Efficacy and safety of extended duration to perioperative thromboprophylaxis with low molecular weight heparin on disease-free survival after surgical resection of colorectal cancer (PERIOP-01): multicentre, open label, randomised controlled trial.

OBJECTIVE: To determine the efficacy and safety of extended duration perioperative thromboprophylaxis by low molecular weight heparin when assessing disease-free survival in patients undergoing resection for colorectal cancer. DESIGN: Multicentre, open label, randomised controlled trial. SETTINGS: 12 hospitals in Quebec and Ontario, Canada, between 25 October 2011 and 31 December 2020. PARTICIPANTS: 614 adults (age ≥18 years) were eligible with pathologically confirmed invasive adenocarcinoma of the colon or rectum, no evidence of metastatic disease, a haemoglobin concentration of ≥8 g/dL, and were scheduled to undergo surgical resection. INTERVENTIONS: Random assignment to extended duration thromboprophylaxis using daily subcutaneous tinzaparin at 4500 IU, beginning at decision to operate and continuing for 56 days postoperatively, compared with in-patient postoperative thromboprophylaxis only. MAIN OUTCOME MEASURES: Primary outcome was disease-free survival at three years, defined as survival without locoregional recurrence, distant metastases, second primary (same cancer), second primary (other cancer), or death. Secondary outcomes included venous thromboembolism, postoperative major bleeding complications, and five year overall survival. Analyses were done in the intention-to-treat population. RESULTS: The trial stopped recruitment prematurely after the interim analysis for futility. The primary outcome occurred in 235 (77%) of 307 patients in the extended duration group and in 243 (79%) of 307 patients in the in-hospital thromboprophylaxis group (hazard ratio 1.1, 95% confidence interval 0.90 to 1.33; P=0.4). Postoperative venous thromboembolism occurred in five patients (2%) in the extended duration group and in four patients (1%) in the in-hospital thromboprophylaxis group (P=0.8). Major surgery related bleeding in the first postoperative week was reported in one person (<1%) in the extended duration and in six people (2%) in the in-hospital thromboprophylaxis group (P=0.1). No difference was noted for overall survival at five years in 272 (89%) patients in the extended duration group and 280 (91%) patients in the in-hospital thromboprophylaxis group (hazard ratio 1.12; 95% confidence interval 0.72 to 1.76; P=0.1). CONCLUSIONS: Extended duration to perioperative anticoagulation with tinzaparin did not improve disease-free survival or overall survival in patients with colorectal cancer undergoing surgical resection compared with in-patient postoperative thromboprophylaxis alone. The incidences of venous thromboembolism and postoperative major bleeding were low and similar between groups. TRIAL REGISTRATION: ClinicalTrials.gov NCT01455831.

Wait Times for Melanoma Surgery: Is There an Association with Overall Survival?

INTRODUCTION: Wait times for access to care have been of increasing interest to public health care officials, health care providers, and the public. There is a paucity of data determining whether extended wait times for melanoma surgery influence patient outcomes. This study measured the association of wait times to surgical treatment with overall survival in patients with melanoma. METHODS: Population-based health administrative databases were used to identify all Ontario adults diagnosed with melanoma between 2004 and 2011, time to various treatment modalities, and death dates. Proportional hazards modeling using time-dependent covariates was used to determine the adjusted association of time from melanoma diagnosis to various post-diagnostic surgical interventions with overall survival. RESULTS: A total of 2573 patients were included. The 5-year overall survival was 81.1% [95% confidence interval (CI) 79.1-83.0]. Of all patients, 82.9% underwent a wide local excision (WLE) with a median wait time of 43 days [interquartile range (IQR) 24-64], 29.1% underwent a sentinel lymph node biopsy (SNB) with a median wait time of 59 days (IQR 41-81), and 35.0% underwent a lymph node dissection (LND) with a median wait time of 63 days (IQR 43-91). After adjusting for age, sex, rural residence, and risk of mortality from comorbidities, wait times to WLE [hazard ratio (HR) 0.97; 95% CI 0.87-1.08; p = 0.62], SNB [HR 1.04; 95% CI 0.68-1.59; p = 0.86], and LND [HR 0.99; 95% CI 0.89-1.11; p = 0.92] were not associated with overall survival. CONCLUSIONS: Overall survival for patients with melanoma was not influenced by wait times to WLE, SNB, and LND.

Patient fire during dental care: A case report and call for safety.

BACKGROUND AND OVERVIEW: Fire risk is present whenever there is a convergence of fuel, oxidizer, and an ignition source, which is called the fire triangle. A heightened awareness of fire risk is necessary whenever a fire triangle is present. The authors provide a sentinel event case report of fire in a dental office. CASE DESCRIPTION: A 72-year-old woman received second-degree facial burns from a fire that ignited near the nasal hood supplying a nitrous oxide-oxygen mixture. The presumed ignition source was heat generated during the preparation of a titanium post with a high-speed, irrigated carbide bur. The patient was transferred to the local emergency department and subsequently discharged after possible pulmonary complications were ruled out. The patient was then transferred to a regional burn unit and was discharged home with second-degree burns. CONCLUSIONS AND PRACTICAL IMPLICATIONS: When the source of a fuel cannot be removed from the immediate area, soaked with water, or covered with a water-soluble jelly, the dentist should stop the open flow of oxygen or nitrous oxide-oxygen mixtures to the patient for 1 minute before the use of a potential ignition source, and intraoral suction should be used to clear the ambient atmosphere of oxidizer-enriched exhaled gas.

Clinical and pathological features of intraductal papillary neoplasm of the biliary tract and gallbladder.

BACKGROUND: Intraductal papillary neoplasms of the biliary tract (IPNB) and intracholecystic papillary neoplasms (ICPN) are rare tumours characterized by intraluminal papillary growth that can be associated with invasive carcinoma. Their natural history remains poorly understood. This study examines clinicopathological features and outcomes. METHODS: Patients who underwent surgery for IPNB/ICPN (2008-2014) were identified. Descriptive statistics and survival data were generated. RESULTS: Of 23 patients with IPNB/ICPN, 10 were male, and the mean age was 68 years. The most common presentations were abdominal pain (n = 10) and jaundice (n = 9). Tumour locations were: intrahepatic (n = 5), hilar (n = 3), the extrahepatic bile duct (n = 8) and the gallbladder (n = 7). Invasive cancer was found in 20/23 patients. Epithelial subtypes included pancreatobiliary (n = 15), intestinal (n = 7) and gastric (n = 1). The median follow-up was 30 months. The 5-year overall (OS) and disease-free survivals (DFS) were 51% and 57%, respectively. Decreased OS (P = 0.09) and DFS (P = 0.05) were seen in patients with tumours expressing MUC1 on immunohistochemistry (IHC). CONCLUSION: IPNB/ICPN are rare precursor lesions that can affect the entire biliary epithelium. At pathology, the majority of patients have invasive carcinoma, thus warranting a radical resection. Patients with tumours expressing MUC1 appear to have worse OS and DFSs.