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

Release Date: November 19, 2014
Expiration Date: November 19, 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: 1405238A

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 475 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 194 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.

Folic Acid and B12 Vitamin Supplementation May Not Affect Cognitive Outcomes Despite Reducing Homocysteine Levels in Elderly Persons With High Homocysteine Levels
Reference: Neurology 2014 Nov 12 early online (level 2 [mid-level] evidence)

Low levels of folate in the blood and higher levels of plasma homocysteine have been associated with poor cognitive function and increased risk for dementia and Alzheimer disease (J Nutr 2007 Jul;137(7):1789, Am J Clin Nutr 2005 Sep;82(3):636). Vitamin B supplementation in elderly populations has had inconsistent results on cognitive function (Cochrane Database Syst Rev 2008 Oct 8;(4):CD004514, Am J Clin Nutr 2014 Jun 25;100(2):657), likely due to heterogeneity in the population of interest, vitamin supplementation use, and duration of intervention. Recently, prominent news outlets reported on a secondary analysis of a randomized trial evaluating the effect of daily folic acid and vitamin B12 vs. placebo for 2 years in 3,027 elderly persons (mean age 74 years) with elevated homocysteine levels, but without cognitive impairment.

Global cognitive function was assessed at baseline and at 2 years using the Mini-Mental State Examination (MMSE). During the trial period, 26.8% of patients discontinued the intervention or were lost to follow up, but MMSE data was available for 2,556 persons. While homocysteine levels significantly decreased in persons receiving the folic acid and vitamin B12 supplement compared to placebo (p < 0.01), there was no clinically significant between-group difference in cognitive function on the MMSE (mean decrease 0.3 points vs. 0.1 points, p = 0.05). No significant between-group differences in other cognitive domains were found in a subset of patients from 1 center having additional cognitive assessments.

This study illustrates a number of interesting aspects of the application of clinical research to the practice of medicine. At first glance, the results of this trial suggests that folate and vitamin B12 may not affect cognitive function in persons with high homocysteine levels at increased risk of cognitive decline and many clinicians may choose to change practice based on that interpretation of the trial. However, because there was no clinically significant decline in the control group, it is hard to say the supplementation has no clinical value. A longer duration trial, or one that looks at more sensitive measures of cognitive decline than the MMSE, would be necessary to truly evaluate any beneficial effect on changes in cognitive function. In addition, the fact that there was significant improvement in the homocysteine level without corresponding clinical benefit highlights the limitations of using surrogate outcomes. Finally, the primary outcome of this trial was actually to determine the effects of B vitamins on risk of osteoporotic fractures (BMC Geriatr 2011 Dec 2;11:80), and their effect on cognitive function was specified as a secondary outcome. All trial participants received vitamin D3 to ensure normal vitamin D status. While vitamin D is an important factor in osteoporosis, low vitamin D levels have been associated with cognitive decline (Neurology 2012 Sep 25;79(13):1397, Arch Intern Med 2010 Jul 12;170(13):1135), and so supplementation may have confounded the results. This article is a good reminder of the importance of critically appraising research studies, particularly those that get widespread attention in the lay press.

For more information, see the Mild cognitive impairment (MCI) topics in DynaMed.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Ophthalmology, Orthopedics, Pediatric Endocrinology, Pediatric Neurology, and Vascular.

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

Pediatric Procedures, Pain Management, and Sedation

PEMSoft Complimentary Webinar: Monday, November 24, 2014 at 1:30pm

Join Kelly Young, MD, MS for a short lecture reviewing pain management options using a clinical scenario of a child that is not tolerating a Lumbar Puncture.

Kelly D. Young, MD, MS is Editor-in-Chief of PEMSoft and Health Sciences Clinical Professor of Pediatrics at David Geffen School of Medicine at UCLA. She is Associate Fellowship Director for Pediatric Emergency Medicine at Harbor-UCLA Medical Center in Torrance, California. Dr. Young is board certified in pediatrics and pediatric emergency medicine from the American Board of Pediatrics. She was an NIH K23 mentored patient-oriented research career development awardee, and obtained a masterís of science in epidemiology from the UCLA School of Public Health. Dr Young is also an Associate Editor for Annals of Emergency Medicine.

Click here to register.

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.

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