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

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ACP InternistWeekly



In the News for the Week of January 29, 2013




Highlights

More than half of hypertensive black patients don't receive diuretics

More than half of black patients with uncontrolled hypertension don't receive diuretics, despite recommendations favoring their use as a first-line agent, a study found. More...

Vaccine recommendations updated for pneumococcus, Tdap and flu

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) issued a new adult immunization schedule that adds the pneumococcal conjugate vaccine, updates Tdap regimens for the elderly and pregnant women, and eliminates the egg-allergy exception for influenza vaccines. More...


Test yourself

MKSAP Quiz: ED evaluation for dizziness, shortness of breath and palpitations

A 76-year-old woman is evaluated in the emergency department for dizziness, shortness of breath, and palpitations that began acutely 1 hour ago. She has a history of hypertension and heart failure with preserved ejection fraction. Following a physical exam and electrocardiogram, what is the most appropriate acute treatment? More...


Antibiotics

Inappropriate antibiotic use for acute bronchitis decreased with decision support

Decision support resulted in less inappropriate use of antibiotics for acute bronchitis in primary care, a recent study showed. More...


Transitions of care

Readmission causes, timing and reductions analyzed

Readmissions of recently hospitalized patients were the focus of several studies published last week in the Jan. 23/30 Journal of the American Medical Association. More...


Breast cancer

Study compares survival with early-stage breast cancer treatments

Breast-conserving surgery plus radiation was associated with better disease-specific survival than mastectomy alone in patients with early-stage breast cancer, according to a new study. More...


Clinician resources

ACP launches new High Value Care website as latest resource in ACP's High Value Care initiative

ACP has launched a new High Value Care website that will help physicians and other health care professionals, medical students, and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues and whether they provide good value. More...


Tobacco control

Opportunity to train in tobacco control advocacy

Apply by Jan. 31 for the opportunity to be trained as a physician leader in tobacco control advocacy. More...


From ACP Internist

Share your stories

Have you as a physician been a patient? If so, ACP Internist wants to hear from you. More...


From ACP Hospitalist

The latest issue of ACP Hospitalist is online

The January issue of ACP Hospitalist is online, including stories on global health hospitalists, routine catheter replacement and post-discharge call services. More...


Patient-centered medical homes

Columnist: What I've learned from my medical home

Yul Ejnes, MD, MACP, continues his column at KevinMD.com by sharing some observations that might help practices pursuing a patient-centered medical home model of care. More...


From the College

AMA Foundation recognizes Council of Associates chair

Jay D. Bhatt, DO, MPH, MPA, an ACP Associate Member and current chair of ACP's Council of Associates, has been named a recipient of the American Medical Association Foundation's 2013 Leadership Award. More...


Cartoon caption contest

Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner. More...


Physician editor: Philip Masters, MD, FACP



Highlights


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More than half of hypertensive black patients don't receive diuretics

More than half of black patients with uncontrolled hypertension don't receive diuretics, despite recommendations favoring their use as a first-line agent, a study found.

The study was conducted in the post-acute care division of a large, urban Medicare/Medicaid-certified home health organization. Prescribing clinicians came from a wide variety of service settings, the researchers noted.

Results appeared in the American Journal of Hypertension.

Of the 658 patients with uncontrolled hypertension (defined as home blood pressure readings of ≥140/90 mm Hg or ≥130/80 mm Hg in patients with diabetes), 300 (46%) took a diuretic, including 30 who were taking more than one. Among these 300 patients, 68% received a thiazide diuretic, 33.3% received a loop diuretic, and 4.3% received a potassium-sparing diuretic (including 3% who took an aldosterone receptor blocker).

Participants who were not taking a diuretic took fewer antihypertensive medications (1.7 vs. 2.9 medications; P<0.0001) compared with those who were. They had a higher mean diastolic blood pressure (89.2 vs. 85.5 mm Hg; P=0.0005) and were more likely to have a systolic blood pressure of 160 mm Hg or greater (57.6% vs. 49.0%; P=0.04).

Among the 94.5% of participants taking antihypertensive medication, 26.5% (n=165) took just one drug. In this group, only 12% (n=19) took a diuretic. The percentage taking a diuretic increased to 43% among those taking two drugs, 73% among those taking three drugs and 90% among those taking four or more medications.

Diuretics were associated with lower systolic and diastolic blood pressure. The mean systolic difference was −5 mm Hg (95% CI, −8.80 to −1.21; P=0.01) and the mean diastolic difference was −3.79 mm Hg (95% CI, −6.16 to −1.41; P=0.002) in patients taking a diuretic-containing regimen compared with those treated with other antihypertensive agents.

The authors also speculated that the dose in diuretic-treated patients may have been inadequate based on recent research evaluating the efficacy of different diuretic regimens. While 67.3% of patients who were taking a diuretic received hydrochlorothiazide, in 93.1% of cases the dose was less than or equal to 25 mg/d, a level associated with a lower antihypertensive effect than higher doses. The remaining patients received a higher dose or a combination with a potassium-sparing agent.

"These findings are particularly striking, because all of the patients assessed in this study were black and had uncontrolled hypertension, in whom a diuretic would almost always be recommended," the researchers wrote. "The finding is even more disturbing given the socioeconomic status of most patients in this study and the low cost of diuretic therapy that could enhance patient adherence."


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Vaccine recommendations updated for pneumococcus, Tdap and flu

The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) issued a new adult immunization schedule that adds the pneumococcal conjugate vaccine, updates Tdap regimens for the elderly and pregnant women, and eliminates the egg-allergy exception for influenza vaccines.

annals.jpg

Because current vaccination rates are low, ACIP also urges clinicians to regularly assess patient vaccination histories and implement intervention strategies to increase adherence, the recommendations state.

The recommendations were published online Jan. 29 by Annals of Internal Medicine.

For the first time, the 13-valent pneumococcal conjugate vaccine (PCV13) was added to the adult schedule. PCV13 should be used with the 23-valent pneumococcal polysaccharide vaccine (PPSV23) for immunocompromised adults, or those with diseases such as HIV, cancer, advanced kidney disease, functional or anatomic asplenia, cerebrospinal fluid leaks or cochlear implants. The schedule also clarifies which adults would need one or two doses of PPSV23 before the age of 65.

Recommendations for the Tdap vaccine have expanded to include routine vaccination of adults age 65 or older and vaccination of pregnant women with each pregnancy. The ideal timing of Tdap vaccination during pregnancy is in the third trimester, between 27 and 36 weeks' gestation. This recommendation was made to safeguard the pregnant woman and her baby, as protective maternal antibodies will pass to the fetus. Infants are too young for the vaccination but are at the highest risk for severe illness or death from pertussis, the recommendations noted.

All patients age six months and over should continue to be vaccinated against influenza. Mild egg allergy is no longer a contraindication, but patients with an egg allergy should get the inactivated flu shot because that is what has been studied. The FDA has approved a quadrivalent influenza vaccine that contains influenza A (H3N2), influenza A (H1N1), and two influenza B vaccine virus strains, one from each lineage of circulating influenza B viruses. This is meant to increase the likelihood that the vaccine provides cross-reactive antibody against a higher proportion of circulating influenza B viruses.

Beginning with the 2013-2014 season, it is expected that only the quadrivalent formulation will be available. Because a mix of quadrivalent and trivalent influenza vaccines may be available in 2013-2014, the abbreviation for inactivated influenza vaccine has been changed from TIV (trivalent inactivated influenza vaccine) to IIV (inactivated influenza vaccine). The abbreviation for live-attenuated influenza vaccine (LAIV) remains unchanged.

ACP and 16 other medical societies comprise ACIP, which annually reviews the vaccination schedule to ensure that it reflects current clinical recommendations for licensed vaccines.



Test yourself


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MKSAP Quiz: ED evaluation for dizziness, shortness of breath and palpitations

A 76-year-old woman is evaluated in the emergency department for dizziness, shortness of breath, and palpitations that began acutely 1 hour ago. She has a history of hypertension and heart failure with preserved ejection fraction. Medications are hydrochlorothiazide, lisinopril, and aspirin.

mksap.gif

On physical examination, she is afebrile, blood pressure is 80/60 mm Hg, pulse rate is 155/min, and respiration rate is 30/min. Oxygen saturation is 80% with 40% oxygen by face mask. Cardiac auscultation reveals an irregularly irregular rhythm, tachycardia, and some variability in S1 intensity. Crackles are heard bilaterally one-third up in the lower lung fields.

Electrocardiogram demonstrates atrial fibrillation with a rapid ventricular rate.

Which of the following is the most appropriate acute treatment?

A: Adenosine
B: Amiodarone
C: Cardioversion
D: Diltiazem
E: Metoprolol

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


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Antibiotics


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Inappropriate antibiotic use for acute bronchitis decreased with decision support

Decision support resulted in less inappropriate use of antibiotics for acute bronchitis in primary care, a recent study showed.

Researchers performed a three-arm cluster randomized trial of 33 primary care practices in an integrated health care system to determine whether provision of decision support would lead to more appropriate use of antibiotics for acute bronchitis. Eleven practices received printed brochures about decision support for acute cough illness, 11 practices received decision support via the electronic medical record, and 11 practices served as controls. At practices in the printed and electronic decision support groups, clinicians also received education and feedback about prescribing and patients received education brochures at check-in. Clinicians at the control sites were not aware of the study objectives.

The intervention was aimed at care of patients who were at least 13 years old and had an office visit for acute bronchitis during the baseline and intervention periods. The researchers used an intention-to-treat analysis to compare antibiotic prescription rates for uncomplicated acute bronchitis after the intervention (2009-2010) with rates in the same time period over the previous three years (2006-2007, 2007-2008 and 2008-2009). Only visits from Oct. 1 through March 31 were considered in each time period in order to capture the highest volume of visits for acute bronchitis. The study results were published online Jan. 14 by JAMA Internal Medicine.

Overall, 9,808 visits took place during the baseline periods and 6,242 took place during the intervention periods. When compared with the baseline periods, antibiotic use rates among adolescents and adults in the intervention period decreased in practices in the printed and electronic decision support groups (from 80.0% to 68.3% and from 74.0% to 60.7%, respectively) but increased in the control group (from 72.5% to 74.3%). The researchers controlled for patient and clinician characteristics and for clustering of observations by clinician and by practice site and found that the differences between each type of decision support group and the control group were statistically significant (P=0.003 for control vs. printed decision support and P=0.01 for control vs. electronic decision support). However, the effectiveness of the two types of decision support did not differ significantly (P=0.67).

The authors noted that their study took place in a health care delivery system that had been using a comprehensive electronic medical record for several years, and that all of the study sites were in rural or semi-rural areas. They also pointed out that they could not tell how each component of the multipart interventions (patient education, physician education, etc.) affected antibiotic prescribing rates. However, they concluded that a decision support strategy for acute bronchitis can lead to reduced rates of antibiotic use in primary care and that written support is as effective as computer-based support.

"Studies of computer-assisted decision support tools that do not include a comparison with more traditional implementation strategies may significantly overestimate the value of this type of decision support," the authors concluded.

The author of an invited commentary pointed out that although the interventions were deemed effective, more than 60% of patients still received antibiotics inappropriately, indicating that more work needs to be done. He recommended that clinicians communicate the risks and benefits of antibiotic prescribing more clearly to patients; that continuous quality improvement techniques and measurement of results replace randomized, controlled trials; and that new interventions involving organizational change be investigated to try to change physician behavior. Last, he suggested that successful reduction of antibiotic prescribing in this context be redefined.

"Success is not reducing the antibiotic prescribing rate by 10%," he wrote. "Success is reducing the antibiotic prescribing rate to 10%."



Transitions of care


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Readmission causes, timing and reductions analyzed

Readmissions of recently hospitalized patients were the focus of several studies published last week in the Jan. 23/30 Journal of the American Medical Association.

The first study assessed Medicare patients who were hospitalized between 2007 and 2009 for heart failure (HF), acute myocardial infarction (MI) or pneumonia. Within 30 days of discharge, 24.8% of HF patients had been readmitted, 19.9% of MI patients and 18.3% of pneumonia patients. However, most of these patients were readmitted for a reason other than the primary diagnosis of their initial hospitalizations.

Researchers also looked at the timing of readmissions, finding that the median time to readmission was 10 days for MI patients and 12 for HF and pneumonia patients, but that readmissions were frequent throughout the month. Based on these findings, the authors called for broader approaches to preventing readmissions, rather than efforts focused on specific diseases or limited time periods after discharge.

The second study looked how often recently hospitalized patients had treat-and-release visits to emergency departments (EDs), in addition to being readmitted. The prospective study included patients 18 and older hospitalized in California, Florida and Nebraska in 2008 to 2009. Researchers found that 17.9% of hospitalizations resulted in another acute care encounter within 30 days. Most of these encounters were hospital readmissions, but 39.8% were treat-and-release ED visits.

The rate of ED visits varied by condition, with digestive disorders and psychosis being the highest-volume causes. The most common reasons for returning to the ED were related to the diagnosis of the initial hospitalization. Study authors concluded that the many studies and interventions focused solely on 30-day readmissions miss these common ED encounters.

Finally, the third study reported on a successful effort to reduce readmissions, conducted by the Centers for Medicare and Medicaid Services. A multicomponent care transitions intervention was applied in 14 communities in 2009 to 2010, and 30-day readmission rates were compared before and after in the intervention communities and 50 control communities.

The mean rate of 30-day readmissions dropped in both groups, but more significantly in the intervention communities; intervention communities dropped from 15.21 readmissions per 1,000 beneficiaries in 2006 to 2008 to 14.24 in 2009 to 2010 versus from 15.03 per 1,000 to 14.72 in control communities over the same time periods (P=0.03).

The overall mean rate of hospitalizations followed a similar trend, with the result that readmissions didn't decrease as a percentage of all hospitalizations. The authors noted that the project's interventions (such as better elder care in the community, palliative care counseling, disease management, and care plans) could be expected to reduce initial hospitalizations as well as readmissions.

Combined, the findings of these studies support a patient-centered approach to improving care and reducing readmissions, concluded an accompanying editorial. The studies highlight the fragmentation of care under the current system. Attempts to correct this and reduce readmissions should be broadly focused, using multiple solutions and engaging the community, the editorialist wrote.



Breast cancer


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Study compares survival with early-stage breast cancer treatments

Breast-conserving surgery plus radiation was associated with better disease-specific survival than mastectomy alone in patients with early-stage breast cancer, according to a new study.

Researchers performed a large, population-based study to determine whether breast-conserving surgery plus radiation or mastectomy alone yielded similar outcomes in patients with early breast cancer outside randomized clinical trials. They also examined whether survival rates differed according to patient age and hormone-receptor (HR) status.

Data were obtained from the California Cancer Registry on women who were diagnosed with stage I or stage II breast cancer between 1990 and 2004 and who underwent breast-conserving surgery or mastectomy. Vital status was followed through 2009, with a median follow-up of 110.6 months. The researchers used Cox proportional hazards modeling to compare overall and disease-specific survival in those who received each type of therapy, and analyses were stratified by age (<50 years or ≥50 years) and tumor HR status. The study results were published online Jan. 28 by Cancer.

Overall, 112,154 women were eligible for the study. Of these, 61,771 (55%) opted for lumpectomy and radiation and 50,383 (45%) had mastectomy without radiation. Those who had breast-conserving surgery plus radiation had better overall and disease-specific survival compared with those who had mastectomy alone (adjusted hazard ratio for overall survival in the entire cohort, 0.81; 95% CI, 0.80 to 0.83).

Kaplan-Meier survival estimates indicated that survival benefit was greater with breast-conserving surgery in both younger and older women and in those with both HR-positive and HR-negative disease. In Cox multivariable analysis, women 50 years of age and older who had HR-positive disease had the largest benefit from breast-conserving surgery over mastectomy, while younger women with HR-negative disease had the smallest benefit (hazard ratios, 0.86 [95% CI, 0.82 to 0.91] vs. 0.88 [95% CI, 0.79 to 0.98]).

The authors noted that their study was limited by its population-based design and that the California Cancer Registry did not collect data on variables such as comorbid conditions and patient and clinician preferences. They also noted that data on radiation therapy in particular may have been incomplete.

However, they concluded that breast-conserving surgery plus radiation was associated with improved disease-specific survival versus mastectomy without radiation among patients with early disease. "These findings support the notion that [breast-conserving therapy], when combined with radiation, confers at least equivalent and perhaps even superior survival to mastectomy as definitive breast cancer treatment," they wrote.



Clinician resources


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ACP launches new High Value Care website as latest resource in ACP's High Value Care initiative

In support of one of the College's top priorities, ACP has launched a new High Value Care website that will help physicians and other health care professionals, medical students, and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues and whether they provide good value.

The new website centralizes resources and information, simplifying access to clinical, advocacy, patient and academic resources. Clinicians are encouraged to spend some time on the new site to learn about this important initiative that began in 2010 and how they and their patients can pursue care together to improve health, avoid harms and reduce wasteful practices. Check back often as the College continues to address this important issue.



Tobacco control


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Opportunity to train in tobacco control advocacy

Apply by Jan. 31 for the opportunity to be trained as a physician leader in tobacco control advocacy.

ACP, in conjunction with other physician groups, is seeking applicants who are interested in advocating at the state and local level for policies that support tobacco control, protect nonsmokers, and provide better access to tobacco cessation services. Training will take April 26 and 27 in Washington, D.C. Applicants selected to participate will be provided airfare and hotel accommodations. Learn more online.



From ACP Internist


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Share your stories

Have you as a physician been a patient? If so, ACP Internist wants to hear from you.

Our new column, "Doctor as Patient," will look at physicians' thinking as applied to their own health and wellness, based on real stories from readers. It will be written by Jerome Groopman, MD, FACP, and Pamela Hartzband, MD, FACP, coauthors of the bestseller "Your Medical Mind: How to Decide What Is Right for You." Both are on the Harvard Medical School faculty and serve as staff physicians at Boston's Beth Israel Deaconess Medical Center.

If your submission is chosen for print, Drs. Groopman and Hartzband will interview you and you will be recognized by name in the resulting article. You'll also receive a $50 gift certificate good toward any ACP product, program or service. Contact us at acpinternist@acponline.org if you have a story to tell. We look forward to hearing from you!



From ACP Hospitalist


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The latest issue of ACP Hospitalist is online

The January issue of ACP Hospitalist is online. Featured stories include the following:

acpi-20130129-hospitalist-2.jpg

Global health hospitalists on the rise. More physicians are focusing on a particular country, and frequently a particular hospital, to bring about lasting change. Rather than short, episodic experiences abroad, these hospitalists work to improve treatment protocols in order to effect change in the long term.

Is routine catheter replacement outdated? A recent study found that peripheral venous catheter replacement when clinically indicated is just as safe as routine replacement. We examine whether hospitals should rethink their catheter replacement policies, and if so, the elements to consider when devising a new plan.

Post-discharge call services. Several companies have recently launched post-discharge services, which contract with hospitals to handle phone calls to patients after they leave the hospital. These can help relieve the pressure on physicians and nurses to follow up with patients.



Patient-centered medical homes


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Columnist: What I've learned from my medical home

Yul Ejnes, MD, MACP, immediate past chair of ACP's Board of Regents, a practicing internist in Cranston, R.I., and a member of ACP Internist's editorial board, continues his column at KevinMD.com, one of the Web's leading destinations for provocative physician commentary. In this month's post, Dr. Ejnes shares some observations that might help practices pursuing a patient-centered medical home model of care.



From the College


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AMA Foundation recognizes Council of Associates chair

Jay D. Bhatt, DO, MPH, MPA, an ACP Associate Member and current chair of ACP's Council of Associates, has been named a recipient of the American Medical Association Foundation's 2013 Leadership Award.

Dr. Bhatt is a National Health Service Corps Scholar and a geriatrics fellow at the University of Michigan Health System. He has served on the Governing Council of the American Public Health Association, the leadership team of Doctors for America and as an advisor for Primary Care Progress and the Harvard Center for Primary Care.

Dr. Bhatt and other recipients will be honored at the AMA Foundation's annual Excellence in Medicine Awards on Feb. 11 in Washington, D.C. More information is available online.



Cartoon caption contest


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Vote for your favorite entry

ACP InternistWeekly's cartoon caption contest continues. Readers can vote for their favorite caption to determine the winner.

acpi-20130129-cartoon.jpg

"No, your news isn't hard for me to swallow, Doc. It just takes a while."

"At least your diagnosis is not a zebra."

"I'd like to proceed with X-rays. Of course, the cervical spine series will take a bit longer than usual."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Feb. 4, with the winner announced in the Feb. 5 issue.


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MKSAP Answer and Critique



The correct answer is C: Cardioversion. This item is available to MKSAP 16 subscribers as item 10 in the Cardiovascular Medicine section.

MKSAP 16 released Part A on July 31. More information is available online.

This patient with atrial fibrillation is hemodynamically unstable and should undergo immediate cardioversion. She has hypotension and pulmonary edema in the setting of rapid atrial fibrillation. In patients with heart failure with preserved systolic function, usually due to hypertension, the loss of the atrial "kick" with atrial fibrillation can sometimes lead to severe symptoms. The best treatment in this situation is immediate cardioversion to convert the patient to normal sinus rhythm. Although there is a risk of a thromboembolic event since she is not anticoagulated, she is currently in extremis and is at risk of imminent demise if not aggressively treated. In addition, she acutely became symptomatic 1 hour ago, and while this is not proof that she developed atrial fibrillation very recently, her risk of thromboembolism is low if the atrial fibrillation developed within the previous 48 hours.

Adenosine can be useful for diagnosing a supraventricular tachycardia and can treat atrioventricular node-dependent tachycardias such as atrioventricular nodal reentrant tachycardia, but it is not useful in the treatment of atrial fibrillation.

Amiodarone can convert atrial fibrillation to normal sinus rhythm as well as provide rate control, but immediate treatment is needed and amiodarone may take several hours to work. Oral amiodarone may be a reasonable option for long-term atrial fibrillation prevention in this patient given the severity of her symptoms, especially if she has significant left ventricular hypertrophy.

Metoprolol or diltiazem would slow her heart rate; however, she is hypotensive and these medications could make her blood pressure lower. In addition, she is in active heart failure, and metoprolol or diltiazem could worsen the pulmonary edema.

Key Point

  • Patients with atrial fibrillation who are hemodynamically unstable should undergo immediate cardioversion.

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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.