2011 First Aid for the USMLE Step 1 Official Updates, Corrections, and Clarifications Updated May 17,

2011 Despite our best efforts, errors do occur during the revision. If you see a verifiable error not on this list, please report it to our blog at www.firstaidteam.com. If you are the first to report the error, you will receive a $10 gift certificate. In order to identify and correct every possible error, we review every single submission, as well as search other websites and blogs that claim to have a comprehensive listing of errors in First Aid 2011. If you find that our material conflicts with a source that youre reviewing, please point us toward it with a corroborating reference. As always, we will check every submission against primary references to ensure the most accurate, high-yield study guide available. If you submitted an erratum and it does not appear in an update, then either it does not agree with the primary literature in the field or we consider it a detail beyond the scope of the book. Please note that we will not list simple typos or, unless egregious, omitted material; our goal is to provide a high-yield framework for studying and not a comprehensive textbook. The list below reflects content errors and typos that may create confusion that were submitted before May 1, 2011. As always, updates are available at www.firstaidteam.com. Good luck with your studies! The First Aid/USMLERx Team Page # Entry Title Correction/Clarification In the second full paragraph, change "To avoid a rescheduling fee, you will need to request a change before noon EST at least five business days before your appointment" to "No fee is charged for changing your testing appointment 31 or more calendar days prior to the first day of the scheduled test." Shift the reference to sleep spindle in the figure slightly to the left. The figure should illustrate the phosphodiester linkage between the top two deoxyribonucleotides, which is an important component of the DNA backbone, and also crucial for binding of phosphodiesterases. In the diagram, change the 5' cap to "Gppp. It is a TRIphosphate cap (rather than 4 phosphates). In the figure, the mRNA sequence should not be altered by splicing. The original sequence, GUA, should become GUA in step 2. It should remain GUA in step 3, not UGA as written. Note that using a DNA fragment from a eukaryotic cell and inserting that into a plasmid would not generate a cDNA library as stated, but would generate a genomic DNA library (which includes introns) because the bacterium used to clone the plasmid cannot splice out the introns; they would remain intact. Familial adenomatous polyposis is due to a mutation (rather than a deletion) on chromosome 5. The 2 Cs entry in column 3 should align with the entry for Deficiency. The statement "High blood levels of fructose and galactose also result in conversion via aldose reductase..." is incorrect. Fructose is not an aldose sugar and therefore cannot be acted upon by aldose reductase. Include lactulose in the list of treatments for hyperammonemia. (1) The arrows for dihydropterin reductase reaction are both pointing the wrong direction. The enzyme recovers THB from DHB and makes NADP+ from NADPH. Reverse the arrows. (2) Carbidopa inhibits dopa decarboxylase, not dopamine hydroxylase; thus the carbidopa over the arrow should move up one arrow. Glycogen phosphorylase leads to the creation of limit dextrins (not dextrans).

6 62

Rescheduling an exam Sleep stages

71 72 *

DNA/RNA/protein synthesis direction RNA processing (eukaryotes)

73 *

Splicing of pre-mRNA

82 * 86 91

Cloning methods Autosomal-dominant diseases VitaminB 2 (riboflavin)

104 * 105 *

Sorbitol Hyperammonemia

107 109

Catecholamine synthesis Glycogen

110 123

Glycogenolysis/glycogen synthesis Heart embryology

127

Posterior fossa malformations

128

Branchial arch derivatives Pancreas and spleen embryology Kidney embryology Special culture requirements

131 132 138

The enzyme responsible for glycogen synthesis is glycogen synthase, not glycogen synthetase. Change the entry for "Primitive ventricle" to "Trabeculated parts of right and left ventricles. On further examination by multiple authors, we conclude that the original text is correct in listing a Chiari type II (not type I) malformation. Sorry for the confusion, the literature is rather confusing on this as well. The list of muscles of pharyngeal arch 1 includes the anterior 2/3 of the tongue. While it is true that CN V supplies somatic sensation to the mucosa of the tongue via the lingual nerve, it does not innervate any of the muscles of the tongue. All of the muscles of the tongue are innervated by CN XII, with the exception of CN X's contribution by innervating the palatoglossus. The dorsal and ventral pancreatic buds contribute to the pancreatic head and the main pancreatic duct. The uncinate process is formed by the ventral bud alone. In the last line of text, change uteropelvic to ureteropelvic. Change the media used for isolation for Legionella to include iron in addition to cysteine. Add Yersinia sp. (both Y. pestis and Y. pseudotubercolosis) to the list of facultative intracellular bugs. Modify the mnemonic to read Some Nasty Bugs May Live FacultativeLY. In the entry for ADP ribosylating A-B toxins, note that the terms "adenylyl cyclase (in the description for Vibrio) and "adenylate cyclase (in the description for E. coli) refer to the same cyclase molecule and are used interchangeably. Note that tuberculoid disease is the result of high cell-mediated immunity with a largely Th 1 -type immune response, and lepromatous leprosy is characterized by low cell-mediated immunity with a humoral Th 2 response. EIEC does not produce Shiga-like toxin as stated. EIEC invades the mucosa like Shigella, but produces no toxins. Include a third, and newest, triple therapy for H. pylori, (3) proton pump inhibitor, clarithromycin, and either amoxicillin or metronidazole. The fever associated with Plasmodium malariae infection is quartan, with a 72-hour cycle. The fever of P. vivax/ovale infection is tertian, occurring every 48 hours. In the entry for Reoviruses, note that coltivirus (not reovirus) is the cause of Colorado tick fever. Although rubella is associated with a "truncal rash," typically the rash begins at the head and moves down. In adults, S. pneumoniae is a more common cause of bacterial meningitis than N. meningitidis. Revise the clinical presentation of Mumps virus to include rash. In the entry for bacterial vaginosis, note that it can be sexually transmitted, but it is not exclusively an STD. Change the statement "C. trachomatis --the most common STD in the United States" to "C. trachomatis -- the most common bacterial STD in the United States." Shift the entry for HBV down one line, so that HBV and its risk factor do not overlap with the Pseudomonas notes. Note that Cilastatin is an inhibitor of renal dehydropeptidase.

139 *

Intracellular bugs

141 *

Bugs with exotoxins

149 151 *

Leprosy (Hansens disease) E. coli

152

161 168 170 * 177 * 180 181

Helicobacter pylori Medically important protozoasingle-celled organisms (continued) RNA viruses Rubella virus Common causes of meningitis Red rashes of childhood Sexually transmitted diseases

181 181 * 186 *

Pelvic inflammatory disease Nocosomial infections Imipenem/cilastatin, meropenem

197 *

HIV therapy

200

Lymph drainage

206 * 207

Immunoglobulin isotypes Complement

213 * 216 220

Immune deficiencies Sirolimus (rapamycin) Necrosis

(1) Delete the c from the NNRTI declaviridine, the correct spelling is delaviridine. (2) Zalcitabine and amprenavir have both been withdrawn from the market. In item 6 under Area of body, change Anal canal below to Anal canal below pectinate line" with primary lymph drainage to the superficial inguinal nodes. Note that isotype switching proceeds through DNA recombination, not by alternative splicing of mRNA. It is a permanent differentiation step. Change the classical pathway convertase for C3 from C4b,2b to C4b2a. Under Bruton's agammaglobulinemia, in the Defect column, change blocks B-cell differentiation/maturation to blocks pro-B cell from forming pre-B cell. Make the B in pro-B cell bold as part of the mnemonic for remembering Brutons. Note that sirolimus inhibits (not binds to) mTOR. In item 5, change Fibroid to Fibrinoid. (1) Change menstruation to menopause, since an example of atrophy is the endometrial lining during menopause. (2) Change the title of the diagram to read Intrinsic apoptosis vs. extrinsic apoptosis. In item 3, change CCi 4 to CCl 4 (carbon tetrachloride). The associated tumor of ret should be MEN types IIA and IIB instead of types II and III. (1) Under EBV, add Hodgkins lymphoma. (2) Schistosoma haematobium, not merely Schistosoma, is associated with SCC of the bladder. Under Neoplasm, change Renal cell carcinoma, hemangioblastoma to read Renal cell carcinoma, hemangioblastoma, hepatocellular carcinoma, pheochromocytoma. Change text in first paragraph to conversion of lactate to pyruvate In the entry for mitral prolapse, change the last sentence to read, Enhanced by maneuvers that venous return (e.g., standing or Valsalva). In the entry for phase 0, the text states that pacemaker cells lack + fast voltage-gated Na channels. In fact, such channels are present, but they are permanently inactivated because of the resting voltage of pacemaker cells. Change vascular hypertrophy to ventricular hypertrophy. Change the entry under Subendocardial infarcts to "Subendocardium especailly vulnerable to ischemia due to fewer collaterals, higher pressure." (all on one line.) In the diagram, change the arrow from " sympathetic activity" that + currently points to " renal Na and H 2 O reabsorption so that it points to " renin-angiotensin-aldosterone." Change the title of the Fact from Rheumatic heart disease to Rheumatic fever. (1) Delete the reference to (Kussmaul's pulse) after "pulsus paradoxus" as Kussmauls pulse is a sign of constrictive pericarditis, not cardiac tamponade. (2) As a result of (1), the updated correct definition for pulsus paradoxus is a in amplitude of SBP by 10 mm Hg during inspiration.

220 * 222 227 *

Apoptosis vs. necrosis Free radical injury Oncogenes

229 *

Oncogenic microbes

229 246

Paraneoplastic effects of tumors Alcohol toxicity

259

Heart murmurs

261 267 *

Pacemaker action potential Eisenmengers syndrome

272

Types of infarcts

274 * 276

CHF Rheumatic heart disease

276 *

Cardiac tamponade

288 * 305 310 313 318 319 320 323 * 327

Pituitary gland Propylthiouracil, methimazole Digestive tract anatomy Portosystemic anastomoses GI secretory products Gastric parietal cell Carbohydrate digestion Esophageal cancer Meckels diverticulum Wilsons disease (hepatolenticular degeneration)

Neurophysins carry ADH and oxytocin only from their site of synthesis (hypothalamus) to their site of release (posterior pituitary). The notation that they carry hormones in circulation is incorrect. Propylthiouracil can also cause hepatotoxicity. In the diagram, change Mucularis mucosae to "Mucularis mucosa." Delete the number 4 from the diagram. Change the text under Pepsin regulation, third column, to stimulation and local Move the reference to Gastric lumen to the other side of the diagram under Gastric parietal cell. Under Salivary amylase, change dextrans to dextrins. The plural of diverticulum is "diverticula," not "diverticuli. Change Dx: Pertechnetate. Study for ectopic uptake. to Dx: Pertechnetate study for ectopic uptake. (1) Remove "Choreiform movements" from the list of characteristic features. (2) Next to "Dementia," add dyskinesia and dysarthria. In reference to biliary colic, remove the phrase that states, "... cause bile duct obstruction which results in bile duct contraction." It is a repeat of the previous sentence. Under causes, change Hyperlipidemia to Hypertriglyceridemia. Note that cromolyn sodium is used as asthma prophylaxis, not to treat asthma as indicated. In addition to factors IXa, Xa, XIa, and XIIa, antithrombin also inhibits factor VIIa. In the first sentence of the last column, change Warfarin inhibits reductase to Warfarin inhibits epoxide reductase. Change the Adhesion box entry to Platelets bind vWF via GpIb receptor at the site [not side] of injury only (specific). Remove G6PD deficiency from extravascular hemolysis and include under intravascular hemolysis. Orotic aciduria is not a nonmegaloblastic macrocytic anemia. Orotic aciduria is a megaloblastic macrocytic anemia that cannot be fixed with treatment of either folate or vitamin B12. G6PD deficiency is associated with both intravascular and extravascular hemolysis. (1) In the entry for paroxysmal nocturnal hemoglobinuria, the text synthesis of GPI anchor appears twice. Delete one occurrence of this text. (2) In the entry for hereditary spherocytosis, change band 4.1 to band 3.1. Note that the nodular sclerosis type occurs with equal frequency in males and females. The M protein in multiple myeloma is most commonly IgA or IgG. Multiple myeloma cells produce excessive monoclonal proteins, called M proteins, and are recognized as IgA, IgD, IgG, IgE, IgM. The M protein level is referred to as the M-spike. Change the CML Comments to "Responds to imatinib (a small molecule inhibitor of the bcr-abl tyrosine kinase). Imatinib is not an antibody. Shift the second CML label down one line so that it aligns with "bcr-abl transformation leads to..."

333

335 335 * 343 * 345 * 346 * 346 350

Gallstones (cholelithiasis) Acute pancreatitis Mast cell Coagulation, complement, and kinin pathways Coagulation cascade Platelet plug formation Normocytic, normochromic anemia Macrocytic (MCV >100) anemia Normocytic, normochromatic anemia

350 350

352* 357 *

Intrinsic hemolytic normocytic anemia Hodgkins lymphoma

358

Multiple myeloma

359 361

Leukemias Chronic myeloproliferative disorders

361 * 362 365

Polycythemia Heparin Antimetabolites

(1) Note that RCC, Wilms' tumor, cyst, HCC, and hydronephrosis are associated diseases of inappropriate absolute polycythemia due to ectopic erythropoietin. (2) Note that EPO is indeed decreased in polycythemia vera. (3) In the second row under Associated Diseases, the word congenital is misspelled as "congential." The "decrease" sign in the first sentence refers to both thrombin and Xa levels. Cytarabine is a pyrimidine analog, not a pyrimidine antagonist. (1) Change Median (C6-C8, T1) to Median (C5-C8, T1). (2) In the third column, the ape hand description should indicate that a distal median nerve lesion can also cause ape hand. (3) The median motor deficits are transposed. Switch the positions of Lateral finger flexion/wrist flexion and Opposition of thumb. In addition to flexing the MCP joint, the lumbrical muscles extend the PIP and DIP joints There is no perifascicular inflammation in polymyositis. In dermatomyositis, perifascicular atrophy is sufficient for diagnosis. Include a reference to image 66 in the description of acanthosis nigricans. ACh in REM sleep is increased, not decreased. (1) Change the VPL reference from "position and proprioception to pressure, touch, vibration, and proprioception." (2) The input of the MGN is the superior olive and inferior collculus of tectum [not pons]. (1) Medullary syndrome is most often caused by infarcts in the vertebral artery, so the first entry should read, Vertebral artery/anterior spinal artery (medial medullary syndrome). (2) In the last line in the entry, change dominant hemisphere (ataxia) to dominant hemisphere (aphasia). Note that the guidelines for the administration of tPA have extended the window to a 4.5-hour time frame. (1) In the entry for CN XII, all corticobulbar tracts are bilaterally innervated except that of CN VII. The reason we "lick toward the lesion" is due to a lower motor lesion of the 12th nucleus or CN XII leading to a weakened tongue on the lesioned side. (2) In the entry for CN V, the reason the jaw deviates toward the side of the lesion is due to unopposed force from the opposite pterygoid muscle. The output to ocular muscles is due to decreased [not increased] diffusion to interior. In item 7, central scotoma, change the image of the left eye to show a dark circle in the middle as opposed to being completely shaded in. Partial seizures most commonly originate in the medial, not mesial, temporal lobe. Redirect arrow 3 from the uncus through the tentorium cerebelli. In the first entry in column 2, change the text to read, Bromocriptine (ergo derivative) and pramipexole and ropinirole (non-ergot derivatives). The latter are preferred and have largely replaced bromocriptine as the preferred treatment for Parkinsons. Change the first sentence to read, "Unconscious mental processes of the ego used [not uses] to resolve conflict and prevent feelings of anxiety and depression." Under Huntingtons disease, add dopamine.

374 376 386 389 397

Upper extremity nerves Hand muscles Polymyositis/dermatomyositis Skin disorders (continued) Neurotransmitters

399 *

Thalamus

405 * 407 *

Circle of Willis Ischemic brain disease

418 * 423

Cranial nerve lesions Cranial nerve III in crosssection

423 426 429

Visual field defects Seizures Herniation syndromes

435 *

Parkinsons disease drugs

440 * 442

Ego defenses Neurotransmitter changes with disease

450

Signs and symptoms of substance abuse

451 453 *

Signs and symptoms of substance abuse Antipsychotics (neuroleptics)

461 463 *

Nephron physiology Kidney endocrine functions

467

Nephritic syndrome

468

Nephrotic syndrome

469 470

Kidney stones Transitional cell carcinoma

479 484 * 486 * 489 * 492 * 492 *

Derivation of sperm parts Pregnancy Kallmann syndrome Endometriosis Ovarian non-germ cell tumors Benign breast tumors

(1) Under alcohol, add a period after "Serum -glutamyltransferase (GGT) - sensitive indication of alcohol use" (2) Delete naltrexone as a treatment for alcohol intoxication; it is used to treat alcohol and opioid dependence, not acute intoxication. The top of page 451 is a continuation of Signs and symptoms of substance abuse from page 450. The top of page 451 should be changed to include the title, Signs and symptoms of substance abuse (continued). Under the treatment options for neuroleptic malignant syndrome, agonists should be changed to D 2 agonists. (1) In the upper left drawing, within the proximal convoluted tubule, show that H2CO3 splits into H+ and HCO3- and the H+ then goes into the lumen and the HCO3 goes into the interstitium. (2) In the lower right drawing, change the label from Distal convoluted tubule to Collecting tube transport. In the entry for vitamin D, note that 1,25-(OH) 2 vitamin D increases intestinal absorption, not reabsorption. (1) In the entry for RPGN, in the second column, delete the word function. The entry should read, Crescents consist of fibrin and plasma proteins (e.g., C3b) with glomerular parietal cells, monocytes, and macrophages. (2) In the entry for diffuse proliferative glomerulonephritis, in the last column, the text should read (see next page) instead of (see below). (3) For Alports syndrome, change deafness X-linked dominant to deafness X-linked. Transmission of Alport's syndrome can be Xlinked, autosomal recessive, or autosomal dominant. (1) Note that focal segmental glomerulosclerosis, not membranous glomerulonephritis, is the most common cause of adult nephrotic syndrome. (2) In the entry for membrano-proliferative glomerulonephritis, tram tracking can be seen on LM, not EM. Under Ammonium magnesium phosphate, in the Notes column, delete magnesium; these stones are caused by infection with urease-positive or radiolucent bugs. In the right column, insert a comma between Smoking and Aniline dyes. Some text is repeated: "and flagellum (tail) from one of the centrioles" and "Tail forms from centrioles." Please delete the duplicate text. Trophoblasts secrete hCG, not -hCG. Decreased synthesis of gonadotropin occurs in the hypothalamus, not the anterior pituitary. Delete ascending infection as a cause of endometriosis. Note that serous cystadenocarcinomas make up 45% of malignant ovarian tumors. Note that fibroadenomas are the most common tumor in those <35 [not 25] years old. In three instances, in the abbreviation for arterial carbon dioxide pressure, change the capital A to a lower case a, to indicate were measuring arterial carbon dioxide pressure instead of Arterial. In item 4, change "2,3-DPG" to "2,3-BPG" (to represent 2,3bisphosphoglyceric acid).

508 509

Alveolar gas equation Response to high altitude

510

Obstructive lung disease (COPD)

510 *

Embolus types

519

Classic presentations

524

Classic labs/findings

526 *

Classic labs/findings

528 *

Key associations

529 * 595

Key associations Abbreviations and symbols

604

Endocarditis

I-11 * I-14 * I-21 I-22 * I-30 *

Image 43 Image 56 Image 86A Image 88b Image 119B

(1) Formatting error: shift Bronchiectasis and Chronic necrotizing infection of down one line so that they line up with Associated with bronchial obstruction (third column). (2) The criteria for chronic bronchitis is productive cough for >3 months/year for 2 consecutive years. The imaging of choice for emboli is incorrectly stated as CT angiography. In fact, helical CT is the imaging test of choice for emboli. (1) The 4 F risk factors of Fat, Female, Forty, and Fertile suggest acute cholelithiasis, not acute cholecystitis. (2) In the diagnosis/disease associated with hypertension, hypokalemia, metabolic acidosis, delete the 1 hyperaldosteronism in parentheses. (1) In the diagnosis/disease associated with Hair-on-end (crewcut) appearance on x-ray, change extramedullary hematopoiesis to marrow expansion. (2) Hilar lymphadenopathy, peripheral granulomatous lesions in middle or lower lung lobes is associated with a Ghon complex (not a Ghon focus). In the entry for spikes on basement membrane, change "domelike" endothelial deposits to read dome-like subepithelial deposits. (1) In the entries for hematoma, the shape descriptions of the ruptures of epidural and subdural hematomas are reversed. In actuality, epidural hematomas are lentiform shaped, and subdural hematomas are crescent shaped. (2) Additionally, epidural hematomas are more strongly associated with trauma from fractures than subdural hematomas. Segmental glomerulosclerosis, not membranous glomerulonephritis, is the most common cause of adult nephrotic syndrome. SNRI is an abbreviation for serotonin and norepinepherine reuptake inhibitor. Add these pages to the index entry: 275, bacterial endocarditis 275, Libman-Sacks endocarditis The # 6 label on the image is difficult to see (in black) and is currently labeling the frontal lobe or the posterior orbit, not the frontal sinus as indicated. The image shows Boutonniere deformity, not swan-neck. Change hyercellularity to hypercellularity. A staghorn calculus is composed of ammonium magnesium phosphate, not calcium oxalate. Joint is incorrectly spelled as join.

*corrections and clarifications added since March 15, 2011.