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

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ACP InternistWeekly



In the News for the Week of January 7, 2014




Highlights

Vitamin E may slow functional decline in patients with mild to moderate Alzheimer's disease

Taking 2,000 IU of vitamin E daily slowed functional decline and reduced caregiver time in patients with mild to moderate Alzheimer's disease, a study found. More...

USPSTF recommends annual CT for patients at high risk of lung cancer

Patients at high risk for lung cancer should be screened annually with low-dose computed tomography (CT), the U.S. Preventive Services Task Force (USPSTF) recently recommended. More...


Test yourself

MKSAP Quiz: exertional chest pain of 3 months' duration

A 68-year-old man is evaluated for exertional chest pain of 3 months' duration. He describes the chest pain as pressure in the midsternal area with no radiation that occurs with walking one to two blocks and resolves with rest or sublingual nitroglycerin. No symptoms have occurred at rest. Following a physical exam and electrocardiogram, what is the most appropriate management? More...


Quality of care

Many general internists uncomfortable caring for childhood cancer survivors, unfamiliar with relevant cancer surveillance guidelines

Internists reported that they were "somewhat uncomfortable" caring for childhood cancer survivors, were unfamiliar with available surveillance guidelines, and preferred to collaborate with cancer treatment centers and clinicians in a recent survey. More...


Rheumatology

Methotrexate intolerance common in patients with rheumatoid, psoriatic arthritis

Gastrointestinal symptoms are common in patients who are prescribed methotrexate for rheumatoid and psoriatic arthritis, in some cases even before they start taking the drug, according to a new study. More...


Influenza

H1N1 hitting young and middle-aged adults

Early reports from the 2013-2014 flu season indicate that young and middle-aged adults may be disproportionately affected by the influenza A (H1N1) pdm09 (pH1N1) virus, the CDC recently warned. More...


CMS update

You can request a review of your eRx payment adjustment

Physicians and practices who were not successful electronic prescribers under CMS's 2012 or 2013 Electronic Prescribing Incentive Program will be subject to a payment adjustment of 2% of Medicare Part B charges for all of 2014. More...


Practice management

Practice tips on the Affordable Care Act

With the bulk of the Affordable Care Act's (ACA) coverage provisions having gone into effect on Jan. 1, the College has updated its resources on ACA enrollment. More...


Ethics

New ethics case study, "When an Aging Colleague Seems Impaired"

"When an Aging Colleague Seems Impaired" is a new ACP ethics case study that is available online for CME credit. This case study explores the physician's ethical obligation to address a colleague's (or one's own) impairment in order to protect the safety of patients and to assist the impaired physician. More...


High-value care

ACP launches new "Online High Value Care Cases"

A series of free online cases and questions addressing high-value care is available to help clinicians weigh the benefits, harms, and costs of tests and treatment options for common conditions in order to improve health and eliminate waste. More...


From the College

Chapter awardees announced

ACP chapter awards honor Members, Fellows, and Masters of ACP who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, research, or service to their community, their chapter, and ACP. More...


From ACP Internist

ACP Internist is online and coming to your mailbox

January's issue of ACP Internist features stories on pancreatitis, implementing team-based care, and "prescribing" exercise. 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: Daisy Smith, MD, FACP



Highlights


.
Vitamin E may slow functional decline in patients with mild to moderate Alzheimer's disease

Taking 2,000 IU of vitamin E daily slowed functional decline and reduced caregiver time in patients with mild to moderate Alzheimer's disease, a study found.

Researchers examined the effectiveness and safety of vitamin E, memantine, and the combination for treatment of functional decline in patients with mild to moderate Alzheimer's disease who were taking an acetylcholinesterase inhibitor.

The trial included 613 patients at 14 Veterans Affairs medical centers, with 52 later excluded for a lack of follow-up data. Participants were randomized to receive either 2,000 IU of vitamin E daily (n=140), 20 mg of memantine daily (n=142), both (n=139) or placebo (n=140). Change in functional decline was measured via the Alzheimer's Disease Cooperative Study/Activities of Daily Living (ADCS-ADL) Inventory score (range, 0 to 78).

Results appeared in the Jan. 1 Journal of the American Medical Association.

Over the mean follow-up of 2.27 years, ADCS-ADL Inventory scores declined by 3.15 units (95% CI, 0.92 to 5.39; adjusted P=0.03) less in the vitamin E group compared with the placebo group. In the memantine group, these scores declined 1.98 units less (95% CI, −0.24 to 4.20; adjusted P=0.40) than in the placebo group. The researchers noted that the difference in the vitamin E group translates into a 19% per year delay in clinical progression compared to the placebo group, or a delay of about 6.2 months during the study's follow-up period. Caregiver time was also reduced by 2.17 hours per day (95% CI, 0.63 to 3.71 hours per day) in the vitamin E group compared with the memantine group.

All-cause death and safety analyses showed a difference only on the serious adverse event of "infections or infestations," with greater frequencies in the memantine (31 events in 23 participants) and combination groups (44 events in 31 participants) compared with placebo (13 events in 11 participants).

The researchers noted that decline in functioning in Alzheimer's disease is increasingly recognized as an important determinant of both patient quality of life and social and economic costs. The difference in function between groups could mean retaining the ability to dress or bathe independently for some patients, they noted. "Because vitamin E is inexpensive, it is likely these benefits are cost-effective as alpha tocopherol improves functional outcomes and decreases caregiver burden," the authors wrote.

An editorial noted that as with almost all previous trials, the therapeutic effect seen was modest and more relevant to symptoms and consequences than to reversal of the disease process. "Considering the difficulties inherent in trying to treat rather than prevent very high-prevalence diseases and the limitations thus far of the therapeutic efforts for people with [Alzheimer's disease], shifting to more emphasis on prevention seems warranted," the editorial stated.


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USPSTF recommends annual CT for patients at high risk of lung cancer

Patients at high risk for lung cancer should be screened annually with low-dose computed tomography (CT), the U.S. Preventive Services Task Force (USPSTF) recently recommended.

Specifically, the guideline recommended annual CT screening for adults age 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or willingness to have curative lung surgery, the USPSTF advised.

annals.jpg

The recommendation, which was published online Dec. 31 by Annals of Internal Medicine, was based on adequate evidence of moderate certainty (primarily the National Lung Screening Trial), the statement said. It updated the Task Force's 2004 recommendation, which found insufficient evidence to recommend for or against screening.

The new recommendation noted that harms of screening include false negatives and false positives, incidental findings, overdiagnosis and radiation exposure. Patients in the screened population should also receive smoking cessation treatment, and the decision to screen should be shared between clinician and patient after a "thorough discussion of the possible benefits, limitations, and known and uncertain harms." Screening should be done in accordance with quality standards and protocols for follow-up, the recommendation said.

The recommendation was based on a comparative modeling study, also published by Annals on Dec. 31, which found that the screening strategy chosen by the USPSTF would lead to 50% of lung cancers being detected at stage I or II, 575 screens per lung cancer death averted, and a 14% (range, 8.2% to 23.5%) reduction in lung cancer mortality and 5,250 life-years gained per 100,000 people born in 1950 (the cohort used in the model). As for screening harms, the strategy would cause 67,550 false positives, 910 unnecessary biopsies or surgeries and 190 overdiagnosed cases of cancer, the model showed.

Two editorials were also published with the recommendation. One raised questions about the implementation of the recommendation, including the challenge of getting high-risk patients to submit to screening and refraining from screening patients who request scans but don't meet the criteria. The editorialist also asked how much of the responsibility for screening will fall on primary care physicians versus other clinicians. A second editorial expressed concern about the Task Force's reliance on modeling and the wide variation in harms and benefits of screening within the population recommended for screening.



Test yourself


.
MKSAP Quiz: exertional chest pain of 3 months' duration

A 68-year-old man is evaluated for exertional chest pain of 3 months' duration. He describes the chest pain as pressure in the midsternal area with no radiation that occurs with walking one to two blocks and resolves with rest or sublingual nitroglycerin. No symptoms have occurred at rest. Medical history is significant for myocardial infarction 3 years ago, hypertension, and hyperlipidemia. Medications are aspirin, metoprolol 25 mg twice daily, simvastatin, isosorbide dinitrate, and sublingual nitroglycerin as needed for chest pain.

mksap.gif

On physical examination, temperature is normal, blood pressure is 150/85 mm Hg, pulse rate is 80/min, and respiration rate is 12/min. BMI is 26. No carotid bruits are present, and a normal S1 and S2 with no murmurs are heard. Lung fields are clear, and distal pulses are normal.

Electrocardiogram shows normal sinus rhythm, no left ventricular hypertrophy, no ST- or T-wave changes, and no Q waves.

Which of the following is the most appropriate management?

A: Add diltiazem
B: Add ranolazine
C: Coronary angiography
D: Increase metoprolol dosage

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


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Quality of care


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Many general internists uncomfortable caring for childhood cancer survivors, unfamiliar with relevant cancer surveillance guidelines

Internists reported that they were "somewhat uncomfortable" caring for childhood cancer survivors, were unfamiliar with available surveillance guidelines, and preferred to collaborate with cancer treatment centers and clinicians in a recent survey.

annals.jpg

Researchers mailed a survey between September 2011 and August 2012 to a random sample of general internists. The survey used a 7-point Likert scale to measure comfort levels with caring for survivors and familiarity with available surveillance guidelines and a clinical vignette to assess compliance with the Children's Oncology Group Long-Term Follow-Up Guidelines. Results appeared in Annals of Internal Medicine on Jan. 7.

The response rate was 61.6% (1,110 of 1,801). More than half the internists (51.1%) reported caring for at least 1 survivor, but 72% of these physicians had never received a treatment summary from the patient's cancer care clinician or team. Only 5.5% of internists preferred to care for survivors independently. Most (84%) preferred to comanage with a cancer center-based physician or long-term-follow-up clinic, and 10.5% said they would refer survivors to a cancer center-based physician, follow-up program, or another primary care clinician.

On average, internists were "somewhat uncomfortable" caring for survivors of Hodgkin's lymphoma, acute lymphoblastic leukemia and osteosarcoma. A smaller proportion of respondents said that they were "somewhat comfortable" or "comfortable" caring for Hodgkin's lymphoma (36.9%), acute lymphoblastic leukemia (27%), and osteosarcoma survivors (25%). Comfort levels were higher among male internists, those with a larger patient volume and those who had seen at least 1 survivor in the preceding 5 years.

Internists reported being "somewhat unfamiliar" with available surveillance guidelines, and only 12% stated that they felt at least "somewhat familiar" with them.

Knowledge of available surveillance guidelines for breast cancer and cardiac and thyroid function was assessed by using a clinical vignette, which found:

  • 9.4% of internists (95% CI, 7.7% to 11.2%) complied with guidelines for breast cancer surveillance in women exposed to chest radiation by recommending annual mammography and breast MRI, and an additional 17.8% (95% CI, 15.6% to 20.2%) recognized the need for surveillance for early breast cancer with annual mammograms;
  • 14.9% (95% CI, 12.8% to 17.1%) correctly recommended biennial echocardiographic surveillance for cardiac dysfunction;
  • 76.4% (95% CI, 73.7% to 78.8%) correctly recommended annual surveillance with serum thyroid-stimulating hormone and free thyroxin testing for thyroid dysfunction; and
  • 5.4% (95% CI, 4.2% to 6.9%) answered all 3 surveillance questions correctly.

The most useful tools, according to the internists, would be long-term follow-up guidelines and patient-specific standardized letters from specialists with follow-up recommendations sent directly to the primary care physician (PCP). The researchers concluded, "Concentrated efforts to improve these gaps should include enhanced education of PCPs through webinars, education sessions at national meetings, and guidelines linked to internal medicine websites. Focused efforts should also be made to improve comanagement by oncologists and PCPs throughout the cancer care trajectory (cancer diagnosis through survivorship)."

The authors of an accompanying editorial wrote that caring for childhood cancer survivors is a shared responsibility among pediatric oncology care clinicians, patients and internists.

ACP Internist addressed how internists can better handle the adult survivors of childhood cancer, as well as survivors of other pediatric diseases, in a story in its September 2010 issue.



Rheumatology


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Methotrexate intolerance common in patients with rheumatoid, psoriatic arthritis

Gastrointestinal symptoms are common in patients who are prescribed methotrexate for rheumatoid and psoriatic arthritis, in some cases even before they start taking the drug, according to a new study.

Researchers performed a cross-sectional descriptive study of patients with both types of arthritis who were treated at 4 hospitals in the Netherlands as outpatients between May 2011 and June 2012. All patients received methotrexate for at least 3 months, along with folic acid. Data were collected on disease activity, methotrexate dose, route of administration, other medications, and history of peptic ulcers and smoking.

Patients' gastrointestinal and behavioral symptoms were assessed by asking them to complete the Methotrexate Intolerance Severity Score (MISS), which evaluates adverse effects after taking methotrexate, before taking methotrexate (anticipatory symptoms), and while thinking of methotrexate (associative symptoms). Gastrointestinal symptoms included abdominal pain, nausea and vomiting; behavioral symptoms included restlessness, irritability and refusal to take the drug. A score of 0 (no symptoms), 1 (mild symptoms), 2 (moderate symptoms) or 3 (severe symptoms) was possible for each item, and methotrexate intolerance was defined as a score of 6 or higher including 1 or more anticipatory, associative or behavioral symptom. Results were published online Dec. 18 by Arthritis Research & Therapy.

A total of 291 patients were included in the study, 249 with rheumatoid arthritis and 42 with psoriatic arthritis. Most patients (62.2%) were women; the mean age was 59.4 years. Oral administration of methotrexate was the most common route (66.7%), and the median dose per week was 20 mg. Overall, 123 patients (43%) had at least 1 gastrointestinal symptom during methotrexate treatment, most commonly nausea (32.0%), followed by abdominal pain (11.3%) and vomiting (6.5%). Before treatment, 8.6% of patients had anticipatory nausea; 11.0% had associative nausea. A total of 16.5% of patients reported behavioral symptoms, most commonly restlessness (13.1%).

Methotrexate intolerance occurred in 32 patients (11.0%), with a median MISS score of 9, all of whom had nausea after treatment. Anticipatory and associative nausea were also common in this group (56.3% and 53.1%, respectively), as were behavioral symptoms (81.3%). Of those who had behavioral symptoms, 37.5% declined methotrexate. Prevalence of methotrexate intolerance was significantly higher in patients receiving the drug via the parenteral route compared with those taking an oral formulation (20.6% vs. 6.2%; P<0.001). Intolerance was less common in patients 65 years and older than in younger patients (odds ratio, 0.21; P=0.03).

The authors noted that the MISS was designed for assessing juvenile idiopathic arthritis and needs to be validated in adults with rheumatic disease. They also pointed out that their study did not identify variables that are associated with development of methotrexate intolerance or how frequently the drug is withdrawn or another drug is substituted as a result. However, they concluded that gastrointestinal and behavioral symptoms are common in patients taking methotrexate and can also occur before treatment and while thinking about treatment in some cases.

"As persisting [methotrexate] intolerance could have a negative impact on patients' quality of life and hamper the use of [methotrexate], [rheumatoid arthritis] and [psoriatic arthritis] patients on [methotrexate] should be monitored with the MISS for early detection of [methotrexate] intolerance," the authors wrote. "This would create a window of opportunity to intervene … and avoid incompliance and discontinuation of an otherwise efficacious treatment.



Influenza


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H1N1 hitting young and middle-aged adults

Early reports from the 2013-2014 flu season indicate that young and middle-aged adults may be disproportionately affected by the influenza A (H1N1) pdm09 (pH1N1) virus, the CDC recently warned.

In November and December, the CDC received a number of reports of severe respiratory illness in this patient population, many of which resulted in hospitalizations, intensive care unit admission and even some fatalities. Most of the patients with severe illness had risk factors for influenza-associated complications, including pregnancy and morbid obesity, but several did not. Since its emergence in 2009, the pH1N1 virus has been known to cause more illness in younger patients, the CDC noted.

The pH1N1 virus has been the predominant circulating virus so far this flu season. If it continues to circulate widely, flu outbreaks may disproportionately affects young and middle-aged adults, the CDC warned. Flu activity nationally is currently at low levels, but some areas of the United States are already experiencing high activity and activity is expected to increase during the next few weeks. The spectrum of illness in the 2013-2014 season has ranged from mild to severe and is consistent with that of other influenza seasons, the CDC said.

The agency stressed that annual vaccination is recommended for everyone 6 months and older and that antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who is hospitalized; has severe, complicated, or progressive illness; or is at higher risk for complications.



CMS update


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You can request a review of your eRx payment adjustment

Physicians and practices who were not successful electronic prescribers under CMS's 2012 or 2013 Electronic Prescribing Incentive Program will be subject to a payment adjustment of 2% of Medicare Part B charges for all of 2014.

If your practice is notified that you will be subject to the 2014 penalty, you can request an informal review from CMS through Feb. 28.

Eligible professionals and group practices should submit their eRx informal review request via e-mail to the informal review mailbox. Complete instructions on how to request an informal review are available in the educational document "2014 eRx Payment Adjustment Informal Review Made Simple."

Additional information about e-prescribing is available on the College's website.



Practice management


.
Practice tips on the Affordable Care Act

With the bulk of the Affordable Care Act's (ACA) coverage provisions having gone into effect on Jan. 1, the College has updated its resources on ACA enrollment.

ACP members are encouraged to visit ACP's website for more information about resources to help patients enroll in the health insurance exchanges. We also have a new resource, "Affordable Care Act Issues Physicians Need to Know," which can help guide clinicians in speaking with patients about concerns such as network issues, deductibles and prescription drug coverage.



Ethics


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New ethics case study, "When an Aging Colleague Seems Impaired"

"When an Aging Colleague Seems Impaired" is a new ACP ethics case study that is available online for CME credit. This case study explores the physician's ethical obligation to address a colleague's (or one's own) impairment in order to protect the safety of patients and to assist the impaired physician.

Addressing apparent impairment in a colleague can be uncomfortable; however, the privilege of self-regulation that society affords the medical profession carries with it both a shared and an individual responsibility to ensure that members of the profession have the ability to practice with reasonable skill and safety.

This case study, and other case studies in the professionalism case study series, is available on the College's website.



High-value care


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ACP launches new "Online High Value Care Cases"

A series of free online cases and questions addressing high-value care is available to help clinicians weigh the benefits, harms, and costs of tests and treatment options for common conditions in order to improve health and eliminate waste.

Each topic can be completed in 30 to 60 minutes on a desktop, laptop, tablet or smartphone. These interactive cases offer clinicians the opportunity to earn free CME credits and ABIM Medical Knowledge (MOC) points.

The five topics are:

  • Avoid Unnecessary Testing
  • Use Emergency and Hospital Level Care Judiciously
  • Improve Outcomes with Health Promotion and Disease Prevention
  • Prescribe Medications Safely and Cost Effectively
  • Overcome Barriers to High Value Care

To learn more about ACP's High Value Care initiative and access other helpful and free materials, visit the website.



From the College


.
Chapter awardees announced

ACP chapter awards honor Members, Fellows, and Masters of ACP who have demonstrated by their example and conduct an abiding commitment to excellence in medical care, education, research, or service to their community, their chapter, and ACP.

Awardees have a long history of excellence and peer approval in the specialty of internal medicine. In recognition of their outstanding service, these exceptional individuals received chapter awards in fall 2013 and winter 2014.



From ACP Internist


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ACP Internist is online and coming to your mailbox

January's issue of ACP Internist features these stories:

acpi-20140107-internist.jpg

Long-term view for chronic pancreatitis. Unlike acute cases of pancreatitis, chronic cases present with varying degrees and types of pain and without other clinical indicators such as calcification or damage to pancreatic ducts. It's best to refer to a gastroenterologist early to clarify the diagnosis, so the internist can better manage the patient.

Taking team care from policy to practice. Medical practice is becoming increasingly team-based, which is leading to a renegotiation of the roles each clinician brings to patient care.

To prescribe exercise, start specific and small. Primary care physicians can offer more specific advice when they suggest exercise—frequency, intensity and type, for example—to increase their patients' likelihood of following through.

More stories, Test Yourself with the MKSAP Quiz and our blog are 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-20140107-cartoon.jpg

"It definitely sounds guttural."

"Always an innovator, Dr. Brown was ready when he encountered 'distant' heart sounds."

"Dr. Smith can tell just by auscultating when a patient is circling the drain."

Go online to pick the winner, who receives a $50 gift certificate good toward any ACP program, product or service. Voting ends on Monday, Jan. 13, with the winner announced in the Jan. 14 issue.


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MKSAP Answer and Critique



The correct answer is D: Increase metoprolol dosage. This item is available to MKSAP 16 subscribers as item 99 in the Cardiology section. More information is available online.

This patient with coronary artery disease (CAD) and continuing angina should have his medical therapy optimized by increasing his dosage of β-blocker. Physical examination is notable for a blood pressure and heart rate that would allow further up-titration of the β-blocker. The β-blocker dose is adjusted to achieve a resting heart rate of approximately 55 to 60/min and approximately 75% of the heart rate that produces angina with exertion.

Calcium-channel blockers are first-line antianginal therapy in patients with contraindications to β-blockers. In patients with continuing angina despite optimal doses of β-blocker and nitrates, a calcium-channel blocker may be added. A calcium-channel blocker such as diltiazem is not indicated in this patient because his dosage of metoprolol is not yet optimal.

Ranolazine should be considered in patients who remain symptomatic despite optimal doses of β-blockers, calcium-channel blockers, and nitrates. Ranolazine is metabolized in the liver by the cytochrome P-450 system and its use is therefore contraindicated in patients with hepatic impairment, those with baseline prolongation of the QT interval, and those taking other drugs that inhibit the cytochrome P-450 system. Diltiazem and verapamil increase serum levels of ranolazine, and combined use of ranolazine with either of these agents is contraindicated.

Coronary angiography would be indicated if the patient was on maximal medical therapy with continued angina symptoms that were affecting his quality of life. Referral for coronary angiography is not indicated because the patient is not currently receiving optimal medical therapy.

Key Point

  • In the treatment of chronic stable angina, the β-blocker dose is adjusted to achieve a resting heart rate of approximately 55 to 60 beats/min and approximately 75% of the heart rate that produces angina with exertion.

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Test yourself

A 76-year-old woman is evaluated for a 3-month history of left knee pain of moderate intensity that worsens with ambulation. She reports minimal pain at rest and no nocturnal pain. There are no clicking or locking symptoms. She has tried naproxen and ibuprofen but developed dyspepsia; acetaminophen provides mild to moderate relief. The patient has hypertension, hypercholesterolemia, and chronic stable angina. Medications are lisinopril, metoprolol, simvastatin, low-dose aspirin, and nitroglycerin as needed. Following a physical exam, lab results and radiograph, what is the next best step in management?

Find the answer

Have questions about the new ABIM MOC Program?

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ACP explains the ABIM requirements and offers many free solutions to earn MOC points.

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