MKSAP 15 Errata and Revisions (Updated December 2012)

Corrections have been made in MKSAP 15 Online but not in the print and CD-ROM versions of MKSAP 15. CD-ROM users should check the online version to identify the location of text errors.


Announcement: During a system upgrade between 5/11 and 5/13, some users submitted answers to questions that were not permanently stored. Please note that all CME and MOC submissions during this time are still valid, so you do not need to re-submit for credit. We sincerely apologize for any inconvenience this may have caused.

Cardiovascular Medicine

Page 24, left column, last sentence should be changed to: "For patients intolerant of an ACE inhibitor, an angiotensin blocker can be considered." (Added September 2011)

Page 44, Specific Therapies in the Treatment of Restrictive Cardiomyopathy: The first sentence of the first paragraph states that "restrictive cardiomyopathy from mutant-type transthyretin amyloidosis may regress with stem cell transplantation." This statement is incorrect and should be deleted. Similarly, in Table 17, "stem cell transplant" should be removed from the first row of the second column. (Added April 2011)

NEWPage 71, Valvular Heart Disease: The entries for "Mitral regurgitation" and "Mitral valve prolapse with mitral regurgitation" in Table 27, Cardiac Murmurs and Associated Findings, require clarification: With the second phase of the Valsalva maneuver (in which left ventricular volume is reduced), the murmur of mitral regurgitation is diminished owing to decreased flow across the valve; in mitral valve prolapse, the decreased left ventricular volume causes prolapse to occur sooner and with greater severity, moving the click associated with prolapse closer to S1 and accentuating the intensity and length of the murmur if regurgitation occurs. Maneuvers that increase left ventricular volume have an opposite effect. (Added December 2012)

Page 76, Acute Aortic Regurgitation: In the third sentence, "During cardiac auscultation, the S2 may be soft..." should be "During cardiac auscultation, the S1 may be soft..." (Added September 2011)

Page 79, The last sentence in column 2 should read: "Oral prophylaxis is a single 2-g dose of amoxicillin taken 30 to 60 minutes before the procedure. Options for patients allergic to penicillins or ampicillins include cephalexin (2 g), clindamycin (600 mg), or azithromycin or clarithromycin (500 g)." (Added March 2010)

Page 192, Item 85: In the first paragraph of the critique, the sixth sentence discussing American College of Cardiology/American Heart Association recommendations regarding surgery for asymptomatic patients with severe aortic regurgitation is incorrect. Surgery is recommended when the left ventricular ejection fraction is 50% or less, not less than 60%. The corresponding Key Point should also be corrected such that the end of the sentence reads "...or the left ventricular ejection fraction is 50% or less. (Added April 2011)

Page 159, left column, 1st sentence in the 2nd full paragraph under Item 26: "In patients with acute myocardial infarction with reduced left ventricular function (ejection fraction ≥40%)" should read "≤40%." (Added July 2010)

Page 195, Item 91: Although high-sensitivity C-reactive protein (hs-CRP) levels may be used at the discretion of the physician for directing further therapy of patients with an intermediate risk of a cardiovascular event, the U.S. Preventive Services Task Force has concluded that the current evidence is insufficient to recommend for or against using nontraditional risk factors (including hs-CRP) to screen asymptomatic patients with no history of cardiovascular disease. [PMID: 19805770] (Added July 2010)


Dermatology

Page 39 states that lentigo maligna is the most common form of melanoma. This statement is based upon results of a study performed in a single dermatopathology practice in south Texas serving primarily active and retired military personnel and their dependents. The results of this study may not be generalizable to all patients with melanoma of different ages and located in different parts of the country. (Added July 2010)

Page 102, Item 14: In the left column, the word "metacarpal" should be "metatarsal" in the sentence "Neuropathic ulcers are often associated with peripheral neuropathy, appear over pressure points such as the metacarpal joints, and may have a hyperkeratotic border." (Added July 2010)


Endocrinology and Metabolism

Page 1, The last sentence of paragraph 4 states that "A recent expert committee statement recommended that the hemoglobin A1c test be used to diagnose diabetes, but major professional organizations have not yet endorsed this recommendation." Since publication of MKSAP 15, the American Diabetes Association, the American Association of Clinical Endocrinologists, and the American College of Endocrinology have endorsed the use of an A1c value of 6.5 or greater as an additional way of diagnosing diabetes mellitus.

The current criteria for diagnosing diabetes mellitus, which update those appearing in Table 2 (Diagnostic Criteria for Diabetes Mellitus and Prediabetic States), page 2, of MKSAP 15 Endocrinology and Metabolism, are provided below:

  1. A1c value ≥6.5%. The test should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program–certified and standardized to the Diabetes Control and Complications Trial assay.*
    OR
  2. Fasting plasma glucose level ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*
    OR
  3. Two-hour plasma glucose level ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g of anhydrous glucose dissolved in water.*
    OR
  4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose level ≥200 mg/dL (11.1 mmol/L).
*In the absence of unequivocal hyperglycemia, criteria 1 through 3 should be confirmed by repeat testing. (Added March 2010)

Page 51, Figure 12: The words "or gonadotropins" should not appear in the left-hand bottommost box ("Algorithm for evaluating male hypogonadism"). (Added April 2011)

Page 61, Table 29: At the bottom of the first column, "Artifactual hypoglycemia..." should be "Artifactual hypocalcemia...". (Added November 2010)

Page 72, Item 5: The follicle-stimulating hormone value listed under "Laboratory studies" should be 5 mU/mL (5 U/L). (Added July 2012)

NEWPage 114, Item 29: In the third sentence of the critique, the parenthetical words "serum hypo-osmolality, and hyperosmolar urine" should be replaced with "plasma hyperosmolality, and urine hypo-osmolality." (Added December 2012)


Gastroenterology and Hepatology

Page 7, Table 4, the third column head should read "5-year Survival Rate (%)" not "5-Year Mortality Rate (%). (Added March 2010)

Page 45, first column, last sentence of first paragraph: "chloride channel antagonist" should be "chloride channel agonist." (Added March 2012)

Page 75, second column, second full sentence: "penicillamine" should be "penicillin." (Added April 2011)


General Internal Medicine

Page 3, Breast Cancer Screening: In a recommendation statement published in November 2009, after MKSAP 15 General Internal Medicine went to press, the U.S. Preventive Services Task Force (USPSTF) issued revised recommendations regarding breast cancer screening. The revised guidelines can be accessed at http://www.annals.org/content/151/10/716.full. (Added March 2010)

Page 56, Bursitis: At the bottom of the first column, the first clause of the 5th sentence should be changed from "The suprapatellar bursa sits directly under the distal portion of the gastrocnemius muscle" to "The suprapatellar bursa sits directly under the distal portion of the quadriceps muscle." (Added November 2010)

Page 82, bottom of column 1: In the following statement, the relative cardiovascular risks of oral contraceptive pills versus hormone replacement therapy were mischaracterized: "Because the estrogen dose in OCPs is usually significantly lower than what has been used in postmenopausal estrogen replacement, the cardiovascular risks are not as great, although there is still a greater risk of myocardial infarction for women older than 35 years who smoke or have hypertension." This sentence should be changed to "OCPs carry an increased risk of myocardial infarction for women older than 35 years who smoke or have hypertension." (Added September 2011)

Page 111, Mental and Behavioral Health, Depression, Treatment: In the second column, first full paragraph, second to the last sentence: "Patients with no response should be switched to a different category of drug or to psychotherapy." This sentence should be changed to: "Patients with no response to one type of agent should be switched to a different agent from within the same class of antidepressants, to an agent from a different class, to augmentation with a second agent, or to psychotherapy." (Added November 2010)

Page 173, Item 12: In the second paragraph of the Critique it states that "No randomized trial has compared varenicline with nicotine replacement therapy alone." In fact, there has been one randomized, open-label trial that demonstrated varenicline was somewhat more effective compared with the nicotine patch. The study is Aubin HJ, Bobak A, Britton JR, Oncken C, Billing CB Jr, Gong J, Williams KE, Reeves KR. Varenicline versus transdermal nicotine patch for smoking cessation: results from a randomised open-label trial. Thorax. 2008 Aug;63(8):717-24. Epub 2008 Feb 8. PubMed PMID: 18263663; PubMed Central PMCID: PMC2569194. This Cochrane review also includes the following study: Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006103. Review. PubMed PMID: 18646137. The greatest weakness of the study was that documentation of abstinence from smoking was by self-report. Nevertheless, this study contradicts the content of the Critique, but the keyed (correct) answer is unchanged. (Added March 2010)


Hematology and Oncology

Page 27, left column, line 6: "Hemoglobin H disease (γ4)..." should read "Hemoglobin H disease (β4)..." (Added March 2010)

Page 56, left column, first line should read: "Gestational anemia is defined as hemoglobin levels less than 11.0 g/dL (110 g/L) in the first and third trimesters and less than 10.5 g/dL (105 g/L) in the second trimester." (Added September 2011)

Page 98, Table 41: In the second row under the heading "IPI (for Large Cell Carcinoma)," Stage I or II should read stage III or IV. In addition, the performance status (third row) should be 2 or greater, not 0 or 1. (Added March 2012)

Page 115, Item 11: The correct answer should be Plasmapheresis, not Plasma exchange. (Added September 2011)

Page 130, Item 64: Last line of the second paragraph should read: "Neurologic examination reveals constriction of the left pupil and ptosis," not right pupil and ptosis. (Added September 2011)

Page 145, Item 11: Last sentence of the first paragraph: "Plasmapheresis (not Plasma exchange) is indicated for managing acute symptoms in conjunction with managing acute symptoms in conjunction with administration of rituximab or fludarabine for treating the lymphoplasmacytic lymphoma." Similarly, in the Key Point: "Plasmapheresis (not Plasma exchange) is appropriate for treating hyperviscosity syndrome, and rituximab or fludarabine is indicated for specific treatment of lymphoplasmacytic lymphoma (Walderström macroglobulinemia)." (Added March 2012)


Infectious Disease

Page 30, left column, "Treatment" section and page 156, item 87: It is stated that the standard treatment for active tuberculosis is "four-drug therapy with isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months, followed by de-escalation of antimicrobial therapy once drug susceptibility of isoniazid and rifampin is established. These agents are then continued for 7 months, totaling a 9-month treatment course."

This is not correct. The standard regimen is 2 months of the four-drug therapy followed by 4 months of isoniazid and rifampin, for a total treatment duration of 6 months. Total treatment of 9 months is used if there is delayed clinical response in cavitary disease, no pyrazinamide for the induction phase, or in other situations based on clinical judgment (pleural disease, uncontrolled HIV infection, etc). (Added September 2011)

Page 38, Table 24: The entry for Pelvic Inflammatory Disease under the Chlamydial Infections heading states "Ceftriaxone 250 mg IM in a single dose; or ceftriaxone 2 g IM once plus probenecid..." It should read "Ceftriaxone 250 mg IM in a single dose; or cefoxitin 2 g IM once plus probenecid..." (Added March 2010)

Page 50, Table 27, second row, first column: "Mefloquine (250 mg daily)" should state "Mefloquine (250 mg weekly)." (Added September 2011)


Nephrology

NEWPage 23, Hyperkalemic Distal Renal Tubular Acidosis: The last sentence of the first paragraph states: "Patients in whom this condition is caused by a defect in mineralocorticoid activity typically have a urine pH higher than 5.5." This should read: "Patients in whom this condition is caused by a defect in mineralocorticoid activity typically have a urine pH less than 5.5." (Added December 2012)

Page 24, Renal Tubular Acidosis of Kidney Insufficiency: the sentence "Initiation of sodium bicarbonate once the serum sodium level decreases to less than 22 meq/L" should read "Initiation of sodium bicarbonate once the serum bicarbonate level decreases to less than 22 meq/L." (Added November 2010)

Page 26, Mixed Metabolic Disorders: The corrected bicarbonate level should be 24 ± 2 meq/L (24 ± 2 mmol/L), not 24 + 2 meq/L (24 + 2 mmol/L). The "+" should be "±". (Added April 2011)

Page 35, Secondary Hypertension: The statement "The most common causes of renovascular hypertension include kidney disease, primary aldosteronism, renovascular disease, and pheochromocytoma" should be "The most common causes of secondary hypertension include. . . ." (Added April 2011)

Page 45, The Nephritic Syndrome: The last sentence in the first paragraph states:"Urinalysis usually reveals pyuria and cellular and granular casts , and nephrotic-range proteinuria is often present." This should read: "Urinalysis usually reveals dysmorphic erythrocytes, acanthocytes, and erythrocyte casts. Proteinuria, sometimes in the nephrotic range, is usually present, but can be in the normal range." (Added April 2011)

NEWPage 71, Table 31. In the fifth column, "Familial hypocalciuric hypocalcemia" should be "Familial hypocalcemic hypercalciuria" and "Idiopathic hypercalciuria (can also be sporadic)" has been added in the sixth column. (Added December 2012)

Page 104, Item 22. The patient described in the clinical scenario does not have hypertension as defined by the Seventh Report of the Joint National Committee (JNC 7), which is based on the average of two or more properly measured readings at each of two or more visits after an initial screen; therefore, option A (lisinopril and hydrochlorothiazide) is not the correct answer. The following information should have been included in the clinical scenario: "After 5 minutes, the blood pressure remains at 160/100 mm Hg." Also, the correct answer should be Option D, which should read "Reevaluation of blood pressure in 1 month." (Added November 2010)

Page 113, Item 52: In the third paragraph, the glucose level mistakenly reads 120 mg/dL (120 mmol/L). It should be 120 mg/dL (6.66 mmol/L). (Added July 2010)


Neurology

Page 11, Figure 6: The legend should read: "Diffusion-weighted MRIs (top) and perfusion-weighted MRIs (bottom) illustrate a diffusion-perfusion mismatch." (Added November 2010)

Page 57, Table 24: In the "Notes" column to the right of the agent Natalizumab, the capital epsilon at the end of TOUCH should be a trademark symbol (TOUCH).(Added March 2010)

Page 94, Item 21: The second sentence of the last paragraph, which currently reads "A CT scan of head obtained within an hour of his arrival reveals no early ischemic changes" should read "A CT scan of head obtained within an hour of his arrival reveals no early ischemic changes, but there is evidence of a hyperdense left middle cerebral artery lesion." (Added July 2012)


Pulmonary and Critical Care Medicine

Page 37, last sentence of the first column: The word "serum" should be deleted. (Added April 2011)

Page 69, Figure 13: The figure legend is incorrect and should read: "Flow-time curve of a mechanically ventilated patient. Note at point D that expiratory flow continues as inspiration starts, indicating incomplete expiration. This pattern suggests the presence of auto (intrinsic) positive-end expiratory pressure, which would be confirmed by the measurement of airway pressure during an end-expiratory pause. A-B: inspiration; B: end of inspiration, beginning of exhalation; B-C-D: expiratory flow. Reproduced with permission from Raoof S, Khan FA. Mechanical ventilation manual. Philadelphia. Copyright American College of Physicians, 1998." (Added November 2010)

NEWPage 72, Activated Protein C section: This content is no longer valid because activated protein C (drotrecogin alfa activated) has been withdrawn from the market. For further information, please see http://www.fda.gov/Drugs/DrugSafety/ucm277114.htm. (Added December 2012)

NEWPage 73, right-hand column, second key point: This key point is no longer valid because activated protein C (drotrecogin alfa activated) has been withdrawn from the market. For further information, please see http://www.fda.gov/Drugs/DrugSafety/ucm277114.htm. (Added December 2012)

Page 77 (in the print version), second to last sentence of the first paragraph, "hypothermia" should be "hyperthermia." (Added April 2011)

Page 101, Item 44: This question is no longer valid because activated protein C (drotrecogin alfa activated) has been withdrawn from the market. For further information, please see http://www.fda.gov/Drugs/DrugSafety/ucm277114.htm. (Added March 2012)

NEWPage 111, Item 86: This question is no longer valid because activated protein C (drotrecogin alfa activated) has been withdrawn from the market. For further information, please see http://www.fda.gov/Drugs/DrugSafety/ucm277114.htm. (Added December 2012)

Page 145, Item 64: In the right column, the text in the Critique and Key Point states "...initial screening with supine and upright abdominal radiographs to look for air-fluid levels, suggestive of a perforated viscus, should be done." It should say "...initial screening with supine and upright abdominal radiographs to look for air-fluid levels, suggestive of a bowel obstruction, and free peritoneal air, suggestive of a perforated viscus, should be done." (Added March 2010)


Rheumatology

Page 23, Figure 9: The diagram shown mistakenly depicts the metacarpophalangeal (MCP) joint as having osteoarthritic involvement. The carpometacarpal joint, which is the circle directly above the MCP joint in the diagram, should have been shaded to show osteoarthritic involvement. (Added March 2010)

Page 55, Table 15: In the list of streptococcal organisms that can cause septic arthritis, Streptococcus pyogenes and Streptococcus pneumoniae are incorrectly categorized as non-group A β-hemolytic streptococcal organisms. Streptococcus pyogenes is a group A streptococcal organism, and Streptococcus pneumoniae is an α-hemolytic streptococcal organism. (Added November 2010)

Page 60, Table 17: Under the Inclusion Body Myositis entry, "A combination of proximal and distal weakness that may be asymmetric" should read "A combination of proximal and distal weakness that is typically symmetric." (Added March 2012)

Page 64, Table 19: In the microscopic polyangiitis row under the heading Small-Vessel Vasculitis, "c-ANCA positivity" should read "p-ANCA positivity." (Added November 2010)

Page 118, Item 31 Critique (second sentence): "This condition typically manifests as muscle weakness that affects the proximal and distal muscles and often has an asymmetric pattern of involvement" should read "This condition typically manifests as muscle weakness that affects the proximal and distal muscles and typically has a symmetric pattern of involvement." (Added March 2012)

Page 138, Item 69: The Educational Objective reads "Manage suspected reactivation tuberculosis." It should read "Diagnose and treat a patient at risk for latent tuberculosis." (Added March 2010)


Normal Laboratory Values

Creatinine: The conversion factor used to calculate SI laboratory value units was incorrect. The correct SI conversion factor is 88.4. (Added March 2010)

D-Dimer: The SI conversion should be 0.5 mg/L, not 500 mg/L. (Added April 2011)

Ferritin: Ferritin SI units were incorrectly presented as "mg/L" in some instances. The appropriate presentation of ferritin SI units is "μg/L." The SI conversion values themselves are correct. (Added March 2010)


Board Basics 2

Page 8: The statement indicating that Prinzmetal angina is associated with ST-segment "depression" should be changed to ST-segment "elevation." (Added March 2010)

Page 21: "Murmurs due to HCM increase in intensity during the Valsalva maneuver and on standing from a squatting position." (Added July 2010)

Page 79, line 4 states that: "Hyponatremia and hypokalemia are associated with primary adrenal insufficiency." This should be changed to "Hyponatremia and hyperkalemia are associated with primary adrenal insufficiency." (Added March 2010)

Page 169, Study Table: Compensatory Response to a Primary Acid-Base Disturbance: In the "Metabolic alkalosis" row, the units of measure for PaCO2 and HCO3 are reversed. The cell under "Expected Compensation" should read, "1 mm Hg ↑ in PaCO2 for each 0.7 meq/L ↑ in HCO3." (Added July 2012)

Page 209, Study Table: Colon Cancer Screening: Delete the following phrase where it is used a second time: "First-degree relative diagnosed with adenomatous polyp or colon cancer ≤50." (Added March 2010)

Page 230: The last sentence "DLCO is normal in patients with asthma, acute bronchitis, and carbon dioxide poisoning" is incorrect. The corrected sentence should read "DLCO is normal in patients with asthma and acute bronchitis." (Added March 2010)


MKSAP 15 Self-Assessment Updates

Update 2, Dermatology Item 3: The correct answer should be option (A) In situ melanoma. (Added April 2011)

Update 2, Endocrinology and Metabolism Item 11: The lead-in statement ("Which of the following is the most appropriate treatment?") should read "In addition to discontinuing glimepiride, which of the following is the most appropriate treatment?" (Added July 2012)

Update 4, General Internal Medicine Item 6: In the critique, third paragraph, the last sentence should be changed from "This patient is 55 years old and is therefore too young to receive the zoster vaccine." to "Although the zoster vaccine is approved for use in persons aged 50 years and older, it is not currently recommended for routine use by persons younger than 60 years, and, therefore, is not the correct option for this 55-year-old patient." (Added July 2012)