Quick Links

Share with Colleagues
Previous EBM Focus Issues
Become a DynaMed Reviewer
DynaMed Free Trial
Send Comment to Editor

Join Our Mailing List



Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: September 3, 2014
Expiration Date: September 3, 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 above.

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 Education Company 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: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. 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(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Program ID: 1405237P

Last week 550 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 213 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.

In Children With Sickle Cell Disease and Silent Cerebral Infarct, Regular Blood Transfusions Might Decrease Risk of Overt Stroke or Silent Infarct Recurrence
Reference: N Engl J Med 2014 Aug 21;371(8):699 (level 2 [mid-level] evidence)

Silent cerebral infarction is the most common neurologic injury in children with sickle cell anemia, with a cumulative risk of about 37% by age 14 (Blood 2011 Jan 27;117(4):1130 full-text). Children with sickle cell disease and silent cerebral infarction have an increased risk of other adverse neurologic outcomes, including stroke (Blood 2002 Apr 15;99(8):3014) and reduced cognitive function (Neurology 2001 Apr 24;56(8):1109). The STOP trial previously demonstrated that regular blood transfusions reduced the risk of stroke in children with sickle cell disease and abnormal transcranial Doppler ultrasound findings (N Engl J Med 1998 Jul 2;339(1):5 full-text). Based on these findings, the current guidelines from the American Heart Association/American Stroke Association recommend blood transfusion therapy for these patients (Stroke 2011 Feb;42(2):517 full-text). However, the optimal management of children with sickle cell disease who have other risk factors for stroke is currently unclear. A recent randomized trial compared regular blood transfusions with usual care in 196 children aged 5-15 years with sickle cell disease who had 1 or more silent cerebral infarctions demonstrated on MRI but no history of overt stroke.

The regular blood transfusion intervention targeted a hemoglobin level > 9 g/dL and a hemoglobin S level ≤ 30% of the total hemoglobin, and was given about once monthly for a median of 3 years. It also included additional chelation therapy if the ferritin level was > 1,500 ng/mL for at least 2 months. The primary outcome was a composite of overt stroke, new silent cerebral infarct, or enlargement of an existing infarct (as assessed by neuroimaging). Transfusion therapy was associated with a significant improvement in the primary outcome compared to usual care during follow-up (2 vs. 4.8 per 100 patient years, incidence rate ratio 0.41, 95% CI 0.12-0.99, NNT 36 per year). Overt stroke occurred in 1% with regular blood transfusion vs. 7% with usual care (no p value reported). Compared to usual care, regular blood transfusion was associated with significantly decreased rates of vaso-occlusive pain, acute chest syndrome, and symptomatic avascular necrosis of the hip. There were no significant between-group differences in IQ or function scores, and no deaths occurred.

The results of this trial support the use of regular blood transfusions in children with sickle cell anemia with evidence of a silent cerebral infarct on MRI. These results, combined with the results of the STOP trial, suggest that regular transfusion therapy may improve neurologic outcomes for a significant proportion of children with sickle cell disease. However, children receiving hydroxyurea were excluded from the current trial, which limits the generalizability of these new findings. In addition, a previous Cochrane review of 3 randomized trials evaluating blood transfusion for children with sickle cell disease (including the STOP trial) found that transfusions were associated with several complications, including iron overload, alloimmunization, and transfusion reactions (Cochrane Database Syst Rev 2013 Nov 14;(11):CD003146). Importantly, the current trial did not demonstrate any between-group differences in IQ or other neurocognitive outcomes, and the long-term effects on cognitive function are currently unknown.

For more information see the Transfusion therapy in sickle cell disease topic in DynaMed.

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

EBSCO Health Launches Pediatric Clinical Information Mobile App

PEMSoft Now Available For iPhone, iPad, and Android Devices

A mobile app designed specifically for pediatricians, emergency department physicians, physicians-in-training and other medical providers caring for children with acute illnesses and injury, is now available from EBSCO Health, the leading provider of clinical decision support solutions for the healthcare industry.

Designed by pediatricians, emergency physicians and other medical specialists, PEMSoft is a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools. The vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

The PEMSoft Mobile app includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms and content covering pediatric injuries and management approaches. More than 3,000 evidence-based pediatric topics and a similar number of medical illustrations, clinical images and videos are also available via the mobile app.

The PEMSoft Mobile App is accessible from both Apple and Android devices.

Visit the PEMSoft page for more 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 Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training

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.

Section Editor of Specialty Content