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

Release Date: October 22, 2014
Expiration Date: October 22, 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 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 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: 1405237W

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.

Ebola: Updated CDC Guidelines

The world is presently experiencing the largest outbreak of Ebola virus disease (Ebola) in history. Over 9,000 persons have been infected in West Africa, resulting in over 4,500 deaths. Three cases have been diagnosed in the United States, two among nurses caring for the first patient. 

Following the transmission of Ebola to healthcare workers, Centers for Disease Control and Prevention (CDC) have revised their guidelines on the use of personal protective equipment (PPE).  New CDC guidance emphasizes:

  1. Rigorous and repeated training in performing all infection control procedures, specifically the donning and doffing of PPE, with demonstration of competency for all healthcare workers involved in the care of Ebola patients.
  2. No skin exposure when PPE is worn.  New step-by-step instructions require full-body coverage, including use of a surgical hood with single use face shield, fluid-resistant gowns supplemented by waterproof aprons and boot covers, double gloves and either N95 respirator or powered air purifying respirator (PPAR).   Use of facemasks and goggles are no longer considered adequate.
  3. Supervision by a trained observer to ensure that there is no breach in protocol when healthcare workers don or doff PPE. 

CDC also reminds all healthcare works to “Think Ebola” and “Care Carefully.”  Ask any patient with a febrile illness about travel to an area with Ebola transmission or any potential Ebola exposure within the past 21 days. Immediately isolate any patient with potential Ebola and institute your institution’s Ebola preparedness plan. Contact local or state health departments when Ebola is suspected or if an asymptomatic exposure is identified.

For more information, see the Ebola virus disease topic in DynaMed.  CDC guidelinesfact sheet and triage algorithm and additional information can be found at CDC Ebola virus disease homepage.

Last week 509 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 274 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.

ADNEX Model Predicts Risk of Malignancy and Stratifies Risk Across Tumor Subtypes in Women With Adnexal Mass
Reference: BMJ 2014 Oct 15;349:g5920 (level 1 [likely reliable] evidence)

Predicting tumor malignancy of adnexal masses found incidentally can be challenging. In addition to risk of malignancy, the disease stage of malignant masses at diagnosis is an important factor not only for determining the best treatment course, but also for predicting survival. A recent study developed a new clinical prediction rule for estimating risk of malignancy in 5,909 women with ≥ 1 adnexal mass judged not to be physiological cysts.

All 5,909 women included in the study were part of the International Ovarian Tumour Analysis (IOTA) study group, were assessed by transvaginal ultrasound, and later had surgical intervention.  The Assessment of Different NEoplasias in the adneXa (ADNEX) model was developed from a cohort of 3,506 women and includes 9 criteria: age, serum CA-125 level, type of center (oncology center vs. other hospital), maximum lesion diameter, solid tissue proportion, presence of > 10 cyst locules, papillary projection number, presence of acoustic shadows, and presence of ascites.  In the validation cohort of 2,403 women, the ADNEX model had excellent performance for discrimination of benign and malignant tumors (c-statistic 0.94).  Using 3% as a cutoff for risk of malignancy, the ADNEX model had 98.9% sensitivity and 46.6% specificity. The positive and negative likelihood ratios were 1.9 and 0.02, respectively.  Based on the negative likelihood ratio, the risk of malignancy with a negative result is very low.  In addition to classifying the risk of a tumor being benign vs. malignant, the ADNEX model also stratifies the risk of malignancy into 4 subtypes (borderline tumor, stage I invasive, stage II-IV invasive, and secondary metastatic), all of which had good discrimination (c-statistic 0.75-0.96 in combined data set) and calibration.

The ADNEX model improves the classification of tumor type in women with adnexal masses. The National Institutes for Health and Care Excellence (NICE 2011 Apr: CG122) currently recommends using the risk of malignancy index (RMI) for assessing tumor risk, however in the IOTA data set the RMI had lower predictive performance than the ADNEX model (c-statistic 0.88). The ADNEX model also offers additional benefit by classifying risk of malignancy into several subtypes, which may inform patient triage as well as care decisions and management. The model is available as a free online calculator or can be purchased as an app for android mobile phones (iPhone app is not yet available).

For more information, see the Ovarian cancer and Adnexal mass topics in DynaMed.

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

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: ENT, Gastroenterology, Hematology, Nephrology, Ophthalmology, Orthopedics, Surgery, Vascular.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

PEMSoft Mobile

PEMSoft Now Available For iPhone, iPad, and Android Devices

The PEMSoft Mobile app, a pediatric evidence-based point-of-care medical reference tool for hospitals, emergency departments, clinics, pediatric group practices, transport services, and medical schools, is now available from EBSCOHealth. Designed by pediatricians, emergency physicians and other medical specialists, 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.

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