Most patients who undergo anterior cruciate ligament (ACL) reconstruction with a hamstring graft experience a loss of sensation, also referred to “hypoesthesia,” in the lower leg region after the operation, according to findings reported in the International Journal of Sports Medicine.

The results also indicate that using an oblique incision rather than a vertical one to remove the graft does not prevent this complication or reduce the affected area.

Ligaments are strong, dense structures made of connective tissue that stabilize a joint. The ACL is one of the strongest ligaments in the body, connecting bone to bone and stabilizing the knee joint. It is commonly injured or torn, often as a result of a sports injury. The injury is often repaired by transplantation of a new graft to the site of the injury.

The current study involved 50 patients who underwent ACL reconstruction with a hamstring graft, including 25 patients who underwent a vertical incision and 25 who had an oblique incision.

“We showed that hypoesthesia is a very common complication, but fortunately we found it not to be associated with poor knee function,” lead author Dr. Janni Kjaergaard, from Randers Hospital in Denmark, told Reuters Health. Furthermore, the area of hypoesthesia had decreased by 46.3 percent at 1 year of follow-up.

Kjaergaard also noted that “we had hoped to find an advantage of the oblique incision parallel to the nerve. We were surprised not to find any difference at all.”

Hypoesthesia of the lower leg following ACL reconstruction is a result of injury to the branch of the saphenous nerve that passes through the front of the knee. The researchers thought that making the incision parallel to the branch might avoid this complication.

“This study demonstrates that hypoesthesia is a common complication after ALC surgery using hamstring grafts. The preoperative patient information should, therefore, include the risk of hypoesthesia in the infrapatellar region,” Kjaergaard said.

Patients and physicians should also be aware that the hypoesthesia does not affect knee function and that it decreases over time, the investigators add.

SOURCE: International Journal of Sports Medicine, June 2008.

Maintaining proper blood sugar levels after heart surgery is essential, whether one is or isn’t a diabetic, a new study shows.

The British report, published in Circulation, shows that poor blood sugar control in post-heart surgery patients is linked to a fourfold increase in death and major complications, such as heart attack, neurological, kidney, lung and gastrointestinal injury.

The research, involving 9,000 heart surgery patients, was conducted by a team at the University of Bristol in the U.K. More than half of the patients who developed moderate to poor blood sugar control after surgery were not thought to be diabetic, the researchers found.

Diabetes has long been tied to post-heart surgery problem. Many advances in operative and intensive care techniques for diabetic heart patients have been implemented in recent years.

“Currently, the absence of recognized guidelines is creating confusion on how to face the challenge of clinical conditions other than diabetes leading to derangement of glucose metabolism. The lack of rigorous research in this field does not help,” lead researcher Raimondo Ascione, reader and consultant in Cardiac Surgery at the Bristol Heart Institute, said in a news release issued by the university.

He called for doctors to issue strict protocols to actively manage blood sugar in all patients admitted for major surgery.

Peter Weissberg is medical director of the British Heart Foundation, which co-funded the study. In the same news release, he noted that, “while previous research has shown blood sugar levels have an important impact on the outcome of patients suffering a heart attack, this study shows for the first time the same may also be true for patients undergoing heart surgery.

“This research provides the basis for further, in depth studies to try to understand how better sugar control can help save more lives during and after heart surger,” he said.

Men who thought they had a lower risk of dying from heart disease turned out to be right over the next 15 years, no matter what their conventional risk factors showed.

The death rate for men who had the optimistic point of view was only one-third that of those who listed themselves as being at average risk, said the report in the July/August issue of the Annals of Family Medicine.

But the happy result of an upbeat outlook was not seen among the women in the study. The cardiovascular death rate was the same for women who listed themselves as having below-average risk as for those who said they were at average risk.

The lesson of the study isn’t that men can cheerfully ignore what their doctors tell them about risk factors such as cholesterol, smoking and obesity, said Dr. Robert Gramling, who led the study while at Brown University. He now is assistant professor of family medicine at the University of Rochester, in New York.

It does say that physicians could do a better job of describing risk factors and what to do about them, Gramling said.

“In medical systems, we often have a pessimistic bias,” he said. “We use normative language, telling people their risk might be high. Using the Framingham Heart Score places a fair amount of people into the categories of high or very high risk. After the age of 40, 80 percent might be viewed as at high risk.”

That is how a physician would see it, but it is a question “of how we communicate uncertainty to patients about different aspects of medical care,” he said.

A high-risk classification often strikes fear, “and I would suggest that fear-based prevention, meaning making changes based on fear, is not as helpful as holding an optimistic view,” Gramling said. “We should focus on helping make changes easy to do, rather than on making people more fearful.”

The failure to see a similar effect in women can be explained by the era in which the study was started — the early 1990s, when the focus was entirely on the risk of cardiovascular disease for men, he said.

Today, it is widely known that cardiovascular disease is the leading cause of death for American women as well as men, Gramling said. “So, in men, you got more of a fear response,” he said. “In women, being at higher risk was not as threatening. That might not be true any more.”

Gramling is working along the same lines at Rochester. “The next step is to test under what conditions holding an optimistic view is most helpful and under what conditions it is not helpful,” he said.

Meanwhile, there is no harm in feeling cheerful about cardiovascular health, as long as you follow the advice about the value of a good diet, exercise, blood pressure control and the like, Gramling said.

Another report in the same issue of the journal described a helpful outcome of combined treatment for high blood pressure and depression. A study of 64 adults found that those who had drug therapy for both conditions simultaneously achieved lower blood pressure level and were more likely to take their antidepressant drugs on schedule, according to physicians at the University of Pennsylvania.

New research suggests that there may be a “disconnect” between patients and hospitals when it comes to reporting adverse events that occur during hospitalization.

In a study of 998 recently hospitalized adults, interviews conducted months after hospitalization identified 21 serious and preventable events that were not documented in the medical record.

“Hospitals should consider monitoring patient safety by adding questions about adverse events to post-discharge interviews,” Dr. Joel S. Weissman, from the Massachusetts Executive Office of Health and Human Services in Boston, and colleagues conclude.

The study, which is reported in the Annals of Internal Medicine, involved a random survey of patients discharged from Massachusetts hospitals from April 1 to October 1, 2003. The interviews took place 6 to 12 months after discharge.

Overall, 23 percent of subjects had at least one adverse event identified during the post-discharge interview. A review of the hospital records, by contrast, documented an adverse event for only 11 percent of patients.

Statistical analysis confirmed the poor agreement between the medical record and post-discharge interview in identifying adverse events in general. A slightly better agreement was seen for the detection of serious or life-threatening events.

SOURCE: Annals of Internal Medicine, July 2008.

Elderly people who bring along a companion when they visit their doctor may be more satisfied with the care they receive than those who go it alone, a study indicates.

“Patients’ visit companions, hidden, but in plain sight, are a valuable quality of care resource whose efforts, if further optimized, could enhance the experience of care for millions of vulnerable Americans,” conclude Drs. Jennifer L. Wolff and Debra L. Roter, of the Johns Hopkins Bloomberg School of Public Health, Baltimore in a report published today in the medical journal Archives of Internal Medicine.

Among 12,018 Medicare beneficiaries aged 65 and older surveyed in 2004, Wolff and Roter found that roughly 39 percent reported regularly being accompanied to medical visits, most often by their spouse (53 percent) and grown children (32 percent), followed by other relatives (7 percent), roommates, friends or neighbors (5 percent), non-relatives (3 percent); or nurses, nurse aides or legal or financial officers (less than 1 percent).

Accompanied patients were older, less educated and in worse health than their unaccompanied counterparts.

Sixty-four percent of companions helped with communication by jotting down the doctor’s comments and instructions, sharing information about the patient’s medical condition with the doctor, asking questions and explaining doctor’s instructions.

More than half (52 percent) of the medical visit companions said they assisted with transportation, 28 percent said they were there for company and moral support, 17 percent to help schedule appointments and 8 percent to provide physical assistance.

According to Wolff and Roter, elderly individuals with regular companions on their trips to the doctor were more satisfied with their doctor’s technical skills, information-giving and interpersonal skills.

These findings, Wolff and Roter say, “establish that visit companions, most often spouses and adult children, are commonly present in older adults’ routine medical encounters, actively engaged in the exchange of health information between patients and their physicians and influential in patients’ perceptions of physician interpersonal rapport and information giving.”

SOURCE: Archives of Internal Medicine, July 14, 2008.

British children’s brain development is being threatened by their failure to work with their hands in school and at home, said a report released on Monday.

With woodwork, metalwork, craft, music or car mechanic classes dropped by many schools and children wanting to play computer games at home the UK is becoming a “software instead of a screwdriver society”, said the report, commissioned by the Ruskin Mill Educational Trust.

“Working with one’s own hands in a real-world 3-D environment is imperative for full cognitive and intellectual development,” said the report’s author Dr. Aric Sigman.

“Research is showing that increasing time spent in the virtual world of computers is displacing hands-on play and hands-on learning.

“That allows young people to experience how the world works in practice, to gain an understanding of materials and processes and to make informed judgments about abstract concepts.”

The report cited examples of 11-year-olds with deficits in certain areas of their cognitive development and a decline in the ability of young engineers and apprentices to conceptualise straightforward mechanical problems.

“The findings of this report clearly point to strengthening the role of ‘3-D’ learning and crafts in educational policy-making today,” said Sigman.

“The implications for the economy are significant and will actually improve the workforce’s ability to use computers in research, design and development.

“But parents too have a responsibility to ensure their children have more of a ‘hands-on’ upbringing.”

Sigman also warned class-obsessed Britons needed to drop their snobbish attitude to hands-on vocational training within schools.

“Working with your hands is considered declasse and the sciences are often seen as ‘trade’”, said Dr. Sigman.

Young adults with the borderline high blood pressure called prehypertension are more likely later in life to have calcium deposits in their coronary arteries, a new study finds.

“They’re too young to have very many heart attacks and strokes,” lead author Dr. Mark J. Pletcher said of the 3,560 participants whose ages were 18 to 30 when the study started. “But looking at coronary calcium is a way of measuring atherosclerosis, which is a strong predictor of heart attacks.”

Almost 20 percent of the people in the study developed prehypertension — which is blood pressure higher than the recommended 120 over 80 but below the 140 over 80 reading of treatable high blood pressure — before the age of 35. Coronary scans showed accumulation of calcium deposits in their heart arteries during the 20-year study.

“What we have shown is that these low-level elevations, above 120 over 80, appear to be associated with atherosclerosis later in life and probably with heart attacks and stroke,” said Pletcher, an assistant professor of epidemiology, biostatistics and medicine at the University of California, San Francisco.

The findings were published in the July 15 issue of the Annals of Internal Medicine.

“This is another bit of evidence that we should pay attention to prehypertension in young people,” said Dr. Richard B. Devereux, professor of medicine at Weill Cornell Medical College in New York City. He led a study several years ago of American Indians that found an association between prehypertension in early adulthood and abnormalities of the heart muscles.

“They used a totally different bioassay,” Devereux said of the San Francisco researchers. “It helps flesh out a more complete story.”

Prehypertension early in life is associated not only with development of atherosclerosis, the formation of plaques that can eventually block arteries, but also with arteriosclerosis, stiffening of the arteries, Devereux said.

The new study found hypertension more common in men, blacks, and people who were overweight and of low socioeconomic status. Participants with annul incomes below $25,000 and no college education were twice as likely to have early prehypertension as those with annual incomes of more than $100,000 and a postgraduate education.

Drug treatment isn’t a real option for prehypertension in young people, Pletcher said. “We don’t have evidence that treating prehypertension in young adulthood prevents cardiovascular disease, so we don’t recommend it,” he said.

But physicians should pay attention to borderline high blood pressure in young people, and should recommend preventive measures if it is found, Pletcher said.

“We recommend lifestyle modifications, more exercise, better diet, and so on, to improve cardiovascular health,” he said.

Devereux agreed. “Exercise, better diet, getting away from smoking, avoiding things which can be damaging to the arteries,” he advised.

Men and women with early-stage Alzheimer’s disease who were more physically fit also had larger brains compared to their counterparts in less stellar shape.

The findings, though preliminary, may indicate that staying physically fit could slow the brain atrophy (shrinkage) associated with Alzheimer’s disease. Or they may indicate that some common underlying process affects both brain atrophy and cardiorespiratory fitness.

“This is a valid, reliable comparison, [but] it’s cross-sectional, it provides only a snapshot of fitness as it relates to brain volume,” said Dr. Gary Kennedy, director of geriatric psychiatry at Montefiore Medical Center in New York City. “We can’t say if increased fitness increases brain volume. Animal models show this is possible. This sets the stage for an interventional study.”

The findings are published in the July 15 issue of Neurology.

In older adults without dementia, staying in good physical shape may help offset the changes in the brain, such as cognitive decline, associated with normal aging.

But experts have not yet clearly defined whether or not physical activity has an effect on those with Alzheimer’s.

“We’re interested in how exercise impacts the Alzheimer’s disease process. There’s a lot of data in normal older adults that exercising and fitness may have a beneficial effect on brain health, but there’s not a lot on Alzheimer’s in terms of studies to draw on to inform our recommendations for exercise and fitness,” said study author Dr. Jeffrey Burns, director of the Alzheimer’s and Memory Program at the University of Kansas School of Medicine in Kansas City. “We’re interested in better defining that relationship.”

For this study, 57 people with early-stage Alzheimer’s and 64 people without dementia, all aged 60 and over, underwent standard fitness tests and MRI brain scans.

“We used an objective, gold-standard measure of fitness which hadn’t been assessed in Alzheimer’s patients yet, cardiorespiratory fitness, or VO2 peak, where we basically measure how much work someone is capable of doing,” Burns explained.

Participants walked on a treadmill while their oxygen consumption was measured. “At their peak, how much oxygen they’re consuming is a measure of how physically fit they are,” Burns said.

MRI scans measured brain atrophy.

The VO2 peak was slightly lower in people with Alzheimer’s compared to controls. And individuals with Alzheimer’s who were less physically fit had quadruple the amount of brain shrinkage compared to normal older adults.

“The people with higher fitness levels had larger brains, and there was a strong correlation between the two,” Burns explained. “We’re limited because of the study design, but it could suggest that maintaining fitness may have a beneficial effect on the Alzheimer’s disease process.”

“We didn’t find fitness to be associated clearly with cognitive performance, but that may be, because we need to study more people or the cognitive performance measures may not be sensitive enough,” he added.

The study pointed to three possible explanations for the relationship: cardiorespiratory fitness affects brain atrophy related to Alzheimer’s disease; the Alzheimer’s disease process affects fitness; or some other, as-yet-unknown factor underlies both Alzheimer’s-related brain atrophy and physical fitness.

“We’re designing a study where we try to establish the cause and effect,” Burns said. “Can we use exercise to enhance fitness in Alzheimer’s disease and, by doing that, will it affect disease progression?”

Although it may take several weeks for elderly patients to recover from joint replacement surgery, excellent long-term outcomes are often seen, new research indicates.

The goal of the study, reported in the Archives of Internal Medicine, was to clarify the risks and benefits of hip or knee replacement surgery in elderly patients.

Dr. Mary Beth Hamel, from Beth Israel Deaconess Medical Center in Boston, and colleagues examined the outcomes of 174 patients, 65 years of age or older, with severe osteoarthritis of the hip or knee who were followed for 12 months. During follow-up, 29 percent of the patients underwent joint replacement surgery.

None of the surgical patients died, but 17 percent had postoperative complications and 38 percent had pain that lasted longer than 4 weeks. Moreover, it took patients an average of 12 days to recover independence in walking and 49 days to regain the ability to perform household chores.

No differences in these recovery times were noted between patients younger than 74 or those aged 75 or older.

Overall, the surgical patients experienced a 24-point improvement on a standard osteoarthritis function test compared with just a 0.5-point improvement in nonsurgical patients.

Forty-five percent of the non-surgical patients said that joint replacement surgery was never discussed as a treatment option, the report indicates.

“Our findings of excellent outcomes from joint replacement surgery in elderly patients with severe hip or knee osteoarthritis corroborate and extend the findings of previous studies,” the investigators conclude.

“These data should help inform discussion about joint replacement surgery and allow patients to consider the risks and benefits of surgery as well as the expected postoperative recovery experience.”

SOURCE: Archives of Internal Medicine, July 14, 2008.

One of the country’s leading sports doctors reports that he’s performing more surgeries on sprained elbows in young athletes, a fact that reflects higher numbers of children focusing on just one sport.

The findings suggest that more young athletes are specializing only in baseball and putting their arms at risk, said co-author Dr. E. Lyle Cain, fellowship director for the American Sports Medicine Institute at the Andrews Sports Medicine & Orthopaedic Center, in Birmingham, Ala.

“Sports specialization at a young age encourages overuse,” Cain said. “The bodies of athletes have no chance to rest and recover.”

The good news: The surgeon who did the study, Dr. James Andrews, reported that 83 percent of his patients who underwent surgery recovered well enough to return to playing sports.

At issue are injuries to the ulnar collateral ligament, or UCL. It’s a tiny ligament — just a half-inch long — that’s crucial to keeping the elbow stable when a person throws something, Cain said.

In some cases, the ligament tears or becomes stretched out. “The patient generally has pain, and they lose the ability to throw, lose velocity,” Cain explained.

The injury strikes baseball pitchers and other athletes who throw or swing their arms, such as tennis players, javelin throwers, quarterbacks and weightlifters.

“It’s pretty common,” said Dr. Robert Gotlin, director of Sports Rehabilitation with Beth Israel Medical Center in New York City. “Any particular league anywhere in the country is going to see injuries to the UCL but not necessarily requiring surgery.”

Before the mid-1970s, the injuries ended athletic careers if they didn’t heal. But a form of reconstructive surgery first performed on Hall of Fame baseball pitcher Tommy John has allowed many athletes to continue playing.

Surgeons typically replace the damaged ligament with ligament from another part of the arm or the leg, Cain said.

In the new study, released Saturday at the American Orthopaedic Society for Sports Medicine annual meeting, in Orlando, Fla., researchers looked at athletes treated by Andrews between 1988 and 2006. The study, said to be the largest of its kind, focused on 743 patients who were followed for at least two years after their surgeries; almost all were baseball players. Eighty-three percent were able to return to the same level of play or higher.

The researchers also found that surgeries on athletes 18 and younger are becoming more common. They made up 12 of 97 patients before 1997, according to Cain. But high school students made up 62 of 188 operations in 2005.

“There’s no question that this comes from specialization in single sports” in recent years, Cain said. “Even 10 to 15 years ago, it was uncommon for a young athlete to pick one sport at a young age and focus on that sport.”

Gotlin said the study is useful, but he cautioned that “in the best of all worlds, we’re talking about a 75 to 80 percent success rate.”

What to do? “We should encourage young kids and athletes to cross train,” Cain said. “There’s no good reason for an 8-year-old child to play baseball year-round and specialize in baseball.”