Errata and Revisions
(Updated October 2021)
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 40, Item 65, Item 74, Item 83 from Cardiovascular Medicine,
Item 21 from Endocrinology and Metabolism, Item 45, Item 85 from Gastroenterology and Hepatology, Item 22, Item 31, Item 40, Item 103, Item 124 from General Internal Medicine, Item 8 from Hematology and Oncology, Item 6, Item 11, Item 33, Item 40, Item 56, Item 61, Item 73, Item 89, Item 94 from Infectious Disease, Item 37, Item 61, Item 74, Item 107 from Nephrology, Item 11, Item 34, Item 98 from Pulmonary and Critical Care Medicine, Item 28 from Virtual Dx3, Gastroenterology and Hepatology and Item 29 from Virtual Dx3, Cardiology.
Reference Ranges
Lactate, plasma: The reference range upper limit is incorrect. The entry should read as follows: 0.5-1.6 mEq/L (0.5-1.6 mmol/L). (Added September 2019)
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)
Diagnostic Testing in Cardiology
Page 12: Diagnostic Testing in Cardiology, Diagnostic Testing for Structural Heart Disease, Table 4: Diagnostic Testing for Structural Heart Disease. In the sixth entry, which corresponds to coronary CT angiography, "Invasive" has been deleted from the Limitations column. (Added October 2020)
Heart Failure
Page 33: Heart Failure, Medical Therapy for Systolic Heart Failure, Aldosterone Antagonists. The second sentence of the third paragraph ("Generally, the doses of both the ACE inhibitor and β-blocker should be uptitrated to maximal levels before spironolactone or eplerenone is added.") has been deleted. According to the 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment, target or maximally tolerated doses of an ACE inhibitor/angiotensin receptor blocker/angiotensin receptor–neprilysin inhibitor and a β-blocker do not need to be achieved before initiating an aldosterone antagonist. (Added October 2021)
Page 35: Heart Failure, Assessment of Chronic Heart Failure, Echocardiography in Chronic Heart Failure. The last sentence of this section has been revised to read as follows: "Current guidelines recommend against routine surveillance echocardiography in the absence of a change in clinical status or planned treatment interventions." (Added September 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)
Peripheral Artery Disease
Page 98: Peripheral Artery Disease, Evaluation, Diagnostic Testing, Table 39: Comparison of Imaging Modalities for the Diagnosis of Peripheral Artery Disease. In the rows corresponding to CT angiography and Magnetic resonance angiography, "Very expensive" has been moved from the "Advantages" column to the "Limitations" column. (Added October 2021)
Questions
Page 129, Item 40: 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 for athletes with hypertrophic cardiomyopathy, the 2020 American Heart Association/American College of Cardiology guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy recommends a comprehensive evaluation and shared discussion of potential risks of sports participation by an expert provider. Thus, option A (advise the patient that he should not play basketball) is not definitively correct. (Added March 2021)
Page 136, Item 65: 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 the 2020 American Heart Association/American College of Cardiology guideline for the diagnosis and treatment of patients with hypertrophic cardiomyopathy recommends direct oral anticoagulants in preference to warfarin for anticoagulation in patients with hypertrophic cardiomyopathy and concomitant atrial fibrillation. Therefore, option A (dabigatran) is now the correct answer. (Added March 2021)
Page 139, Item 74: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C 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 guideline recommendations differ on the preferred level of statin intensity for secondary prevention. The American Heart Association/American College of Cardiology recommend high-intensity statin therapy for secondary prevention in patients with clinical atherosclerotic cardiovascular disease. In contrast, the 2020 updated U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) clinical practice guideline on management of dyslipidemia for cardiovascular disease risk reduction makes a strong recommendation for moderate-intensity statin therapy for secondary prevention. The VA/DoD guideline suggests offering high-intensity statin therapy to higher-risk patients (those with a myocardial infarction or acute coronary syndrome in the past 12 months; recurrent acute coronary syndrome, myocardial infarction, or stroke; or established cardiovascular disease with additional risk factors) who are willing to intensify treatment. Because of these conflicting guideline recommendations, both option C (high-intensity atorvastatin) and option D (moderate-intensity pravastatin) can be considered correct. (Added March 2021)
Page 142, Item 83: 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.
According to the 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment, target or maximally tolerated doses of an ACE inhibitor/angiotensin receptor blocker/angiotensin receptor–neprilysin inhibitor and a β-blocker do not need to be achieved before initiating an aldosterone antagonist. Thus, there is insufficient information to conclude that adding spironolactone (Option B) is incorrect. (Added October 2021)
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 155, Item 4: The second paragraph of the critique has been revised to read as follows: “Cisplatin has been associated with increased risk for venous thromboembolism, supraventricular tachycardia, myocardial ischemia, and cardiomyopathy. It may be associated with an increased risk for late development of hypertension in long-term cancer survivors; however, it has not been associated with acute onset of hypertension during treatment.” (Added September 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)
Page 176, Item 47: In the third sentence of the first paragraph of the critique, the stated QRS morphology has been revised to read as follows: “RsR′ pattern in lead V1, RSR′ pattern in leads V2 and V3, and deep terminal S waves in leads I and V6.” (Added September 2019)
Page 180, Item 55: In the first paragraph of the critique, the seventh sentence ("In this case, exercise echocardiography, using either pharmacologic or physical stressors, should be pursued to assess the response of the mitral gradient and pulmonary pressures.") has been revised to read as follows: "In this case, stress echocardiography should be pursued to assess the response of the mitral gradient and pulmonary pressures. Both exercise and dobutamine echocardiography are viable options, but exercise is generally preferred as the more physiologic test." (Added March 2021)
Page 204, Item 104: The first sentence of the critique has been revised to read as follows: “The factor associated with the highest risk for atherosclerotic cardiovascular disease (ASCVD) in this woman is the diagnosis of diabetes mellitus.” (Added September 2019)
Page 209, Item 114: In the last paragraph of the critique, the fifth sentence has been revised to read: “In this patient who is taking an ACE inhibitor and β-blocker and is experiencing symptomatic orthostatic hypotension, the substitution of valsartan-sacubitril for lisinopril is not indicated.” (Added September 2019)
Dermatology
Disorders of Pigmentation
Page 12: Disorders of Pigmentation, Vitiligo. The second paragraph has been changed to read: "Occasionally, it can be challenging to distinguish vitiligo from other conditions that cause depigmentation such as postinflammatory hypopigmentation, tinea versicolor, pityriasis alba, and leprosy. (Added September 2019)
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)
Questions
Page 138, Item 53: The second sentence in the fourth paragraph of the critique has been changed to read: "There is no reason to suspect a fungal infection in this patient." (Added March 2021)
Endocrinology and Metabolism
Disorders of Glucose Metabolism
Disorders of the Pituitary Gland
Page 19: Acute Complications of Diabetes Mellitus, Diabetic Ketoacidosis/Hyperglycemic Hyperosmolar Syndrome. The third sentence of the seventh paragraph has been changed to read: "Hypertonic hypernatremia may occur in DKA and HHS with extreme hyperglycemia and osmotic shifts of water from intracellular to extracellular compartments." (Added October 2021)
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 40: Disorders of the Adrenal Glands, Pheochromocytoma and Paraganglioma. In the second sentence of the second paragraph, the term "multiple endocrine neoplasia type 2" has been corrected to "multiple endocrine neoplasia type 1." (Added March 2021)
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 47: Disorders of the Thyroid Gland, Structural Disorders of the Thyroid Gland, Thyroid Nodules. The first sentence of the third paragraph should be deleted and replaced with the following content: "Thyroid ultrasonography with survey of the cervical lymph nodes should be performed in all patients with known or suspected thyroid nodules. This includes the subset of patients with low serum TSH levels who have undergone radionuclide thyroid scintigraphy suggesting nodularity, to evaluate both the presence of nodules concordant with the hyperfunctioning areas on the scan, which do not require FNAB, as well as other nonfunctioning nodules that meet sonographic criteria for FNAB." (Added October 2020)
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
Page 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)
Pages 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)
Page 106, Item 4: The last two sentences of the second paragraph of the critique have been changed to read: "The Schizophrenia Patient Outcomes Research Team psychopharmacologic treatment recommendations support continued antipsychotic treatment in order to maintain symptom relief. If the medication cannot be discontinued, and likely will not be in this patient, a pituitary MRI is required to exclude the diagnosis of pituitary tumor." (Added March 2021)
Page 123, Item 38: In the second paragraph, "sliding scale insulin" has been changed to "correction insulin." (Added May 2019)
Page 123, Item 39: The Key Point has been reworded as follows: Biochemical testing for pheochromocytoma should be undertaken in all patients with an adrenal mass that is clearly not an adenoma, even in the absence of typical symptoms or hypertension. (Added October 2021)
Page 125, Item 44: In the sixth sentence of the first paragraph of the critique, the word "diarrhea" was removed. The sentence now reads: "The patient reports abdominal pain, weight loss, and a rash that is characteristic of dermatitis herpetiformis, a finding that is unique to celiac disease." (Added March 2021)
Page 128, Item 50: The fourth sentence of the last paragraph of the critique has been revised to read as follows: "Treatment of patients with overt hypothyroidism is indicated to ameliorate the risk of these complications. Guidelines differ regarding when to treat subclinical hypothyroidism (elevated serum TSH level with free T4 or total T4 levels within the reference range). For most adults with subclinical hypothyroidism, thyroid hormone replacement will result in no clinical benefits and may have little or no effect on cardiovascular events or mortality. However, treatment should be provided to women who are trying to become pregnant or patients with TSH level greater than 20 µU/mL (20 mU/L), and treatment may be reasonable for patients with severe symptoms or adults aged 30 years old or younger. (Added October 2021)
Page 134, Item 61:
At the end of the first paragraph of the critique, the following content should be added: "Finally, guidelines recommend that thyroid sonography with survey of the cervical lymph nodes should be performed in all patients with known or suspected thyroid nodules. This includes the subset of patients with low serum TSH levels who have undergone radionuclide thyroid scintigraphy suggesting nodularity, to evaluate both the presence of nodules concordant with the hyperfunctioning areas on the scan, which do not require fine needle aspiration biopsy (FNAB), as well as other nonfunctioning nodules that meet sonographic criteria for FNAB." (Added October 2020)
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)
Page 136, Item 65: The fifth paragraph of the critique has been changed to read: "Guidelines differ regarding when to treat subclinical hypothyroidism (elevated serum TSH level with free T4 or total T4 levels within the reference range). For most adults with subclinical hypothyroidism, thyroid hormone replacement will result in no clinical benefits and may have little or no effect on cardiovascular events or mortality. However, treatment should be provided to women who are trying to become pregnant or patients with a TSH level greater than 20 µU/mL (20 mU/L), and treatment may be reasonable for patients with severe symptoms or adults aged 30 years or younger. Guidelines stress that clinicians make individualized, patient-specific decisions about treatment. However, the most appropriate next step is to reassess the patient’s TSH level and symptoms before making treatment decisions. (Added October 2021)
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)
Page 8: Disorders of the Esophagus, Metaplastic and Neoplastic Disorders of the Esophagus, Barrett Esophagus, Epidemiology and Screening: The word "solely" has been added to the second sentence of the second paragraph: "Some studies have suggested that the use of PPIs, NSAIDs, and statins may be protective; however, this has not been established, and the use of these agents solely for prevention of progression to dysplasia is not recommended." (Added March 2020)
Page 9: Disorders of the Esophagus, Metaplastic and Neoplastic Disorders of the Esophagus, Barrett Esophagus, Diagnosis and Management: The first sentence of the third paragraph has been changed to "In patients with Barrett esophagus, medical therapy should be used to treat reflux symptoms and to heal reflux esophagitis." The first sentence of the fourth paragraph has been changed to "Patients with a diagnosis of Barrett esophagus indefinite for dysplasia should start or optimize PPI therapy to treat symptoms or heal esophagitis, followed by repeat upper endoscopy." (Added March 2020)
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 9: In the fourth row, footnote "b" has been added to "Nitroimidazole, 500 mg twice daily." The footnote is "bMetronidazole or tinidazole." (Added March 2020)
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)
Page 14: Disorders of the Stomach and Duodenum, Helicobacter pylori Infection, Treatment, Table 10: In the third row, footnote "a" has been added to "Nitroimidazole, 500 mg twice or three times daily." The footnote is "aMetronidazole or tinidazole." (Added March 2020)
Disorders of the Small and Large Bowel
Page 29: Disorders of the Small and Large Bowel, Celiac Disease and Nonceliac Gluten Sensitivity, Nonceliac Gluten Sensitivity: The third sentence has been changed to "Because gluten-containing foods can also contain nonabsorbable carbohydrates, such as fructans, they can cause gastrointestinal symptoms due to osmotic mechanisms, as well as fermentation by colonic bacteria." (Added March 2020)
Page 29: Disorders of the Small and Large Bowel, Celiac Disease and Nonceliac Gluten Sensitivity, Nonresponsive Celiac Disease: Added "most commonly, olmesartan enteropathy," after "Possible medication-induced sprue" (fourth sentence in second paragraph under "Nonresponsive Celiac Disease") (Added March 2021)
Colorectal Neoplasia
Page 46: Colorectal Neoplasia, Surveillance: In Table 25, row 2, the first cell has been changed to "3-10 adenomas, ≥10 mm in size, villous histology, or high-grade dysplasia." In addition, a footnote has been added to this table: "Data from Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-857. [PMID: 22763141] doi:10.1053/j.gastro.2012.06.001." (Added March 2020)
Disorders of the Liver
Page 56: In the third key point after the heading "Alcohol-Induced Liver Disease," "prednisone" has been changed to "prednisolone." (Added March 2021)
Page 56: Under the heading "Drug-Induced Liver Injury," in the second sentence of the second paragraph, "common drugs" has been changed to "common antimicrobials." (Added March 2021)
Page 58: Disorders of the Liver, Metabolic Liver Diseases, α1-Antitrypsin Deficiency: In the first sentence, "an autosomal recessive genetic disorder" has been changed to "a codominant genetic disorder." In addition, the following sentences have been added: "In codominant inheritance, two different versions (alleles) of a gene are expressed rather than only the dominant allele. In situations of codominance, each allele codes for a slightly different protein and both proteins influence the expression of the genetic trait." (Added October 2021)
Gastrointestinal Bleeding
Page 74: Gastrointestinal Bleeding, Lower Gastrointestinal Bleeding, Causes: In the first sentence of the fifth paragraph, "ischemic colitis" has been changed to "acute mesenteric ischemia." (Added October 2021)
Questions
Page 92, Item 45: 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. As a result of a recent change in USPSTF colonoscopy screening guidelines, there are now two correct answers (A and B). (Added October 2021)
Page 101, Item 85: 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 on the basis of the 2020 guideline on follow-up after colonoscopy and polypectomy published by the US Multi-Society Task Force on Colorectal Cancer, there are now two correct answers (B and C). (Added October 2020)
Page 106, Item 4: In the fourth sentence of the first paragraph of the critique, "as well as an enlarged liver on physical examination" has been deleted. (Added March 2021)
Page 123, Item 37: In the fourth paragraph of the critique, "(except in microscopic colitis)" has been added to the second sentence. This sentence now reads, "Patients with inflammatory causes of chronic diarrhea present with bloody stools (except in microscopic colitis), nocturnal symptoms, and sometimes anemia." (Added October 2020)
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 128, Item 48: The second sentence of the third paragraph of the critique has been revised to read as follows: "This patient reports no dysphagia, a common presenting symptom of motility disorders, so esophageal manometry is not indicated." (Added March 2020)
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)
Page 140, Item 72: In the last paragraph of the critique, "CT angiogram" has been changed to "CT." (Added October 2020)
General Internal Medicine
Routine Care of the Healthy Patient
Page 17: Routine Care of the Healthy Patient, Screening, Specific Screening Tests, Screening for Cancer, Additional Cancer Screening Tests. The first sentence of the fifth paragraph has been revised to state, "Lung cancer screening with annual low-dose CT is recommended for persons aged 50 years to 80 years with a 20-pack-year smoking history; screening should be discontinued in former smokers who have not smoked for 15 years (see MKSAP 18 Pulmonary and Critical Care Medicine)." (Added October 2021)
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)
Common Symptoms
Page 54: Common Symptoms, Fatigue and Systemic Exertion Intolerance Disease, Management. The fourth sentence of the first paragraph has been revised to state, "There is inconsistent evidence that CBT may decrease fatigue and improve function." In the second key point, the phrase "cognitive behavioral therapy and graded exercise therapy may decrease fatigue and improve function and should be offered" has been deleted. (Added October 2021)
Musculoskeletal Pain
Page 75: Musculoskeletal Pain, Lower Extremity Disorders, Knee Pain, Ligament and Meniscal Tears. In the seventh sentence of the first paragraph, "posterior collateral ligament" has been changed to "posterior cruciate ligament." (Added March 2020)
Page 77: Key Points. In the second Key Point, "posterior collateral ligament" has been changed to "posterior cruciate ligament." (Added March 2020)
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)
Women's Health
Page 102: Women’s Health, Menopause, Management, Vasomotor Symptoms. The last sentence of the first paragraph has been revised to state, “Commonly cited contraindications to hormone therapy include pregnancy, unexplained vaginal bleeding, liver disease, coronary artery disease, stroke, thromboembolic disease, breast cancer, and endometrial cancer.” (Added September 2019)
Questions
Page 163, Item 22: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer E 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 option B, “Obtain a social and sexual history,” may also be correct, as inclusion of a brief social history is appropriate for a new patient visit related to cough. Given no prior relationship with the patient, he should be briefly assessed for tobacco status, inhalant use (vaping, snorting), and possible allergen exposures, all of which are part of the social history. Additionally, referring to the patient as “nervous” suggests the need for a brief but sensitive patient-centered communication to acknowledge his concerns and help to establish a more therapeutic relationship.
(Added October 2020)
Page 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 166, Item 40: 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 guidelines published by the American Diabetes Association in 2020 state that the use of aspirin for primary prevention (option B) may be considered in this patient group, thus indicating that not using aspirin may also be appropriate (option E). Therefore, options B and E are both potentially correct answers. (Added March 2021)
Page 173, Item 76: In the question stem, all instances of “right eye” have been changed to “left eye.” The funduscopic image shown is of the left eye. (Added September 2019)
Page 179, Item 103: 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 guidelines published by the American Cancer Society in 2020 recommend high-risk human papilloma virus detection as the preferred cervical cancer screening strategy for women age 25 to 65 years. (Added March 2021)
Page 182, Item 124: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C 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 option B is also correct. Based on the 2020 Centers for Disease Control and Prevention recommendations for hepatitis C screening among adults in the United States, one-time screening for hepatitis C virus should be completed in all patients aged 18 years and older. Therefore, options B and C are both correct. (Added October 2020)
Page 193, Item 1: The following text has been added to the first paragraph of the critique: "Sexually active women of childbearing age who are receiving statin therapy should be counseled to use a reliable form of contraception. Women who plan to become pregnant should stop taking statins 1 to 2 months before pregnancy is attempted. Those who become pregnant while on therapy should discontinue statins as soon as the pregnancy is discovered." (Added October 2021)
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 215, Item 44: The following sentence has been added to the end of the first paragraph of the critique: "Therefore, the study cannot conclude that statins cause memory loss and should not recommend avoidance of statin therapy." The following sentences have been added to the end of the third paragraph of the critique: "Self-reported data do not necessarily result in recall bias. A well-constructed survey can minimize recall bias by focusing on the collection of the most objective data that are available (for example, by asking if the patient has consulted a physician about memory loss, has been evaluated for memory loss, is being treated for memory loss, or has been told by family members that memory loss is present)." (Added October 2020)
Page 215, Item 45: In the fourth paragraph of the critique, "α2-blockade" has been changed to "α1-blockade" in the second sentence, and "α2-Blockers" has been changed to "α1-Blockers" in the third sentence. (Added October 2020)
Page 238, Item 91: In the fourth paragraph of the critique, the first sentence was revised to state, "The USPSTF recommends lung cancer screening with annual low-dose CT in persons aged 50 to 80 years with a 20-pack-year smoking history, including former smokers who have quit in the last 15 years." (Added October 2021)
Page 247, Item 110: In the first paragraph of the critique, the fourth sentence has been revised to state, "Although vigorous aerobic exercise may be beneficial for many chronic illnesses, patients with SEID do not tolerate such exercise routines. Standard exercise recommendations for healthy people may be harmful for patients with SEID. However, it is important that patients with SEID undertake activities that they can tolerate." The following sentence has been added to the same paragraph: "There is some evidence, although inconsistent, that cognitive behavioral therapy may improve function in patients with SEID." The key point has been revised as follows: "The treatment of systemic exertion intolerance disease involves a structured, multimodal, nonpharmacologic approach that includes regularly scheduled office visits, cognitive behavioral therapy, and sleep hygiene education." (Added October 2021)
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 251, Item 120: In the first paragraph of the critique, the last sentence has been revised as follows: "In older men and persons who practice insertive anal intercourse, infectious epididymitis should be treated with ceftriaxone and a fluoroquinolone, such as levofloxacin, to provide antimicrobial activity against cephalosporin-resistant organisms, including Pseudomonas species." In the third paragraph of the critique, first sentence, C. trachomatis was changed to Chlamydia trachomatis. The following sentence was added after this first sentence: "Ceftriaxone is adequate coverage for N. gonorrhoeae but not C. trachomatis infection, and would not be an appropriate choice in a younger patient." Based on the revisions in the critique, the second paragraph has been deleted. (Added October 2020)
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
Multiple Myeloma and Related Disorders
Page 12: Multiple Myeloma and Related Disorders, Monoclonal Gammopathy of Undetermined Significance, Table 8. In the table on Diagnostic Criteria for the Plasma and Lymphoplasmacytic Cell Dyscrasias, the "Involved: uninvolved serum FLC ratio" has been corrected from ≥10 to ≥100; in footnote C, the involved light chain has been corrected from 100 mg/dL to 100 mg/L. (Added October 2020)
Iron Overload Syndromes
Page 31: Iron Overload Syndromes, Primary/Hereditary Hemochromatosis. In the second paragraph, the penultimate sentence beginning, "Skin hyperpigmentation, accounting for the 'bronze diabetes' terminology for HH..." the word "melatonin" should be "melanin." (Added March 2021)
Platelet Disorders
Page 33: Platelet Disorders, Thrombocytopenic Disorders, Increased Destruction, Non–Immune-Mediated Thrombocytopenia, Hemolytic Uremic Syndrome. In the second sentence of the section, "enterotoxin-producing Escherichia coli O157:H7" has been revised to the more accurate "enterohemorrhagic Escherichia coli O157:H7." (Added October 2020)
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 120, Item 8: 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.
A 2019 systematic review and network meta-analysis published in PLoS ONE compared rates of recurrence and bleeding risk in patients with cancer-associated thrombosis treated with non–vitamin K antagonist oral anticoagulants (NOACs) or low-molecular-weight heparin (LMWH). Recurrence rates were lower with NOACs compared with LMWH, although bleeding rates were higher. LMWH and NOACs were both considered superior to vitamin K antagonists for prevention of recurrence. The authors concluded that the choice of anticoagulant should be personalized, with consideration given to the patient's bleeding risk, cancer site, and the patient's own preferences. (Added September 2019)
Page 140, Item 93: The third paragraph of the critique has been revised to state, "The U.S. Preventive Services Task Force (USPSTF) recommends annual low-dose CT imaging of the thorax for all patients 50 to 80 years of age who have a 20-pack-year smoking history and currently smoke or who have quit within the past 15 years." (Added October 2021)
Page 174, Item 45: The end of the Key Point should state, "pre-eclampsia is defined by hypertension, edema, and proteinuria after the 20th week of gestation", not "after the 12th week of gestation." (Added March 2020)
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)
Page 138, Item 80: The following text has been added to the first paragraph of the critique to clarify why “cetuximab plus radiation” is the most appropriate answer: “Cisplatin is nephrotoxic and should be avoided or used cautiously in patients with preexisting kidney injury. Although no threshold exists to determine safe use, past and most current studies have not included patients with a serum creatinine level greater than 1.5 mg/dL (132.6 µmol/L). If there is a compelling reason to use cisplatin, dose reduction based on creatinine clearance is recommended.”
Additionally, the last sentence of the first paragraph has been revised to state, “For this patient, who has chronic kidney disease with a baseline creatinine level of 1.8 mg/dL (159.1 µmol/L), cisplatin should be avoided and, therefore, cetuximab combined with radiotherapy is the most appropriate treatment.” (Added October 2020)
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 second sentence has been reworded to clarify organism involvement in patients who are hospitalized: "Hospitalized patients with CAP are most commonly infected with the organisms shown in Figure 4." (Added March 2020)
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)
Bioterrorism
Page 56: Infectious Disease, Bioterrorism, Table 40. In the table on Class A Bioterrorism Agents, "Plus vaccination" has been added to the Prophylaxis column for anthrax. (Added October 2020)
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)
Stewardship and Emerging Resistance
Page 100: Stewardship and Emerging Resistance, Antibiotics for Antibiotic-Resistant Organisms, Fosfomycin. Both instances of the term "vancomycin-resistant Enterobacteriaceae" should be "vancomycin-resistant enterococci." (Added March 2021)
Questions
Page 108, Item 6: 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.
Guidelines from the American Thoracic Society regarding laboratory testing for the diagnosis of fungal pulmonary infections recommend serum galactomannan testing in patients with suspected invasive pulmonary aspergillosis. Bronchoalveolar lavage and biopsy, if necessary, are recommended if the serum galactomannan result is negative but strong risk factors are present. (Added March 2020)
Page 109, Item 11: 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 Centers for Disease Control and Prevention published updated guidelines for the treatment of sexually transmitted infections in July 2021. For pelvic inflammatory disease treated in the outpatient setting, the ceftriaxone dose has been increased, and administration of metronidazole added to the regimen with doxycycline. A single dose of intramuscular ceftriaxone, 500 mg, should be given (for persons ≥150 kg, the dose should be 1 g) along with oral doxycycline and metronidazole for 14 days. (Added October 2021)
Page 114, Item 33: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer E 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.
New clinical practice guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR) published in 2020 on the prevention, diagnosis, and treatment of Lyme disease allow for the choice of either intravenous (ceftriaxone, cefotaxime, penicillin G) or oral (doxycycline) antibiotics in patients with peripheral and/or central nervous system involvement without brain parenchymal involvement. Lumbar puncture is no longer necessary in these patients. (Added October 2021)
Page 116, Item 40: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C 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.
Guidelines were updated regarding the prevention and treatment of travelers' diarrhea. Ciprofloxacin is no longer recommended for prophylaxis. (Added October 2020)
Page 119, 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 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 Centers for Disease Control and Prevention published updated guidelines for the treatment of sexually transmitted infections in July 2021. For urethritis, combination therapy with azithromycin is no longer recommended. A single dose of intramuscular ceftriaxone, 500 mg, should be given (for persons ≥150 kg, the dose should be 1 g). If concomitant chlamydial infection is not ruled out, oral doxycycline, 100 mg 2 times/day for 7 days, should be included. (Added October 2021)
Page 120, Item 61: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C 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.
Ceftriaxone plus azithromycin is no longer recommended for uncomplicated gonococcal infections of the cervix, urethra, or rectum. The CDC recommends ceftriaxone monotherapy for treatment because Neisseria gonorrhoeae remains susceptible to ceftriaxone, and azithromycin resistance is increasing; the recommended dose of ceftriaxone has increased. (Added March 2021)
Page 123, Item 73: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C 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 Infectious Diseases Society of America/American Thoracic Society published updated guidelines on the treatment of community-acquired pneumonia in adults. The keyed answer is not consistent with the new guideline recommendations for a quinolone antibiotic; ciprofloxacin is not a respiratory quinolone. The quinolone choice should be either levofloxacin or moxifloxacin. (Added March 2020)
Page 125, Item 81: The patient's temperature provided in the second paragraph of the Stem is incorrectly converted. The temperature should be "38.2 °C (100.8 °F)". (Added September 2019)
Page 127, Item 89: 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.
The Infectious Diseases Society of America/American Thoracic Society published updated guidelines on the treatment of community-acquired pneumonia in adults. The keyed answer is not consistent with the new guideline recommendations not to provide different empiric treatment of suspected aspiration pneumonia; a standard empiric regimen should be chosen. (Added March 2020)
Page 134, Item 3: In the last paragraph of the Critique, the last sentence, "Finally, pulmonary tuberculosis is excluded by the negative interferon-γ release assay" has been removed, because an IGRA is a tool used to diagnose latent tuberculosis, not active tuberculosis. (Added March 2021)
Page 137, Item 10: In the item Critique, the duration for the patient's injury was incorrectly provided as "1 month ago" in the final paragraph. This should be "3 months ago." (Added October 2020)
Page 156, Item 50: The final sentence of the first paragraph of the Critique has been deleted. The clinical scenario does not mention the patient having a penicillin allergy. (Added October 2020)
Page 177, Item 93: The final sentence of the first paragraph in the Critique has been deleted. The patient's cerebrospinal fluid opening pressure is normal, not elevated. (Added September 2019)
Page 128, Item 94: 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.
An alternative approach, referred to as a modified two-tier test, has been developed for validating positive enzyme immunoassay (EIA) testing for Lyme disease; this approach uses a different second step test (typically a second EIA) rather than a Western blot. Therefore, the answer option of "C6 enzyme immunoassay antibody test" could also be correct. (Added March 2020)
Page 179, Item 97: In the first Critique paragraph, in the sentence, "Thus, antifungal therapy with an echinocandin should be initiated immediately," "an echinocandin" has been changed to "amphotericin B". The Key Point for this item has also been revised: "In patients with invasive candidiasis, therapy with an oral azole (if the Candida species is susceptible) or amphotericin B should be initiated immediately; the total duration of therapy should be 10 to 14 days." (Added September 2019)
Page 184, Item 105: Page 184, Item 105: The last paragraph of the Critique states, "Because the TST is considered negative and the chest radiograph is normal…" No chest radiograph is described in the Stem of this item, so reference to a negative chest radiograph should be removed. The sentence should read, "Because the TST is considered negative, tuberculosis has been ruled out in this patient, and she does not need to be removed from her work area." (Added March 2020)
Nephrology
Clinical Evaluation of Kidney Function
Page 1: Assessment of Kidney Function, Estimation of Glomerular Filtration Rate. In September 2021, the Task Force of the National Kidney Foundation and the American Society of Nephrology recommended the immediate adoption of a new 2021 Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation, which has been refitted to estimate glomerular filtration rate without a race variable. Based on this recommendation, the following revisions have been made:
Paragraph 1, sentence 2: "These formulas take into account" has been replaced with "These formulas may take into account."
Paragraph 2, sentence 2 has been replaced with "To estimate GFR, the National Kidney Foundation and the American Society of Nephrology recommend using the CKD-EPI Creatinine Equation (2021) (http://www.kidney.org/professionals/kdoqi/gfr_calculator), which has been refitted to estimate kidney function without a race variable (see Table 1). The race-based modifier may lead to inaccurately high GFR estimates in patients who identify as Black. CKD-EPI equations presume standard body surface area and therefore require adjustment for very large or small persons. Combining filtration markers (creatinine and cystatin C) into the CKD-EPI creatinine-cystatin C equation is more accurate and informs clinical decision making better than either marker alone." (Added October 2021)
Page 2: Assessment of Kidney Function, Estimation of Glomerular Filtration Rate, Table 1. Methods for Estimating Kidney Function. To reflect the Task Force of the National Kidney Foundation and the American Society of Nephrology recommendation for the immediate adoption of a new 2021 Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation, which has been refitted to estimate glomerular filtration rate without a race variable, Table 1 was revised as follows:
- Row 3, column 1 heading revised to: CKD-EPI Creatinine (2021); line 1: "race" was deleted; lines 2-6 were deleted.
- Row 4, column 1: lines 2-5 were deleted.
- Row 5. column 1: lines 2-8 were deleted; column 3: "The most accurate formula for estimating eGFR in most situations" was added.
(Added October 2021)
Page 3: Assessment of Kidney Function, Estimation of Glomerular Filtration Rate, Key Points. To reflect the Task Force of the National Kidney Foundation and the American Society of Nephrology recommendation for the immediate adoption of a new 2021 Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation, which has been refit to estimate glomerular filtration rate without a race variable, the second Key Point was revised to, "To estimate glomerular filtration rate, the National Kidney Foundation and the American Society of Nephrology recommend using Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation (2021), which has been refitted to estimate kidney function without a race variable." (Added October 2021)
Page 4: Clinical Evaluation of Kidney Function; Interpretation of the Urinalysis; Table 2, Findings on Urinalysis: Row 2, Column 3: "urease-splitting organisms" has been replaced with "urease-producing organisms" (Added March 2020)
Acid-Base Disorders
Page 23: Acid-Base Disorders, Metabolic Acidosis, Normal Anion Gap Metabolic Acidosis, Table 10: Diagnostic Approach to Normal Anion Gap Metabolic Acidosis. In the row corresponding to type 2 (proximal) renal tubular acidosis, the urine anion gap (second column) has been changed from “Negative” to “Typically negative.” (Added September 2019)
Hypertension
Page 29: Hypertension; Screening and Diagnosis: At the end of the first paragraph, the following text was added: "The ACC/AHA recommend that adults not on hypertensive therapy with an elevated BP (120–129 mm Hg and <80 mm Hg) or stage 1 hypertension (130–139 mm Hg or 80–89 mm Hg) who have an estimated 10-year ASCVD risk less than 10% should have a repeat BP evaluation within 3 to 6 months." (Added March 2020)
Chronic Kidney Disease
Page 75: Diagnosis. To reflect the Task Force of the National Kidney Foundation and the American Society of Nephrology recommendation for the immediate adoption of a new 2021 Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation, which has been refitted to estimate glomerular filtration rate without a race variable, the equation in sentence 1 has been revised to "Chronic Kidney Disease Epidemiology (CKD-EPI) Creatinine Equation (2021)." (Added October 2021)
Page 78: Chronic Kidney Disease; Complications and Management; Chronic Kidney Disease-Mineral and Bone Disorder; Calcium and Phosphorus Homeostasis: In the first sentence of the second paragraph, the phrase "osteocytes and osteoclasts." has been replaced with "various types of bone cells." (Added March 2020)
Page 78: Chronic Kidney Disease; Complications and Management; Chronic Kidney Disease-Mineral and Bone Disorder; Renal Osteodystrophy; Adynamic Bone Disease: In the second sentence of the first paragraph, the phrase "Histopathologic abnormalities include decreased osteoclast activity with an increase in osteoid" has been replaced with "Histopathologic abnormalities include decreased osteoclast activity without an increase in osteoid due to decreased osteoblast activity." (Added March 2020)
Page 83: Chronic Kidney Disease, End-Stage Kidney Disease, Kidney Transplantation, Referral. In the first sentence, the phrase “the eGFR is <20 mL/min/1.73 m2.” has been replaced with “the eGFR is <30 mL/min/1.73 m2.” (Added September 2019)
Page 85: Chronic Kidney Disease, End-Stage Kidney Disease, Kidney Transplantation, Referral. In the first Key Point, the phrase “the estimated glomerular filtration rate is <20 mL/min/1.73 m2.” has been replaced with “the estimated glomerular filtration rate is <30 mL/min/1.73 m2.” (Added October 2021)
Questions
Page 109, Item 74: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C 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 option A (Administer intravenous 0.9% saline) is also a correct answer for this patient if there is concern for impending sepsis. Therefore, options A and C are both correct. (Added October 2021)
Page 119, Item 2: In first sentence of the fourth paragraph of the critique, "because glucocorticoids would not be efficacious" has been replaced with "because glucocorticoid monotherapy would not be efficacious." (Added March 2020)
Page 122, Item 7: In the third sentence of the last paragraph of the critique, "156 mOsm/kg H2O" has been replaced with "263 mOsm/kg H2O." (Added March 2020)
Page 124, Item 12: In the seventh sentence of the first paragraph of the critique, "fractional excretion of sodium <1%," has been replaced with "a low urinary sodium." (Added October 2020)
Page 126, Item 16: In the third sentence of the first paragraph of the critique, "Aristolochia clematis" has been changed to "Aristolochia clematitis.” (Added September 2019)
Page 127, Item 17: In the fourth sentence of the first paragraph of the critique, the phrase "production of ADH by the posterior pituitary gland" has been replaced with "release of ADH from the pituitary gland." (Added March 2020)
Page 100, Item 37: 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.
In 2018, the FDA approved the use of tolvaptan in patients with autosomal dominant polycystic kidney disease who also met certain criteria indicating high risk of rapid progressive loss of kidney function and likely benefit of treatment. Therefore, option D is a possible correct answer. (Added March 2020)
Page 106, Item 61: 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 2017 American College of Cardiology/American Heart Association Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults, two or more antihypertensive medications are recommended to achieve a blood pressure (BP) target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension. Four classes of drugs are available (thiazide diuretic, calcium channel blocker [CCB], ACE inhibitor, or angiotensin receptor blocker [ARB]). Except for the combination of ACE inhibitors and ARBs, regimens containing any combination of these classes are reasonable to achieve the BP target. Furthermore, the combination of an ACE inhibitor or ARB with a CCB or thiazide diuretic produces similar BP lowering in blacks as in other racial or ethnic groups. Therefore, answers A and B are both correct. (Added March 2020)
Page 151, Item 66: In the critique, the second sentence of the third paragraph should read as follows: “It is usually associated with hypokalemia, which is not present in this patient.” The first sentence of the fourth paragraph should read as follows: “Type 2 (proximal) RTA results from failure of the proximal tubule to adequately reclaim filtered bicarbonate, driving the development of a normal anion gap metabolic acidosis; the urine anion gap is usually negative.” (Added September 2019)
Page 165, Item 95: In the second sentence of the first paragraph of the Critique, the phrase “the estimated glomerular filtration rate (eGFR) is <20 mL/min/1.73 m2.” has been replaced with “the estimated glomerular filtration rate (eGFR) is <30 mL/min/1.73 m2.” In the Key Point, the phrase “the estimated glomerular filtration rate is <20 mL/min/1.73 m2” has been replaced with “the estimated glomerular filtration rate is <30 mL/min/1.73 m2”. (Added September 2019)
Page 117, Item 107: 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 American College of Cardiology/American Heart Association recommend that adults not receiving hypertensive therapy with an elevated BP (120–129 mm Hg and <80 mm Hg) or stage 1 hypertension (130–139 mm Hg or 80–89 mm Hg) and who have an estimated 10-year ASCVD risk less than 10% should have a repeat BP evaluation within 3 to 6 months. Because of this, the answer to this question, B. Annual blood pressure screening, is incorrect for this patient. (Added March 2020)
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)
Page 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)
Questions
Page 102, Item 26: In the question stem, the fourth sentence of the second paragraph should read: "Biceps, triceps, and brachioradialis reflexes are increased on the right." (Added March 2021)
Page 125, Item 15: : In the last sentence of the last paragraph of the Critique, the phrase "but not" was replaced with "and rarely." The sentence should read: "The antibodies associated with these syndromes include anti-Hu, anti-LGI1 (voltage-gated potassium channel), anti-CRMP5 antibodies, and rarely the anti-NMDAR antibody." (Added October 2020)
Pulmonary and Critical Care Medicine
Lung Tumors
Page 47: Lung Tumors, Lung Cancer, Screening. The last two sentences of the paragraph have been revised to read: "The U.S. Preventive Services Task Force has recommended annual lung cancer screening using low-dose CT scan for those who are age 50 to 80 years, have at least a 20-pack-year smoking history, and are current smokers or have quit within the last 15 years. Screening should be discontinued for those who have not smoked for 15 years, those with limited life expectancy, and those who would not be candidates for or willing to undergo surgery."
The related Key Point has been changed to read: "The U.S. Preventive Services Task Force recommends annual lung cancer screening using low-dose CT scan for those who are age 50 to 80 years, have at least a 20-pack-year smoking history, and are either current smokers or have quit smoking within the last 15 years." (Added October 2021)
Sleep Medicine
Page 51: Sleep Medicine, Obstructive Sleep Apnea. The last sentence of the paragraph has been changed from "An AHI of 5/hour to 15/hour indicates mild OSA, 15/hour to 30/hour indicates moderate OSA, and more than 30/hour indicates severe OSA." to "An AHI of 5/hour to less than 15/hour indicates mild OSA, 15/hour to less than 30/hour indicates moderate OSA, and 30/hour or greater indicates severe OSA." (Added March 2020)
Common ICU Conditions
Page 73: Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure, Management of Hypercapnic Respiratory Failure, Decreased Tidal Volume and Increased Dead Space, Neuromuscular Weakness. The last sentence of the fifth paragraph has been changed from "Glucocorticoids have no benefit in Guillain-Barré syndrome, but are indicated in addition to cholinesterase inhibitors in myasthenic crisis." to "Glucocorticoids have no benefit in Guillain-Barré syndrome, but are indicated—in addition to plasma exchange or intravenous immune and cholinesterase inhibitors—in myasthenic crisis." (Added October 2020)
Page 73: Common ICU Conditions, Hypercapnic (Ventilatory) Respiratory Failure, Management of Hypercapnic Respiratory Failure, Obesity Hypoventilation Syndrome. The Key Point under Obesity Hypoventilation System should say “obesity hypoventilation syndrome” rather than “obesity hyperventilation syndrome.” (Added September 2019)
Questions
Page 95: Item 11: 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 the 2019 GINA guidelines classify this patient with symptoms for more than 2 days a week as having mild persistent asthma. The treatment for mild persistent asthma is to use a daily low-dose inhaled glucocorticoid and a short-acting beta agonist (SABA) as needed for relief of symptoms or daily with low dose inhaled glucocorticoid-LABA combination, with as-needed SABA . Therefore, options A and B are both correct. (Added March 2020)
Page 100: Item 33: In the first sentence of the first paragraph of the Critique the phrase "peripheral wide-bore central venous catheter" has been changed to "peripheral wide-bore catheter". In the first sentence of the last paragraph of the Critique, the phrase "peripheral wide-bore central venous catheter" has been changed to "peripheral wide-bore catheter". (Added March 2020)
Page 100, Item 34: 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 2018 guidelines from the Infectious Diseases Society of America recommend that during influenza season, clinicians should test for influenza in patients who present with acute onset of respiratory symptoms and either exacerbation of chronic medical conditions or known complications of influenza, if the testing result will influence clinical management. Therefore, options B and C are both correct. (Added October 2020)
Page 106: Item 60, Laboratory studies. The Lactate values should be “11 mEq/L (11 mmol/L)” rather than “11 mEqL/ (1.2 mmol/L)”. (Added September 2019)
Page 114, Item 98: 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 the Stem of the question does not include enough information to exclude early ethylene glycol or methanol intoxication. (Added March 2021)
Page 120, Item 9: The third sentence of the third paragraph of the critique has been changed to read as follows: "The U.S. Preventive Services Task Force does recommend annual screening for lung cancer with LDCT in adults age 50-80 years who have a 20-pack-year smoking history and currently smoke or have quit within the past 15 years." (Added October 2021)
Page 130, Item 28: The Educational Objective has been changed from "Evaluate a patient with upper-lobe emphysema and significant exercise limitations for lung volume reduction surgery." to "Evaluate a patient with heterogenous emphysema and significant exercise limitations for lung volume reduction surgery." In the first sentence of the first paragraph, "upper-lobe" has been changed to "heterogenous". The second to last sentence of the first paragraph was changed from "The National Emphysema Treatment Trial (NETT) demonstrated that carefully selected patients with upper-lobe predominant emphysema and significant exercise limitation despite participation in a pulmonary rehabilitation program had improved quality of life and survival with lung volume reduction surgery." to "The National Emphysema Treatment Trial (NETT) demonstrated that overall, lung-volume-reduction surgery increases the chance of improved exercise capacity but does not confer a survival advantage over medical therapy. It does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low base-line exercise capacity." The following sentence was added to the end of the first paragraph: "It is reasonable to evaluate this patient with heterogenous emphysema, poor exercise capacity, and reduced quality of life for lung volume reduction surgery." (Added October 2020)
Page 136, Item 41: In the second sentence of the first paragraph, "compensatory" has been changed to "complicating". (Added October 2020)
Page 147, Item 62: The second sentence of the critique has been revised to read as follows: "Patients recommended for screening are those aged 50 to 80 years with a greater than 20-pack-year history of tobacco use within the previous 15 years." The related Key Point has been changed to: "Patients recommended for lung cancer screening are those aged 50 to 80 years with a greater than 20-pack-year history of tobacco use within the previous 15 years." (Added October 2021)
Page 151: Item 70: In the second sentence of the first paragraph, the phrase "of 300" has been changed to "of less than 300". (Added March 2020)
Page 151, Item 71: The last sentence of the last paragraph has been changed from "Procalcitonin level has no evidence-based role in the management of sepsis in the hospital." to "Its use promotes lower usage of antibiotics, but mortality benefit is unproven." (Added October 2020)
Page 155, Item 78: In the first sentence of the critique, the words "and wheezing" have been removed. (Added March 2021)
Page 161, Item 90: In the third sentence of the first paragraph of the critique, the term "leukotriene receptor antagonists" has been changed to "leukotriene modifiers." In addition, the second paragraph of the critique has been revised to read as follows: "Treatment with a regular daily low-dose inhaled glucocorticoid and an as-needed short-acting β2-agonist (SABA) is highly effective in reducing asthma symptoms, severe exacerbations, hospitalization, and death. For patients with persistent symptoms and/or exacerbations despite use of a low-dose glucocorticoid and an as-needed SABA, the preferred step-up therapy is a combination low-dose inhaled glucocorticoid and long-acting β2 agonist such as fluticasone-salmeterol." (Added October 2021)
Rheumatology
Systemic Sclerosis
Page 53, Table 31: In the last section of the table ("Pulmonary arterial hypertension"), the drug class "soluble guanylate cyclase inhibitors" has been changed to "riociguat" (a soluble guanylate cyclase stimulator). (Added October 2020)
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 152, Item 93: In the first paragraph of the critique, the phrase "a photosensitive rash occurring especially on the arms, neck, upper trunk, and face" has been changed to "a photosensitive rash occurring especially on the arms, neck, and upper trunk, usually sparing the central face." (Added October 2020)
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)
Page 104, Item 80: The following sentence has been added to the end of the first paragraph of the critique: "Methotrexate is highly teratogenic and abortifacient; patients should be tested for pregnancy before initiation, and methotrexate must be discontinued at least 3 months before planned pregnancy." (Added October 2021)
Page 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
Cardiology
Item 29: 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 the ECG shows left ventricular hypertrophy in addition to intraventricular conduction delay. (Added March 2021)
Endocrinology and Metabolism
Item 8: The second paragraph of the critique has been revised to include updated information on appropriate thresholds and populations for treatment of subclinical hypothyroidism. (Added October 2021)
Gastroenterology and Hepatology
Item 28: 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 the first paragraph should state that the patient has "normal," not "elevated," liver enzyme levels. (Added October 2020)
Nephrology
Item 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)
Item 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)
Rheumatology
Item 24: In the last paragraph of the critique, the phrase "The rash...spares the face" has been changed to "...usually spares the central face." (Added October 2020)
Item 25: In the last paragraph of the critique, the phrase "photosensitive rash that usually spares the face" has been changed to "...usually spares the central face." (Added October 2020)
