Essential Medical Facts Every Clinician Should Know (eBook)

Dr. Robert B. Taylor is a professor emeritus of Family Medicine at Oregon Health & Science University, and is the author of more than 25 books.

Essential Medical Facts Every Clinician Should Know 3
Preface 9
Acknowledgments 13
Contents 15
Clinical Practice Notice 47
Chapter 1: Medical Facts, Errors, and This Book 49
Medical Errors Matter 50
Essential Medical Facts Involve the Full Panorama of Medicine: Epidemiology, Prevention, Diagnosis, Laboratory Testing, Imagi 51
This Book Is Written for Clinicians, Those of Us on the Front Lines Actually Seeing Patients 52
References 50
Chapter 2: Challenging Current Medical Misconceptions 54
Continuous Intrapartum Electronic Fetal Monitoring (EFM) Has Not Been Found to Decrease the Incidence of Fetal Mortality or Ce 56
Visual Assessment Is Not Reliable in Screening Newborns for Significant Hyperbilirubinemia Prior to Discharge from the Nurser 56
Pallor of the Palmar Creases Is Unreliable in Detecting Anemia 57
The Levine Sign – Chest Discomfort Described by Placing a Clenched Fist on the Chest – Is Not a Reliable Indicator in Determi 57
Pain Relief Following a GI Cocktail Is Not Limited to Gastrointestinal Disease 58
Contrary to Lore, Women with Ovarian Cancer Usually Have Symptoms Which May Be Noted Months Before Diagnosis 59
It Is Safe to Use Opiates to Relieve Abdominal Pain, Even if the Diagnosis Is in Doubt 59
It Seems Safe for Patients with Diverticular Disease to Eat Nuts, Corn and Popcorn, After All 60
Lactic Acidosis May Not Be a Special Risk Associated with Metformin Use, After All 60
Night Pain in Back Pain Patients Might Not Really Be an Ominous Symptom 61
The Prehn Sign Is Not Dependable in Differentiating Between Epididymitis and Testicular Torsion 62
Monofilament Testing Is Not Reliable in the Diagnosis of Peripheral Neuropathy 62
Bed Rest Is No Longer the Preferred Treatment for Acute Low Back Strain 63
Spinal Manipulation Is Not Useful in the Treatment of Infant Colic 63
It Is Generally Safe to Use Prescription Medications for a Year or Two Following Their Expiration Date 64
Selected Cephalosporins Can Be Used in Patients with a History of Penicillin Allergy 65
The Use of Intravenous Drugs Such as Epinephrine in the Setting of Out-of-Hospital Cardiac Arrest Does Not Improve the Odds of 65
Patients with Mild or Moderate Depression May Experience Little or No Benefit from the Use of Antidepressant Medication 66
Oral Dexamethasone Is Not Helpful in the Treatment of Acute Bronchiolitis in Children 67
Short Courses of Steroids Used to Treat Asthma Need Not Be Tapered, and Can Be Simply Stopped 67
Guillain–Barré Syndrome (GBS) Is More Likely to Be Caused by Influenza than by an Influenza Vaccine 68
Exposure to Cold May Have Something to Do with Upper Respiratory Infections, After All 69
Ginkgo biloba Does Not Prevent Cognitive Decline in Older Adults 70
Antipyretic Agents Do Not Prevent Recurrences of Febrile Seizures 70
Supplementary Use of Vitamins C and E Does Not Offer Protection Against Heart Disease 71
We Do Not Need to Drink Eight Glasses of Water a Day 72
Low Dose Vitamin K Does Not Reduce Bleeding in Warfarin Patients with Elevated International Normalized Ratios (INRs) 72
Vitamin B12 Need Not Be Given by Injection 73
Oral Antibiotics Are the Best Outpatient Treatment for Pneumonia 73
Childhood Vaccines Do Not Cause Autism 74
References 55
Chapter 3: Epidemiologic Realities and Gee-Whiz Facts 75
The Overall Life Expectancy at Birth in the United StatesIs Now 77.7 Years 76
Heart Disease and Cancer Are the Leading Causes of Death in America 77
The Leading Cause of Death in Young Persons Ages 1–24 Years Is Accidents 77
In America, the Leading Actual Cause of Death – in Contrast to Data Usually Recorded on Death Certificates – Is Smoking 78
According to One Report, the Fifth Leading Cause of Death in America Is Medical Error 78
Acute Medication Poisoning Accounts for Nearly Half of All Poisonings Reported in the US 79
According to the Morbidity and Mortality Weekly Report (MMWR), the Leading Cause of Disability in US Adults Is Arthritis 79
Headache Is the Most Common Pain Condition Resulting in Lost Time from Work 81
If We Look Beyond Skin Cancer, the Most Common Cancer of All, the Next Most Commonly Occurring Malignancy Is Lung Cancer 81
Lung Cancer Is, Far and Away the Leading Cause of Cancer Death in America 82
The Most Common Initial Symptom of the Leading US Cancer Killer, Lung Cancer, Is Cough 83
Almost One Half of All Persons Report Using a Prescription Drug in the Past Month 83
According to a Commercial Source, Lipitor (Brand of Atorvastatin) Is the Top of the Proprietary Drug List in Sales 84
Americans Spend an Estimated 2.9 Billion Dollars on Over-the-Counter Cold Remedies Each Year 84
Sudden Infant Death Syndrome Is the Chief Cause of Healthy Infant Deaths 85
In One Large Study, Half of All Patients in Intensive Care Units Were Considered Infected and Receiving Antibiotics 85
Clostridium difficile Is Now the Leading Cause of Nosocomial Infections in Community Hospitals 86
Methicillin-Resistant Staphylococcus aureus, No Longer Confined to the Hospital Setting, Has Become a Community Problem 86
There Is Almost a 50:50 Chance that a Teenager in Your Office Is Sexually Active 87
Forced Sexual Intercourse Is More Common than We Have Thought 87
More than One Million Americans Are Infected with the Human Immunodeficiency Virus (HIV) 88
The Centers for Disease Control and the U.S. Census Bureau Estimate that by the Year 2030, There Will Be Approximately 71 Milli 88
Most US Pregnant Women Begin Prenatal Care During the 8th to 12th Week of Pregnancy 89
One in Four Pregnant Women Will Report Spotting in the First Few Weeks of Pregnancy, and Half of Those Who Bleed Will Miscarr 90
Almost One-Third of American Adults Are Obese 90
There Were More than Ten Million Aesthetic Procedures Performed in the U.S. in 2008 91
Approximately One-Third of All Persons in the World Are Latently Infected With Mycobacterium tuberculosis 91
Inherited Cardiovascular Diseases Can Be Transmitted Through Voluntary Sperm Donation 92
The Most Common Things Occur Most Commonly 92
References 76
Chapter 4: Disease Prevention and Screening 94
There Are Approximately One Million New Cases of Herpes Zoster (HZ) Each Year 95
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 96
Obesity Brings a Fourfold Higher Relative Risk of Fatal Cardiovascular Disease when Compared with Normal Weight Persons 96
Breastfeeding May Help to Prevent Obesity in Children 97
Three Percent of American Women Take Potentially Teratogenic Medications 97
Many Otherwise Healthy Infants and Toddlers Have Low Vitamin D Levels 98
Vitamin D Supplementation in Children May Help Prevent Seasonal Influenza A 99
In Adults, Adequate Vitamin D Levels Can Help Prevent Fractures 99
Vitamin D May Help Prevent Colorectal Adenomas and Cancer, as Well as Other Tumors 100
Aspirin May Help Prevent Colorectal Cancer Deaths 100
Aspirin, While of Benefit for Many with Occlusive Vascular Disease, Is of Uncertain Benefit in the Primary Prevention of Occlu 101
Close Contacts of Immunocompromised Persons Can Be Immunized Safely, with Two Exceptions: Oral Polio Vaccine and Some Instanc 102
Immunocompromised Patients Require Extra Attention when Receiving Immunizations 102
The Surgical Mask Is Comparable – “Non-inferior” – to the Fit-Tested N95 Respirator in Preventing Influenza 103
Warfarin Seems to Be No Better than Aspirin or Even Placebo in Preventing Recurrent Strokes 104
Breast Cancer and Prostate Cancer Account for One Quarter of All Cancers in the United States 104
The US Preventive Services Task Force (USPSTF) Has Recommended that Mammography No Longer Be Considered a “Standard” Test for 105
There Is Controversy Over the Net Benefits of Adding Clinical Breast Examination (CBE) to Screening Mammography 106
There Is No Clear Consensus About Screening for Prostate Cancer Using Prostate Specific Antigen (PSA) Determinations in Men Und 106
Electrocardiography May Have a Role in Screening College Athletes Before Sports Participation 107
Obesity Is the Best Predictor of Undiagnosed Diabetes 108
Men Age 65–75 Years Old Who Have Ever Smoked Should Be Screened for Abdominal Aortic Aneurysm (AAA) 108
There Is One Global Question that Is a Good Indicator of Unrecognized Hearing Loss in the Elderly: “Do You Have a Hearing Pro 109
Sometimes the Patient’s Ancestry Is the Key to Needed Preconceptual or Prenatal Screening 110
Male Circumcision Reduces the Risk of Herpes Simplex Virus Type 2 (HSV-2) and Human Papillomavirus (HPV) 110
Just Because We Can Screen for a Disease Does Not Mean Everyone Needs to Be Screened 111
References 95
Chapter 5: Risk Factors and Disease Correlates 112
Beta-Blocker Use Increases the Risk of Severe Anaphylaxis 113
Perceived and Actual Overweight Increases the Risk of Suicide Attempts in Young Persons 114
Risk Factors for Childhood Obesity Include Parental Obesity, Early Overweight, and Too Much Television Viewing 114
Acetaminophen Use Increases the Risk of Asthma in Both Children and Adults 115
Aspirin Use After a Diagnosis of Breast Cancer May Reduce the Risk of Metastasis 115
There Is an Especially High Risk of Venous Thromboembolism Following Hip or Knee Replacement 116
Obese Adolescents Are at Increased Risk of Developing Multiple Sclerosis (MS) 117
High Consumption of Red Meat Increases the Risk of Early Age-Related Macular Degeneration (AMD) 117
Vitamin D Deficiency Increases the Risk of Myocardial Infarction (MI) 118
Eating Chocolate May Reduce the Risk of Cardiovascular Disease 118
Despite Earlier, Hopeful Studies, Selenium Does Not Seemto Reduce the Risk of Prostate Cancer 119
Multivitamin Use Just Might Increase the Risk of Advanced and Fatal Prostate Cancer 120
Patients with Down Syndrome Are More Likely to Develop Hyperthyroidism than Those Without Down Syndrome 120
There Is an Increased Incidence of CerebralThromboembolism in Patients with Crohn Disease 121
Migraine Patients Have a Higher Incidence of PatentForamen Ovale (PFO) than Normal Persons 122
Migraine Headache with Aura Is Associated with a Twofold Increased Risk of Ischemic Stroke 123
A Third of Headache Patients Are Also Depressed 123
Prior Statin Use Is Correlated with Improved Outcomes in Patients with Community-Acquired Pneumonia (CAP) 124
Parkinson Disease Is Associated with Less of Some Cancers, but Not All 124
In Patients with Colorectal Cancer, Physical Activity Is Correlated with a Lower Risk of Death 125
There Is a High Prevalence of Osteopenia and Osteoporosis in Patients with Chronic Obstructive Pulmonary Disease (COPD) 125
Married Patients with Cancer Live Longer 126
Patients with Endometriosis Have a Higher Prevalenceof Infection, Melanoma and Ovarian Cancerthan the General Population 126
There Seems to Be a Negative Correlation Between Alzheimer Disease (AD) and Cancer 127
Higher Circulating Leptin Levels Are Associated with Reduced Incidence of Alzheimer Disease 127
Sleep Restriction May Correlate with Alzheimer Disease 128
There Is a Link Between Cardiovascular Disease (CVD) and Hip Fracture 128
There Is an Association Between Coronary Artery Disease and Major Depression 129
Depression Rivals Smoking as a Risk Factor for Death 129
There Are Some Diverse Clinical Findings Associated with an Increased Risk of Death 130
References 113
Chapter 6: Practical Clinical Pearls 132
It Is Not a Stroke Until the Patient Has Had 50 of D50 134
A Handshake Can Be the First Step in Diagnosis 134
Drooping Eyelids and the “Peek” Sign May Signal the Presence of Myasthenia Gravis 135
Beware of Future Migraine when a Child Has Severe Motion Sickness 135
Three of Every Ten Patients with Subarachnoid Hemorrhage (SAH) Are Initially Misdiagnosed 136
When a Long Distance Runner Is Found to Be Anemic, Think of Runner’s Anemia 136
A Patient with Early and Rampant Dental Caries May Have Sjögren Syndrome 137
Behçet Syndrome May Present as Severe, Recurrent Aphthous Stomatitis 137
The First Indication of Hyperthyroidism May Be the Onset of Atrial Fibrillation (AF) 138
A Patient with Chest Pain Relieved by Leaning Forward May Have Pericarditis 138
The Patient with Cough and Dyspnea Who Uses a Hot Tub Might Just Have Hot Tub Lung 139
A Patient with Acute Appendicitis Usually Has a Loss of Appetite 139
The Jump Test Can Help Clarify a Suspected Diagnosis of Appendicitis 140
Painless Jaundice in a Patient with a Palpable Gall Bladder Is Probably Not Caused by Gallstones 140
A Patient with Flushing that Does Not Respond to Usual Therapy May Have Carcinoid Syndrome 141
Sarcoidosis Is an Unlikely, but Possible, Cause of Joint Symptoms in Children 141
The Spleen Must Triple in Size Before Becoming Palpable 142
Varicocele Generally Occurs on the Left, and a Unilateral Right-Sided Varicocele Is a Worrisome Finding 143
When a Male with Scrotal Pain Has an Intact Cremasteric Reflex, the Diagnosis May Be Something Other than Testicular Torsion 143
The Best Test to Detect Diabetic Peripheral Neuropathy Is the 128-Hz Tuning Fork 144
When a Patient with Back Pain Experiences Decreased Pain with Forward Flexion of the Spine, Think of Lumbar Spinal Stenosis 144
A Schoolchild with Backache: Think Backpack 145
Patients Who Cannot Fully Extend the Elbow Following an Injury Have a 50:50 Chance of Fracture 145
The Patient with Bone Pain at Night Relieved by Aspirin May Have Osteoid Osteoma 146
Plantar Fasciitis Is Like Pregnancy It Goes Away in About 9 Months146
Not Every Person Has a Dorsalis Pedis Pulse 147
The First Sign of Parkinson Disease (PD) May Be Micrographia 147
Parkinsonism that Begins with a Tremor Runs a Slower Course than Disease that Starts with Rigidity or Hypokinesia 148
Patients with Drug-Induced Parkinsonism Tend Not to Exhibit Tremor 148
Auditory Hallucinations Are Usually Psychotic in Origin, While Visual Hallucinations Are More Likely to Be Caused by Chemicals, 149
When a Patient with Dementia Suddenly Develops Coexistent Delirium, Suspect a Urinary Tract Infection 149
The Characteristics of Bruising Can Help Differentiate Between Accidental and Abusive Trauma in Children 150
A Patient with Slate Blue, Silvery Discoloration of the Skin May Have Argyria 150
Premature Whitening of the Hair Can Be due to Vitamin B12 Deficiency 151
A Skin Lesion Showing the “Dark Dot Sign” Is Most Likely to Be a Basal Cell Carcinoma 152
The “Ugly Duckling” Sign May Signal the Presence of a Melanoma 152
Sudden, Effortless Smoking Cessation May Indicate Lung Cancer 153
Sometimes Clinicians Can Be Part of the Infection Problem 153
References 133
Chapter 7: Laboratory Testing, Electrocardiography and Imaging 155
Policy Edicts Can Influence Diagnostic Testing Decisions 156
Elevated Red Blood Cell Distribution (RWD) Is Associated with an Increased Risk of Death 157
Glycosylated Hemoglobin (HbA1c) Is a Useful Screening Test for Diabetes Mellitus 157
Decreasing Low Density Lipoprotein Cholesterol (LDL-C) Is the Key to Lowering the Risk of Cardiovascular Disease, and Simply 158
HbA1c Levels of 5.5% or Greater Are Associated with an Increased Risk of Diabetic Retinopathy 159
Lipid Studies Can Be Done Without the Need for Fasting 159
Elevated C-Reactive Protein (CRP) Levels Are Associated with an Increased Risk of Diabetes Mellitus 160
Elevated Serum Uric Acid (SUA) Levels Are Associated with an Increased Risk of Death 161
Elevated Serum Tumor Necrosis Factor Alpha (TNF-Alpha) Is Associated with Increased Cognitive Decline in Alzheimer Disease 161
Fluoroquinolone Use Can Cause a False Positive Opiate Urine Drug Screen 162
Tricyclic Antidepressants Can Cause a False Positive Test for Pheochromocytoma 163
Vitamin C Can Cause False Negative Dipstick Tests for Urinary Hemoglobin and Glucose 163
Digital Rectal Examination (DRE) of the Prostate Can Increase the Level of Prostatic Specific Antigen (PSA), but Not Very Muc 164
There May Be a Role for Glucose Oxidase Strip Testing for Cerebrospinal Fluid (CSF) Rhinorrhea, After All 165
A Normal d-Dimer Test Does Not Always Rule Out Pulmonary Embolism (PE) 166
If You See an Inverted P Wave on an Electrocardiogram (ECG), Think First of Electrode Misplacement 166
First Degree Heart Block (FDHB) Is Not a Benign Incidentaloma 167
Low-Dose Computed Tomography (CT) Screening for Lung Cancer Has a High Rate of False-Positive Results 168
Don’t Count on a Normal Chest Radiograph to Rule Out Pneumonia in a Bedridden Patient 168
There Is Some Cancer Risk Associated with Every Computed Tomography Scan 169
Thoracoabdominal Calcifications Noted on Roentgenograms Are Significant Predictors of Cardiovascular Disease and Total Mortali 169
Routine Lumbar Imaging for Low Back Pain Is Unhelpful Unless There Is an Indication of a Serious Underlying Condition 170
Newly Proposed Prediction Rules Allow Avoidance of Computed Tomography Head Imaging in Children at Very Low Risk of Clinically 170
Imaging May Be Helpful in Selected Instances of Newly Diagnosed Epilepsy in Children 171
In Suspected Acute Appendicitis, Computed Tomography Use Can Lower the Rate of Negative Appendectomies: Especially in Young Wo 172
In the Setting of Possible Appendicitis During Pregnancy, an Ultrasound (US) Determination Read as Positive May Require No Fu 173
Migraine Patients Are at Increased Risk for Subclinical Brain Infarcts, Detectable on Magnetic Resonance Imaging 173
Transdermal Patches Containing Metal in the Backing Can Cause Burns During an MRI Scan 174
After Starting a Potent Bisphosphonate in a Postmenopausal Woman with Osteoporosis, Wait 3 Years Before Monitoring Response Usi 175
Be Alert to the Seductive Power of Testing, Tracings, and Images 175
Reference 156
Chapter 8: Alarming Symptoms and Red Flag Findings 176
Four General Alarm Symptoms Are: Rectal Bleeding, Hematuria, Dysphagia, and Hemoptysis 177
Fever, Headache and a Centripetal Rash Suggest Rocky Mountain Spotted Fever (RMSF) 178
In a Patient with Fever or Other Evidence of Infection, There Are Three Manifestations that May Be Early Signs of Sepsis: Leg P 179
A Rash with Central Clearing Could Be Erythema Migrans (EM), the Tip-Off to Lyme Disease 179
A Skin Lesion with an Area of Anesthesia in a Person with a Suspicious Exposure History Could Be a Sign of Hanson Disease/Lep 180
A Child with an Unexplained Fever for 5 Days or More Just Might Have Kawasaki Disease (KD) 180
A History of a Penetrating Injury, Increasing Wound Pain and Soft Tissue Crepitus Strongly Suggest the Diagnosis of Gas Gangr 181
Bloody Diarrhea, Vomiting and Abdominal Pain May Be the Precursors to the Hemolytic Uremic Syndrome (HUS) 181
The Patient Who Travels and Who Reports Linear or Clustered Bites Might Have Bedbugs 182
Think of Wilms Tumor in a Child with a Painless Abdominal Mass or Swelling 182
A Child with Purpura, Joint Symptoms and Abdominal Pain May Have Henoch–Schönlein Purpura 183
The “Red Flag” Findings for Osteogenesis Imperfecta Are Excessive Numbers of Fractures, Perhaps Associated with Hearing Loss, 184
Fever, Irritability and Bone Hyperplasia in an Infant Suggest the Presence of Caffey Disease, aka Infantile Cortical Hyperost 184
A Young Child with a Fracture Attributed to Falling Out of Out of Bed Is a Red Flag for Child Abuse 185
Herpes Zoster Involving the Tip of the Nose Can Presage a Sight-Threatening Herpes Zoster Ophthalmicus Inflammation of the E 185
A Painful Red Eye Associated with Headache, Nausea and Vomiting Is Often Seen with Acute Angle Closure Glaucoma 186
The Sudden Appearance or Increase in Retinal Floaters in One Eye May Herald the Onset of Retinal Detachment 186
A Patient Taking Alpha-Adrenergic Receptor Blockers and Headed for Cataract Surgery Is at Risk for Floppy Iris Syndrome (FIS) 187
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 188
Most Headache Patients Do Not Require Imaging, but Some Do 189
The Combination of Headache, Palpitations and Sweating Suggests the Possibility of Pheochromocytoma 189
A Diagnosis of “Non-specific Chest Pain” Carries a Significant Mortality Risk over the Next 5 Years 190
Sudden Chest or Abdominal Pain Described as “Tearing” or “Ripping” Is a Red Flag for the Possibility of Aortic Dissection 190
The Sudden Onset of Fever and Dyspnea in a Nursing Home Patient Is Aspiration Pneumonitis until an Alternative Diagnosis Is Co 191
The Sudden Onset of Labored and Rapid Breathing in an Otherwise Healthy Person May Be Alarm Symptoms of Pulmonary Embolism (P 191
Be Concerned When Presented with the Very Obese Patient with Sleep Disordered Breathing He or She Might Have the Obesity Hypo192
New Onset Diabetes Mellitus in an Older Adult May Herald a Later Diagnosis of Pancreatic Cancer 193
In Any Patient with Acute or Chronic Diarrhea Accompanied by Abdominal Distension, the Possibility of Toxic Megacolon Should Be 193
Low Back Pain Plus Bladder or Bowel Dysfunction Signal a Surgical Emergency 194
When Evaluating a Low Back Pain Patient for Fracture, There Are Three Red Flags to Consider: Prolonged Use of Corticosteroids 194
An Injury Such as a Fall Followed by Bilateral Upper Extremity Weakness Is an Alarm Scenario that May Indicate the Presence o 195
Symmetrical Limb Weakness Following a Respiratory Infection or Gastroenteritis Describes the Classic Onset of Guillain–Barré 195
Patient Distress during Pelvic Examinations May Signal Past Sexual Violence 196
Be Alarmed and Suspect Ectopic Pregnancy (EP) When a Woman of Childbearing Age Reports Lower Abdominal or Pelvic Pain, Especi 197
Factors Making Ectopic Pregnancy Diagnosis More Likely 197
Gynecomastia Can Be an Early Clue to Testicular Cancer 198
Here Is the Red Flag Scenario for Stevens–Johnson Syndrome (SJS): a Child Or Young Person with an Infectious Disease, Perhaps T 198
A Patient with Intermittent Abdominal Pain Who Mentions that His or Her Urine Turns Red upon Standing (In a Glass Container) M 199
The Diabetic Patient Who also Has Hyperpigmentation of the Skin Might Have Hemochromatosis (“Bronze Diabetes”) 199
Reporting Late to Establish Prenatal Care During a Pregnancy May Be an Alarm Signal Indicating the Presence of Domestic Viole 200
Of All Disease Entities, Cancer Is Especially Likely to Reveal Itself, to Borrow Dr. Trotter’s Words, in Casual Parentheses 200
Patients Who State that they Are Going to Die Soon Often Do So 201
References 177
Chapter 9: Therapeutic Insights 202
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– 203
Insulin Use Seems to Increase Mortality Risk 204
There Are Risks Associated with the Use of Various Oral Antidiabetic Agents 204
In China, Metformin Has Been Prescribed for Antipsychotic-Induced Weight Gain 205
Treating Periodontal Disease Can Improve Glycemic Control in Type 2 Diabetic Patients 206
When Initiating Treatment for the Acute Phase of Major Depression, Sertraline (Zoloft) May Be the Best Choice 206
Selective Serotonin Reuptake Inhibitor (SSRI) Use Can Be Associated with Upper Gastrointestinal Bleeding (UGB) 207
The Use of SSRIs in Pregnancy May Adversely Affect Pregnancy Outcomes 207
SSRIs Increase the Risk of Hemorrhagic and Fatal Stoke in Postmenopausal Women 208
The Risk of Suicidality in Patients Taking Antidepressants Varies with Age 208
Testosterone Therapy May Help Relieve Depression in Hypogonadal Older Men with Subthreshold Depression 209
The Initiation of Antipsychotic Drug Treatment in Older Diabetic Persons Is Associated with an Increased Risk of Hospitalizati 210
Initial Treatment of Children and Adolescents with Second Generation Antipsychotic Medications Is Associated with Weight Gain 210
Patients with Alzheimer Disease Taking Antipsychotic Medications Are at Increased Risk of Death 211
Long-Chain Omega-3 Fatty Acids May Help Prevent the Onset of Psychotic Disorders 211
When It Comes to Preventing Coronary Heart Disease (CHD) Events and Stroke, There Is Little Difference Among the Various Class 212
In the Initial Treatment of High Blood Pressure, Low Dose Thiazides Seem to Be a Good Default Choice 212
Combination Therapy Yields Greater Decrement in Blood Pressure when Compared with Increasing the Doseof a Single Drug Used to 213
Treating Patients to Lower than Standard Blood Pressure Targets, £140–160/90–100 mmHg, Does Not Reduce Mortality or Morbidity 214
The Patient with Severe but Asymptomatic Hypertension May Not Need Rapid Lowering of Blood Pressure 215
Beta-Blocked Patients Tolerate Surgical Anemia Less Well Than Those Who Have Not Received Beta Blockers 215
In Patients with Atrial Fibrillation (AF) and Heart Failure (HF), Rhythm Control Is Not Superior to Rate Control 216
Lenient Rate Control in Patients with Atrial Fibrillation Is as Effective as Strict Rate Control 216
In a Patient with Acute Cardioembolic Stroke, Anticoagulation Therapy May Not Be the Best Choice 217
The HMG-CoA Reductase Inhibitors (Statins) Have Diverse and Generally Beneficial Effects, Actions That Involve More than Redu 217
There Are Some Adverse Effects That Can Occur with Use of Statins 219
Triptan Medications Should Not Be Used in Complicated Migraine Headaches, Such as Hemiplegic or Basilar Migraine 220
High-Flow Oxygen May Be Useful in Treating Cluster Headache 221
Varenicline Can Cause Potentially Dangerous Psychiatric Symptoms 221
A Mother’s Antiepileptic Therapy During Pregnancy Risks Impaired Cognitive Function in the Child 222
Oral Acyclovir (Zovirax) Does Not Seem to Be Helpful in Preventing Postherpetic Neuralgia 223
Steroids Are Helpful in Treating Bell Palsy Antiviral Agents May or May Not Be Beneficial223
Neither Antibiotic nor Topical Steroid Therapy Is Likely to Be Effective in the Treatment of Acute Sinusitis 224
Steroids May Be Useful Adjuvant Therapy in Acute Pharyngitis 225
The Use of Long-Acting Beta Agonists in Asthma May Increase the Risk of Asthma-Related Intubations and Death 225
A Selective Serotonin Reuptake Inhibitor (SSRI) May Be Useful in Treating Premature Ejaculation (PE) 226
Phosphodiaesterase-5 (PDE5) Inhibitors May Be Useful in Treating Lower Urinary Tract Symptoms (LUTS) 226
Sildenafil Increases Exercise Capacity Under Hypoxic Conditions 227
A Small Dosage Increment of Phenytoin Can Bring a Large Increase in Serum Levels of the Drug 228
Some Drugs We Commonly Prescribe Are Restricted or Banned from Athletic Competition 228
Short Course Treatment of Uncomplicated, Symptomatic Lower Urinary Tract Infections (UTIs) Works as Well as Longer Duration T 229
Procalcitonin Testing Can Provide Useful Guidance when Deciding About Antibiotic Use in Lower Respiratory Tract Infections (L 230
C-Reactive Protein (CRP) Point-of-Care Testing Can Be Helpful in Deciding About Antibiotic Prescribing in LRTIs and Rhinosinu 230
Consider the Possibility of Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency Before Prescribing Primaquine for Malaria Prop 231
The Sequence of Infant Vaccine Injections Matters 231
The Antiemetic Ondansetron (Zofran) Is Useful in Controlling Vomiting in Children with Acute Gastroenteritis and Mild/Moderate 232
Oral Bisphosphonates Have Not Been Shown to Cause Atypical Subtrochanteric Fractures of the Femur 233
In Older Persons with Memory Problems, Physical Activity May Improve Cognition 233
Vitamin D Deficiency May Play a Role in Chronic Tension-Type Headache 234
Vitamin B12 Is Worth a Try in Treating the Patient with Recurrent Aphthous Stomatitis (RAS) 234
Supplementary Antioxidant Vitamin Use Does Not Reduce the Incidence of Heart Attacks or Other Vascular Events, Cancer, or Othe 235
References 203
Chapter 10: Idiosyncratic and Uncommon Drug Effects 236
Beta Blockers Can Cause or Aggravate Psoriasis 237
Spironolactone Causes Changes in the Ratio of Testosterone to Estradiol, Contributing to the Likelihood of Gynecomastia as a 237
Acetazolamide Has Two Curious Side Effects: It Can Cause Tingling of the Fingertips and Can Make Carbonated Beverages Seem to 238
ACE Inhibitors and Angiotensin Receptor Blockers (ARBs) Help Prevent the Development of Diabetes Mellitus 238
Valsartan Use in Hypertension May Help Prevent Cardiovascular Events 239
Angiotensin Receptor Blockers May Reduce the Development or Progression of Alzheimer Disease and Dementia 239
Regular Analgesic Use Can Lead to Hearing Loss 240
Non-Steroidal Anti-Inflammatory Drugs Can Cause a Wide Variety of Skin Rashes 240
Salicylates Carry a Significant Risk of Toxicity 241
Antibacterial Agents Can Cause a Panoply of Neurotoxic Manifestations 242
Tetracycline and Its Derivatives Can Stain Adult Teeth 243
Fluoroquinolone Antibiotics Can Cause Tendinitisor Tendon Rupture 243
Some, But Not All, Fluoroquinolones Can Disrupt Glucose Homeostasis, Causing Severe Hypoglycemia or Hyperglycemia 244
Fluoroquinolones May Cause Diplopia 244
Serotonin Selective Reuptake Inhibitors (SSRIs) Can Cause Delayed Ejaculation in Men, Although the EffectVaries Among Specifi 245
Trazodone (Desyrel) Can Cause Priapism 245
The Nonbenzodiazepine Receptor Agonist (NBRA) Hypnosedatives Can Induce Sleep-Related Complex Behaviors 246
Epilepsy and Other Illnesses for Which Antiepileptic Drugs (AEDs) Are Prescribed Are Associated with an Increased Risk of Suici 246
Topiramate (Topamax) Can Cause ImpairedCognitive Function 247
Carbamazepine (Tegretol) Can Cause a Shift in Musical Pitch Perception 248
Purple Glove Syndrome Is a Rare, But Serious, Complication of Intravenous Phenytoin (Dilantin) Therapy 248
Sumatriptan (Imitrex) and Related Triptan DrugsCan Cause Ischemic Colitis 249
Sumatriptan, in Large Doses, Can Cause Sulfhemoglobinemia 249
Digitalis, Even in Modest Doses, Can Cause Yellow Vision 250
Under Certain Circumstances, Acid-Suppressing DrugsMay Be Associated with an Increased Risk of Community Acquired Pneumonia (C 250
Metoclopramide (Reglan) Is the Most Common Cause of Drug-Induced Movement Disorders, Such as Tardive Dyskinesia 251
Post-Menopausal Women Who Take Estrogen Plus Progestin and Who Develop Lung Cancer Face a Higher Risk of Death 251
Long-Term Users of Metformin May Develop a VitaminB12 Deficiency 252
Quinine Can Cause Thrombocytopenia Accompanied by Bleeding Symptoms 252
Mefloquine (Lariam) Can Cause Acute Psychosis 253
Oral Bisphosphonates May Offer Some Protection Against Invasive Breast Cancer 254
Dopaminergic Agents Can Cause Pathologic Gambling 254
Phosphodiesterase Type 5 (PDE5) Inhibitors CanCause Sudden Hearing Impairment 255
Methylphenidate (Ritalin) Can Cause Complex Visual Hallucinations 255
Idiopathic Intracranial Hypertension (ICH), Aka Pseudotumor Cerebri, Has Been Linked to Lithium Therapy 256
Human Immunodeficiency Virus (HIV)-Infected Patients Are at Greatly Increased Risk of Severe Cutaneous Reactions to Some of t 256
Gadolinium-Based Contrast Agents Can Cause Nephrogenic Systemic Fibrosis (NSF) 257
References 237
Chapter 11: Drug Interactions and Adventures in Polypharmacy 258
Our Patients Take a Lot of Drugs and Herbal Remedies, and Hence Have Abundant Opportunities for Drug Interactions 259
Drugs with a Narrow Therapeutic Range Pose an Extra Risk of Drug–Drug Adverse Effects 260
Some Adverse Drug–Drug Interactions Involve Decreased Efficacy of One of the Drugs 261
Much of the Risk of Drug–Drug Interactions is Preventable, if Only We Could Reduce the Incidence of Inappropriate Prescribing 262
Nonsteroidal Antiinflammatory Drugs Can Blunt the Cardioprotective Effect of Aspirin 263
NSAIDs, Including Selective Cyclooxygenase 2 Inhibitors, Can Increase Serum Lithium Concentrations, Leading to Toxicity 264
In the Setting of Aspirin and Clopidogrel (Plavix) Used to Prevent Cardiovascular Disease, Doses of Aspirin 100 mg or Greater 264
“Patients at Risk for Heart Attacks or Strokes Who Use Clopidogrel to Prevent Blood Clots Will Not Get the Full Effect of Thi 265
Carisoprodol (Soma) and Oxycodone (OxyContin) Can Have Additive Depressant Effects on the Central Nervous System (CNS) 266
Selective Serotonin Reuptake Inhibitors (SSRIs), Notably Paroxetine (Paxil), Can Blunt the Effectiveness of Tamoxifen as Anti- 267
The Combination of Adderall-XR and Alcohol Can Be Associated with Myocardial Infarction 268
Concomitant Use of an Angiotensin Converting Enzyme (ACE) Inhibitor and an Angiotensin Receptor Blocker (ARB) Brings No Added 269
The Combination of Trimethoprim-Sulfa with Angiotensin-Converting Enzyme Inhibitors or Angiotensin Receptor Blockers Can Result 270
Combining a Fibrate with a Statin Drug Increases the Risk of Rhabdomyolysis 270
Ketoconazole (Nizoral) Can Increase Plasma Concentrations of Mefloquine (Lariam) 271
Concomitant Use of Clarithromycin and Digitalis Can Lead to Toxic Levels of Digitalis 272
Sildenafil (Viagra) May Relieve Antidepressant-Induced Sexual Dysfunction in Women 272
The Concomitant Use of Phosphodiesterase-5 Inhibitors and Nitrates Can Cause an Unsafe Drop in Blood Pressure 273
Smoking Cessation Can Increase Plasma Levels of Clozapine (Clozaril) 273
Initiating Treatment with Two Antidepressant Medications May Bring Superior Results 274
Serum Levels of Warfarin (Coumadin), Whether Increased or Decreased, Can Be Affected by Dozens of Drugs 274
Herbal Substances and Dietary Supplements Can Also Interact with Drugs We Prescribe 276
Probiotic Dietary Supplements Help Prevent Antibiotic-Associated Diarrhea (AAD) 277
Grapefruit Can Increase the Bioavailability of a Number of Medications 278
References 259
Chapter 12: Alcohol, Nicotine and Caffeine 279
Alcohol Leads Both Prescription and Illicit Drugs in Causing Fatal Motor Vehicle Accidents 281
Patients with Breast Cancer and Who Consume 7 or More Alcoholic Beverages Per Week Have an Increased Risk of Developing a Cont 281
Acute Alcohol Exposure Prior to Trauma Impairs Wound Healing 282
The Drug Most Often Implicated in Substance-Related Sexual Assault Is Alcohol 282
African-American Men Seem Especially Prone to Alcohol-Associated Hypertension 282
Drinking Without Eating May Increase the Risk of Alcohol-Associated Hypertension 283
Not All Studies Find a Relationship Between Alcohol Consumption and Hypertension 283
Weekly Alcohol Consumption May Help Prevent Gallstones 284
Beer Drinking Has Been Reported to Increase Bone Mass in Women 285
Alcohol Use Is Associated with a Decreased Risk of Benign Prostatic Hyperplasia (BPH) 285
The Often-Dramatic Suppression of Essential Tremor Following Alcohol Ingestion Is Related to a Reduction of Cerebellar Synapt 286
Light to Moderate Alcohol Use Seems to Help Protect Against Coronary Heart Disease (CHD) 286
Eleven Percent of Women Smoke During Pregnancy 287
Newborns Exposed to Maternal Smoking In Utero Can Experience Neurotoxic Effects, Including a Nicotine Withdrawal Syndrome 288
Maternal Smoking Increases the Risk of Attention Deficit Hyperactivity Disorder (ADHD) in Offspring 288
The Use of Nicotine Gum by Pregnant Smokers Can Help Increase Birth Weight and Gestational Age 289
Cigarette Smoking Increases the Risk of Colorectal Cancer 289
Smokeless Tobacco Can Increase the Risk of Myocardial Infarction and Stroke 290
Electronic Cigarettes Are Not Safe, Either 290
Asking Two Questions – About Current Smoking and Plans to Quit – Increases the Likelihood that Patients Who Smoke Receive Cess 291
Smoking Increases the Risk of Type 2 Diabetes 292
Tobacco and Also Marijuana Use Can Lead to Reduced Blood Levels of the Human Immunodeficiency Virus (HIV) Drug Atazanavir (Reya 293
Tobacco Smoking May Double the Risk of Active Tuberculosis 293
Tobacco Smoking Seems to Be Inversely Associated with Parkinson Disease (PD) 294
Nicotine Seems to Improve Some of the Manifestations of ADHD in Adults 295
Nicotine Can Enhance Cognitive Function 296
The U.S. Food and Drug Administration Now Has the Authority to Regulate Tobacco 297
Caffeine Is the Most Widely Used of All Drugs 297
Caffeine Can Enhance Cognitive Performance, Even at Quite Low Doses 298
High Caffeine Consumption Cannot Be Relied Upon to Prevent Age-Related Cognitive Decline 298
Don’t Count on Caffeine to Reverse the Cognitive Impairment Associated with Alcohol Use 299
Caffeine Can Enhance Athletic Performance, in Some Sports, Sometimes, Maybe 300
High Coffee Intake Reduces the Risk of Type 2 Diabetes Mellitus 301
References 280
Chapter 13: Unforeseen, Counterintuitive and Possibly Prophetic Findings 303
Essential Tremor (ET) Is Often Not “Benign” 305
Aspirin Rivals Sumatriptan in Providing Relief of Acute Migraine Headache 305
Surgical Deactivation of Migraine Trigger Sites May Prove to Be Useful Therapy for Some 306
Women with Migraine Seem to Have a Reduced Risk of Breast Cancer 307
Children with Acute Otitis Media (AOM) Initially Treated with Amoxicillin Have Been Found to Have More Recurrences When Compa 307
Withholding Antibiotic Treatment of Acute Otitis Media Influences the Incidence of Acute Mastoiditis 308
Adjuvant Tamoxifen Therapy of Primary Breast Cancer May Increase the Risk of Estrogen Receptor (ER) Negative Contralateral Bre 309
Breast Cancer in Men, When it Occurs, Is Likely to Be Hormone Receptor Positive 309
Pneumococcal Polysaccharide Vaccination (PPV) May Not Provide Adults the Protection Against Pneumonia We Would Like to Think 310
Pneumococcal Vaccine Does Seem to Offer Protection to Human Immunodeficiency Virus (HIV)-Infected Adults Against Recurrent Pne 311
Statins May Play a Beneficial Role in Patients with Chronic Obstructive Lung Disease (COPD) 311
Statins May Reduce Proteinuria and Slow the Rate of Kidney Function Loss, Especially in Patients with Cardiovascular Disease 312
In Patients with Worsening Heart Failure (HF), Statin Use May Improve Left Ventricular Ejection Fraction (LVEF) and Decrease 313
Appendicitis and Mesenteric Lymphadenitis When Young Reduces the Risk of Adult Ulcerative Colitis 313
A Family History of Colorectal Cancer May Offer a Reduced Risk of Cancer Recurrence and Death in Patients with Stage III Colon 314
Screening Colonoscopy Reduces the Prevalence of Colorectal Cancer, But Chiefly in Regard to Neoplasms in the Left Colon 314
The Venerated Digital Rectal Examination (DRE) May Be as Harmful as Helpful in Diagnosis, at Least in Patients with Undiffere 315
Diabetic Self-Monitoring May Risk Depression with No Gain in Glycemic Control 316
Bariatric Surgery May Yield a Dividend Beyond Weight Loss: Remission of Type 2 Diabetes 316
Persons Taking Hydroxychloroquine for Rheumatoid Arthritis Seem to Have a Reduced Risk of Developing Diabetes 317
In Patients with Both Heart Failure and Diabetes Mellitus, There Is a “Sweet Spot” in the Middle Range of Glycosylated Hemoglob 317
Type 2 Diabetics at High Risk for Cardiovascular Events May Not Benefit from Rigorous Blood Pressure Control 318
In Patients with Diabetic Neuropathy, High Dose B-Vitamins Can Adversely Affect Renal Function and Increase the Risk of Vascul 318
In One Study, Placebo Therapy Both Helped and Harmed Patients with Benign Prostatic Hyperplasia (BPH) 319
Minimally Invasive Radical Prostatectomy (MIRP) Offers Short Term Advantages, But a GreaterRisk of Long Term Problems When Co 320
Vertebroplasty Seems to Offer “No Beneficial Effect” in the Treatment of Painful Osteoporotic Vertebral Fractures 320
Conventional Non-steroidal Antiinflammatory Drugs (NSAIDs) May Harm Knee Cartilage, While Cyclooxygenase (COX)-2 Inhibitors May 321
Men with Restless Leg Syndrome (RSL) Are at Increased Risk of Having Erectile Dysfunction (ED) 322
Depression Is an Inflammatory State with Implications for Cardiac Disease 323
###Overweight Older Children and Adolescents Consume Fewer Calories than Their Healthy Weight Peers 324
###Women Who Have Menopausal Night Sweats May Enjoy a Reduced Risk of Death Over the Following 20 Years 324
###Marijuana Use May Be Associated with a Reduced Risk of Head and Neck Squamous Cell Carcinoma (HNSCC) 325
Eating Egg Yolks – 4 a Day, and Maybe Even Just 2 a Day – Reduces the Risk of Dry, Age-Related Macular Degeneration 326
Metformin Inhibits Endometrial Cancer Cell Proliferation In Vitro 326
Transmission of Rabies Virus from an Organ Donor to Transplant Recipients Has Been Reported 327
Massive Cola Ingestion Can Cause Hypokalemic Myopathy 327
Electromagnetic Field (EMF) Exposure Has Shown Benefit in Both Normal Mice and Transgenic Mice Destined to Develop Alzheimer-Li 328
A Study Has Reported Finding No Evidence to Support the Contention that Resident Fatigue Leads to Increased Medical Errors 328
References 304
Chapter 14: Some Timeless Truths About Medical Practice 330
The Best Physicians Often Employ Fact-Based, Intuition-Guided Decision-Making 331
Only Rarely Does a Patient Have Just One Disease 333
No Drug Has Only One Action 335
Just Being in a Medical Journal Doesn’t Make it True 336
Statistical Analysis Can Be Misleading 338
Publication Bias Can Influence What We Read 339
Pharmaceutical Advertisements, Even Those Appearing in Esteemed Medical Journals, Must Be Read with Great Care 341
Some of Today’s Great Ideas – and the “Facts”We Cherish – Will Prove to Be Wrong 342
In the End, the Best Physicians, Like the Best Generals,Make the Fewest Errors 344
References 332
A Clinician’s Glossary of Statistical Terms 346
Index 351