January 1, 2014

DynaMed EBM Journal Volume 9, Issue 1

DynaMed Weekly Updates

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Critical Appraisal Webinar

    On December 4th Brian Alper, MD, MSPH, FAAFP, Founder of DynaMed, hosted a webinar on critical appraisal of the randomized trial, Prevention on Cardiovascular Disease with a Mediterranean Diet (N Eng J Med 2013; 368: 1279-1290).

    We welcome you watch his presentation here and share your feedback with us.
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Physicians: .25 AMA PRA Category ICreditsTM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: January 1, 2014

Expiration Date: January 1, 2015

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: 1304159I


Last week 231 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 127 articles were added to DynaMed content.

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

Arthroscopic Partial Meniscectomy Does Not Improve Symptoms of Degenerative Medial Meniscus Tear in Patients Without Knee Osteoarthritis
Reference:N Engl J Med 2013 Dec 26;369(26):2515 (level 1 [likely reliable] evidence)

Arthroscopic surgeries for patients with established knee osteoarthritis are becoming less common due to a lack of clinical evidence supporting their use. A Cochrane review found that arthroscopic surgery is ineffective for unselected patients with knee osteoarthritis (Cochrane Database Syst Rev 2008 Jan 23;(1):CD005118), based partly on the findings of a randomized trial showing no significant improvement in pain or function scores with either arthroscopic debridement or arthroscopic lavage compared to placebo surgery (N Engl J Med 2002 Jul 11;347(2):81 full-text). Another randomized trial subsequently showed that the addition of arthroscopic surgery to physical and medical therapies did not improve function or pain scores in patients with moderate-to-severe knee osteoarthritis (N Engl J Med 2008 Sep 11;359(11):1097 full-text). More recently, a randomized trial in patients with meniscal tear and knee osteoarthritis showed that arthroscopic partial meniscectomy plus physical therapy did not improve symptoms more than physical therapy alone (N Engl J Med 2013 May 2;368(18):1675 full-text, see DynaMed EBM Focus Volume 8, Issue 13).

However, the implications for patients without clearly established knee osteoarthritis have remained unclear. A recent randomized trial comparing meniscectomy to strengthening exercises in patients presenting with degenerative medial meniscus tear and no clear evidence of osteoarthritis (Kellgren-Lawrence grade 0-1) found no significant between-group differences in function, pain, or patient satisfaction scores (Am J Sports Med 2013 Jul;41(7):1565). Now, a randomized trial compares arthroscopic partial meniscectomy to sham surgery in patients with medial meniscus tear without knee osteoarthritis.

A total of 146 patients aged 35-65 years with symptomatic degenerative medial meniscus tear without knee osteoarthritis were randomized to arthroscopic partial meniscectomy vs. sham surgery and followed for 12 months. Postoperative care, including walking aids and instructions for graduated exercises, was identical for both groups, and all patients were instructed to take over-the-counter analgesics as required. Symptoms were assessed using the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores, which both range from 0 to 100, with higher scores indicating less severe symptoms. Knee pain was assessed after exercise using a numeric rating scale with a range of 0 to 10, with higher scores indicating greater pain severity.

Both groups had a significant improvement from baseline in symptom and knee pain scores, but there were no significant between-group differences for these outcomes at 12 months. The mean improvement in the Lysholm score was 21.7 points with arthroscopic partial meniscectomy group vs. 23.3 points with sham surgery, with a difference of 11.5 points considered clinically meaningful. Similarly, the mean improvement in the WOMET score was 24.6 points with partial meniscectomy vs. 27.1 points with sham surgery, with a difference of 15.5 points considered clinically meaningful. The mean improvement in knee pain was 3.1 points with partial meniscectomy vs. 3.3 points with sham surgery, with a difference of 2 points considered clinically meaningful. There were also no significant differences in the rate of subsequent knee surgery, patient-reported satisfaction, patient-reported improvement, or serious adverse events.

Recent clinical evidence from randomized trials has consistently shown a lack of efficacy of arthroscopic surgeries for patients with knee osteoarthritis, including patients with meniscus tears. This trial extends those findings to patients with meniscus tears but without established knee osteoarthritis, showing no significant difference in symptom or pain scores between patients receiving arthroscopic partial meniscectomy and those receiving sham surgery. It should be noted that the Lysholm and WOMET scores used in this trial for symptom assessment are primarily focused on basic activities of daily living, and may not adequately describe high-level function as may be required for strenuous work or sports.

For more information, see the Meniscus tears topic in DynaMed.

Prednisolone for 3 Days May Be an Alternative to Dexamethasone Single Dose for Management of Mild-to-Moderate Croup Symptoms
Reference: Clin Pediatr (Phila) 2013 Nov;52(11):1014 (level 2 [mid-level] evidence)

Cases of mild-to-moderate croup are often treated with corticosteroids, mostly based on results from randomized trials in emergency department settings. A recent Cochrane review demonstrated that corticosteroid treatment (dexamethasone in most trials) improves croup symptoms and reduces return visits or readmissions (Cochrane Database Syst Rev. 2011 Jan 19;(1):CD001955), and a high-quality randomized trial has shown that a single course of dexamethasone reduces symptom severity in children with mild croup (N Engl J Med. 2004 Sep 23;351(13):1306). However, surveys have shown that the type of steroid used can vary across practices. A 3-day course of prednisolone is commonly prescribed by primary care pediatricians, but the clinical evidence supporting its use is limited, especially in settings outside the emergency department. Now, a community-based randomized trial has compared a 3-day course of prednisolone to a single course of dexamethasone in children with mild-to-moderate croup.

A total of 87 children aged 1-8 years were randomized to prednisolone 2 mg/kg/day orally for 3 days vs. a single dose of dexamethasone 0.6 mg/kg orally plus 2 doses of placebo on successive days. All children had croup symptoms for a maximum of 48 hours, and symptoms were classified as mild in 42% and moderate in 58%. Children were followed for 8 days after the completion of treatment. There were no significant differences between groups in the duration of symptoms, nonbarky cough, disturbed parental sleep, or days with stress. Similarly, there was no significant difference in the need for additional health care for croup. However, it is noteworthy that this trial failed to reach its target sample size of 200 children with croup. This may have resulted in inadequate statistical power to rule out clinically meaningful differences between the 2 groups. Still, the findings from this trial demonstrate that prednisolone appears to be a reasonable alternative to dexamethasone for children with mild-to-moderate croup in community practices.

For more information, see the Croup topic in DynaMed.

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

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