Essential Medical Facts Every Clinician Should Know - To Prevent Medical Errors, Pass Board Examinations and Provide Informed Patient Care

Essential Medical Facts Every Clinician Should Know

Preface

Acknowledgments

Contents

Clinical Practice Notice

Chapter 1: Medical Facts, Errors, and This Book

Medical Errors Matter

Essential Medical Facts Involve the Full Panorama of Medicine: Epidemiology, Prevention, Diagnosis, Laboratory Testing, Imagi

This Book Is Written for Clinicians, Those of Us on the Front Lines Actually Seeing Patients

References

Chapter 2: Challenging Current Medical Misconceptions

Continuous Intrapartum Electronic Fetal Monitoring (EFM) Has Not Been Found to Decrease the Incidence of Fetal Mortality or Ce

Visual Assessment Is Not Reliable in Screening Newborns for Significant Hyperbilirubinemia Prior to Discharge from the Nurser

Pallor of the Palmar Creases Is Unreliable in Detecting Anemia

The Levine Sign – Chest Discomfort Described by Placing a Clenched Fist on the Chest – Is Not a Reliable Indicator in Determi

Pain Relief Following a GI Cocktail Is Not Limited to Gastrointestinal Disease

Contrary to Lore, Women with Ovarian Cancer Usually Have Symptoms Which May Be Noted Months Before Diagnosis

It Is Safe to Use Opiates to Relieve Abdominal Pain, Even if the Diagnosis Is in Doubt

It Seems Safe for Patients with Diverticular Disease to Eat Nuts, Corn and Popcorn, After All

Lactic Acidosis May Not Be a Special Risk Associated with Metformin Use, After All

Night Pain in Back Pain Patients Might Not Really Be an Ominous Symptom

The Prehn Sign Is Not Dependable in Differentiating Between Epididymitis and Testicular Torsion

Monofilament Testing Is Not Reliable in the Diagnosis of Peripheral Neuropathy

Bed Rest Is No Longer the Preferred Treatment for Acute Low Back Strain

Spinal Manipulation Is Not Useful in the Treatment of Infant Colic

It Is Generally Safe to Use Prescription Medications for a Year or Two Following Their Expiration Date

Selected Cephalosporins Can Be Used in Patients with a History of Penicillin Allergy

The Use of Intravenous Drugs Such as Epinephrine in the Setting of Out-of-Hospital Cardiac Arrest Does Not Improve the Odds of

Patients with Mild or Moderate Depression May Experience Little or No Benefit from the Use of Antidepressant Medication

Oral Dexamethasone Is Not Helpful in the Treatment of Acute Bronchiolitis in Children

Short Courses of Steroids Used to Treat Asthma Need Not Be Tapered, and Can Be Simply Stopped

Guillain–Barré Syndrome (GBS) Is More Likely to Be Caused by Influenza than by an Influenza Vaccine

Exposure to Cold May Have Something to Do with Upper Respiratory Infections, After All

Ginkgo biloba Does Not Prevent Cognitive Decline in Older Adults

Antipyretic Agents Do Not Prevent Recurrences of Febrile Seizures

Supplementary Use of Vitamins C and E Does Not Offer Protection Against Heart Disease

We Do Not Need to Drink Eight Glasses of Water a Day

Low Dose Vitamin K Does Not Reduce Bleeding in Warfarin Patients with Elevated International Normalized Ratios (INRs)

Vitamin B12 Need Not Be Given by Injection

Oral Antibiotics Are the Best Outpatient Treatment for Pneumonia

Childhood Vaccines Do Not Cause Autism

References

Chapter 3: Epidemiologic Realities and Gee-Whiz Facts

The Overall Life Expectancy at Birth in the United StatesIs Now 77.7 Years

Heart Disease and Cancer Are the Leading Causes of Death in America

The Leading Cause of Death in Young Persons Ages 1–24 Years Is Accidents

In America, the Leading Actual Cause of Death – in Contrast to Data Usually Recorded on Death Certificates – Is Smoking

According to One Report, the Fifth Leading Cause of Death in America Is Medical Error

Acute Medication Poisoning Accounts for Nearly Half of All Poisonings Reported in the US

According to the Morbidity and Mortality Weekly Report (MMWR), the Leading Cause of Disability in US Adults Is Arthritis

Headache Is the Most Common Pain Condition Resulting in Lost Time from Work

If We Look Beyond Skin Cancer, the Most Common Cancer of All, the Next Most Commonly Occurring Malignancy Is Lung Cancer

Lung Cancer Is, Far and Away the Leading Cause of Cancer Death in America

The Most Common Initial Symptom of the Leading US Cancer Killer, Lung Cancer, Is Cough

Almost One Half of All Persons Report Using a Prescription Drug in the Past Month

According to a Commercial Source, Lipitor (Brand of Atorvastatin) Is the Top of the Proprietary Drug List in Sales

Americans Spend an Estimated 2.9 Billion Dollars on Over-the-Counter Cold Remedies Each Year

Sudden Infant Death Syndrome Is the Chief Cause of Healthy Infant Deaths

In One Large Study, Half of All Patients in Intensive Care Units Were Considered Infected and Receiving Antibiotics

Clostridium difficile Is Now the Leading Cause of Nosocomial Infections in Community Hospitals

Methicillin-Resistant Staphylococcus aureus, No Longer Confined to the Hospital Setting, Has Become a Community Problem

There Is Almost a 50:50 Chance that a Teenager in Your Office Is Sexually Active

Forced Sexual Intercourse Is More Common than We Have Thought

More than One Million Americans Are Infected with the Human Immunodeficiency Virus (HIV)

The Centers for Disease Control and the U.S. Census Bureau Estimate that by the Year 2030, There Will Be Approximately 71 Milli

Most US Pregnant Women Begin Prenatal Care During the 8th to 12th Week of Pregnancy

One in Four Pregnant Women Will Report Spotting in the First Few Weeks of Pregnancy, and Half of Those Who Bleed Will Miscarr

Almost One-Third of American Adults Are Obese

There Were More than Ten Million Aesthetic Procedures Performed in the U.S. in 2008

Approximately One-Third of All Persons in the World Are Latently Infected With Mycobacterium tuberculosis

Inherited Cardiovascular Diseases Can Be Transmitted Through Voluntary Sperm Donation

The Most Common Things Occur Most Commonly

References

Chapter 4: Disease Prevention and Screening

There Are Approximately One Million New Cases of Herpes Zoster (HZ) Each Year

If All U.S. Adults Became Nonsmokers of Normal Weight by 2020, We Forecast that the Life Expectancy of an 18-Year-Old Would I

Obesity Brings a Fourfold Higher Relative Risk of Fatal Cardiovascular Disease when Compared with Normal Weight Persons

Breastfeeding May Help to Prevent Obesity in Children

Three Percent of American Women Take Potentially Teratogenic Medications

Many Otherwise Healthy Infants and Toddlers Have Low Vitamin D Levels

Vitamin D Supplementation in Children May Help Prevent Seasonal Influenza A

In Adults, Adequate Vitamin D Levels Can Help Prevent Fractures

Vitamin D May Help Prevent Colorectal Adenomas and Cancer, as Well as Other Tumors

Aspirin May Help Prevent Colorectal Cancer Deaths

Aspirin, While of Benefit for Many with Occlusive Vascular Disease, Is of Uncertain Benefit in the Primary Prevention of Occlu

Close Contacts of Immunocompromised Persons Can Be Immunized Safely, with Two Exceptions: Oral Polio Vaccine and Some Instanc

Immunocompromised Patients Require Extra Attention when Receiving Immunizations

The Surgical Mask Is Comparable – “Non-inferior” – to the Fit-Tested N95 Respirator in Preventing Influenza

Warfarin Seems to Be No Better than Aspirin or Even Placebo in Preventing Recurrent Strokes

Breast Cancer and Prostate Cancer Account for One Quarter of All Cancers in the United States

The US Preventive Services Task Force (USPSTF) Has Recommended that Mammography No Longer Be Considered a “Standard” Test for

There Is Controversy Over the Net Benefits of Adding Clinical Breast Examination (CBE) to Screening Mammography

There Is No Clear Consensus About Screening for Prostate Cancer Using Prostate Specific Antigen (PSA) Determinations in Men Und

Electrocardiography May Have a Role in Screening College Athletes Before Sports Participation

Obesity Is the Best Predictor of Undiagnosed Diabetes

Men Age 65–75 Years Old Who Have Ever Smoked Should Be Screened for Abdominal Aortic Aneurysm (AAA)

There Is One Global Question that Is a Good Indicator of Unrecognized Hearing Loss in the Elderly: “Do You Have a Hearing Pro

Sometimes the Patient’s Ancestry Is the Key to Needed Preconceptual or Prenatal Screening

Male Circumcision Reduces the Risk of Herpes Simplex Virus Type 2 (HSV-2) and Human Papillomavirus (HPV)

Just Because We Can Screen for a Disease Does Not Mean Everyone Needs to Be Screened

References

Chapter 5: Risk Factors and Disease Correlates

Beta-Blocker Use Increases the Risk of Severe Anaphylaxis

Perceived and Actual Overweight Increases the Risk of Suicide Attempts in Young Persons

Risk Factors for Childhood Obesity Include Parental Obesity, Early Overweight, and Too Much Television Viewing

Acetaminophen Use Increases the Risk of Asthma in Both Children and Adults

Aspirin Use After a Diagnosis of Breast Cancer May Reduce the Risk of Metastasis

There Is an Especially High Risk of Venous Thromboembolism Following Hip or Knee Replacement

Obese Adolescents Are at Increased Risk of Developing Multiple Sclerosis (MS)

High Consumption of Red Meat Increases the Risk of Early Age-Related Macular Degeneration (AMD)

Vitamin D Deficiency Increases the Risk of Myocardial Infarction (MI)

Eating Chocolate May Reduce the Risk of Cardiovascular Disease

Despite Earlier, Hopeful Studies, Selenium Does Not Seemto Reduce the Risk of Prostate Cancer

Multivitamin Use Just Might Increase the Risk of Advanced and Fatal Prostate Cancer

Patients with Down Syndrome Are More Likely to Develop Hyperthyroidism than Those Without Down Syndrome

There Is an Increased Incidence of CerebralThromboembolism in Patients with Crohn Disease

Migraine Patients Have a Higher Incidence of PatentForamen Ovale (PFO) than Normal Persons

Migraine Headache with Aura Is Associated with a Twofold Increased Risk of Ischemic Stroke

A Third of Headache Patients Are Also Depressed

Prior Statin Use Is Correlated with Improved Outcomes in Patients with Community-Acquired Pneumonia (CAP)

Parkinson Disease Is Associated with Less of Some Cancers, but Not All

In Patients with Colorectal Cancer, Physical Activity Is Correlated with a Lower Risk of Death

There Is a High Prevalence of Osteopenia and Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease (COPD)

Married Patients with Cancer Live Longer

Patients with Endometriosis Have a Higher Prevalenceof Infection, Melanoma and Ovarian Cancerthan the General Population

There Seems to Be a Negative Correlation Between Alzheimer Disease (AD) and Cancer

Higher Circulating Leptin Levels Are Associated with Reduced Incidence of Alzheimer Disease

Sleep Restriction May Correlate with Alzheimer Disease

There Is a Link Between Cardiovascular Disease (CVD) and Hip Fracture

There Is an Association Between Coronary Artery Disease and Major Depression

Depression Rivals Smoking as a Risk Factor for Death

There Are Some Diverse Clinical Findings Associated with an Increased Risk of Death

References

Chapter 6: Practical Clinical Pearls

It Is Not a Stroke Until the Patient Has Had 50 of D50

A Handshake Can Be the First Step in Diagnosis

Drooping Eyelids and the “Peek” Sign May Signal the Presence of Myasthenia Gravis

Beware of Future Migraine when a Child Has Severe Motion Sickness

Three of Every Ten Patients with Subarachnoid Hemorrhage (SAH) Are Initially Misdiagnosed

When a Long Distance Runner Is Found to Be Anemic, Think of Runner’s Anemia

A Patient with Early and Rampant Dental Caries May Have Sjögren Syndrome

Behçet Syndrome May Present as Severe, Recurrent Aphthous Stomatitis

The First Indication of Hyperthyroidism May Be the Onset of Atrial Fibrillation (AF)

A Patient with Chest Pain Relieved by Leaning Forward May Have Pericarditis

The Patient with Cough and Dyspnea Who Uses a Hot Tub Might Just Have Hot Tub Lung

A Patient with Acute Appendicitis Usually Has a Loss of Appetite

The Jump Test Can Help Clarify a Suspected Diagnosis of Appendicitis

Painless Jaundice in a Patient with a Palpable Gall Bladder Is Probably Not Caused by Gallstones

A Patient with Flushing that Does Not Respond to Usual Therapy May Have Carcinoid Syndrome

Sarcoidosis Is an Unlikely, but Possible, Cause of Joint Symptoms in Children

The Spleen Must Triple in Size Before Becoming Palpable

Varicocele Generally Occurs on the Left, and a Unilateral Right-Sided Varicocele Is a Worrisome Finding

When a Male with Scrotal Pain Has an Intact Cremasteric Reflex, the Diagnosis May Be Something Other than Testicular Torsion

The Best Test to Detect Diabetic Peripheral Neuropathy Is the 128-Hz Tuning Fork

When a Patient with Back Pain Experiences Decreased Pain with Forward Flexion of the Spine, Think of Lumbar Spinal Stenosis

A Schoolchild with Backache: Think Backpack

Patients Who Cannot Fully Extend the Elbow Following an Injury Have a 50:50 Chance of Fracture

The Patient with Bone Pain at Night Relieved by Aspirin May Have Osteoid Osteoma

Plantar Fasciitis Is Like Pregnancy

Not Every Person Has a Dorsalis Pedis Pulse

The First Sign of Parkinson Disease (PD) May Be Micrographia

Parkinsonism that Begins with a Tremor Runs a Slower Course than Disease that Starts with Rigidity or Hypokinesia

Patients with Drug-Induced Parkinsonism Tend Not to Exhibit Tremor

Auditory Hallucinations Are Usually Psychotic in Origin, While Visual Hallucinations Are More Likely to Be Caused by Chemicals,

When a Patient with Dementia Suddenly Develops Coexistent Delirium, Suspect a Urinary Tract Infection

The Characteristics of Bruising Can Help Differentiate Between Accidental and Abusive Trauma in Children

A Patient with Slate Blue, Silvery Discoloration of the Skin May Have Argyria

Premature Whitening of the Hair Can Be due to Vitamin B12 Deficiency

A Skin Lesion Showing the “Dark Dot Sign” Is Most Likely to Be a Basal Cell Carcinoma

The “Ugly Duckling” Sign May Signal the Presence of a Melanoma

Sudden, Effortless Smoking Cessation May Indicate Lung Cancer

Sometimes Clinicians Can Be Part of the Infection Problem

References

Chapter 7: Laboratory Testing, Electrocardiography and Imaging

Policy Edicts Can Influence Diagnostic Testing Decisions

Elevated Red Blood Cell Distribution (RWD) Is Associated with an Increased Risk of Death

Glycosylated Hemoglobin (HbA1c) Is a Useful Screening Test for Diabetes Mellitus

Decreasing Low Density Lipoprotein Cholesterol (LDL-C) Is the Key to Lowering the Risk of Cardiovascular Disease, and Simply

HbA1c Levels of 5.5% or Greater Are Associated with an Increased Risk of Diabetic Retinopathy

Lipid Studies Can Be Done Without the Need for Fasting

Elevated C-Reactive Protein (CRP) Levels Are Associated with an Increased Risk of Diabetes Mellitus

Elevated Serum Uric Acid (SUA) Levels Are Associated with an Increased Risk of Death

Elevated Serum Tumor Necrosis Factor Alpha (TNF-Alpha) Is Associated with Increased Cognitive Decline in Alzheimer Disease

Fluoroquinolone Use Can Cause a False Positive Opiate Urine Drug Screen

Tricyclic Antidepressants Can Cause a False Positive Test for Pheochromocytoma

Vitamin C Can Cause False Negative Dipstick Tests for Urinary Hemoglobin and Glucose

Digital Rectal Examination (DRE) of the Prostate Can Increase the Level of Prostatic Specific Antigen (PSA), but Not Very Muc

There May Be a Role for Glucose Oxidase Strip Testing for Cerebrospinal Fluid (CSF) Rhinorrhea, After All

A Normal d-Dimer Test Does Not Always Rule Out Pulmonary Embolism (PE)

If You See an Inverted P Wave on an Electrocardiogram (ECG), Think First of Electrode Misplacement

First Degree Heart Block (FDHB) Is Not a Benign Incidentaloma

Low-Dose Computed Tomography (CT) Screening for Lung Cancer Has a High Rate of False-Positive Results

Don’t Count on a Normal Chest Radiograph to Rule Out Pneumonia in a Bedridden Patient

There Is Some Cancer Risk Associated with Every Computed Tomography Scan

Thoracoabdominal Calcifications Noted on Roentgenograms Are Significant Predictors of Cardiovascular Disease and Total Mortali

Routine Lumbar Imaging for Low Back Pain Is Unhelpful Unless There Is an Indication of a Serious Underlying Condition

Newly Proposed Prediction Rules Allow Avoidance of Computed Tomography Head Imaging in Children at Very Low Risk of Clinically

Imaging May Be Helpful in Selected Instances of Newly Diagnosed Epilepsy in Children

In Suspected Acute Appendicitis, Computed Tomography Use Can Lower the Rate of Negative Appendectomies: Especially in Young Wo

In the Setting of Possible Appendicitis During Pregnancy, an Ultrasound (US) Determination Read as Positive May Require No Fu

Migraine Patients Are at Increased Risk for Subclinical Brain Infarcts, Detectable on Magnetic Resonance Imaging

Transdermal Patches Containing Metal in the Backing Can Cause Burns During an MRI Scan

After Starting a Potent Bisphosphonate in a Postmenopausal Woman with Osteoporosis, Wait 3 Years Before Monitoring Response Usi

Be Alert to the Seductive Power of Testing, Tracings, and Images

Reference

Chapter 8: Alarming Symptoms and Red Flag Findings

Four General Alarm Symptoms Are: Rectal Bleeding, Hematuria, Dysphagia, and Hemoptysis

Fever, Headache and a Centripetal Rash Suggest Rocky Mountain Spotted Fever (RMSF)

In a Patient with Fever or Other Evidence of Infection, There Are Three Manifestations that May Be Early Signs of Sepsis: Leg P

A Rash with Central Clearing Could Be Erythema Migrans (EM), the Tip-Off to Lyme Disease

A Skin Lesion with an Area of Anesthesia in a Person with a Suspicious Exposure History Could Be a Sign of Hanson Disease/Lep

A Child with an Unexplained Fever for 5 Days or More Just Might Have Kawasaki Disease (KD)

A History of a Penetrating Injury, Increasing Wound Pain and Soft Tissue Crepitus Strongly Suggest the Diagnosis of Gas Gangr

Bloody Diarrhea, Vomiting and Abdominal Pain May Be the Precursors to the Hemolytic Uremic Syndrome (HUS)

The Patient Who Travels and Who Reports Linear or Clustered Bites Might Have Bedbugs

Think of Wilms Tumor in a Child with a Painless Abdominal Mass or Swelling

A Child with Purpura, Joint Symptoms and Abdominal Pain May Have Henoch–Schönlein Purpura

The “Red Flag” Findings for Osteogenesis Imperfecta Are Excessive Numbers of Fractures, Perhaps Associated with Hearing Loss,

Fever, Irritability and Bone Hyperplasia in an Infant Suggest the Presence of Caffey Disease, aka Infantile Cortical Hyperost

A Young Child with a Fracture Attributed to Falling Out of Out of Bed Is a Red Flag for Child Abuse

Herpes Zoster Involving the Tip of the Nose Can Presage a Sight-Threatening Herpes Zoster Ophthalmicus Inflammation of the E

A Painful Red Eye Associated with Headache, Nausea and Vomiting Is Often Seen with Acute Angle Closure Glaucoma

The Sudden Appearance or Increase in Retinal Floaters in One Eye May Herald the Onset of Retinal Detachment

A Patient Taking Alpha-Adrenergic Receptor Blockers and Headed for Cataract Surgery Is at Risk for Floppy Iris Syndrome (FIS)

A Child with a Croupy Cough Whose Symptoms Do Not Respond Promptly to the Home Remedy of Sitting in a Steamy Bathroom Has a Lif

Most Headache Patients Do Not Require Imaging, but Some Do

The Combination of Headache, Palpitations and Sweating Suggests the Possibility of Pheochromocytoma

A Diagnosis of “Non-specific Chest Pain” Carries a Significant Mortality Risk over the Next 5 Years

Sudden Chest or Abdominal Pain Described as “Tearing” or “Ripping” Is a Red Flag for the Possibility of Aortic Dissection

The Sudden Onset of Fever and Dyspnea in a Nursing Home Patient Is Aspiration Pneumonitis until an Alternative Diagnosis Is Co

The Sudden Onset of Labored and Rapid Breathing in an Otherwise Healthy Person May Be Alarm Symptoms of Pulmonary Embolism (P

Be Concerned When Presented with the Very Obese Patient with Sleep Disordered Breathing

New Onset Diabetes Mellitus in an Older Adult May Herald a Later Diagnosis of Pancreatic Cancer

In Any Patient with Acute or Chronic Diarrhea Accompanied by Abdominal Distension, the Possibility of Toxic Megacolon Should Be

Low Back Pain Plus Bladder or Bowel Dysfunction Signal a Surgical Emergency

When Evaluating a Low Back Pain Patient for Fracture, There Are Three Red Flags to Consider: Prolonged Use of Corticosteroids

An Injury Such as a Fall Followed by Bilateral Upper Extremity Weakness Is an Alarm Scenario that May Indicate the Presence o

Symmetrical Limb Weakness Following a Respiratory Infection or Gastroenteritis Describes the Classic Onset of Guillain–Barré

Patient Distress during Pelvic Examinations May Signal Past Sexual Violence

Be Alarmed and Suspect Ectopic Pregnancy (EP) When a Woman of Childbearing Age Reports Lower Abdominal or Pelvic Pain, Especi

Factors Making Ectopic Pregnancy Diagnosis More Likely

Gynecomastia Can Be an Early Clue to Testicular Cancer

Here Is the Red Flag Scenario for Stevens–Johnson Syndrome (SJS): a Child Or Young Person with an Infectious Disease, Perhaps T

A Patient with Intermittent Abdominal Pain Who Mentions that His or Her Urine Turns Red upon Standing (In a Glass Container) M

The Diabetic Patient Who also Has Hyperpigmentation of the Skin Might Have Hemochromatosis (“Bronze Diabetes”)

Reporting Late to Establish Prenatal Care During a Pregnancy May Be an Alarm Signal Indicating the Presence of Domestic Viole

Of All Disease Entities, Cancer Is Especially Likely to Reveal Itself, to Borrow Dr. Trotter’s Words, in Casual Parentheses

Patients Who State that they Are Going to Die Soon Often Do So

References

Chapter 9: Therapeutic Insights

In the Intensive Care Unit (ICU) Setting, a Target Glucose of 180 mg/dL or Less Yields a Lower Mortality than a Target of 81–

Insulin Use Seems to Increase Mortality Risk

There Are Risks Associated with the Use of Various Oral Antidiabetic Agents

In China, Metformin Has Been Prescribed for Antipsychotic-Induced Weight Gain

Treating Periodontal Disease Can Improve Glycemic Control in Type 2 Diabetic Patients

When Initiating Treatment for the Acute Phase of Major Depression, Sertraline (Zoloft) May Be the Best Choice

Selective Serotonin Reuptake Inhibitor (SSRI) Use Can Be Associated with Upper Gastrointestinal Bleeding (UGB)

The Use of SSRIs in Pregnancy May Adversely Affect Pregnancy Outcomes

SSRIs Increase the Risk of Hemorrhagic and Fatal Stoke in Postmenopausal Women

The Risk of Suicidality in Patients Taking Antidepressants Varies with Age

Testosterone Therapy May Help Relieve Depression in Hypogonadal Older Men with Subthreshold Depression

The Initiation of Antipsychotic Drug Treatment in Older Diabetic Persons Is Associated with an Increased Risk of Hospitalizati

Initial Treatment of Children and Adolescents with Second Generation Antipsychotic Medications Is Associated with Weight Gain

Patients with Alzheimer Disease Taking Antipsychotic Medications Are at Increased Risk of Death

Long-Chain Omega-3 Fatty Acids May Help Prevent the Onset of Psychotic Disorders

When It Comes to Preventing Coronary Heart Disease (CHD) Events and Stroke, There Is Little Difference Among the Various Class

In the Initial Treatment of High Blood Pressure, Low Dose Thiazides Seem to Be a Good Default Choice

Combination Therapy Yields Greater Decrement in Blood Pressure when Compared with Increasing the Doseof a Single Drug Used to

Treating Patients to Lower than Standard Blood Pressure Targets, £140–160/90–100 mmHg, Does Not Reduce Mortality or Morbidity

The Patient with Severe but Asymptomatic Hypertension May Not Need Rapid Lowering of Blood Pressure

Beta-Blocked Patients Tolerate Surgical Anemia Less Well Than Those Who Have Not Received Beta Blockers

In Patients with Atrial Fibrillation (AF) and Heart Failure (HF), Rhythm Control Is Not Superior to Rate Control

Lenient Rate Control in Patients with Atrial Fibrillation Is as Effective as Strict Rate Control

In a Patient with Acute Cardioembolic Stroke, Anticoagulation Therapy May Not Be the Best Choice

The HMG-CoA Reductase Inhibitors (Statins) Have Diverse and Generally Beneficial Effects, Actions That Involve More than Redu

There Are Some Adverse Effects That Can Occur with Use of Statins

Triptan Medications Should Not Be Used in Complicated Migraine Headaches, Such as Hemiplegic or Basilar Migraine

High-Flow Oxygen May Be Useful in Treating Cluster Headache

Varenicline Can Cause Potentially Dangerous Psychiatric Symptoms

A Mother’s Antiepileptic Therapy During Pregnancy Risks Impaired Cognitive Function in the Child

Oral Acyclovir (Zovirax) Does Not Seem to Be Helpful in Preventing Postherpetic Neuralgia

Steroids Are Helpful in Treating Bell Palsy

Neither Antibiotic nor Topical Steroid Therapy Is Likely to Be Effective in the Treatment of Acute Sinusitis

Steroids May Be Useful Adjuvant Therapy in Acute Pharyngitis

The Use of Long-Acting Beta Agonists in Asthma May Increase the Risk of Asthma-Related Intubations and Death

A Selective Serotonin Reuptake Inhibitor (SSRI) May Be Useful in Treating Premature Ejaculation (PE)

Phosphodiaesterase-5 (PDE5) Inhibitors May Be Useful in Treating Lower Urinary Tract Symptoms (LUTS)

Sildenafil Increases Exercise Capacity Under Hypoxic Conditions

A Small Dosage Increment of Phenytoin Can Bring a Large Increase in Serum Levels of the Drug

Some Drugs We Commonly Prescribe Are Restricted or Banned from Athletic Competition

Short Course Treatment of Uncomplicated, Symptomatic Lower Urinary Tract Infections (UTIs) Works as Well as Longer Duration T

Procalcitonin Testing Can Provide Useful Guidance when Deciding About Antibiotic Use in Lower Respiratory Tract Infections (L

C-Reactive Protein (CRP) Point-of-Care Testing Can Be Helpful in Deciding About Antibiotic Prescribing in LRTIs and Rhinosinu

Consider the Possibility of Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency Before Prescribing Primaquine for Malaria Prop

The Sequence of Infant Vaccine Injections Matters

The Antiemetic Ondansetron (Zofran) Is Useful in Controlling Vomiting in Children with Acute Gastroenteritis and Mild/Moderate

Oral Bisphosphonates Have Not Been Shown to Cause Atypical Subtrochanteric Fractures of the Femur

In Older Persons with Memory Problems, Physical Activity May Improve Cognition

Vitamin D Deficiency May Play a Role in Chronic Tension-Type Headache

Vitamin B12 Is Worth a Try in Treating the Patient with Recurrent Aphthous Stomatitis (RAS)

Supplementary Antioxidant Vitamin Use Does Not Reduce the Incidence of Heart Attacks or Other Vascular Events, Cancer, or Othe

References

Chapter 10: Idiosyncratic and Uncommon Drug Effects

Beta Blockers Can Cause or Aggravate Psoriasis

Spironolactone Causes Changes in the Ratio of Testosterone to Estradiol, Contributing to the Likelihood of Gynecomastia as a

Acetazolamide Has Two Curious Side Effects: It Can Cause Tingling of the Fingertips and Can Make Carbonated Beverages Seem to

ACE Inhibitors and Angiotensin Receptor Blockers (ARBs) Help Prevent the Development of Diabetes Mellitus

Valsartan Use in Hypertension May Help Prevent Cardiovascular Events

Angiotensin Receptor Blockers May Reduce the Development or Progression of Alzheimer Disease and Dementia

Regular Analgesic Use Can Lead to Hearing Loss

Non-Steroidal Anti-Inflammatory Drugs Can Cause a Wide Variety of Skin Rashes

Salicylates Carry a Significant Risk of Toxicity

Antibacterial Agents Can Cause a Panoply of Neurotoxic Manifestations

Tetracycline and Its Derivatives Can Stain Adult Teeth

Fluoroquinolone Antibiotics Can Cause Tendinitisor Tendon Rupture

Some, But Not All, Fluoroquinolones Can Disrupt Glucose Homeostasis, Causing Severe Hypoglycemia or Hyperglycemia

Fluoroquinolones May Cause Diplopia

Serotonin Selective Reuptake Inhibitors (SSRIs) Can Cause Delayed Ejaculation in Men, Although the EffectVaries Among Specifi

Trazodone (Desyrel) Can Cause Priapism

The Nonbenzodiazepine Receptor Agonist (NBRA) Hypnosedatives Can Induce Sleep-Related Complex Behaviors

Epilepsy and Other Illnesses for Which Antiepileptic Drugs (AEDs) Are Prescribed Are Associated with an Increased Risk of Suici

Topiramate (Topamax) Can Cause ImpairedCognitive Function

Carbamazepine (Tegretol) Can Cause a Shift in Musical Pitch Perception

Purple Glove Syndrome Is a Rare, But Serious, Complication of Intravenous Phenytoin (Dilantin) Therapy

Sumatriptan (Imitrex) and Related Triptan DrugsCan Cause Ischemic Colitis

Sumatriptan, in Large Doses, Can Cause Sulfhemoglobinemia

Digitalis, Even in Modest Doses, Can Cause Yellow Vision

Under Certain Circumstances, Acid-Suppressing DrugsMay Be Associated with an Increased Risk of Community Acquired Pneumonia (C

Metoclopramide (Reglan) Is the Most Common Cause of Drug-Induced Movement Disorders, Such as Tardive Dyskinesia

Post-Menopausal Women Who Take Estrogen Plus Progestin and Who Develop Lung Cancer Face a Higher Risk of Death

Long-Term Users of Metformin May Develop a VitaminB12 Deficiency

Quinine Can Cause Thrombocytopenia Accompanied by Bleeding Symptoms

Mefloquine (Lariam) Can Cause Acute Psychosis

Oral Bisphosphonates May Offer Some Protection Against Invasive Breast Cancer

Dopaminergic Agents Can Cause Pathologic Gambling

Phosphodiesterase Type 5 (PDE5) Inhibitors CanCause Sudden Hearing Impairment

Methylphenidate (Ritalin) Can Cause Complex Visual Hallucinations

Idiopathic Intracranial Hypertension (ICH), Aka Pseudotumor Cerebri, Has Been Linked to Lithium Therapy

Human Immunodeficiency Virus (HIV)-Infected Patients Are at Greatly Increased Risk of Severe Cutaneous Reactions to Some of t

Gadolinium-Based Contrast Agents Can Cause Nephrogenic Systemic Fibrosis (NSF)

References

Chapter 11: Drug Interactions and Adventures in Polypharmacy

Our Patients Take a Lot of Drugs and Herbal Remedies, and Hence Have Abundant Opportunities for Drug Interactions

Drugs with a Narrow Therapeutic Range Pose an Extra Risk of Drug–Drug Adverse Effects

Some Adverse Drug–Drug Interactions Involve Decreased Efficacy of One of the Drugs

Much of the Risk of Drug–Drug Interactions is Preventable, if Only We Could Reduce the Incidence of Inappropriate Prescribing

Nonsteroidal Antiinflammatory Drugs Can Blunt the Cardioprotective Effect of Aspirin

NSAIDs, Including Selective Cyclooxygenase 2 Inhibitors, Can Increase Serum Lithium Concentrations, Leading to Toxicity

In the Setting of Aspirin and Clopidogrel (Plavix) Used to Prevent Cardiovascular Disease, Doses of Aspirin 100 mg or Greater

“Patients at Risk for Heart Attacks or Strokes Who Use Clopidogrel to Prevent Blood Clots Will Not Get the Full Effect of Thi

Carisoprodol (Soma) and Oxycodone (OxyContin) Can Have Additive Depressant Effects on the Central Nervous System (CNS)

Selective Serotonin Reuptake Inhibitors (SSRIs), Notably Paroxetine (Paxil), Can Blunt the Effectiveness of Tamoxifen as Anti-

The Combination of Adderall-XR and Alcohol Can Be Associated with Myocardial Infarction

Concomitant Use of an Angiotensin Converting Enzyme (ACE) Inhibitor and an Angiotensin Receptor Blocker (ARB) Brings No Added

The Combination of Trimethoprim-Sulfa with Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Can Result

Combining a Fibrate with a Statin Drug Increases the Risk of Rhabdomyolysis

Ketoconazole (Nizoral) Can Increase Plasma Concentrations of Mefloquine (Lariam)

Concomitant Use of Clarithromycin and Digitalis Can Lead to Toxic Levels of Digitalis

Sildenafil (Viagra) May Relieve Antidepressant-Induced Sexual Dysfunction in Women

The Concomitant Use of Phosphodiesterase-5 Inhibitors and Nitrates Can Cause an Unsafe Drop in Blood Pressure

Smoking Cessation Can Increase Plasma Levels of Clozapine (Clozaril)

Initiating Treatment with Two Antidepressant Medications May Bring Superior Results

Serum Levels of Warfarin (Coumadin), Whether Increased or Decreased, Can Be Affected by Dozens of Drugs

Herbal Substances and Dietary Supplements Can Also Interact with Drugs We Prescribe

Probiotic Dietary Supplements Help Prevent Antibiotic-Associated Diarrhea (AAD)

Grapefruit Can Increase the Bioavailability of a Number of Medications

References

Chapter 12: Alcohol, Nicotine and Caffeine

Alcohol Leads Both Prescription and Illicit Drugs in Causing Fatal Motor Vehicle Accidents

Patients with Breast Cancer and Who Consume 7 or More Alcoholic Beverages Per Week Have an Increased Risk of Developing a Cont

Acute Alcohol Exposure Prior to Trauma Impairs Wound Healing

The Drug Most Often Implicated in Substance-Related Sexual Assault Is Alcohol

African-American Men Seem Especially Prone to Alcohol-Associated Hypertension

Drinking Without Eating May Increase the Risk of Alcohol-Associated Hypertension

Not All Studies Find a Relationship Between Alcohol Consumption and Hypertension

Weekly Alcohol Consumption May Help Prevent Gallstones

Beer Drinking Has Been Reported to Increase Bone Mass in Women

Alcohol Use Is Associated with a Decreased Risk of Benign Prostatic Hyperplasia (BPH)

The Often-Dramatic Suppression of Essential Tremor Following Alcohol Ingestion Is Related to a Reduction of Cerebellar Synapt

Light to Moderate Alcohol Use Seems to Help Protect Against Coronary Heart Disease (CHD)

Eleven Percent of Women Smoke During Pregnancy

Newborns Exposed to Maternal Smoking In Utero Can Experience Neurotoxic Effects, Including a Nicotine Withdrawal Syndrome

Maternal Smoking Increases the Risk of Attention Deficit Hyperactivity Disorder (ADHD) in Offspring

The Use of Nicotine Gum by Pregnant Smokers Can Help Increase Birth Weight and Gestational Age

Cigarette Smoking Increases the Risk of Colorectal Cancer

Smokeless Tobacco Can Increase the Risk of Myocardial Infarction and Stroke

Electronic Cigarettes Are Not Safe, Either

Asking Two Questions – About Current Smoking and Plans to Quit – Increases the Likelihood that Patients Who Smoke Receive Cess

Smoking Increases the Risk of Type 2 Diabetes

Tobacco and Also Marijuana Use Can Lead to Reduced Blood Levels of the Human Immunodeficiency Virus (HIV) Drug Atazanavir (Reya

Tobacco Smoking May Double the Risk of Active Tuberculosis

Tobacco Smoking Seems to Be Inversely Associated with Parkinson Disease (PD)

Nicotine Seems to Improve Some of the Manifestations of ADHD in Adults

Nicotine Can Enhance Cognitive Function

The U.S. Food and Drug Administration Now Has the Authority to Regulate Tobacco

Caffeine Is the Most Widely Used of All Drugs

Caffeine Can Enhance Cognitive Performance, Even at Quite Low Doses

High Caffeine Consumption Cannot Be Relied Upon to Prevent Age-Related Cognitive Decline

Don’t Count on Caffeine to Reverse the Cognitive Impairment Associated with Alcohol Use

Caffeine Can Enhance Athletic Performance, in Some Sports, Sometimes, Maybe

High Coffee Intake Reduces the Risk of Type 2 Diabetes Mellitus

References

Chapter 13: Unforeseen, Counterintuitive and Possibly Prophetic Findings

Essential Tremor (ET) Is Often Not “Benign”

Aspirin Rivals Sumatriptan in Providing Relief of Acute Migraine Headache

Surgical Deactivation of Migraine Trigger Sites May Prove to Be Useful Therapy for Some

Women with Migraine Seem to Have a Reduced Risk of Breast Cancer

Children with Acute Otitis Media (AOM) Initially Treated with Amoxicillin Have Been Found to Have More Recurrences When Compa

Withholding Antibiotic Treatment of Acute Otitis Media Influences the Incidence of Acute Mastoiditis

Adjuvant Tamoxifen Therapy of Primary Breast Cancer May Increase the Risk of Estrogen Receptor (ER) Negative Contralateral Bre

Breast Cancer in Men, When it Occurs, Is Likely to Be Hormone Receptor Positive

Pneumococcal Polysaccharide Vaccination (PPV) May Not Provide Adults the Protection Against Pneumonia We Would Like to Think

Pneumococcal Vaccine Does Seem to Offer Protection to Human Immunodeficiency Virus (HIV)-Infected Adults Against Recurrent Pne

Statins May Play a Beneficial Role in Patients with Chronic Obstructive Lung Disease (COPD)

Statins May Reduce Proteinuria and Slow the Rate of Kidney Function Loss, Especially in Patients with Cardiovascular Disease

In Patients with Worsening Heart Failure (HF), Statin Use May Improve Left Ventricular Ejection Fraction (LVEF) and Decrease

Appendicitis and Mesenteric Lymphadenitis When Young Reduces the Risk of Adult Ulcerative Colitis

A Family History of Colorectal Cancer May Offer a Reduced Risk of Cancer Recurrence and Death in Patients with Stage III Colon

Screening Colonoscopy Reduces the Prevalence of Colorectal Cancer, But Chiefly in Regard to Neoplasms in the Left Colon

The Venerated Digital Rectal Examination (DRE) May Be as Harmful as Helpful in Diagnosis, at Least in Patients with Undiffere

Diabetic Self-Monitoring May Risk Depression with No Gain in Glycemic Control

Bariatric Surgery May Yield a Dividend Beyond Weight Loss: Remission of Type 2 Diabetes

Persons Taking Hydroxychloroquine for Rheumatoid Arthritis Seem to Have a Reduced Risk of Developing Diabetes

In Patients with Both Heart Failure and Diabetes Mellitus, There Is a “Sweet Spot” in the Middle Range of Glycosylated Hemoglob

Type 2 Diabetics at High Risk for Cardiovascular Events May Not Benefit from Rigorous Blood Pressure Control

In Patients with Diabetic Neuropathy, High Dose B-Vitamins Can Adversely Affect Renal Function and Increase the Risk of Vascul

In One Study, Placebo Therapy Both Helped and Harmed Patients with Benign Prostatic Hyperplasia (BPH)

Minimally Invasive Radical Prostatectomy (MIRP) Offers Short Term Advantages, But a GreaterRisk of Long Term Problems When Co

Vertebroplasty Seems to Offer “No Beneficial Effect” in the Treatment of Painful Osteoporotic Vertebral Fractures

Conventional Non-steroidal Antiinflammatory Drugs (NSAIDs) May Harm Knee Cartilage, While Cyclooxygenase (COX)-2 Inhibitors May

Men with Restless Leg Syndrome (RSL) Are at Increased Risk of Having Erectile Dysfunction (ED)

Depression Is an Inflammatory State with Implications for Cardiac Disease

###Overweight Older Children and Adolescents Consume Fewer Calories than Their Healthy Weight Peers

###Women Who Have Menopausal Night Sweats May Enjoy a Reduced Risk of Death Over the Following 20 Years

###Marijuana Use May Be Associated with a Reduced Risk of Head and Neck Squamous Cell Carcinoma (HNSCC)

Eating Egg Yolks – 4 a Day, and Maybe Even Just 2 a Day – Reduces the Risk of Dry, Age-Related Macular Degeneration

Metformin Inhibits Endometrial Cancer Cell Proliferation In Vitro

Transmission of Rabies Virus from an Organ Donor to Transplant Recipients Has Been Reported

Massive Cola Ingestion Can Cause Hypokalemic Myopathy

Electromagnetic Field (EMF) Exposure Has Shown Benefit in Both Normal Mice and Transgenic Mice Destined to Develop Alzheimer-Li

A Study Has Reported Finding No Evidence to Support the Contention that Resident Fatigue Leads to Increased Medical Errors

References

Chapter 14: Some Timeless Truths About Medical Practice

The Best Physicians Often Employ Fact-Based, Intuition-Guided Decision-Making

Only Rarely Does a Patient Have Just One Disease

No Drug Has Only One Action

Just Being in a Medical Journal Doesn’t Make it True

Statistical Analysis Can Be Misleading

Publication Bias Can Influence What We Read

Pharmaceutical Advertisements, Even Those Appearing in Esteemed Medical Journals, Must Be Read with Great Care

Some of Today’s Great Ideas – and the “Facts”We Cherish – Will Prove to Be Wrong

In the End, the Best Physicians, Like the Best Generals,Make the Fewest Errors

References

A Clinician’s Glossary of Statistical Terms

Index