October 9, 2013

DynaMed EBM Journal Volume 8, Issue 41

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: October 9, 2013

Expiration Date: October 9, 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: 1210393W


Last week 805 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 228 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.

Addition of Rifaximin to Lactulose Reduces Mortality in Patients with Overt Hepatic Encephalopathy
Reference: (Am J Gastroenterol 2013 Sep;108(9):1458) (level 1 [likely reliable] evidence)

Hepatic encephalopathy is a common complication of liver failure with manifestations ranging from minor cognitive and motor dysfunction to stupor or coma. The clinical course may be lethal, but the condition may also be reversible. Lactulose is a widely used treatment directed at reducing blood ammonia levels, but evidence for its efficacy is limited (Cochrane Database Syst Rev 2004;(2):CD003044). Rifaximin has been shown to be at least as effective as lactulose (Pharmacotherapy 2008 Aug;28(8):1019), and to improve cognitive function in patients with minimal hepatic encephalopathy (Am J Gastroenterol 2011 Feb;106(2):307). A recent randomized trial compared the combination of rifaximin plus lactulose to lactulose alone in 120 patients with overt hepatic encephalopathy.

Inpatients (mean age 39 years, 74% men) with overt hepatic encephalopathy were randomized to rifaximin 1,200 mg/day orally vs. placebo for up to 10 days and followed until death or hospital discharge. All patients received lactulose 30-60 mL 3 times daily (targeting 2-3 semisoft stools per day). Grade 3 disease was present in 33% of patients (gross disorientation, confusion, bizarre behavior, asterixis usually absent, somnolence or stupor), and 48% had grade 4 disease (coma).

At the end of treatment, 76% in the rifaximin plus lactulose group had complete reversal of symptoms compared to 44% receiving lactulose alone (p = 0.004, NNT 4). Mortality was 23.8% with rifaximin vs. 49.1% without rifaximin (p < 0.05, NNT 4). Rifaximin plus lactulose was also associated with reduced risk of sepsis (11% vs. 29%, p = 0.01, NNT 6) and shorter mean hospital stay (5.8 days vs. 8.2 days, p = 0.001). There were no significant differences in rates of gastrointestinal bleeding or hepatorenal syndrome, and no treatment-related serious adverse events occurred in either group.

For more information, see the Hepatic encephalopathy and Rifaximin topics 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 Pediatrics (AAP), October 24 - 29, 2013
Deputy Editor Mike Woods, MD, MS, FAAP, will be attending the AAP conference, held at the Orange County Convention Center in Orlando, Florida. Representatives will be available to discuss peer review, mobile access, and free trial information.

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

If you would like to meet with a DynaMed representative at an event, please contact us at DynaMedCommunity@ebscohost.com.

Call for Peer Reviews

We are currently seeking reviewers for:


Acute mesenteric ischemia