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

Release Date: January 14, 2015
Expiration Date: January 14, 2016

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: 1405237J2

Last week 608 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 233 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.

Extending Strict Rest to 5 Days from 1-2 Days May Not Improve Symptoms in Children with Mild Concussion

Reference: Pediatrics 2015 Jan 5 early online (level 2 [mid-level] evidence)

Emergency department visits for concussions and traumatic brain injury have increased in the United States over recent years (JAMA 2014 May 14;311(18):1917). There has been a 60% increase in sports-related injuries in children over the last 10 years (MMWR Morb Mortal Wkly Rep 2011 Oct 7;60(39):1337). Reinjury during the recovery process can have significant consequences and rest is therefore recommended to prevent reinjury and allow for full recovery (Pediatrics 2009 Jan;123(1):114, Br J Sports Med 2013 Apr;47(5):250). Information is lacking on the optimal duration of rest, however, especially for children. A recent randomized trial compared strict rest for 5 days vs. usual care in 99 patients aged 11-22 years (mean age 14 years, 34% female) presenting to the pediatric emergency department within 24 hours of mild traumatic brain injury or concussion. Seventy-one percent of injuries were sports-related.

Strict rest was defined as no school, work, or physical activity followed by a stepwise return to normal activities. For patients randomized to usual care, physicians were instructed to recommend activity restriction as they deemed appropriate, which in most cases was rest for 1-2 days followed by a stepwise return to activity after symptoms resolved. All patients were discharged from the emergency department after neurocognitive, balance, and symptoms assessment and were asked to complete an activity diary including a standard Post-Concussive Symptoms Scale (PCSS) for 10 days after injury. PCSS rates 19 symptoms in 4 domains (physical, cognitive, emotional, and sleep) each on 0-6 scale, with higher score indicating greater severity and in this study, resolution of symptoms defined as total PCSS score ≤ 7. The trial analysis included patients completing the 10-day follow-up (89%). There was no significant difference in physical activity between groups during the first 5 days post-injury, however the strict rest group reported fewer total hours of moderate-to-high mental activity on days 2-5 (mean 4.86 hours with strict rest vs. 8.33 hours with usual care, p = 0.03). Though there was no significant difference in the number of patients reporting a resolution of symptoms by day 10 post-injury, the median time to symptom resolution was 7 days with strict rest vs. 4 days with usual care (p = 0.08). The strict rest group also reported a significantly higher total PCSS score period (mean 187.9 vs. 131.9, p < 0.03) as well as a greater number of total post-concussive symptoms (mean 70.4 vs. 50.2) over the 10 day study period compared to the group receiving usual care. There were no significant differences between groups in neurocognitive or balance tests at day 3 and day 10.

This trial suggests that there may be no benefit to an extended period of strict rest for children after mild traumatic brain injury or concussion. In fact, symptom reporting was increased in children who were recommended extended rest. The increased period of rest may have influenced the perception of illness or caused greater emotional distress due to the absence from school and activities. The strict rest group was slightly, but significantly, older than the children in the usual care group, and this age difference may have influenced symptom reporting. The results of this trial may not apply to children with more significant symptoms post-injury, as children admitted to the hospital were excluded from analysis.

For more information, see the Concussion and mild traumatic brain injury topic in DynaMed.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Oncology (especially Breast cancer, Head and neck cancer, Pancreatic cancer), Ophthalmology, Orthopedics, Pediatric Neurology, and Vascular.

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

PEMSoft Mobile

Free Trial of PEMSoft Mobile 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 EBSCO Health. 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.

Content in the PEMSoft Mobile app covers more than 3,000 conditions and includes a similar number of medical illustrations, clinical images and videos. PEMSoft Mobile also includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms, and topics covering pediatric injuries and management approaches.

Visit the PEMSoft Mobile App Trial page to access a free trial for both Apple and Android devices.

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