MKSAP 18

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Errata and Revisions

(Updated May 2019)


Invalidated MKSAP 18 Questions

The following questions have been invalidated as a result of postpublication analysis and/or new data that are relevant to the question: Item 21 from Endocrinology and Metabolism and Item 31 from General Internal Medicine.


Cardiovascular Medicine

Epidemiology and Risk Factors

Page 2: Epidemiology and Risk Factors, Calculating Cardiovascular Risk. In the second sentence of the second paragraph, the cardiovascular end points included in the Pooled Cohort Equations have been changed to "fatal and nonfatal MI or stroke." (Added March 2019)

Arrhythmias

Page 39: Arrhythmias, Approach to Bradycardia, Atrioventricular Block. In the second paragraph, the second and third sentences have been replaced with the following: "Mobitz type 1 second-degree (Wenckebach) AV block is characterized electrocardiographically by a PR interval that progressively prolongs until a beat is dropped, resulting in grouped beating (Figure 10). Mobitz type 2 second-degree AV block is typified by intermittent nonconducted P waves with unchanging PR intervals (Figure 11)." (Added March 2019)

Questions

Page 154, Item 3: In the last sentence of the first paragraph of the critique, "aortic emptying" has been changed to "ventricular emptying" ("Notably, a left ventricular ejection fraction of 60% or less is used in defining left ventricular systolic dysfunction in mitral regurgitation because ventricular emptying into the left atrium contributes to the relatively lower afterload conditions and higher ejection fraction despite impaired left ventricular performance."). (Added March 2019)

Page 161, Item 17: The last sentence of the first paragraph of the critique should read as follows: "This patient's 10-year cardiovascular risk based on the American College of Cardiology/American Heart Association Pooled Cohort Equations risk calculator is 6.9%, and he should be counseled regarding therapeutic lifestyle changes, including dietary modification, regular physical activity, weight loss, and continued smoking cessation." (Added March 2019)

Page 166, Item 28: The following sentence has been added to the end of the first paragraph of the critique: "It should be noted that the American College of Cardiology Heart Failure Toolkit (https://www.acc.org/tools-and-practice-support/clinical-toolkits/heart-failure-practice-solutions/beta-blocker-therapy) advises that β-blockers should be used with caution in patients with second-degree atrioventricular block, such as this one." (Added March 2019)


Dermatology

Acneiform Eruptions

Page 19: Acneiform Eruptions, Acne. The last sentence of the fifth full paragraph should state "Oral contraceptives are pregnancy category X whereas spironolactone is pregnancy category C." (Added March 2019)


Endocrinology and Metabolism

Disorders of the Pituitary Gland

Page 32: Disorders of the Pituitary Gland, Pituitary Hormone Deficiency, Growth Hormone Deficiency. The last sentence of the third paragraph has been changed to read: “Provocative tests such as an insulin tolerance test or GHRH-arginine test can be performed in consultation with an endocrinologist to establish the diagnosis of adult GH deficiency.” (Added March 2019)

Disorders of the Adrenal Glands

Page 41: Disorders of the Adrenal Glands, Adrenal Hormone Excess, Pheochromocytoma and Paraganglioma. The second sentence of the first full paragraph has been revised. The corrected sentence is as follows: "Preoperative α-receptor blockade with phenoxybenzamine for 10 to 14 days before surgery is essential to prevent hypertensive crises during surgery." (Added March 2019)

Disorders of the Thyroid Gland

Page 61: Disorders of the Thyroid Gland, Thyroid Emergencies, Myxedema Coma. The third sentence of the first full paragraph should read: "If random cortisol level is above 18 µg/kg (496.8 nmol/L), hydrocortisone can be discontinued." (Added March 2019)

Reproductive Disorders

Pages 64-65: Reproductive Disorders, Hyperandrogenism Syndromes, Hirsutism and Polycystic Ovary Syndrome, Evaluation of Hyperandrogenism. The last sentence on page 64 (which runs onto page 65) has been changed to read: "Patients with total testosterone levels greater than 200 ng/dL (6.9 nmol/L) or DHEAS values greater than 700 µg/mL (18.9 µmol/L) require imaging to assess for adrenal tumor (adrenal CT or MRI) or ovarian tumor (transvaginal ultrasound)." (Added March 2019)

Page 66: Reproductive Disorders, Hypogonadism, Evaluation. The last sentence of this section should read: “Dedicated pituitary MRI should be performed if hyperprolactinemia is present, other pituitary hormone abnormalities are identified, testosterone level is less than 150 ng/dL (5.2 nmol/L), or if there are signs or symptoms of mass effect (Figure 14).” (Added March 2019)

Questions

NEWPage 89, Item 11: The first sentence of the fourth paragraph should read: "Cardiac examination reveals new findings of an irregularly irregular rhythm and an S3. (Added May 2019)

NEWPages 90-91, Item 21: 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 glipizide in option D, "Increase glipizide dose," is not mentioned as one of the patient's medications. (Added May 2019)

NEWPage 123, Item 38: In the second paragraph, "sliding scale insulin" has been changed to "correction insulin." (Added May 2019)

Page 136, Item 65: The second sentence of the critique has been changed to read: "Free thyroxine (T4) and thyroid peroxidase antibodies could also be measured at that time." (Added March 2019)


Gastroenterology and Hepatology

Disorders of the Esophagus

Page 4: Nonmalignant Disorders of the Esophagus, Gastroesophageal Reflux Disease, Diagnosis: In the first paragraph, the last sentence, "Symptom relief from medical therapy can confirm the diagnosis," has been deleted. (Added March 2019)

Page 8: Key Points: In the first Key Point, the phrase "and confirm the diagnosis" has been deleted. (Added March 2019)

Disorders of the Stomach and Duodenum

Pages 10-11: Disorders of the Stomach and Duodenum, Dyspepsia, Evaluation and Management: In the first paragraph, the last two sentences have been revised; the corrected sentences are as follows: "The ACG/CAG guidelines recommend against the routine use of upper endoscopy in patients younger than age 60 years, even in the presence of alarm features including weight loss, anemia, dysphagia, persistent vomiting, and severe symptoms, because these features are poor predictors of organic pathology, such as malignancy, peptic ulcer disease, or esophagitis. Consideration of endoscopy at a younger age is reasonable for patients at higher risk of malignancy, such as those with childhood years spent in a region where gastric cancer is endemic (Asia, Russia, and South America) or those with a positive family history." The following Key Point has been deleted: "Upper endoscopy should be considered for patients with alarm features such as a family history of gastric cancer, immigration from a region with increased risk for gastric cancer, or severe symptoms, regardless of age." (Added March 2019)

Page 14: Disorders of the Stomach and Duodenum, Helicobacter Pylori Infection, Treatment, Table 9: In the third row, the dose frequency of tetracycline has been changed from three to four times daily. In the fifth row, the dose frequency for levofloxacin has been changed from twice to once daily. (Added March 2019)

Page 14: Disorders of the Stomach and Duodenum, Helicobacter Pylori Infection, Treatment, Table 10: In the first row, the dose frequency of tetracycline has been changed from three to four times daily, and the dose for metronidazole has been changed to "500 mg three or four times daily." In the second row, the dose frequency for levofloxacin has been changed from twice to once daily. In the third row, the PPI dose has been changed to "standard dose twice daily," and an additional drug has been added: "Nitroimidazole, 500 mg twice or three times daily." Also in the third row, the duration of therapy has been changed from 14 to 10-14 days. The fourth row of the table has been deleted. (Added March 2019)

Questions

Page 126, Item 44: In the first paragraph of the critique, the last sentence, "Symptom relief with the use of a PPI confirms the diagnosis of GERD," has been deleted. (Added March 2019)

Page 130, Item 52: In the critique, the third paragraph has been revised. The third paragraph should read as follows: "Upper endoscopy should be performed routinely in patients older than age 60 years with persistent dyspeptic symptoms. Clinicians may treat a minority of patients older than age 60 years with empirical therapy instead of endoscopy, provided the risk of upper gastroenterologic malignancy is low. Upper endoscopy could be considered in younger patients with a family history of gastric cancer or who have emigrated from a region with increased risk for gastric cancer (Asia, Russia, and South America). Upper endoscopy is considered the gold standard for the exclusion of upper gastrointestinal structural causes of dyspepsia." (Added March 2019)


General Internal Medicine

Routine Care of the Healthy Patient

Page 20: Routine Care of the Healthy Patient, Immunization, Vaccinations Recommended for Some Adults, Human Papillomavirus. In the fourth sentence, "immunocompromised men" has been changed to "immunocompromised persons" ("In males, the series should be administered at age 11 or 12 years, between the ages of 13 and 21 years if not previously administered, or through age 26 years for immunocompromised persons [including those with HIV infection] and men who have sex with men."). (Added March 2019)

Dyslipidemia

Page 84: Dyslipidemia, Metabolic Syndrome, Management. The following sentence has been deleted: "Aspirin is indicated for patients with metabolic syndrome and a 10-year ASCVD risk of 10% or greater, assuming there is not increased bleeding risk." (Added March 2019)

Questions

NEWPage 165, Item 31: 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.

According to the 2018 American Heart Association/American College of Cardiology Guideline on the Management of Blood Cholesterol, it is reasonable to initiate a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor, such as alirocumab, in patients with clinical atherosclerotic cardiovascular disease (ASCVD) who are at very high risk and are taking maximally tolerated lipid-lowering therapy with an LDL cholesterol level of 70 mg/dL (1.8 mmol/L) or higher or a non-HDL cholesterol level of 100 mg/dL (2.6 mmol/L) or higher. Very high risk is defined as the presence of more than one major ASCVD event or one major ASCVD event with multiple high-risk conditions. High-risk conditions include age 65 years or older, heterozygous familial hypercholesterolemia, prior coronary artery bypass or percutaneous coronary intervention outside of the major ASCVD event, diabetes mellitus, hypertension, chronic kidney disease, current smoking, persistently elevated LDL cholesterol (≥100 mg/dL [≥2.6 mmol/L]) despite maximally tolerated statin therapy and ezetimibe therapy, and history of heart failure. This patient does not meet the criteria for very high risk, and therefore, he does not meet the indications for PCSK9 inhibitor therapy with alirocumab. (Added May 2019)

Page 195, Item 5: In the first paragraph of the critique, the next-to-last sentence has been revised as follows: "Methylphenidate is a rapid-acting psychostimulant that is well tolerated and may be effective in the treatment of depression; once initiated, results can be seen within 24 to 48 hours." (Added March 2019)

Page 247, Item 110: The first sentence of the third paragraph of the critique incorrectly states that mirtazapine is an α2-agonist; this sentence has been revised to reflect that mirtazapine is an α2-antagonist. (Added March 2019)

Page 256, Item 128: In the Key Point and the sixth sentence of the first paragraph of the critique, "immunocompromised men" has been changed to "immunocompromised persons." (Added March 2019)


Hematology and Oncology

Bleeding Disorders

Page 39: Bleeding Disorders, Acquired Bleeding Disorders, Coagulopathy of Liver Disease. In the second paragraph, the sentence beginning, "Measuring factor VIII levels..." has been revised to state, "Measuring factor VIII levels provides a theoretical means of separating the two disorders. Factor VIII is not produced in the hepatocytes, is often elevated in liver disease, but is usually consumed in intravascular coagulation. Additionally, a stable platelet count with mildly elevated D-dimer level suggests liver disease, especially if clinical findings of portal hypertension, consistent with that diagnosis, are present." (Added March 2019)

Thrombotic Disorders

Page 47: Thrombotic Disorders, Thrombophilia, Inherited Thrombophilias. In the first sentence of the first paragraph, the figure referred to in the Bleeding Disorders chapter should be Figure 18, not Figure 2. (Added March 2019)

Page 52: Thrombotic Disorders, Deep Venous Thrombosis and Pulmonary Embolism, Diagnosis. The last sentence of the first full paragraph (bottom of left column) should state, "D-dimer testing may be considered in patients with moderate pretest probability of pulmonary embolism (~20%) but should not be pursued in patients with high pretest probability because results would not change the need for imaging." (Added March 2019)

Page 57: Thrombotic Disorders, Anticoagulants, Non-Vitamin K Antagonist Oral Anticoagulants. In the fifth sentence of the last paragraph, the text should state, "antifibrinolytic agents such as tranexamic acid or ε-aminocaproic acid..." The print text indicates "fibrinolytic agents." (Added March 2019)

Effects of Cancer Therapy and Survivorship

Page 107: Effects of Cancer Therapy and Survivorship, Effects of Cancer Therapy, Hematologic Toxicity, Neutropenia and Fever. In the fourth sentence of the first paragraph, the information on antibiotics has been updated to specify that the antibiotic administered must have antipseudomonal activity. (Added March 2019)

Questions

Page 136, Item 75: In the Laboratory studies table, the unit of measurement was missing for the platelet count. The corrected platelet count is 145,000/µL. (Added March 2019)


Infectious Disease

Contributors

Page iii, under Committee, Infectious Disease Reviewers: The list of reviewers for the Infectious Disease book should include Fida A. Khan, MD, FACP1. (Added March 2019)

Community-Acquired Pneumonia

Page 19: Community-Acquired Pneumonia, Management, Antimicrobial Therapy. In the fourth paragraph, the figure referenced should be Figure 4, not Figure 1. (Added March 2019)

Urinary Tract Infections

Page 30: Infectious Disease, Urinary Tract Infections, Management, Acute Bacterial Prostatitis. In the last paragraph, the first two sentences have been revised to state, "Fluoroquinolone antibiotics (ciprofloxacin, levofloxacin) may be the preferred oral agents for treating acute bacterial prostatitis but should not be used if recent genitourinary instrumentation was performed, especially transrectal prostate biopsies, because most E. coli strains are now resistant to fluoroquinolones. Trimethoprim-sulfamethoxazole also has good tissue penetration and is a viable treatment option. Treatment duration is typically 4 to 6 weeks." (Added March 2019)

Infections in Transplant Recipients

Page 75: Infections in Transplant Recipients, Posttransplantation Infections, Timeline and Type of Transplant, Figure 21. In the column for Phase I, Preengraftment, <30 days, the cell titled "Streptococcus epidermidis" should be "Staphylococcus epidermidis." (Added March 2019)


Neurology

Movement Disorders

Page 61: Movement Disorders; Hyperkinetic Movement Disorders; Restless Legs Syndrome and Sleep-Related Movement Disorders: At the end of the first paragraph, several short sentences were added to address restrictions on the use of opioids and the need to be adherent to the Centers for Disease Control and Prevention guideline for prescribing opioids. (Added March 2019)

Neuro-oncology

Page 88: Neuro-oncology; Primary Central Nervous System Tumors; Primary Central Nervous System Lymphomas: In the fourth sentence of the first paragraph, the phrase “without mass effect or edema” has been changed to “with minimal mass effect or edema.” (Added March 2019)

NEWPage 90: Neuro-oncology; Medical Management of Complications of Central Nervous System Tumors; Edema and Herniation: In the fourth sentence of the first paragraph, the phrase "hyperventilation (usually with mechanical ventilation) to an arterial PCO2 greater than 26 mm Hg (3.5 kPa)" has been changed to “hyperventilation (usually with mechanical ventilation) to an arterial PCO2 of 20 to 25 mm Hg (2.7-3.3 kPa).” (Added May 2019)


Rheumatology

Questions

Page 88, Item 14: First paragraph of the question's Critique. In the sentence "Treatment is with rotating antibodies to try to reduce the overgrowth using agents with both aerobic and anaerobic coverage," the word antibodies has been replaced with the correct term, antibiotics. (Added March 2019)

Page 94, Item 38: Second paragraph of the question's Critique. In the sentence "In addition, the angiotensin-converting enzyme level is only 75% specific (25% of cases will be missed) and 90% specific (10% of positive results will be false positive), decreasing the usefulness of this test for sarcoidosis," 75% specific has been replaced with the correct term, 75% sensitive. (Added March 2019)

NEWPage 115, Item 16: In the first paragraph of the critique, the phrase "an area endemic for" has been replaced by "an area of emerging risk for." (Added May 2019)

Page 139, Item 66: Critique, first paragraph, third sentence: Diuretic use has been removed as a risk factor for allopurinol sensitivity in this specific patient. Although diuretic use is a risk factor for allopurinol sensitivity, this patient in the question is not taking a diuretic. (Added March 2019)


Virtual Dx

Nephrology

NEWItem 9: In the last sentence of the critique, the phrase "the bicarbonate value should increase by 4.0-5.0 mEq/L (4.0-5.0 mmol/L) for every 100-mm Hg (1.3 kPa) increase in arterial PCO2" has been replaced by "the bicarbonate value should increase by 3.5 mEq/L (3.5 mmol/L) for every 10-mm Hg (1.3 kPa) increase in arterial PCO2." (Added May 2019)

NEWItem 17: In the last sentence of the critique, the phrase "the bicarbonate value should increase by 1.0 mEq/L (1.0 mmol/L) for every 10-mm Hg (1.3 kPa) increase in arterial PCO2 (as opposed to 4.0-5.0 mEq/L [4.0-5.0 mmol/L]" has been replaced by "the bicarbonate value should increase by 1.0 mEq/L (1.0 mmol/L) for every 10-mm Hg (1.3 kPa) increase in arterial PCO2 (as opposed to 3.5 mEq/L [3.5 mmol/L]." (Added May 2019)