Preventive Medicine show that the risk of colorectal cancer patients with proven HCC, and in patients who have had adenomas screened 201 patients for HCC risk When to Screen for removed may be no greater than that in using platelet counts as a marker. the general population. Among patients with chronic HCV, Postpolypectomy Polyps Understandably, factors such as mean platelet counts dropped in rela- A patient is 55, male, has no family shifting guidelines, malpractice suits, tion to both increased pathologic fibro- history of colorectal cancer, but just and the very real possibility of missing sis scores and parenchyma scores. This had a colonoscopy that revealed a a polyp that turns a low risk patient was not the case in patients with HBV, hyperplastic polyp. How soon into a high risk patient influence however. should he receive a surveillance practitioners’ decision making. The Nevertheless, the researchers calcu- colonoscopy? intense surveillance of low risk polyps, lated a cutoff platelet count of 150 x This, and similar questions about however, compromises the capacity to 103/mm3 for predicting stage IV fibrosis differing colonoscopy results, were perform screening colonoscopy and or ultrasound-confirmed cirrhosis in answered by 568 primary care phy- evaluation in symptomatic patients, patients with either HCV or HBV. The sicians through a mail survey con- the researchers warn. They note that sensitivity and specificity of this cutoff ducted by researchers from University the reduction in risk from surveil- value were 68% and 76%, respectively, Hospitals of Cleveland, Cleveland, lance alone after polypectomy remains for pathologic cirrhosis and 76% and OH; Henry Ford Hospital, Detroit, unclear. The prevalence of adenomas is 88%, respectively, for ultrasound cirrho- MI; and Central Texas Veterans Health 30% to 50%, but the incidence of can- sis. The validity was comparable to that Care System, Temple. The investiga- cer is 6%. They add the caveat, how- of other combinations of serum mark- tors found that these providers may ever, that the results of their survey are ers for patients at high risk for HCC. be ordering surveillance colonoscopy based on physicians’ self-reports and Source: Cancer. 2006;107:2212–2222. more often than necessary. may not match actual practice. For instance, 61% reported that Source: Ann Intern Med. 2006;145:654–659. they would survey a single 6-mm, Rehabilitative Medicine hyperplastic polyp in the sigmoid colon in five years or less, and 71% Hepatology Recovering from Stroke with reported that they would survey a One Hand Tied Up single 6-mm, tubular adenoma in the Can Thrombocytopenia sigmoid colon in three years or less. Signal Cirrhosis? Promoting the use of the affected hand Most would survey two 6-mm, tubular can strengthen arm function after adenomas in three years or less. And Thrombocytopenia is a useful sur- stroke—and the results can last for 80% would recommend repeat surveil- rogate for cirrhosis when identifying at least a year—according to findings lance in five years or less for a patient patients at high risk for hepatocellular from the Extremity Constraint Induced who’d had a 12-mm, tubular adenoma carcinoma (HCC), according to results Therapy Evaluation (EXCITE) trial. three years before but who had a nor- from a series of three pilot studies led All patients had experienced a mal result on surveillance colonoscopy. by researchers from Kaohsiung Chang stroke within the previous three to Current guidelines from the U.S. Gung Memorial Hospital, Kaosiung nine months, with 106 participating in Multisociety Task Force on Colorectal and Chang Gung University, Taoyuan, constraint-induced movement therapy Cancer recommend surveillance colo- both in Taiwan. These investiga- (CIMT) and 116 receiving usual care noscopy every five to 10 years for tors determined platelet counts and (ranging from no treatment to formal patients with average risk (one or two pathologic hepatic fibrosis scores for rehabilitation). During CIMT, patients adenomas smaller than 1 cm) and 122 patients with chronic hepatitis B wore a restraining mitt on the less- every three years for those with three virus (HBV) infection and 244 patients affected hand while engaging in func- or more adenomas, regardless of size. with chronic hepatitis C virus (HCV) tional repetitive tasks (such as writing) The researchers note that those inter- infection, examined the prevalence and behavioral shaping, or adaptive, vals could be lengthened, as some data of thrombocytopenia among 4,042 tasks with the hemiplegic hand. The

FEBRUARY 2007 • FEDERAL PRACTITIONER • 47 CLINICAL DIGEST

researchers encouraged the patients to students, and 15 nursing assistants— CHD symptoms. Of this group, 155 wear the mitt for 90% of their waking with 800 backrests (at angles of 20, 30, patients were sent directly to the emer- hours over two weeks. 35, and 45 degrees) and asked them gency department, but the remaining While the control group showed to estimate their angles. Only 15% of 106 became “missed opportunities.” some improvement at 12 months, the angles were estimated accurately, The findings weren’t surprising, the CIMT group showed significantly with 62% overestimated and 24% the researchers say, given the lack of greater improvements immediately after underestimated. There was no correla- structured evaluation in most cases. therapy in quality and speed of paretic tion between the participants’ years of Half of the patients who did seek arm movements and in the quality and nursing experience and the accuracy of primary care in the month prior to amount of paretic arm use in daily life. their estimates. their AMI didn’t have an electrocar- Moreover, the CIMT group showed The researchers point out that, diogram (ECG) during the visit, and improvement at four-, eight-, and 12- among other problems, a backrest when they did, it wasn’t always inter- month follow-ups. The advantages for that isn’t elevated enough can put the preted before they left the office. The the CIMT group on various perfor- patient at risk for pulmonary compro- researchers add that primary care cli- mance scales lasted for 12 months. mise or pulmonary aspiration. They nicians may attempt to manage unsta- The EXCITE trial is the first random- also note that all the study’s partici- ble coronary conditions themselves ized, multicenter trial of CIMT among pants were fully aware of the clinical to avoid sending patients to already patients experiencing recent stroke, the importance of backrest angles, par- crowded emergency departments. researchers say. Their results support ticularly in patients with respiratory or What should these clinicians, who findings from other studies that have neurologic conditions, and that 93% don’t have access to cardiac enzyme used CIMT for patients with long-term did not consider their own angle esti- tests or stress testing equipment, do for stroke disabilities. mations to be accurate. The researchers patients with CHD symptoms? Turn Source: JAMA. 2006;296:2095–2104. call for a more objective, simple, and to tools such as the Framingham Risk readily available method of determin- Score (FRS), the researchers advise. In ing backrest angles. this study, the FRS was strongly associ- Critical Care Source: Heart Lung. 2006;35:391–396. ated with the occurrence of AMI. The researchers note that the FRS can be Finding the Right Angle calculated readily through electronic Judging the angle of a critically ill Cardiovascular Disease medical records, either in real-time patient’s backrest can be a difficult task, or intermittently, and placed on the say researchers from Federal University Early Intervention for CHD: patient’s problem list. of São Paulo, São Paulo City, Brazil. An FRS of 10% or higher may They conducted a study in which they Don’t Miss Out prompt more ECGs or influence the presented 160 participants—97 regis- Primary care physicians miss a sur- interpretation of borderline abnormali- tered nurses, 48 undergraduate nursing prising number of opportunities to ties, the researchers suggest. It might intervene in cases that later lead to also spur practitioners to prescribe acute myocardial infarction (AMI) and cardioprotective medications or hos- hospitalization. This was the conclusion pital evaluations. Among the high risk drawn by researchers from Brigham and patients in this study, prescription rates Women’s Hospital, Harvard Medical for beta-blocker and aspirin therapy School, Harvard Vanguard Medical were low. Of 90 patients who had a Associates, and Partners Healthcare “moderately elevated” FRS, only 12% System, all in Boston, MA, based on a began aspirin treatment and only 8% case-control study in a population of started taking a beta-blocker. ● 966 patients admitted to the hospital Source: Arch Intern Med. 2006;166:2237–2243. with AMI who had no known history of coronary heart disease (CHD). More than one quarter (261) of E-mail us at: the patients had visited a primary care practitioner in the preceding month, [email protected] specifically for chest pain or other

48 • FEDERAL PRACTITIONER • FEBRUARY 2007