Literature Review Nancy Risser, MN, RN,C, ANP Mary Murphy, CPNP, PhD Literature Review Editors

body mass index (BMI) >30 had a mal hospital diet or normal diet plus RR of 1.3 compared to those with a oral nutrition supplements until BMI of 21 to 23. For women, the hospital discharge. In a second trial, RR of kidney stones was double in patients who were enrolled within those with BMI >30 compared to several days of admission received UROLOGY those with a BMI of 21 to 23. Al- either early enteral tube feeding or though the mechanism by which no tube feeding for more than 7 ■ Kidney Stones and Obesity obesity increases the risk of kidney days. In the third trial, patients re- Taylor EN, Stampfer MJ, Curhan GC: Obesity, stones is unknown, these results are ceived either percutaneous endo- weight gain, and the risk of kidney stones. one more reason to encourage scopic gastrostomy (PEG) or JAMA 2005;293(4):455-62. weight control. nasogastric feeding. Patients were Obesity is associated with insulin prospectively followed to determine resistance and metabolic changes poor outcome or death at 6 months. that may lead to the formation of Between 1996 and 2003, in 125 hos- calcium-containing kidney stones. pitals in 15 countries, 4,023 patients Using large cohorts from the Health were enrolled in the first trial. In Professionals Follow-up and the 3,709 patients (92%) who were Nurses’ Health Studies, 4,827 kid- judged to be well nourished on ad- ney stones were documented over a CARDIOVASCULAR CARE mission, supplemented diet was as- combined 46 years of follow-up sociated with an insignificant 0.7% with over 240,000 men and women. ■ Nutrition Supplements reduction in death risk and 0.7% in- After adjustments for age, dietary after Stroke creased risk of death or poor out- factors, fluid intake, and thiazide The Food Trial Collaboration: Routine oral come at 6 months. In the second diuretic use, the relative risk (RR) nutritional supplementation for stroke trial, in 859 patients, early tube feed- of stone formation in men who patients in hospital (FOOD): a multicenter ing was associated with a 5.8% re- weighed more than 220 pounds randomized controlled trial. Lancet duced death risk (p = 0.09) and a versus men who weighed less than 2005;365(9461):755-63. 1.2% reduced risk of death or poor 150 pounds was 1.44 (95% CI 1.11- The FOOD Trial Collaboration: Effect of outcome (p = .7). In the PEG versus 1.86; p = .0002). In women, corre- timing and method of enteral tube feeding nasogastric tube trial, 321 patients sponding RR for these weight for dysphagic stroke patients (FOOD): a mul- were enrolled in 47 hospitals in 11 categories was 1.89 for women aged ticenter randomized controlled trial. Lancet countries. Percutaneous endoscopic 40 to 75 years at baseline and 1.82 2005;365(9461):764-72. gastrostomy feeding was associated for women aged 27 to 44 years at After a stroke, patients often receive with an insignificant 1% increased baseline. Increased risk for sympto- nutritional supplements. The au- risk of death (p = 0.9), but with a matic nephrolithiasis was also re- thors tested several approaches to significant 7.8% increased risk of ported for men and women who timing and use of supplemental and death or poor outcome (p = 0.05). gained more than 35 pounds since enteral feeding. In one trial, patients These data do not support the rou- age 21 years versus subjects whose with stroke who could swallow were tine use of oral supplementation af- weight did not change. Men with a randomly allocated to receive nor- ter stroke or the early use of PEG

Literature Review offers succinct summaries of articles published in recent clinical journals.

The journals reviewed include: American Family Physician • American Journal of Medicine • Annals of Internal Medicine • Archives of Pediatric and Adolescent Medicine • British Journal of Medicine • CA: A Cancer Journal for Clinicians • Cancer • Clinical Pediatrics • Journal of Emergency Medicine • Journal of the American Medical Association • Journal of Pediatric Health Care • Obstetrics and Gynecology • Lancet • Mayo Clinic Proceedings • MCN: The American Journal of Maternal/Child Nursing • The Medical Letter • Morbidity and Mortality Weekly Report • New England Journal of Medicine • Pediatric Annals • Pediatric Nursing • Pediatrics • Pediatrics in Review

54 The Nurse Practitioner • Vol. 30, No. 6 www.tnpj.com Literature Review

and feeding tubes. Whatever slight tional therapy plus amiodarone, or ber ICD as long as they are enrolled reduction in fatality from early tube conventional therapy plus a pro- in a prospective registry. feeding might occur would be offset grammed ICD, patients were fol- by increased survival with a poor lowed for an average of 45 months. ■ Aspirin and Proton Pump Inhibitor outcome. There were 244 deaths (29%) in the Chan FKL, Ching JYL, Hung LCT, et al: placebo group, 240 (28%) in the Clopidogrel versus aspirin and esomepra- ■ ICD for Heart Failure amiodarone group, and 182 (22%) zole to prevent recurrent ulcer bleeding. N Bardy GH, Lee KL, Mark DB, et al: in the ICD group. In these patients Engl J Med 2005;352(3):238-44. Amiodarone or an implantable cardioverter- with NY Heart Association Class II Cryer B: Reducing the risks of gastroin- defibrillator for congestive heart failure. N or III CHF, amiodarone had no fa- testinal bleeding with antiplatelet therapies. Engl J Med 2005;352(3):225-37. vorable effect on survival (p = 0.53), N Eng J Med 2005;352(3):287-9 (editorial). Kadish A: Prophylactic defibrillator but single-lead shock-only ICD re- Current cardiology guidelines rec- implantation—toward an evidence-based duced overall mortality by 23%. The ommend clopidogrel for patients approach. N Engl J Med 2005;352(3):285-87 benefit from ICD use did not vary unable to take aspirin because of (editorial). by ischemic or nonischemic cause of previous gastrointestinal intoler- The authors recruited 2,521 patients CHF and occurred despite an acute ance. Chan and colleagues studied with congestive heart failure (CHF) device complication rate of 5%. 320 patients with upper gastroin- and a left ventricular ejection frac- These findings raise the standard of testinal bleeding. After healing and tion (LVEF) of < 35% to test care for many patients with CHF. A eradication of Helicobacter pylori whether amiodarone therapy or an preliminary ruling indicates bacteria, patients were randomly as- implantable cardioverter-defibrilla- Medicare and Medicaid coverage signed to receive clopidogrel (Plavix) tor (ICD) would improve outcomes. may be extended to patients with 75 mg daily or the proton pump in- After random assignment to conven- LVEF < 31% to allow a single-cham- hibitor esomeprazole (Nexium) 20

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mg twice daily plus 80 mg aspirin selves with minimal adult supervi- lifetime bipolar disorder was 9.8% (n daily. After one year, 8.6% of the pa- sion. They easily learned problem = 112) and did not differ by age, sex, tients in the clopidogrel group had a solving, appropriate social skills, or- or race. Patients who screened posi- recurrent ulcer compared to 0.7% in ganization, planning, and self-es- tive for bipolar disorder reported sig- the aspirin plus esomeprazole group teem from these unstructured times. nificantly worse health-related (p = .001). These surprising results Today, many children are kept busy quality of life and increased social reinforce the need to focus on base- in scheduled, supervised, structured and family life impairment com- line gastrointestinal risk factors in activities during every moment of pared to those who screened negative patients being considered for any the day. The authors suggest pro- (p <.001). Only seven of the 112 pa- type of antiplatelet therapy. Even moting physical activity by encour- tients reported taking a mood-stabi- among patients taking no medica- aging a broader view of play—a lizing agent in the past month. tions, asymptomatic gastroduodenal daily time to have unstructured, cre- Primary care clinicians recorded evi- ulcers spontaneously form at a rate ative, spontaneous, developmentally dence of current depression in 47 of of 2% a month. Platelet aggregation appropriate activities. There should the 112 patients, but did not record a plays a critical role in healing. Per- be an emphasis on attention or cog- bipolar disorder diagnosis in any of haps any antiplatelet agent may im- nitive activities, affiliation or social these patients. Current guidelines for pair healing and convert skills, and affect or emotional attrib- bipolar disorders caution against asymptomatic ulcers into clinically utes. Free play requires a safe space monotherapy with antidepressants apparent bleeding ulcers. This study and safe equipment—safe play- because this may induce hypomania, indicates that replacing aspirin with grounds, parks, yards—where chil- mania, or a mixed depressive/manic clopidogrel does not protect patients dren can experience the joy of episode. Clinicians need to recognize at high risk of gastrointestinal com- movement, creativity, friendship, and screen for bipolar disorder along plication. Instead, patients who need and selflearning. with depression in primary care set- antiplatelet therapy to prevent tings in order to appropriately diag- thrombotic complication should be nose and manage this common and given the lowest effective dose of as- underrecognized problem. pirin plus a proton pump inhibitor. ■ Therapy for Panic Disorder Ham P, Waters DB, Oliver MN: Treatment of panic disorder. Am Fam Physician 2005; PSYCHIATRIC CARE 71(4):733-40. Patients with panic disorder present ■ Bipolar Disorder Underrecognized complicated and time-consuming is- Das AK, Olfson M, Gameroff MJ, et al: sues to the primary care provider. PEDIATRIC CARE Screening for bipolar disorder in a primary This review article concisely presents care practice. JAMA 2005;293(8):956-63. diagnostic criteria and evidence- ■ Free Play Routine screening for depression is based options for therapy. Patients Burdette HL, Whitaker RC: Resurrecting free advised in primary care settings, but with panic disorder usually have a play in young children. Arch Pediatr Adolesc little attention has been focused on sudden onset of an attack, which in- Med 2005; 159(1):46-50. screening for past episodes of hypo- cludes intense fear and some combi- Fitness and fatness are frequent top- mania or mania, a history that may nation of somatic symptoms such as ics discussed in anticipatory pedi- indicate bipolar disorder and a need chest pain, sweating, palpitations, atric care, and usually involve for specialized therapy. The re- nausea, dizziness, paresthesias, or structured, programmed, limited searchers identified 1,157 patients shortness of breath. Panic attacks, activity to fit into the child’s and between the ages of 18 and 70 years which usually last more than 10 min- family’s daily schedule. But children who were scheduled to see a primary utes, may account for nearly one- may need active, unstructured, out- care clinician on a return visit to an fourth of patients who present to door play to develop attention, affil- urban general medicine clinic. Study emergency departments with chest iation, and affect. Until recently, participants received clinical assess- pain. Antidepressant drug therapy play was a spontaneous activity in ment and chart review. The preva- alone is highly effective in reducing which children could occupy them- lence of positive screening results for panic severity and number of attacks,

56 The Nurse Practitioner • Vol. 30, No. 6 www.tnpj.com Literature Review

and tricyclic antidepressants and selective serotonin re- for FOBT as the sole method of colon cancer screen- uptake inhibitors show equal effectiveness. Choice of ing. In addition, after a positive FOBT result, many drug is based on side effect profile, patient preference physicians report they perform either a follow-up and cost. Drug therapy should be continued for 6 FOBT or a sigmoidoscopy rather than going directly months after the patient is symptom-free before consid- to a colonoscopy as recommended. To effectively ering medication withdrawal with monthly monitoring screen for colorectal cancer, providers should recom- for relapse. Cognitive behavior therapy, which includes mend FOBT on six samples obtained at home or an- cognitive restructuring, exposure in vivo and through other type of screening test. Providers who rely on a imagery, and relaxation and breathing retraining, im- single office FOBT sample will miss 95% of advanced proves panic symptoms and overall disability. Providers neoplasia. may choose to refer patients to an experienced cognitive In the Rockey et al study, the authors recruited 614 behavior therapist. Self-help videotapes or reading mate- patients who had positive FOBTs, iron deficiency ane- rials are effective, but less so than cognitive behavior mia, or a family history of colon cancer. Patients under- therapy. went an air contrast barium enema (ACBE) followed a week later by computed tomographic colonography (CTC) and colonoscopy on the same day. The ability of these tests to detect colon polyps and cancers were re- ported. For lesions 10 mm or larger in size (n = 63), the sensitivity of ACBE was 48%, CTC 59%, and colonoscopy 98%. For lesions 6 to 9 mm in size, sensitiv- ity was 35% for ACBE, 51% for CTC, and 99% for ONCOLOGY colonoscopy. Colonoscopy is more sensitive than either ACBE or CTC to detect colon polyps. ■ Screening for Colon Cancer Collins JF, Lieberman DA, Durbin TE, et al and the Veterans Affairs Cooperative Study #380 Group: Accuracy of screening for fecal occult blood on a single stool sample obtained by digital rectal examination: a comparison with recommended sampling practice. Ann Intern Med 2005;142(2):81-5. Nadel MR, Shapiro JA, Klabunde CN et al: A national survey of primary care physicians’ methods for screening for fecal occult blood. Ann Intern Med 2005;142(2):86-94. Sox HC: Office-based testing for fecal occult blood: do only in case of emergency. Ann Intern Med 2005;142(2):146-8(editorial). Rockey DC, Paulson E, Niedzwiecki D, et al: Analysis of air con- trast barium enema, computed tomographic colonography, and colonoscopy: prospective comparison. Lancet 2005;365(9456):305-11. The study by Collins and colleagues is the first to evalu- ate whether a single office-based fecal occult blood test (FOBT) has any screening value. In a population of asymptomatic male veterans 50 to 75 years of age, there was a 10.6% prevalence of advanced neoplasia (adenoma >10 mm, dysplastic or villous adenoma, or invasive can- cer). Fecal occult blood tests done at home (2 samples from each of 3 stools) identified 24% of the neoplasia found on colonoscopy. A FOBT on a single sample of stool obtained by digital rectal examination only de- tected 4.9% of the patients with advanced colonic neo- plasia. Nadel and coauthors report that one-third of physicians use a single sample obtained in the office

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