Background: Delirium is common after cardiac surgery and is associated with adverse outcomes. Perioperative benzodiazepine use is associated with delirium and is common during cardiac surgery, which may increase the risk of postoperative delirium. We undertook a pilot study to inform the feasibility of a large randomised cluster crossover trial examining whether an institutional policy of restricted benzodiazepine administration during cardiac surgery (compared with liberal administration) would reduce delirium. Methods: We conducted a two-centre, pilot, randomised cluster crossover trial with four 4 week crossover periods. Each centre was randomised to a policy of restricted or liberal use, and then alternated between the two policies during the remaining three periods. Our feasibility outcomes were adherence to each policy (goal !80%) and outcome assessment (one delirium assessment per day in the ICU in !90% of participants). We also evaluated the incidence of intraoperative awareness in one site using serial Brice questionnaires. Results: Of 800 patients undergoing cardiac surgery during the trial period, 127/800 (15.9%) had delirium. Of these, 355/ 389 (91.3%) received benzodiazepines during the liberal benzodiazepine periods and 363/411 (88.3%) did not receive benzodiazepines during the restricted benzodiazepine periods. Amongst the 800 patients, 740 (92.5%) had !1 postoperative delirium assessment per day in the ICU. Of 521 patients screened for intraoperative awareness, one patient (0.2%), managed during the restricted benzodiazepine period (but who received benzodiazepine), experienced intraoperative awareness.

Aim Up to 30% of patients with squamous cell cancer of the anus (SCCA) will require a salvage abdominoperineal resection (APR) for either persistent or recurrent disease. The objective of this study was to assess cancer‐related outcomes in patients with (i) persistent or (ii) recurrent SCCA. Method Embase and MEDLINE were searched. Publications were included if they assessed overall survival (OS), disease‐free survival (DFS) and locoregional recurrence or metastatic disease after salvage APR for persistent or recurrent SCCA. Results A total of 28 retrospective case series (study size ranged from nine to 111) met our inclusion criteria. The median time to salvage APR was 2.6 months [interquartile range (IQR) 2.6–5.0 months, six studies] for persistent disease and 27.6 months (IQR 15.0–32.7 months, five studies) for recurrent disease. The median 5‐year OS from the time of salvage APR was 45.0% (IQR 32.0%–52.3%, 10 studies) for persistent disease and 51.0% (IQR 36.0%–60.9%, 11 studies) for recurrent disease. The median 5‐year DFS following salvage APR was 44.0% (IQR 29.5%–53.0%, 10 studies) for all patients. Following salvage APR, the median locoregional recurrence rate was 23.5% (IQR 15.8%– 46.9%, 19 studies) and 9.0% (IQR 6.4%–13.3%, 16 studies) of patients developed metastatic disease after salvage APR. Conclusion Our review characterizes the best evidence for outcomes following salvage APR for patients with persistent or recurrent SCCA. The evidence is limited by the quality of included studies, as many were single centre case series.

In patients with mechanical valves, higher INR targets are not supported by current evidence, which is of very low quality. In fact, our systematic review suggests that lower INR targets offer significantly lower bleeding risks with no significant difference in thromboembolic risk.

BACKGROUND: Latent causes of apparently unexplained cardiac arrest (UCA) may influence the risk of life-threatening recurrence. We reported the arrhythmic outcomes in the Cardiac Arrest Survivors with Preserved Ejection Fraction Registry (CASPER). METHODS: CASPER is a prospective Canadian registry of cardiac arrest survivors and their first-degree relatives (FDR). Patients were enrolled at 14 centers with demographics, cardiac diagnoses, and follow-up events recorded. Patients with significant coronary artery disease were excluded, and all patients had at least one follow-up visit. Kaplan-Meier and Cox regression analyses were used to compare a composite event of cardiac arrest, appropriate ICD shock, or ATP. RESULTS: 670 patients (330 probands, 340 FDR) were enrolled with a median age of 43 years (IQR 29-53 years, 53% male). Diagnostic categories included structural (9% probands vs. 6% FDRs), electrical (20% vs. 26%), idiopathic (71% of probands), and unaffected (68% of FDRs). Specific diagnoses included structural disease (8%; 4% ARVC, 0.5-1% for each HCM, DCM, coronary spasm, myocarditis), electrical (23%; 12% LQTS, 4% CPVT, 4% Brugada), idiopathic (35%, probands only), and unaffected (33%, FDRs only). 54 patients (8%) had a pathogenic mutation and 348 patients (95% of probands, 10% of FDRs) had an ICD at follow-up. The median follow-up was 3.5 years (IQR 1.56-4.97, cumulative 2517.8 patient-years) with a similar follow-up between probands (3.2 years, IQR 1.82-5.07) and FDRs (2.7 years, IQR 1.30-4.88). 18% of probands experienced an event, compared to 1% of FDRs (p<0.001), with a median time-to-event of 1.08 years (IQR 0.41-2.65). Follow-up events included ICD shock (11%, appropriate and inappropriate), ATP (6%), appropriate shock or ATP (10%), and syncope (7%), with 1% of patients deceased at follow-up. Patients with structural diagnoses had a higher composite event rate compared to electrical (Figure, KM analysis, p¼0.009), and electrical/ idiopathic combined (p¼0.009), with unaffected patients having no events (p<0.001). Among probands, structural diagnoses were an independent predictor of recurrent events (OR 3.45, Table). Among relatives,

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