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

Release Date: June 3, 2015
Expiration Date: June 3, 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 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.

DynaMed Careers

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 rbrady@ebsco.com.

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
Education for Clinicians in Training

Last week 439 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 151 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.

Supplemental Oxygen May Be Harmful in Normoxive Patients with ST-Elevation Myocardial Infarction

Reference: AVOID trial (Circulation 2015 May 22 early online) (level 2 [mid-level] evidence)

Supplemental oxygen therapy is commonly given as part of the initial treatment to all patients with ST-elevation myocardial infarction (STEMI), even when the oxygen saturation is normal, though studies supporting its use are limited. Current guidelines recommend administration of oxygen in patients with STEMI presenting with hypoxia, but exact definitions and recommendations vary (Circulation. 2013 Jan 29;127(4):e362-425, Eur Heart J. 2012 Oct;33(20):2569-619). A previous Cochrane review found routine oxygen therapy may not reduce mortality in patients with suspected or proven acute myocardial infarction (Cochrane Database Syst Rev 2013 Aug 21;(8):CD007160), but only 4 trials (all with with wide confidence intervals) were included in this analysis. A recent randomized trial compared oxygen supplementation at 8 L/min vs. no oxygen supplementation in 441 adults with normal oxygen saturation who had chest pain for < 12 hours and confirmed STEMI. Patients with suspected STEMI on prehospital electrocardiogram and oxygen saturation > 94% (638) were randomized by paramedics who initiated therapy before hospital admission. Paramedics also administered aspirin 300 mg orally to all patients. Only patients later confirmed to have STEMI by emergent coronary angiography were included in the analysis.

Patients in the no oxygen group were started on oxygen if their oxygen saturation went below 94% before or on arrival to the cardiac catheterization lab, which occurred in 7.7% of patients randomized to no oxygen. All patients with no contraindications were invited for contrast enhanced cardiac magnetic resonance (CMR) imaging at 6 months, and patients not electing for CMR had 6-month follow-up telephone assessment. Although mean peak troponin I levels did not differ significantly between groups, oxygen supplementation was associated with increased mean peak creatine kinase levels compared to no oxygen supplementation (1,948 units/L vs. 1,543 units/L, p = 0.01). In the 32% of patients completing the 6-month CMR assessment, supplemental oxygen was also associated with an increase in median infarct size (20.3 g vs. 13.1 g, p = 0.04). Furthermore, a greater number of patients receiving supplemental oxygen had recurrent in-hospital myocardial infarctions (5.5 % vs. 0.9%, p = 0.006), in-hospital cardiac arrhythmia (40.4% vs. 31.4%, p = 0.05), and 6-month major cardiovascular adverse events (21.9% vs. 15.4%, p = 0.08). There were no significant differences in mortality during hospital stay or at 6 months.

A major limitation of previous studies evaluating oxygen supplementation is the randomization of patients upon reaching the hospital, after oxygen therapy is routinely administered. The randomization method employed by this trial accounted for pre-hospital interventions by providing sealed, opaque, externally numbered randomization envelopes to ambulances. In this study, oxygen was provided by face mask at 8 L/minute, but oxygen is often provided by nasal cannulation at 2-4 L/minute, making generalizations difficult. It is unknown if the adverse effects of oxygen observed in this trial also pertain to lower level oxygen administration. Finally, the primary outcome of this trial was myocardial injury assessed by peak cardiac troponin I and creatine kinase levels, and the trial was powered to detect differences in these surrogate outcomes. Although the rate of in-hospital recurrent myocardial infarctions was significantly higher in the group receiving oxygen therapy, the 6-month rate of recurrent myocardial infarctions was no longer significant (p = 0.07). This trial was underpowered to detect differences in clinical endpoints, however, and further evaluation is necessary to determine if the observed increase in myocardial injury translates into an increase in clinical outcomes. Overall, the results of this trial call into question the routine use of oxygen therapy, suggesting oxygen supplementation in patients with normal oxygen saturation levels may increase myocardial injury in patients having STEMI.

For more information see the ST-elevation myocardial infarction (STEMI) topic in DynaMed.

EBSCO Health’s New DynaMed Plus Delivers Trusted, Evidence-Based Content to Physicians on Any Platform

EBSCO Health recently launched DynaMed Plus, a cross-platform, evidence-based clinical decision support tool that provides clinicians with the ideal blend of evidence and expertise to help them determine optimal patient care paths.

DynaMed Plus helps medical professionals quickly find evidence-based answers to make the best treatment decisions in any location. With DynaMed Plus, clinicians (and their patients) will benefit from:

  • Quickest time-to-answer—Including intelligent auto-suggest, direct-to-section search results, exact match summary display, dynamic linking and quick access to relevant calculators.
  • Concise, accurate overviews and recommendations—For the most common conditions as well as evidence-based recommendations for action.
  • Comprehensive image library—Over 4,000 full-color medical graphics and images to help clinicians make the best decisions.
  • Rigorous editorial process—Subject-specific experts review topics on a daily basis using the DynaMed Plus proprietary evidence-based methodology and quality assurance process.
  • Access to specialty content—Clinicians can view thousands of topics covering emergency medicine, cardiology, oncology, infectious disease, pediatrics, obstetrics and gynecology, and much more.
  • Anywhere, anytime accessDynaMed Plus can be used on iOS and Android mobile devices, making access fast and easy, and providing clinicians with an intuitive and elegant mobile experience.

To read the press release and for more information on DynaMed Plus, click here. For free trial information, click here.

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.