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

Release Date: June 24, 2015
Expiration Date: June 24, 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

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.

Last week 836 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 195 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.

Expectant Monitoring of Women with Non-Severe Hypertensive Disorders of Pregnancy at 34-37 Weeks Gestation Appears to Improve Neonatal Outcomes, but Effect on Maternal Outcomes is Uncertain

Reference: HYPITAT-II trial (Lancet 2015 June 20;385(9986):2492) (level 2 [mid-level] evidence)

Hypertensive disorders of pregnancy, which includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia, are the most common medical complications of pregnancy and affect 5-8% of all pregnancies in the United States (J Clin Hypertens (Greenwich) 2009 Apr;11(4):214). Induction of labor was previously found to significantly reduce the risk of severe hypertension, with a nonsignificant decrease in incidence of both HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) and intensive maternal hospital care compared to expectant monitoring in women with gestational hypertension or mild preeclampsia at 36-41 weeks gestation (Lancet 2009 Sep 19;374(9694):979). Current guidelines recommend considering delivery in women with non-severe hypertensive disorders of pregnancy at > 37 weeks gestation and indicate earlier delivery with the presence of maternal or fetal distress, severe preeclampsia, or HELLP syndrome (Obstet Gynecol 2013 Nov;122(5):1122, J Obstet Gynaecol Can 2014 May;36(5):416). Recommendations are less clear, however, for women with non-severe hypertensive disorders of pregnancy at 34-37 weeks gestation. A recent randomized trial compared immediate delivery vs. expectant management in 703 women with non-severe hypertensive disorders of pregnancy at 34-37 weeks gestation. Immediate delivery included the induction of labor or cesarean delivery within 24 hours of randomization, while women randomized to expectant monitoring received interventions aimed at prolonging pregnancy until 37 weeks gestation.

The median time between randomization and delivery was 2 days with immediate delivery vs. 7 days with expectant monitoring (p < 0.05).  In the expectant monitoring group, 36% of women delivered before 37 weeks gestation due to maternal or fetal indications.  The composite outcome of maternal adverse events was defined as thromboembolic complication, pulmonary edema, HELLP syndrome, eclampsia, placental abruption, or maternal death.  Although there were no significant differences in maternal adverse events between groups, there was a nonsignificantly lower rate of adverse events with immediate delivery compared to expectant monitoring (1.1% vs. 3.1%, p = 0.069).  There were no significant differences in individual maternal complications including HELLP syndrome, thromboembolic process, or eclampsia.  Immediate delivery was associated with increased adverse neonatal outcomes, however.  Neonatal respiratory distress syndrome occurred in 5.7% of infants with immediate delivery vs. 1.7% with expectant monitoring (p = 0.005, NNH 25) and neonatal morbidity was reported in 49.1% of immediate deliveries vs. 36.3% of monitored pregnancies (p < 0.05, NNH 8).

While this trial did not find that immediate delivery was associated with a significant decrease in overall maternal complications, these results are limited by the low number of maternal adverse events in both groups as well as the high rate of delivery before 37 weeks in the expectant monitoring group.  However, the increased risk of neonatal adverse events was clear, with a significant increase in the rates of neonatal respiratory distress syndrome and overall neonatal morbidity in the immediate delivery group.  Overall, these results suggest that expectant management for women at 34-37 weeks gestation with non-severe hypertensive disorders may result in better outcomes for the baby, but the question of possible increase in adverse maternal outcomes will need to be evaluated in subsequent trials.

For more information see the Hypertensive disorders of pregnancy topic in DynaMed.

We have been informed that many subscribers did not receive last week’s version of EBM Focus. To read the article, Nivolumab May Increase Overall Survival and Progression-Free Survival Compared to Docetaxel in Patients with Advanced Squamous Cell Non-Small Cell Lung Cancer, please visit our archive on the DynaMed website. Many thanks for your patience.

DynaMed Extra

US Food and Drug Administration allows marketing of new device that helps blind persons process visual information through signals to the tongue (FDA Press Release 2015 June 18)
The FDA recently allowed marketing of a new device, the BrainPort V100, designed to complement other forms of assistance for blind persons. The device works by using a transducer to send signals to the tongue which are then processed by the brain. The device is composed of a video camera mounted to a pair of glasses, and a small flat oral device which delivers electrical signals to the tongue. The user can then interpret this stimulation, which may be perceived as a vibration or tingling sensation, into information about the location, position, size, and shape of objects, as well as whether objects are moving or stationary. Preliminary clinical examination of the safety and effectiveness of the device has demonstrated that 69% of subjects trained for 1 year with the device were successful at an object recognition test. Only minor adverse effects were reported, including burning, stinging and metallic taste of the oral device. This device was approved in Europe in 2013 where it is marketed for approximately $10,000.

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.