March 21, 2013

DynaMed EBM Journal Volume 8, Issue 12

DynaMed Weekly Updates

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: March 21, 2013

Expiration Date: March 21, 2014

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote EducationCompany and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1210393C


Last week 386 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 242 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article of significant interest was selected by the DynaMed Editorial Team.

Increasing Radiation Exposure of the Heart Associated with Increasing Cardiovascular Risk in Women with Breast Cancer Treated with Radiation Therapy
Reference: N Engl J Med 2013 Mar 14;368(11):987, (level 2 [mid-level] evidence)

Incidental exposure of the heart to radiation is a common unintended consequence of radiation therapy for breast cancer. A recent population-based case-control study with women from Swedish and Danish cancer registries investigated the association between cardiac radiation exposure and the development of ischemic heart disease.

A total of 2,168 women < 75 years old who had radiation therapy for breast cancer from 1958-2001 were analyzed. The cases were 963 women who had a major coronary event (myocardial infarction, revascularization, or death from ischemic heart disease) before breast cancer recurrence or diagnosis of a second cancer. The controls were 1,205 women (matched to cases on age and year of diagnosis) who also had radiation therapy, but who did not have a major coronary event before the time to event of the matched case. The women were assessed for incidental radiation exposure of whole heart and left anterior descending coronary artery based on reviews of their treatment fields and dose plans.

The estimated mean radiation exposure of the heart was 4.9 Gy overall (cases and controls). For each 1 Gy increase in heart exposure, the risk of a major coronary event was increased by 7.4% (95% CI 2.9%-14.5%) overall. The increase in risk was highest within the first 4 years following radiation treatment (16.3%, 95% CI 3%-64.3%) and fell to 8.2% (95% CI 0.4%-26.6%) at ≥ 20 years after treatment. Cases had higher rates of baseline cardiovascular factors than controls, and women with risk factors had higher absolute event rates than women without, but the increase in risk per radiation dose was independent of underlying risk.

The treatment period of this study spans many decades, and breast radiation techniques have evolved to limit the exposure of the heart and left anterior descending coronary artery, although radiation exposures may not be eliminated entirely. The current data suggest that there is no threshold level of radiation at which cardiovascular risk begins to increase. Therefore, these findings may be useful in deciding what treatment approach for breast cancer is most appropriate, taking into account the woman’s underlying cardiovascular risk profile. They may also may help guide the care of women who were treated before improved radiation methods were in use and may have increased risks comparable to the women in this study.

For more information, see the Radiation therapy for breast cancer topic in DynaMed.

Earn CME Credit for reading this e-Newsletter.
For more information on this educational activity, see the CME sidebar.

DynaMed Events

Evidence Live 2013, March 25 - 26, 2013
Claire Honeybourne will be presenting a poster on behalf of Editor-in-Chief Brian Alper, MD, MSPH, FAAFP, at the Evidence Live 2013 annual conference. The conference is being held at the University of Oxford in Oxford, UK. The topic of the poster is "How Frequently Does Our Core Evidence and Guidance Change?" Oral presentation and Poster no. 22 will be presented during the 4:00 hour on March 25th.

Visit the Evidence Live website to learn more about the event and for registration information.

American College of Physicians (ACP) Internal Medicine 2013, April 11- 13, 2013
Senior Deputy Editor Larissa Lucas, MD, FACP, and Deputy Editor Sheila Bond, MD, will be attending the American College of Physicians Internal Medicine 2013 conference, held at The Moscone Center in San Francisco, California. Representatives will be available at the DynaMed booth (1402) to discuss peer review, mobile access, and free trial information.

Visit the American College of Physicians website to learn more about the event and for registration information.

Massachusetts Academy of Family Physicians (MassAFP) 2013 Spring CME Refresher, April 12 – 13, 2013
Senior Deputy Editor Alan Ehrlich, MD, will be presenting at the Massachusetts Academy of Family Physicians 2013 Spring CME Refresher, held at the Four Points Sheraton in Leominster, Massachusetts. The topic of the presentation is “Medical uses of Cannabinoids”.

Visit the Massachusetts Academy of Family Physicians website to learn more about the event and for registration information.

If you would like to meet with a DynaMed representative at any of our conferences, please contact us at

Call for Peer Reviews

We are currently seeking reviewers for:

Mature cystic teratoma of the ovary

Placental site trophoblastic tumor