which affected 71% of our responding institutions. Somewhat to our surprise, only 40% of our respondents said that the budget cuts specifically impacted components that involve family medicine faculty. The often expressed perception that community engagement and practice-based research were cut more than other CTSA components was not supported by the responses we received. Of course, we do not know what the original allocation was relative to other components, and our anecdotal impression is that only some CTSAs have managed to support community engagement and practice-based research at levels adequate to build a robust infrastructure for research in these settings. For departments that plan to participate in future CTSA applications, our respondents made recommendations along the following themes: Identify strengths that the department can contribute to a successful application. Focus on “T2” translation, especially community engagement, community based participatory research and practice based research. Educate the principal investigator through personal meetings and in writing about what you have to offer. We would add that reviewing the applications of funded CTSAs, engaging funded CSA researchers as consultants, and approaching the CTSA process as team players are all potentially productive strategies. The CTSA Web site of the National Center for Research Resources of the NIH contains a plethora of information as well as links to all currently funded CTSA Web sites.3 A final strategy that we will mention is that 8 of our respondents indicated that they would be applying as a collaborative institution rather than as a lead institution. As mentioned above, 1 family medicine department is currently participating through a collaborative arrangement. This may be a productive strategy for departments that have a distinctive contribution to make, but are located in institutions that would not otherwise be competitive for a CTSA. Collaboration across institutions and between CTSAs is strongly encouraged as part of the vision of accelerating research findings into improved outcomes for patients.