2015FirstAidfortheUSMLEStep1

OfficialUpdates,Corrections,andClarifications
June8,2015

Despiteourbestefforts,errorsdooccurduringarevision.Thislistaddressescontenterrorsthatmaycreate
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TheFirstAid/USMLERxTeam

CATEGORIESOFUPDATES

MajorCorrections

Factualerrorsthatcouldinterferewithcomprehension

MinorCorrections

Lesssignificanterrorsthatmaycauseconfusion

Clarifications

Thetextisaccurate,butcouldbewrittenmoreclearly
Minorformattingissues(misalignments,indents,etc)thatmayconfuse

MAJORCORRECTIONS

Page

FactName

Revision

57

Advance
directives

IntheentryforMedicalpowerofattorney,replace"Canberevoked
anytimepatientwishes(regardlessofcompetence)."with"Canberevoked
atanytimebyapatientwithdecisionmakingcapacity."Thishighlightsthe
notionthatadvancedirectivesservetoguidedecisionmakingwhena
patientisunabletodosothemselves.

83

Autosomal
dominant
disorders

(1)IntheentryforMarfansyndrome,replacedefectivefibrinwith
defectivefibrillin
(2)IntheentryforTuberousSclerosis,removeIncompletepenetrance
fromthelastsentence,asmostsourcesnowcharacterizeitashaving
completeornearcompletepenetrance.

112

Fattyacid
metabolism

Inthelowerrightsideofthefigure,replace"AcylCoA"with"AcetylCoA,"
asshownintheimagebelow,toreflectthatitisAcetylCoAthatcanbe

usedtoformketonebodiesorenterintotheTCAcycle.

294

EvolutionofMI

Intherowfor424hr,inthecolumnforLIGHTMICROSCOPE,change
"(duetofreeradicaldamage)"to"(duetoinfluxofcalciumions)."

337

Multiple
endocrine
neoplasias

IntheentryforMEN2A,replace"Associatedwithmarfanoidhabitus
mutationin
RET
gene(codesforreceptortyrosinekinase)"with
"Associatedwithmutationin
RET
gene(codesforreceptortyrosine
kinase)"

379

Octreotide

IntherowforMECHANISM,replace...inhibitsactionsofmanysplanchnic
vasoconstrictionhormones."with"...inhibitsactionsofmanysplanchnic
vasodilatoryhormones."

460

Aphasia

IntheentryforMixedtranscortical,replace"BrocaandWernickeareas
involved..."with"BrocaandWernickeareasnotdirectlyinvolved
(involvementofsurroundingareasresultsinsimilarpresentation)..."

499

Baclofen

IntherowforMECHANISM,replaceInhibitsGABA
"withActivates
B
GABA

500

Parkinson
diseasedrugs

IntherowforPreventdopaminebreakdown,replacethetwobulletpoints
withthefollowing:
SelegilineblocksconversionofdopaminetoDOPACby
selectivelyinhibitingMAOB.
Tolcaponeblocksconversionofdopamineto3MTbyinhibiting
centralCOMT.

524

Atypical
antidepressants

IntheentryforTrazodone,replace"Primarilyblocks5HT
and
2

adrenergicreceptors."with"Primarilyblocks5HT
and
adrenergic
1
2
1
receptors,alsoweaklyinhibits5HTreuptake."Theblockadeof5HT
reuptakeisbelievedtobeonthecomponentsmostresponsibleforthe
antidepressanteffectathigherdosages.

535

Juxtaglomerular
apparatus

Replacethesecondandthirdsentencesinthesecondcolumnwith"JG
cellssecreterenininresponsetoBP,sympathetictone(1),and
NaCldeliverytomaculadensainDCT."


MINORCORRECTIONS

Page

FactName

Revision

96

Ratedetermining IntheentryforGluconeogensis,inthecolumnforRegulators,remove
enzymesof
"ATP(+)andacetylCoA(+),"asthereispaucityofevidencesuggesting
metabolic
theseactdirectlyonFructose1,6bisphosphatase.
processes

99

Pyruvate
dehydrogenase
complex

Atthebottomofthesecondcolumn,replace"Activatedbyexercise,
which:"with"Activatedby:"forclarityastheeffectsofexercisearemore
complicatedthandescribedhere.Ingeneral,exerciseresultsinadecrease
+
intheNAD
/NADHratio.However,thepyruvatedehydrogenasecomplexis
+
activatedbyanincreaseintheNAD
/NADHratio.

102

HMPshunt
(pentose
phosphate
pathway)

IntheentryforNonoxidative(reversible),replace"Glucose3phosphate"
with"Glyceraldehyde3phosphate"asshownbelow:

110

Glycogen
storagediseases

IntheentryforMcArdledisease(typeV),underCOMMENTS,remove
"TreatwithvitaminB
(cofactor),"asthereisinsufficientevidenceto
6
suggestthisisaneffectiveformoftreatment.

114

Lipidtransport,
keyenzymes

Inthefirstimage,deletethegreenLPLandHL(totheright)thatact
uponchylomicronremnantspriortotheiruptakebytheliver

229

Woundhealing

IntherowforEGF,replace"Stimulatescellgrowth...asexpressedby
ERBB2
)with"Stimulatedcellgrowth...asexpressedby
ERBB1
."
ERBB2
isthegenethatisoverexpressedinsometypesofbreastcancer(also
knownas
HER2
/
Neu
)"

309

Antiarrhythmics
potassium
channelblockers
(classIII)

Inthefigureforthisfact,pleasenotethatthevoltageshownontheYaxis
shouldbe85mV(not85mV).

313

Pituitarygland

IntheentryforPosteriorpituitary(neurohypophysis),replace"...(supraoptic
andparaventricularnuclei,respectively)..."with"...(supraopticand
paraventricularnuclei)...."

328

Hypothyroidism

IntheentryforHashimotothyroiditis,replace"...anautoimmunedisorder
(antithyroidperoxidase,antimicrosomalandantithyroglobulinantibodies)."
with"...anautoimmunedisorderwithantithyroidperoxidase(aka,
antimicrosomal)andantithyroglobulinantibodies."

330

Thyroidcancer

Makethefollowingchangestoclarifythecommonpathwaysofmetastasis
indifferenttypesofthyroidcancer:
IntheentryforFollicularcarcinoma,changetextsothatitreads
Goodprognosis,invadesthyroidcapsule(unlikefollicular
adenoma),uniformfollicles,hematogenousspreadiscommon."
IntheentryforMedullarycarcinoma,remove"hematogenous
spreadcommon."

380

Metoclopramide

IntherowforTOXICITY,replace"...(duetoD
receptorblockade)"with
1
"...(duetodopamineblockade)."AsdescribedintherowforMECHANISM,
themajoreffectisthatofD
receptorantagonism.
2

390

Microcytic,
hypochromic
(MCV<80fL)
anemia

IntheentryforIrondeficiency,underFINDINGS,replace
"...PlummerVinsonsyndrome(triadofirondeficiencyanemia,esophageal
webs,andatrophicglossitis)."with"...PlummerVinsonsyndrome(triadof
irondeficiencyanemia,esophagealwebs,anddysphagia)."

393

Nonhemolytic,
normocytic
anemia

IntheentryforAplasticanemia,inthesecondbullet,replace"Viralagents
(parvovirusB19,EBV,HIV,HCV)"with"Viralagents(parvovirusB19,EBV,
HIV,viralhepatitis)".

405

Warfarin

IntherowforTOXICITY,secondcolumn,replace"ProteinsCandS...
clottingfactorsII,VI,IX,andX"with"ProteinsCandS...clottingfactorsII,
VII,IX,andX"tomaintainconsistencywiththelistvitaminKdependent
clottingfactorsdescribedpreviously.Specifically,notethatitshouldbe
FactorVII,notFactorVI,inthislist.

412

Rituximab

IntherowforCLINICALUSE,replace"IBD"with"ITP"tomore
appropriatelyreflecttheuseofthisdrug.

438

Pigmentedskin
disorders

IntherowforAlbinism,changethesecondsentencetoreadasfollows:
"Piebaldismreferstoaseparateconditioncharacterizedbyafailureof
neuralcrestcellmigrationduringdevelopment."

489

Seizures

Intherighthandcolumn,regardingStatusepilepticus,replace"variably
definedas>1030min"with"operationallydefinedas>5min."Althougha
consensusdefinitionbasedontimeislacking,mostclinicalguidelines
agreethatseizureslastinggreaterthan5minutesshouldbetreatedas
statusepilepticus.

521

Antipsychotics
(neuroleptics)

(1)Inthethirdcolumn,intherowforMECHANISMandCLINICALUSE,
replace"(e.g.,Huntingtondisease,delirium,EPSsymptoms)."with"(e.g.,
extrapyramidalsymptoms)."
(2)Inthesecondcolumn,intherowforCLINICALUSE,replace"...acute
mania,Tourettesyndrome."with"...acutemania,Tourettesyndrome,
Huntingtondisease."

559

Embryologic
derivatives

IntheentryforMesoderm,replace"...vagina,kidneys,adrenalcortex..."
with"...uppervagina,kidneys,adrenalcortex..."

IntheentryforEndoderm,replace"...mostofurethra(derivedfrom
urogenitalsinus)..."with"...mostofurethraandlowervagina(derivedfrom
urogenitalsinus)...."

Thishighlightstheimportancethatthevaginaandotherurogenital
structureshaveamixedembryologicaloriginbetweenmesodermand
endoderm.
563

Vitellineduct

Intheimage,thepartlabelled"Vitellinefistula"wouldbemore
appropriatelyclassifiedasa"Vitellinecyst,"giventhatitscavityisin
discontinuitywithboththelumenofadjacentbowelandthesurfaceofthe
umbilicus.

Avitellinefistulawouldbemoreappropriatelyshownasfollows:

568

Uterine
(M

llerianduct)
anomalies

Inthesetoffiguresforthisfact,pleasenotethatthefigureforDidelphys
shoulddepictadoublevaginainadditiontoadoubleuterusanddouble
cervix,asdescribedinthetext.Pleaseseethisimageforanexampleof
suchadiagram.

571

Urethralinjury

Thebulbarurethraismoreappropriatelyconsideredaspartoftheanterior
urethraandiscommonlyinjuredinperinealsaddleinjuries.Pleasechange
thetextasfollows:

Posteriorurethramembranousurethrapronetoinjuryfrompelvic
fracture.Injurycancauseurinetoleakintoretropubicspace.

Anteriorurethrabulbarandpenileurethraatriskofdamagedueto
perinealstraddleinjury.Cancauseurinetoleakbeneathdeepfasciaof
Buck.Iffasciaistorn,urineescapesintosuperficialperinealspace.
583

Gynecological
tumor
epidemiology

Replace"Worstprognosisovarian>cervical>endometrial."with
"Mortalityovarian>endometrial>cervical."toalignmoreappropriately
withthestatisticsandterminologyusedincurrentliterature.

587

Ovarian
neoplasms

IntheentryforChoriocarcinoma,remove"Veryresponsiveto
chemotherapy."

CLARIFICATIONS

Page

FactName

Revision

291

Arteriosclerosis

IntheentryforMnckeberg(medialcalcificsclerosis),replace
CalcificationofelasticlaminaofarterieswithCalcificationofinternal
elasticlaminaandmediaofarteries

322

Thyroid
hormones(T
/T
)
3
4

IntherowforREGULATION,secondcolumn,replaceThyroidstimulating
immunoglobulins(e.g.,TSH)stimulatefollicularcells(e.g.,Graves
disease).with"InGravesdisease,thyroidstimulatingimmunoglobulins
stimulateTSHreceptorsonfollicularcells,causinghyperthyroidism."

369

Alcoholicliver
disease

IntheentryforAlcoholichepatitis,intherighthandcolumn,replace"(ratio
usually>1:5)"with"(ratiousually>2:1)"toremainconsistentwithcriteria
usedelsewhereinthebook.

423

Muscle
conductionto
contraction

Intherighthandcolumn,notethatterminalcisternaearepartofthe
sarcoplasmicreticulum.Forclarity,replacethefirstsentenceinthethird
columnwiththefollowing:
Ttubulesareextensionsofplasmamembranejuxtaposedwithterminal
cisternaofthesarcoplasmicreticulum.

494

Glaucomadrugs

IntheentryforCholinomimetics,Direct(pilocarpine,carbachol),under
SIDEEFFECTS,replace"Miosisandcyclospasm(contractionofthe
ciliarymuscle)"with"Miosis(contractionofthepupillarysphincter
muscles)andcyclospasm(contractionoftheciliarymuscle)"

524

Atypical
antidepressants

IntheentryforTrazodone,thefirstsentenceshouldread:Primarily
blocks5HT

and
adrenergicreceptorsalsoweaklyinhibits5HT
2
1
reuptake.