December 4, 2013

DynaMed EBM Journal Volume 8, Issue 49

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: December 4, 2013

Expiration Date: December 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: 1304159E


Last week 427 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 125 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Multivitamin plus Selenium Supplement May Slow Progression of HIV Disease in Treatment-Naive Adults in Low-Resource Settings
Reference: JAMA 2013 Nov 27;310(20):2154 (level 2 [mid-level] evidence)

Micronutrient deficiencies are common in patients with HIV infection and may occur very early in the course of disease, affecting immune function and disease progression. In low-resource settings where availability of antiretroviral therapy (ART) can be limited, other interventions to slow disease progression may be particularly valuable. Previous studies have suggested that micronutrient supplements may improve HIV markers in patients with advanced disease. A recent randomized trial in Botswana evaluated the effects of supplementation in 878 treatment-na´ve adults with early, asymptomatic HIV infection.

Patients with HIV infection subtype C were randomized to 1 of 4 daily treatments for 2 years: multivitamins plus selenium (in 1 tablet) vs. multivitamin only vs. selenium only vs. placebo. Vitamins included thiamin 20 mg, riboflavin 20 mg, niacin 100 mg, vitamin B6 25 mg, vitamin B12 50 mcg, folic acid 800 mcg, vitamin C 500 mg, and vitamin E 30 mg. The selenium dose was 200 mcg. All patients had a CD4 count > 350/mcL and no history of AIDS-defining conditions at baseline. The primary outcome was disease progression defined as CD4 count ≤ 250/mcL, and the secondary outcome was a composite of disease progression, development of AIDS-defining conditions, and AIDS-related death.

A total of 24.9% of patients were lost to follow-up or dropped out of the trial (with 7.5% discontinuing due to pregnancy). The incidence of the composite outcome (progression plus AIDS outcomes) was significantly reduced in the multivitamin plus selenium group (6.48 per 100 person-years) compared to placebo (10.95 per 100 person-years, p = 0.04). Incidence in the other 2 groups was not significantly different from placebo. For the primary outcome of disease progression, incidence in both the multivitamin plus selenium group and the multivitamin alone group were significantly reduced compared to placebo. The rates of adverse events were similar among groups, and there were no significant differences in HIV viral load among groups.

These results suggest an inexpensive way to improve treatment for HIV patients early in the course of the disease in low-resource settings. It remains to be seen whether the benefits would also be found in parts of the world where most patients have access to a diet that is more likely to supply all of the essential nutrients.

For more information, see the HIV infection topic in DynaMed.

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

DynaMed Events

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

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.

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.

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