November 6, 2013

DynaMed EBM Journal Volume 8, Issue 45

DynaMed Weekly Updates

Quick Links

Join Mailing List



Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: November 6, 2013

Expiration Date: November 6, 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: 1210393Z


Last week 745 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 374 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.

Steroids Reduce Time to Discharge from Observation Unit in Infants with Acute Bronchiolitis and Suspected Asthma
Reference: (Pediatrics 2013 Oct;132(4):e810) (level 1 [likely reliable] evidence)

Bronchiolitis commonly affects young children, and is the most frequent cause of hospitalization among infants during winter months. A recent Cochrane review (Cochrane Database Syst Rev 2013 Jun 4;(6):CD004878) found that systemic and inhaled corticosteroids do not reduce rates of hospital admissions or readmissions in children with acute bronchiolitis, and current guidelines do not recommend routine use of steroids in this patient population (Pediatrics 2006 Oct;118(4):1774-93). However, some infants initially presenting with bronchiolitis are subsequently diagnosed with asthma, where corticosteroids are used for long-term symptom control. Data evaluating efficacy of steroids in infants with bronchiolitis who are at high risk for asthma have been limited thus far. Now, a recent randomized trial has compared oral dexamethasone vs. placebo in 200 such infants.

Infants (median age 3.5 months) presenting for emergency care with acute bronchiolitis were randomized to dexamethasone (1 mg/kg orally on day 1 followed by 0.6 mg/kg orally once daily for 4 more days) vs. placebo. All infants were at high risk for asthma based on either the presence of eczema or history of asthma in a first-degree relative. All infants received nebulized salbutamol 2.5 mg 4 times over first 2 hours and every 2 hours until discharge, and infants could receive nebulized epinephrine or other treatments at the discretion of the treating physician. Infants were evaluated for readiness for discharge from an observation unit at least every 6 hours, and were followed for 1 week after discharge.

A modified intention-to-treat analysis was used to assess the efficacy of dexamethasone after excluding 10 infants for admission to intensive care unit, failure to meet inclusion criteria, or withdrawal after randomization. The mean time to readiness for discharge was 18.6 hours with dexamethasone vs. 27.1 hours with placebo (p = 0.015), and the dexamethasone group had a lower rate of nebulized epinephrine use (19% vs. 34.4%, p = 0.03, NNT 7). However, the frequency of return visit within 1 week of discharge was 22% for dexamethasone vs. 21% for placebo (not significant). No hospitalizations or adverse events occurred in either group.

Collectively, these results suggest that oral dexamethasone may be useful for treatment of bronchiolitis in the emergency department in this subpopulation by substantially decreasing the amount of time infants spend under observation. The increased turnaround associated with short-term dexamethasone treatment may be particularly beneficial during winter months, when cases of bronchiolitis in the emergency department are at their maximum frequency. However, these data do not support continued treatment for 5 days, since there was no reduction in return visits in the week following discharge.

For more information, see the Bronchiolitis topic in DynaMed.

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

DynaMed Events

Kidney Week, November 5-10, 2013
Representatives will be attending Kidney Week, held at the Georgia World Congress Center in Atlanta, Georgia. Visit booth 1231 to discuss peer review, mobile access, and free trial information.

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

American Society of Hematology (ASH), December 7-10, 2013
Representatives will be attending the ASH conference, held at the Ernest N. Morial Convention Center in New Orleans, Louisiana. Stop by booth 3907 to discuss peer review, mobile access, and free trial information.

Visit the ASH 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

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Deputy Editor of Cardiology
Deputy Editor of Oncology
Medical Writer
Medical Editor
Associate Editor