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

Release Date: October 8, 2014
Expiration Date: October 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 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 Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive 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: 1405237

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.

Last week 480 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 228 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.

Timing of gluten introduction in high-risk infants does not appear to influence the risk of celiac disease at age 3-5 years
Reference: N Engl J Med 2014 Oct 2;371(14):1304, N Engl J Med 2014 Oct 2;371(14):1295 (level 2 [mid-level] evidence)

Celiac disease affects approximately 1% of people in western populations, but the prevalence increases to as high as 20% in first-degree relatives of patients with celiac disease (Gastroenterology 2005 Apr;128(4 Suppl 1):S57), suggesting a genetic association. It has been observed that 95% of patients with celiac disease express the HLA-DQ2 genotype and almost all remaining patients express HLA-DQ8 (Curr Allergy Asthma Rep 2013 Aug;13(4):347), but 30-40% of the general population also express HLA-DQ2, indicating the risk is a combination of genetic and environmental factors. Previous observational studies have suggested that age of introduction to gluten-containing foods and breastfeeding may influence the development of celiac disease in high-risk populations (Aliment Pharmacol Ther 2012Oct;36(7):607). Specifically, these studies suggest that introduction of gluten between ages 4-7 months might reduce the risk of celiac disease. Two recent randomized trials sought to further investigate the effect of timed introduction of dietary gluten (pasta, semolina, and biscuits) for infants at high risk for celiac disease.

The PreventCD trial (N Engl J Med 2014 Oct 2;371(14):1304) randomized 944 infants with at least 1 first-degree relative with celiac disease to 100 mg immunologically active gluten vs. placebo daily from age 16 weeks to 24 weeks. All infants included in this trial were also positive for HLA-DQ2, HLA-DQ8, or HLA-DQB1*02 heterodimer. At age 3 years, there were no significant differences comparing gluten vs. placebo in development of overt celiac disease (5.9% vs. 4.5%) and breastfeeding did not influence the development of celiac disease.

Similarly, the CELIPREV trial (N Engl J Med 2014 Oct 2;371(14):1295) randomized 823 infants with at least one first-degree relative with celiac disease to introduction of dietary gluten at age 6 months vs. age 12 months. Only 553 children who completed at least 3 years of follow-up and were found to be positive for HLA-DQ2 or HLA-DQ8 were included in the analysis. Overt celiac disease was significantly greater at age 2 years in children randomized to introduction of gluten at 6 months vs. 12 months (12% vs. 5%, p = 0.01 NNH 14). However by age 5 years, there was no significant difference between groups in diagnosis of overt celiac disease (16% in each). This trial also found no association between breastfeeding and the development of celiac disease.

The results from these trials suggest that the introduction of dietary gluten at a specific time during infancy does not significantly influence the development of celiac disease. These are the first large randomized trials specifically evaluating the association of timing of gluten introduction and risk of celiac disease. Based on these new findings, specific timeframes for introducing gluten for the prevention of celiac disease in high risk infants do not appear warranted.

For more information, see the Celiac disease topic in DynaMed.

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

DynaMed Events

Family Medicine Midwest Conference: October 10-12, 2014

Deputy Editor Tom Hilts, DO, will be attending the Family Medicine Midwest Conference in Minneapolis, Minnesota. Representatives will be available to discuss peer review, mobile access, and free trial information.

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

American Academy of Pediatrics National Conference: October 11-14, 2014

Deputy Editor Mike Woods, MD, MS, FAAP, will be attending the American Academy of Pediatrics National Conference in San Diego, California. Representatives will be available to discuss peer review, mobile access, and free trial information.

Visit the AAP website to learn more about the event and for registration information

American Academy of Family Physicians Conference: October 21-25, 2014

Representatives will be available at the American Academy of Family Physicians Assembly in Washington, District of Columbia to discuss peer review, mobile access, and free trial information.

Executive Deputy Editor Alan Ehrlich, MD, will be attending and will also be presenting on Medical Marijuana: What You Need To Know on Friday at 9:15am and 2:45pm.

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

If you would like to meet with a DynaMed representative at any of our conferences, please contact us at DynaMedCommunity@ebscohost.com.

PEMSoft Mobile

PEMSoft Now Available For iPhone, iPad, and Android Devices

The PEMSoft Mobile app, a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools, is now available from EBSCOHealth. Designed by pediatricians, emergency physicians and other medical specialists, 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.

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
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Education for Clinicians in Training

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Nephrology, Ophthalmology, Orthopedics, Surgery, Vascular.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.