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https://mksap.acponline.org/16/errata.html 2

(Updated November 2014)

Cardiovascular MedicineDermatologyEndocrinologyGastroenterology and HepatologyGeneral Internal MedicineHematology and Oncology

Infectious DiseaseNephrologyNeurologyPulmonology and Critical Care MedicineRheumatologyInvalidated QuestionsFootnotes

Cardiovascular Medicine

Page 13: Coronary Artery Disease, Risk Factors for Coronary Artery Disease, Established Risk Factors.See the ACC/AHA cholesterol management guideline summaries for more information. (Added June2014)

Page 13: Coronary Artery Disease, Risk Factors for Coronary Artery Disease, Established Risk Factors.See the JNC 8 guideline summary for more information. (Added June 2014)

Page 17: Coronary Artery Disease, Chronic Stable Angina, Medical Therapy, Cardiovascular-ProtectiveMedications. See the ACC/AHA cholesterol management guideline summaries for more information.(Added June 2014)

Page 19: Coronary Artery Disease, Chronic Stable Angina, Follow-up Care, After SurgicalRevascularization. See the ACC/AHA cholesterol management guideline summaries for moreinformation. (Added June 2014)

Page 22: Coronary Artery Disease, NonST-Elevation Myocardial Infarction and Unstable Angina,Medical Therapy, Lipid-Lowering Medications. See the ACC/AHA cholesterol management guidelinesummaries for more information. (Added June 2014)

Page 28: Coronary Artery Disease, ST-Elevation Myocardial Infarction, Long-Term Medical Therapy.See the ACC/AHA cholesterol management guideline summaries for more information. (Added June

2014)

Page 29: Coronary Artery Disease, Coronary Artery Disease in Patients with Diabetes Mellitus,Pharmacologic Treatment and Secondary Prevention. See the ACC/AHA cholesterol managementguideline summaries for more information. (Added June 2014)

Page 29: Coronary Artery Disease, Coronary Artery Disease in Patients with Diabetes Mellitus,Pharmacologic Treatment and Secondary Prevention. See the JNC 8 guideline summary for moreinformation. (Added June 2014)

Page 31: In Heart Failure, Diagnosis and Evaluation of Heart Failure, Clinical Evaluation, the credit line
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for Table 13 (Clinical Signs of Heart Failure) should read as follows: Adapted from Journal of CardiacFailure. 16(6). Heart Failure Society of America. Lindenfeld J, Albert NM, Boehmer JP, et al. HFSA2010 Comprehensive Heart Failure Practice Guideline. e1-e194. Copyright 2010, with permission fromElsevier. [PMID: 20610207]. Sensitivity and specificity data from Wang CS, FitzGerald JM, Schulzer MMak E, Ayas NT. Does this dyspneic patient in the emergency department have congestive heart failure?JAMA. 2005294(15):1944-56. [PMID: 16234501]. (Added January 2013)

Page 38: In Heart Failure, Inpatient Management of Heart Failure, Acute Decompensated Heart Failure,

in the first sentence of the last paragraph, the words "or hypovolemic" should be deleted. The sentenceshould read as follows: "Two vasopressin antagonists are used to treat euvolemic hyponatremia..."Vasopressin antagonists may be used for treatment of euvolemic hyponatremia but are contraindicated in

patients with hypovolemic hyponatremia. (Added June 2014)

Page 70, left column, first paragraph: In the last sentence, the phrase "because a compensatory increase inheart rate is expected" should be deleted. The sentence should read: "Rate response in atrial fibrillationshould be controlled with conventional medications, but bradycardia should be avoided." (AddedJanuary 2013)

Page 89, right column, bottom of the page: In the first sentence of the last paragraph, "CMR imaging"

should be "MRI." (Added January 2013)

Page 99: Peripheral Arterial Disease, Medical Therapy, Cardiovascular Risk Reduction. See theACC/AHA cholesterol management guideline summaries for more information. (Added June 2014)

Page 99: Peripheral Arterial Disease, Medical Therapy, Cardiovascular Risk Reduction. See the JNC 8guideline summary for more information. (Added June 2014)

Page 119: Item 2. This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer A to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOC

submission. See the ACC/AHA cholesterol management guideline summaries for more information.(Added June 2014)

Page 120: Item 5. See the ACC/AHA cholesterol management guideline summaries for moreinformation. (Added June 2014)

Page 120: Item 5. See the JNC 8 guideline summary for more information. (Added June 2014)

Page 123, Item 12: This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer C to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOC

submission. Although the published correct answer C, start eplerenone, is the most appropriate choiceamong the options listed, it may not be the best first treatment option for the patient described in thisitem. Although the efficacy of eplerenone is substantiated by the results of the EPHESUS trial cited inthe critique, the educational objective of the question was to emphasize the benefit of aldosteroneantagonist therapy in specific patients with heart failure or other comorbidities. Eplerenones benefits assupported by the study may be offset by this agents high cost spironolactone is an acceptable alternativethat could have been used initially in this patient before another aldosterone antagonist such aseplerenone was tried.

In addition, a Cardiovascular Medicine committee member disclosed a relationship with themanufacturer of the agent eplerenone (Pfizer) as part of MKSAPs conflict of interest disclosure policy.
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After further postpublication review of MKSAP, the Editors determined that, although the question istechnically correct as written, invalidation of item 12 was necessary in our efforts to provide evidence-

based medical education without the appearance of bias that models appropriate care and is in alignmentwith ACPs emphasis on high-value care. (Added September 2013)




Page 150: Item 103. This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer C to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOCsubmission. See the ACC/AHA cholesterol management guideline summaries for more information.(Added June 2014)

Page 161, Item 11: In the first line of the critique, diastolic heart failure should be changed tosystolic heart failure: "This patient has decompensated systolic heart failure..." (Added November 2014)

Page 211, Item 114: The last sentence of the first paragraph of the critique should read: "In a normalstudy without an intracardiac shunt, the bubbles produced in an agitated saline contrast study dissipate inthe pulmonary microcirculation and do not opacify the left ventricle." (Added April 2013)

Dermatology

Page 9, Figure 13: The figure legend should be changed to read: "Atopic dermatitis of the popliteal fossademonstrating characteristic erosions, crusting, and lichenification the antecubital fossa may also beinvolved." (Added April 2013)

Page 13: In Pityriasis Rosea, the following should be added after the third sentence: "Trailing scale refersto an area of scaling that follows an advancing border or rash, usually associated with annular lesionssuch as pityriasis or erythema annulare centrifugum." (Added April 2013)

Page 25: In the second paragraph of the Cellulitis and Erysipelas section, the first sentence should read:"In contrast to cellulitis which involves the deeper layers of the skin (lower dermis, subcutaneous fat, and

other structures), erysipelas refers to an infection of the upper dermis and superficial lymphatics."Similarly, the second key point on that page should also be changed. (Added September 2013)

Page 38, Figure 72: The figure legend should be changed to read: "Acral melanomas are found on thepalms, soles, and on subungual surfaces typically presenting as black or dark brown irregularlypigmented macules or patches." (Added April 2013)

Pages 45-46: The fourth sentence in Autoimmune Bullous Diseases should read: "Several autoimmunebullousdiseases can be associated with systemic disease, including malignancy, and their presence maynecessitate further medical evaluation." (Added April 2013)
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Page 60, The fourth bullet in Diabetes Mellitus: "Scleroderma" should be "Scleredema." (Added April2013)

Page 66: In Androgenetic Alopecia, the following sentences should be added at the end of the paragraph:"Finasteride is contraindicated (FDA category X) in pregnant women because it is known to cause birthdefects in the male fetus. Women who are or may potentially be pregnant should not take finasteride andshould avoid contact with crushed or broken tablets because it can be absorbed through the skin."(Added April 2013)

Page 69: In Onychomycosis, delete the reference to Figure 116 and insert the following: "However,onychomycosis may be difficult to differentiate from other nail disorders such as onycholysis andonychodystrophy that may be seen with systemic diseases (Figure 116)." (Added April 2013)

Page 69, Figure 116. The figure legend should be changed to read: "This patient with psoriatic arthritishas onycholysis and onychodystrophy and is clinically difficult to distinguish from onychomycosiscaused by a fungal infection. Before treatment of onychomycosis is instituted, it is important to confirmthe diagnosis by potassium hydroxide (KOH) examination of the nail, a fungal culture, or by histologicexamination of the nail clippings." (Added April 2013)

Page 104, Item 72: Option C should read "Treat with high-potency topical corticosteroid." (Added April2013)

Endocrinology and Metabolism

Page 5, Management of Diabetes, Glycemic Monitoring: The third column of Table 6 inadvertentlylisted incorrect values. The correct values in mmol/L are as follow: 5.4, 7.0, 8.5, 10.2, 11.8, 13.3, 14.9,and 16.5. This table has been corrected in the online version of MKSAP 16. (Added November 2014)

Page 6, Diabetes Mellitus, Management of Diabetes, Cardiovascular Risk: Number 8 in the list appearingafter the first paragraph (left hand column) and sentence five of the paragraph beginning after thenumbered list (lines 12 through 18 of the second column). See the ACC/AHA cholesterol managementguideline summaries for more information. (Added June 2014)

Page 6, Diabetes Mellitus, Management of Diabetes, Cardiovascular Risk: Number 9 on the listappearing after the first paragraph (left hand column) and last paragraph of the section (right-handcolumn). See the JNC 8 guideline summary for more information. (Added June 2014)

Page 11: In Inpatient Management of Hyperglycemia and Diabetes, the last sentence of the firstparagraph should be changed from "For these reasons, measurement of plasma glucose and hemoglobin

A1clevels should be routine when most adults are admitted" to "For these reasons, hospital admission

provides a good opportunity to screen for the presence of diabetes through measurement of plasmaglucose and hemoglobin A1clevels. However, the benefits of this screening are likely greatest in patients

with specific risk factors. For example, the United States Preventive Services Task Force (USPSTF)concludes that screening for diabetes in adults with sustained blood pressure greater than 135/80 mm Hghas benefit but that no clear evidence of benefit exists when blood pressures are 135/80 mm Hg or less.Similarly, the ADA, on the basis of expert opinion, recommends consideration of screening patients forimpaired fasting glucose, impaired glucose tolerance, or diabetes in persons age 45 years or older,

particularly those with a body mass index of 25 or greater this organization also states that diabetesscreening should be considered in persons younger than 45 years who are overweight if they have
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another risk factor for diabetes, including inactivity, family history of type 2 diabetes, membership in ahigh-risk ethnic group, gestational diabetes, hypertension, dyslipidemia, impaired fasting glucose,impaired glucose tolerance, or a history of vascular disease." (Added April 2013)

Page 11: In the first sentence, fourth paragraph, and first Key Point of Inpatient Management ofHyperglycemia and Diabetes, the recommended plasma glucose range for critically ill hospitalized

patients with hyperglycemia should be changed, according to American College of Physicians guidelinesfrom 140 to 180 mg/dL (7.8-10.0 mmol/L) to 140 to 200 mg/dL (7.8-11.1 mmol/L). Similarly, the second

sentence of the same paragraph about the consensus statement by the American Diabetes Association andthe American Association of Clinical Endocrinologists (that recommends maintaining fasting and

premeal glucose levels of less than 140 mg/dL [7.8 mmol/L] but no lower than 90 mg/dL [5.0 mmol/L]and random or postprandial levels of less than 180 mg/dL [10.0 mmol/L] in noncritically ill hospitalized

patients) should have been followed by the statement: "However, the American College of Physiciansrecommends not using intensive insulin therapy to strictly control blood glucose levels in noncritically illhospitalized patients with or without diabetes mellitus, noting that avoiding targets less than 140 mg/dL(7.8 mmol/L) should be a priority because harms are likely to increase at lower blood glucose targets."The second Key Point at the end of this section should also have been followed by this clarification.(Added April 2013)

Page 11: The last sentence of the last paragraph of the Inpatient Management of Hyperglycemia andDiabetes section should read: "For patients who are more critically ill or whose blood glucose levelcannot be maintained in target range with subcutaneous insulin, an intravenous insulin (not glucose)infusion, which allows much more rapid adjustments, should be considered..." (Added September 2013)

Page 24: In Disorders of the Pituitary Gland, Hyperprolactinemia and Prolactinomas, Clinical Featuresand Therapy of Hyperprolactinemia and Prolactinomas, the end of second key point should read "andwhose tumor is no longer visible" (not "or whose tumor is no longer visible"). (Added June 2014)

Page 36: In Structural Disorders of the Thyroid Gland, Thyroid Nodules, the first sentence of the thirdfull paragraph in the right-hand column should be replaced with the following: "Patients with nodules

greater than 4 cm who have associated worrisome historical findings (such as a history of externalradiation to the neck), clinical findings (such as abnormal cervical lymphadenopathy or hoarseness), orradiologic features (see Table 20) but benign results of FNA biopsy can be considered forthyroidectomy." (Added April 2013)

Page 41: In the third sentence of the first paragraph of Description, Causes, and Diagnosis of AdrenalInsufficiency, the word "diminished" should precede the abbreviation "ACTH" ("In contrast, centraladrenal insufficiency is caused either by diminished ACTH secretion...") (Added April 2013)

Page 45, Disorders of the Adrenal Glands, Cushing syndrome: In the last sentence on this page (fifthparagraph of section), the phrase "Using a CRH plus desmopressin stimulation test" is incorrect andshould be replaced with the phrase "Adding CRH to a low-dose dexamethasone suppression test" foraccuracy. (Added June 2014)

Page 89, Item 39: In the table of laboratory values, the seventh line on this page listing "Cortisol, random(1 PM) 2.5 g/dL" should have included the normal range this line is now replaced with "Cortisol,random (1 PM) 2.5 g/dL (normal, > 3 g/dL [83 nmol/L])" to be clearer. Additionally, the fourthsentence of the critique for this item ("Although the random serum cortisol level..."), which appears on

page 119, should be replaced by "The random serum cortisol level is inappropriately low for the degreeof hypotension experienced by this patientespecially because hypotension is a strong stimulus forACTH and cortisol release. Any serum cortisol level (random or 8:00 AM) of 3 g/dL (83 nmol/L) or
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less is suggestive of adrenal insufficiency, and no ACTH stimulation test is required for diagnosis. In thissetting, if the ACTH level is greater than 100 pg/mL (22 pmol/L), then the diagnosis is primary adrenalinsufficiency. A random serum cortisol of greater than 17 g/dL (469 nmol/L) essentially rules out thediagnosis of adrenal insufficiency, and a level this elevated would be expected with the degree ofhypotension in this patient." (Added June 2014)

Page 90, item 45 (see also page 122 for critique). See the ACC/AHA cholesterol management guidelinesummaries for more information. (Added June 2014)

Page 93, Item 56: In the last line of the left-hand column of this page (second sentence of the question),the phrase "moderate fatigue" should be replaced with the phrase "occasional tiredness." (Added June2014)

Page 135, Item 75: In the first sentence of the second paragraph at the top of the right-hand column(fourth paragraph of the critique), the word "hypocalcemia" should be replaced by "hypomagnesemia."(Added June 2014)

Page 135, Item 76: The last word of the critique for this item should be "hyperglycemia" not"hypoglycemia." (Added June 2014)

Gastroenterology and Hepatology

Page 38, fourth sentence under Health Care Maintenance for the Patient with Inflammatory BowelDisease should read: "Immunosuppressed patients should receive influenza vaccination every year and

pneumococcal vaccination as recommended by the Advisory Committee on Immunization Practices(ACIP)."

In October 2012, the Advisory Committee on Immunization Practices (ACIP) updated recommendationsfor pneumococcal vaccination in patients with immunocompromising conditions, anatomic or functionalasplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants. Immunocompromising conditions aredefined as follows: congenital or acquired immunodeficiency, HIV infection, chronic kidney disease, thenephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenicimmunosuppression (such as long-term corticosteroid therapy), solid organ transplant, and multiplemyeloma. For adults 19 years of age with an immunocompromising condition, functional asplenia, aCSF leak, or cochlear implants who have never received any pneumococcal vaccination, an initial doseof 13-valent pneumococcal conjugate vaccine (PCV-13) should be given, followed by a first dose of 23-valent pneumococcal polysaccharide vaccine (PPSV-23) at least 8 weeks later. A single, second dose ofPPSV-23 should be given 5 years after the first PPSV-23 vaccination in those with anatomic orfunctional asplenia or with an immunocompromising condition. For adults 19 years of age with

immunocompromising conditions, anatomic or functional asplenia, CSF leaks, or cochlear implants whohave previously received at least one dose of PPSV-23, a single PCV-13 dose should be given 1 yearafter their last PPSV-23 immunization. All patients who have ever received a PPSV-23 vaccinationshould receive another dose of PPSV-23 at age 65 years, or later if at least 5 years have elapsed sincetheir last PPSV-23 dose. (Added April 2013)

Page 59, third paragraph under Wilson Disease: The second-to-last sentence should read, "Kayser-Fleischer rings, noted on ophthalmologic examination, indicate copper deposition in the Descemetmembrane of the cornea." (Added June 2014)

Page 63, Table 32, second row, second column: The starting dose of nadolol should be 40 mg orally once
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a day (rather than twice a day). (Added June 2014)

Page 69, third sentence under Immunizations should read: "Pneumococcal vaccination should be givenaccording to the recommendations of the Advisory Committee on Immunization Practices (ACIP) forimmunosuppressed patients, and tetanus toxoid should be given every 10 years." See new informationabove clarifying the use of pneumococcal vaccination in patients with immunocompromising conditions.(Added April 2013)

Page 117, Item 15: In the first paragraph of the critique, the second-to-last sentence should read: "Thus,predominant heartburn or regurgitation symptoms should be categorized as GERD rather thandyspepsia." (Added January 2013)

Page 123, Item 30, second paragraph of critique, third sentence: See new informationabove clarifyingthe use of pneumococcal vaccination in patients with immunocompromising conditions. (Added April2013)

Page 124, critique of Item 32: The first paragraph of the critique should read: "In this patient withchronic hepatitis C virus (HCV) infection and advanced fibrosis, antiviral therapy is indicated. ChronicHCV infection is often progressive and may result in cirrhosis and hepatocellular carcinoma. The goal ofHCV treatment is sustained virologic response (SVR), defined as loss of HCV RNA 6 months aftercompletion. SVR results in improved patient outcomes, including a decrease in all-cause mortality.Patients with cirrhosis are less likely to achieve SVR than those without cirrhosis. The treatment of HCVis evolving rapidly. New oral direct-acting antiviral combinations are likely to be approved in 2014 bythe FDA and will result in a decrease in the use of peginterferon." The Key Point should read: "Thetreatment of hepatitis C is evolving rapidly new oral direct-acting antiviral combinations are likely to beapproved by the FDA and will result in a decrease in the use of peginterferon." (Added November 2014)

General Internal Medicine

Page 5, Table 3: In the "Positive likelihood ratio (LR+)" row, the entry in the "Definition" columnshould be changed to read: "The likelihood that a positive test result would be expected in a patient withthe disease compared with the likelihood that a positive test result would be expected in a patient withouta disease." (Added November 2014)

Page 8: Routine Care of the Healthy Patient, Screening, Specific Screening Tests. See the ACC/AHAcholesterol management guideline summaries for more information. (Added June 2014)

Page 14, Pneumococcal Disease (text and Table 8 ): The following new information clarifies the use of

pneumococcal vaccination in patients with immunocompromising conditions.

In October 2012, the Advisory Committee on Immunization Practices (ACIP) updated recommendationsfor pneumococcal vaccination in patients with immunocompromising conditions, anatomic or functionalasplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants. Immunocompromising conditions aredefined as follows: congenital or acquired immunodeficiency, HIV infection, chronic kidney disease, thenephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenicimmunosuppression (such as long-term corticosteroid therapy), solid organ transplant, and multiplemyeloma. For adults 19 years of age with an immunocompromising condition, functional asplenia, aCSF leak, or cochlear implants who have never received any pneumococcal vaccination, an initial doseof 13-valent pneumococcal conjugate vaccine (PCV-13) should be given, followed by a first dose of 23-
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valent pneumococcal polysaccharide vaccine (PPSV-23) at least 8 weeks later. A single, second dose ofPPSV-23 should be given 5 years after the first PPSV-23 vaccination in those with anatomic orfunctional asplenia or with an immunocompromising condition. For adults 19 years of age withimmunocompromising conditions, anatomic or functional asplenia, CSF leaks, or cochlear implants whohave previously received at least one dose of PPSV-23, a single PCV-13 dose should be given 1 yearafter their last PPSV-23 immunization. All patients who have ever received a PPSV-23 vaccinationshould receive another dose of PPSV-23 at age 65 years, or later if at least 5 years have elapsed sincetheir last PPSV-23 dose. (Added April 2013)

Page 14: In Table 8, Indications for Pneumococcal Polysaccharide Vaccination in Adults 19 to 64 Yearsof Age, under specific indications for immunocompetent patients, "chronic cardiovascular disease(including hypertension)" should be changed to "chronic cardiovascular disease (including heart failureand cardiomyopathies, excluding hypertension)." (Added June 2014)

Page 47, top of first column: The last sentence of the section "Diagnostic Evaluation of Syncope" shouldbe deleted, and replaced with new text.

The sentence that is deleted is as follows: "Tilt-table testing should be reserved for patients withsuspected neurocardiogenic syncope not confirmed by history and physical examination, for those with

recurrent syncopal episodes, and for patients suspected of having arrhythmogenic syncope or who have ahigh risk profile for cardiovascular events in whom previous testing has not been revealing."

The new text that is inserted is as follows: "Tilt-table testing should be reserved for patients withrecurrent episodes of syncope in the absence of known heart disease or in patients with documented heartdisease in whom a cardiac cause has been excluded. Tilt-table testing may also have a role in evaluating

patients in whom documenting neurocardiogenic syncope is important (such as in high-risk occupationalsettings), and differentiating the cause of syncope from neurologic (such as seizure) or psychiatricetiologies." (Added April 2013)

Page 62: Dyslipidemia, Screening. See the ACC/AHA cholesterol management guideline summaries for

more information. (Added June 2014)

Page 62: Dyslipidemia, Evaluation of Lipid Levels, LDL cholesterol. See the ACC/AHA cholesterolmanagement guideline summaries for more information. (Added June 2014)

Page 63: Table 24. See the ACC/AHA cholesterol management guideline summaries for moreinformation. (Added June 2014)

Page 63: Table 25. See the ACC/AHA cholesterol management guideline summaries for moreinformation. (Added June 2014)

Page 64: Dyslipidemia, Management of Dyslipidemias, Therapeutic Lifestyle Changes. See theACC/AHA cholesterol management guideline summaries for more information. (Added June 2014)

Page 64: Dyslipidemia, Management of Dyslipidemias, Drug Therapy. See the ACC/AHA cholesterolmanagement guideline summaries for more information. (Added June 2014)

Page 65, first column, sixth line of text: The following sentence should be inserted after the sentenceending "... with multiple medications": "However, because warfarin is also metabolized by CYP2C9,

both fluvastatin and rosuvastatin have been associated with increases in the INR in warfarin-treatedpatients concurrent use of either of these medications with warfarin should be avoided or monitoredclosely." (Added April 2013)
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Page 66: In Dyslipidemia, Management of Dyslipidemias, Management of Hypertriglyceridemia, theeffects of fibrate therapy on LDL cholesterol levels has been clarified. The 5th and 6th sentences of the

paragraph should read: "Fibrates are also effective for reducing triglycerides and increasing HDLcholesterol levels (changes of 40%-60% and 15%-25%, respectively), but in persons with familialhypertriglyceridemia, they can raise LDL cholesterol levels by up to 30%. Thus, fibrate monotherapymay be ineffective in these patients for achieving non-HDL cholesterol goals." Additionally, in Table 26(page 65), in the Fibrates row, the entry in the second column should read "LDL cholesterol 5%-20%( in some patients with elevated TGs) . . . " and the entry in the fourth column should read "Most

effective agents for reducing TGs, but may raise LDL cholesterol in patients with familialhypertriglyceridemia. . . . " (Added June 2014)

Page 67: Dyslipidemia, Metabolic Syndrome, Epidemiology and Pathophysiology. See the ACC/AHAcholesterol management guideline summaries for more information. (Added June 2014)

Page 67: Dyslipidemia, Metabolic Syndrome, Management of Metabolic Syndrome. See the ACC/AHAcholesterol management guideline summaries for more information. (Added June 2014)

Page 69: Dyslipidemia, Dyslipidemia Management and Stroke Prevention. See the ACC/AHAcholesterol management guideline summaries for more information. (Added June 2014)

Page 86: In Intrauterine Devices, in the last sentence of the paragraph, "within 7 days" should be changedto "within 5 days." (Added April 2013)

Page 89, first column, Nonhormonal Therapy: The following sentence should be added after the 2ndsentence of the paragraph: "Different antidepressant agents appear to have variable efficacy for this use:Venlafaxine, desvenlafaxine, and paroxetine have been demonstrated to be effective in some women incontrast, few studies have shown efficacy with fluoxetine, sertraline, or citalopram." (Added April 2013)

Page 143, Item 2: In the first sentence, "left hand" should be "right hand." (Added January 2013)

Page 144, Item 7: This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer D to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOCsubmission.

Because the patient was not specifically noted to have had an erythrocyte sedimentation rate (ESR)performed as part of her prior laboratory studies, and obtaining an ESR is reasonable to assess for thepresence of an active inflammatory process as the cause of chronic fatigue, this option would bepotentially correct. (Added April 2013)

Page 148, Item 26: In the second paragraph of the stem, the phrase "left arm" should be replacedwith the phrase "right arm." (Added November 2014)

Page 152: Item 41. This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer C to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOCsubmission. See the ACC/AHA cholesterol management guideline summaries for more information.(Added June 2014)

Page 153, Item 47: The lead-in question should be changed from "Which of the following should berecommended before surgery?" to "Which of the following interventions is most likely to reduce this
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patient's risk of perioperative pulmonary complications?" (Added September 2013)



Page 159, Item 74: See new informationabove clarifying the use of pneumococcal vaccination inpatients with immunocompromising conditions. (Added April 2013)



Page 175, Item 148: At the end of the first paragraph of the stem, the sentence "Her only medication istiotropium" should be changed to "She is on no medications." (Added April 2013)

Page 235, Item 118: In the first paragraph of the critique, the link for accessing the "Am I a SafeDriver" self-assessment tool is outdated. The fifth sentence should be replaced with the followingsentence: "A more complete set of questions to assess driving risk can be found in the 'Am I a SafeDriver' self-assessment tool, available in thePhysician's Guide to Assessing and Counseling Older

Drivers, 2nd Edition (http://geriatricscareonline.org/ProductAbstract/physicians-guide-to-assessing-and-counseling-older-drivers/B013)." (Added November 2014)

Hematology and Oncology

Page 17, fourth paragraph in Waldenstrm Macroglobulinemia: The first sentence should be changedfrom "Diagnosis requires demonstration of lymphoplasmacytic lymphoma comprising 10% or more ofthe bone marrow cellularity and the presence of an IgM M protein" to "Diagnosis requires demonstrationof lymphoplasmacytic lymphoma (a neoplastic infiltrate consisting of lymphocytes, plasmacytoidlymphocytes, plasma cells, and immunoblasts)comprising 10% or more of the bone marrow cellularityand the presence of an IgM M protein." (Added January 2013)

Page 28, The first sentence of the first full paragraph should read: "The deletion of three genes (--/-)leads to hemoglobin H (4) disease, which may be associated with severe anemia and clinical sequelae,

including heart failure and hypoxia, and is identifiable on hemoglobin electrophoresis." (Added January2013)

Page 35, the third sentence in first paragraph in Other Causes of Hemolysis should read: "Babesiosis mayalso lead to severe hemolytic anemia in patients with previous splenectomy or functional asplenia andshould be suspected in patients with hemolysis after recent travel to high-incidence areas, such as statesin the northeast United States (including Nantucket Island and Cape Cod), and the upper midwesternstates." (Added September 2013)

Page 69, Table 37: The last row of the table was incorrect it has been split into two rows andrevised to reflect the following: Imatinib and Gefitinib are both tyrosine kinase inhibitors, but only
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gefitinib targets epidermal growth factor receptor. Imatinib targetsBCR-ABLin chronic myeloidleukemia and k-KITin gastrointestinal stromal tumors. (Added November 2014)

Page 72, right-hand column, the third full paragraph, first sentence ANDpage 219, Item 142, fifthsentence of critique should read: "Postmenopausal women with hormone receptorpositive breast cancershould take a 5-year course of an aromatase inhibitor as primary treatment or for an additional 5 yearsafter completing a 5-year course of tamoxifen therapy. In women who are initially treated withtamoxifen, an aromatase inhibitor may be started following 2 to 3 years of tamoxifen therapy to complete

a total of 5 years of hormonal therapy." (Added January 2013)

Page 125, Item 24: Answer option C should read: "Initiate low-molecular-weight heparin and increasewarfarin to 6 mg/d" (Added June 2014)

Page 160, Item 3: In the sentence "Although fresh frozen plasma (FFP) is the main blood componentcontaining anti-IgA antibodies, erythrocytes and platelet products also contain...," the words "containinganti-IgA antibodies..." should read "containing IgA...." (Added April 2013)

Page 171, Item 28: The second sentence of critique should read: "This patient has cobalamin deficiencyas evidenced by elevations in homocysteine and methylmalonic acid, with a typical peripheral blood

smear." (Added January 2013)

Page 172, Item 31: In the first paragraph of the critique, regarding the Mentzer index, "fluid liters"should be changed to "femtoliters." (Added November 2014)

Page 180, Item 48: In the last paragraph of the critique, the inheritance pattern of protein Cdeficiency is inaccurately described. The first sentence of this paragraph should be replaced by thefollowing: "Both antithrombin deficiency and protein C deficiency are inherited in an autosomaldominant pattern." (Added November 2014)

Page 186, Item 62: In the first paragraph of the critique, listing the criteria for diagnosis of acutechest syndrome in sickle cell disease patients: "temperature less than 38.5 C (101.3 F)" should bechanged to "temperature greater than or equal to 38.5 C (101.3 F)." (Added November 2014)

Page 186, Item 62: The first sentence of third paragraph should read: "Furosemide may be helpful inthose patients who are hypervolemic, but there is no clinical evidence to support this diagnosis in this

patient." (Added January 2013)

Page 189, Item 69: The following sentence was deleted from the 4th paragraph of the critique:

"Teratomas may be evident on plain chest radiograph or CT scan." The sentence is factually correct, butmay be confusing in the context of the question. (Added November 2014)

Page 208, Item 114: This question has been invalidated. The correct answer is B, not C as it appears inprint. 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. (Added January 2013modified June 2014)

Page 212, Item 124: In the last sentence of the first paragraph of the critique, cefepime is afourth-generation, not a third-generation, cephalosporin. (Added September 2013)
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Page 213, Item 127: The second sentence of the second paragraph of the critique should bechanged. Radiation is not recommended for patients with early-stage bladder cancer that does not invadethe muscle (original version stated "does not invade the bladder"). (Added November 2014)

Infectious Disease

Page 7: In the left-hand column, third paragraph, the sentence "For abscesses in the early cerebritis stage(that is, the earliest stage of purulent brain infection when there is little or no enhancement onneuroimaging) or when all the abscesses are smaller than 2.5 cm, the largest lesion should be aspiratedfor diagnosis and microbiologic identification" should be replaced with the following sentences:"Diagnosis is more challenging in the early cerebritis stage (that is, the earliest stage of purulent braininfection when there is little or no enhancement on neuroimaging). If multiple focal lesions developmeasuring less than 2.5 cm in an area of suspected infection, the largest lesion present should beaspirated for diagnosis and microbiological identification." (Added April 2013)

Page 56: In the first paragraph, the sentence "Conjugate vaccines are preferred to polysaccharidevaccines in these patients" should be deleted. The following new information clarifies the use of

pneumococcal vaccination in patients with immunocompromising conditions.

In October 2012, the Advisory Committee on Immunization Practices (ACIP) updated recommendationsfor pneumococcal vaccination in patients with immunocompromising conditions, anatomic or functionalasplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants. Immunocompromising conditions aredefined as follows: congenital or acquired immunodeficiency, HIV infection, chronic kidney disease, thenephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenicimmunosuppression (such as long-term corticosteroid therapy), solid organ transplant, and multiplemyeloma. For adults 19 years of age with an immunocompromising condition, functional asplenia, aCSF leak, or cochlear implants who have never received any pneumococcal vaccination, an initial doseof 13-valent pneumococcal conjugate vaccine (PCV-13) should be given, followed by a first dose of 23-valent pneumococcal polysaccharide vaccine (PPSV-23) at least 8 weeks later. A single, second dose ofPPSV-23 should be given 5 years after the first PPSV-23 vaccination in those with anatomic orfunctional asplenia or with an immunocompromising condition. For adults 19 years of age withimmunocompromising conditions, anatomic or functional asplenia, CSF leaks, or cochlear implants whohave previously received at least one dose of PPSV-23, a single PCV-13 dose should be given 1 yearafter their last PPSV-23 immunization. All patients who have ever received a PPSV-23 vaccinationshould receive another dose of PPSV-23 at age 65 years, or later if at least 5 years have elapsed sincetheir last PPSV-23 dose. (Added April 2013)

Page 81: After the last sentence of the Treatment section, the following sentence defining antibiotic lock

therapy was added: "Antibiotic lock therapy involves the instillation of a highly concentrated antibioticsolution into an intravenous catheter to facilitate sterilization in order to treat a catheter-related bloodstream infection." (Added April 2013)

Page 88: In the first paragraph under Immunizations and Prophylaxis for Opportunistic Infections, theword "polysaccharide" should be deleted. See new informationabove clarifying the use of pneumococcalvaccination in patients with immunocompromising conditions. (Added April 2013)

Page 124, Item 53: The sentence "A radiograph of the left foot reveals soft tissue swelling with erosionof the cortex at the head of the metatarsal bone beneath the site of the ulceration" was changed to "Aradiograph of the left foot indicates no subcutaneous gas or foreign bodies." (Added April 2013)
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Page 132, Item 86: The first sentence of the question should read: "A 25-year-old woman undergoesfollow-up evaluation of an episode of anaphylaxis that occurred 3 weeks ago following a transfusion of

packed red blood cells after trauma resulting from a motor vehicle collision." (Added January 2013)

Page 152, Item 29: The second sentence of the last paragraph of the critique is incorrect. It shouldread, "In addition, reactive arthritis tends to present as an asymmetric oligoarthritis, and this patient'sarthritis is monoarticular." (Added November 2014)

Page 180, Item 92: The second sentence of the first paragraph of the critique should state that thepre-engraftment phase is 30 days. (Added November 2014)

Page 134, Item 97: This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Specifically, both options (A) avoidance of tap water and (E)

prophylactic rifaximin could be construed as correct. As stated in the critique, although the avoidance oftap water has been shown to confer only a mild benefit, this practice continues to be recommended fortravelers by the Centers for Disease Control and Prevention. Therefore, this could be considered a correctoption. 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. (Added April 2013)

Page 180, Item 92. The last sentence of the first paragraph of the critique should be changed to "Thisemphasizes the need for diligent administration of pneumococcal vaccines in solid organ transplant

patients who are by definition considered to have an immunocompromising condition." See newinformationabove clarifying the use of pneumococcal vaccination in patients with immunocompromisingconditions. (Added April 2013)

Page 186, Item 106: The second paragraph of the critique of item 106 was changed to the following:"Although continuous antibiotic prophylaxis is a treatment option, in women with recurrent urinary tractinfections temporally related to sexual intercourse, postcoital prophylaxis is generally the preferredapproach because of patient convenience, a decreased overall exposure to antibiotics, and a lower risk ofdevelopment of antimicrobial resistance." (Added April 2013)

Nephrology

Page 3, Table 2: Under the Considerations column of the Chronic Kidney Disease Epidemiology (CKD-

EPI) Collaboration Study Equation section, the eGFR should be >60 mL/min/1.73 m2not


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Page 17, Hypernatremia: The second sentence of the first paragraph states "Therapy is then directedtoward correcting the hyponatremia based on estimating the water deficit..." This sentence should read"Therapy is then directed toward correcting the hypernatremia based on estimating the water deficit..."(Added January 2013)

Page 39: Essential Hypertension, Management, Blood Pressure Goals. See the JNC 8 guideline summaryfor more information. (Added June 2014)

Page 39: Essential Hypertension, Management, Choosing an Antihypertensive Agent. See the JNC 8guideline summary for more information. (Added June 2014)

Page 39: Essential Hypertension, Management, Combination Therapy. See the JNC 8 guideline summaryfor more information. (Added June 2014)

Page 41: Secondary Hypertension, Kidney Disease, Management. See the JNC 8 guideline summary formore information. (Added June 2014)

Page 43: Special Populations, Patients with Diabetes Mellitus. See the JNC 8 guideline summary formore information. (Added June 2014)

Page 43: Special Populations, Black Patients. See the JNC 8 guideline summary for more information.(Added June 2014)

Page 43: Special Populations, Older Patients. See the JNC 8 guideline summary for more information.(Added June 2014)

Page 54: Conditions that Cause the Nephrotic Syndrome, Systemic Diseases that Cause the NephroticSyndrome, Diabetic Nephropathy, Management. See the JNC 8 guideline summary for more information(Added June 2014)

Page 63: Kidney Cystic Disorders, Clinical Manifestations and Management. See the JNC 8 guidelinesummary for more information. (Added June 2014)

Page 70, Pigment Nephropathy: In the fourth paragraph of this section, the callout for Figure 18 has beendeleted. (Added April 2013)

Page 78: Hypertensive Disorders Associated with Pregnancy, Chronic Hypertension. See the JNC 8guideline summary for more information. (Added June 2014)

Page 79:Hypertensive Disorders Associated with Pregnancy, Preeclampsia, Prevention and Treatment.See the JNC 8 guideline summary for more information. (Added June 2014)

Page 83: Prevention of Progression, Hypertension. See the JNC 8 guideline summary for moreinformation. (Added June 2014)

Page 85: Prevention of Progression, Proteinuria. See the JNC 8 guideline summary for more information(Added June 2014)

Page 90, Special Considerations, Vaccination: In the second paragraph of this section, the phrase "and at5-year intervals" has been deleted. The following new information clarifies the use of pneumococcalvaccination in patients with immunocompromising conditions.
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In October 2012, the Advisory Committee on Immunization Practices (ACIP) updated recommendationsfor pneumococcal vaccination in patients with immunocompromising conditions, anatomic or functionalasplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants. Immunocompromising conditions aredefined as follows: congenital or acquired immunodeficiency, HIV infection, chronic kidney disease, thenephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenicimmunosuppression (such as long-term corticosteroid therapy), solid organ transplant, and multiplemyeloma. For adults 19 years of age with an immunocompromising condition, functional asplenia, aCSF leak, or cochlear implants who have never received any pneumococcal vaccination, an initial dose

of 13-valent pneumococcal conjugate vaccine (PCV-13) should be given, followed by a first dose of 23-valent pneumococcal polysaccharide vaccine (PPSV-23) at least 8 weeks later. A single, second dose ofPPSV-23 should be given 5 years after the first PPSV-23 vaccination in those with anatomic orfunctional asplenia or with an immunocompromising condition. For adults 19 years of age withimmunocompromising conditions, anatomic or functional asplenia, CSF leaks, or cochlear implants whohave previously received at least one dose of PPSV-23, a single PCV-13 dose should be given 1 yearafter their last PPSV-23 immunization. All patients who have ever received a PPSV-23 vaccinationshould receive another dose of PPSV-23 at age 65 years, or later if at least 5 years have elapsed sincetheir last PPSV-23 dose. (Added April 2013)

Page 93, Special Considerations in Transplant Recipients, Vaccinations: In the second sentence of this

section, "every 5 years" has been deleted. See new informationabove clarifying the use of pneumococcalvaccination in patients with immunocompromising conditions. (Added April 2013)

Page 99, Item 1. See the JNC 8 guideline summary for more information. (Added June 2014)

Page 102, Item 12: The third sentence of the second paragraph has been changed to "Anunchangedsystolic crescendo-decrescendo murmur is noted at the right upper sternal border." Also, thelead-in question has been changed to "Which of the following is the most appropriate next step inmanagement of this patient's blood pressure?" (Added November 2014)

Page 107, Item 29: This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer A to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOCsubmission. This item has been excluded because the patient is currently taking simvastatin, and addingdiltiazem would cause a class D drug-drug interaction. (Added June 2014)


Page 113, Item 48: This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer C to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOC

submission.

This item has been excluded because of inconsistencies in the normal values of 24-hour protein excretiongiven in the text, Table 6, and this question's critique. The normal value for 24-hour protein excretion is


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Page 121, Item 75: In the second paragraph of the Stem, the sentence "There is abdominal guarding"should be deleted. Although abdominal guarding is occasionally noted to be caused by nephrolithiasis, itis not considered a "classic" finding and is more commonly associated with peritoneal inflammation(which usually does not occur with kidney stones). (Added April 2013)



Neurology

Page vi: The first sentence under the heading "Permission/Consent for Use of Figures Shown in MKSAP16 Neurology Multiple-Choice Questions" should read "The figure shown in Self-Assessment Test item7..." (not "item 8" as listed). (Added January 2013)

Page xi(Neurology High-Value Care Recommendations): The third bullet on the right-hand side of the

page should end "(see Item 7)" (not Item 8). Similarly, the fifth bullet should end "(see Item 8)" (not Item7). (Added January 2013)

Page 11, Head Injury, Concussive Head Injury: In March 2013, after publication of MKSAP 16, theAmerican Academy of Neurology published a summary of its updated evidence-based guideline on theevaluation and management of concussion in sports (Giza CC, Kutcher JS, Ashwal S, et al. Summary ofevidence-based guideline update: Evaluation and management of concussion in sports: Report of theGuideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013 March18 [Epub ahead of print] [PMID: 23508730]). This guideline updates assessment of risk factors forconcussion, assessment of concussion, and short- and long-term management of concussion, includingevaluation for return to play for sports-associated concussion. This supersedes the information containedin MKSAP 16 Neurology. See this article and also http://www.aan.com/go/practice/concussionfor fullerinformation on this updated guideline. (Added September 2013)

Page 27, Ischemic Stroke, Large Artery Atherosclerosis. See the JNC 8 guideline summary for moreinformation. (Added June 2014)

Page 30, Acute Ischemic Stroke, Treatment, Thrombolysis. In the second full paragraph of the firstcolumn of this page (third paragraph of "Thrombolysis"), the second sentence through the end of the

paragraph should be replaced with the following: "These techniques include local delivery of thethrombolytic agent at the site of a vascular occlusion or mechanical thrombectomy. Both methods have

been shown to improve recanalization rates. A previous study showed intra-arterial thrombolytic agentsto be superior to intravenous heparin alone if started within 6 hours of stroke onset in patients with large-vessel occlusions. However, subsequent clinical trials have not shown improved outcomes whencatheter-based therapies are added to intravenous thrombolysis or a benefit in using intra-arterialtherapies alone compared with intravenous thrombolysis. Further, no findings with neuroimaging have

been identified that predict a favorable response to intra-arterial therapies. Therefore, intravenousthrombolysis is considered first-line therapy for patients with acute ischemic stroke seen within 4.5 hoursof stroke onset. Mechanical thrombectomy remains a reasonable alternative for patients seen in this timeframe who have an occlusion of a large intracranial artery but have a contraindication to thrombolytictherapy." (Added September 2013)
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Page 32: In Acute Ischemic Stroke, Treatment, Figure 13 has been replaced because of recentlypublished studies showing no benefit in adding catheter-based therapies to intravenous thrombolysis or inusing intra-arterial therapies alone compared with intravenous thrombolysis. The previous figure legendshould be replaced with the following legend: "Algorithm for treating patients within 6 hours of anischemic stroke. AVM = arteriovenous malformation ICU = intensive care unit IV = intravenous MCA= middle cerebral artery NIHSS = National Institutes of Health Stroke Scale PTT = partialthromboplastin time rtPA = recombinant tissue plasminogen activator." (Added September 2013)

Page 36, Stroke, Secondary Stroke Prevention, Dyslipidemia. See the ACC/AHA cholesterolmanagement guideline summaries for more information. (Added June 2014)

Page 36: Stroke, Secondary Stroke Prevention, Hypertension. See the JNC 8 guideline summary for moreinformation. (Added June 2014)

Page 73, Neuromuscular Disorders, Treatment of Neuropathic Pain: The first full sentence in thesecond column of this page has been modified slightly to read "Duloxetine and gabapentin are generallywell tolerated but can be associated with weight gain and drowsiness duloxetine also is more expensive."(Added November 2014)

Page 89, Item 10 (see also page 114 for critique). See the JNC 8 guideline summary for moreinformation. (Added June 2014)

Page 89, Item 11: This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer B to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOCsubmission. This item has been excluded because the American Academy of Neurology (AAN) recently

published a summary of its updated evidence-based guideline on the evaluation and management ofconcussion in sports (Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guidelineupdate: Evaluation and management of concussion in sports: Report of the Guideline Development

Subcommittee of the American Academy of Neurology. Neurology. 2013 March 18 [Epub ahead ofprint] [PMID: 23508730]) that outlines a more individualized approach to the athlete with a concussionand makes specifying a particular time period to exclude an athlete from competition problematic. Seethis articles and also http://www.aan.com/go/practice/concussionfor fuller information on this updatedguideline. (Added September 2013)

Page 91, Item 17 (see also page 118 for critique): This question has been invalidated as a result ofpostpublication analysis and/or new data that are relevant to the question. Please select answer A to earna point for this item and ensure completion of all items in this self-assessment examination, which isnecessary for CME/MOC submission. See the ACC/AHA cholesterol management guideline summariesfor more information. (Added June 2014)

Page 94, item 30 (see also page 123 for critique): This question has been invalidated as a result ofpostpublication analysis and/or new data that are relevant to the question. Please select answer E to earna point for this item and ensure completion of all items in this self-assessment examination, which isnecessary for CME/MOC submission. "Reassurance" was replaced by "Continued clinical observation"as the answer because of a concern that the original option could be misinterpreted as suggesting that nofurther monitoring or possible subsequent evaluation of the patient's symptoms would be indicated.Additionally, invalidation of the question was supported by a lack of consensus about treatment of

patients with memory loss. (Added June 2014)

Page 96, Item 38: The cerebrospinal fluid protein level in the table of laboratory values should be 150
https://mksap16.acponline.org/groups/nr/figures/mk16_a_nr_f13http://www.ncbi.nlm.nih.gov/pubmed/?term=PMID%3A+23508730https://mksap16.acponline.org/groups/nr/topics/mk16_a_nr_s4_8_2https://mksap16.acponline.org/groups/nr/questions/mk16_a_nr_q030https://mksap16.acponline.org/groups/nr/questions/mk16_a_nr_q011https://mksap16.acponline.org/groups/nr/questions/mk16_a_nr_q017https://mksap16.acponline.org/groups/nr/questions/mk16_a_nr_q038http://-/?-https://mksap16.acponline.org/groups/nr/questions/mk16_a_nr_q010http://www.aan.com/go/practice/concussionhttp://-/?-http://-/?-http://-/?-https://mksap16.acponline.org/groups/nr/topics/mk16_a_nr_s9_2https://mksap16.acponline.org/groups/nr/topics/mk16_a_nr_s4_8_1


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mg/dL (1500 mg/L), not 15 mg/dL (150 mg/L) as listed. (Added September 2013)

Page 100, Item 55 (see also page 134 for critique): This question has been invalidated as a result ofpostpublication analysis and/or new data that are relevant to the question. Please select answer A to earna point for this item and ensure completion of all items in this self-assessment examination, which isnecessary for CME/MOC submission. See the ACC/AHA cholesterol management guideline summariesfor more information. (Added June 2014)

Page 101, Item 62 (see also page 137 for critique). See the ACC/AHA cholesterol management guidelinesummaries for more information. (Added June 2014)

Page 103, Item 73 (see also page 142 for critique). See the ACC/AHA cholesterol management guidelinesummaries for more information. (Added June 2014)

Page 106, Item 81: In the first line on this page (fourth paragraph of the item), the word "right" should bereplaced with the word "left"" ("...shows a left thalamic intracerebral hemorrhage..."). (AddedSeptember 2013)

Page 106, Item 86: In the first sentence of the question, the phrase "...is evaluated for a 60-minute

episode of..." should be replaced with the phrase "...is evaluated 1 day after experiencing a 60-minuteepisode of..." In the third sentence of the critique, which appears on page 148, the phrase "whose ABCD 2

scores are 3 or greater" should be followed by the phrase "within 72 hours of symptom onset." (AddedJanuary 2013)

Page 108, Item 93, and page 151: In options C and D of this question, the phrase Twice yearly replacesthe word Biannual, which was used to mean occurring twice a year. Although this usage is correct, the

potential for confusion exists because the term also has a secondary definition of occurring every twoyears. The word biannual also has been changed to twice yearly in the first sentence of the first

paragraph and the first sentence of the fourth paragraph of the critique. (Added June 2014)

Page 143, Item 74: In the first paragraph of the critique, the fifth sentence ("Inhibitors includemacrolides...") should be replaced with the following sentence: "Drugs that strongly inhibit cytochromeP3A4 include macrolides, protease inhibitors, and azole antifungals (such as itraconazole) althoughfibric acid derivatives are only weak inhibitors of the cytochrome pathway, they are independentlyassociated with muscle toxicity, particularly when administered concurrently with certain statinmedications." (Added September 2013)

Page 149, Item 87: In the first full paragraph on this page (third paragraph of the critique), the phrase"proximally to distally" in line 5 should be replaced with "distally to proximally." (Added September2013)

Pulmonary and Critical Care Medicine

Page 25: The second sentence under Other Agents should read: "Mucolytic agents (mucokinetic,mucoregulatory) may provide minor benefit to afew patients with viscous sputum however, their usecannot currently be recommended." (Added April 2013)

Page 25, Vaccines, second sentence: Guidelines on pneumococcal vaccination have been updated.

In October 2012, the Advisory Committee on Immunization Practices (ACIP) updated recommendations
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for pneumococcal vaccination in patients with immunocompromising conditions, anatomic or functionalasplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants. Immunocompromising conditions aredefined as follows: congenital or acquired immunodeficiency, HIV infection, chronic kidney disease, thenephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenicimmunosuppression (such as long-term corticosteroid therapy), solid organ transplant, and multiplemyeloma. For adults 19 years of age with an immunocompromising condition, functional asplenia, aCSF leak, or cochlear implants who have never received any pneumococcal vaccination, an initial doseof 13-valent pneumococcal conjugate vaccine (PCV-13) should be given, followed by a first dose of 23-

valent pneumococcal polysaccharide vaccine (PPSV-23) at least 8 weeks later. A single, second dose ofPPSV-23 should be given 5 years after the first PPSV-23 vaccination in those with anatomic orfunctional asplenia or with an immunocompromising condition. For adults 19 years of age withimmunocompromising conditions, anatomic or functional asplenia, CSF leaks, or cochlear implants whohave previously received at least one dose of PPSV-23, a single PCV-13 dose should be given 1 yearafter their last PPSV-23 immunization. All patients who have ever received a PPSV-23 vaccinationshould receive another dose of PPSV-23 at age 65 years, or later if at least 5 years have elapsed sincetheir last PPSV-23 dose. (Added April 2013)

Page 28, Table 16, 5th row: "Postbronchodilator total lung capacity of >150% AND residual lungvolume >100% of predicted" should read, "Postbronchodilator total lung capacity of >100%AND

residual lung volume >150%of predicted." (Added April 2013)

Page 84, the last sentence under Hyperglycemia should read, "Therefore, based on this data, the ACPClinical Practice Guideline for Use of Intensive Insulin Therapy for the Management of GlycemicControl in Hospitalized Patients recommends that, following initial stabilization, patients with severesepsis and hyperglycemia who are admitted to the ICU should receive insulin therapy to achieve a

plasma glucose level between 140 and 200 mg/dL (7.8 and 11.1 mmol/L)." The ACP Clinical PracticeGuideline can be found here: http://annals.org/article.aspx?articleid=746815. (Added April 2013)

Page 89, the fifth sentence under Alcohols should be deleted and the following should be inserted in itsplace: "As withdrawal becomes more severe, patients may experience seizures and/or hallucinations,usually within 12 to 24 hours of abstinence. Delirium tremens is a systemic syndrome characterized byhypertension, tachycardia, diaphoresis, fever, disorientation, and hallucinations." (Added April 2013)

Page 110, Item 39: Despite no clinical evidence of active infection in this patient (negative imaging andsputum culture), many clinicians would also treat with a course of empiric broad-spectrum antibiotics for

possible pulmonary infection in addition to high-dose glucocorticoids, as suggested in the critique,despite a lack of clear evidence that such treatment is beneficial. (Added June 2014)

Page 112, Item 46, third paragraph, second sentence should read: "Ventilation-perfusion lung scanningshows multiple bilateral segmental filling defects consistent with a high probability of pulmonary

embolism." (Added April 2013)

Page 117, Item 65: This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer C to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOCsubmission. Following the publication of MKSAP 16, the American College of Chest Physicians issued arevised clinical practice guideline for the diagnosis and management of lung cancer (Detterbeck FC,Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Executive Summary: Diagnosis andmanagement of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical

practice guidelines. Chest. 2013143(5 Suppl):7S-37S. [PMID: 23649434]). These updated guidelinesrecommend review of prior imaging, if available, in a patient with a pulmonary nodule. In a patient with
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a solid, indeterminate nodule that shows clear evidence of malignant growth on serial imaging,nonsurgical biopsy and/or surgical resection is recommended unless specifically contraindicated. (AddedApril 2013 and updated September 2013)

Page 119, Item 72, the last sentence of the first paragraph should read, "She notes a 2-month history ofnewstiffness and mild pain in her joints, for which she takes NSAIDs as needed." (Added April 2013)

Page 147, critique of Item 41, 8th and 10th sentences: "the nephritic syndrome" should read "the

nephrotic syndrome." (Added April 2013)

Page 147, critique of Item 41, 11th and 12th sentences: See new informationabove clarifying the use ofpneumococcal vaccination in patients with immunocompromising conditions. (Added April 2013)

Page 172, critique of Item 95, second sentence: "...(2) postbronchodilator total lung capacity greater than150% and residual volume greater than 100% of predicted..." should read, "...(2) postbronchodilator totallung capacity greater than 100%and residual volume greater than 150%of predicted..." (Added April2013)

Page 172, critique of Item 96, third paragraph: The second sentence should read, "Chest examination will

reveal severely decreased breath sounds with or without wheezing and a prolonged expiratorytoinspiratoryratio." (Added June 2014)

Rheumatology

Page 14: Tocilizumab is incorrectly listed as a chimericmonoclonal antibody this agent is a humanizedmonoclonal antibody. (Added September 2013)

Page 30: In Psoriatic Arthritis, the callout for Figure 14 has been deleted from the third paragraph of thissection and moved to the second paragraph as follows: "Nails should be examined for pitting oronycholysis (Figure 13 and Figure 14)." (Added April 2013)

Page 58: In the second paragraph of Management, Pharmacologic Therapy, the second sentence "Thosewith arthralgia or tenosynovitis rather than a frank septic arthritis can be transitioned to oral therapy withciprofloxacin after symptoms subside" has been deleted.

The following should appear after "Treatment is usually continued for 7 to 14 days depending on theseverity of illness": "Although parenteral antibiotics have traditionally been changed to an oral agentfollowing an initial response to therapy to complete a full treatment course, increasing resistance to oralantibiotics has limited their effectiveness for this use. Fluoroquinolones (including ciprofloxacin) are nolonger recommended for either initial or step-down therapy for disseminated gonococcal infection.Cefixime is a reasonable alternative for oral therapy, although increasing resistance is of concern forlonger-term treatment of disseminated disease. Continuing parenteral antibiotics to complete atherapeutic course should be considered, particularly in areas with known increased resistance to oralcephalosporins." (Added April 2013)

Page 91, Item 39: This question has been invalidated as a result of postpublication analysis and/or newdata that are relevant to the question. Please select answer C to earn a point for this item and ensurecompletion of all items in this self-assessment examination, which is necessary for CME/MOCsubmission. This item has been excluded because the original question did not mention that the patienthad hemoptysis, which, in combination with her other clinical findings, suggests pulmonary vasculitis
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and the need for a diagnostic open lung biopsy. (Added April 2013)

Page 93, Item 48: The SI unit conversion for the C4 value should be 86 mg/L, not 860 mg/L. (AddedJune 2014)

Page 117, Item 23: At the end of the first paragraph, "...and it does not cause constipation" hasbeen deleted because constipation is a possible side effect of tramadol. (Added November 2014)

Invalidated Questions

The following questions have been invalidated as a result of postpublication analysis and/or new data thatare relevant to the question: Item 12from Cardiovascular Medicine, item 7from General InternalMedicine, item 114from Hematology and Oncology, item 97from Infectious Disease, item 48from

Nephrology, item 11from Neurology, item 65from Pulmonary and Critical Care Medicine, and item 39from Rheumatology.

Footnotes

Cholesterol Management Guideline Updates

In 2013, the American College of Cardiology (ACC) and the American Heart Association (AHA) jointlyreleased new cholesterol guidelines, supplanting the National Cholesterol Education Program AdultTreatment Panel III (ATP III) guidelines published in 2002. The major changes from the previousguidelines are outlined below.

Cardiovascular risk assessment: In patients 20-79 years of age, assess traditional cardiovascular riskfactors every 4-6 years in those 40-79 years, estimate the 10-year risk using the Pooled CohortEquations. (A calculator based on these equations is available here:http://my.americanheart.org/professional/StatementsGuidelines/PreventionGuidelines/Prevention-Guidelines_UCM_457698_SubHomePage.jsp.) If low-risk (


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mmol/L) and no ASCVDNo ASCVD or diabetes and estimated 10-year ASCVD risk 7.5%

The 10-year risk for ASCVD is estimated by using the Pooled Cohort Equations, which were derivedfrom data from multiple longitudinal study databases, including the Framingham cohort.

For patients in any one of the four statin benefit groups, therapy with a statin is indicated, with theintensity determined by specific g

mksap 16_ errata and revisions

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