Perioperative Dietary Restriction of Carbohydrates in the Management of Blood Glucose Levels in Patients Undergoing Total Knee Replacement.

BACKGROUND: Approximately 75% of the US population over 65 years has prediabetes or diabetes. Despite current evidence for the efficacy of carbohydrate restriction in managing blood glucose, this practice has not been implemented as part of routine perioperative blood sugar management. We hypothesize that a carbohydrate reduced hospital diet (CRD) of 135 g/d may improve blood sugar levels following total knee arthroplasty (TKA) compared to a non-carbohydrate reduced hospital diet (NCRD). METHODS: We randomized non-insulin-dependent prediabetic and diabetic patients undergoing TKA to either an NCRD or a CRD. Sixty-four patients were enrolled in the study and 2 were excluded, leading to 62 patients in the final analysis. The NCRD group included 14 females (47%) and 16 males (53%), with mean age of 68.5 years (±6.3 years). The CRD group included 16 females (50%) and 16 males (50%), with mean age of 68.0 years (±8.0 years). For hemoglobin A1C, the NCRD group had mean 5.8% (±0.6%) and the CRD group had mean 5.7% (±0.8%). For body mass index, the NCRD group had mean 29.3 kg/m2 (±6.3 kg/m2) and the CRD group 32.7 kg/m2 (±5.0 kg/m2). The primary outcome measure was mean blood glucose. RESULTS: Mean blood sugar values during hospital stay were significantly lower in the CRD group with 121.5 mg/dL (±17.1 mg/dL) compared to the NCRD group 141.2 mg/dL (±31.3 mg/dL, P = .0031). CONCLUSION: Blood sugar levels after surgery can be significantly reduced with a CRD. Further research is necessary to study the effect of reduced blood sugar levels on complications and infection rates following TKA surgery. LEVEL OF EVIDENCE: I.

Thoracoscopic Left Atrial Appendage Exclusion for Atrial Fibrillation Patients Intolerant to Anticoagulation.

OBJECTIVE: Outcomes associated with isolated epicardial left atrial appendage (LAA) exclusion in atrial fibrillation (AF) patients with a contraindication or intolerance to anticoagulation are not clearly defined, especially in patients with prior stroke. This study evaluated the perioperative safety, medication use, and stroke outcomes for isolated thoracoscopic LAA exclusion for stroke prevention. METHODS: A single-center retrospective study was performed of adults undergoing isolated thoracoscopic LAA exclusion with an epicardial exclusion device without a concomitant surgical procedure. Descriptive statistics were performed. RESULTS: Twenty-five patients met the inclusion criteria. The cohort was 68% male (n = 17) with a mean age of 76.4 ± 6.5 years, a mean preoperative CHA2DS2-VASc score of 4.2 ± 1.4, and a mean preoperative HAS-BLED score of 2.68 ± 1.03. Seventeen patients (68%) had nonparoxysmal AF. There were 11 patients with intolerance of anticoagulation due to intracranial hemorrhage (44%), 6 due to gastrointestinal bleeding (24%), and 4 due to genitourinary bleeding (16%). All procedures were performed thoracoscopically with 100% technical success-the mean LAA stump length was 5.5 ± 2.3 mm on intraoperative transesophageal echocardiography. The median hospital length of stay was 2 (interquartile range [IQR] 1, 6.5) days. The median follow-up time was 430 (IQR 125, 972) days. During follow-up, 1 patient with cerebral angiopathy had temporary neurologic deficits at an outside institution, with brain imaging showing no evidence of ischemic injury. There were no other thromboembolic events over the 38.8 postoperative patient-years examined. All patients were off anticoagulation at last follow-up. CONCLUSIONS: This study shows the perioperative safety, technical success, freedom from anticoagulation, and stroke outcomes of isolated thoracoscopic LAA exclusion in patients with AF at high risk for thromboembolic disease.

Not Everything That Shakes Is a Seizure: A Case Report.

Not everything that shakes is an epileptic seizure. We present a patient who repeatedly exhibited severe shaking at emergence from general anesthesia. Her nonepileptic myoclonus was mistaken for a refractory seizure and treated with benzodiazepines and intravenous anesthetics. The resulting depressed level of consciousness rendered myoclonus clinically indistinguishable from refractory seizures. Over the course of 6 procedures, we found that levetiracetam, a first-line antiepileptic drug, effectively suppressed her myoclonus. The episodic nature of perioperative anesthesia care presents a challenge for differentiating myoclonus from seizure while balancing the concerns raised by different surgical procedures, rare comorbidities, and the subjective patient experience.

Supply-and-demand discrepancy in academic pigmented lesion clinics: a case for a new health care delivery model.

IMPORTANCE: There is an increasing demand for a limited number of pigmented lesion clinic (PLC) visits at dermatology centers. OBJECTIVE: To determine the proportion of visits to PLCs that are more frequent ("additional screening") than the recommended ("standard") follow-up schedule and to determine if certain patient characteristics correlate with the demand for these visits. DESIGN, SETTING, AND PARTICIPANTS: A retrospective medical chart review of all PLC visits at an academic dermatology center from October 2010 to January 2012. A total of 609 patients associated with 1756 visits were identified. Of these, 25 patients associated with 26 visits were excluded owing to lack of melanoma diagnosis or risk factors, leaving 584 patients and 1730 visits. Diagnoses of these patients included in situ and invasive melanoma, dysplastic nevi, Spitz nevi, atypical nevus syndrome, family history of melanoma only, and other risk factors. The mean (SD) age was 48 (16) years, and 235 (40.2%) of the patients were male. MAIN OUTCOMES AND MEASURES: The proportion of additional screening visits compared with standard visits. Standard visits were defined as occurring at the following frequencies: annually for mildly dysplastic nevi, Spitz nevi, or solely family history of melanoma; biannually for the first year, then annually thereafter for moderately dysplastic nevi or atypical nevus syndrome; biannually for up to 3 years, then annually thereafter for severely dysplastic nevi or melanomas in situ; every 3 months for 2 years, biannually for the following 2 years, then annually thereafter for invasive melanoma. RESULTS: A total of 1400 visits (80.9%) were standard, 257 (14.9%) were for additional screening, and 73 (4.2%) were "problem focused." Thirty percent of patients had at least 1 additional screening visit. The distribution of diagnoses among standard vs additional screening visits differed significantly, with "family history only" and "other risk factors" taking up a larger percentage of standard visits (15.1%) than the percentage of additional screening visits (8.9%), and all other diagnoses being better represented among additional screening visits (P = .04). No particular patient characteristic described those who sought additional screening visits. CONCLUSIONS AND RELEVANCE: A substantial proportion of additional screening PLC visits exist and are desired by all patients with pigmented lesions. We propose alternative clinic models, such as diagnosis-specific, adjunctive fee-for-additional-service, and teledermatology clinics to meet patient needs while creating resources to expand PLC visits.