September 18, 2013

DynaMed EBM Journal Volume 8, Issue 38

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: September 4, 2013

Expiration Date: September 4, 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: 1210393T


Last week 503 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 262 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.

Steroid Injection Reduces Need for Surgery in Patients with Mild to Moderate Carpal Tunnel syndrome and Failed Wrist Splinting
Reference: (Ann Intern Med 2013 Sep 3;159(5):309), (level 1 [likely reliable] evidence)

When conservative treatments such as wrist splinting fail to provide lasting relief, many patients with carpal tunnel syndrome (CTS) opt for surgery. Local steroid injections are also a common treatment, but injections have not been shown to be effective for more than 1 month in high-quality randomized trials (Cochrane Database Syst Rev 2007 Apr 18;(2):CD001554). A new randomized trial evaluated the efficacy of steroid injections for reducing symptom severity and need for surgery.

A total of 111 adults aged 18-70 years with mild to moderate CTS who had been unsuccessfully treated with wrist splints were randomized to local injections with methylprednisolone (80 mg vs. 40 mg) vs. placebo. Local anesthesia with lidocaine 1 mL was given with all injections. Symptoms were assessed using the CTS symptom severity scale, which measures 11 items including severity, frequency, and duration of pain at day and night, and numbness or tingling (5-point scale). Patients could choose to have surgery after 3 months.

The primary outcomes were rates of surgery at 1 year and symptom severity scores at 10 weeks. In the placebo group, 92% had had surgery by the 12 month evaluation . The surgery rate with 80 mg methylprednisolone was 73% (p = 0.042 vs. placebo, NNT 6). In the 40 mg methylprednisolone group, 81% had surgery, but this rate was not significantly different from placebo. Symptom severity at 10 weeks was significantly reduced with both doses of prednisolone compared to placebo. The mean reductions were 0.9 points with methylprednisolone 80 mg (p = 0.003 vs. placebo), 1.17 points with methylprednisolone 40 mg (p < 0.001 vs. placebo), and 0.3 points with placebo. There were no significant differences in CTS symptom severity scores, disability scores, quality of life, or treatment satisfaction at 1 year.

Despite the significant benefit from the steroid injection, nearly 3/4 of the 80 mg methylprednisolone group did ultimately have surgery. Nonetheless, for clinicians counseling their patients with persistent carpal tunnel syndrome symptoms, this trial demonstrates that in addition to providing short-term symptom relief, the injection may result in avoiding surgery in a sizable minority of patients.

For more information, see the Carpal tunnel steroid injection and Carpal tunnel syndrome 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 Academy of Family Physicians (AAFP) Conference, September 24-28, 2013
Senior Deputy Editor Alan Ehrlich, MD, will be attending the American Academy 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 Academy of Family Physicians website to learn more about the event and for registration information.

ID Week, October 2-6, 2013
Deputy Editor Sheila Mitsuma, MD, will be attending ID Week, held at the Moscone Convention Center in San Fransisco, California. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the ID Week 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:

Compartment syndrome

Hallux valgus and bunion