Quick Links

Share with Colleagues
Previous EBM Focus Issues
Become a DynaMed Reviewer
DynaMed Free Trial
Send Comment to Editor

Join Our Mailing List



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

Release Date: September 24, 2014
Expiration Date: September 24, 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 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 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


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 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 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus 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 0.25 contact hour(s) of continuing education by the American Association of Nurse Practitioners. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Program ID: 1405237S

Last week 493 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 200 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.

Bedside Ultrasound May Be an Alternative to Computed Tomography for Evaluation of Suspected Nephrolithiasis in the Emergency Department
Reference: N Engl J Med 2014 Sep 18;371(12):1100 (level 2 [mid-level] evidence)

Suspected nephrolithiasis is commonly encountered in the emergency department, with almost 1 million emergency department visits annually in the United States (J Urol 2014 Jan;191(1):90). Imaging is typically required to confirm the diagnosis. Noncontrast computed tomography (CT) is recommended to confirm a diagnosis of nephrolithiasis in adults by both the American Urological Association (AUA 2012 May PDF) and the European Association of Urology (EAU 2014 Mar PDF). Ultrasound has also been evaluated in this setting, and has several potential advantages over CT, including lack of radiation exposure and lower cost. A small diagnostic cohort study previously found that ultrasound had moderate sensitivity and high specificity for detecting nephrolithiasis in children (J Urol 2009 Oct;182(4 Suppl):1829). A new randomized trial in adults assessed initial diagnostic evaluation with ultrasound performed by an emergency physician, ultrasound performed by a radiologist, or abdominal CT in 2,759 patients presenting to the emergency department with suspected nephrolithiasis.

The study was powered to detect between-group differences of 5% for events with a prevalence of 10% or differences of 0.34% for events with a prevalence of 0.5%. All emergency physicians involved in the study had training and certification in bedside ultrasound, and subsequent imaging and management was left to the discretion of the treating physician. About 41% of patients in the bedside ultrasound group and 27% of those in the radiology ultrasound group had a subsequent CT as part of their initial workup. In contrast, about 5% of patients in the CT group had a subsequent ultrasound. There were no significant differences among groups in rate of return emergency department visits or hospitalizations after emergency department discharge; however, patients randomized to CT had significantly higher radiation exposure compared to other groups (see table below).

Outcome Bedside ultrasound Radiology ultrasound CT p Value
Return ED visits 27.5% 28.3% 29.2% Not significant
Hospitalization after ED discharge 10.4% 10.3% 9.5% Not significant
Cumulative radiation exposure 6.5 mSv 4.7 mSv 14.1 mSv p < 0.0001
ED, emergency department; CT, computed tomography

The findings from this new trial suggest bedside ultrasound and abdominal CT have similar rates of return emergency department visits and hospitalization after emergency department discharge. However, the large proportion of patients who were randomized to initial bedside ultrasound who subsequently received CT is a potential limitation, since some of the evaluation performance attributed to bedside ultrasound may have resulted from the combination of ultrasound and CT. Nonetheless, this new study demonstrates that bedside ultrasound may be a reasonable alternative to CT for assessing suspected nephrolithiasis in the emergency department, potentially reducing radiation exposure and costs associated with CT.

For more information see the Nephrolithiasis topic in DynaMed.

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

DynaMed Extra

Updated ACP Guideline for Nonsurgical Management of Urinary Incontinence in Women

The American College of Physicians (ACP) guidelines for nonsurgical management of urinary incontinence in women have recently been updated (Ann Intern Med 2014 Sep 16;161(6):429 PDF). The guidelines have been incorporated into the Urinary incontinence in women and Behavioral interventions for urinary incontinence topics. For more information, see these topics in DynaMed.

EBSCO Health Launches Pediatric Clinical Information Mobile App

PEMSoft Now Available For iPhone, iPad, and Android Devices

A mobile app designed specifically for pediatricians, emergency department physicians, physicians-in-training and other medical providers caring for children with acute illnesses and injury, is now available from EBSCO Health, the leading provider of clinical decision support solutions for the healthcare industry.

Designed by pediatricians, emergency physicians and other medical specialists, PEMSoft is a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools. The vast content in PEMSoft addresses the entire spectrum of neonatal, infant, child, adolescent and young adult health. PEMSoft authors adhere to a strict evidence-based editorial policy focused on systematic identification, evaluation and consolidation of practice-changing clinical literature.

The PEMSoft Mobile app includes explicit step-by-step emergency critical care procedures, information about common pediatric signs and symptoms and content covering pediatric injuries and management approaches. More than 3,000 evidence-based pediatric topics and a similar number of medical illustrations, clinical images and videos are also available via the mobile app.

The PEMSoft Mobile App is accessible from both Apple and Android devices.

Visit the PEMSoft page for more information.

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.

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
DynaMed Peer Review
Editorial Policies for Reviewers
Education for Clinicians in Training

DynaMed Careers

Looking for a change? The DynaMed editorial team is expanding and looking for talented and driven individuals. Visit the links below to learn about these exciting opportunities.

Section Editor of Specialty Content