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Summary Background Blood transfusion might affect long-term mortality by changing immune function and thus potentially increasing the risk of subsequent infections and cancer recurrence. Compared with a restrictive transfusion strategy, a more liberal strategy could reduce cardiac complications by lowering myocardial damage, thereby reducing future deaths from cardiovascular disease. We aimed to establish the effect of a liberal transfusion strategy on long-term survival compared with a restrictive transfusion strategy. Methods In the randomised controlled FOCUS trial, adult patients aged 50 years and older, with a history of or risk factors for cardiovascular disease, and with postoperative haemoglobin concentrations lower than 100 g/L within 3 days of surgery to repair a hip fracture, were eligible for enrolment. Patients were recruited from 47 participating hospitals in the USA and Canada, and eligible participants were randomly allocated in a 1:1 ratio by a central telephone system to either liberal transfusion in which they received blood transfusion to maintain haemoglobin level at 100 g/L or higher, or restrictive transfusion in which they received blood transfusion when haemoglobin level was lower than 80 g/L or if they had symptoms of anaemia. In this study, we analysed the long-term mortality of patients assigned to the two transfusion strategies, which was a secondary outcome of the FOCUS trial. Long-term mortality was established by linking the study participants to national death registries in the USA and Canada. Treatment assignment was not masked, but investigators who ascertained mortality and cause of death were masked to group assignment. Analyses were by intention to treat. The FOCUS trial is registered with ClinicalTrials.gov, number NCT00071032. Findings Between July 19, 2004, and Feb 28, 2009, 2016 patients were enrolled and randomly assigned to the two treatment groups: 1007 to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The median duration of follow-up was 3·1 years (IQR 2·4–4·1 years), during which 841 (42%) patients died. Long-term mortality did not differ significantly between the liberal transfusion strategy (432 deaths) and the restrictive transfusion strategy (409 deaths) (hazard ratio 1·09 [95% CI 0·95–1·25]; p=0·21). Interpretation Liberal blood transfusion did not affect mortality compared with a restrictive transfusion strategy in a high-risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death did not differ between the trial groups. These findings do not support hypotheses that blood transfusion leads to long-term immunosuppression that is severe enough to affect long-term mortality rate by more than 20–25% or cause of death. Funding National Heart, Lung, and Blood Institute.

Objectives: To determine whether a higher blood transfusion threshold would prevent new or worsening delirium symptoms in the hospital after hip fracture surgery. Design: Ancillary study to a randomized clinical trial. Setting: Thirteen hospitals in the United States and Canada. Participants: One hundred thirty-nine individuals hospitalized with hip fracture aged 50 and older (mean age 81.5 ± 9.1) with cardiovascular disease or risk factors and hemoglobin concentrations of less than 10 g/dL within 3 days of surgery recruited in an ancillary study of the Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair. Intervention: Individuals in the liberal treatment group received one unit of packed red blood cells and as much blood as needed to maintain hemoglobin concentrations at greater than 10 g/dL; those in the restrictive treatment group received transfusions if they developed symptoms of anemia or their hemoglobin fell below 8 g/dL. Measurements: Delirium assessments were performed before randomization and up to three times after randomization. The primary outcome was severity of delirium according to the Memorial Delirium Assessment Scale (MDAS). The secondary outcome was the presence or absence of delirium defined according to the Confusion Assessment Method (CAM). Results: The liberal group received a median two units of blood and the restrictive group zero units of blood. Hemoglobin concentration on Day 1 after randomization was 1.4 g/dL higher in the liberal group. Treatment groups did not differ significantly at any time point or over time on MDAS delirium severity (P = .28) or CAM delirium presence (P = .83). Conclusion: Blood transfusion to maintain hemoglobin concentrations greater than 10 g/dL alone is unlikely to influence delirium severity or rate in individuals with hip fracture after surgery with a hemoglobin concentration less than 10 g/dL.

Background The hemoglobin threshold at which postoperative red-cell transfusion is warranted is controversial. We conducted a randomized trial to determine whether a higher threshold for blood transfusion would improve recovery in patients who had undergone surgery for hip fracture. Methods We enrolled 2016 patients who were 50 years of age or older, who had either a history of or risk factors for cardiovascular disease, and whose hemoglobin level was below 10 g per deciliter after hip-fracture surgery. We randomly assigned patients to a liberal transfusion strategy (a hemoglobin threshold of 10 g per deciliter) or a restrictive transfusion strategy (symptoms of anemia or at physician discretion for a hemoglobin level of

The purpose of this study was to evaluate the 8-year effect of a hip fracture service on time to surgery; duration of surgery; length of stay in acute care, intensive care, and rehabilitation unit; and incidence of postoperative complications and in-hospital mortality. The study group consisted of 50 female patients 65 years of age or older who were treated for hip fractures in 1999 and 50 case-, age-, and American Society of Anesthesiologists score-matched female patients treated in 2006. Group differences were compared via the Student paired t test and χ² analysis (statistical significance, p ≤ .05). The 2006 group had a significantly shorter mean surgical time than did the 1999 group, but time to surgery did not change. The 2006 group showed improvements (but not statistically significant ones) in length of stay in acute care, intensive care, and rehabilitation unit, and in the incidence of complications and in-hospital mortality.

To test the hypothesis that sedation in elderly patients is often electrophysiologically equivalent to general anesthesia (GA).Prospective, observational study.Operating room of a university medical center.40 elderly patients (or=65 yrs of age) undergoing hip fracture repair with spinal anesthesia and propofol-based sedation.In the routine practice group (RP; n = 15), propofol sedation was administered per the usual routine of the anesthesiologist. In the targeted sedation group (TS; n = 25), sedation was titrated to an observer's assessment of alertness/sedation (OAA/S) score of 4 (ie, lethargic in response to name called) to 5 (ie, awake and alert).Both patient groups underwent processed electroencephalographic monitoring using bispectral index (BIS) intraoperatively. BIS levels were compared between groups to determine amount of surgical time spent in GA (BISor= 60).In the RP group, subjects spent 32.2% of surgical time at BIS levels consistent with GA. Although averaged BIS values during surgery increased from (mean +/- SD) 71 +/- 16 to 88 +/- 9 (P0.001), GA was still observed during 5% of surgical time in the TS group. Overall, 13 of 15 (87%) RP group patients and 11 of 25 (44%) TS group patients (P0.010) experienced some period of GA.BIS levels consistent with GA occur frequently in elderly patients during propofol-based sedation for spinal anesthesia. Altering routine practice such that sedation is titrated to a targeted clinically-determined sedation level reduces - but does not eliminate - this incidence.

[Graphic][1] Introduction There are a large number of randomized clinical trials comparing short-term mortality between liberal and restrictive transfusion strategies. However, transfusion is thought to have long-term consequences related to alteration of immune function. These effects have been hypothesized to increase the risk of subsequent infections and recurrence of cancer. Thus, it is possible that transfusion will increase the risk of long-term mortality by increasing the deaths due to infections and recurrent cancer. Alternatively, more liberal transfusion might reduce cardiac complications by increasing oxygen to vulnerable myocardium and reduce deaths from cardiovascular disease. We hypothesized that liberal transfusion would affect cause specific mortality and might affect all-cause mortality, depending on the predominant impact of transfusion. Methods We performed a secondary analysis of the FOCUS trial that randomly allocated patients undergoing hip fracture repair with postoperative hemoglobin concentrations below 10 g/dL within 3 days of surgery. Patients were eligible for the trial if they had underlying cardiovascular disease (coronary artery disease, congestive heart failure, stroke, peripheral vascular disease) or cardiovascular risk factors (diabetes mellitus, hypertension, hyperlipidemia, tobacco use, or renal insufficiency). We randomly allocated patients to liberal transfusion where patients received blood transfusion to maintain hemoglobin 10 g/dL or greater, or restrictive transfusion where patients received blood transfusion when hemoglobin level was less than 8 g/dL or for symptoms. Long-term mortality was determined by linking the study subjects to national death registries in US and Canada. We compared survival time between the two transfusion treatment strategies using the unadjusted log-rank test and Cox proportional hazard models. The underlying cause of death was identified by the national death registries and grouped into seven categories: cardiovascular disease, cancer, infection, stroke, dementia, pulmonary, and other. Results There were 1007 subjects randomly allocated to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The baseline clinical status was similar between the two groups; mean age of the study population was 81.6 years (range, 51 to 103). The liberal transfusion group were transfused a total of 1866 units and restrictive transfusion group 652 units. We established long-term survival for 2002 (99.3%) of the study population. The median follow-up was 3.1 years (interquartile range, 2.4 to 4.1 years) and there were 841 (42.0%) deaths. There was no difference in the long-term mortality between the liberal transfusion strategy (N=432 deaths) and restrictive transfusion strategy (N= 409 deaths); hazard ratio =1.09; 95% confidence interval 0.95 to 1.25 (Figure). The results were consistent across all subgroups including demographics and multiple co-morbidities. There was also no difference in the underlying cause of death between the transfusion strategies (p=0.99) (Table); Cardiovascular disease (liberal-32.6%, restrictive-33.5%), Cancer (liberal-12.5%, restrictive-12.0%), Infection (liberal-9.5%, restrictive 9.0%). Conclusions Liberal transfusion of 10 g/dL did not reduce or increase long-term mortality compared to restrictive transfusion strategy using an 8 g/dL threshold or symptoms in a high risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death were similar in both arms of the trial and liberal transfusion did not appear to increase risk of death from infection or cancer or reduce the risk of death from cardiovascular disease. These results do not support the hypotheses that transfusion leads to long-term immunosuppression that is severe enough to influence mortality or cause of death. Our findings suggest that clinicians should primarily consider short-term effects of transfusion when deciding whom to transfuse. | | | | | | | || | | | Total N (%) | Liberal N (%) | Restrictive N (%) | | | | Cardiovascular Disease | 278 (33.1) | 141 (32.6) | 137 (33.5) | | | | Cancer | 103 (12.2) | 54 (12.5) | 49 (12.0) | | | | Infection | 78 (9.3) | 41 (9.5) | 37 (9.0) | | | | Stroke | 57 (6.8) | 27 (6.3) | 30 (7.3) | | | | Dementia | 108 (12.8) | 56 (13.0) | 52 (12.7) | | | | Pulmonary | 58 (6.9) | 29 (6.7) | 29 (7.1) | | | | Other | 147 (17.5) | 79 (18.3) | 68 (16.6) | | | | Unknown | 12 (1.4) | 5 (1.2) | 7 (1.7) | | | | Totals | 841 | 432 | 409 | | Table ![Figure 1][2] Figure 1 Disclosures Magaziner: Ammonett : Consultancy; Sanofi: Consultancy; Regeneron: Consultancy; Novartis: Consultancy; Eli Lilly: Consultancy; American Orthopedic Association: Consultancy. [1]: /embed/inline-graphic-2.gif [2]: pending:yes

In this study, we sought to determine the incidence of recovery room delirium in elderly patients having hip-fracture repair under general anesthesia and to discover whether recovery room delirium is associated with continuing postoperative delirium. In this prospective study, patients undergoing hip-fracture repair were anesthetized using a standardized protocol. In addition, postoperative pain management was standardized in both the postoperative anesthesia care unit and in the hospital ward. The presence of delirium was determined using the confusion assessment method (CAM) score. Recovery room delirium was assessed by obtaining a CAM score at 60 min after discontinuation of isoflurane. Postoperative delirium was assessed by obtaining a daily CAM score during the postoperative in-hospital recovery period. Fifty patients consented to the study and 47 patients were included in the analysis (surgery cancelled postinduction n = 1; nonadherence to protocol n = 2). Average patient age was 77 +/- 1 (mean +/- SE) yr (range, 56-98 yr). Seventy-seven percent of the study patients were ASA class III or more. The prevalence of recovery room delirium was 45%. The prevalence of postoperative delirium was 36%. Recovery room delirium predicted postoperative delirium (P0.001, Fisher's exact test) with a sensitivity of 100% and a specificity of 85%. Analgesic doses administered in the postoperative anesthesia care unit and ward were similar in patients with or without postoperative delirium. Results of this study show that recovery room delirium is a strong predictor of postoperative delirium.In patients undergoing hip-fracture repair, recovery room delirium is a strong predictor of postoperative delirium when using a standardized protocol for general anesthesia and postoperative pain management.

UNLABELLED: It is unclear how brief postoperative delirium (DEL) affects functional outcomes. In this study, we sought to determine if patients with brief postoperative DEL (

Postoperative delirium is a major problem in elderly patients undergoing surgical repair of hip fracture. It is imperative to identify potentially treatable preoperative factors associated with the onset of postoperative delirium to optimize outcome. We sought to determine what preoperative variables are associated with postoperative delirium in geriatric patients undergoing surgical repair of hip fracture. In a prospective, IRB-approved study, patients admitted to the geriatric hip fracture service were examined daily in the hospital for the occurrence of postoperative delirium. All patients with a preoperative diagnosis of dementia or delirium were eliminated. A positive confusion assessment method score ([+]CAM) was used to determine the presence of postoperative delirium during the acute hospital stay. To determine the association between preoperative variables (demographics, laboratory values, and comorbidities) and postoperative (+)CAM scores, chi(2) and logistic regression analysis were performed with calculation for the odds ratios (OR). One-hundred-sixty-eight patients (72% women) were included in the analysis. Twenty-eight percent (n = 47) of patients had a (+)CAM score. Three variables were significant predictors of a (+)CAM score: (a) normal white blood cell count (OR, 2.2), (b) abnormal serum sodium (OR, 2.4); and (c) ASA physical statusII (OR, 11.3). The results suggest that preoperative medical conditions (abnormal serum sodium and ASA physical statusII) and an inability to mount a stress response (normal white blood cell count) may influence the patient's postoperative mental status. In particular, two of the risk factors we identified may be amenable to therapy and are abnormal serum sodium and lack of an increase in white blood cell count during the stress of trauma and surgery.This prospective study investigated preoperative variables that are predictive of postoperative delirium in geriatric patients undergoing surgical repair of hip fracture. The results suggest that the patient's preoperative medical condition and inability to mount a stress response influence postoperative delirium.

The foliar epidermis and cuticle of Staurogyne longifolia (Nees) Kuntze, Elytraria acaulis (L.f.) Lindau var. acaulis, E. acaulis var. lyrata (Nees) Bremek. and Nelsonia campestris R.Br, have been investigated, revealing broad similarities with those of the rest of the Acanthaceae; the presence of diacytic stomata in the Nelsonioideae is evidence of its affinity with the Acanthaceae in general-, while the presence of panduriform glandular hairs and the absence of the cystoliths in Nelsonioideae indicate its particular affinity with the Thunbergioideae. Substantial evidence is provided to support the retention of Nelsonioideae as a subfamily of the Acanthaceae, rather than its transfer to the Scrophulariaceae.

Cuticular investigations have been carried out in three species ofHemigraphis and nine ofStrobilanthes. The two genera belonging to the family Acanthaceae are generally placed together within the same tribe by taxonomists.Hemigraphis andStrobilanthes show broadly similar epidermal characters though there are significant differences also. On the basis of the present study, the placement of these genera in two different sub-tribes but under the same tribe appears to be justified. The three species ofHemigraphis show more or less uniform epiderma1 characters butH. colorata andH. hirta are more close to each other than toH. alternata.

Foliar epidermal features of three known taxa of Fittonia Coemans belonging to the family Acanthaceae have been studied. The genus shows typical features of Acanthaceae (sub-family Acanthoideae) like diacytic stomata, sub-sessile glandular hairs with globular head and the presence of cystoliths. While all the three taxa show broadly similar epidermal features, there are distinct variations which help in distinguishing them from one another. The presence of ocelli (lens cells) on the upper epidermis of F. verschaffeltii var. pearcei is significant and indicates that the latter might be a distinct species. Die Blattepidermis-Merkmale von drei bekannten Taxa der Gattung Fittonia Coemans (Acanthaceae) wurden untersucht. Die Gattung zeigt typische Merkmale der Acanthaceae (Subfam. Acanthoideae) wie diazytische Stomata, fast ungestielte drusige Haare mit kugeligem Kopf und das Vorhandensein von Cystolithen. Obwohl alle drei Taxa deutlich einfache Epidermismerkmale aufweisen, gibt es bestimmte Abweichungen, durch die sich unterscheiden. Das Vorkommen von sehr kleinen linsenartigen Derivaten auf der oberen Epidermis bei F. verschaffeltii var. pearcei ist signifikant und zeigt an, das die Varietat als Art einzustufen ist.

Foliar cuticle and epidermis, including trichomes, of 26 species (17 genera) of Solanaceae from India and South America have been studied. Most of the species are amphistomatic and possess either 'cruciferous' stomata or both 'cruciferous' and 'ranunculaceous' types intermingled; only a few species show exclusively the ranunculaceous type of stomata. Several types of epidermal hairs (both glandular and non-glandular) are found and these appear to be of great diagnostic value. This fact is particularly important as many species are of pharmacognostic interest. Some interesting characters such as 'cuticular striations', 'single guard cells', and 'degenerated stomatal cells' have also been recorded in a number of species. Further subdivisions of the family have been evaluated in the light of the present investigations, and regrouping of different genera under various tribes has been suggested.

Structure and distribution of the foliar epidermal hairs of 109 species and two varieties belonging to 39 genera of the family Acanthaceae have been studied. Both glandular and non-glandular epidermal hairs have been recorded in the investigated taxa. The glandular hairs may be subsessile or long-stalked. The subsessile glandular hairs are of two types: i) Glandular head panduriform, 2-celled, and ii) Glandular head globular or disc-shaped, 2—8- or more-celled. Subfamilies Nelsonioideae and Thunbergioideae are characteri«*H hv thfi nanduriform hairs, while Mendoncioideae and Acanthoideae have glandular hairs with a globular head. Long-stalked glandular hairs are present only in nine species. Non-glandular hairs are also widely distributed in the family; they are present in all but ten species. They may be unicellular, or multicellular uniseriate; rarely they are branched. Though the non-glandular hairs are of diagnostic importance at species level only, in some genera like Barleria, Ruttya, , and Äphelandra, they are quite characteristic. The present study does not support Bremekamp's (1965) delimitation of the family Acanthaceae, involving the transfer of Lindau's (1895) subfamily Nelsonioideae to Scrophulariaceae, and the raising of his subfamilies Thunbergioideae and Mendoncioideae to the rank of independent families. Instead, the retention of Nelsonioideae, Thunbergioideae, Mendoncioideae, and Acanthoideae within the family Acanthaceae is favoured.

Prevention; Lymphoma Prevenció; Limfoma Prevención; Linfoma Secondary central nervous system (CNS) lymphoma (SCNSL) is defined by the involvement of the CNS, either at the time of initial diagnosis of systemic lymphoma or in the setting of relapse, and can be either isolated or with synchronous systemic disease. The risk of CNS involvement in patients with diffuse large B-cell lymphoma is approximately 5%; however, certain clinical and biological features have been associated with a risk of up to 15%. There has been growing interest in improving the definition of patients at increased risk of CNS relapse, as well as identifying effective prophylactic strategies to prevent it. SCNSL often occurs within months of the initial diagnosis of lymphoma, suggesting the presence of occult disease at diagnosis in many cases. The differing presentations of SCNSL create the therapeutic challenge of controlling both the systemic disease and the CNS disease, which uniquely requires agents that penetrate the blood-brain barrier. Outcomes are generally poor with a median overall survival of approximately 6 months in retrospective series, particularly in those patients presenting with SCNSL after prior therapy. Prospective studies of intensive chemotherapy regimens containing high-dose methotrexate, followed by hematopoietic stem cell transplantation have shown the most favorable outcomes, especially for patients receiving thiotepa-based conditioning regimens. However, a proportion of patients will not respond to induction therapies or will subsequently relapse, indicating the need for more effective treatment strategies. In this review we focus on the identification of high-risk patients, prophylactic strategies and recent treatment approaches for SCNSL. The incorporation of novel agents in immunochemotherapy deserves further study in prospective trials.