January 8, 2014

DynaMed EBM Journal Volume 9, Issue 2

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 8, 2014

Expiration Date: January 8, 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: 1304159J


Last week 211 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 121 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.

Walking Appears to Reduce Risk of Cardiovascular Events in Patients With Impaired Glucose Tolerance at Risk of Cardiovascular Disease
Reference:Lancet 2013 Dec 19 early online (level 2 [mid-level] evidence)

Lifestyle modifications have been shown to reduce the rate of progression to type 2 diabetes in patients with impaired glucose tolerance (BMJ 2007 Feb 10;334(7588):299 full-text). In fact, the Diabetes Prevention Program trial demonstrated that lifestyle changes can reduce the incidence of diabetes more effectively than metformin (N Engl J Med 2002 Feb 7;346(6):393 full-text), and a secondary analysis showed that such changes are cost-effective for diabetes prevention across all age groups (Ann Intern Med 2005 Mar 1;142(5):323 full-text). However, the impact of lifestyle changes on cardiovascular outcomes in patients with impaired glucose metabolism has remained unclear. Now, a cohort analysis of data from a randomized trial evaluates the association between walking and the risk of cardiovascular events in a patient population at risk of developing cardiovascular disease.

A total of 9,018 patients with impaired glucose tolerance and increased risk of cardiovascular disease from the NAVIGATOR trial were included in the analysis. All patients had existing cardiovascular disease if ≥ 50 years old, or had at least 1 additional cardiovascular risk factor if ≥ 55 years old. Ambulatory activity was assessed using a pedometer at baseline and again at 12 months.

Overall, 531 patients had a cardiovascular event (defined as a composite of cardiovascular mortality, non-fatal stroke, or myocardial infarction) during 45,211 person-years of follow-up. Each increase in activity by 2,000 steps per day (about 20 minutes of walking at a moderate pace) was associated with a decrease in the risk of cardiovascular events, with a hazard ratio of 0.92 (95% CI 0.86-0.99) when evaluating the change in activity level from baseline to 12 months. Similarly, a higher baseline activity rate was also associated with decreased risk of cardiovascular events, with a hazard ratio of 0.9 (95% CI 0.84-0.96). These findings were consistent across additional analyses adjusted for all potential confounders evaluated, including treatment group and changes in body mass index. However, an important limitation of this study is the large proportion of patients with some missing data (25% at baseline and 45% at 12 months).

Previous studies evaluating interventions in patients with prediabetes have focused only on prevention of a diabetes diagnosis. There has been an absence of more patient-oriented outcomes. This study extends the previous findings by evaluating clinical complications among patients with prediabetes, specifically showing decreased cardiovascular events with increased activity levels. Further, it quantifies the relationship between activity and cardiovascular risk in a way that is easy to communicate to patients.

For more information, see the Prediabetes and Physical activity for cardiovascular disease prevention topics 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 Managing Editor