August 14, 2013

DynaMed EBM Journal Volume 8, Issue 33

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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: August 14, 2013

Expiration Date: August 14, 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 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

James McLellan, PhD - Senior Medical Writer, DynaMed, Ipswich, Massachusetts, USA


Dr. Ehrlich, Dr. Fleming, Dr. McLellan, 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 Education Company 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: This enduring material activity, DynaMed EBM Focus Volume 8, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 6, 2013. Term of approval is for one year from this date with the option of yearly renewal. Each weekly updated is approved for 0.25 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: 1304158O


Last week 412 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 201 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.

Intermittent Pneumatic Compression Appears to Reduce Risk of DVT After Acute Stroke
Reference - CLOTS 3 trial  Lancet 2013 Aug 10;382(9891):516, (level 2 [mid-level] evidence)

Patients who are hospitalized and immobile following an acute stroke are at increased risk for deep vein thrombosis (DVT), and most guidelines recommend antithrombotic drugs for DVT prophylaxis in these patients. Mechanical prophylaxis with intermittent pneumatic compression (IPC) is commonly used for surgical patients but its efficacy in patients with stroke (and in medical patients in general) has not been well established. The CLOTS 3 trial evaluated IPC for prevention of DVT in 2,876 patients with acute stroke.

Patients (median age 76 years) with acute stroke within 3 days who were unable to walk to the toilet without help were randomized to IPC for ≥ 30 days vs. no IPC and were followed for 6 months. IPC was applied continuously, except during washing, physical therapy, and during compression duplex ultrasound. Treatment was discontinued early if the patient became independently mobile, was discharged from hospital, declined to continue IPC, or had adverse events. Patients in each group could receive heparin for prophylaxis or treatment at the discretion of treating clinicians. 24% in each group were receiving warfarin or heparin at recruitment or had received thrombolysis (alteplase) for treatment of acute stroke. The primary outcome was any proximal DVT (symptomatic or asymptomatic detected on ultrasound) within 30 days.

Median duration of IPC use was 9 days (only 31% used the device every day). The primary outcome occurred in 8.5% with IPC vs. 12.1% without IPC (p < 0.05, NNT 28). Symptomatic proximal or calf DVTs occurred in 4.6% vs. 6.3% (p = 0.045, NNT 59). The beneficial effects of IPC on DVT rates were similar in subgroup analyses of patients who did or did not receive heparin, warfarin, or alteplase. Rates of prophylactic and therapeutic heparin use after randomization were similar between the IPC and no IPC groups. IPC was also associated with a reduced rate of any DVT at 6 months (16.7% vs. 25.1%, p = 0.001, NNT 12), and with nonsignificant reductions in mortality at 30 days (10.8% vs. 13.1%, p = 0.057) and at 6 months (22.3% vs. 25.1%, p = 0.059). Skin breakdown was more common in the IPC group. There was no significant difference in the rate of falls.

For more information, see the Anticoagulation therapy for acute stroke and Deep vein thrombosis (DVT) prophylaxis for medical patients topic in DynaMed.

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

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We are currently seeking reviewers for:

Long QT syndrome

Pelvic vein thrombosis in women

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