August 21, 2013

DynaMed EBM Journal Volume 8, Issue 34

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: August 21, 2013

Expiration Date: August 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: 1210393P


Last week 390 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 198 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.

In Patients with High-Risk Smoldering Myeloma, Early Treatment May Delay Disease Progression and Increase Survival
Reference: (N Engl J Med 2013 Aug 1;369(5):438), (level 2 [mid-level] evidence)

Standard care for patients with smoldering (asymptomatic) myeloma is observation for emergence of myeloma-related organ impairment with monitoring of serum and urine paraprotein levels. The risk of disease progression is generally low (about 10% annually over the first 5 years) (N Engl J Med 2002 Feb 21;346(8):564), and guidelines recommend chemotherapy only in cases of symptomatic myeloma-related organ impairment (Br J Haematol. 2011 Jul;154(1):32).  However, in a sizeable subpopulation of asymptomatic patients with greater bone marrow infiltration, the risk of progression is increased.  A recent unblinded randomized trial evaluated the efficacy of early treatment in 125 patients with high-risk smoldering myeloma.

Patients aged 38-91 years with high-risk smoldering myeloma (43% with diagnosis within 6 months) were randomized to early treatment vs. observation. Early treatment consisted of induction with lenalidomide 25 mg/day on days 1-21 plus dexamethasone 20 mg/day on days 1-4 and 12-15 every 4 weeks for 9 cycles, followed by maintenance therapy with lenalidomide 10 mg/day on days 1-21 every 4 weeks for 2 years. High-risk disease was defined as either plasma-cell bone marrow infiltration ≥ 10% plus a monoclonal component (IgG level ≥ 3 g/dL, IgA level ≥ 2 g/dL, or urinary Bence Jones protein level >1 g/day) or 1 of these criteria plus ≥ 95% phenotypically aberrant plasma cells in the bone marrow plasma cell compartment with ≥ 25% decrease in 1-2 uninvolved immunoglobulins.

After median follow-up of 40 months, early treatment was associated with longer time to progression than observation (hazard ratio for progression 0.18, p < 0.001). The median time to progression was not reached in the early treatment group (i.e. fewer than half the group had progression during follow-up), vs. 21 months in the observation group . Early treatment was also associated with significantly higher 3-year survival (94% vs. 80%, p = 0.03, NNT 8). In the early treatment group, at least partial response was observed in 79% during the induction phase and 90% during maintenance.

For more information, see the Multiple Myeloma topic in DynaMed.

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

DynaMed Events

American Association of Family Physicians (AAFP) Conference, September 24-28, 2013
Senior Deputy Editor Alan Ehrlich, MD, will be attending the American Association of Family Physicians conference, held at the San Diego Convention Center in San Diego, California. Representatives will be available to discuss peer review, mobile access, and free trial information.

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

If you would like to meet with a DynaMed representative, please contact us at

Call for Peer Reviews

We are currently seeking reviewers for:

Primary myelofibrosis

Protein C deficiency