May 2004 (Part II)

Continued from previous page Surgeons Who Play Video Games Err Less All those years on the couch playing Nintendo and PlayStation appear to be paying off for surgeons. Researchers found that doctors who spent at least three hours a week playing video games made about 37 percent fewer mistakes in laparoscopic surgery and performed the task 27 percent faster than their counterparts who did not play video games. I use the same hand-eye coordination to play video games as I use for surgery, said Dr. James Butch Rosser, 49, who demonstrated the results of his study Tuesday at Beth Israel Medical Center. Rosser said the skill needed for laparoscopic surgery is like tying your shoelaces with 3-foot-long chopsticks. Yes, here we go! said Rosser, sitting in front of a Super Monkey Ball game, which shoots a ball into a confined goal. This is a nice, wholesome game. No blood and guts. But I need the same kind of skill to go into a body and sew two pieces of intestine together. The study on whether good video game skills translate into surgical prowess was done by researchers with Beth Israel and the National Institute on Media and the Family at Iowa State University. It was based on testing 33 fellow doctors 12 attending physicians and 21 medical school residents who participated from May to August 2003. Each doctor completed three video game tasks that tested such factors as motor skills, reaction time and hand-eye coordination. The study landmarks the arrival of Generation X into medicine, said the study’s co-author, Dr. Paul J. Lynch, a Beth Israel anesthesiologist who has studied the effects of video games for years. Kurt Squire, a University of Wisconsin researcher of video game effects on learning, said that with a video game, you can definitely develop timing and a sense of touch, as well as a very intuitive feel for manipulating devices. Squire, who was not involved in Rosser’s project, said applying such games to surgery training could play a key role in preparing medical health professionals. Beth Israel is now experimenting with applying the findings. Rosser has developed a course called Top Gun, in which surgical trainees warm up their coordination, agility and accuracy with a video game before entering the operating room. It’s like a good football player, Rosser said, you have to warm up first. Number of Breaths Given During CPR May be Linked to Survival Researchers have identified a factor that may improve cardiac arrest survival rates, according to a study of paramedic responses. Researchers found that some ambulance crews giving cardiopulmonary resuscitation (CPR) exceeded the American Heart Association’s recommendation of 12 to 15 breaths per minute when treating cardiac arrest victims. The overall survival rate in the United States from cardiac arrest is about 5 percent, said researcher Tom P. Aufderheide, MD, professor of emergency medicine at the Medical College of Wisconsin in Milwaukee. Excessive ventilation may be contributing to that poor outcome. The observational study included 13 cardiac arrest victims. Examining data from the first seven patients, the researchers found the average maximum ventilation rate was 37 breaths a minute, roughly 250 to 300% greater than the rate the American Heart Association recommends. After a CPR retraining program was instituted, the average ventilation rate for the next six patients dropped to 22 breaths per minute. He suggested one solution might be to use a system that flashes a light every five seconds to let a rescuer know when to deliver another breath of oxygen. The decreased return of blood to the heart reduces the blood going out of the heart, and that may decrease the effectiveness of CPR. Aufderheide said. Medical directors of all systems all professional rescuers, including EMTs, nurses, doctors, respiratory therapists and anyone else who would do CPR as part of their profession need to get this message: Do not hyperventilate, he said. Although the small study focused on cardiac arrests in only one city, the researchers strongly believe that hyperventilation could occur nationwide. As a result of their findings, the researchers urge that all hospitals and emergency medical services assess whether hyperventilation is a problem in their units. If it is, they suggest reducing ventilation during CPR to 12 breaths a minute. Angioplasty, Stenting Linked to New Eye Condition Japanese researchers describe a new abnormality of the retina that can occur in patients who have undergone angioplasty or stenting. The eye disorder seems to clear up spontaneously without treatment a few weeks after the heart procedure. Dr. M. Kawakami and colleagues, from Jichi Medical School in Saitama, first became aware of the condition after noticing cotton wool spots around the retina of a heart attack patient who had received a coronary stent. This led the researchers to examine the retinas of similar patients. Among 40 patients screened, 30 had been treated for a heart attack and 10 for stable chest pain. Eye exams began three days after their procedures and continued for up to three months. Seventeen of the heart attack patients developed the eye condition, which was most apparent at 1 to 2 months. Seven of these patients also developed superficial bleeding in the retina. Although none of the affected patients had objective evidence of visual impairment, four complained of blurred or distorted vision. In most patients, the condition subsidedafter a few weeks, but in six patients it persisted for more than 3 months before resolving. None of the patients with stable chest pain had the abnormality, the investigators report. Kawakami’s team says that if doctors are not aware that this benign condition can occur in heart attack patients after they’ve been treated, it might lead to unnecessary invasive examinations. Hormone May Cut Heart Attack Risk Men with high levels of a hormone secreted by fat cells run a lower risk of a heart attack, according to a study that could lead to new ways to prevent or treat heart disease. The findings follow animal studies showing that high levels of the hormone adiponectin help diabetic mice make better use of insulin. Adiponectin, discovered a few years ago, is a new kid on the block and pharmaceutical companies already are racing to develop treatments that take advantage of its beneficial properties, said Dr. Robert Eckel, an American Heart Association spokesman. While the results are too preliminary to warrant routine blood tests to measure adiponectin levels, ultimately, this could have very practical value, said Eckel, who is conducting similar research but was not involved in the study. The study involved 18,225 men ages 40 to 75 who had blood tests and were followed for about six years. During the follow-up, 266 men had nonfatal heart attacks or died of heart disease. Men with the highest initial blood levels of adiponectin were 40 percent less likely to have heart attacks or die of heart disease than men with the lowest levels. The study was led by Dr. Tobias Pischon of the Harvard School of Public Health. Pischon said the hormone is believed to help keep fats from accumulating in arteries. There is also evidence that it might help reduce inflammation. Although the hormone is produced by fat cells, obese people have reduced levels of it, Pischon said. Blood tests to detect adiponectin are not widely available, he said. Eckel said it is unclear whether knowing a patient’s adiponectin levels would help guide treatment decisions. For example, losing weight helps increase adiponectin levels, but weight loss already is recommended to help prevent heart problems. Heart Attack Hospital Stays Decline, Study Finds Patients recovering from severe heart attacks in the United States are kept in hospitals less than a week, compared to stays of more than six weeks in the 1950s, researchers said. But the change has not been accompanied by higher death rates after discharge, researchers at the University of Massachusetts Medical School in Worcester said. Much of the observed decline in hospital length of stay may be attributed to improvements in the management of acute myocardial infarction, including increased use of coronary reperfusion modalities, said the report. Today's hospital stay for an acute heart attack without ensuing complications averages five days, the study said. The findings were based on a look at 4,551 patients discharged from a number of Massachusetts hospitals between 1986 and 1999. Early in the study patients were averaging 11.7 days, a figure which had declined to 5.9 in later years, the study said. Patients who stayed longer were more likely to be older, female and have cardiac complications. In the 1950s, prolonged bed rest and rehabilitation were prescribed, with stays of more than six weeks common. Atherosclerosis Linked with Depression The greater the degree of atherosclerosis, the more strongly it is tied to depression late in life, according to findings from a Dutch study. The vascular depression theory suggests that atherosclerosis of brain arteries can lead to clinical depression, but studies to date have not included actual measurement of atherosclerosis, Dr. Monique M. B. Breteler and colleagues explain. The group, based at Erasmus Medical Center in Rotterdam, the Netherlands, evaluated atherosclerosis in areas other than the heart in 4019 men and women who were 60 years of age or older. Ultrasound was used to measure thickening of the carotid artery, and the aorta was assessed by x-ray. Depressive symptoms were identified in 285 participants, and actual depression was confirmed in 119 of these individuals. More severe atherosclerosis, in both the carotid artery and the aorta, was associated with increased risk of a depressive disorder even when demographic factors and a prior heart attack were taken into account. Breteler’s group notes that their study doesn’t prove that atherosclerosis causes depression, and that it is possible depression and atherosclerosis are manifestations of a common underlying process. Longer Diabetes Means Higher Heart Risk Investigators found that for every 10 years a person has diabetes, his or her chance of developing heart disease increases by 38%. Furthermore, after 10 years of diabetes, the risk of dying from heart disease increases by nearly 90%. More studies are needed to determine why having diabetes for longer increases the risk of heart disease, Dr. Caroline Fox of the National Institutes of Health and her colleagues say. The findings come from a study of people with type 2 diabetes. New cases of the illness among people 30 to 39 have risen 70% in the last decade. Previous research has shown that people with type 2 diabetes are up to 3 times more likely to develop heart disease than non-diabetics. However, results of studies into whether having diabetes for longer puts people at higher risk of heart disease have been contradictory. During the current study, Fox and her colleagues reviewed information collected from 483 people participating in the Framingham Heart Study. Begun in 1948, the study has followed the heart health of thousands of residents of Framingham, Massachusetts, and their children. All participants were initially free of cardiovascular disease. Fox and her colleagues followed them for 12 years, noting who developed heart disease and how long they had had diabetes. Over the course of the study, 86 cardiovascular events occurred, including 36 deaths. Longer duration of diabetes appeared to increase the risk of both heart disease and dying from heart disease, Fox and her team report. Possible reasons for why more years with diabetes translates to a higher risk of heart disease include the fact that longer duration of diabetes may raise the risk of artery clogging, heart rate problems and cell damage, the researchers note. Long-Term Diabetes Control Pays Off for the Heart People with diabetes are urged to keep their blood sugar levels in check to avoid multiple complications down the road. While that can be tiresome day in and day out, the effort is rewarded in the long run, Norwegian researchers confirm. They have found that good long-term glucose control by type 1 diabetic patients preserves the automatic responses of the heart to varying situations, while a lack of adequate glycemic control leads to poor so-called cardiac autonomic function. Our findings confirm the important role of good glycemic control in the functioning of the autonomic nervous system in type 1 diabetes and validate after 18 years our findings from 8 years’ observation in the Oslo study, the investigators note. Dr. Jakob R. Larsen and colleagues from Ulleval University Hospital in Oslo followed 39 patients with type 1 diabetes for 18 years. For 14 of those years, the participants adhered to intensive insulin treatment, based on studies showing that tight glucose control can slow the development and progression of abnormal autonomic function. Levels of glycosylated hemoglobin an indicator of glucose control over a period of time were measured yearly, and the subjects underwent a battery of tests widely used to assess cardiac autonomic function, including heart rate responses to deep breathing, to being tilted into various positions, and maximal exercise testing. The investigators found that an average glycosylated hemoglobin level of less than 8.4 percent over 18 years was strongly associated with preserved cardiac autonomic function. Conversely, a level higher than that predicted impaired cardiac autonomic function. For all the cardiac function tests, values stayed within normal for participants with the lowest glycosylated hemoglobin levels but were pathological in those with the highest levels, Larsen’s team reports. Dysfunction of the cardiac autonomic nervous system increases the risk of death in diabetic patients, the researchers note, but the risk can be lowered by reining in blood glucose levels consistently. Cholesterol Imperils Many Diabetics Adults with type 2 diabetes who have just one additional risk factor for heart disease should be taking medication to lower cholesterol levels, according to new guidelines from the American College of Physicians (ACP). Dr. Vincenza Snow and members of the Clinical Efficacy Assessment Subcommittee of the ACP based their recommendations on the results of 12 lipid-lowering studies that contained information about outcomes for people with diabetes. Pooled data from the 12 studies indicated that statin drugs (e.g., Lipitor, Zocor or Crestor), along with another lipid-lowering agent gemfibrozil, lead to a greater than 20 percent reduction in major heart-related events in patients with diabetes. "This is life-saving information," Snow commented. "In addition to controlling blood sugar levels, people with diabetes may be surprised to know that they must also be vigilant about controlling their blood pressure and cholesterol levels." Snow, of the ACP in Philadelphia, and her team recommend lipid-lowering therapy for all patients with diabetes and known coronary disease. Such treatment is also advised for patients with any significant risk factor for heart disease, including age older than 55 years, high blood pressure, smoking, enlargement of the left ventricle of the heart, previous stroke, and peripheral arterial disease. The only patients with diabetes for whom these drugs seemed to provide little benefit were those with no risk factors for cardiovascular disease. The researcher also found that statins were extremely safe.

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