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

Advertisement

ACP InternistWeekly



In the News for the Week of 2-28-12




Highlights

Rapid flu tests more accurate when positive, but negative results require confirmation

Rapid influenza diagnostic tests were more accurate at diagnosing the flu than ruling it out in a new study, indicating that patients with a negative result would need additional testing. More...

Conjugate pneumonia vaccines cost-effective for adults, model finds

Vaccinating adults with the 13-valent pneumococcal conjugate vaccine (PCV13) may be more cost-effective than vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23), a new study found. More...


Test yourself

MKSAP Quiz: recurrent, bilateral eye pain and redness

This week's quiz asks readers to evaluate a 25-year-old woman with recurrent, bilateral eye pain and redness. More...


Cardiology

Different MI presentations between the sexes diminish with age, observational study finds

Women who have a myocardial infarction (MI) are more likely than men to present without chest pain and have higher mortality than men of the same age, but the differences faded with age, researchers found in an observational study. More...


Gastroenterology

Further evidence indicates screening colonoscopy reduces mortality and may detect more adenomas than fecal occult blood testing

Two new studies provided evidence of colonoscopy's effectiveness at detecting cancer and reducing mortality. More...


Sinusitis

Amoxicillin no better than placebo for symptom relief in uncomplicated acute sinusitis

Amoxicillin did not reduce symptoms of sinusitis compared with placebo, according to a recent study. More...


CMS update

Problems with eRx hardship exemptions

CMS is having trouble keeping up with the volume of physician applications for eRx hardship exemptions, the agency announced. More...


Education and certification

NCQA to recognize medical home neighbors

The National Committee for Quality Assurance (NCQA) has recently announced the development of a specialty practice recognition program related to the patient-centered medical home. More...

Intensive training seminar on consumer and patient engagement offered

The National Partnership for Women and Families/Campaign for Better Care, along with Emory Healthcare, is co-sponsoring an intensive seminar, "Hospitals and Communities Moving Forward with Patient- and Family-Centered Care." More...

Correctional health care conference to be held in May

The National Commission on Correctional Health Care will hold a conference on updates in correctional health care May 19-22 in San Antonio, Texas. More...


From ACP Hospitalist

The February issue is now online

February's ACP Hospitalist is now online, with stories about managing pressure ulcers, incorporating the arts in the hospital, and spotting untreated bowel disorders. More...


From the College

ACP pledges support for Joining Forces

The American College of Physicians is pleased to announce it has joined the Joining Forces campaign. More...

ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a job seeker's profile to the ACP Job Placement Center, a service available at Internal Medicine 2012, to be held April 19-21 in New Orleans. More...

Join ACP's online discussion groups for members

ACP members are invited to participate in ACP's Special Interest Groups, a private online community that allows members to share experiences, questions and creative solutions with like-minded physicians at their own convenience. More...


Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for our new cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service. More...


Physician editor: Daisy Smith, MD, FACP



Highlights


.
Rapid flu tests more accurate when positive, but negative results require confirmation

Rapid influenza diagnostic tests (RIDTs) were more accurate at diagnosing the flu than ruling it out in a new study, indicating that patients with a negative result would need additional testing.

annals.jpg

Researchers reviewed 159 published studies to determine the accuracy of RIDTs in diagnosing flu in adults and children presenting with flu-like symptoms. RIDTs were defined as any commercially available assay that identified flu antigens or neuraminidase activity in respiratory specimens through simple immunochromatographic formats. In all studies, RIDTs were tested against one of two accepted reference standards. Results appeared online Feb. 27 at Annals of Internal Medicine.

Specificity was more consistent across studies than sensitivity, with specificity estimates ranging from 50.5% to 100% and sensitivity estimates ranging from 4.4% to 100%. For all RIDTs, the pooled sensitivity from bivariate random-effects regression was 62.3% (95% CI, 57.9% to 66.6%) and the pooled specificity was 98.2% (95% CI, 97.5% to 98.7%). This corresponds to a positive likelihood ratio of 34.5 (95% CI, 23.8 to 45.2) and a negative likelihood ratio of 0.38 (95% CI, 0.34 to 0.43).

Subgroup analyses showed a higher pooled sensitivity in children (66.6%; 95% CI, 61.6% to 71.7%) compared with adults (53.9%; 95% CI, 47.9% to 59.8%; P<0.001). Pooled sensitivity differences between children and adults remained statistically significant when adjusted for brand of RIDT, specimen type or reference standard. Virus type also had an effect on the accuracy of RIDTs. The tests had better sensitivity for detecting influenza A (64.6%; 95% CI, 59.0% to 70.1%) than influenza B (52.2%; 95% CI, 45.0% to 59.3%; P=0.05).

The authors noted that a positive test is unlikely to be a false-positive result, allowing clinicians to confidently diagnosis and treat the flu.

"RIDTs fill a void at the point of care that no other test is likely to fill in the near future: as a first-line test to be confirmed (especially if negative) by more time-consuming, definitive testing," they wrote. "As long as clinicians understand the limitations of RIDTs, namely that a negative result is unreliable and should be confirmed by using culture or RT-PCR [reverse transcription polymerase chain reaction], RIDTs could enable clinicians to institute prompt infection-control measures, begin antiviral treatment in high-risk populations, and make informed decisions about further diagnostic investigations."

A second meta-analysis also published by Annals on Feb. 27 concluded that oral oseltamivir and inhaled zanamivir may provide a net benefit over no treatment for influenza in high-risk populations, although quality of evidence was low due to study designs.

Oral oseltamivir compared with no treatment reduced mortality in high-risk populations (odds ratio [OR], 0.23; 95% CI, 0.13 to 0.43), hospitalization (OR, 0.75; 95% CI, 0.66 to 0.89) and duration of symptoms (33 hours; 95% CI, 21 to 45 hours). For every 1,000 patients, approximately 12 patients require hospitalization, and oral oseltamivir treatment can reduce this by 3 to 9 per 1,000 patients. Earlier treatment with oseltamivir was generally associated with better outcomes.

Inhaled zanamivir led to shorter symptom duration (23 hours; 95% CI, 17 to 28 hours) and fewer hospitalizations (OR, 0.66; 95% CI, 0.37 to 1.18) but more complications than no treatment. Direct comparison of oral oseltamivir and inhaled zanamivir does not suggest important differences in key outcomes, the authors said.

Although there is low to very low confidence in the estimates of effect, randomized controlled trials and "the substantial burden of influenza disease worldwide" lends importance to the findings, the authors wrote.

"The potential positive effect of earlier rather than later administration of oseltamivir on death in hospitalized patients and suggestions that pregnant women, children and patients who are immunocompromised may also benefit from treatment are among the key contributions of our study," they wrote. "In addition, we found moderate quality evidence for the reduction in signs and symptoms from treatment with inhaled zanamivir compared to no treatment."


.
Conjugate pneumonia vaccines cost-effective for adults, model finds

Vaccinating adults with the 13-valent pneumococcal conjugate vaccine (PCV13) may be more cost-effective than vaccination with the 23-valent pneumococcal polysaccharide vaccine (PPSV23), a new study found.

The findings were based on a Markov model of hypothetical cohorts of U.S. 50-year-olds, using current data (from the Centers for Disease Control and Prevention, the National Hospital Discharge Survey and the National Health Interview Survey, among other sources) and expert estimates. Researchers calculated the number of pneumococcal disease cases that would be prevented by various vaccination strategies and calculated the resulting gains in quality-adjusted life-years (QALYs). The results were published in the Feb. 22/29 Journal of the American Medical Association.

If PCV13 were simply substituted for PPSV23 in current recommendations (vaccination at age 65 or younger if comorbidities are present), the cost per QALY would be $28,900 with PCV13 compared to $34,000 with PPSV23. If vaccination recommendations were increased to routine vaccination at age 50 and 60, PCV13 would cost $45,100 per QALY, the researchers calculated. They found overall that PCV13 vaccination compared favorably with PPSV23 and thus concluded that a change in vaccine recommendations might lead to a cost-effective reduction in pneumococcal disease burden.

However, the study was limited by the lack of data about the vaccines' effects, the authors noted. For example, if PCV13 were found to have low effectiveness against nonbacteremic pneumococcal pneumonia (NPP), it would not compare as well against PPSV23. Or, if recent recommendations to vaccinate children with PCV13 create a large amount of herd protection for adults, that would affect the value of vaccinating adults with PCV13. The researchers expressed optimism than current trials will provide more data on these questions.

However, an accompanying editorial noted that the difficulty of accurately diagnosing NPP makes a clear answer to that question unlikely. Policymakers will have to decide on a vaccination strategy without definitive data, the editorialist said, adding that analyses such as this one may provide a reasonable framework for the decision. Whatever is decided, ongoing advances in vaccines appear likely to reduce the burden of pneumococcal infections, he concluded.



Test yourself


.
MKSAP Quiz: recurrent, bilateral eye pain and redness

A 25-year-old woman presents for evaluation of recurrent, bilateral eye pain and redness. Symptoms began several months ago without a specific inciting event. With each episode, she has deep or boring pain that is constant and has awakened her from sleep. She has had photophobia, tearing, and decreased vision during the episodes.

mksap.jpg

Vital signs are normal. Visual acuity is 20/40 bilaterally. There is photophobia. The pupils are equal, round, and reactive to light. Extraocular movements are intact but painful. The corneas appear clear. On the lateral aspect of both eyes, there is a localized area of raised erythema, with superficial blood vessels coursing over top of erythema but no white sclera visible between the blood vessels. There is no discharge or crusting of the lids.

Which of the following is the most likely diagnosis regarding her eyes?

A) Episcleritis
B) Scleritis
C) Subconjunctival hematoma
D) Uveitis
E) Viral conjunctivitis

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


.

Cardiology


.
Different MI presentations between the sexes diminish with age, observational study finds

Women who have a myocardial infarction (MI) are more likely than men to present without chest pain and have higher mortality than men of the same age, but the differences faded with age, researchers found in an observational study.

To examine the relationship among sex, symptoms and hospital mortality, researchers conducted an observational study from the National Registry of Myocardial Infarction, an industry-funded registry of more than 1.1 million patients. In the study, 42% of patients were women, and they were significantly older than men at hospital presentation, with a mean age of 73.9 versus 66.5 years (P<0.001).

Researchers recorded the presence of chest pain (defined as any symptom of chest discomfort, sensation or pressure, or tightness) or arm, neck, or jaw pain occurring before coming to the hospital and receiving a diagnosis of MI. Results appeared in the Feb. 22/29 Journal of the American Medical Association.

The percentage of MI patients who presented without chest pain was 35.4% (95% CI, 35.4% to 35.5%) and was significantly higher among women than men (42.0% [95% CI, 41.8% to 42.1%] vs. 30.7% [95% CI, 30.6% to 30.8%]; P<0.001).

Multivariable analyses showed that sex-specific differences in MI presentation without chest discomfort decreased with advancing age. Odds ratios were broken down by age brackets comparing women to men (P<0.001 for trend):

  • younger than age 45 years, 1.30 (95% CI, 1.23 to 1.36);
  • age 45 to 54 years, 1.26 (95% CI, 1.22 to 1.30);
  • age 55 to 64 years, 1.24 (95% CI, 1.21 to 1.27);
  • age 65 to 74 years, 1.13 (95% CI, 1.11 to 1.15); and
  • age 75 years or older, 1.03 (95% CI, 1.02 to 1.04).

In-hospital mortality was 14.6% for women and 10.3% for men. Younger women presenting without chest pain had higher hospital mortality than younger men without chest pain. Again, these sex differences decreased (or even reversed) as patients aged. Odds ratios for mortality comparing women to men were:

  • age younger than 45 years, 1.18 (95% CI, 1.00 to 1.39);
  • age 45 to 54 years, 1.13 (95% CI, 1.02 to 1.26);
  • age 55 to 64 years, 1.02 (95% CI, 0.96 to 1.09);
  • age 65 to 74 years, 0.91 (95% CI, 0.88 to 0.95); and
  • age 75 years or older, 0.81 (95% CI, 0.79 to 0.83).

The three-way interaction (sex, age, and chest pain) on mortality was significant (P<0.001).

Absence of chest pain may be a more important predictor of death in younger women with MI compared with other similarly aged groups, the authors concluded. "Younger women who experience MI may have significantly less narrowing of the coronary arteries than older women or men, possibly because of a hypercoagulable state, inflammation, coronary spasm, or plaque erosion vs. rupture," they wrote. Another possible explanation is sex differences in cardiovascular risk factors, they added.



Gastroenterology


.
Further evidence indicates screening colonoscopy reduces mortality and may detect more adenomas than fecal occult blood testing

Two new studies provided evidence of colonoscopy's effectiveness at detecting cancer and reducing mortality.

The first study included 2,602 patients who had adenomas removed during colonoscopy between 1980 and 1990. In the median 15-year follow up, 1,246 patients died of any cause and 12 of colorectal cancer. Researchers compared those findings to expected rates of colon cancer mortality in the general population and found that about half as many polypectomy patients died than would be expected (incidence-based mortality ratio, 0.47; 95% CI, 0.26 to 0.80). Patients with adenomas and patients with nonadenomatous polyps had similar mortality rates, although with a large confidence interval (relative risk, 1.2; 95% CI, 0.1 to 10.6).

The study authors noted that the results may underestimate the effect of colonoscopy, because they used data from the general population and patients with adenomas are at higher risk. However, the study also included only well-trained gastroenterologists and thus may not be generalizable in the community. Still, the authors concluded that the results support current recommendations for screening colonoscopy.

The second study compared colonoscopy and fecal immunochemical testing (FIT) in a randomized trial of more than 50,000 asymptomatic Spanish adults ages 50 to 69. Participants were invited to one colonoscopy or FIT every two years. According to interim results (including only the first FIT), participation was higher in the FIT group than the colonoscopy group (34.2% vs. 24.6%, P<0.001). Colorectal cancer was found at similar rates in both groups (0.1%), but advanced adenomas were found in more colonoscopy patients (1.9% vs. 0.9%; odds ratio, 2.3; P<0.001), as were nonadvanced adenomas (4.2% vs. 0.4%; odds ratio, 9.8; P<0.001).

The study authors noted that the primary outcome of their trial is colorectal cancer mortality at 10 years of follow-up. The ongoing nature of the FIT screening, and the greater participation that it attracted, could mean that this method will show improvement in cancer detection and mortality reduction as the years go by, the authors said. On the other hand, colonoscopy may be preventing tumors by detecting adenomas early more effectively than FIT, they said.

An editorial accompanying both studies in the Feb. 23 New England Journal of Medicine concluded that the results support use of colonoscopy. The editorialist suggested education about the actual process of colonoscopy to improve compliance and a triage screening system in which everyone is screened at age 60 and only patients with adenomas receive strict follow-up surveillance.



Sinusitis


.
Amoxicillin no better than placebo for symptom relief in uncomplicated acute sinusitis

Amoxicillin did not reduce symptoms of sinusitis compared with placebo, according to a recent study.

Researchers in Missouri performed a randomized, placebo-controlled trial between Nov. 1, 2006 and May 2, 2009 to determine whether amoxicillin offered any quality-of-life advantage compared with symptomatic treatments in patients with uncomplicated acute sinusitis. Patients from 10 community practices were randomly assigned to receive a 10-day course of amoxicillin, 1,500 mg/d, or placebo, each delivered in three doses daily. All patients were also given five to seven days' worth of symptomatic treatments for fever, pain, cough and nasal congestion and were instructed to use them as needed.

Improvement in disease-specific quality of life after three to four days of treatment, as determined by the modified Sinonasal Outcome Test-16, was the primary outcome. Secondary outcomes were patients' retrospective rating of change in symptoms and functional status, relapse or recurrent infection, satisfaction with treatment, and adverse effects. Researchers assessed outcomes by telephone on days 3, 7, 10 and 28. The study results were published in the Feb. 15 Journal of the American Medical Association.

Overall, 166 patients were assigned to receive amoxicillin (85 patients) or placebo (81 patients). Most of the patients were women (64%) and white (78%). Rates of use of at least one symptomatic treatment were similar between groups (94% for the amoxicillin group vs. 90% for the placebo group; P=0.34). No significant difference in the primary outcome was seen between groups at days 3 or 10, but the amoxicillin group appeared to do better at day 7 (mean between-group difference in Sinonasal Outcome Test-16 score, 0.19 [95% CI, 0.024 to 0.35]). The groups did not differ in reporting improvement in symptoms at day 3 or day 10, but significantly more patients in the amoxicillin group did report improved symptoms at day 7 (74% vs. 56%; P=0.02). No serious adverse events were reported in either group, and no between-group differences were seen in any other secondary outcomes.

The authors noted that acute sinusitis may not have been present in all of the study patients and that the Sinonasal Outcome Test-16 may not have been able to pinpoint significant between-group differences precisely. However, they concluded that a 10-day course of amoxicillin appears to offer little to no benefit in uncomplicated acute sinusitis. They stressed that their results apply only to those with uncomplicated disease and that patients with serious complications "likely need a different management strategy."



CMS update


.
Problems with eRx hardship exemptions

CMS is having trouble keeping up with the volume of physician applications for eRx hardship exemptions, the agency announced.

Because of the backlog of applications, some physicians may find that they are being subjected to the 1% payment penalty despite not having received any determination from CMS on their hardship status. CMS has asked that physicians who believe they are being affected by this situation contact the Quality Net Help Desk at (866) 288-8912 or by e-mail. It will take approximately 45 days to correct payments.

CMS has also recently announced that the application period for hardship requests to avoid the 2013 payment adjustment will begin in early April and close on June 30, 2012. Information about qualifying and applying for a hardship is available among the College's Running a Practice eRx resources in the overview of the 2012 program.



Education and certification


.
NCQA to recognize medical home neighbors

The National Committee for Quality Assurance (NCQA) has recently announced the development of a specialty practice recognition program related to the patient-centered medical home.

The goal of the program is to recognize and certify practices that successfully coordinate care with their primary care colleagues and each other. The program will be released for public comment in summer 2012 and for use in early 2013. ACP has been an advocate for a recognition process for these practices. Additional information about NCQA and its programs is available on the organization's website.


.
Intensive training seminar on consumer and patient engagement offered

The National Partnership for Women and Families/Campaign for Better Care, along with Emory Healthcare, is co-sponsoring an intensive seminar, "Hospitals and Communities Moving Forward with Patient- and Family-Centered Care."

Produced by the Institute for Patient- and Family-Centered Care (IPFCC), the seminar will be held in Atlanta on March 19-22 at the Emory Conference Center. The seminar is designed to help physicians, administrators, health systems, nurses, health care workers, and patient/family leaders become effective agents for patient- and family-centered change in their own organizations. Information and registration are available online.


.
Correctional health care conference to be held in May

The National Commission on Correctional Health Care will hold a conference on updates in correctional health care May 19-22 in San Antonio, Texas.

The theme of the conference will be "Preventing Recidivism: Where Do You Fit In?" and will address the role of good physical and mental health in easing reintegration into society after release from prison. Preconference seminars will address fundamental topics in correctional health care, including the Commission's health services standards. The conference itself will feature more than 50 presentations on a broad range of subjects, including medical care, nursing, cost containment, legal issues and mental health care.

ACP is a supporting organization of the National Commission on Correctional Health Care. For more complete information, visit the commission website, call 773-880-1460, or send an e-mail.



From ACP Hospitalist


.
The February issue is now online

February's ACP Hospitalist is now online, with stories about managing pressure ulcers, incorporating the arts in the hospital, and spotting untreated bowel disorders.

acpi-20120228-hospitalist.jpg

Pressure ulcers are a common source of lawsuits and withheld payments. Read about the types of patients most inclined to develop pressure ulcers, how to prevent pressure ulcers when possible, how to distinguish ulcers from similar-looking wounds, and the best treatment for each ulcer stage.

More facilities are bringing arts and music to the bedside. Programs that use these arts in the hospital have been shown to reduce pain scores, stress and anxiety among patients with conditions ranging from stroke to cancer. Read about who is using these techniques and how such programs are funded.

Bowel disorders are going unrecognized. Hospitalists may be inclined to order scans and tests to pinpoint the cause of severe, persistent abdominal pain. But a careful patient history, screening and minimal blood work may be all that are needed if a patient has a previously undiagnosed functional bowel disorder.



From the College


.
ACP pledges support for Joining Forces

The American College of Physicians is pleased to announce it has joined the Joining Forces campaign, a national initiative championed by First Lady Michelle Obama and Dr. Jill Biden that aims to give service members and their families opportunities and support in the areas of wellness, employment and education.

One of the goals of the initiative is to help meet the neurological and psychological needs of service members, veterans and their family members. For more information, visit the campaign's website.


.
ACP Job Placement Center calls for job seekers' profiles

Physicians looking for a new job may submit a job seeker's profile to the ACP Job Placement Center, a service available at Internal Medicine 2012, to be held April 19-21 in New Orleans. The Center, located in the New Orleans Ernest N. Morial Convention Center, Booth 430, provides physicians with tools to assist in job searches as well as the opportunity to meet with potential employers.

Profiles will be included in one of two booklets based on job seekers' criteria and distributed only to Job Placement Center sponsors and exhibitors who have submitted a job posting. After reviewing a profile, a recruiter may contact the physician to schedule a private on-site interview at the Center. Profiles can be submitted online.


.
Join ACP's online discussion groups for members

ACP members are invited to participate in ACP's Special Interest Groups, a private online community that allows members to share experiences, questions and creative solutions with like-minded physicians at their own convenience.

The special interest group forums are free and exclusive to ACP members. Groups include Physician Educators, Clinical Research, Hospital Medicine, Caring for Adults with Developmental Disabilities, Caring for Vulnerable Populations, Small Practices, ACO/New Practice Models, Work-Life Balance, Maintenance of Certification and Emerging Technologies. Members are welcome to start their own groups, too.

To sign up and join the conversation, go online.



Cartoon caption contest


.
Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner. Pen the winning caption and win a $50 gift certificate good toward any ACP product, program or service.

acpi-20120228-cartoon.jpg

E‑mail all entries to acpinternist@acponline.org. ACP staff will choose finalists and post them online for an online vote by readers. The winner will appear in an upcoming edition.


.


MKSAP Answer and Critique



The correct answer is B) Scleritis. This item is available to MKSAP 15 subscribers as item 17 in the General Internal Medicine section. More information about MKSAP 15 is available online.

Painful red eye should prompt consideration of conjunctivitis, episcleritis, scleritis, keratitis or corneal ulcer, iritis, endophthalmitis, uveitis, and glaucoma. This patient has severe bilateral eye pain that is described as deep and boring, has awakened her from sleep, and has associated photophobia, tearing, and eye findings of erythema localized to the sclera. The most likely diagnosis is scleritis.

Scleritis is a serious eye condition that can lead to permanent visual loss or globe rupture and should be treated urgently in consultation with an ophthalmologist. Nearly half of patients with scleritis have an underlying systemic problem, often a connective tissue disease.

Episcleritis is an inflammation of the superficial blood vessels overlying the sclera. Patients may present with no symptoms or mild ocular pain and redness, which may occur abruptly. The blood vessels appear prominent and engorged, but normal white sclera may be visible between the blood vessels, helping to distinguish this from scleritis. This patient's severe pain and raised erythematous lesions make scleritis the more likely diagnosis.

Subconjunctival hematoma causes an often well-localized area of bright erythema that overlies but does not involve the sclera. It causes a painless red eye and resolves spontaneously and does not affect visual acuity. This patient's red eyes are associated with diminished visual acuity and severe pain and involve the sclera, ruling out subconjunctival hematoma.

Patients with anterior uveitis present with the abrupt onset of eye pain and redness. The redness is typically adjacent and circumferential to the iris. Patients may have photophobia, tearing, decreased vision, and headache. As the inflammation involves the iris and ciliary body, patients may have an irregular pupil. Uveitis requires emergency ophthalmology consultation. The patient's focal inflammation and equal pupils make anterior uveitis an unlikely diagnosis.

Viral conjunctivitis can present with the abrupt onset of diffuse conjunctival erythema and injection associated with a foreign body sensation and discharge. This patient's deep, severe pain and localized, raised erythema and diminished visual acuity are more consistent with scleritis.

Key Point

  • Patients with a severely painful, red eye should be considered to have a sight-threatening condition until proven otherwise.

Click here to return to the rest of ACP InternistWeekly.

Top




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.

To add your e-mail address to your member record and to begin receiving ACP InternistWeekly, please click here.

Copyright © by American College of Physicians.

Test yourself

A 50-year-old man is evaluated in follow-up for a recent diagnosis of cirrhosis secondary to nonalcoholic steatohepatitis. He has a history of asthma, type 2 diabetes mellitus, hyperlipidemia, and obesity. His current medications are inhaled fluticasone, montelukast, insulin glargine, insulin lispro, simvastatin, and lisinopril. Following a physical exam, lab studies, and upper endoscopy, what is the most appropriate treatment?

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.