American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News
for the Week of 10-6-09

Highlights

  • Influenza: masks, bacteria and vaccination effectiveness
  • Evidence insufficient for use of nontraditional CHD risk factors in screening, task force finds

Test yourself

  • MKSAP Quiz: increasing asthma symptoms

Men's health

  • PSA screens need more discussion

Care management

  • At-home treatment for heart failure matches hospital

Pain control

  • Antidepressant combined with anticonvulsant effective for neuropathic pain

Low back pain

  • Many ‘red flag’ questions useless for diagnosing serious back problems

FDA update

  • Diabetes drugs get warning about pancreatitis
  • Heparin to be less potent

From the College

  • Physician, immunize thyself
  • New book on publishing and presenting in the sciences
  • Fellow to head federation of medical boards

Professional opportunities

  • HRSA needs grant reviewers

Cartoon caption contest

Physician editor: Vincenza Snow, FACP


Highlights

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Influenza: masks, bacteria and vaccination effectiveness

A comparison of surgical masks and N95 respirators, reports of bacterial co-infections, and evaluations of the effectiveness of widespread vaccination were among the top news about influenza last week.

Surgical masks were about as effective as N95 respirators in preventing influenza infection among health care workers in a recent randomized trial. More than 400 nurses in eight Ontario hospitals were assigned to wear either a fit-tested N95 respirator or a surgical mask when providing care to patients with febrile respiratory illness during the 2008-2009 influenza season. Influenza infection was measured by polymerase chain reaction or a fourfold rise in hemagglutinin titers. Influenza infection occurred in 50 nurses (23.6%) in the surgical mask group and 48 (22.9%) in the respirator group, an absolute risk difference of -0.73% (P=0.86). The results were published online Oct. 1 by the Journal of the American Medical Association.

The level of protection provided by the two kinds of masks appears to be similar in routine health care settings, although the results cannot be generalized to higher-risk procedures producing aerosolization, the study authors concluded. Current CDC recommendations call for N95 respirators for all health care worker contacts with influenza patients, although the agency is now reviewing its guidelines. According to an accompanying editorial, the JAMA study will likely not resolve debate on the issue, and should not distract from other means to prevent influenza spread in health care facilities, including hand hygiene, staying home from work when sick and vaccination of health care workers.

Vaccination against pneumococcus could play a role in reducing mortality from H1N1 influenza, according to the CDC's Morbidity and Mortality Weekly Report. An analysis of specimens from 77 patients who died of the pandemic strain this summer revealed that 22 of them (29%) had concurrent bacterial infections. Ten of the patients had pneumococcus. In addition to highlighting the benefits of vaccination, the findings underscore the importance of managing influenza patients who might also have bacterial pneumonia with both empiric antibacterial therapy and antiviral medications, the CDC said. The agency also released a 2009-2010 Influenza Season Triage Algorithm to assist physicians and those under their supervision in identifying indicators of and responses to symptoms of influenza-like illness in adults.

Annals of Internal MedicineIn the latest issue of Annals of Internal Medicine, researchers used mathematical models of New York City to forecast the effectiveness and cost-effectiveness of vaccination against the current H1N1 outbreak as well as a hypothetical pandemic of H5N1. In the case of an H5N1 pandemic, they concluded that expanded use of an adjuvanted vaccine would be worthwhile. As for the current influenza, the study concluded that vaccination would be effective in shortening the pandemic if about 40% of the population could be vaccinated in November, although the results would depend on when the epidemic peaks.

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Evidence insufficient for use of nontraditional CHD risk factors in screening, task force finds

Existing evidence does not support the use of nontraditional risk factors to screen for coronary heart disease in asymptomatic persons, according to the U.S. Preventive Services Task Force.

Current preventive treatment for coronary heart disease (CHD) is based on the Framingham risk score, which classifies patients as being at low, intermediate or high risk. It has been suggested that the risk model might be improved by the addition of nontraditional CHD risk factors, especially to further classify intermediate-risk patients as high or low risk. Researchers reviewed literature published since 1996 on nine proposed markers of CHD risk that are not included in the Framingham risk score: high-sensitivity C-reactive protein, ankle-brachial index, leukocyte count, fasting blood glucose, periodontal disease, carotid intimal thickness, electron-beam computed tomography, homocysteine and lipoprotein(a). The task force's findings appear in the Oct. 6 Annals of Internal Medicine.

Annals of Internal MedicineThe task force concluded that there was insufficient evidence to determine the percentage of intermediate-risk persons whose risk would be reclassified by screening with nontraditional factors. Although some patients were reclassified as high risk based on high-sensitivity C-reactive protein level and ankle-brachial index, researchers were not able to determine whether this group would benefit from additional interventions. Potential harms of screening with nontraditional risk factors include medication use without proven benefit and the psychological effects of being mistakenly classified as higher risk, the researchers noted. The task force wrote that clinicians should continue to use the Framingham risk score to assess CHD risk and guide therapy in their practice.

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Test yourself

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MKSAP Quiz: increasing asthma symptoms

MKSAP QuizA 75-year-old woman with a long-standing history of asthma is evaluated for increased nocturnal asthma symptoms and a frequent need to use an albuterol inhaler. Her treatment regimen now consists of daily moderate-dose inhaled corticosteroids. On physical examination she has occasional wheezing; the examination is otherwise unremarkable. Office spirometry shows a forced expiratory volume in 1 second (FEV1) of 2.2 L (75% of predicted).

Which of the following is the most appropriate adjustment to this patient's asthma therapy?

A) Doubling the inhaled corticosteroid dose
B) Adding theophylline
C) Adding a leukotriene receptor antagonist
D) Adding a long-acting β-agonist
E) Adding anti-IgE antibody

Click here or scroll to the bottom of the page for the answer and critique.

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Men's health

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PSA screens need more discussion

Physicians need to involve men more in the decision to undergo prostate-specific antigen (PSA) tests, concluded two studies and two editorials in Archives of Internal Medicine.

Clinicians strongly influence men's decisions to undergo PSA screening, but the conversations about screening fail to qualify as shared decision making because patients received more information about the pros than the cons, had limited knowledge of their importance, and were not routinely asked for their preferences.

In one study, researchers conducted a telephone survey of 375 men who had either undergone or discussed with clinicians PSA testing in the previous two years. Researchers assessed the character of the discussion, the patient's knowledge of prostate cancer and the importance of decision factors.

Almost 70% of patients discussed screening beforehand. Clinicians most often raised the idea of screening (64.6%), and 73.4% recommended PSA testing. Clinicians emphasized the pros of testing in 71.4% of discussions but addressed the cons in 32% of talks.

Researchers then asked the patients three questions to test their knowledge:

  • "Of every 100 men, about how many do you think will die of prostate cancer?"
  • "Of 100 men, about how many will be diagnosed as having prostate cancer at some time in their lives?"
  • "For every 100 times a PSA test result suggests the need for further testing, about how many times does it turn out to be cancer?"

Although 58% of patients reported they felt well-informed about PSA testing, 47.8% failed to correctly answer any of the three questions, and only 7.2% of respondents could correctly answer more than one.

Only 54.8% of subjects reported being asked for their screening preferences. The clinicians' recommendations were the only discussion characteristic associated with testing (odds ratio, 2.67; 95% CI, 1.08-6.58). "Indeed, few subjects sought second opinions," researchers wrote.

An editorial concluded the research was an important step in prompting discussion about the tradeoffs between overdiagnosis and treatment complications versus the benefits of reduced risk of prostate cancer-related mortality.

A second editorial chided, "Today's practice environment presents few incentives or support tools for those clinicians and patients who prefer a discussion rather than simply marking a checkbox for PSA on a laboratory requisition form." It also noted some physicians may not ask to screen beforehand, but instead piggyback PSA tests onto other bloodwork.

A second study aimed to support individual decision making by creating a model of the likely benefits and harms.

Researchers in Australia created a model for men aged 40, 50, 60, and 70 years at low, moderate and high risk for prostate cancer. A Markov model compared patients with and without annual PSA screening using a 20% relative risk in prostate cancer mortality as a best-case scenario. The model estimated numbers of biopsies, prostate cancers and deaths from prostate cancer per 1,000 men over 10 years and cumulated to age 85 years.

Benefits and harms vary substantially with age and familial risk, the model found. As an example, among 1,000 60-year-old men with low risk screened annually, 115 would undergo biopsy triggered by an abnormal PSA screen. Among screened men, 53 would be diagnosed with prostate cancer over 10 years, compared with 23 men diagnosed as having prostate cancer among 1,000 unscreened men.

Among screened men, 3.5 would die of prostate cancer over 10 years compared with 4.4 deaths in unscreened men. For every 1,000 men screened from 40 to 69 years of age, there would be 27.9 prostate cancer deaths and 639.5 deaths overall by age 85 years compared with 29.9 prostate cancer deaths and 640.4 deaths overall in unscreened men. Higher-risk men have more prostate cancer deaths but also incurred more prostate cancers diagnosed and related harms.

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Care management

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At-home treatment for heart failure matches hospital

Heart failure patients who were treated at home for acute decompensation of chronic heart failure (CHF) had similar outcomes to those admitted to the hospital, a new study found.

The Italian study was a randomized, controlled trial of the Geriatric Home Hospitalization Service, in which hospital professionals (including geriatricians, nurses, physiotherapists and a social worker and counselor) treated patients at their homes. The study participants were at least 75 years old and were admitted to the study hospital's emergency department for acute decompensation of CHF. They were then either admitted to the general medicine ward or the hospital-at-home program (which included education for patients and families and frequent physician and nurse visits).

The primary outcome, six-month mortality, was the same in the two groups, as was the number of hospital admissions during six-month follow-up. The patients treated at home had a longer mean time to their next admission (84.3 days vs. 69.8 days, P=0.02). The home group also showed improvements in depression, nutritional status and quality of life. Four of the home patients were transferred to the hospital during the study, but after discharge, all were at home, while 16% of the hospital group were discharged to long-term care facilities.

The study demonstrates that hospital-at-home care is a viable, efficacious alternative to hospitalization for acutely decompensated CHF, the study authors concluded. They noted that although the home patients were on average treated for longer than the inpatients, the mean total cost was lower for patients treated at home ($2,604 vs. $3,027). The study was published in the Sept. 28 Archives of Internal Medicine.

Despite its successes, wider dissemination of the hospital-at-home model is impeded by many factors, including Medicare reimbursements, hospital incentives, geriatrician shortages, and adaptability, according to an accompanying editorial that called for a broadening of the availability of these models and awareness campaigns to educate consumers about their benefits, since 46% of patients eligible for the study declined to participate.

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Pain control

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Antidepressant combined with anticonvulsant effective for neuropathic pain

Combining a tricyclic antidepressant with an anticonvulsant was more effective than treatment with either drug alone for neuropathic pain, according to results of a recent trial.

In the single-center, double-blind, double-dummy crossover trial, 47 patients with diabetic polyneuropathy or postherpetic neuralgia with daily pain scores of at least 4 on a 0-10 scale received either daily oral gabapentin, nortriptyline or a combination. A different drug was given to each randomized group in sequence during three treatment periods, and doses were titrated over six weeks. At the maximum tolerated dose, pain scores were 3.2 for gabapentin, 2.9 for nortriptyline and 2.3 for the combination treatment. The findings were published online Sept. 30 in The Lancet.

The results demonstrate that combining an antidepressant and an anticonvulsant may be better than monotherapy for neuropathic pain, the authors concluded. The combination treatment resulted in an increased percentage change in pain and reduced pain intensity. Of note, they said, was the improvement in sleep in those taking the combination.

At maximum dose, adverse events were similar across treatment groups except that dry mouth was more common in the combination and nortriptyline groups. The combination treatment was not superior to gabapentin for improvements in mood and depression scores, the authors said, suggesting that gabapentin has a mood-elevating effect independent of analgesia and that the combination treatment can improve mood better than nortriptyline alone.

While acknowledging that more research is needed, the authors recommended using gabapentin and nortriptyline together for patients who have a partial response to either drug alone and seek more pain relief.

An accompanying editorial noted that the results are welcome because of the urgent need for new chronic pain treatments. However, the study has two drawbacks in terms of clinical application, the editorialist noted: It does not tell physicians whether a pain-relieving effect of each drug alone is needed to achieve effect with the combination, and drugs in the study were given simultaneously instead of sequentially, which is most common in actual practice.

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Low back pain

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Many ‘red flag’ questions useless for diagnosing serious back problems

A study of low back pain in primary care found that recommended “red flag” screening questions are of little use in diagnosing serious disease.

Researchers followed a cohort of 1,172 consecutive patients receiving care for acute low back pain for up to 12 months in Australia. Physicians provided an initial diagnosis based on responses to 25 red flag questions at initial consultation. Even though most patients (80.4%) had at least one red flag, the prevalence of serious pathology was less than 1%. Only three of the red flags for fracture were informative: prolonged use of corticosteroids, age over 70 and significant trauma. Results appear in the October issue of Arthritis and Rheumatism.

The most common serious pathology observed during the study was vertebral fracture, researchers noted. A four-point prediction rule was moderately associated with the presence of fracture: female sex, age over 70, significant trauma and prolonged use of corticosteroids. Physicians identified half of the cases of serious pathology at the initial consultation.

Some red flags had very high false-positive rates, suggesting that they have little value in isolation, the authors said. For example, red flag questions such as “tried bed rest but no relief,” "morning back stiffness lasting more than 30 minutes” and “insidious onset” had high false-positive rates.

The high level of false-positives for some recommended red flags suggests that they are not useful in isolation, the authors said. An alternative approach might be to use multivariate statistical methods to evaluate a combination of red flags for serious pathology. The finding that age over 70, significant trauma and prolonged use of corticosteroids, combined with physician judgment, can identify fracture is consistent with past research, they added.

An accompanying editorial noted that too much focus on red flag questions can distract physicians from reassuring patients that most low back pain is benign and advising them to avoid bed rest and maintain normal activities. Indiscriminately using red flag symptoms can lead to unnecessary tests that can inflict more harm through radiation than benefits, especially considering that many tests produce false-positive results, the editorial continued.

Instead of recording every red flag, physicians should focus on a small number of disorders where early diagnosis and treatment make a big difference, such as cauda equina syndrome, major intra-abdominal pathology, focal infections and fractures. In the absence of sufficient data to create formal decision rules, the editorial said, diagnosis hinges on good physician judgment.

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FDA update

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Diabetes drugs get warning about pancreatitis

Changes have been made to the prescribing information for sitagliptin (Januvia) and sitagliptin/metformin (Janumet) because of reports of acute pancreatitis, the FDA said last week.

Eighty-eight post-marketing cases of acute pancreatitis, including two cases of hemorrhagic or necrotizing pancreatitis in patients using sitagliptin, were reported to the agency between October 2006 and February 2009. It is recommended that health care professionals monitor patients carefully for the development of pancreatitis after initiation or dose increases of sitagliptin or sitagliptin/metformin, the FDA said.

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Heparin to be less potent

The FDA announced a change to the United States Pharmacopeia monograph for heparin, effective October 1. The change, which comes in response to the 2007-2008 heparin contamination problem, will lessen the potential for contamination of heparin and harmonize the USP unit dose with the WHO International Standard unit dose, according to an FDA alert.

It will result in approximately a 10% reduction in the potency of the heparin marketed in the U.S. The change in potency may have clinical significance in some situations, such as when heparin is administered as a bolus intravenous dose and an immediate anticoagulant effect is clinically important. In such situations clinicians should consider the change in potency when making decisions about what dose to administer, the FDA said. The change is expected to be less clinically significant when heparin is administered subcutaneously due to the low and highly variable bioavailability associated with this route. Also, more heparin may be required to achieve and maintain the desired level of anticoagulation in some patients.

Heparin manufactured to meet the old and new USP monograph will likely be available simultaneously, with potential differences in potency. Products using the new potency definition are anticipated to be available on or after October 8. The FDA is working with the manufacturers of heparin to ensure that an appropriate identifier is placed on heparin made under the new USP monograph. Most manufacturers will place an “N” next to the lot number.

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From the College

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Physician, immunize thyself

Steven Weinberger, FACP, continues his monthly column for KevinMD.com, one of the Web's most influential medical blogs.

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New book on publishing and presenting in the sciences

ACP Press recently released "How to Write, Publish, & Present in the Health Sciences: A Guide for Clinicians & Laboratory Researchers," by Thomas A. Lang, MA.

"The purpose of this book is to introduce clinicians and laboratory researchers to the major types of written and visual communications they need to advance their careers," said Mr. Lang, an experienced medical writer and educator. "It also teaches the skills and strategies needed for preparing these communications to meet current professional standards."

Other topics include how to write effectively, how to write efficiently, and how to prepare drawings, photographs, and diagnostic images for publication in scientific journals. A chapter on tables and graphs includes a series of questions to guide authors in choosing the best way to communicate their data. The book also provides detailed insights on the ethics and procedures of publishing research in basic science and clinical research journals.

"How to Write, Publish, & Present in the Health Sciences: A Guide for Clinicians & Laboratory Researchers" can be ordered online at www.acponline.org/acppress. The book is also available at all major booksellers, both in stores and online, and electronically at www.acppress-ebooks.com. To order by phone, call 800-523-1546, ext. 2600 (M-F, 9:00 a.m.-5 p.m. ET).

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Fellow to head federation of medical boards

Humayun J. Chaudhry, FACP, has been named the new president and CEO of the Federation of State Medical Boards, the national non-profit organization representing the 70 state medical boards of the United States and a co-sponsor of the United States Medical Licensing Examination (USMLE). The previous president was James Thompson, MD, a surgeon. The interim president is Barbara Schneidman, MD, a psychiatrist. Dr. Chaudhry will assume the position in mid-October.

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Professional opportunities

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HRSA needs grant reviewers

The Health Resources and Services Administration is soliciting reviewers for primary care training grants.

The HRSA is anticipating a special request for Title VII applications this fall and an overall increase in new programs due to the American Recovery and Reinvestment Act's provision of additional training grants in primary care. Earlier this year the availability of $200 million to support grants, loans, loan repayment, and scholarships to expand the training of health care professionals was announced.

Grant reviewers are responsible for objectively evaluating and scoring applicants against published evaluation criteria. Reviewer selection for specific grant programs is based on knowledge, education and experience.

Serving as a reviewer entails participation in a three-day meeting that will likely be held in the Washington, D.C., area. HRSA handles all travel expenses, other related costs, and logistics for the meeting. Those selected to serve as reviewers will receive an honorarium. To register to serve as a grant reviewer, please visit HRSA's grant reviewer portal. For assistance, contact the HRSA Call Center at (877) 464-4772 or CallCenter@hrsa.gov.

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Cartoon caption contest

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And the winner is …

ACP InternistWeekly has compiled the results from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

This issue's winning cartoon caption was submitted by John P. Reed, FACP, of the Smithsburg Family Medical Center in Maryland. He is also our first repeat winner, having won the contest in April of this year. He will receive a $50 gift certificate good toward any ACP product, program or service. Readers cast 156 ballots online to choose the winning entry. Thanks to all who voted!

"Apparently, HIPAA now requires we keep personal health information from the patient as well."
The winning entry captured 59.6% of the votes.

The runners up were:
"We always cover the ears of the patient whenever we need to ask the nurse how to do something."
"As you may have surmised, palpation of the ears of a patient who presented with topical epoxy exposure is ill-advised."

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MKSAP answer and critique

The correct answer is D) Adding a long-acting β-agonist. This item is available online to MKSAP subscribers in the Pulmonary section, Item 11.

ACP's Medical Knowledge Self-Assessment Program (MKSAP) allows you to:

  • Update your knowledge in all areas of internal medicine
  • Prepare for ABIM certification or recertification
  • Support your clinical decisions in practice
  • Assess your medical knowledge with 1,200 multiple-choice questions

To order the latest edition of MKSAP, go online.

Having asthma symptoms two or more days per week (or two or more nights per month) indicates that the patient has persistent asthma. Patients with persistent asthma should all be treated with daily inhaled corticosteroids. When asthma is not adequately controlled on low- or moderate-dose inhaled corticosteroids, adding a long-acting β-agonist has been shown to be superior to doubling the corticosteroid dose in terms of improving asthma control and the patient's quality of life. Theophylline and leukotriene receptor antagonists are third-line drugs and should be considered in patients who are still symptomatic after adding a long-acting β-agonist. Recent concerns about the side effects of long-acting β-agonists have led some experts to recommend considering the leukotriene receptor antagonists or theophylline ahead of long-acting β-agonists. Anti-IgE therapy should be reserved for patients who have elevated IgE levels and uncontrolled symptoms despite high-dose inhaled corticosteroids and a long-acting β-agonist.

Although the benefits of long-acting β-agonists in asthma are well established, concerns about increased asthma-related deaths in patients using these agents have prompted a re-evaluation of their use. The FDA has mandated including a “black box” warning in the package insert for these drugs to warn patients about this possible risk. The National Asthma Education and Prevention Program (NAEPP) expert panel is revising its asthma treatment guidelines and is expected to address the proper placement of long-acting β-agonists in the stepwise approach to treatment of asthma.

Key Point

  • In patients with persistent asthma not adequately controlled with daily low- or moderate-dose inhaled corticosteroids, adding a long-acting β-agonist improves asthma control and quality of life.

Click here to return to the rest of ACP InternistWeekly.

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About ACP InternistWeekly

ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2009 by the American College of Physicians.

Test yourself

A 38-year-old man is evaluated for a mass in his right neck that he first noticed 2 weeks ago while shaving. The patient also reports experiencing a pressure sensation when swallowing solid foods for the past year and daily diarrhea for the past 2 months. His personal medical history is unremarkable. His younger brother has nephrolithiasis, and his father died of a hypertensive crisis and cardiac arrest at age 62 years while undergoing anesthesia induction to repair a hip fracture. Following a physical exam, lab studies, and a chest radiograph, what is the most likely diagnosis?

Find the answer

MKSAP 16® Holiday Special: Save 10%

MKSAP 16 Holiday Special:  Save 10%

Use MKSAP 16 to earn MOC points, prepare for ABIM exams and assess your clinical knowledge. For a limited time save 10% when you use priority code MKPROMO! Order now.

Maintenance of Certification:

What if I Still Don't Know Where to Start?

Maintenance of Certification: What if I Still Don't Know Where to Start?

Because the rules are complex and may apply differently depending on when you last certified, ACP has developed a MOC Navigator. This FREE tool can help you understand the impact of MOC, review requirements, guide you in selecting ways to meet the requirements, show you how to enroll, and more. Start navigating now.