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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours
Release Date: May 27, 2015
Expiration Date: May 27, 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.
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.
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.
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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 providership 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 10+, has been reviewed and is acceptable for up to 13.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins April 29, 2015. Term of approval is for one year from this date. Each weekly update 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 13.0 contact hour(s) of continuing education by the American Association of Nurse Practitioners. Program ID 1504207. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.
Last week 418 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 150 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.
Oral Prednisone Can Improve Functional Status in Patients with Acute Radiculopathy Due to a Herniated Disk, but Does Not Improve Pain
Reference: JAMA 2015 May 19;313(19):1915 (level 1 [likely reliable] evidence)
Lumbar disk herniation often presents with sciatica pain radiating from the lower back to the lower leg and foot. Though radiculopathic pain usually begins to resolve within 2-4 weeks with conservative management, the pain may persist for greater than 1 year in up to 30% of patients (BMJ 2007 Jun 23;334(7607):1313). Systemic steroids are often prescribed as part of conservative management, but data on the efficacy of this approach is limited (Rheumatology (Oxford) 2011 Sep;50(9):1603). A recent randomized trial compared oral prednisone vs. placebo for 15 days in 269 adults with acute radiculopathy due to lumbar disk herniation. The steroid dosing regimen consisted of prednisone 20 mg capsules given as 60 mg daily for 5 days, then 40 mg daily for 5 days, and then 20 mg daily for the final 5 days. Patients randomized to placebo received identical appearing capsules and dosing schedule. Nonsteroidal anti-inflammatory drugs were prohibited for 3 weeks following randomization.
For trial inclusion, patients were required to have radicular pain for ≤ 3 months, a herniated disk confirmed by magnetic resonance imaging (MRI), and an Oswestry Disability Index (ODI) score ≥ 30 indicating at least moderate disability (mean ODI score 51). The minimum clinically important difference was predefined as a 7-point difference between groups in the ODI score. At 3 weeks after randomization, the mean ODI score in patients randomized to prednisone decreased by 19 points compared to 13.3 points for patients receiving placebo (adjusted mean difference 6.4 points, p = 0.006). Predinsone was also associated with a greater number of patients achieving a ≥ 50% reduction in ODI score at this time point (33% vs. 19.8%, p = 0.01, NNT 8). By 52 weeks, the mean difference from baseline ODI scores was 37.8 points the prednisone group vs. 30.4 points for the placebo group (adjusted mean difference 7.4 points, p = 0.005). Prednisone did not improve pain scores at 3 or 52 weeks, but prednisone was associated with an increased risk of adverse events. At least 1 adverse event was reported in 49.2% of patients with prednisone vs. 23.9% with placebo (p < 0.001, NNH 4). Insomnia, nervousness, and increased appetite were all significantly more common with prednisone compared to placebo.
Treatment with prednisone resulted in a significantly greater proportion of patients having at least a 50% improvement their ODI scores at 3 weeks. Although the adjusted mean difference between groups was just below the 7-point minimum clinically important difference, mean outcomes can mask significant benefits for subgroups (although whether there is an identifiable subgroup that might be specifically targeted remains to be seen). Prednisone did not decrease pain or the risk of back surgery, and was associated with an increase in adverse events. Overall, these findings suggest that prednisone may improve disability in some patients with acute radiculopathy due to lumbar disk herniation, but it does not improve pain status, and will result in some type of adverse effect in nearly half of patients. Benefits and risks seem closely balanced and the decision to use steroids for this indication should be made on an individual basis.
For more information see the Lumbar disk herniation and Sciatica topics in DynaMed.
New High-Value Care Advice from the ACP on Screening for Cancer
The American College of Physicians (ACP) has released new advice on high-value care for screening average-risk adults for 5 common types of cancer, including breast cancer, prostate cancer, colorectal cancer, cervical cancer, and ovarian cancer. Screening strategies from several different clinical guidelines and evidence syntheses were reviewed. A “high value” label was given to screening approaches if there was consensus across guidelines that benefits of screening likely outweigh the harms. A “low value” label was used for certain screening approaches considered overly intensive, which are not recommended.
For more information, see the Screening for cancer topic in DynaMed.
Critical Appraisal of the Medical Literature: A Simplified Approach
July 8 – 9, 2015 – Portland State University - Portland, Oregon.
Join our Editorial Board members Sheri Strite and Michael Stuart and improve your critical appraisal skills. We aim to make critical appraisal of the medical literature meaningful, useful, simple, and doable. This program will be particularly helpful to those who routinely evaluate the medical literature.
Visit the Seminar page for more details.
The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.
If interested, please send a recent copy of your CV to Rachel Brady at firstname.lastname@example.org.
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