Managing NON-DIAGNOSTIC biopsies in musculoskeletal tumours in a specialist centre: Deciding on the algorithm.

INTRODUCTION: Core needle biopsy is an effective method of obtaining tissue diagnosis. However, a diagnostic dilemma arises when lesional tissue is non-diagnostic which obviates considering radiological guided re-biopsy (RB) or an open surgical biopsy but the question raised is which serves as a better diagnostic tool. PATIENT AND METHODS: We retrospectively reviewed data from a prospectively collected database of 4516 core needle biopsies performed in our specialist musculoskeletal tumour centre over a 6-year period. Our aim was to evaluate the management of non-diagnostic biopsies (NDB) and establish a safe and accurate diagnostic strategy in the presence of a NDB. RESULTS: Two hundred fifteen (4.8%) NDB cases with complete follow-up were identified. Of these 157 (73%) were treated definitively on the basis of imaging and 58 (27%) had a RB, 48 (83%) of which led to a positive histological diagnosis. The remaining 10 were again non-diagnostic giving a total of 167 patients being treated definitively without a tissue diagnosis. The sensitivity and specificity for multidisciplinary team (MDT) assessment as a diagnostic tool was 0.75 and 0.88 respectively while that for RB was 0.91 and 0.9. CONCLUSION: Re-biopsy after first non-diagnostic core needle biopsy offers high sensitivity and specificity, especially in the presence of malignancy. In the absence of tissue diagnosis, however, MDT assessment is also highly accurate and a safe strategy in managing this complex group of patients. LEVEL OF EVIDENCE: Diagnostic Level III.

Management of Acute Coronary Syndromes Beyond the First Year: A Canadian Clinical Practice Survey.

BACKGROUND: Antithrombotic management following acute coronary syndromes (ACSs) has evolved significantly. However, given lingering uncertainty as to when an ACS may be considered stable, there is the possibility of practice divergence beyond the first year. METHODS: An online adaptive survey describing patients with varying cardiac and extracardiac ischemic risk was developed in order to asses self-reported physician practice intentions pertaining to the antithrombotic management of ACS patients who lack a formal indication for therapeutic anticoagulation. Provincial "champions" (Prince Edward Island not represented) were identified to ensure dissemination of the survey within their jurisdictions via 3 coordinated e-mailings; the survey was made available in French and English from November 2018 through January 2019. RESULTS: A total of 135 practitioners responded to the survey (response rate 15%). Surveys were fully completed in all cases. Nearly all respondents (97%) were cardiologists; 76% worked at an academic center, and 54% had been in practice ≥ 10 years. Most respondents (81%-90%, depending on the scenario) preferred ticagrelor-based dual antiplatelet therapy as the initial ACS treatment. However, beyond 12 months, management decisions differed significantly according to the balance of cardiac and extracardiac risk. CONCLUSIONS: This study provides a first look at how the introduction of rivaroxaban 2.5 mg might be integrated into the clinical management of ACS patients beyond the first year in Canada. Whether to pursue dual antiplatelet therapy or transition early to low-dose rivaroxaban plus acetylsalicylic acid will likely be driven by patient clinical characteristics and perceived cardiac vs extra-cardiac ischemic risk.

CONTEXTE: La prise en charge antithrombotique des patients ayant subi un syndrome coronarien aigu (SCA) a sensiblement évolué au fil du temps. Toutefois, compte tenu de l'incertitude qui persiste quant aux critères définissant un SCA stable, il est possible que les pratiques divergent après la première année. MÉTHODOLOGIE: Nous avons mis au point un questionnaire adaptatif en ligne décrivant les cas de patients présentant divers degrés de risque d'ischémie cardiaque ou extracardiaque, afin d'évaluer les objectifs autodéclarés des médecins quant à la prise en charge antithrombotique des patients ayant subi un SCA chez qui une anticoagulothérapie n'est pas formellement indiquée. Des « champions ¼ provinciaux (l'Île-du-Prince-Édouard n'étant pas représentée) ont été désignés pour assurer la diffusion du questionnaire dans leur province respective en trois envois par courriel coordonnés; le questionnaire était offert en français et en anglais, et l'enquête s'est déroulée de novembre 2018 à janvier 2019. RÉSULTATS: Au total, 135 praticiens ont répondu au sondage (taux de réponse : 15 %). Tous les participants ont répondu à toutes les questions. Presque tous les participants (97 %) étaient cardiologues; 76 % des participants travaillaient dans un centre universitaire, et 54 % exerçaient depuis 10 ans ou plus. La plupart des participants (de 81 à 90 %, selon le scénario) préféraient une bithérapie antiplaquettaire à base de ticagrélor comme premier traitement après un SCA. Toutefois, les décisions quant au traitement au-delà des 12 premiers mois suivant le SCA variaient considérablement selon le risque cardiaque et extracardiaque résiduel évalué. CONCLUSIONS: L'étude constitue une première évaluation de la façon dont le rivaroxaban à 2,5 mg pourrait être intégré à la stratégie canadienne de prise en charge des patients au-delà de la première année suivant le SCA. Le choix de poursuivre la bithérapie antiplaquettaire ou de faire promptement la transition vers un traitement associant rivaroxaban à faible dose et acide acétylsalicylique dépendra vraisemblablement des caractéristiques cliniques du patient et du risque d'ischémie cardiaque et extracardiaque perçu.

Post-operative outcomes of arthroscopic tarsal coalition resection: A systematic review.

BACKGROUND: Arthroscopic resection of tarsal coalitions is a relatively new technique. This systematic review aimed to investigate the post-operative complications and functional outcomes in arthroscopic resection of tarsal coalitions. METHODS: PubMed, Medline, Embase and Cochrane library were searched for studies that reported outcomes in arthroscopic resection of tarsal coalitions. RESULTS: 8 studies met the inclusion criteria. Post-operative outcomes were reported in 103 cases. The overall complication rate was 13.6%. Tibial nerve injury was reported in 1 patient. All included studies demonstrated post-operative improvement in functional outcomes. CONCLUSION: Arthroscopic resection is a feasible and effective treatment method for symptomatic tarsal coalitions.

A Randomized Controlled Trial Assessing the Effect of a Continuous Subcutaneous Infusion of Local Anesthetic Following Elective Surgery to the Great Toe.

Local anesthetic use for wound infusions, single injection, and continuous nerve blocks for postoperative analgesia is well established. No study has investigated the effect of a continuous block of the saphenous and superficial peroneal nerves at the level of the ankle joint following first ray surgery. A double blind randomized controlled trial was designed. One hundred patients with hallux valgus and rigidus requiring surgical correction were recruited and randomized to receive a postoperative continuous infusion at the ankle of normal saline or ropivacaine for 24 hours. Pain scores were recorded on postoperative days 1 and 7. There were more females than males. Follow-up was 100%. There were no significant differences in demographic data between the 2 randomized groups. There was no significant difference between the absolute visual analog scale scores on day 1 (P = .14) and day 7 (P = .16); nor was there a significant difference in reduction in scores between days 1 and 7 (P = .70). This study has shown no benefit to postoperative analgesia with the use of a continuous infusion of ropivacaine at the ankle. We, therefore, cannot currently recommend its use in the way described. Further studies may still identify a role for continuous local anesthetic infusions at the ankle to improve postoperative analgesia. LEVELS OF EVIDENCE: Level I : Prospective randomised control trial.

Ischemic and bleeding events in patients with myocardial infarction undergoing percutaneous coronary intervention who require oral anticoagulation: Insights from the Canadian observational AntiPlatelet sTudy.

BACKGROUND: Since the introduction of newer, more potent P2Y12 receptor inhibitors (P2Y12ris), practice patterns and associated clinical outcomes in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) and also requiring oral anticoagulation (OAC) have not been fully characterized. METHODS: The Canadian Observational Antiplatelet Study was a prospective, multicenter, longitudinal, observational study (26 hospitals, December 2011 to May 2013) describing P2Y12ri treatment patterns and outcomes in patients with ST-elevation and non-ST-elevation MI undergoing PCI. We describe the clinical characteristics, treatment patterns, bleeding, and ischemic outcomes over the 15-month follow-up within and between the subgroups of patients discharged on either dual-antiplatelet therapy (DAPT) (acetyl salicylic acid [ASA]+P2Y12ri) or triple therapy (ASA+P2Y12ri+OAC). RESULTS: Of the 2,034 patients at discharge, 86% (n = 1,757) were on DAPT, whereas 14% (n = 277) were on triple therapy (50% warfarin, 50% non-vitamin K OAC [NOAC]). The frequency of newer P2Y12ri use (prasugrel or ticagrelor) was similar in the DAPT and triple therapy groups (28% vs 26%, respectively). In the triple therapy group, NOAC use was higher in those receiving a new P2Y12ri compared to those receiving clopidogrel (75% vs 41%, respectively, P < .0001). The unadjusted and adjusted events of major cardiovascular event (MACE) and bleeding were higher in the triple therapy group. For patients on triple therapy, the bleeding or MACE events were not significantly different between those on clopidogrel versus those on ticagrelor or prasugrel. CONCLUSION: In this observational study of MI patients requiring PCI, 1 in 8 were discharged on triple antithrombotic therapy, of whom 26% were on newer P2Y12ris. Patients on triple therapy had higher risk at baseline, with higher unadjusted and adjusted MACE and bleeding events compared to those on DAPT alone. Among triple therapy-treated patients, there was no difference in the MACE and bleeding events regardless of the P2Y12ri used.

Bone Marrow Edema Syndrome of the Foot and Ankle: Mid- to Long-Term Follow-up in 18 Patients.

UNLABELLED: Bone marrow edema syndrome (BMES) is a condition characterized by pain and an increase interstitial fluid within the bone marrow in the absence of a definable cause. The purpose of this study was to assess the changes in the pattern of bone edema and quality of pain over time. In patients diagnosed with BMES of the foot and ankle, we investigated the benefit of treatment with bisphosphonates and immobilization in a pneumatic walking boot compared with immobilization in a boot alone. This study is a retrospective review of 18 consecutive patients (mean age 54 years) diagnosed with foot and ankle BMES. Twelve (67%) patients were female and 6 were male with a mean age of 60.1 and 43.0 years, respectively (P < .05). The minimum follow-up was 2 years (range 2-11 years, mean 5.75 years). Five females and no males were found to suffer from generalized osteoporosis. The average duration of symptoms prior to presentation was 22 weeks and the most common bone affected was the talus (56%). More than one bone was affected in 8 (44%) patients. All patients were given a walking boot at first attendance for 8 weeks. The mean time to resolution of pain in patients treated with a pneumatic walker alone (7 patients) was 25.6 weeks (range 8-36 weeks). In the 11 patients whose pain had not improved at their first follow-up, treatment with bisphosphonates led to a more rapid resolution of pain in 13.8 weeks if given intravenously, and 24.0 weeks if given orally. Statistical analysis demonstrated a significant advantage in using a bisphosphonate versus a protected weightbearing alone (P < .01). Recurrence within the same foot and ankle occurred in 44% of patients at a mean interval of 15.6 months and migration to a different site occurred in 6% of patients. LEVELS OF EVIDENCE: Therapeutic, Level III: Retrospective, comparative trial.

Lengthening scarf osteotomy for recurrent hallux valgus.

BACKGROUND: We describe using the scarf osteotomy to correct a recurrent hallux valgus deformity and lengthen the shortened first metatarsal in symptomatic iatrogenic first brachymetatarsia. METHODS: Thirty-six lengthening scarf osteotomies were undertaken in 31 patients. Clinical and radiographic measures were taken pre and postoperatively. RESULTS: Mean age at presentation was 53.4 years, and mean followup 3.9 years. The mean lengthening achieved was 4.9mm. All osteotomies united with no complications. The mean IMA reduction was 4.0° (p<0.001) and HVA 13.0° (p<0.001). The mean AOFAS score increase was 33.8 (p<0.001). There was a positive trend but no correlation (r=0.28) between amount of metatarsal lengthening and AOFAS score change. CONCLUSIONS: We describe the largest lengthening scarf osteotomy series for recurrent hallux valgus with iatrogenic first brachymetatarsia. The results suggest the procedure is successful, with a low complication rate. We anticipate that restoring first metatarsal length and alignment may reduce biomechanical transfer metatarsalgia over time.

Use and timing of coronary angiography and associated in-hospital outcomes in Canadian non-ST-segment elevation myocardial infarction patients: insights from the Canadian Global Registry of Acute Coronary Events.

BACKGROUND: Although an early invasive approach has become standard strategy for the management of non-ST-segment elevation myocardial infarction (NSTEMI), the frequency and timing in Canada is uncertain. METHODS: We examined the use and timing of coronary angiography, revascularization, and cardiovascular outcomes of NSTEMI patients: (1) admitted on weekdays vs weekends; and (2) stratified according to presentation risk level, in the Canadian Global Registry of Acute Coronary Events (GRACE)/Expanded GRACE (GRACE(2))/Canadian Registry of Acute Coronary Events (CANRACE) population. RESULTS: Of 6711 NSTEMI patients, 1956 (29.1%) were admitted on the weekend. The median (interquartile range) wait time for coronary angiography was 58 (32-106) and 70 (50-112) hours for weekday and weekend patients, respectively (P = 0.32). Compared with lower-intermediate risk, higher-risk patients were less likely to undergo angiography (44.7% vs 69.7% for weekdays and 45.2% vs 69.6% for weekends; both P < 0.0001) and waited longer for angiography (median 71 vs 61 hours; P < 0.0001). Weekend admission was independently associated with higher mortality (adjusted odds ratio [OR], 1.52; 95% confidence interval [CI], 1.15-2.01; P = 0.004), recurrent ischemia (adjusted OR, 1.16; 95% CI, 1.01-1.32; P = 0.03), and heart failure (adjusted OR, 1.28; 95% CI, 1.00-1.63; P = 0.048) but not with reinfarction. CONCLUSIONS: Median wait time for angiography in Canadian NSTEMI patients admitted on the weekend was not significantly longer than for those who presented on a weekday. Patients admitted on weekends had higher adjusted mortality and cardiovascular event rates. Higher-risk patients were less likely to undergo angiography and waited longer, with higher observed in-hospital event rates. Systematic, guideline-recommended risk stratification should be considered to ensure that optimal management strategies (eg, timely coronary angiography in higher-risk patients) are matched to level of risk.

Treatment and outcomes of non-ST elevation acute coronary syndromes in relation to burden of pre-existing vascular disease.

BACKGROUND: Patients with atherosclerotic disease in one territory often have disease in other vascular territories. However, the relationships between pre-existing vascular disease and the treatment and outcome of acute coronary syndrome (ACS), have not been well characterized. METHODS: The Canadian ACS2, Global Registry of Acute Coronary Events (GRACE/GRACE(2)), and Canadian Registry of Acute Coronary Events (CANRACE) were used to obtain data on 10,667 non-ST segment elevation acute coronary syndrome (NSTEACS) patients between 2002 and 2008. Multivariable analysis was used to examine the relationships between the number of vascular beds affected and both in-hospital coronary angiography and in-hospital mortality. The ACS2 registry (2002-2003) included physician-reported reasons for non-invasive management, which were stratified by vascular disease burden. RESULTS: Patients with more vascular disease had higher GRACE risk scores at presentation, but less frequently received antiplatelet agents and angiography. The most common reason in the ACS2 registry for patients who did not undergo angiography was "not high enough risk." There was an independent inverse relationship between the extent of vascular disease and in-hospital angiography. Patients with higher vascular disease burden had higher unadjusted in-hospital mortality. In multivariable analysis, patients with 1 vascular territory affected had the lowest and those with 3 vascular beds affected had the highest adjusted in-hospital mortality. In the ACS2 registry, patients with more extensive vascular disease had higher rates of 1-year mortality and death/re-infarction (both p for trend <0.001). CONCLUSIONS: NSTEACS patients with more vascular disease received less intensive treatment, with an associated worse outcome. This undertreatment might be partly mediated by physicians' underestimation of patient risk. More aggressive risk factor modification and intensive ACS therapies may improve the outcome of these high-risk patients.

Management and outcomes of non-ST elevation acute coronary syndromes in relation to previous use of antianginal therapies (from the Canadian Global Registry of Acute Coronary Events [GRACE] and Canadian Registry of Acute Coronary Events [CANRACE]).

Randomized trials have established the efficacy of antianginal medications in the treatment of chronic stable coronary disease. Using data from the Global Registry of Acute Coronary Events (GRACE) and Canadian Registry of Acute Coronary Events (CANRACE), we examined the temporal trends in antianginal use (beta blockers, calcium antagonists, and nitrates) before non-ST-elevation acute coronary syndrome presentation from 1999 to 2008 in 10,019 patients. The relationships among previous antianginal use, clinical characteristics on presentation, and in-hospital management and outcomes were examined. Beta blockers were the most commonly used agents, and there was a significant decline in the use of nitrates over time. Compared with patients not on any antianginal therapy before presentation, those on treatment were more likely to be older, female, and have a history of hypertension, diabetes, previous angina, and myocardial infarction; they were less likely to present with positive biomarkers (all p <0.001). Patients not on antianginal therapy before presentation were more likely to undergo coronary angiography and percutaneous coronary intervention and less likely to have recurrent ischemia during hospitalization (all p <0.001). In multivariable analysis, previous antianginal use was independently associated with lower use of coronary angiography in hospital (p = 0.034) but not with in-hospital mortality. In conclusion, there has significant temporal decline in nitrate use before non-ST-elevation acute coronary syndrome. Patients receiving antianginal therapy before presentation more frequently had preexisting cardiovascular disease and previous revascularization and were less likely to present with non-ST-segment elevation MI compared with patients on no antianginal therapies. Previous antianginal use was independently associated with a lower use of coronary angiography in hospital.

The effect of the grade of surgeon on blood loss in fractured neck-of-femur surgery.

Significant blood loss in neck-of-femur (NOF) fracture surgery contributes to the high morbidity and mortality. Since the introduction of the European Working Time Directive, trainee surgeons are more junior and inexperienced. We assessed NOF surgical blood loss in relation to the surgeon grade and experience. We assessed a prospective consecutive cohort of 105 acute NOF fracture patients treated surgically. Blood loss was calculated as the difference between the pre- and post-operative haemoglobin levels. Warfarin was reversed pre-operatively where necessary. There were 32 male and 73 female patients, with mean age 83.8 years (range 48-98). One patient died peri-operatively and was excluded. There were 49 intra-capsular fractures and 55 extra-capsular fractures, with no significant difference in group characteristics. Mean haemoglobin drop was 2.8 g/dL [intra-capsular fractures, 2.5 g/dL; extra-capsular fractures, 3.1 g/dL (p = 0.019)]. The difference in blood loss between different surgeon grades was not significant: consultants 2.4 g/dL (21 cases), senior staff grades 2.7 g/dL (17 cases), junior staff grades 3.1 g/dL (15 cases) and registrars 2.9 g/dL (50 cases). Whilst mean haemoglobin drop was least for consultants, the mean for trainees was only marginally higher than for experienced staff grade surgeons and lower than for their junior counterparts. Mean blood loss for patients taking anti-platelet agents was not significantly different (aspirin 2.7 g/dL, clopidogrel 3.7 g/dL, 4.4 g/dL for those taking both) compared to patients taking neither agent (2.8 g/dL). We conclude that surgeon grade does not significantly impact peri-operative haemoglobin drop, regardless of pre-operative morbidity. It is safe for trainees to operate, with adequate supervision where appropriate, on all NOF fracture patients without compromising blood loss.

Elective hip and knee arthroplasty and the effect of rivaroxaban and enoxaparin thromboprophylaxis on wound healing.

INTRODUCTION: Rivaroxaban is the first licensed oral direct inhibitor of factor Xa. Recent studies from the RECORD trials suggest rivaroxaban has superior efficacy compared to enoxaparin in preventing venous thromboembolism (VTE) with no significant increase in the major bleeding risk. Concerns remain regarding the incidence of minor bleeding, consequent delayed wound healing and subsequent risk of infection. The aim of this observational study was to assess the incidence of post-operative complications in patients receiving either rivaroxaban or enoxaparin thromboprophylaxis following elective hip and knee arthroplasty. METHODS: A total of 258 patients undergoing elective total hip or knee arthroplasty within one NHS Trust were included. A total of 202 subjects (mean age, 70.7 years ± 10.0, 43 % men) received a daily dose of 10 mg of oral rivaroxaban and 56 (mean age, 70.9 years ± 9.8, 39 % men) had a daily subcutaneous injection of 40 mg of enoxaparin as thromboprophylaxis. Endpoints included VTE (deep vein thrombosis and pulmonary embolism), haemorrhagic wound complications, hospital re-admission, requirement for blood transfusion, minor and major bleeding and death. RESULTS: There were no significant differences in the incidence of VTE, requirement for blood transfusion and readmission rate between rivaroxaban and enoxaparin-treated patients. The incidence of minor bleeding (2.0 vs. 0 %) and haemorrhagic wound complications (5.0 vs. 1.8 %) were non-significantly higher in the rivaroxaban-treated group. There were no cases of pulmonary embolism, major bleeding or death in either group. CONCLUSION: Our experience with rivaroxaban in elective hip and knee arthroplasty showed no significant difference in the incidence of VTE or major bleeding. There was, however, a tendency to greater risk of minor bleeding and wound complications that were largely haemorrhagic in nature, which may have reached significance in a larger study.

Gemella haemolysans Infection in Total Hip Arthroplasty.

Gemella haemolysans is a Gram-positive coccus and commensal of the upper respiratory tract and oral mucosa that rarely causes clinically important infections. There is only one previous report of this organism causing periprosthetic infection, in a total knee arthroplasty. We present a case of septic loosening of an uncemented total hip arthroplasty due to G. haemolysans, in an asplenic patient with insulin dependent diabetes mellitus. Treatment with two-stage revision has been successful at 7 years of follow-up.

The association between prior use of aspirin and/or warfarin and the in-hospital management and outcomes in patients presenting with acute coronary syndromes: insights from the Global Registry of Acute Coronary Events (GRACE).

BACKGROUND: The role of acetylsalicylic acid (ASA [aspirin]) and warfarin in secondary prevention after acute coronary syndromes (ACS) is well established. However, there are sparse data comparing the presentation and outcomes of patients who present with ACS while on ASA and/or warfarin therapy and those on neither. METHODS: Using data from the Canadian Global Registry of Acute Coronary Events (GRACE), we stratified 14,090 ACS patients into 4 groups according to prior use of antithrombotic therapies and compared in-hospital management and outcomes. RESULTS: Among 14,090 ACS patients, 7411 (52.6%) were not on prior ASA or warfarin therapy, 5724 (40.6%) were on ASA only, 593 (4.2%) were on warfarin only, and 362 (2.6%) were on both ASA and warfarin. ACS patients taking ASA and/or warfarin were older with more comorbidities than the patients on neither drug. Patients receiving prior warfarin only or ASA and warfarin were less likely to receive guideline-recommended therapies. Patients who were taking prior warfarin only had higher unadjusted rates of death, death and/or reinfarction (re-MI), congestive heart failure (CHF), and major bleeding as compared with patients on no prior therapy. Furthermore, patients who were taking ASA and warfarin had higher unadjusted rates of death and/or re-MI and CHF than patients on prior ASA only. CONCLUSIONS: ACS patients on prior warfarin are a high-risk population, yet they receive less guideline-recommended therapies and have higher unadjusted adverse event rates during their index hospitalization. With the increasing use of oral anticoagulants, clinical trials are needed to guide the optimal management of these ACS patients.

Reperfusion strategies and outcomes of ST-segment elevation myocardial infarction patients in Canada: observations from the Global Registry of Acute Coronary Events (GRACE) and the Canadian Registry of Acute Coronary Events (CANRACE).

BACKGROUND: We examine the clinical characteristics and outcomes of ST-elevation myocardial infarction (STEMI) patients receiving various reperfusion therapies in 2 contemporary Canadian registries. METHODS: Of 4045 STEMI patients, 2024 received reperfusion therapy and had complete data on invasive management. They were stratified by reperfusion strategy used: primary percutaneous coronary intervention (PCI) (n = 716); fibrinolysis with rescue PCI (n = 177); fibrinolysis with urgent/elective PCI (n = 210); and fibrinolysis without PCI (n = 921). Data were collected on clinical and laboratory findings, and outcomes. RESULTS: Compared with fibrinolytic-treated patients, patients treated with primary PCI were younger and had higher Killip class, had longer time to delivery of reperfusion therapy, and utilized more antiplatelet therapy but less heparin, ß-blockers and angiotensin-converting enzyme inhibitors. In-hospital death occurred in 2.7% of patients treated with primary PCI, 1.7% fibrinolysis-rescue PCI, 1.0% fibrinolysis-urgent/elective PCI, and 4.8% fibrinolysis-alone (P = 0.009); the rates of death/reinfarction were 3.9%, 4.0%, 4.3%, and 7.1% (P = 0.032), respectively. The rate of shock was highest in the primary PCI group. Rates of heart failure or major bleeding were similar in the 4 groups. In multivariable analysis, no PCI during hospitalization was associated with death and reinfarction (adjusted odds ratio = 1.66; 95% confidence interval, 1.03-2.70; P = 0.04). CONCLUSIONS: Clinical features, time to reperfusion, and medication utilization differed with respect to the reperfusion strategy. While low rates of re-infarction/death were observed, these complications occurred more frequently in those who did not undergo PCI during index hospitalization.

The clinical significance of the FUS-CREB3L2 translocation in low-grade fibromyxoid sarcoma.

BACKGROUND: Low-grade fibromyxoid sarcoma (LGFMS) is a rare soft-tissue neoplasm with a deceptively benign histological appearance. Local recurrences and metastases can manifest many years following excision. The FUS-CREB3L2 gene translocation, which occurs commonly in LGFMS, may be detected by reverse-transcriptase polymerase chain reaction (RT-PCR) and fluorescence in situ hybridisation (FISH). We assessed the relationship between clinical outcome and translocation test result by both methods. METHODS: We report genetic analysis of 23 LGFMS cases and clinical outcomes of 18 patients with mean age of 40.6 years. During follow-up (mean 24.8 months), there were no cases of local recurrence or metastasis. One case was referred with a third recurrence of a para-spinal tumour previously incorrectly diagnosed as a neurofibroma. RESULTS: Results showed 50% of cases tested positive for the FUS-CREB3L2 translocation by RT-PCR and 81.8% by FISH, suggesting FISH is more sensitive than RT-PCR for confirming LGFMS diagnosis. Patients testing positive by both methods tended to be younger and had larger tumours. Despite this, there was no difference in clinical outcome seen during short and medium-term follow-up. CONCLUSIONS: RT-PCR and FISH for the FUS-CREB3L2 fusion transcript are useful tools for confirming LGFMS diagnosis, but have no role in predicting medium-term clinical outcome. Due to the propensity for late recurrence or metastasis, wide excision is essential, and longer-term follow-up is required. This may identify a difference in long-term clinical outcome between translocation-positive and negative patients.

Comparison of baseline characteristics, management and outcome of patients with non-ST-segment elevation acute coronary syndrome in versus not in clinical trials.

Previous studies have questioned the external validity of randomized controlled trial results of acute coronary syndrome (ACS) because of potential selection bias toward healthier patients. We sought to evaluate differences in clinical characteristics and management of patients admitted with non-ST-elevation ACS according to participation in clinical trials over the previous decade. The Canadian ACS I (1999 to 2001), ACS II (2002-2003), GRACE (2004-2007), and CANRACE (2008) were prospective, multicenter registries of patients admitted to hospitals with ACS. We examined 13,556 patients with non-ST-elevation ACS, of whom 1,126 (8.3%) participated in clinical trials. Data were collected on baseline characteristics, medication use at admission and discharge, in-hospital procedures, and in-hospital adverse events. Patients enrolled in clinical trials were younger, more likely to be men, and had fewer co-morbidities. They were significantly more likely to be on several guideline-recommended medications and were significantly more likely to undergo invasive procedures, including coronary angiography, percutaneous coronary intervention, and coronary bypass surgery (all p values <0.001). Unadjusted in-hospital (2.1% vs 0.7%, p = 0.001) and 1-year (8.9% vs 6.3%, p = 0.037) mortality rates were higher in non-enrolled patients. In multivariable analysis, patients who were older, women, had a history of heart failure, and increased creatinine levels on presentation were less likely to be enrolled into clinical trials. In conclusion, significant differences persist in baseline characteristics, treatment, and outcomes between patients enrolled and those not enrolled in clinical trials. Consequently, generalization of ACS clinical trials over the previous decade to the "real-world" patient may remain in question.

Temporal trend of in-hospital major bleeding among patients with non ST-elevation acute coronary syndromes.

BACKGROUND: Although randomized controlled trials support the use of intensive medical and invasive therapies for non-ST segment elevation acute coronary syndromes (NSTE-ACS), major bleeding is a serious treatment complication. We sought to determine the temporal trend of in-hospital major bleeding among patients with NSTE-ACS, in relation to the evolving management pattern. METHODS: We identified 14 111 NSTE-ACS patients enrolled in 4 successive, prospective, multicenter registries (ACS I, 1999-2001; ACS II, 2002-2003; GRACE, 2004-2007; and CANRACE, 2008) in Canada between 1999 and 2008. We collected data on patient characteristics, use of cardiac medications and procedures on standardized case report forms. In all registries, major bleeding was defined a priori as life threatening or fatal bleeding, bleeding requiring transfusion of ≥2 U of packed red cells, or resulting in an absolute decrease in hemoglobin of >30g/L. RESULTS: A total of 14 111 patients had a final diagnosis of NSTE-ACS and were included in this study (3294 in the ACS-I registry, 1956 in the ACS-II registry, 7543 in GRACE, and 1318 in CANRACE). Over time, there was a substantial increase in the use of dual anti-platelet (aspirin and thienopyridine) therapy (P for trend <.001), and in rates of in-hospital cardiac catheterization and percutaneous coronary intervention (both Ps for trend <.001). Overall, major bleeding was relatively infrequent (1.7%). There was no significant increase in the unadjusted rates of major bleeding over time (P for trend = .19). In multivariable analysis adjusting for GRACE risk score and intensive treatment, enrolment period was not an independent predictor of bleeding (P for trend = .98). There was no interaction between the enrolment period and the use of intensive medical and invasive management. CONCLUSION: Despite more widespread use of dual anti-platelet therapies and invasive cardiac procedures in the management of NSTE-ACS, the rate of major bleeding remains relatively low and has not increased significantly over time. Our findings suggest that physicians selectively target treatment for their patients, and these evidence-based therapies can be safely administered to ACS patients in clinical practice.

Disparities in management patterns and outcomes of patients with non-ST-elevation acute coronary syndrome with and without a history of cerebrovascular disease.

Cerebrovascular (CVD) disease is commonly associated with coronary artery disease and adversely affects outcome. The goal of the present study was to examine the temporal management patterns and outcomes in relation to previous CVD in a contemporary "real-world" spectrum of patients with acute coronary syndrome (ACS). From 1999 to 2008, 14,070 patients with non-ST-segment elevation ACS were recruited into the Canadian Acute Coronary Syndrome I (ACS I), ACS II, Global Registry of Acute Coronary Events (GRACE/GRACE(2)), and Canadian Registry of Acute Coronary Events (CANRACE) prospective multicenter registries. We stratified the study patients according to a history of CVD and compared their treatment and outcomes. Patients with a history of CVD were older, more likely to have pre-existing coronary artery disease, elevated creatinine, higher Killip class, and ST-segment deviation on admission. Despite presenting with greater GRACE risk scores (137 vs 117, p <0.001), patients with previous CVD were less likely to receive evidence-based antiplatelet and antithrombin therapies during the initial 24 hours of hospital admission. They were also less likely to undergo in-hospital coronary angiography and revascularization. These disparities in medical and invasive management were preserved temporally across all 4 registries. Patients with concomitant CVD had worse in-hospital outcomes. Previous CVD remained an independent predictor of in-hospital mortality (adjusted odds ratio 1.43, 95% confidence interval 1.06 to 1.92, p = 0.019) after adjusting for other powerful prognosticators in the GRACE risk score. However, it was independently associated with a lower use of in-hospital coronary angiography (adjusted odds ratio 0.70, 95% confidence interval 0.60 to 0.83, p <0.001). Underestimation of patient risk was the most common reason for not pursuing an invasive strategy. Revascularization was independently associated with lower 1-year mortality (adjusted odds ratio 0.48, 95% confidence interval 0.33 to 0.71, p <0.001), irrespective of a history of CVD. In conclusion, for patients presenting with non-ST-segment elevation-ACS, a history of CVD was independently associated with worse outcomes, which might have been, in part, because of the underuse of evidence-based medical and invasive therapies.