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MKSAP 19 - Errata and Revisions
(Updated August 2022)
Invalidated MKSAP 19 Questions
The following questions have been invalidated as a result of postpublication analysis and/or new data that are relevant to the question: Item 31, Item 67, and Item 120 from Cardiovascular Medicine; Item 42, Item 74 and Item 79 from Endocrinology and Metabolism; Item 70 and Item 88 from General Internal Medicine 1; Item 56 from Infectious Disease; Item 50, Item 52, and Item 58 from Nephrology.
Cardiovascular Medicine
Epidemiology and Risk Factors
Pages 1-3: The text has been revised to acknowledge that the significant racial and ethnic disparities in the prevalence of cardiovascular disease in the United States are driven by multiple factors, including structural social factors and inequitable access to care. Many calculators of cardiovascular risk, including the Pooled Cohort Equations recommended by the U.S. Preventive Services Task Force, the Society of Thoracic Surgeons Adult Cardiac Surgery Risk Calculator, and the Multi-Ethnic Study of Atherosclerosis risk score, include race as a variable in estimating cardiovascular risk. The inclusion of race as a predictor of risk is problematic, and guidelines are likely to evolve to better reflect individualized risk.
In addition, the text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Heart Failure
Page 30: Screening. The text has been revised to acknowledge that inclusion of race as a variable in calculating risk for heart failure is likely a flawed approach. (Added March 2022)
Pages 32-35: Heart Failure With Reduced Ejection Fraction. The text, including the Figure 13 legend, has been revised to acknowledge that race-based heart failure treatment recommendations are under scrutiny. (Added March 2022)
Page 41: Black Patients. The text has been revised to remove race-based treatment recommendations that are under scrutiny. (Added March 2022)
Valvular Heart Disease
Page 63: Clinical Presentation and Evaluation. In the last sentence of the first paragraph, "non-Hodgkin" was changed to "Hodgkin." (Added January 2022)
Pregnancy and Cardiovascular Disease
Pages 115-116: Peripartum Cardiomyopathy. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Questions
Pages 125 and 155, Question 1: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option A has been changed from "Add isosorbide dinitrate–hydralazine" to "Add digoxin." In addition, the second paragraph of the critique has been revised to remove race-based treatment recommendations that are under scrutiny. (Added March 2022)
Page 125, Question 2: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the last paragraph of the stem, the word “atypical” in “atypical chest pain” was deleted. (Added May 2022)
Pages 127 and 160, Question 10: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option D has been changed from "Isosorbide dinitrate–hydralazine" to "Ivabradine." In addition, the fourth paragraph of the critique has been revised to remove race-based treatment recommendations that are under scrutiny. (Added March 2022)
Pages 129 and 162, Question 16: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option D has been changed from “Switch esmolol to metoprolol” to “Switch nitroprusside to amlodipine.” Accordingly, the fourth paragraph of the critique now states, “Although control of blood pressure and shear forces remains an important objective, the focus in this patient should be on urgent surgical intervention rather than changing the nitroprusside to amlodipine (Option D). Furthermore, the abrupt discontinuation of nitroprusside may lead to rebound hypertension and the blood pressure–lowering effect of amlodipine may be delayed for several days, making this an inappropriate change in antihypertensive therapy. (Added May 2022)
Page 132, Question 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 B to earn CME/MOC credit for this question. The item has been excluded because the guideline recommendations on which it was based included racial variables that are under scrutiny. (Added March 2022)
Pages 140-141 and 189, Question 65: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option B has been changed to “Discontinue aspirin and clopidogrel,” and the critique has been revised accordingly. (Added May 2022)
Page 141, Question 67: 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 CME/MOC credit for this question. This item has been excluded because the educational objective is no longer relevant on the basis of new guidelines from the American College of Cardiology. (Added May 2022)
Page 154, Question 120: 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 CME/MOC credit for this question. This item has been excluded because new guidelines specifically eliminate the terms typical and atypical angina. (Added May 2022)
Page 158, Question 7: The first paragraph of the critique was revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 164, Question 19: The first paragraph of the critique was revised to acknowledge that the inclusion of race as a predictor of cardiovascular risk is problematic and that the guidelines are likely to evolve to better reflect individualized risk. (Added March 2022)
Page 175, Question 38: The second to last sentence in the fourth paragraph of the critique was changed to “However, the risk for angioedema is higher with valsartan-sacubitril than with ACE inhibitor or ARB therapy, and valsartan-sacubitril is contraindicated in patients who have had angioedema while receiving an ACE inhibitor.” (Added July 2022)
Endocrinology and Metabolism
Disorders of Glucose Metabolism
Page 3: Idiopathic Type 1 Diabetes Mellitus. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 12: Therapy for Type 2 Diabetes Mellitus. In the sixth paragraph, the following text has been added after the third sentence: “Renal dose adjustment is required for all SGLT2 inhibitors. The GLP-1 RAs exenatide and lixisenatide should be avoided in patients with an eGFR less than 30 mL/min/1.73 m2.” (Added January 2022)
Page 24: Hypoglycemia in Patients With Diabetes Mellitus. The third paragraph has been changed to: "Hypoglycemia can also occur with the use of oral antidiabetic agents (especially sulfonylureas or meglitinides) because of incorrect dosages, drug-drug interactions, and intercurrent illnesses that alter the metabolism or excretion of drugs." (Added January 2022)
Disorders of the Adrenal Glands
Page 41: Pheochromocytoma and Paraganglioma. In the second sentence of the seventh paragraph, "multiple endocrine neoplasia type 1" has been changed to "multiple endocrine neoplasia type 2." (Added May 2022)
Reproductive Disorders
Page 67: Management. In the second paragraph, the following information has been added to clarify the risk for cardiovascular events in men receiving certain testosterone therapies: "However, two products (oral testosterone undecanoate and subcutaneous testosterone enanthate) have boxed warnings regarding the potential for increased blood pressure, which can increase the risk for major adverse cardiovascular events." (Added March 2022)
Page 69: Table 42. Recommended Testosterone Replacement Therapy. This table has been updated to add information on testosterone undecanoate. (Added March 2022)
Calcium and Bone Disorders
Page 77: Pathophysiology. A second paragraph has been added, as follows: "Glucocorticoids are a well-recognized cause of significant bone loss, and risk is increased in older patients, larger doses, and longer duration of therapy. Patients taking glucocorticoids should be on the lowest dose possible for the shortest duration necessary." (Added January 2022)
Questions
Pages 92 and 116, Question 18: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option D has been changed from "Order dual-energy x-ray absorptiometry scan" to "Discontinue teriparatide, start abaloparatide." In addition, the fourth paragraph of the critique has been removed. (Added March 2022)
Page 97, Item 42: 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 CME/MOC credit for this question. This item has been excluded because option C (Adrenocorticotropin hormone stimulation test) is a logical step next in the evaluation of this patient and is therefore a correct answer. (Added March 2022)
Page 103, Question 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 A to earn CME/MOC credit for this question. The item has been excluded because the most appropriate pathway in evaluating hypercalcemia in general involves ruling out other potential causes first. Additionally, according to the relevant literature, alkaline phosphatase levels may be variable and may not corroborate the diagnosis. (Added May 2022)
Pages 104 and 150, Question 80: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The question stem has been revised, and Option D has been changed from "13-Valent pneumococcal conjugant" to "23-Valent pneumococcal polysaccharide vaccine." In addition, the first, second, and fourth paragraphs of the Critique have been revised. The first Key Point has been removed, and the second Key Point has been revised. (Added May 2022)
Page 149, Item 79: 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 CME/MOC credit for this question.
This item has been excluded because the best pharmacologic agent to treat type 2 diabetes mellitus in this patient with stage 4 chronic kidney disease, a glucagon-like peptide 1 receptor agonist (GLP-1 RA) such as liraglutide, was not included in the option list. GLP-1 RAs improve cardiovascular outcomes and reduce albuminuria. The dosage of these agents can be adjusted in patients with chronic kidney disease, although exenatide and lixisenatide should be avoided in patients with an estimated glomerular filtration rate less than 30 mL/min/1.73 m2. (Added January 2022)
Pages 150-151, Question 81: In the second paragraph of the Critique, "screening patients with overweight or obesity between age 40 and 70 years for diabetes" has been changed to "screening for diabetes in patients aged 35 to 70 years with overweight or obesity" based on updated USPSTF guidance on screening for prediabetes and type 2 diabetes. The related Key Point has also been revised accordingly. (Added May 2022)
Gastroenterology
Disorders of the Small and Large Bowel
Page 27: History and Physical Examination. In the last sentence of the second paragraph, "age 50 years" has been changed to "age 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)
Page 28: Additional Testing. In the last sentence of the sixth paragraph, "age older than 50 years" has been changed to "age older than 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)
Page 37: Evaluation. In the third sentence of the first paragraph, "age older than 50 years" has been changed to "age older than 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)
Page 42: Perianal Disorders. In the last sentence of the first paragraph, "age older than 50 years" has been changed to "age older than 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)
Colorectal Neoplasia
Page 45: : Risk Factors. In the first sentence of the first paragraph, the "≥50 years" has been changed to "≥45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. The same change has been made in the related key point. (Added January 2022)
Page 45: Risk Factors. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Disorders of the Liver
Page 59: Drug-Induced Liver Injury. In the first paragraph, the last sentence has been changed to "Use of the Web-based tool LiverTox (www.ncbi.nlm.nih.gov/books/NBK547852/) from the National Institutes of Health can help assess risk for hepatotoxicity." (Added August 2021)
Gastrointestinal Bleeding
Page 81: Table 43. In the fifth row, ">50" in the "Patient Age" column has been changed to ">45" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)
Questions
Page 87, Question 4: Under "Laboratory studies" in the question stem, "Hepatitis E antigen" and "Hepatitis E IgG antibody" have been changed to "Hepatitis B e antigen" and "Hepatitis B e IgG antibody," respectively. (Added January 2022)
Page 88, Question 9: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The total IgA level in the question stem has been changed to “less than 5 mg/dL (0.05 g/L).” (Added January 2022)
Page 93, Question 35: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the question stem, data regarding platelet count have been added to allow a Fibrosis-4 calculation to be performed. In addition, the first paragraph of the Critique has been revised. (Added May 2022)
Page 102, Question 77: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the first sentence of the Stem, the age of the patient has been changed to 76 years. In the second sentence of the Stem, diabetes and mild congestive heart failure have been added as comorbid conditions. (Added July 2022)
Page 104, Question 88: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option A has been changed from "Broad-spectrum antibiotics" to "Standard-dose esomeprazole and broad-spectrum antibiotics". Option B has been changed from "Esomeprazole, intravenously twice daily" to "High-dose esomeprazole". Option C has been changed from "Octreotide, intravenously by continuous infusion" to "High-dose esomeprazole and octreotide". Option D has been changed from "Omeprazole, orally once daily" to "Standard-dose esomeprazole". In addition, the first and fourth paragraphs of the Critique have been revised. (Added May 2022)
Page 107, Question 2: In the first paragraph of the critique, the second sentence has been revised as follows: "This patient most likely has primary biliary cholangitis (PBC), a diagnosis that is best established by imaging with ultrasound or magnetic resonance cholangiopancreatography to exclude extrahepatic obstruction and by positive results for AMA." (Added January 2022)
Page 114, Question 14: In the first paragraph of the critique and in the related key point, "age older than 50 years" has been changed to "age older than 45 years" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)
Page 137, Question 59: In the second paragraph of the critique, "age 50 years or older" has been changed to "age 45 years or older" based on updated USPSTF guidance on colorectal cancer risk and screening. (Added January 2022)
Page 146, Question 76: : In the first paragraph of the critique, text was revised to better reflect the risk factors for gastric cancer identified by the American Gastroenterological Association. (Added March 2022)
Page 149, Question 83: In the first sentence of the second paragraph of the critique, “cholecystitis” has been changed to “cholangitis.” The sentence now reads, “Surgical drainage of the biliary tree, either open or laparoscopic (Option A), is reserved for patients with acute cholangitis who cannot undergo ERCP or in whom ERCP has failed.” (Added January 2022)
General Internal Medicine 1
Common Symptoms
Page 19: Acute Cough. In the third sentence of the third paragraph, the phrase "the most current" was changed to "additional." The sentence now reads, "For additional information on SARS-CoV-2, see COVID-19: An ACP Physician's Guide (https://www.acponline.org/clinical-information/clinical-resources-products/coronavirus-disease-2019-covid-19-information-for-internists)." (Added January 2022)
Page 28: Evaluation. The first sentence in the second to last paragraph was revised to read: “Although the pathophysiology of SEID remains unclear, central sensitization may contribute.” The following sentence was added to the last paragraph: “Comorbid conditions, such as fibromyalgia, irritable bowel syndrome, and interstitial cystitis, are common.” (Added March 2022)
Page 29: Management. The second sentence in the first paragraph was changed to: “In patients with SEID, treatment is supportive and focuses on treatment of symptoms and comorbid conditions.” The sentence “Cognitive behavioral therapy (CBT) may decrease fatigue and improve function” was deleted. The second sentence in the second paragraph was changed to: “Medical therapy is therefore typically limited to the treatment of symptoms and comorbid conditions.” The second sentence in the last paragraph was changed to: “It depends on many factors, including patient age, formal education level, severity and duration of symptoms, decline in functional status relative to premorbid level of functioning, presence of other symptoms, comorbid conditions, and availability of resources.” (Added March 2022)
Page 29: Management. In the fourth sentence of the first paragraph, the phrases "and graded exercise therapy" and "and these therapies should be offered to all patients" were deleted. The sentence now reads, "Cognitive behavioral therapy (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 to all patients" was deleted. The key point now states, "Patients with systemic exertion intolerance disease benefit most from a structured, multimodal approach that includes regularly scheduled office visits." (Added January 2022)
Questions
Page 118, Item 42: In the second paragraph of the stem, the fourth sentence was corrected to state that the patient’s left leg calf is 4 cm larger than the right. (Added January 2022)
Page 119, Item 46: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The first paragraph of the stem was revised to convey that the patient's race is reported for the purposes of calculating risk for atherosclerotic cardiovascular disease. (Added March 2022)
Page 124, Item 70: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. Please select answer C to earn CME/MOC credit for this question.
This item has been excluded because the history and examination findings described in the stem may be insufficient to make the correct diagnosis. (Added May 2022)
Page 124, Item 72: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The first paragraph of the stem was revised to convey that the patient's race is reported for the purposes of calculating risk for atherosclerotic cardiovascular disease. (Added March 2022)
Page 124, Item 74: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In the lead-in question, “another overdose” was changed to “an overdose-related death.” (Added March 2022)
Page 127, Item 88: 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 CME/MOC credit for this question.
This item has been excluded because there is more than one correct answer. Option B (knee strengthening exercises) is not an unreasonable answer for this patient who also has limiting knee osteoarthritis. (Added January 2022)
Page 127, Item 91: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option A has been changed from "Graded exercise program" to "Pacing strategies." (Added March 2022)
Page 137, Item 9: In the third paragraph of the critique, pemoline was deleted from the parenthetical list of psychostimulants because it has been discontinued. (Added May 2022)
Page 142, Item 19: The reference was updated to: Fowler JR, Hughes TB. Scaphoid fractures. Clin Sports Med. 2015;34:37-50. [PMID: 25455395] doi:10.1016/j.csm.2014.09.011. The previous reference--Mawdsley MJ, Harrison J. Conservative interventions for treating scaphoid fractures in adults. Cochrane Database Syst Rev. 2018;2018:CD010713. doi:10.1002/14651858.CD010713.pub2—was removed from the Cochrane Library and is no longer accessible. (Added March 2022)
Page 170, Item 74: In the next to last sentence in paragraph 1 of the critique, “ways to prevent overdose” was changed to “ways to reverse overdose and prevent overdose death.” (Added March 2022)
Page 178, Item 91: The critique and key point have been revised to reflect the current evidence for systemic exertion intolerance disease therapies. (Added March 2022)
General Internal Medicine 2
Routine Care of the Healthy Patient
Pages 5-6: Screening for Chronic Diseases. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Obesity
Page 43: Screening and Evaluation. The first sentence of the first paragraph was revised to, "Multiple organizations, including the American College of Cardiology, American Heart Association, and The Obesity Society, recommend annual screening of adults with BMI and waist circumference measurements." (Added March 2022)
Women's Health
Page 56: Contraception. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Eye Disorders
Page 72: Glaucoma. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Ear, Nose, Mouth, and Throat Disorders
Page 79: Upper Respiratory Tract Infection/Sinusitis. Sentence three in paragraph one was revised to, “It is usually self-limited; therapies that may relieve symptoms include systemic decongestants, saline nasal irrigation, and intranasal glucocorticoids, all targeted to the patient's specific symptoms.” (Added March 2022)
Page 82: Legend for Figure 30: In the first sentence, “loss or diminution of the interdental papilla, and necrotic sloughing of the gingiva” was revised to “loss or diminution of the interdental papilla (green arrow), and necrotic sloughing of the gingiva (blue arrow).” (Added January 2022)
Dermatologic Disorders
Page 97: Table 74. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Questions
Pages 138 and 168, Item 6: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option C has been changed from "23-Valent pneumococcal polysaccharide vaccine" to "20-Valent pneumococcal conjugate vaccine." In addition, the second sentence of the question stem and the first and third paragraphs of the critique have been revised. (Added May 2022)
Page 168, Item 7: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added March 2022)
Pages 141 and 176, Item 20: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option B has been changed from "13-Valent pneumococcal conjugate vaccine" to "20-Valent pneumococcal conjugate vaccine." In addition, the second sentence of the question stem and the first and third paragraphs of the critique have been revised. (Added May 2022)
Page 144, Item 33: In the sixth sentence of the question stem, "and recently completed the hepatitis B vaccine series" was added. (Added May 2022)
Page 185, Item 37: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added March 2022)
Page 196, Item 55: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added March 2022)
Pages 152 and 204, Item 70: In the third sentence of the question stem, "and has additionally completed the hepatitis B vaccine series" was added. In addition, the third paragraph of the critique has been revised. (Added May 2022)
Page 224, Item 106: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added March 2022)
Pages 162 and 231, Item 117: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. In paragraph two of the question stem, "BMI is 22 kg/m2." has been added after the second sentence. In addition, the second paragraph of the critique has been revised. (Added May 2022)
Pages 162 and 233, Item 121: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option C has been changed from "13-Valent pneumococcal conjugate vaccine" to "20-Valent pneumococcal conjugate vaccine." In addition, the first paragraph of the critique has been revised. (Added May 2022)
Hematology
Approach to Nonmalignant Leukopenia and Leukocytosis
Page 1: Lymphopenia and Neutropenia. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Erythrocyte Disorders
Page 24: α-Thalassemia. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 28: Sickle Cell Syndromes. The discussion has been revised to clarify that sickle cell disease is most common in patients from sub-Saharan Africa, India, the Middle East, the Caribbean, and Central and South America. (Added March 2022)
Iron Overload Syndromes
Page 34: Primary/Hereditary Hemochromatosis. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 34: Primary/Hereditary Hemochromatosis. In the fourth paragraph, the final sentence beginning, “Pituitary injury leads to androgen deficiency…” the word “melatonin” should be “melanin.” (Added July 2022)
Thrombotic Disorders
Pages 51-53: Inherited Thrombophilias. The discussion has been revised to clarify that some inherited thrombophilias (heterozygous factor V Leiden, prothrombin G20210A mutation, and heterozygous methylene tetrahydrofolate reductase polymorphisms) are most commonly found in patients of European ancestry. (Added March 2022)
Questions
Page 71, Item 4: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The pneumococcal vaccine formulation has been updated from “13-valent pneumococcal conjugate” to “20-valent pneumococcal conjugate”. (Added May 2022)
Page 104, Item 29: The Critique has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 112, Item 45: The third Critique paragraph has been revised to clarify that heterozygous factor V Leiden is most commonly found in patients of European ancestry. (Added March 2022)
Page 114, Item 48: In the final Critique paragraph, the first sentence has been revised to, "A low vitamin B12 level is associated with intramedullary hemolysis because of ineffective erythropoiesis and resultant elevated LDH and bilirubin (indirect) and decreased haptoglobin levels, which are normal in this patient (Option D)." The sentence previously stated, "...elevated LDH, haptoglobin, and bilirubin (indirect) levels..." (Added July 2022)
Page 121, Item 63: The epidemiologic information regarding hereditary hemochromatosis in the first Critique paragraph has been revised. (Added March 2022)
Page 126, Item 73: The epidemiologic information regarding glucose-6-phosphate dehydrogenase deficiency in the first Critique paragraph has been revised. (Added March 2022)
Infectious Disease
Central Nervous System Infection
Page 3: Table 2. Under "Empiric Antibiotic Regimen" for patients >50 years or with altered cell-mediated immunity, the phrase “or cefotaxime” has been added as an alternative treatment instead of ceftriaxone. “In countries with ceftriaxone resistance rate >1%, such as the United States” has been moved to the footnotes section. (Added January 2022)
Community-Acquired Pneumonia
Page 21: Complications. In the final paragraph, the word "without" should be "with." The sentence should read, "Glucocorticoids are not routinely recommended and should be reserved for patients with documented adrenal insufficiency or refractory septic shock." (Added January 2022)
Tick-Borne Diseases
Page 23: Early Disseminated Disease. In the paragraph beginning, "Neurologic infection occurs…," the sentence on lumbar puncture has been revised to, "Serum antibody testing, rather than polymerase chain reaction or culture of either cerebrospinal fluid or serum, is recommended for the diagnosis of Lyme disease involving the peripheral or central nervous system." This change makes the content more consistent with current guidelines. (Added January 2022)
Mycobacterium tuberculosis Infection
Page 37: Management, Drug-Resistant Tuberculosis. The last sentence and the Key Point box have been clarified concerning treatment duration and culture conversion. Both sentences now state, "…the recommendation is to use five drugs in the intensive phase of treatment and four drugs in the continuation phase of treatment. The recommended intensive-phase duration is between 5 and 7 months after culture conversion, with the total duration between 15 and 21 months after culture conversion." (Added January 2022)
Nontuberculous Mycobacterial Infection
Page 38: Mycobacterium avium Complex Infection. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Fungal Infections
Page 43: Coccidioidomycosis. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Questions
Pages 115-116, Item 14: The patient's history has been revised to indicate meningococcal meningitis as a child; the family history has been removed. (Added March 2022)
Page 119, Item 30: The sentence, "An interferon-γ release assay is negative," has been removed from the Stem and replaced with, "Nucleic acid amplification testing for Mycobacterium tuberculosis is negative." In addition, the first and third Critique paragraphs have been revised consistent with this change. (Added July 2022)
Page 125, 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 CME/MOC credit for this question. (Added August 2022)
Page 134, Item 92: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option E has been changed from “Clindamycin and gentamicin” to “Cefotetan and doxycycline.” In addition, the associated Critique paragraph has been revised. (Added May 2022)
Page 154, Item 30: The first Critique paragraph has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 160, Item 41: In the final Critique paragraph, the first sentence, "Hepatitis B vaccination and immune globulin are used to prevent HBV infection in nonimmune persons (negative surface antigen and positive surface antibody)," the parenthetical note should indicate "negative surface antigen and negative surface antibody." (Added March 2022)
Page 163, Item 48: In the first Critique paragraph, following the sentence that reads, "In countries such as the United States with a prevalence of greater than 1% of ceftriaxone-resistant pneumococcus, …provide coverage for possible Listeria monocytogenes (Option A)," a sentence has been added, indicating, "Cefotaxime is also effective against pneumococcus and may be given instead of ceftriaxone." The first Key Point has also been revised to state, "Empiric therapy for bacterial meningitis should include vancomycin, ceftriaxone or cefotaxime, and ampicillin in adult patients older than 50 years." (Added January 2022)
Page 166, Item 53: In the last sentence in the first paragraph of the Critique, "oral" has been removed. The sentence should read, "Ertapenem has an advantage over the other carbapenems with once-daily dosing, but some ESBL-producing organisms are resistant to it." Ertapenem does not have oral dosing. (Added March 2022)
Page 174, Item 70: In the first sentence of the Critique, Heartland virus is classified as a Phlebovirus. The taxonomy of Heartland virus was recently revised, and the virus is now classified as part of the new genus Bandavirus. (Added January 2022)
Page 189, Item 98: The last Critique paragraph has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Nephrology
Clinical Evaluation of Kidney Function
Page 1: Assessment of Kidney Function. The text has been revised to acknowledge that inclusion of race in glomerular filtration rate (GFR) calculation may lead to inaccurately higher GFR estimates for Black patients, which could subsequently translate into delayed or inequitable care in some cases. In addition, epidemiologic information that is irrelevant to the discussion has been removed. (Added February 2022)
Page 1: 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 refit to estimate glomerular filtration rate without a race variable. Based on this recommendation, the following revisions have been made:
In the first paragraph, sentence 2, "These formulas take into account" has been replaced with "These formulas may take into account."
In the second paragraph, 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) (www.kidney.org/professionals/kdoqi/gfr_calculator), which has been refit to estimate kidney function without a race variable (see Table 1). 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: 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 refit to estimate glomerular filtration rate without a race variable, Table 1 was revised as follows:
- Row 3, column 1. Column heading was revised to "CKD-EPI Creatinine (2021)." In sentence 1, the term "race" was deleted.
- Row 3, column 3. Sentence 2 was deleted.
- Row 5, column 3. "The most accurate formula for estimating GFR in most situations" was added.
- (Added October 2021)
Page 3: 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 refit to estimate kidney function without a race variable." (Added October 2021)
Fluids and Electrolytes
Page 15, Figure 7: : Hypokalemia. In the last row of the algorithm, in the sixth box from the left, "diuretics" was added, as hypokalemia due to diuretics can occur with or without metabolic alkalosis. (Added May 2022)
Hypertension
Pages 26-41: The text has been revised to acknowledge that race-based antihypertensive prescribing recommendations are under scrutiny. In addition, epidemiologic information that is irrelevant to the discussion has been removed. (Added February 2022)
Glomerular Diseases
Pages 44-55: The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added February 2022)
Genetic Disorders and Kidney Disease
Page 60: Apolipoprotein L1 Nephropathy. The text has been revised to acknowledge the multifactorial reasons for disparities in the incidence of kidney failure. (Added February 2022)
Acute Kidney Injury
Page 68: Tumor Lysis Syndrome. In sentence three of the second paragraph, "80 to 100 mL/kg/h" has been changed to "80 to 100 mL/h." (Added July 2022)
Kidney Stones
Page 70: Overview. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added February 2022)
Chronic Kidney Disease
Page 76: 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 refit 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 85: Non-Dialytic Palliative Therapy. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added February 2022)
Questions
Page 99, Item 22: This question has been revised to exclude mention of race-based antihypertensive prescribing recommendations that are under scrutiny. (Added February 2022)
Page 106, Item 50: 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 CME/MOC credit for this question. The item has been excluded because the guideline recommendations on which it was based included racial variables that are under scrutiny. (Added February 2022)
Page 107, Item 52: 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 CME/MOC credit for this question. The item has been excluded because the guideline recommendations on which it was based included racial variables that are under scrutiny. (Added February 2022)
Page 108, Item 58: This question has been invalidated as a result of postpublication analysis and/or new data that are relevant to the question. CME credit and ABIM MOC points will be honored for this invalidated question. Please select option D for CME and MOC credit. This item has been excluded because there is more than one correct answer. Option B (mycophenolate mofetil) can cause tremor. Therefore, both options B and D are correct. (Added July 2022)
Page 139, Item 36: The critique of this question has been updated to remove epidemiologic information that is irrelevant to the question. (Added February 2022)
Page 140, Item 39: The critique of this question has been updated to exclude mention of race-based antihypertensive prescribing recommendations that are under scrutiny. (Added February 2022)
Page 164, Item 87: . In paragraph two of the critique, the second sentence, "In this case, the urine anion gap will be positive, reflecting increase urinary excretion of hydrogen ions," has been replaced with "In these types of cases, the urine anion gap will be negative, reflecting increased urinary excretion of hydrogen ions." (Added July 2022)
Page 166, Item 91: The critique of this question has been updated to exclude mention of race-based antihypertensive prescribing recommendations that are under scrutiny. (Added February 2022)
Page 168, Item 94: The Educational Objective, "Manage end-stage kidney disease with non-dialytic palliative therapy," has been replaced with "Manage advanced chronic kidney disease with non-dialytic palliative therapy." (Added July 2022)
Neurology
Stroke
Page 36: Primary Prevention. In the first sentence of the first paragraph, the cross-reference should be: MKSAP 19 General Internal Medicine 2. (Added August 2021)
Neuromuscular Disorders
Page 83: Paraproteinemic Neuropathy. The cross-reference at the end of the third sentence of this paragraph should be: (See MKSAP 19 Hematology.) (Added August 2021)
Neuro-oncology
Page 90: Table 53. In the second row of the table, "thymoma" has been added to the "Associated Cancers" column. (Added July 2022)
Questions
Page 101, Question 20: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. The fifth sentence of the first paragraph of the question stem has been revised to read as follows: "Her sister, brother, mother, and maternal aunt have similar muscle, neurologic, and multiorgan symptoms, but her father and a second brother do not." (Added March 2022)
Page 111, Question 72: In the question stem, the second sentence of the second paragraph should read: "She has right facial weakness, dysarthria, and right arm and leg weakness with a downward drift, with the leg not touching the examination table." (Added August 2021)
Pages 114 and 159-160, Question 87: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option D has been changed from "Recombinant herpes zoster vaccine" to "Varicella vaccine." In addition, the first and fourth paragraphs of the Critique have been revised accordingly. (Added May 2022)
Page 126, Question 20: After the third sentence of the first paragraph of the critique, the following text was inserted: “Offspring of affected fathers do not inherit these diseases, but all offspring regardless of sex are at equal risk for inheriting the disease when a mother possesses the mutation. Each cell carries multiple copies of the mitochondrial genome and deleterious mutations usually affect some but not all copies of the mitochondrial genome. The expression of disease due to mitochondrial DNA depends on the relative proportions of normal and abnormal mitochondrial DNA. This means that there can be substantial variation in the likelihood of developing the disease and the disease severity. In this case, three of the offspring are affected because of this variable expression of disease. ” In addition, the last sentence of the first paragraph should read: “In this patient, fluctuating weakness, ophthalmoplegia, multiorgan symptoms, and family history should prompt consideration of mitochondrial myopathy.” Finally, the Key Point should read: “Mitochondrial myopathy is associated with fluctuating weakness, ophthalmoplegia, multiorgan symptoms, and maternal inheritance.” (Added March 2022)
Page 133, Question 35: The third sentence of the first paragraph of the critique should read: "He is receiving the most appropriate medical therapy, including aspirin and a high-intensity statin." (Added January 2022)
Page 144, Question 56: In the first paragraph of the critique, after the 11th sentence, the following text was added: "The Infectious Disease Society of America recommends careful observation rather than antimicrobial treatment in older patients with functional and/or cognitive impairment with bacteriuria and delirium and without local genitourinary symptoms or other systemic signs of infection (strong recommendation, very low-quality evidence). The next sentence should read “In this patient who cannot give a symptom history, a urinalysis seems a reasonable initial management step." (Added January 2022)
Oncology
Breast Cancer
Page 9: Ductal Carcinoma in Situ: The last sentence of the third paragraph should read: "Following bilateral mastectomy, adjuvant endocrine therapy is not indicated." (Added January 2022)
Page 10: Adjuvant Endocrine Therapy. The second sentence in the third paragraph should read: “Extended aromatase therapy up to 10 years increases disease-free survival in patients with high-risk features but does not have an impact on overall survival.” (Added March 2022)
Gastroenterological Malignancies
Page 18: Colon Cancer: The fourth key point should read: "Patients with stage II colon cancer that is microsatellite stable and lacks high-risk features are unlikely to benefit from adjuvant chemotherapy." (Added January 2022)
Genitourinary Cancer
Page 26: Epidemiology and Risk Factors. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Questions
Page 60, Question 40: The first sentence of the stem should read: "A 50-year-old woman is evaluated for heaviness and swelling of her right breast of 3 weeks' duration." (Added March 2022)
Pulmonary and Critical Care Medicine
Pulmonary Diagnostic Tests
Page 1: Pulmonary Function Testing. The text has been updated to acknowledge that the use of race as a variable in establishing predicted values for pulmonary function tests is inappropriate and that alternate means of describing norms have been proposed. (Added March 2022)
Airways Disease
Pages 5 and 7: Epidemiology and Natural History. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 14: Controller Medications: In the first full sentence at the top of page 14, the eosinophil counts given in SI units in parentheses have been corrected from "0.15 x 109/L" and "0.4 x 109/L" to "0.15 x 109/L" and "0.4 x 109/L." (Added January 2022)
Page 20: Other Agents. In the first sentence of the first paragraph, the word "inflammatory" has been changed to "anti-inflammatory." (Added March 2022)
Diffuse Parenchymal Lung Disease
Page 31: Sarcoidosis. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Common ICU Conditions
Page 78: Epidemiology of Sepsis. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 78: Management of Sepsis: In the first paragraph, "time-based metrics" has been changed to "the development of separately created time-based performance improvement metrics." The fourth sentence has been revised to read as follows: "In 2018, the 3- and 6-hour bundles were combined into a single 1-hour performance improvement bundle." Under the subheading "Initial Resuscitation," the first two sentences of the second paragraph have been revised to read as follows: "The Surviving Sepsis Campaign guidelines recommend early and aggressive fluid resuscitation for sepsis-induced hypoperfusion or shock with an initial bolus of 30 mL/kg of crystalloid fluid given within the first 3 hours of resuscitation. The 1-hour performance improvement bundle indicates that fluid bolus should be initiated within the first hour of presentation." (Added January 2022)
Questions
Page 102, Item 36: In the fourth sentence of the first paragraph of the stem, "21-pack-year history" has been changed to "15-pack-year history." (Added March 2022)
Page 115, Item 96: In the second sentence of the first paragraph of the stem, “On the day of admission,” has been changed to “Prior to admission” (Added May 2022)
Page 155, Item 68: In the first sentence of the fourth paragraph of the critique, the word "performed" has been changed to "initiated." (Added January 2022)
Rheumatology
Questions
Page 109, Question 43: This question has been updated as a result of postpublication analysis and/or new data that are relevant to the question. Option C has been changed from "Quadrivalent influenza" to "Recombinant influenza," and option E has been changed from "13-Valent pneumococcal conjugate" to "15-Valent pneumococcal conjugate". (Added May 2022)
Board Basics
Cardiovascular Medicine
Page 8: Study Table: Treatment of HFrEF. Some table content has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 30: Cardiac Physical Diagnosis, Heart Murmurs. The highlighted sentence beginning, "Signs of serious cardiac disease include..." has been revised to, "Signs of possible significant cardiac disease include..." (Added May 2022)
Endocrinology and Metabolism
Page 69: Pheochromocytoma, Don’t Be Tricked. The second sentence of this bullet point has been corrected to, “β-Adrenergic blockade before adequate α-adrenergic blockade can result in severe paroxysmal hypertension.” (Added July 2022)
Gastroenterology and Hepatology
Page 90: Chronic Pancreatitis, Diagnosis. The last bullet point in the list should read “endocrine pancreatic insufficiency (diabetes mellitus)” not “exocrine.” (Added July 2022)
General Internal Medicine
Page 120: Systemic Exertion Intolerance Disease, Diagnosis & Treatment. The first sentence under "Diagnosis" has been revised to state, "Systemic exertion intolerance disease (SEID) is defined as an impairment or reduction in the ability to engage in pre-illness activities lasting more than 6 consecutive months that is accompanied by fatigue and not alleviated by rest." The second sentence under "Treatment" has been revised to state, "Patients with SEID benefit most from a structured, multimodal approach that includes regularly scheduled office visits and that focuses on symptom and comorbid disease management." (Added March 2022)
Hematology
Page 217: Thrombophilia, Inherited Thrombophilia. The discussion has been revised to clarify that factor V Leiden mutation is the most common hereditary thrombophilia in those of European ancestry. (Added March 2022)
Nephrology
Page 269: Study Table: Presentation and Treatment of Alcohol Poisoning. For the row on "Ethanol," the Anion Gap should indicate "Possible" rather than "No." (Added March 2022)
Pages 271-272: Hypertension, Treatment. The text has been revised to acknowledge that race-based antihypertensive prescribing recommendations are under scrutiny. (Added February 2022)
Page 272: Hypertension, Treatment. The "Don't Be Tricked" point, "Thiazide diuretics are not effective in patients with kidney disease (GFR <30 mL/min/1.73 m2); select a loop diuretic" has been revised to, "Choose a loop diuretic rather than a thiazide diuretic for patients with GFR <30 mL/min/1.73 m2." (Added May 2022)
Page 274: Study Table: Common Causes of the Nephrotic Syndrome. The table has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added February 2022)
Rheumatology
Page 389: Study Table: Vasculitis Diagnosis. Some table content has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)
Page 390: Vasculitis, Don't Be Tricked. The second Don't be Tricked point has been revised for consistency. The point now reads, "Polyarteritis nodosa kidney disease does not involve the glomerulus (no urine erythrocyte casts, but hematuria and proteinuria may occur)." (Added May 2022)
Page 391: Vasculitis, Test Yourself. The text has been revised to remove epidemiologic information that is irrelevant to the discussion. (Added March 2022)