MKSAP 17

MKSAP 16

Other MKSAP Products

Errata and Revisions

(Updated February 2017)


Invalidated MKSAP 17 Questions

The following questions have been invalidated as a result of postpublication analysis and/or new data that are relevant to the question: Item 36 and Item 70 from Cardiovascular Medicine; Item 154 from General Internal Medicine; Item 146 from Hematology and Oncology; and Item 3 and Item 56 from Neurology.


Invalidated Virtual Dx Questions

The following questions have been invalidated as a result of postpublication analysis and/or new data that are relevant to the question: Item 19 from Nephrology.


MKSAP 17

Disclosures

MKSAP 17 A books, Page iv under ACP Principal Staff: In the Disclosures of Relationships section, Patrick C. Alguire, MD, FACP, is incorrectly listed as a Board Member with Teva Pharmaceuticals. This listing should be deleted. The remainder of Dr. Alguire's disclosures are correct. (Added November 2015)


Cardiovascular Medicine

Coronary Artery Disease

Page 15: Coronary Artery Disease, Stable Angina Pectoris, Diagnosis and Evaluation, Table 8: Pretest Likelihoods of Coronary Artery Disease in Low-Risk and High-Risk Symptomatic Patients. The credit line for Table 8 has been changed to "Adapted with permission of Elsevier Science and Technology Journals, from Gibbons RJ, Abrams J, Chatterjee K, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for the Management of Patients With Chronic Stable Angina). 2002. Permission conveyed through Copyright Clearance Center, Inc." (Added March 2016)

Heart Failure

Page 35: Heart Failure, Medical Therapy for Systolic Heart Failure, ACE Inhibitors and Angiotensin Receptor Blockers. The last sentence of the second paragraph has been changed to read: "In patients with angioedema while taking ACE inhibitors, ARBs should be used with caution as an alternative because there are reports of angioedema also occurring with these agents." (Added July 2016)

Page 39: Heart Failure, Inpatient Management of Heart Failure, Acute Decompensated Heart Failure. The following two sentences have been added to the end of the second paragraph: "However, serial assessment of BNP levels during therapy has not been definitively shown to be beneficial, and no guidelines currently recommend serial assessment of BNP levels in patients being treated for heart failure." (Added January 2016)

Arrhythmias

Page 54: Arrhythmias, Supraventricular Tachycardias, Atrioventricular Reciprocating Tachycardia. In the fifth sentence of the first paragraph, "Orthodromic AVNRT" has been changed to "Orthodromic AVRT" ("Orthodromic AVRT, the most common type of AVRT (more than 90% to 95% of cases), is characterized by a narrow QRS complex resulting from conduction over the AV node and the His-Purkinje system."). (Added January 2016)

Page 66: Pericardial Disease, Constrictive Pericarditis, Clinical Presentation and Evaluation, Figure 22. In the top and bottom panels of Figure 22, "Expiration" has been changed to "Inspiration." Additionally, the second full sentence of the figure legend should read: "Arrows indicate onset of inspiration and subsequent respective changes in left ventricular and right ventricular systolic pressures." (Added March 2016)

Valvular Heart Disease

Page 76: Valvular Heart Disease, General Principles of Management of Valvular Heart Disease, Table 34: Indications for Interventions for Valvular Heart Conditions. In the fourth row, first column, a new footnote c has been added after "Mitral regurgitation." The footnote should read: “Indications listed are for chronic severe primary mitral regurgitation unless otherwise specified." (Added July 2016)

Questions

Page 123, Item 11: In the fourth paragraph of the question stem, it is stated that the patient develops chest tightness during the exercise stress test. This information has been deleted, and the second sentence of the fourth paragraph should read: "The patient is able to exercise on the Bruce protocol for 10 minutes and 20 seconds; blood pressure rises appropriately, but he stops because of breathlessness." (Added March 2016)

Page 124, Item 15: In the third sentence of the second paragraph of the stem, "S4" has been changed to "S3" ("Cardiac examination reveals an irregularly irregular rhythm and an S3."). (Added January 2016)

Page 130, Item 36: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer A to earn a point for this item and ensure completion of all items in this self-assessment examination, which is necessary for CME/MOC submission.

The definitive threshold for treatment of chronic hypertension in pregnancy remains controversial. A 2013 guideline published by the American College of Obstetricians and Gynecologists regarding management of hypertension in pregnancy (American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol. 2013 Nov;122(5):1122-31. [PMID: 24150027]) makes a strong recommendation for initiation of pharmacologic therapy for pregnant women with persistent chronic hypertension at a systolic blood pressure of 160 mm Hg or higher or a diastolic blood pressure of 105 mm Hg or higher based on moderate-quality evidence, but it also makes a qualified recommendation against treating blood pressures at lower levels based on low-quality evidence. However, other guidelines continue to recommend initiation of pharmacologic therapy at a systolic blood pressure of 150 mm Hg or higher or a diastolic blood pressure of 95 mm Hg or higher in women without symptoms or evidence of end-organ damage due to hypertension. Consequently, both options A (start labetalol) and D (no intervention is necessary) could be construed as correct. (Added July 2016)

Page 131, Item 40: The following sentence has been added to the stem as a new fourth paragraph: "The patient's 10-year cardiovascular risk estimated with the Pooled Cohort Equations is greater than 10%." (Added March 2016)

Page 132, Item 43: In the fourth sentence of the first paragraph of the stem, the word "exacerbated" has been changed to "improved" ("The pain is constant but improved when leaning forward and not associated with other symptoms."). (Added March 2016)

Page 133, Item 47: In the second paragraph of the stem, the second sentence has been replaced with the following: "Jugular venous distention is noted." In the third sentence of the second paragraph of the stem, "but no crackles are detected" has been changed to "and crackles are detected" ("There are decreased breath sounds throughout both lung fields, and crackles are detected."). (Added March 2016; Revised July 2016)

Page 140, Item 70: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer D to earn a point for this item and ensure completion of all items in this self-assessment examination, which is necessary for CME/MOC submission. Since the writing of this question, the FDA has approved apixaban for use in patients with end kidney disease, and therefore, options A (apixaban) and D (dose-adjusted warfarin) are both correct. (Added March 2016)

Page 163, Item 13: The first sentence of the third paragraph of the critique should read: "Folic acid lowers homocysteine levels, which when elevated have been associated with increased cardiovascular disease in observational studies." (Added March 2016)

Page 204, Item 97: In the first paragraph of the critique, the last two sentences should read: "If the aortic root or ascending aortic diameter is greater than 4.5 cm, reimaging should be performed annually. In those with an aortic diameter between 4.0 cm and 4.5 cm, the examination interval depends on the rate of progression of dilation and the family history." Additionally, the Key Point and the High Value Care Recommendation associated with Item 97 should read: "Patients with an asymptomatic bicuspid aortic valve should undergo surveillance transthoracic echocardiography yearly if the aortic root or ascending aortic diameter is greater than 4.5 cm." (Added January 2016)


Dermatology

Common Rashes

Page 11: Common Rashes, Papulosquamous Dermatoses, Psoriasis. The third sentence in the first full paragraph has been changed to read: "A typical regimen for flares of localized disease might be a medium-potency glucocorticoid applied once or twice a day on the weekdays and a topical vitamin D analogue applied once or twice daily on weekends." (Added March 2016)

Common Skin Infections

Page 23: Common Skin Infections, Bacterial Skin Infections, Impetigo. The second sentence in the first full paragraph has been changed to read: "Topical mupirocin often is first-line therapy, and washes with chlorhexidine and diluted bleach baths also can be used." (Added March 2016)

Page 26: Common Skin Infections, Superficial Fungal Infections, Tinea. The legend to Figure 33 has been changed to read: "Tinea cruris, a dermatophyte infection of the groin, pubic region, and thighs, manifests with patches of erythema with sharply demarcated serpiginous borders and scale at the advancing edges. Involvement of the scrotal skin with the shiny erythema and telangiectasias seen in this image demonstrates the hazards of treating tinea with topical glucocorticoids." (Added March 2016)

Pruritus

Page 46: Pruritus. The cross-reference to Table 2 in the first paragraph has been changed to Table 16. (Added March 2016)

Questions

Page 118, Item 71: The BMI of this patient should be changed to 32. A new chest radiograph of a woman has been added to digital version to replace the existing radiograph. (Added January 2016)

Page 124, Item 9: The second sentence in the second paragraph of the Critique "None of these infections tend to present with a well-demarcated pattern of involvement" has been deleted. (Added March 2016)


Endocrinology and Metabolism

Disorders of the Pituitary Gland

Page 22-23: Disorders of the Pituitary Gland, Hypopituitarism, Adrenocorticotropic Hormone Deficiency (Secondary Cortisol Deficiency). The next to last sentence in the fourth paragraph has been changed to read: "A normal response is a peak serum cortisol greater than 18 µg/dL (496.8 nmol/L). (Added March 2016)

Disorders of the Adrenal Glands

Page 33: Disorders of the Adrenal Glands, Adrenal Hormone Excess, Pheochromocytomas and Paragangliomas. The third paragraph, second sentence has been changed to read: "Evaluation is recommended for all incidentally noted adrenal masses or in the setting of hereditary pheochromocytoma or paraganglioma syndromes." (Added March 2016)

Page 36: Disorders of the Adrenal Glands, Adrenal Hormone Excess, Androgen-Producing Adrenal Tumors. The value for DHEA and its sulfate has been changed to 8 µg/mL (21.6 µmol/L) instead of 800 µg/dL (21.6 µmol/L) for men and 3 µg/mL (8.1 µmol/L) instead of 300 µg/dL (8.1 µmol/L). (Added March 2016)

Page 38: Disorders of the Adrenal Glands, Adrenal Insufficiency, Adrenal Function During Critical Illness. The fourth sentence should read: "A maximum increase in serum cortisol of 9 μg/dL (248.4 nmol/L) or less following the administration of synthetic ACTH has been associated with increased mortality from septic shock; however, results of testing do not predict benefit from glucocorticoid therapy." (Added January 2016)

Page 40: Disorders of the Adrenal Glands, Adrenal Masses, Adrenocortical Carcinoma. The last sentence of the second paragraph has been changed to read: "The pathologic diagnosis of ACC is challenging. Even tumors that appear to be low risk based on histopathology can occasionally be malignant. Patients with low-risk pathology but concerning imaging findings (see Table 19) or tumors larger than 4 cm should have close interval radiographic follow up after surgery." (Added March 2016)

Page 40: Disorders of the Adrenal Glands, Adrenal Masses, Adrenocortical Carcinoma. The first sentence of the third paragraph has been changed to read: "The prognosis of ACC is very poor; the 5-year survival rate for stage I disease is 65%, stage II 65%, stage III 40%, and stage IV less than 10%." (Added March 2016)

Disorders of the Thyroid Gland

Page 48: Disorders of the Thyroid Gland, Euthyroid Sick Syndrome. The second Key Point has been changed to read; "The typical pattern of euthyroid sick syndrome, nonthyroidal illness syndrome, or low triiodothyronine (T3) syndrome is a low thyroxine (T4) level, a low triiodothyronine (T3) level, and as the patient becomes more critically ill, a low thyroid-stimulating hormone (TSH) level. As the patient enters the recovery phase, the T3 and T4 levels remain slightly low, but the TSH level becomes mildly elevated." The associated High Value Care recommendation (page xi) has also been changed. (Added March 2016)

Reproductive Disorders

Page 55: Reproductive Disorders, Hyperandrogenism Syndromes, Hirsutism and Polycystic Ovary Syndrome. At the end of the second paragraph, 700 µg/mL has been changed to 7.0 µg/mL. (Added January 2016)

Page 60: Reproductive Disorders, Anabolic Steroid Abuse in Men. The next to the last sentence in the first paragraph should read: "Aromatase inhibitors are frequently used concurrently with exogenous testosterone preparations to prevent adipose conversion of androgens to estrogens and development of gynecomastia." (Added January 2016)

Calcium and Bone Disorders

Page 65: Calcium and Bone Disorders, Hypercalcemia, Diagnosis and Causes of Hypercalcemia, Parathyroid Hormone-Mediated Hypercalcemia, Medications Causing Hypercalcemia. The first sentence should read: "Thiazide diuretics decrease the excretion of calcium by the kidney and may result in increased serum calcium levels." (Added January 2016)

Page 67: Calcium and Bone Disorders, Metabolic Bone Disease, Osteopenia and Osteoporosis, Diagnosis. In the second paragraph, the sixth sentence has been changed to read: "Osteoporosis is defined as a T-score of -2.5 and below." (Added March 2016)

NEWPage 68: Calcium and Bone Disorders, Metabolic Bone Disease, Osteopenia and Osteoporosis, Risk Assessment and Screening Guidelines, Table 34. According to the U.S. Preventive Services Task Force 2011 Recommendations on Osteoporosis Screening, "the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men"; however, both the Endocrine Society and the National Osteoporosis Foundation recommend screening men 70 and older. (Added February 2017)

Questions

Page 79, Item 19: Under Laboratory studies, the cortisol listing should have the phrase "after 1 mg of dexamethasone the night before" deleted. It has been changed to read: "Cortisol 8 AM 16 µg/dL (441.6 nmol/L)." (Added March 2016)

Page 91, Item 66: The following sentence has been added to the end of the critique: "A review of the patient's laboratory studies shows a normal complete blood count including erythrocyte indices." (Added March 2016)

Page 98, Item 4: The following paragraph has been added to the critique to clarify the Somogyi effect or rebound hyperglycemia: "The Somogyi effect, or rebound hyperglycemia, describes elevated morning blood glucose levels resulting from release of compensatory hormones as described in response to prolonged nocturnal hypoglycemia. Although this mechanism was previously generally accepted, several small studies published in the late 20th century suggested that nocturnal hypoglycemia may not be a common cause of fasting morning hyperglycemia in patients with diabetes treated with insulin, although follow-up studies to confirm these findings have not been performed. Therefore, the clinical significance of rebound hyperglycemia has not been fully elucidated and the existence of the effect is not accepted by all physicians. However, a 3 AM blood glucose check would provide valuable information regarding this patient’s overnight blood glucose pattern useful in informing changes to the patient’s insulin regimen." (Added July 2016)

Page 111, Item 32: In the last paragraph of the critique, the baseline PSA level has been changed to 0.6 ng/mL (0.6 µg/L). (Added March 2016)

Page 113, Item 36: The last paragraph of the critique has been changed to read: "Ultrasound of the neck is normal in patients with central hypothyroidism and would be unlikely to provide any additional information about this patient's thyroid status." (Added July 2016)


Gastroenterology and Hepatology

Colorectal Neoplasia

Page 51-52: Colorectal Neoplasia, Screening: The third paragraph has been revised; the corrected paragraph is as follows: "Because a family history of only small tubular adenomas (< 1 cm) or small adenomas with only low-grade dysplasia in first-degree relatives is not considered to increase the risk for colorectal cancer, individuals with this family history alone should undergo average-risk routine screening. Patients with a family history of an advanced adenoma (defined as ≥1 cm or with high-grade dysplasia or villous elements) or colorectal cancer in a first-degree relative before age 60 years, or in two or more first-degree relatives at any age, should undergo colonoscopy every 5 years beginning at age 40 years (or at an age 10 years younger than the earliest age of the case in the immediate family). Patients with a family history of an advanced adenoma or colorectal cancer in a single first-degree relative age 60 years or older should undergo colorectal cancer screening with any average-risk strategy; however, the U.S. Multi-Society Task Force (MSTF) on Colorectal Cancer recommends initiating screening in these patients at age 40 years, whereas the American College of Gastroenterology recommends beginning at age 50 years. The MSTF recommends stopping colonoscopy surveillance when the risk of the procedure outweighs the benefit to the high-risk patient. At ages 75 to 85 years, the potential benefit of surveillance is higher than for average-risk patients. At ages older than 85 years, patients with high-risk adenomas are at higher risk for metachronous advanced neoplasia than average-risk patients; continued surveillance should be individualized based on medical comorbidities and life expectancy, but routine screening should not be continued." (Added July 2016)

Disorders of the Liver

Page 72: Disorders of the Liver, Hepatocellular Carcinoma, Figure 29: The top right-hand box ("Stage D") should read "Child-Pugh C," instead of "Child-Pugh A-B." The bottom left-hand box ("Curative treatments [30%]") should read "5-year survival: 40%-70%," instead of "50%-70%." The bottom middle box ("Randomized trials [50%]") should read "Median survival: 11-20 months" instead of "3-year survival: 10%-40%." (Added January 2016)

Questions

Page 115, Item 5: In the fourth sentence of the first paragraph of the critique, the patient's polymorphonuclear cell count should be 574/µL, rather than 820/µL. (Added July 2016)

Page 127, Item 31: The second paragraph of the critique should read as follows: "Copper deficiency may cause muscle weakness due to myeloneuropathy, ataxia, and cognitive deficits that may be difficult to differentiate from vitamin B12 deficiency. Less common neurologic findings include bilateral visual loss. Hematologic findings in copper deficiency include microcytic anemia, which may mimic iron deficiency anemia, and leukopenia." (Added March 2016)

Page 140-141, Item 63: In the first paragraph of the critique, the fifth sentence through the end of the paragraph should be replaced with the following: "Because MYH-associated polyposis is an autosomal recessive disorder, the affected patient must have two abnormal copies of the gene (that is, he is homozygous for the abnormal gene), having received an abnormal copy of the gene from each parent. The status of the patient’s wife for the abnormal gene will provide information to help assess risk and guide the need for genetic testing of the couple’s children. If the patient’s wife is negative for the MYH mutation, all of the children would be heterozygous for the mutation (carriers), having received a normal copy of the gene from their mother and an abnormal copy of the gene from their father. In this case, the children would not be affected, but their carrier status would be known and no further genetic testing would be indicated. If the mother is a carrier of the mutation, 50% of their children would be affected with the syndrome and 50% would be carriers. Therefore, testing of each child would be indicated to identify whether the child is homozygous for the mutation and is affected, or whether the child is a heterozygous carrier of the mutation." (Added January 2016)

Page 143, Item 68: In the first paragraph of the critique, the fourth sentence should read as follows: "The cause of ALF is most likely amoxicillin-clavulanate, which is one of the most common causes of drug-induced liver injury." (Added March 2016)


General Internal Medicine

Interpretation of the Medical Literature

Page 6: Interpretation of the Medical Literature, Statistical Analysis, Calculations for Diagnostic Tests and Medical Therapeutics, Likelihood Ratios, Figure 1. Figure 1 has been revised to correct several likelihood ratio values. On the likelihood ratio scale, "00.5" has been changed to "0.05," "00.2" has been changed to "0.02," "00.1" has been changed to "0.01," "000.5" has been changed to "0.005," "000.2" has been changed to "0.002," "000.1" has been changed to "0.001," and "0000.5" has been changed to "0.0005." (Added July 2016)

Routine Care of the Healthy Patient

Page 21: Routine Care of the Healthy Patient, Healthy Lifestyle Counseling. In the fourth paragraph, the second sentence has been replaced with the following text: "Screening for domestic violence in women of childbearing age (14-46 years of age) and screening for home safety are also recommended." (Added March 2016)

Palliative Care

Page 37: Palliative Care, Symptom Management, Pain. In the fifth paragraph, the third sentence has been revised to read: "All patients on scheduled opioids should be on a scheduled stimulant laxative, such as senna or bisacodyl, with or without docusate." (Added March 2016)

Men's Health

Page 88: Men's Health, Male Sexual Dysfunction, Erectile Dysfunction. The second sentence has been revised to read: "The most important risk factors for ED are cardiovascular disease and risk factors for cardiovascular disease (diabetes mellitus, hyperlipidemia, hypertension, smoking, family history)." (Added March 2016)

Questions

Page 168, Item 59: In the second paragraph of the stem, the patient's standing blood pressure has been changed to 102/78 mm Hg. (Added July 2016)

Page 173, Item 84: The following sentence has been added to the end of the second paragraph of the question stem: "Telangiectasias, reticular veins, and small varicose veins are noted at the ankles bilaterally." (Added March 2016)

Pages 175 and 237, Item 93: In the third sentence of the first paragraph of the stem, the phrase "which was scheduled for administration 3 months ago" has been deleted. In the fifth sentence of the first paragraph of the critique, "9 months" has been changed to "18 months" (This patient has only received two doses over a period of 18 months..."). (Added March 2016)

Page 183, Item 125: At the end of the first paragraph of the question stem, clopidogrel has been added to the patient's medication list ("Medications are aspirin, metoprolol, lisinopril, rosuvastatin, and clopidogrel."). (Added March 2016)

NEWPage 190, Item 154: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer A to earn a point for this item and ensure completion of all items in this self-assessment examination, which is necessary for CME/MOC submission. This item has been excluded because recently published high value care advice from the American College of Physicians (Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016 Mar 15;164(6):425-34. [PMID: 26785402]) recommends that patients with symptoms suggestive of group A streptococcal pharyngitis undergo testing with a rapid antigen detection test and/or throat culture; antibiotics should be initiated only in cases of confirmed streptococcal pharyngitis. Therefore, option B (rapid streptococcal antigen test) is now correct. (Added February 2017)

Page 255, Item 131: In the first paragraph of the question critique, the fifth sentence states, "The murmur of HCM is augmented by maneuvers that decrease venous return (Valsalva) and is diminished by those that increase preload (leg elevation, handgrip)." This sentence has been changed to: "The murmur of HCM is augmented by maneuvers that decrease venous return (Valsalva) and is diminished by those that increase preload (leg elevation) or increase afterload (handgrip)." (Added July 2016)


Hematology and Oncology

Multiple Myeloma and Related Disorders

Page 17: Multiple Myeloma and Related Disorders, Treatment. The first sentence of the final paragraph states annual influenza vaccination is recommended. This has been clarified to indicate the inactivated vaccine should be used. (Added March 2016)

Erythrocyte Disorders

Page 24: Erythrocyte Disorders, Anemia Due to Erythrocyte Underproduction or Maturation Defects, Anemia of Kidney Disease. The following statement was added to support a related question, "Erythropoiesis-stimulating agents should be considered for patients with symptomatic anemia attributable to erythropoietin deficiency when the hemoglobin level is less than 10 g/dL (100 g/L)." (Added March 2016)

Page 28: Erythrocyte Disorders, Hemolytic Anemias, Congenital Hemolytic Anemias, Hereditary Spherocytosis. The last sentence of the third paragraph has been revised to state, "Although it has not performed well as a screening test, the osmotic fragility test with 24-hour incubation is a key step in diagnosis." (Added March 2016)

Page 33: Erythrocyte Disorders, Hemolytic Anemias, Congenital Hemolytic Anemias. The fourth Key Point at the end of this section should state "The three common disease-altering strategies in sickle cell disease", not "in congenital hemolytic anemias." (Added March 2016)

Platelet Disorders

Page 39: Platelet Disorders, Thrombocytopenic Disorders, Immune-Mediated Thrombocytopenia, Immune Thrombocytopenic Purpura. The end of the second sentence in the second paragraph should state, "...dexamethasone, 40 mg/d for 4 days, given every 2 to 4 weeks." (Added March 2016)

Page 62: Thrombotic Disorders, Other Sites of Thrombosis, Cerebral and Sinus Vein Thrombosis. The parenthetical term "pseudomotor cerebri" has been deleted as an inaccurate application of this diagnostic term. (Added March 2016)

Issues in Oncology

Page 70: Issues in Oncology, Staging. In the first paragraph, "nodal metastasis" has been changed to "distant metastasis" ("...and 'M' represents the absence or presence of distant metastasis and is designated by M0 or M1."). (Added July 2016)

Breast Cancer

Page 74: Breast Cancer, Epidemiology and Risk Factors. At the end of the second paragraph, this sentence has been added: "Women with newly diagnosed breast cancer who meet one or more of these criteria should be tested for BRCA1/2 prior to surgery since a positive result would indicate the need for bilateral mastectomy.” (Added March 2016)

NEWPage 78, Breast Cancer, Staging and Prognosis of Early Breast Cancer. The second Key Point after this section has been corrected to read "Imaging studies to identify occult metastatic disease are not needed in patients with stage I and II breast cancer unless worrisome signs or symptoms are present." The associated High Value Care Recommendation (page xiv, second column) also has been changed. (Added February 2017)

Gastroenterological Malignancies

NEWPage 92, Gastroenterological Malignancies, Gastrointestinal Stromal Tumors. In the first paragraph, the phrase "intestinal cells of Cajal" should be "interstitial cells of Cajal." (Added February 2017)

Lung Cancer

Page 95: Lung Cancer, Small Cell Lung Cancer, Diagnosis and Staging. In the first paragraph, the word "deficiency" should be changed to "secretion" ("...Cushing syndrome caused by ectopic adrenocorticotropic hormone secretion..."). (Added March 2016)

Genitourinary Cancer

Page 105: Genitourinary Cancer, Renal Cell Carcinoma. In the second Key Point, the last half of the sentence has been revised to better reflect the text. ("...or CT is recommended; a kidney lesion identified as a mass or a complex cyst requires biopsy and/or removal if imaging findings are consistent with malignancy.") (Added March 2016)

Questions

Page 144, Item 59: The transferrin saturation values provided in the laboratory studies table are incorrect. Correct values are 3.55% and 3.75%, respectively. (Added March 2016)

Page 145, Item 65: The first sentence of the question describing the patient's presentation has been revised to indicate she is evaluated for "lower extremity and back pain of 24 hours' duration." (Added March 2016)

Page 148, Item 73: In the physical examination, the sentence on jugular venous distension has been clarified as follows, "Jugular venous pressure measured above the sternal notch with the patient positioned 45 degrees from horizontal is 8 cm of H2O". (Added March 2016)

Page 150, Item 83: Option A should say "Biannual CT scans" instead of simply "CT scans". (Added March 2016)

Page 161, Item 132: The patient's Gleason score has been changed to 6 in order to ensure disease is classified as "low risk". (Added July 2016)

NEWPage 165, Item 146. This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer A to earn a point for this item and ensure completion of all items in this self-assessment examination, which is necessary for CME/MOC submission. This item has been excluded because ibrutinib therapy has become the first-line treatment for patients with chronic lymphocytic leukemia with a chromosome 17p deletion. (Added February 2017)

Page 174, Item 17: In the first paragraph of the Critique, the word "even" has been removed from the final sentence. It should read, "Because of the low-level hemolysis associated with either type of thalassemia, patients with thalassemia (and other chronic hemolytic anemias) can commonly have low folate levels if dietary intake is inadequate, leading to worsening of chronic anemia." (Added March 2016)

Page 186, Item 43: In the Critique, the fifth paragraph should begin "Antifibrinolytic agents...", not "Fibrinolytic agents". (Added March 2016)

Page 192, Item 57: In the Critique, the last sentence of the second paragraph should state, "This patient has evidence of hemoglobinuria but not of hematuria given the lack of erythrocytes in her urine, making this a less likely diagnosis." The sentence originally stated that the patient has evidence of "myoglobinuria." (Added July 2016)

Page 204, Item 82: The second paragraph of the critique was replaced with this text: “Although K-ras testing can help determine the prognosis in patients with NSCLC, there are currently no approved drugs that target ras mutations. Furthermore, K-ras mutations are not negatively predictive for anti-EGFR therapies as in colon cancer.” (Added July 2016)

Page 204, Item 83: In the first paragraph of the critique, the number "74" should be "80" ("...lung cancer screening with low-dose CT as she is between the ages of 55 to 80 years with a smoking history..."). (Added March 2016)

Page 214, Item 102: In the first paragraph of the critique, the number "11" should be "14" ("…showing a translocation [t(14:18)] that causes overexpression of the BCL2 oncogene."). (Added March 2016)

NEWPage 221, Item 118. The third sentence of the first paragraph of the critique should say "These cells..." instead of "These antigens...", referring to cutaneous T-cell lymphomas. (Added February 2017)

Page 225, Item 124: The last sentence claiming surgery has no role in SCLC is replaced with this sentence: "Surgical management of SCLC is a potential option only in select cases in which there is a very small primary tumor without associated lymphadenopathy; surgical resection of a residual lung mass after chemotherapy and radiation therapy is never performed." (Added July 2016)

Page 226, Item 128: Bevacizumab is not an epidermal growth factor receptor inhibitor, it is an anti–vascular endothelial growth factor agent. The last paragraph has been revised to state: "Therapy with bevacizumab, an anti–vascular endothelial growth factor agent, has not been found to improve disease..." (Added July 2016)

Page 233, Item 141: In the Key Point, it originally stated "Patients with a neutrophil count less than 500/μL (0.5 × 109/L)..." The neutrophil count should actually be less than 1000/μL (1.0 × 109/L). (Added November 2015)


Infectious Disease

Tick-Borne Diseases

Page 23: Tick-Borne Diseases, Southern Tick-Associated Rash Illness. The figure callout in the first sentence should indicate Figure 5, not Figure 4. (Added March 2016)

Urinary Tract Infections

Page 26: Urinary Tract Infections, Diagnosis. The end of the first paragraph has been clarified concerning "advanced age" as a potential complicating factor. "Common complicating factors are diabetes, pregnancy, male sex, kidney transplantation, anatomic or functional abnormalities of the urinary tract, urinary catheterization or manipulation, recent antibiotic exposure, and recent hospitalization. Advanced age in the presence of other major comorbidities or with significant frailty may be considered a complicating factor in UTI, although age alone does not define a complicated versus uncomplicated infection." (Added March 2016)

Page 27: Urinary Tract Infections, Diagnosis: Several colony-forming unit values were printed as three-digit numbers; however, the third digit in each value should appear superscripted, as follows: Patients with infection usually have at least 105 colony-forming units (CFU)/mL on culture. In symptomatic patients with pyuria, a colony count between 102 and 105 CFU/mL may still indicate a UTI. Standard criteria are insensitive for cystitis because up to half of women with cystitis have colony counts of 102 to 104 CFU/mL. (Added January 2016)

Page 28: Urinary Tract Infections, Management, Acute Pyelonephritis. The second Key Point has been rewritten for clarity. "Fluoroquinolones are recommended for outpatient empiric therapy of acute pyelonephritis; inpatient empiric antimicrobial regimens include intravenous fluoroquinolones, aminoglycosides with or without ampicillin, extended-spectrum cephalosporins or extended-spectrum penicillins with or without an aminoglycoside, and carbapenems." (Added March 2016)

Travel Medicine

Page 61: Travel Medicine, Travelers' Diarrhea: In the second paragraph, the third sentence detailing water purification, the following revision has been made: "Water can be purified by boiling for 3 minutes or by adding 4 drops of sodium hypochlorite (bleach) or 5 drops of tincture of iodine per liter or quart of water." These revisions are based on WHO recommendations for preventing travelers' diarrhea, available at http://www.who.int/water_sanitation_health/hygiene/envsan/sdwtravel.pdf. (Added January 2016)

Questions

Page 122, Item 65: The patient's temperature has been revised from 38.7 °C (101.7 °F) to 38.0 °C (100.4 °F). (Added July 2016)

Page 125, Item 77: The patient's antihypertensive medication has been changed from hydrochlorothiazide to amlodipine. This change is based on the patient's allergy to sulfonamide antibiotics. There is a technical difference between antibiotics that contain a sulfonamide chemical group and nonantibiotic drugs that contain one. Crossover reactivity almost never occurs; however, the official recommendation is to use nonantibiotics containing a sulfonamide group (such as hydrochlorothiazide) with caution, even though it is extremely common to give these kinds of drugs in patients allergic to sulfa drugs. (Added March 2016)

NEWPage 127, Item 85: The patient's temperature was incorrectly listed as 100.0 °F. To be consistent with the temperature of 37.2 °C, it has been corrected to 99.0 °F. (Added February 2017)

Page 144, Item 21: In the Critique, the second paragraph regarding nitrofurantoin use in pregnancy has been revised to state: "Nitrofurantoin is classified by the FDA as pregnancy category B based on a long history of safe and effective use without significant teratogenic potential in available studies. Because of this, the American College of Obstetricians and Gynecologists Committee Opinion on sulfonamides, nitrofurantoin, and risk of birth defects state that if other treatment options cannot be used, then nitrofurantoin may be used as a first-line agent for the treatment of UTI during the second and third trimesters and in the first trimester if no suitable alternative antibiotics are available. However, a large population-based cohort study from Norway published in 2013 analyzed data from more than 180,000 births to estimate whether exposure to nitrofurantoin is associated with increased incidence of negative pregnancy outcomes. Neonates exposed to nitrofurantoin in the last 30 days before delivery had no increase in birth defects but did have a significantly higher rate of neonatal jaundice requiring treatment than neonates exposed to a beta-lactam antibiotic during the same stage of pregnancy (10.8% and 8.8%, respectively; P = 0.023). Therefore, although not absolutely contraindicated, these data suggest that the use of nitrofurantoin should be avoided in the last 30 days of pregnancy provided that a suitable, safe, antimicrobial agent is available, such as with this patient." (Added July 2016)

Page 146, Item 26: In the Critique, the dose of azithromycin should be 1 g; the original dose provided of 250 mg is incorrect. (Added March 2016)

Page 166, Item 67: In the Key Point and the third to last sentence of the first paragraph of the Critique, the term "centrifugal" should be "centripetal." In the first sentence of the last paragraph, the term "centripetally" should be "centrifugally." (Added March 2016)

Page 167, Item 69: The end of the first paragraph of the Critique has been modified to provide further clarification on the use of CT versus MRI in this situation: "MRI is contraindicated in patients with ferromagnetic metal implants, although MRI is allowable in patients with implants made of titanium. If the composition of the fixation material is unknown, particularly those implanted in the distant past, it is reasonable to assume that MRI would be a contraindicated imaging modality. CT is helpful in evaluating bone anatomy and delineating the adjacent soft tissues and is the next best choice when MRI with contrast is contraindicated. Although CT may undergo signal scattering because of the metallic implant, the distance between the current area of interest (first metatarsal-phalangeal area) and the location of the metal plates (the fourth and fifth metatarsal bones) would likely allow adequate visualization of the first metatarsal-phalangeal area for evaluation of possible osteomyelitis. Radiologic consultation may be helpful in situations in which the preferred imaging modality may be influenced by technical factors to decide the optimal approach, such as in this situation." (Added March 2016)

Page 168, Item 71: In the Critique, it should state that meropenem is a carbapenem, not a monobactam as originally noted. (Added March 2016)

NEWPage 169, Item 74: In the Critique, the second-to-last sentence stated, "Nafcillin does not affect potassium levels, so no monitoring is necessary." This has been revised to indicate, "Nafcillin may affect potassium levels, but monitoring is not indicated as part of current recommendations." (Added February 2017)


Nephrology

Glomerular Diseases

Page 44: Glomerular Diseases, Clinical Manifestations of Glomerular Disease, The Nephrotic Syndrome. The last sentence of the third paragraph of this section states the following: "Diabetes is not only the most common secondary cause of the nephrotic syndrome but also the most common cause of the nephrotic syndrome in adults." This statement has been changed to "The most common secondary cause of the nephrotic syndrome in adults is diabetes." (Added March 2016)

Acute Kidney Injury

Page 61: Acute Kidney Injury, Causes, Prerenal Acute Kidney Injury. The second paragraph of this section incorrectly states that prerenal AKI laboratory findings are listed in Table 36. These findings are found in Table 37. (Added March 2016)

Questions

Page 109, Item 69: In the first paragraph, the dosage of lisinopril has been added: lisinopril, 20 mg/d. (Added March 2016)

Page 136, Item 33: The images in the Critique are incorrectly labeled. Proliferative glomerulonephritis with crescents is shown in the right panel, and linear deposition of immunoglobulin along the GBM by immunofluorescence, but no electron-dense deposits on electron microscopy is shown in the left panel. The identification of the panels has been updated appropriately on the Web site. (Added March 2016)

Page 161, Item 89: The first paragraph of the Critique contains the statement "The dihydropyridine agents verapamil and diltiazem and the non-dihydropyridine agent amlodipine have been associated with increased risk with concurrent therapy with these drugs." This has been changed to "The non-dihydropyridine agents verapamil and diltiazem and the dihydropyridine agent amlodipine have been associated with increased risk with concurrent therapy with these drugs." (Added March 2016)


Neurology

Cognitive Impairment

Page 41: Cognitive Impairment; Definitions, Description, and Evaluation; Evaluation of the Patient with Suspected Cognitive Impairment: The first Key Point after this section has been corrected to read "For older patients with no obvious cognitive symptoms, insufficient evidence supports routine cognitive testing." The associated High Value Care Recommendation (page xii, first column) also has been changed. (Added March 2016)

Page 44: Cognitive Impairment, Pharmacologic Therapies for Cognitive Symptoms: The first Key Point after this section has been corrected to read "Evidence supporting the effectiveness of cholinesterase inhibitors to treat frontotemporal dementia or vascular neurocognitive disorder or to delay progression from mild cognitive impairment to dementia is currently lacking or insufficient. The associated High Value Care Recommendation (page xii, first column) also has been changed. (Added March 2016)

Disorders of the Spinal Cord

NEWPage 68, Disorders of the Spinal Cord, Compressive Myelopathies, Treatment: The first Key Point after this section is overstated and has been corrected to match the text and read "Several trials have shown the benefits of high-dose intravenous glucocorticoids administered within the first 8 hours of traumatic spinal cord injury." (Added February 2017)

Page 68: Disorders of the Spinal Cord, Compressive Myelopathies, Treatment: The second Key Point after this section has been corrected to read "Spinal cord compression from metastatic disease requires emergent use of high-dose glucocorticoids and subsequent treatment with surgical decompression followed by radiation for most tumor types." (Added March 2016)

Questions

Page 91, Item 3: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer B to earn a point for this item and ensure completion of all items in this self-assessment examination, which is necessary for CME/MOC submission. This item has been excluded because of a lack of consensus or clear guidelines about pharmacologic treatment of acute spinal cord injury with methylprednisolone within 8 hours of injury. Recommendations by the American Association of Neurological Surgeons (Hurlbert RJ, Hadley MN, Walters BC, et al. Pharmacological Therapy for Acute Spinal Cord Injury. Neurosurgery. 2013 Mar;72:93-105. [PMNID: 23417182]) state that methylprednisolone administration is not recommended for the treatment of acute spinal cord injuries (although they do not specifically address injuries that are treated within 8 hours of injury). (Added January 2016)

Page 96, Item 22: In the laboratory studies table at the bottom of the left-hand column, the "Chloride" value should be changed to 90 mEq/L (90 mmol/L). (Added January 2016)

Page 104, Item 56: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer D to earn a point for this item and ensure completion of all items in this self-assessment examination, which is necessary for CME/MOC submission. This item has been excluded because of a recently published evidence-based guideline from the American Epilepsy Society (Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016 Jan-Feb;16(1):48-61. [PMID: 26900382]) indicating that intramuscular midazolam, intravenous lorazepam, and intravenous diazepam are equivalent and can all be used as first-line agents for the initial treatment of convulsive status epilepticus. (Added August 2016)

Page 117, Item 5: In the second paragraph of the critique, last sentence, the text has been revised to read "Lumbar puncture is only appropriate in these patients if they have no evidence of increased intracranial pressure, such as papilledema." (Added July 2016)

Page 129, Item 32: In the first paragraph of the critique, second column, line 13, the word "impair" should be "worsen." (Added January 2016)

Page 146, Item 70: In the first paragraph of the critique, third sentence, the text has been revised to read "Onset in a single limb, rapid progression, bulbar involvement, and MRI evidence of a corticospinal tract abnormality are other findings that support a diagnosis of ALS, which can be confirmed by results of a needle electrode examination." (Added July 2016)


Pulmonary and Critical Care Medicine

Pulmonary Diagnostic Tests

Page 1: Pulmonary Diagnostic Tests, Pulmonary Function Testing, Spirometry. The last sentence of the second paragraph should say "and at least" instead of "or" ("...an increase in FEV1 of 12% and at least 200 mL is considered a positive bronchodilator response."). (Added March 2016)

Page 3: Pulmonary Diagnostic Tests, Pulmonary Function Testing, 6-Minute Walk Test. In the third sentence, the phrase "at a normal pace" has been deleted ("...and distance walked in 6 minutes are recorded."). (Added March 2016)

Airways Disease

Page 14: Airways Disease, Asthma, Management of Asthma Exacerbations. The last sentence of the second paragraph should state "respiratory muscle" not "airway muscle" ("...early indicator of respiratory muscle fatigue..."). (Added March 2016)

Page 24: Airways Disease, Chronic Obstructive Pulmonary Disease, Chronic Management, Nonpharmacologic Therapy, Oxygen Therapy. In the last sentence, the second condition for long-term oxygen therapy should be "...with an arterial PO2 less than or equal to 59 mm Hg (7.8 kPa) or oxygen saturation less than or equal to 89% breathing ambient air." (Added March 2016)

Page 28: Airways Disease, Cystic Fibrosis in Adults. In the last sentence of the first paragraph, the word "atresia" has been added ("...involve obstruction of the pancreatic ducts, biliary tree, and atresia of the vas deferens."). (Added March 2016)

Page 29: Airways Disease, Cystic Fibrosis in Adults, Diagnosis. In the second paragraph, the word "pathognomonic" has been replaced with "strongly suggestive" ("...although infection with Burkholderia cepacia is strongly suggestive of CF."). (Added March 2016)

Diffuse Parenchymal Lung Disease

Page 30: Diffuse Parenchymal Lung Disease, Classification and Epidemiology, Table 20. In the "Hypersensitivity pneumonitis" row, second column, "low-molecular-weight" should be deleted ("Immune reaction to an inhaled antigen; may be acute..."). (Added March 2016)

Page 34: Diffuse Parenchymal Lung Disease, Diffuse Parenchymal Lung Diseases with a Known Cause, Hypersensitivity Pneumonitis. In the second key point, the word "centrilobar" should be "centrilobular" ("...ground-glass opacities and centrilobular micronodules..."). (Added March 2016)

Page 35: Diffuse Parenchymal Lung Disease, Diffuse Parenchymal Lung Diseases with a Known Cause, Drug-Induced Parenchymal Lung Disease, Table 23. In the "Nitrofurantoin" row, the second column should say "eosinophilia" instead of "eosinophils" ("Peripheral eosinophilia common"). (Added March 2016)

Page 35: Diffuse Parenchymal Lung Disease, Diffuse Parenchymal Lung Diseases with a Known Cause, Drug-Induced Parenchymal Lung Disease, Table 23. In the "Busulfan" row, 3rd column, the word "centrilobar" should be "centrilobular" ("...peribronchial consolidation, centrilobular nodules..."). (Added March 2016)

Pleural Disease

Page 43: Pleural Disease, Pleural Effusion, Evaluation, Pleural Fluid Analysis. The fourth sentence of the first paragraph has been revised to state: "Purulent fluid can be seen in empyema and can be mimicked by the milky appearance of lipid effusions (chylothorax)." (Added July 2016)

Page 45: Pleural Disease, Pleural Effusion, Management, Parapneumonic Effusions and Empyema, Table 32. In the last two rows of the Management column, the word "thorascopic" has been replaced with "thoracoscopic". (Added July 2016)

Pulmonary Vascular Disease

Page 48: Pulmonary Vascular Disease, Pulmonary Hypertension, Treatment. In the Key Points box regarding advanced therapy, the words "this group" should be "groups 2 through 5 pulmonary hypertension" ("...and may be harmful in groups 2 through 5 pulmonary hypertension."). The associated High Value Care recommendation (page xii) has also been changed. (Added March 2016)

Lung Tumors

Page 54: Lung Tumors, Other Pulmonary Neoplasms, Bronchial Carcinoid Tumors, Figure 16. In the legend of Figure 16, the word "consolidation" has been replaced by the word "collapse". ("...confirmed a persistent right lower lobe collapse (arrow)..." (Added July 2016)

Critical Care Medicine

Page 65: Critical Care Medicine, Principles of Critical Care, General Ventilator Principles, Noninvasive Ventilation, Indications and Patient Selection. In the fourth paragraph of this section, the word "hypoxic" has been replaced with "hypoxemia". ("In patients with hypoxemic respiratory failure…") (Added July 2016)

Page 72: Critical Care Medicine, Common ICU Conditions, Hypoxemic Respiratory Failure. In the third sentence of the first paragraph, "hypoxia" has been replaced with "hypoxemic". ("When hypoxemia does not immediately respond to supplemental oxygen...") (Added July 2016)

Page 72: Critical Care Medicine, Common ICU Conditions, Hypoxemic Respiratory Failure. The second paragraph has been revised as follows: "The most common causes of hypoxemic respiratory failure are conditions that lead to mismatch of the ventilation (V) by inspired air in the alveoli and perfusion (Q) of adjacent alveolar capillaries by blood with the capacity to carry and circulate the oxygen to body tissues (called V/Q mismatch, in which the ratio of V to Q may be “high” if the unbalance is toward more ventilation than perfusion, or “low” if unbalanced toward more perfusion and less ventilation). When the ratio V/Q=0 (that is, there is no ventilation to a perfused region of lung), a shunt is considered to be present. Conditions such as pulmonary embolism lead to V/Q mismatch, where ventilation is not well matched to nonembolized regions of lung that continue to be perfused. More common are conditions (also called intrapulmonary shunt) such as pneumonia or atelectasis, in which blood flows through capillaries adjacent to alveoli that are poorly or not ventilated, so the blood is not adequately oxygenated. Hypoxemia due to areas of shunting (V/Q=0) will not improve with supplemental oxygen because inspired gas does not interface with the shunted blood in the lungs. In contrast, V/Q mismatch without shunt is generally more responsive to oxygen therapy." (Added July 2016)

Page 72: Critical Care Medicine, Common ICU Conditions, Hypoxemic Respiratory Failure, Key Points. The second Key Point has been revised as follows: "Hypoxemic respiratory failure is a result of low or absent ventilation to perfused areas of lung that accompanies ventilation-perfusion (V/Q) mismatch." (Added July 2016)

Page 74: Critical Care Medicine, Common ICU Conditions, Hypoxemic Respiratory Failure, Atelectasis. The first sentence has been revised to state "Atelectasis is collapse of alveolar units, leading to low V/Q or shunt (V/Q=0) physiology.” (Added July 2016)

Page 75: Critical Care Medicine, Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure. The last two sentences of the first paragraph have been revised as follows: "…ventilatory failure are often hypoxemic as well. However, these patients' hypoxemia will typically improve with supplemental oxygen." (Added July 2016)

Page 75: Critical Care Medicine, Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure. The third abnormality listed in the second paragraph has been revised as follows: "…(3) obstructive lung disease, marked by significant V/Q mismatch and areas of high V/Q ratio, in which much of the inspired air is wasted and not ventilating perfused regions of the lung." (Added July 2016)

Page 75: Critical Care Medicine, Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure, Restrictive Lung Disease, Diffuse Parenchymal Lung Disease. In the second sentence of this section, "reduced lung volumes" has been removed. It now states: "...fibrotic changes on high-resolution CT and a reduction in the diffusing capacity of the lungs..." (Added July 2016)

Page 75: Critical Care Medicine, Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure, Restrictive Lung Disease, Diffuse Parenchymal Lung Disease. The phrase "Because of the diffusion abnormality" has been removed from the last sentence of this section, and the word "hypoxia" has been changed to "hypoxemia". ("Hypoxemia is often more severe than hypercapnia in these patients...") (Added July 2016)

Page 76: Critical Care Medicine, Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure, Restrictive Lung Disease, Neuromuscular Weakness. In the last paragraph of this section, the word "hypoxia" has been replaced with "hypoxemia". ("Patients with altered mental status, severe respiratory distress, or profound hypoxemia or hypercapnia...") (Added July 2016)

Page 76: Critical Care Medicine, Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure, Obstructive Lung Disease. The last half of this paragraph has been revised as follows: "This occurs when airway resistance to flow causes incomplete exhalation before the next breath is initiated by the patient or by a mechanical ventilator. This “trapped” volume of air may be small with each breath, but it can build up over many breaths to a significant volume of unexpired air in the chest. This leads to elevated intrathoracic pressure, also called auto-PEEP or intrinsic PEEP, which hyperinflates the chest and reduces fresh gas entry into the alveoli. This increases the work of breathing and decreases the effective alveolar ventilation, leading to a rise in CO2. These patients may also be hypoxemic but usually respond readily to supplemental oxygen. If hypoxemia is profound or refractory to oxygen therapy, it is reasonable to consider another concurrent disease process." (Added July 2016)

Page 76: Critical Care Medicine, Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure, Obstructive Lung Disease, Key Points. In the second Key Point of this section, the word "hypoxic" has been replaced with "hypoxemic" and the word "hypoxia" has been replaced with "hypoxemia". ("...obstructive lung disease may be hypoxemic but usually respond readily to supplemental oxygen; if hypoxemia is profound...") (Added July 2016)

Page 77: Critical Care Medicine, Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure, Obstructive Lung Disease, Critical Care Management of COPD Exacerbation. In the third sentence of this section, the word "hypoxic" has been replaced with "hypoxemic". ("If hypoxemic, they should be given supplemental oxygen...") (Added July 2016)

Questions

Page 116, Item 80: In the first sentence of the question, the word "hypercapnic" has been added ("A 61-year-old man is admitted to the hospital for a hypercapnic COPD exacerbation..."). (Added March 2016)

Page 125, Item 6: In the first paragraph of the critique, the second criteria for long-term oxygen therapy should say an arterial PO2 less than or equal to 59 mm Hg (7.8 kPa) or oxygen saturation less than or equal to 89% breathing ambient air." (Added March 2016)

Page 126, Item 8: In the first paragraph of the critique, the text "...proportional to the fourth radius of the diameter of the catheter" should be "...proportional to the radius of the catheter to the fourth power" ("Flow of fluid through a catheter is inversely proportional to catheter length and proportional to the radius of the catheter to the fourth power."). (Added March 2016)

Page 147, Item 51: In the last paragraph, the number of pleural fluid samplings should be "two" not "three" ("Thoracoscopic pleural biopsy is indicated for all undiagnosed exudative pleural effusions following two pleural fluid samplings."). (Added March 2016)

NEWPage 149, Item 57. In the first paragraph of the critique, the sentence "His risk for mesothelioma is further increased by his tobacco use." has been replaced with "While tobacco use has not been definitively identified as a risk factor for development of mesothelioma, patients with asbestos exposure have a dramatically increased risk for development of asbestos-related lung cancer and should be counseled to stop smoking." (Added February 2017)

NEWPage 153, Item 65. In the first sentence of the last paragraph of the critique, the words "for 3 consecutive years" have been deleted so that the sentence reads "Recent guidelines recommend screening with annual low-dose CT in patients with at least a 30-pack-year history of smoking..." (Added February 2017)


Rheumatology

Questions

Page 93, Item 3: In the second paragraph, metacarpophalengeal joints of the feet is incorrect and has been changed to metatarsophalangeal joints of the feet. (Added March 2016)

Page 152, Item 76: The first paragraph of the Critique states that febuxostat is a purine analogue. This should state that febuxostat is a non-purine, non-competitive xanthine oxidase inhibitor. (Added March 2016)


Virtual Dx

Nephrology

NEWItem 19: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer B to earn a point for this item and ensure completion of all items in this self-assessment examination, which is necessary for CME/MOC submission. Upon closer review of this question, both acute respiratory alkalosis and chronic respiratory alkalosis can be reasonable answers to this question. (Added February 2017)