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  Vol. 9 No. 9, September 2000 TABLE OF CONTENTS
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The Archives of Family Medicine Continuing Medical Education Program

Arch Fam Med. 2000;9:887-891.

PHYSICIANS WHO read selected articles in this issue of Archives of Family Medicine, answer the Self-assessment Quiz, complete the CME Evaluation, and mail in the Answer Card are eligible for category 1 credit toward the American Medical Association (AMA) Physician's Recognition Award (PRA). There is no charge to subscribers or nonsubscribers.

The AMA is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians. The AMA designates this education activity for up to 3 hours of category 1 credit per issue toward the AMA PRA. Each physician should claim only those hours of credit that he or she actually spent in the educational activity.

In addition, Archives of Family Medicine has been approved by the American Academy of Family Physicians (AAFP) as having educational content acceptable for Prescribed credit hours. This issue has been approved for up to 3 Prescribed credit hours. Credit may be claimed for 1 year from date of individual issue.


To earn credit, read the articles designated for CME credit carefully and take the following Self-assessment Quiz. Mark your responses on the accompanying Answer Card and complete the CME Evaluation. Then fax your Answer Card to The Blackstone Group at (312) 269-1636 or mail it to the address on the back of the card. Answers are provided in Figure 1 so that you can immediately assess your performance.

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Answer Cards must be submitted within 1 year of the issue date. The AMA maintains no permanent record of individual quiz scores. A certificate specifying the total amount of credit received for this educational activity will be returned to you by mail or fax. Please allow up to 4 weeks for your certificate to arrive. Questions about CME processing should be directed to the Blackstone Group; tel: (312) 419-0400, ext 225; fax: (312) 269-1636.


Our goal is to continually assess the educational needs of our readership for the purpose of enhancing the educational effectiveness of the Archives of Family Medicine. To achieve this goal, we need your help. You must complete the CME Evaluation on the Answer Card to receive credit. Participants are encouraged to reply within 2 months of the issue date, to facilitate the assessment of its educational value.


The Archives of Family Medicine is devoted to strengthening the science, practice, and art of family medicine. Its emphasis is on original research that is clinically practical and academically sound. A flexible curriculum of article topics is developed annually by the journal's editorial board and is then supplemented throughout the year with information gained from readers, authors, reviewers, and editors.

Readers of the Archives of Family Medicine should be able to attain the following educational objectives: (1) use the latest information on diagnosis and treatment of diseases commonly seen in clinical practice to maximize patient health; (2) recognize uncommon illnesses that present with common symptoms to the family physician and treat or refer as appropriate; (3) use practical tools for health promotion and disease prevention; and (4) learn the clinical indications and adverse effects of pertinent new drugs or new uses for available drugs.

Self-assessment Quiz

Questions for September/October 2000

The Urgent Need to Improve Hypertension Care (SEE ARTICLE)

Q1. Regarding hypertension:

A. Blood pressure control is achieved in approximately 90% of United States patients with hypertension.
B. The JNC-6 recommends at least 2 blood pressure measurements at 2 or more visits to establish a diagnosis of hypertension.
C. Body position during measurement of blood pressure is not important.
D. Benefits of salt reduction, and in obese patients, of weight loss, to control elevated blood pressure, does not have ample documentation.
E. The major double-blind studies that demonstrated decreases in morbidity and mortality in treated patients used either angiotension-converting enzyme inhibitors or calcium channel blockers.

Q2. Regarding health delivery factors in hypertension care:

A. For patients receiving antihypertensive therapy their physician's knowledge or acceptance of JNC-6 guidelines is excellent.
B. An intervention to improve the quality of hypertension care that has been useful is follow-up of newly discovered hypertensive patients at community centers.
C. Use of computer technology to change physician behavior in hypertension care has not been reported.
D. Of methods proposed to improve the quality of hypertension care, perhaps the most impractical is adding a nurse case manager to the primary care team.
E. Optimal management of hypertension as defined in JNC-6 is simple and not time consuming.

Traumatic Life Events in Primary Care Patients: A Study in an Ethnically Diverse Sample (SEE ARTICLE)

Q3. Regarding traumatic life events in primary care patients:

A. Primary care patients did not report a variety of traumatic life events.
B. The highest rates of trauma were reported by the Mexican immigrants.
C. Ethnicity was the strongest predictor of lifetime trauma.
D. Married individuals were significantly more likely to report having experienced either lifetime or recent traumatic events.
E. Women were less likely than men to meet criteria for both 1-year and lifetime psychiatric disorders.

Detecting Symptoms of Alcohol Abuse in Primary Care Settings (SEE ARTICLE)

Q4. Regarding detecting symptoms of alcohol abuse in primary care settings:

A. Only 1 of 6 patients who meet Diagnostic Interview Schedule criteria for abuse or dependence go unrecognized in primary care settings.
B. The CAGE questionnaire is the most gender-biased screening instrument.
C. Patients who meet diagnostic criteria for alcohol abuse or dependence are less likely to be treated for anxiety and depression.
D. There is a low prevalence of individuals with symptoms of harmful and hazardous drinking among otherwise asymptomatic patients in primary care settings.
E. Patient characteristics such as family history, age, and related symptoms could be used to focus screening efforts for alcohol abuse and dependence.

A Questionnaire Survey of Family Practice Physicians' Perceptions of Bereavement Care (SEE ARTICLE)

Q5. Regarding family practice physicians' perceptions of bereavement care:

A. Physicians generally reported strong beliefs that grief contributes significantly to health problems.
B. Physicians reported that their bereaved patients were not interested in discussing their grief.
C. Physicians do not report finding it satisfying to work with grieving patients.
D. Most physicians report that they do not follow most grieving patients themselves.
E. Most physicians did not express interest in continuing medical education on grief identification and management.

Attitudes of Israeli Family Physicians Toward Clinical Guidelines (SEE ARTICLE)

Q6. Regarding clinical guidelines:

A. Evidence-based procedures are increasingly communicated to the practicing physician in the form of clinical guidelines.
B. More than 1 million clinical guidelines can now be found in the clearinghouse site of the Agency for Health Care and Policy Research on the Internet.
C. Clinical guidelines will not eliminate unnecessary variance between medical practices.
D. Clinical guidelines do not serve to contain the cost of care for health care organizations and insurers.

Sexual Orientation and Health: Comparisons in the Women's Health Initiative Sample (SEE ARTICLE)

Q7. Regarding sexual orientation and health:

A. Lesbian and bisexual women, compared with heterosexual women, have a lower risk of engaging in risky behaviors like smoking and heavier alcohol use.
B. Lesbian, bisexual, and "no adult sex" women were more likely than heterosexuals to have recent Papanicolaou tests or mammograms.
C. There are lower rates of depression among lesbians and bisexuals than among heterosexuals.
D. Lesbians and bisexuals report negative attitudes from their health care providers that began when they revealed their sexual orientation.

Obese Women's Perceptions of Their Physicians' Weight Management Attitudes and Practices (SEE ARTICLE)

Q8. Regarding obesity:

A. Fully 2% of US adults are obese, as judged by a body mass index of greater than or equal to 30 kg/m2.
B. A great deal is known about the management of obesity in primary care practice.
C. Studies have suggested that patients are not aware of physicians' reportedly negative attitudes toward obesity.
D. Obese women do not delay or avoid obtaining medical care including clinical breast examination, gynecologic examination, and Papanicolaou smears.
E. Obese women are significantly less satisfied with their care related to weight management.

Antiviral Therapy for Herpes Zoster: Randomized Controlled Trial of Valaciclovir and Famciclovir Therapy in Immunocompetent Patients 50 Years and Older (SEE ARTICLE)

Q9. Regarding herpes zoster:

A. The pain in herpes zoster is not what drives most patients to seek medical attention from their primary care physician.
B. As age increases, the risk of zoster-associated pain persisting after rash healing decreases.
C. The resultant chronic pain, often referred to as postherpetic neuralgia, is easy to treat effectively and inexpensively.
D. Valaciclovir and famciclovir have been developed with the aim of improving on oral acyclovir, a widely recognized standard of care for the treatment of herpes zoster.
E. Valaciclovir has not been shown to be comparable to famciclovir in speeding the resolution of zoster-associated pain and postherpetic neuralgia.

Predictors of Screening Mammography: Implications for Office Practice (SEE ARTICLE)

Q10. Regarding screening mammography:

A. The proportion of women older than 50 years who receive annual screening mammography is not used as a quality indicator by many health insurance and health maintenance organizations.
B. Screening mammography has not been shown to decrease breast cancer mortality rates in women between the ages of 50 and 69 years.
C. Lower rates of screening mammography are associated with a more advanced stage of breast cancer among older African American women as compared with older white women.
D. The United States Preventive Services Task Force recommends screening mammography every 1 to 2 years for women aged 40 to 85 years.
E. Women who receive a clinical breast examination and/or Papanicolaou smear seem less likely to receive screening mammography.

Prevalence of Anxiety, Depression, and Substance Use Disorders in an Urban General Medicine Practice (SEE ARTICLE)

Q11. Regarding the prevalence of mental disorders in an urban general medicine practice:

A. Mental disorders are not highly prevalent in primary care clinics that serve low income, urban, immigrant workers.
B. Major depressive disorder was especially common in patients of Hispanic ancestry.
C. A great deal is known about ethnic group differences in the rates of mental disorders.
D. Mental disorders in an urban general medical practice were less impairing than they are in more affluent primary care populations.

Barriers and Benefits to Leisure-Time Physical Activity Among Older Mexican Americans (SEE ARTICLE)

Q12. One factor associated with lower levels of habitual physical activity among older adults is:

A. Higher education.
B. Male sex.
C. Lower body mass index.
D. Younger age.
E. European American ethnicity.

Use of Simvastatin Treatment in Patients With Combined Hyperlipidemia in Clinical Practice (SEE ARTICLE)

Q13. Regarding treatment of dyslipidemia:

A. The benefit of statin therapy in primary and secondary prevention of coronary heart disease is not well established.
B. Physician adherence to guidelines for improving care of patients with dyslipidemia is optimal.
C. Community-based retrospective studies of patients with coronary disease report that 95% have lipid tests and 80% of patients are on lipid therapy.
D. It has been suggested that statin therapy may have a wider application in the treatment of dyslipidemia in addition to reducing low-density lipoprotein cholesterol levels.
E. Combined hyperlipidemia is defined as elevations in both total cholesterol and high-density lipoprotein cholesterol levels.

Tamoxifen's Clinical Applications: Old and New (SEE ARTICLE)

Q14. Regarding tamoxifen:

A. Tamoxifen was first developed as part of a project to develop an oral contraceptive.
B. Animal studies have shown that tamoxifen has contraceptive properties.
C. Tamoxifen's antiprogesterone activity made it a candidate for endocrine treatment of breast cancer.
D. Tamoxifen remains an infrequently prescribed anticancer agent.

Q15. Regarding tamoxifen's role in the treatment of breast cancer:

A. Tamoxifen is not the treatment of choice for advanced breast cancer in postmenopausal women.
B. In premenopausal women, tamoxifen should not be used as first-line therapy.
C. Individual clinical studies have not shown tamoxifen's treatment benefits to be significant for node-negative disease.
D. To date, there is no convincing evidence of increased benefit of tamoxifen therapy beyond 5 years.
E. Long-term side effects of tamixofen have not been elucidated.

Q16. Regarding tamoxifen for the prevention of breast cancer:

A. Tamoxifen has been approved in the United States to reduce the risk of breast cancer in women at increased risk for the disease.
B. Long-term administration of tamoxifen was associated with an increase in fractures of the hip.
C. Long-term administration of tamoxifen was associated with a decrease in endometrial cancer.
D. Long-term administration of tamoxifen was associated with decreased risks of stroke, pulmonary embolism, and deep-vein thrombosis.
E. Tamoxifen appeared to change the incidence of estrogen-negative tumors.

False-Positive and Indeterminate Human Immunodefiency Virus Test Results in Pregnant Women (SEE ARTICLE)

Q17. Regarding human immunodeficiency virus (HIV):

A. The Centers for Disease Control and Prevention has recommended that all pregnant women be screened for HIV.
B. Physicians have not increased their efforts to screen patients for HIV during the prenatal period.
C. Since the mid 1990s there has been as significant increase in both the rate of mother-child HIV transmission, and in the number of children with acquired immunodeficiency syndrome (AIDS).
D. Pregnancy itself will not cause a false-positive HIV test result.
E. The AIDS Clinical Trial Group 076 study demonstrated that use of the antiviral medication zidovudine does not reduce the risk of vertical HIV transmission.

Q18. Regarding an ambiguous HIV test result in pregnancy:

A. The physician should wait for both the enzyme-linked immunosorbent assay and Western blot test results before the diagnosis of infection is made.
B. In the first and second trimesters, there is more urgency to begin treatment for HIV than in the third trimester.
C. A positive polymerase chain reaction test result for viral nucleic acid sequences does not confirm HIV infection.
D. Most patients who are infected with HIV will have clearly positive Western blot results by 3 days after the initial indeterminate test result.
E. If the HIV Western blot remains indeterminate after 6 months, the patient is probably infected and further testing is recommended.

Are Antibiotics Necessary in the Treatment of Locally Infected Ingrown Toenails? (SEE ARTICLE)

Q19. Regarding ingrown toenails:

A. Ingrown toenails have a prevalence of 2% in the population seeking footcare.
B. Ingrown toenails are treated by a wide variety of medical providers.
C. There are only a few treatments available for ingrown toenails.
D. The use of oral antibiotics as an adjunct to treating ingrown toenails in uncommon.
E. Initial treatment with oral antibiotics definitely decreases healing times.

© 2000 American Medical Association. All Rights Reserved.