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: 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: 1405237X

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.

Screening and Treatment of Thyroid Dysfunction
An Evidence Review for the US Preventive Services Task Force
Reference: Ann Intern Med 2014 Oct 28 early online

In 2004 the United States Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against screening for thyroid disease in asymptomatic adults. Revisiting the evidence 10 years later finds little to update. No study directly assessed benefits and harms of screening. For treatment of subclinical hypothyroidism, 1 fair-quality cohort study found an association with decreased risk for coronary heart disease events, but no study has found benefits for quality of life, cognitive function, blood pressure, or body mass index. No study evaluated clinical outcomes with treatment of subclinical hyperthyroidism. No study evaluated treatment of screen-detected overt thyroid dysfunction compared to no treatment or waiting for symptomatic presentation to initiate treatment.

The review is being published ahead of publishing USPSTF recommendations but is consistent with their 2004 statement and draft 2014 statement finding insufficient evidence to assess the balance of benefits and harms of screening for thyroid dysfunction in nonpregnant asymptomatic adults.

Peak Exercise Brain Natriuretic Peptide May Predict Poor Outcome in Patients With Asymptomatic Severe Aortic Stenosis
Reference: Heart 2014 Oct;100(20):1606 (level 2 [mid-level] evidence)

The optimal timing of aortic valve replacement in patients with severe aortic stenosis is currently unclear, and risk stratification may help identify patients more likely to benefit. Several studies have shown that elevated resting brain natriuretic peptide (BNP) levels are associated with increased risk of poor outcome (Curr Cardiol Rep 2009 Mar;11(2):85, Circulation 2004 May 18;109(19):2302 full-text, Am J Cardiol 2005 Nov 15;96(10):1445, and Circulation 2007 Jun 5;115(22):2848 full-text). A recent study evaluated peak exercise BNP measurement for prediction of aortic valve replacement or death in 157 patients with asymptomatic severe aortic stenosis.

A total of 87 patients (55%) had aortic valve replacement or death during mean 1.5 years follow-up. The mean resting BNP level at baseline was 43 pg/mL overall (16 pg/mL in tertile 1, 45 pg/mL in tertile 2, and 101 pg/mL in tertile 3). The rate of event-free survival at 2 years in an adjusted analysis was:

  • 81% for peak exercise BNP 6-46 pg/mL (reference)
  • 48% for peak exercise BNP 47-94 pg/mL (p = 0.003 vs. reference)
  • 18% for peak exercise BNP 95-956 pg/mL (p < 0.0001 vs. reference)

A peak exercise BNP >86 pg/mL was identified as the optimal cutoff for detection of aortic valve replacement or death. When compared to resting BNP, peak exercise BNP using optimal cutoffs was associated with an improved predictive performance of aortic valve replacement or death at 1 year (p < 0.0001).

The results of this study suggest that for patients with asymptomatic severe aortic stenosis, use of peak exercise BNP may improve risk stratification compared to resting BNP. This may help identify patients who would benefit from closer observation and potentially earlier surgical intervention. Measurement of peak exercise BNP could be part of an exercise-stress echocardiography or a standard treadmill exercise test. However, a significant limitation is the lack of validation for a specific peak exercise BNP cutoff to use for risk stratification and patient management. In addition, there is limited other data on use of peak exercise BNP for risk stratification.

For more information, see the Aortic stenosis and Brain natriuretic peptide (BNP) testing topics in DynaMed.

Recently Released Choosing Wisely Canada Recommendations Added to DynaMed

October 29, 2014: Recommendations from 12 Organizations are Now Easily Accessible at the Point-of-Care

Choosing Wisely Canada just released 61 new recommendations that are now available in DynaMed. These recommendations are intended to help clinicians and patients avoid unnecessary tests and treatments, and are compiled from 12 specialty societies.

Choosing Wisely Canada is modeled after the Choosing Wisely campaign in the United States, an initiative of the ABIM Foundation. The Canadian campaign has been developed in partnership with the Canadian Medical Association and involves more than 30 specialty societies. The recommendations are not meant to be used to establish coverage decisions or exclusions but to spur conversations about what is appropriate and necessary treatment.

All of these recommendations can be found in the Choosing Wisely Canada topic in DynaMed and the DynaMed editorial team is working with the Canadian Medical Association and related organizations to integrate the recommendations across the relevant clinical topics in a way that maximizes their visibility in the flow of patient care where they are most needed.

Click here for more information and to read the official press release.

DynaMed Careers

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

DynaMed Contribution Opportunities

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