External pneumatic compression does not increase urokinase plasminogen activator after abdominal surgery

External pneumatic compression (EPC) devices prevent lower extremity deep venous thrombosis (DVT) by reducing stasis. There is a widely held belief that they also enhance endogenous fibrinolysis; however, recent studies of tissue plasminogen activator (the primary activator of fibrinolysis) and plasminogen activator inhibitor-1 (the primary inhibitor of fibrinolysis) failed to confirm this. The hypothesis of this study was that EPC devices increase the level of urokinase plasminogen activator (uPA), a second activator of fibrinolysis. This was a prospective trial in which 44 subjects who underwent major abdominal surgery were randomized to receive unfractionated heparin injections, thigh-length sequential EPC devices, or both for DVT prophylaxis. Prophylaxis was begun immediately before surgical incision and continued until postoperative day 5 or discharge. Venous blood samples were collected from an antecubital vein for measurement of systemic uPA levels and from the common femoral vein for measurement of regional uPA levels. Samples were collected the day before surgery, after induction of anesthesia but before surgical incision, and on postoperative days 1, 3, and 5. uPA levels (ng/mL) were measured with an enzyme-linked immunoassay. Baseline uPA levels (0.41 to 0.56 ng/mL; P >.05, analysis of variance with repeated measures) were similar among the three groups. uPA levels did not change after surgery in systemic or regional blood samples in any group. There were no significant differences in systemic or regional uPA levels in the groups treated with EPC devices relative to those treated with heparin at any time point (P >.05, analysis of variance with repeated measures). Enhancement of fibrinolysis with EPC devices remains unproven; the findings reported here suggest that effective DVT prophylaxis can only be assured when the devices are used in a manner that reduces venous stasis.     

Double-knot transscleral suture fixation technique for displaced intraocular lenses

PURPOSE: To describe a simplified new technique for repositioning and attaching a suture to the haptic of a displaced posterior chamber intraocular lens (IOL). METHODS: We describe a double-knot technique for repositioning and transscleral suture fixation of a subluxed posterior chamber IOL after penetrating keratoplasty. Two 10-0 Prolene transscleral sutures on straight needles are passed around the IOL haptic, tied extraocularly, and used to secure the repositioned haptic of the IOL. A second knot ties the transscleral suture in the scleral bed, stabilizing the haptic in the ciliary sulcus. RESULTS: In the case described, the IOL was stable and well positioned 2 months after surgery. CONCLUSION: The double-knot technique for intraocular repositioning and transscleral suture fixation of displaced posterior chamber IOLs reduces the extensive intraocular manipulation and scleral incisions required for IOL exchange and may reduce chronic irritation associated with iris fixation.     

Intestinal pseudo-obstruction as an initial presentation of systemic sclerosis in two children

Two children are reported in whom intestinal pseudo-obstruction was the initial manifestation of systemic sclerosis. Gastrointestinal symptoms and skin changes resolved or improved in both children following treatment with prednisone and penicillamine (case 1) or methotrexate (case 2), although radiological changes of the gastrointestinal tract persisted at 3 and 2 yr of follow-up, respectively.      

Robot-assisted epicardial ablation of the pulmonary veins: is a completed isolation necessary?

AIMS: To study the feasibility and electrophysiological efficacy of minimally invasive beating heart ablation of the pulmonary veins (PVs) via a robot-assisted single-sided approach. BACKGROUND: PV isolation by minimally invasive epicardial ablation may offer a new treatment for patients with lone atrial fibrillation (AF). However, complete PV isolation has been shown to be difficult to obtain. METHODS AND RESULTS: In 14 mongrel dogs, robot-assisted epicardial microwave ablation was performed on the beating heart by a single-sided right chest approach. Isolation of all PVs was performed in two steps to study the effect of an incomplete and a complete isolation on AF. AF was studied by random and burst pacing. Incremental pacing was performed to study conduction characteristics across the lesions. Opening of the pericardial reflections, introduction of the catheter and ablation were robotically feasible by a single-sided approach in 11 dogs. The AF duration decreased from 6.6+/-4.1 to 1.3+/-0.8 s (P=0.03) and 1.6+/-1.6 s (P=0.04 compared with control) after incomplete and completed isolation of the PVs. The AF cycle length increased from 134+/-5 to 141+/-5 and 145+/-8 ms (P=0.03) after incomplete and complete isolation, respectively. Several incomplete lesions showed 2:1 exit and/or entrance block during incremental pacing. After complete isolation, AF was no longer inducible from the PVs. CONCLUSION: Epicardial PV isolation can be successfully performed by a single-sided robot-assisted approach. The effect of PV ablation on AF is not an all or none phenomenon. Incomplete isolation already decreases AF duration and lengthens the AF cycle length. However, complete isolation is necessary to prevent AF induction by triggering from the isolated area.