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Credits

Physicians: .25 AMA PRA Category I Credits^TM

Family Physicians: .25 Prescribed credits

Nurse Practitioners: .25 Contact hours

Release Date: April 16, 2014

Expiration Date: April 16, 2015

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 at the end of the article.

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 Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Senior 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

Disclosures

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 Credits^TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: Enduring Material activity, DynaMed EBM Focus, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each EBM Focus is worth .25 Prescribed credits. 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 of continuing education by the American Academy of Nurse Practitioners.

Program ID: 1304159W

Last week 714 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 318 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to change clinical practice," one article was selected by the DynaMed Editorial Team.

Diagnostic Algorithm Using Clinical Prediction Score, D-Dimer Testing, and Ultrasound Predicts Upper Extremity Deep Vein Thrombosis
Reference: Ann Intern Med 2014 Apr 1;160(7):451 (level 1 [likely reliable] evidence)

Although the absolute rate of primary upper extremity deep vein thrombosis (UEDVT) is low, the incidence is increasing due to more widespread use of central venous catheters. Both cancer and use of central venous catheters have been shown to be common risk factors for UEDVT (J Thromb Haemost 2005 Nov;3(11):2471), and a recent systematic review concluded that peripherally inserted central catheters are associated with higher risk of UEDVT than other central venous catheters (Lancet 2013 Jul 27;382(9889):311). Previously, a clinical prediction score has been shown to help predict UEDVT in patients with clinically suspected disease (Thromb Haemost 2008 Jan;99(1):202). A new study evaluates a diagnostic algorithm that uses the clinical prediction score to guide testing with D-dimer and compression ultrasound.

The scoring system gives 1 point each for presence of venous material (such as a catheter), localized pain, and unilateral pitting edema, and subtracts 1 point if there is a plausible alternative diagnosis. For patients who score 1 point or less, the initial test of the algorithm is a serum D-dimer which if negative can rule out a UEDVT. If the D-dimer is elevated, then a compression ultrasound is done. For patients with a score of 2 or 3, the algorithm starts with a compression ultrasound. If that is positive a UEDVT is diagnosed, but if negative a D-dimer test is also obtained to confirm the absence of a UEDVT. Inconclusive results on compression ultrasound were managed with repeat ultrasound and, if necessary, venography. Patients who were classified as having no UEDVT after completing the algorithm had clinical follow-up for 3 months.

A total of 406 patients (mean age 56 years) with suspected UEDVT were enrolled, and 390 patients (96%) had a full workup according to the algorithm. UEDVT was diagnosed by compression ultrasound (done when indicated by the algorithm) in 25%. During clinical follow-up of patients without UEDVT according to the algorithm, UEDVT was subsequently diagnosed in 1.2% of 84 patients initially classified as “likely UEDVT” (including 12 protocol violations), but in none of 162 patients initially classified as “unlikely UEDVT”.

An algorithmic approach to diagnosing lower extremity DVT using a clinical prediction rule, D-dimer testing, and compression ultrasound where indicated has previously been described (J Thromb Haemost 2009 Dec;7(12):2035). These new findings extend the use of a similar diagnostic algorithm to patients with clinical suspicion of UEDVT. Like the previous algorithm, this new algorithm benefits from being relatively simple, quick, and noninvasive. In addition, the similarity of this new diagnostic strategy to an established algorithm may help facilitate its implementation into clinical practice.

For more information see the Upper extremity deep vein thrombosis topic in DynaMed.

Earn CME Credit for reading this e-Newsletter. For more information on this educational activity, see the CME sidebar.

KidsCareEverywhere Blogging from Vietnam

EBSCO Information Services along with PEMSoft and DynaMed are proud sponsors of KidsCareEverywhere. KidsCareEverywhere is a public charity dedicated to transforming pediatric care in under-resourced communities by donating state-of-the-art medical software to public hospitals and training physicians and medical providers in software utilization.

Read about an ongoing initiative in Vietnam at KidsCareEverywhere

Call for Peer Reviews

We are currently seeking subspecialty reviewers for our Patient Education Resource Center (PERC). PERC provides fact sheets and discharge instructions for patients leaving the hospital or emergency room. These hand-outs fulfill the meaningful use requirements for the Medicare & Medicare Services Incentive Programs.

Click here to speak with us about becoming a peer reviewer.

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