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

Release Date: July 29, 2015
Expiration Date: July 29, 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 511 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 165 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.

Medical Expulsion Therapy with Tamsulosin or Nifedipine Does Not Increase the Rate of Spontaneous Stone Passage in Adults with a Single Ureteric Stone

Reference: Lancet 2015 July 25;386(9991):341 (level 1 [likely reliable] evidence)

Renal calculi occur in 5%-15% of the population worldwide (BMJ 2007 Mar 3;334(7591):468). Some stones may cause ureteral obstruction leading to severe and debilitating pain and are a common cause of emergency department visits (J Urol 2014 Jan;191(1):90). Patients with ureteral stones are often simply observed for stone passage, unless there is an indication for active removal, such as persistent obstruction, persistent pain unresponsive to pain medication, or renal insufficiency (EAU 2015 Mar). Medical expulsion therapy with alpha-blockers or nifedipine is currently recommended to help expedite stone passage based on previous meta-analyses of randomized trials (EAU 2015 Mar). However, large, high quality randomized trials evaluating medical expulsion therapy are lacking. To address this issue, a recent randomized trial compared tamsulosin 400 mcg vs. nifedipine 30 mg vs. placebo daily for up to 4 weeks as part of expectant management in 1,167 adults aged 18-65 years with ureteric colic. All patients had computed tomography-confirmed single ureteric stone < 10 mm (75% of patients had stones ≤ 5 mm) in diameter. Patients requiring immediate medical intervention, with sepsis or estimated glomerular filtration rate < 30 mL/min, and already taking or unable to take alpha blocker or calcium channel stabilizer were excluded from the trial.

The primary outcome of this trial was spontaneous stone passage within 4 weeks, defined as no need for additional interventions to assist stone passage within 4 weeks of randomization. Additional imaging was done only if clinically indicated and not routinely to confirm stone passage, as this was felt to better reflect actual clinical practice. While 97% of patients were included in the primary outcome analysis, only 62% of patients completed the 4-week questionnaire and were included in the pain management secondary analysis. At 4 weeks post-randomization, rates of spontaneous stone passage were 81% with tamsulosin vs. 80% with nifedipine vs. 80% with placebo, showing no significant differences among the three groups. Prespecified subgroup analyses examined the effectiveness of each medical expulsive therapy vs. placebo by sex, stone size, and stone location, the results of which were all consistent with the overall analysis. There were also no significant differences in pain scores at 4 weeks or analgesic use in patients completing the 4-week questionnaire.

Though previous meta-analyses found alpha-blockers and calcium channel blockers may increase the clearance of ureteral stones, these analyses were limited by high levels of heterogeneity in the methodologies of the included trials. Many included trials were limited by small trial size, lack of blinding, or unclear randomization, negatively affecting the strength of the meta-analysis. On the other hand, this large randomized trial was well powered to detect differences in stone clearance between medical expulsive therapies and placebo, but found no differences with either tamsulosin or nifedipine. It should be noted, however, that these results are inconsistent with a previous large randomized trial comparing tamsulosin vs. nifedipine in adults with 4-7 mm ureteric stones which found that tamsulosin was associated with significantly higher rates of stone expulsion compared to nifedipine (BJU Int 2011 Jul;108(2):276). This prior trial did not include a placebo comparison, however, making it hard to directly compare the results. One potential limitation of the current trial is the definition of the primary outcome as a lack of further intervention rather than confirmed stone clearance. In fact, a small number of patients were reported to require intervention between 4 and 12 weeks. However, the percentage of patients requiring later intervention was very small and equally distributed among the three groups. The secondary pain management outcomes of this trial were also limited by low participation in the 4-week questionnaire. Overall, the results of this trial suggest that the addition of tamsulosin or nifedipine to expectant management does not increase stone clearance in patients with a ureteric stone and should not be recommended for treatment of ureteric colic.

For more information see the Nephrolithiasis 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, ACP Smart Medicine, such as tables, images, and graphics, will be included in DynaMed Plus. Individual paid ACP Smart Medicine subscribers who wish to convert to DynaMed Plus may do so beginning January 1, 2016, when ACP Smart Medicine will be discontinued.

Click here to read the whole press release

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