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

Release Date: July 22, 2015
Expiration Date: July 22, 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.

Last week 526 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 203 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.

Very Early Mobilization of All Patients with Acute Stroke May Not Improve 3-Month Outcomes

Reference: AAVERT trial (Lancet 2015 July 4;386(9988):46) (level 2 [mid-level] evidence)

Early mobilization (sitting out-of-bed, standing, and walking) is recommended for less severely affected patients after acute stroke to reduce the risk of complications such as pneumonia, deep vein thrombosis, pulmonary embolism, and pressure ulcers (Stroke 2013 Mar;44(3):870). The optimal timing and frequency of early mobilization, however, has not been well-defined. One small randomized trial suggested that mobilization within 52 hours may reduce the risk of life-threatening complications compared to mobilization after 7 days, but the overall complication rate was not significantly different between groups (Clin Rehabil 2012 May;26(5):451). Results of trials examining mobilization within 24 hours have been conflicting. A meta-analysis of 2 small trials found very early mobilization decreased complications and improved independence (Stroke 2010 Nov;41(11):2632), while one small trial published since suggested mobilization within 24 hours might be associated with increased mortality and poorer global function (Stroke 2012 Sep;43(9):2389). To resolve the uncertainty about the impact of early mobilization, a recent randomized trial compared very early mobilization vs. routine mobilization as part of care in the stroke unit in 2,104 adults (mean age 73 years and 61% male) with ischemic or hemorrhagic stroke admitted to the stroke unit within 24 hours of symptom onset.

Very early mobilization began within 24 hours of stroke onset and included at least 3 out-of-bed sessions focusing on sitting, standing, or walking. Usual care varied by treatment location, but thrombolysis with tissue plasminogen activator (tPA) was allowed. Overall, mobilization within 24 hours occurred in 92% of patients randomized to very early mobilization compared to 59% of patients randomized to usual care with a median time to first mobilization of 18.5 hours vs. 22.4 hours, respectively (p < 0.0001). At 3 months post-stroke, 46% of patients with early mobilization and 50% of patients with usual care had a favorable outcome, defined as a modified Rankin Scale score of 0-2 (p = 0.004, NNH 25). These results were consistent, though often not significant, in prespecified subgroup analyses by age, stroke severity, stroke type, recombinant tPA use, and region of recruitment. There were no significant differences in the distribution of patients across all 0-6 point modified Rankin Scale scores, however. There were also no significant differences between groups in mortality, time to walking unassisted, and adverse events.

While previous trials evaluating early mobilization after acute stroke were limited by the small numbers of patients included, the current trial is well powered to detect small differences in patient outcomes after acute stroke. Indeed, it is more than 10 times the size of all previous mobilization trials combined. One drawback of the present trial, however, was that the median time to first mobilization was less than 24 hours in both randomized groups. This reflects the fact that the trials included patients with both mild strokes and severe strokes, in fact approximately 40% of patients in both groups were able to walk independently at baseline. Nonetheless, the very early mobilization group had their median time to first mobilization approximately 4 hours before the usual care group and there was an absolute difference of 33% in the rate of patients being mobilized within 24 hours. These differences in mobilization did not benefit the earlier mobilization group, and very early mobilization may have even negatively impacted global functioning at 3 months. Finally, unlike in previous trials, this trial found that early mobilization did not decrease adverse events, including immobilization-related serious adverse events. Overall, the results of this trial suggest that benefits previously associated with early mobilization do not require mobilization to begin within 24 hours. This suggests current recommendations may need to be updated.

For more information see the Stroke (acute management) topic in DynaMed.

American College of Physicians and EBSCO Health partner to give 141,000 ACP members access to DynaMed Plus

The American College of Physicians (ACP) recently announced a partnership with EBSCO Health to provide the 141,000 members of ACP complimentary access to DynaMed Plus, a new cross-platform evidence-based clinical decision support tool. ACP is contributing expertise, content, and multimedia to DynaMed Plus.

“ACP looks forward to collaborating with the already strong DynaMed editorial team and extending the reach of our content and expertise,” said Dr. Wayne J. Riley, president, ACP. “ACP’s clinical leadership will help to continually develop and maintain internal medicine topics that are important to ACP members.”

Dr. Robert Centor, immediate past chair of ACP’s Board of Regents, and ACP Regent Dr. Jack Ende will join the DynaMed Executive Leadership Board. They will join Dr. Amir Qaseem, ACP’s director of clinical policy, who is a current board member. ACP will also provide a deputy editor to be a part of the editorial team overseeing internal medicine topics for DynaMed Plus.

Select content from ACP’s current clinical reference tool, Smart Medicine, such as tables, images, and graphics, will be included in DynaMed Plus. Individual paid Smart Medicine subscribers who wish to convert to DynaMed Plus may do so beginning January 1, 2016, when Smart Medicine will be discontinued.

Click here to read the whole press release

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