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

Release Date: February 25, 2015
Expiration Date: February 25, 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: 1405237P2

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
Education for Clinicians in Training

Last week 583 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 inform clinical practice," one article was selected by the DynaMed Editorial Team.

Propranolol 3 mg/kg/day for 6 Months May Increase Hemangioma Resolution in Infants with Proliferating Infantile Hemangioma

Reference: N Engl J Med 2015 Feb 19;372(8):735 (level 2 [mid-level] evidence)

Infantile hemangiomas are benign vascular tumors that occur in 1-10% of infants and usually appear between 1-8 weeks after birth (Paediatr Perinat Epidemiol 2008 Nov;22(6):520, Paediatr Perinat Epidemiol 2012 Mar;26(2):156, Br J Dermatol 2014 Apr;170(4):907). Though the majority of infantile hemangiomas ultimately involute and do not require treatment, some proliferating hemangiomas require systemic therapy (Semin Pediatr Surg. 2014 Aug;23(4):162-7). Several case series and small randomized trials have suggested that the beta-blocker propranolol may inhibit hemangioma growth (Pediatrics 2011 Aug;128(2):e259, Br J Dermatol 2013 Jul;169(1):181, J Pediatr Surg 2012 Apr;47(4):707) and cohort studies have found propranolol to be more effective than systematic corticosteroids (Ann Plast Surg 2015 Feb;74(2):237, Pediatr Dermatol 2011 Nov-Dec;28(6):649). Although propanolol has been used more frequently based on these studies, strong evidence supporting its use from a large randomized trial is lacking. A recent randomized trial compared oral propranolol vs. placebo for 6 months in 460 infants aged 1-5 months with proliferating hemangiomas. To determine the most effective propranolol treatment regimen, infants were randomized to 1 of 4 propranolol regimens or placebo, with propranolol regimens including 1 mg/kg/day for 3 months then placebo for 3 months, 3 mg/kg/day for 3 months then placebo for 3 months, 1 mg/kg/day for 6 months, and 3 mg/kg/day for 6 months.

Overall, 29% of infants withdrew from the study, mostly due to a lack of efficacy. The randomized treatment group significantly influenced the discontinuation rate, with 65% of infants in the placebo group, 36% of infants in the 3-month propranolol groups, and 14% of infants in the 6-month propranolol groups withdrawing before 24 weeks. A prespecified interim analysis was performed when 188 patients (including dropouts) reached the 24 week time point to determine which regimen had the highest success rate and would be included in the final efficacy analysis of a single propranolol regimen vs. placebo. Dose and duration of propranolol was significantly associated with treatment success (defined as complete or nearly complete resolution of the target hemangioma) at interim analysis. Treatment success occurred in 38% with propranolol 1 mg/kg/day for 6 months (p = 0.004 vs. placebo) and 63% with propranolol 3 mg/kg/day for 6 months (p < 0.001 vs. placebo) compared to 8% with placebo at interim analysis. There were no significant differences comparing 3-month propranolol treatments vs. placebo. In the 24 week efficacy analysis comparing 3 mg/kg/day propranolol for 6 months vs. placebo, treatment success occurred in 60% vs. 4% (p < 0.001, NNT 2). This propranolol regimen was also associated with an increased rate of improvement at 5 weeks (88% vs. 5%, p < 0.001, NNT 2). There were no significant differences in serious adverse events or adverse events during treatment among all groups.

This trial suggests that propranolol 3 mg/kg/day for 6 months may be effective for resolving hemangiomas in infants with proliferating hemangiomas requiring treatment. Although propranolol treatment was associated with a slightly higher rate of adverse events, such as diarrhea, sleep disorders, and bronchitis, this increase was not significant and adverse events due to important known propranolol associated risks (hypoglycemia, hypotension, bradycardia, and bronchospasm) were rare in all groups. These results support the use of propranolol as first-line therapy for infantile hemangiomas.

For more information, see the Hemangioma in infants and Propranolol topics in DynaMed.

DynaMed Introduces New and Improved Mobile App

February 5, 2015

DynaMed users can now access valuable, evidence-based content anywhere with the new DynaMed mobile app. The new app has been redesigned to make it easier and faster for physicians to find answers to clinical questions. The app features an improved user experience, seamless authentication and easy access to the latest clinical content. It provides offline access, and the ability to denote favorites, email topics and write and save notes about particular topics. Users download the complete DynaMed content set and periodically receive notifications to update the content.

The DynaMed app is a complimentary part of personal and institutional DynaMed subscriptions. The app has also been designed for easy, one-time authentication via email, making the process as convenient as possible.

The app can be downloaded from the iTunes Store or Google Play. For more information, please visit the DynaMed Mobile Access page.

Bronchiolitis and Respiratory Distress in Children

PEMSoft Complimentary Webinar
Thursday, February 26, 2015 @ 2:00 pm EDT

Join Sean Fox, MD, Associate Editor-in-Chief of PEMSoft for a short lecture on bronchiolitis and respiratory distress in children.

Dr. Fox is Associate Professor for the Department of Emergency Medicine and Assistant Program Director for Emergency Medicine Residency at Carolinas Medical Center in Charlotte, North Carolina. He is the 2014 recipient of the ACEP National Emergency Medicine Faculty Teaching Award, the chair for the ACEP Pediatric Emergency Medicine Section and the director of the Emergency Medicine residency didactic curriculum. Dr. Fox received his medical degree and a combined residency in Emergency Medicine/Pediatrics at the University of Maryland. He also manages several educational websites geared toward the practice of emergency medicine

Click here to register.

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.