Atlas Of Clinical Diagnosis

M. Afzal Mir
W.B. Saunders Company, 55 Horner Ave, Toronto, ON M8Z 4X6
1995/266 pp

Strengths

Practical, excellent illustrations

Audience

Medical students and practitioners

This book aims to provide medical students and practitioners with a comprehensive survey of clinical signs organized by external body parts. The underlying assumption is that most diagnoses from clinical signs are based on pattern recognition, so the book is a rich collection of colour illustrations of common, rare, and esoteric conditions. Using arrows to highlight the more subtle signs would help readers, like me, who need more guidance.

The organization of the book is excellent with a logical approach to each external body part; for example, the chapter on the external eye deals with eyelids and orbit and the conjunctiva. Some interesting clinical tips include listening to a patient’s breathing by putting the stethoscope bell in front of the patient’s mouth.

The focus at times is esoteric with eight pages on various porphyrias, something I was taught in great detail in medical school and have yet to see in practice. Useful diagrams for such conditions as acromegaly or Cushing’s disease illustrate that clinical signs from each anatomical area are only part of the overall picture. Suggestions for further investigation of these major conditions are given but are brief and superficial. Common conditions seen in family practice, such as viral exanthemas, otitis media, and pharyngitis, are given less coverage, and there is a paucity of penile or vulval lesions.

The book is a good reference for unusual conditions and has excellent chapters on fundi, nail disorders, and hands. But the high price of the book could limit how widely it is used.

Antioxidants in Nutrition, Health, and Disease

John M.C. Gutteridge, Barry Halliwell
Oxford University Press, 70 Wynford Dr, Don Mills, ON M3C 1J9
1994/143 pp

Strengths

Summarizes current thought on free radicals and antioxidants. A clear, pithy, scientific, informative text

Audience

Physicians, medical students, nurses, biologists, nutritionists, and chemists

The authors have written a short textbook introducing antioxidants to clinical practice. They also refresh readers with a review of the basic clinical sciences.

A short, informative preface asks succinct questions on using antioxidants for treating heart disease, cancer, and degenerative illnesses. The authors answer their questions with sufficient information on free radicals, cholesterol, and oxidative stress for readers to use in laboratories and practices.

A historical discussion of oxygen, oxidation-reduction definitions, and electron transport is followed by scientific information on the Krebs cycle, vitamins, and nutrients and a timely presentation of free radicals as contributing to cardiovascular and degenerative disease.

Later, epidemiologic and pathologic evidence on nutrient use is presented. This evidence allows us to understand information applicable to a scientific study of tissue damage and regeneration. Clearly, interest in the effects of nutrition and vitamins on health has increased. This short text will help practitioners upgrade current knowledge and share the information with patients.

The authors acknowledge the brevity of their text. They have challenged readers to examine modern concepts that might be discussed with our patients in the office. They also give us sufficient information to provide our patients and colleagues with current thinking on the activity of essential vitamins A, E, and C.

The style of this book flows well with diagrams, bold headings, illustrations, and informative tables. I enjoyed the quotations from The Beatles and Butch Cassidy and the Sundance Kid mixed with Paracelsus and Francis Bacon, which set the tone for the discussion in each of the seven chapters.

Appendices supplementing chapters 1, 4, and 5 provide further information on cholesterol, saturated and unsaturated fats, and their effect on the cardiovascular system. The authors raise questions not only for academics, but also for the less scientific. Skillfully, they then lead us through a historical discussion of the building blocks of life: carbon, hydrogen, oxygen, and nitrogen. Are antioxidants elixirs or media hype? Are human phagocytes useful? Does oxidative stress help or hinder our health? Should vitamins and minerals be used as supplements? What is the window of optimum activity of antioxidants?

Although the jury is still out on the results of antioxidant research, the authors present much food for thought. This book is valuable, and a few nights’ perusal should give readers sufficient vital information on antioxidant therapy to guide application.

James McCormack, Glen Brown, Marc Levine, Robert Rangno, John Ruedy
W.B. Saunders Company, 55 Horner Ave, Toronto, ON M8Z 4X6
1996/550

Strengths

Evidence-based approach for making drug therapy decisions

Weaknesses

Missing key information

Audience

Any clinician who prescribes drug therapy, particularly useful for teaching practices

This book is not just another multi-authored reference book. It is designed to wean clinicians away from “habitual or intuitive solutions” and to encourage decisions based on explicit factors. To achieve these goals, the book has a section on drug therapy for disease states to help readers make therapeutic choices that are reasonable if not optimal and to provide information on initiating, altering, or terminating a drug.

For each clinical condition a set of questions is asked. For example, in treating depression, before choosing a therapeutic agent you are asked to consider treatment goals, evidence to support drug therapy, when to consider drug therapy, initial treatment, dosage, the length of the initial treatment regimen, the efficacy parameters and patient assessment interval, when to add an additional drug if initial therapy fails, and the length of drug therapy.

This is good medicine. The process reinforces a framework for making therapeutic decisions and subsequently managing patients appropriately. The text also has sections on common drug-induced adverse reactions and drug monographs. Both these sections use questions to develop rational therapeutic decisions.

No text is perfect. Inevitably some key information is missing. I could not find a specific therapeutic approach to necrotizing fasciitis. Also, the book does not provide advice on how to switch from one group of antidepressants to another. Nevertheless, once I got used to the directed format, I found it is easy to use and helpful in making reasonable if not optimal drug therapy decisions.

Handbook of Substance Abuse: Neurobehavioral Pharmacology.
Robert T. Ammerman, Ralph E. Tarter, Peggy J. Ott (eds).
1998. (602 pp).
ISBN 0306458845 (hard).

To help illuminate the causes and natural history of substance abuse disorders, and given increasing interest in drug therapy for the treatment of addiction, this reference volume provides a comprehensive technical review of the pharmacology of each type of drug known to induce abuse or dependence.

Sections correspond to drug classes listed in the American Psychiatric Association’s 1994 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV): alcohol; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opiates; sedatives, hypnotics, and anxiolytics; and amphetamines. A final section addresses other substances of abuse, including anabolic steroids, ecstasy, and phencyclidine.

In an attempt to integrate neurological, behavioral, and clinical material, each section provides separate chapters on pharmacology, behavioral pharmacology, and psychological and psychiatric consequences. Presentations review human and animal studies (including conflicting or indeterminate data), mechanisms of action, variables related to dose and drug interactions, different effects of closely related specific drugs, and voluminous additional information to provide a panoramic neurobehavioral view. The book has many contributors, numerous tables, extensive references, and a detailed index.

An introduction notes that no common feature has been found for all drugs that lead to abuse or dependence. Drugs’ capacity to produce intoxication, tolerance, and physical dependence and the severity of withdrawal symptoms vary widely. Abusable drugs may provide positive reinforcement, such as enhancing energy, arousal, or euphoria; or negative reinforcement, relieving fatigue, stress, or depression. This ability to alter emotions, cognition, or behavior is not unique to abusable drugs.

Although definitions vary, like DSM-IV this book distinguishes drug abuse from dependence. Abuse criteria include consumption in difficult or dangerous circumstances and interference with normal activities. Dependence may involve tolerance, withdrawal symptoms, loss of control, relinquishing of personal and social roles, and extensive efforts to maintain use.

The editors acknowledge that understanding substance abuse disorders requires examining the contributions of genetic, developmental, neurobiological, behavioral, and social policy factors, as well as the pharmacological properties of drugs. There has been little research on individual and gender differences in drug response and vulnerability to abuse disorders and dependence.

Introduction to Psychosexual Medicine.
For doctors, nurses, students, and other health professionals

R L Skrine (ed)

Montana Press, Carlisle

1989, 211 pages

If a woman patient innocently remarked, ‘I would not have your job for anything’, just as her doctor was about to perform a vaginal examination, then she may be in need of psychosexual counselling. If you accept this concept then Introduction to psychosexual medicine will be of service as it is predominently Freudian in content. It discusses how a general practitioner can be aware of patients’ hidden sexual problems during routine consultations. It certainly cannot be regarded as a good reference book for non-Freudians.

The field of psychosexual counselling is highly specialized, and any attempt to teach it to a wider audience should be met with caution. As such, it is doubtful whether this book will be of value to all doctors, nurses, students, and other health professionals as is suggested by its subtitle. It should be placed beside volumes that express alternative points of view in psychosexual medicine.

Health, Happiness and Security
The creation of the National Health Service

Frank Honigsbaum

Routledge, London

1989, 286 pages

Health, happiness and security describes in detail the ideas and events which led to the founding of the National Health Service in 1948. The author intends that the part played by civil servants should form the central thread of a narrative which begins in 1911. But, seen through the eyes of a doctor, this is an account of the medical profession’s movement towards the same goal of a comprehensive service and the struggles which this movement entailed — struggles to avoid the control, in turn, of the friendly societies, the approved societies, local authorities and finally, but with less determination, the Department of Health. Almost hidden within this movement towards the major goal was another of comparable importance — to enlarge and develop a specialist service which would take over the extensive work done by general practitioners in hospitals and establish for specialists a commanding role in medical care. This proved to be a crucial step in the division of British medicine into primary and secondary care, which is now the most distinctive feature of our system. In both movements the figure of Charles Wilson, Lord Moran, looms large.

This book appears at a time when an upheaval comparable to that of 1945-48 is taking place in the health service. Was this the reason for writing the book? The evidence suggests rather that the reason was the recent availability of crucial documents. In addition, it would have been impossible to write in such detail, with such careful referencing and so little bias without long preparation. Indeed the author’s interest goes back 30 years. This is historical writing, not journalism — and it is not for the casual reader.

Book: Sexual Medicine in Primary Care

Sexual Medicine in Primary Care

William L. Maurice

Mosby-Year Book, Inc, 11830 Westline Industrial Dr, St Louis, MO 63146 USA

1999/366 pp

Overall Rating

Good to excellent

Strengths

Medical and psychological aspects, and factors relevant to couples integrated in a case-based approach. Flow charts, book lists, and websites

Weaknesses

Layout mixing text, cases, and example interviews at times hard to read

Audience

Family physicians, residents (family, obstetrics and gynecology, urology, and psychiatry), medical students, and other health care professionals who manage sexual problems

With the release of sildenafil (Viagra), Dr Maurice, a well-respected Canadian authority on sexual medicine, has provided physicians with a timely reference on how to manage patients and their partners’ sexual concerns beyond merely prescribing pills for potency. This book integrates medical and psychological aspects, and factors relevant to couples in the up-to-date diagnosis and management of sexual difficulties.

Dr Maurice describes the common prevalence of sexual problems and why physicians and patients find it hard to discuss them. More importantly, using case examples and suggested interview questions, he offers solutions to those wanting to deal more directly with their patients’ sexual problems.

In exploring sexual problems, the author provides easy-to-follow flow charts that tie together different diagnostic issues, including medical and drug effects along with psychological and relationship factors. An appendix on medications lists drugs (both prescription and recreational) by sexual side effect. Book lists and websites for patients are also useful.

Dr Maurice makes a cogent argument for primary care physicians to find case examples of sexual problems in their practices. He offers suggestions on what to do once these cases are identified. Most useful is a section for each diagnosis on when to refer for expert consultation or to transfer care.

In combining well referenced text, case studies, and interview questions, Dr Maurice has created an excellent textbook that can function as both an introductory and advanced resource. Readers trying to find a “quick fix” for a particular clinical problem might get frustrated with the layout of the book. This book will, however, amply reward readers who want to learn how to integrate pharmacotherapy with psychotherapy.

I welcome this book and recommend it to all physicians who want to better help their patients deal with sexual concerns.

Managing Side Effects of Psychotropic Drugs. A Clinical Handbook for Health Care Professionals

L. Kola Oyewumi, Renee de Wit

Zxmaxx Communications, Suite 604, 695 Richmond St, London, ON N6A 5M8

1998/264 pp

Strengths

Deals with an important yet neglected area

Weaknesses

Poorly organized; hard to use or find information; no advantages compared with other sources

Audience

Physicians, pharmacists, other health care workers, patients, families

The authors hope this book will be used as a reference manual on the side effects of psychotropics. It is organized on the basis of side effects rather than by classes of medications. The authors believe that this allows them to better address their subject matter while ensuring that the contents remain current.

There are 10 chapters with 21 tables and a figure. Although 283 references are given, rarely are any cited. The table of contents and the index are not very helpful. Early in the book it states that sexual dysfunction will be dealt with as a physical side effect, but later on sexual problems (other than priapism) are listed under psychiatric and behavioural side effects.

Syndrome of inappropriate secretion of antidiuretic hormone (SIADH), diabetes, and primary poly-dipsia are presented poorly. The classification of cognitive disturbances is, in itself, confusing: “confusion,” “intellectual impairment,” and “memory” are separate subheadings while delirium is under “psychosis.” Laboratory tests to perform before prescribing psychotropics are suggested. There is no reference, and it is unclear whether these investigations are recommended for all patients. Postmarketing surveillance for adverse effects is covered, but practical advice is not given.

Book: Physician's Guide to Drug Eruptions

Physician’s Guide to Drug Eruptions

Jerome Z. Litt

Parthenon Publishing, Inc, One Blue Hill Plaza, PO Box 1564, Pearl River, NY 10965 USA
1998/261 pp

Overall Rating

Excellent

Strengths

Comprehensive, current listing of adverse cutaneous reactions and color photographs

Weaknesses

Important systemic syndromes, such as the drug hypersensitivity syndrome and serum sicknesslike reaction, are poorly presented. Readers might miss the opportunity to do a complete clinical evaluation if the information is unavailable

Audience

Dermatologists, physicians, and pharmacists who are confronted with rashes that might be due to drugs

Rashes can be difficult to diagnose for anyone, but even my children can cure classmates by suggesting that they have “a mild dermatitis, try some hydrocortisone cream.” The problem arises when a patient mentions a new drug started 7 days ago. Drug reactions are the core of my academic career, and I know how complicated they can be to manage.

When a drug reaction is suspected, the first step is to make the diagnosis. This book addresses this step with clinical descriptions of a few common drug reactions and a rich set of excellent color plates. This part of the text is only partially successful. Severe systemic reactions are poorly treated, and users will need other sources to help guide management.

Once the best diagnosis is made, the second step is to consider which drugs the patient is receiving and what the likelihood is that each drug caused the rash. This is where this book shines. Does diphenhydramine hydrochloride cause fixed drug eruption? Yes, and there are four good references. Has gemfibrozil caused lichen planus? Apparently so. While this approach will not answer all issues (that is still the job of clinicians), the book is an excellent up-to-date guide to what is known. It also can direct readers to the appropriate references, a very difficult task because drug eruptions are reported in obscure journals or non-indexed letters.

The organization of the text is also strong. A comprehensive list of trade names and associated generic names is provided. Products are then listed by the latter, and the list of rashes and references follows each. For specific rashes, a separate section lists all the drugs reported to cause the reaction.

Several books are available that review drug reactions in the skin, but I believe that, in many ways, this is the most clinically useful. It is comprehensive and has been updated regularly. It falls short in some areas, but that should not detract anyone interested in drug eruptions from buying this gem. It will be well used by the time the next edition is published.